prp for lateral epicondylitis

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PRP for Lateral Epicondylitis. Matthew Bloom, OMS IV. Have you had your morning cup of coffee yet?. 300mg/day. Overview. Lateral Epicondylitis Platelet-Rich Plasma Current research on tx of lateral epicondylitis with PRP vs CSI. Lateral Epicondylitis. Also referred to as: - PowerPoint PPT Presentation

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PRP for Lateral Epicondylitis

PRP for Lateral EpicondylitisMatthew Bloom, OMS IV

1

Have you had your morning cup of coffee yet?300mg/dayLateral Epicondylitis

Platelet-Rich Plasma

Current research on tx of lateral epicondylitis with PRP vs CSIOverviewAlso referred to as:Elbow tendinosisElbow tendonitisElbow tendinopathyEpicondylalgiaTennis elbow

Lateral Epicondylitis

Lateral Epicondylitis

Lateral EpicondylitisEpidemiology13% in general population

Risk FactorsSmokingObesityAge (4554)Repetitive movement (>2 hours daily)Forceful activity (>20 kg)Lateral EpicondylitisClinical AnatomyLateral humeral epicondyle serves as the bony common origin of the wrist extensor musclesInjury to the extensor carpi radialis brevis muscle (ECRB) (felt at tip of lateral epicondyle)Differentiate an effusion in this region, which represents intraarticular pathology or swelling posteriorly due to olecranon bursitis, from the lateral epicondylitis, which is extraarticular in natureLateral Epicondylitis

Lateral EpicondylitisPathophysiologyChronic tendinosis rather than an acute inflammatory processPresence of disorganized tissue and neovasculature with very few inflammatory cellsStudies using grayscale ultrasonography and color Doppler followed by anesthetic injection suggest that vasculoneural growth in the common extensor origin, most commonly the ERCB, is the likely source of painTargeting this degenerative tendinosis and neovascularization is the focus of emerging treatments (PRP?)

Lateral EpicondylitisMechanism of InjuryRepetitive or explosive athletic movements involving eccentric motion, in which the muscle-tendon unit is lengthened while contracting

Clinical PresentationLateral elbow pain with varying severity

Lateral EpicondylitisNirschl characterizes seven stages of tendinopathy:Phase I Mild pain after exercise activity, resolves within 24 hoursPhase II Pain after exercise activity, exceeds 48 hours, resolves with warm-upPhase III Pain with exercise activity that does not alter activityPhase IV Pain with exercise activity that alters activityPhase V Pain caused by heavy activities of daily livingPhase VI Intermittent pain at rest that does not disturb sleep; Pain caused by light activities of daily livingPhase VII Constant rest pain (dull aching) and pain that disturbs sleepLateral EpicondylitisClinical ExaminationLocalized tenderness over the lateral epicondyle and proximal wrist extensor muscle massPain with resisted wrist extension with the elbow in full extensionPain with passive terminal wrist flexion with the elbow in full extensionLateral Epicondylitis

Lateral Epicondylitis

Lateral Epicondylitis

Lateral EpicondylitisCozens TestJAMA February 6, 2013 Vol. 309, No. 5Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients with Unilateral Lateral Epicondylalgia: A Randomized Controlled TrialCoombes BK, Bisset L, Brooks P, Khan A, Vicenzino BDivision of Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, Australia

JAMA Article ReviewObjective: To investigate the effectiveness of corticosteroid injection, multimodal physiotherapy, or both in patients with unilateral lateral epicondylalgia

Design: A 2 2 factorial, randomized, injection-blinded, placebo-controlled trial

Setting: Conducted at a single university research center and 16 primary care settings in Brisbane, Australia

JAMA Article ReviewPatientsN = 165Enrolled between July 2008 and May 20101-year follow-up in May 2011Age 18 years or olderEligibility was determined by telephone interviewPhysical examination was conducted by one researcher and confirmed by a second

JAMA Article ReviewInclusion CriteriaUnilateral lateral epicondylalgia > 6 weeksPain over the lateral epicondyle with pain severity > 30 mm on a 100-mm visual analog scale (VAS)Pain provoked by at least 2 of the following:GrippingPalpationResisted wrist or middle finger extensionStretching of forearm extensor muscles

JAMA Article ReviewExclusion CriteriaReceipt of injection (6 months)Receipt of a course of physiotherapy (3 months)Concomitant neck or other arm pain (6 months)Symptoms suggesting radicular, neurologic, or systemic arthritic conditionsPregnant or breastfeedingContraindication to injectionJAMA Article ReviewRandomizationStratified according to pain severity greater or less than 57.5 mm on a 100-mm VAS

