Platelet-rich plasma (PRP) for muscle injuries. Mohamad Shariff A Hamid MBBS (Adel), Master Sports Med (UM), PhD (UM)

Transcription

1 Platelet-rich plasma (PRP) for muscle injuries Mohamad Shariff A Hamid MBBS (Adel), Master Sports Med (UM), PhD (UM)

2 Overview Muscle injury Management PRP PRP for muscle injuries - evidence?

3 Introduction Muscle injuries 1,2 : 30-50% Causes 3 Contusion Strain Laceration

4 Treatment No standard 1. Pharmacological a) Pain killers (Non-steroidal anti-inflammatories) 4 b) Corticosteroids 5 2. Non-pharmacological a) Rehabilitation program 6 b) Electrotherapeutic modalities 7

5 Recovery Return-to-play (RTP) 6 weeks - never (retired) 8 Malaysian athletes: Median RTP = 7.4 weeks 9 Professional sports AUD 1.6 billion annually 10

6 Alternatives Hyperbaric oxygen therapy 11 Actovegin + traumeel injection 12 Biologicals Autologous blood injection 13 Autologous conditioned serum (ACS) 8 Platelet-rich plasma (PRP) 14

7 PRP Since 1970 s Maxillofacial surgery Dental implant Plastic surgery / Aesthetic medicine Orthopaedic / Tissue engineering Rheumatology Sports Medicine Anitua et al, 2006

8 Platelet-rich plasma (PRP) Venous blood: 150, ,000 platelets / µl ACS: < 1,000,000 platelets / µl PRP: > 1,000,000 / µl 4 to 5 fold increase 15

9 PRP preparation Plasma-based system Slower speed Shorter duration Plasma + Platelet (LP-PRP) Buffy-coat based PPP + Buffy coat Buffy coat = platelet + WBC (LR-PRP)

10

11 PRP Classification Systems Platelet counts WBC counts Activators Classification systems Ehrenfest et al, 2009, Mishra et al, 2012 PAW systems 2013

12 Does PRP works for muscle injuries?

13 Jarvinen, 2007

14 Tiidus, 2008

15

16 Alpha granules Growth factors Cytokines Dense body Histamine Serotonin Marx, 2004

17 Table 2: PRP for muscle injury (animal) Author Year Technique Type Species Tissue Results Wright-Carpenter et al ACS Controlled trial Mice Muscle Increased satellite cells & myofibers Carda et al PRP Cohort Sheep Muscle Improved healing at 6 days Hammond et al PRP Controlled trial Rat Muscle Improve recovery

18 Table 2: PRP for muscle injury (human) Author Year Technique Type Species Tissue Results Wright-Carpenter et al PRP Case control Human Muscle Faster recovery Sanchez et al PRP Case series Human Muscle Faster recovery Loo & Lee PRP Case report Human Muscle Faster recovery Hamilton et al PRP Case report Human Hamstring Faster recovery Rettig et al PRP Case control Human Hamstring No difference

19 p < Wright-Carpenter et al, 2004

20 Rettig et al, 2013

21 DRP (medians) Control days PRP days χ 2 (1, N = 14) = 6.189, p = Figure 3: Survival function of control and PRP groups A Hamid et al, 2014

22 Table 11: Cox-regression analysis of other covariates on hamstring injury Note: *P 0.05 = Significant predictors; B = Regression coefficient; df = Degrees of freedom; IQR = Interquartile range; BPI SF = Brief Pain Inventory Scale - Short Form; AKE = Active knee extension. A Hamid et al, 2014

23 DRP (medians) Control days PRP days p = 0.66 Reurink et al, 2014

24 DRP (medians) No injection days PPP injection days PRP injection days p=0.210 Hamilton et al, 2014

25 Hamilton et al, 2015

26 Summary Author Design Subjects Injury Intervention PRP class Injection Results (RTP) Wright- Carpenter et al.2004 Prospective (nonblinded) n = 11 Grade 2 ACS vs. Actovegin/ Traumeel Unreported 2.5 ml - Non-guided (every 2 days) Significantly faster in ACS Rettig et al Retrospective (case control) n = 10 Grade 1 & 2 PRP vs. Rehab Unreported 6 ml - US guided (x1) No significant difference A Hamid et al, 2014 RCT (single blind) n = 28 Grade 2 PRP vs. Rehab L-PRP 3 ml - US guided (x1) Significantly faster in PRP Reurink et al, 2014 RCT (double blind) n = 80 Grade 1 & 2 ACP vs. N/S Unreported US guided (x2) No significant difference Hamilton et al, 2015 RCT - 3 arm (double blind) n = 90 Grade 1 & 2 PRP vs. PPP vs. No injection L-PRP Non-guided No significant difference ACS - Autologous conditioned serum ACP - Autologous conditioned plasma

27 Current studies Still controversial More robust study needed Different PRP preparation and quality Standard PRP classification

28 PRP treatment protocol Which class of PRP? Which type of muscle injury? How much to administer? How frequent to administer? Post injection care? Which rehabilitation program?

