Is platelet-rich plasma (PRP) a viable treatment option in patients who are not showing improvement with long-term corticosteroid use? Richard Rosenthal, MD, believes so.
The founder and medical director of Nexus Pain Care in Provo, Utah, Dr. Rosenthal told attendees at the American Society of Interventional Pain Physicians’ 2014 annual meeting that studies support PRP’s efficacy for several pain conditions.
These include lateral epicondylitis (tennis elbow), patellar tendon injury and rotator cuff tears. Studies also have shown that PRP use may offer some benefit for refractory diskogenic low back pain, knee osteoarthritis, trochanteric bursitis and plantar fasciitis.
Other pain physicians agree that the treatment appears promising for a selected group of patients.
“I would want to be the first person on the block to use PRP if it pans out in further studies,” said Ezra B. Riber, MD, CEO and president of the South Carolina Society of Interventional Pain Physicians. “It would be a welcome addition to the limited nonsurgical armamentarium that we have for treating multilevel, noncontiguous intradiskal pathology.”
However, Wellington Hsu, MD, Clifford C. Raisbeck Distinguished Professor of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, and his co-authors raised some cautionary flags in a recent review (J Am Acad Orthop Surg 2013;21:739-748). They pointed to “limited reliable clinical evidence to guide the use of PRP” in many conditions, and the voids in “classification systems and identification of differences among products”—some 40 of which are on the market worldwide—that they said should be addressed before clinicians and patients can make fully informed decisions about the use of PRP.
“Although PRP may have theoretical benefits in tissue healing, the literature has shown variable results depending on the medical condition, formulation and tissue type,” Rajesh Kalra, MD, medical director of the Kaiser Permanente Chronic Pain Program in Union City, Calif., wrote in an email. “Further clinical studies are necessary to establish PRP use protocols and determine the short-term and long-term benefits of its use.”
Dr. Rosenthal cited a Dutch randomized controlled trial (RCT) on PRP injections for chronic Achilles tendinopathy that did not show a benefit of PRP over saline injection (JAMA2010;303:144-149), but he questioned the design of the study. Another Dutch study showed PRP was associated with a significant reduction in pain and a significant increase in function in patients with chronic lateral epicondylitis (Am J Sports Med 2010;38:255-262). Dr. Rosenthal also reviewed a Stanford RCT indicating that PRP can help patients with chronic tennis elbow (Am J Sports Med 2014;42:463-471). He also discussed a study on chronic patellar tendinopathy that demonstrated positive results (Am J Sports Med 2013;41:795-803), as well as positive studies on plantar fasciitis; osteoarthritis of the hip, knee and shoulder; and trochanteric bursitis.
Additionally, Dr. Rosenthal described a paper on large to massive rotator cuff tears in patients aged 45 to 85 years, noting a significantly lower re-tear rate in patients who received PRP gel intraoperatively than in those who did not (Am J Sports Med 2013;41:2240-2248). (There was no significant difference in clinical outcomes at one-year follow-up in addition to overall shoulder function.)
Dr. Rosenthal also showed data from a double-blind study of PRP injection at time of diskography for refractory diskogenic low back pain compared with an injection of contrast agent alone. The data were originally presented by Gregory Lutz, MD, physiatrist-in-chief emeritus for the Hospital for Special Surgery, New York City, and chief medical advisor for spine medicine at BioRestorative Therapies, Inc., at the North American Spine Society’s 2013 annual meeting. Pain and functioning appeared to improve significantly more in patients who received PRP than in controls.
“Although more studies are needed, there appears to be enough evidence to recommend the use of PRP for the above conditions when more conservative treatments have failed,” concluded Dr. Rosenthal.
Dr. Hsu and his co-authors, however, said the field is missing standardized and validated definitions for PRP product characteristics, as well as cost–benefit analyses, making study results less meaningful. They also pointed to holes in the evidence for PRP in the management of osteochondral lesions and knee osteoarthritis, as well as rotator cuff repair and Achilles tendon repair, but did conclude that PRP appeared to improve patient outcomes in elbow epicondylitis refractory to nonsurgical treatment.
The treatment also is not covered by insurance plans in the United States. Dr. Rosenthal said he charges approximately $750 for each PRP injection.
—Rosemary Frei, MSc
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