BlindingResearcher who assessed outcomes was blinded to both injection and physiotherapy assignmentPatients were blinded to injection but not physiotherapyJAMA Article ReviewInterventionsCorticosteroid injection (n = 43)10 mg/mL of triamcinolone acetonide in a 1 mL injection plus 1 mL of 1% lignocainePlacebo injection (n = 41)0.5 mL of 0.9% isotonic salineCorticosteroid injection plus physiotherapy (n = 40)Placebo injection plus physiotherapy (n = 41)JAMA Article ReviewInterventionsInjections were applied to the site of maximum palpable tenderness at the common extensor originPhysiotherapy consisted of 8 30-minute sessions over 8 weeksPatients were advised to avoid any activity that caused or provoked pain and to refrain from strenuous activity for 2 weeksJAMA Article ReviewInterventionsAfter 2 weeks, a gradual return to normal activity was encouraged to minimize potential for recurrencePatients were allowed to use an analgesic or anti-inflammatory medication, heat or cold pack, or braces as neededPatients were discouraged from seeking treatments other than those specifically assignedJAMA Article ReviewHypothesesAt 1 year, clinical outcomes would be worse in patients receiving CSI vs. placeboAt 1 year, clinical outcomes would be better in patients receiving physiotherapy vs. no physiotherapy

Outcome MeasuresPatients estimated their global rating of change at 4, 8, 12, 26, and 52 weeks on a 6-point Likert scale ranging from complete recovery to much worse

JAMA Article ReviewPrimary OutcomesCSI demonstrated lower complete recovery or much improvement at 1 year compared with placebo (83% vs. 96%)p = .01CSI demonstrated greater recurrence at 1 year compared with placebo (54% vs. 12%)p < .001

JAMA Article ReviewJAMA Article Review28Primary OutcomesNo interaction between injection (CSI vs. placebo) and physiotherapy (yes vs. no) (p = .99)No difference in physiotherapy vs. no physiotherapy at 1 year for complete recovery or much improvement (91% vs. 88%, p = .56)No difference in physiotherapy vs. no physiotherapy at 1 year for recurrence (29% vs. 38%, p = .25)JAMA Article ReviewSecondary OutcomesAt 4 weeks, significant improvement occurred across the board for CSI compared to placebo injection and physiotherapy (yes vs. no)At 26 weeks, improvement began to decline for CSI compared to placebo and showed no difference for physiotherapy (yes vs. no)p < .001JAMA Article ReviewConclusionsCSI showed improvement at 4 weeks compared to placebo, but a subsequent decline in effectiveness at 6 months, with worse outcome at 1 yearPhysiotherapy showed no benefit when combined with CSI at 4 weeks and no long-term benefit overall, however, it was shown to be useful in the short-term when utilized aloneCorticosteroids are potent in suppressing inflammation, but histological evidence does not support an inflammatory response in this conditionJAMA Article Review

JAMA Article Review

Discussion Time!Strengths vs. Weaknesses?OverviewPRP is a regenerative therapy useful in addressing many musculoskeletal injuriesPRP is being increasingly used for tx of chronic non-healing tendon injuriesPRP contains growth factors (GFs) that stimulate neovascularization to increase the blood supply and available nutrients for damaged tissue to regenerateNeovascularization also brings new cells and removes debris from damaged tissuePlatelet-Rich PlasmaGrowth factorsAlpha granules are storage units within platelets that contain inactive prepackaged growth factors including:Transforming Growth Factor Beta (TGF)Vascular Endothelial Growth Factor (VEGF)Platelet-Derived Growth Factor (PDGF)Epithelial Growth Factor (EGF)Fibroblast Growth Factor (FGF)Together these factors help to stimulate cell replication, angiogenesis, epithelialization, granulation tissue formation, extracellular matrix formation, and regulation of bone cell metabolismPlatelet-Rich PlasmaProductionPRP is a plasma suspension that contains all components of whole blood in varying amountsContains at least 200,000 platelets/L, but generally 3-5 thisCentrifugation of venous whole blood containing an anticoagulant results in a plasma supernatant with a gradient of cellular concentrationPlatelet-Rich PlasmaProductionErythrocytes are the densest and will remain at the bottomA buffy coat of white blood cells followsPlatelets are at the highest concentration in the plasma layer just above the buffy coat and decrease in concentration toward the topPlatelet-Rich PlasmaPlatelet-Rich Plasma

Platelet-Rich PlasmaPathophysiologyWith repetitive overuse, collagen fibers in tendons form micro-tearsInjured tendons heal by scarring, which adversely effects function and increases risk of re-injuryIn addition, tendons heal at a slow rate secondary to poor vascularizationPlatelet-Rich PlasmaPathophysiologyTraditional therapies do not alter the tendons poor healing capabilities, but rather involve long-term palliative careSome studies suggest CSIs have adverse side effects including atrophy and worsening structural changes to tendonsHowever, GFs in platelets are known to promote tissue regeneration

Platelet-Rich PlasmaAJSM July 3, 2013 onlinePlatelet-Rich Plasma Significantly Improves Clinical Outcomes in Patients With Chronic Tennis ElbowAllan K. Mishra, MD, Nebojsa V. Skrepnik, MD, PhD, Scott G. Edwards, MD, Grant L. Jones, MD, Steven Sampson, DO, Doug A. Vermilli

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