29 Conclusion PRP - theoretically is a promising treatment Muscle injury Current evidence insufficient to recommend for or against for muscle injury More studies are required

30 Thank You

31 References 1.Garrett WEJ, Rich FR, Nikolaou PK, Vogler JB. Computed tomography of hamstring muscle strains. Medicine and Science in Sports and Exercise. 1989;21(5): Volpi P, Melegati G, Tornese D, Bandi M. Muscle strains in soccer: a five-year survey of an Italian major league team. Knee Surgery, Sports Traumatology, Arthroscopy. 2004;12(5): Järvinen TAH, Järvinen TLN, Kääriäinen M, Aärimaa V, Vaittinen S, Kalimo H, et al. Muscle injuries: optimising recovery. Best Practice & Research Clinical Rheumatology. 2007;21(2): Drezner JA. Practical management: hamstring muscle injuries. Clinical journal of Sport Medicine. 2003;13(1): Kleinman M, Gross AE. Achilles tendon rupture following steroid injection. Report of three cases. The Journal of Bone and Joint Surgery American volume. 1983;65(9): Sherry MA, Best TM. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. The Journal of Orthopaedic and Sports Physical Therapy. 2004;34(3): Rantanen J, Thorsson O, Wollmer P, Hurme T, Kalimo H. Effects of therapeutic ultrasound on the regeneration of skeletal myofibers after experimental muscle injury. American Journal of Sports Medicine. 1999;27(2): Wright-Carpenter T, Klein P, Schaferhoff P, Appell HJ, Mir LM, Wehling P. Treatment of muscle injuries by local administration of autologous conditioned serum: a pilot study on sportsmen with muscle strains. International Journal of Sports Medicine. 2004;25(8): Shariff AH, Ashril Y, Razif MA. Pattern of muscle injuries and predictors of return-to-play duration among Malaysian athletes. Singapore Medical Journal. 2013;54(10): Orchard J, Seward H. Epidemiology of injuries in the Australian Football League, seasons British Journal of Sports Medicine. 2002;36(1): Bennett M, Best TM, Babul S, Taunton J, Lepawsky M. Hyperbaric oxygen therapy for delayed onset muscle soreness and closed soft tissue injury. Cochrane database of systematic reviews (Online). 2005;(4):CD Engebretsen L, Steffen K, Alsousou J, Anitua E, Bachl N, Devilee R, et al. IOC consensus paper on the use of platelet-rich plasma in sports medicine pp

32 13.Thanasas C, Papadimitriou G, Charalambidis C, Paraskevopoulos I, Papanikolaou A. Platelet-Rich Plasma Versus Autologous Whole Blood for the Treatment of Chronic Lateral Elbow Epicondylitis: A Randomized Controlled Clinical Trial. American Journal of Sports Medicine. 2011;39(10): Schwarz, A. A promising treatment for athletes, in blood. The New Times. pagewanted=all&_r=0 (Accessed on 4 March 2014). 15.Marx RE. Platelet-rich plasma: evidence to support its use. J Oral Maxillofac Surg. 2004;62(4): Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-Rich Plasma: From Basic Science to Clinical Applications. American Journal of Sports Medicine. 2009;37(11): Carda C, Mayordomo E, Enciso M, et al. Structural effects of the application of a preparation rich in growth factor on muscle healing following acute surgical lesion. Paper presented at 2 nd International Conference on Regenerative Medicine: May 18 20, 2005; Leipzig, Germany. 18.Hammond JW, Hinton RY, Curl LA, Muriel JM, Lovering RM. Use of autologous platelet-rich plasma to treat muscle strain injuries. American Journal of Sports Medicine. 2009;37(6): Sanchez, M., Anitua, E., & Andia, I. (2005). Application of autologous growth factors on skeletal muscle healing. Paper presented at the 2 nd World Congress on Regenerative Medicine, Liepzig, Germany. 20.Loo WL, Lee DYH, Soon MYH. Plasma rich in growth factors to treat adductor longus tear. Annals of the Academy of Medicine, Singapore Aug;38(8): Hamilton BB, Knez WW, Eirale CC, Chalabi HH. Platelet enriched plasma for acute muscle injury. Acta orthopaedica Belgica. 2010;76(4): Rettig, A. C., Meyer, S., & Bhadra, A. K. (2013). Platelet-rich plasma in addition to rehabilitation for acute hamstring injuries in nfl players clinical effects and time to return to play. Orthopaedic Journal of Sports Medicine, 1(1). DOI: / Lwanga SK, Lemeshow S, World Health Organization. Sample size determination in health studies. World Health Organization; p. 24.Peetrons P. Ultrasound of muscles. European Radiology. 2002;12(1):35 43.