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Platelet rich plasma: The scientific evidence

Platelet rich plasma: The scientific evidence

17 February 2024

Physiotherapist stretching a patient's leg on a treatment couch
We have already had a look at how platelet rich plasma (PRP) works (if you haven’t had a chance to read this yet, you can find it here), but now we are going to dive more deeply into the scientific evidence behind this treatment.
Randomised controlled trials (RCTs) are the gold standard study for determining if one treatment offers superior benefits over another. In these trials, patients are randomly assigned to either receive the treatment of interest or an alternative treatment, usually the standard of care or a placebo. Moreover, the patients are ‘blind’ to what treatment they are receiving. Here, we are going to look at two RCTs that investigated the use of PRP to treat knee osteoarthritis and chronic tennis elbow.

Knee osteoarthritis

A study by Bansal et al. (2021) investigated the optimal dose and concentration of therapeutic PRP required to achieve the desired physiologic efficacy. One hundred and fifty patients were enrolled in this trial, with then being randomised to either receive PRP or hyaluronic acid for their knee osteoarthritis.
The results revealed a significant improvement in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), International Knee Documentation Committee (IKDC) score*, and six-minute pain free walking distance. Besides external improvements, this trial also noted a significant decline in IL-6 and TNF-a levels in the PRP group when compared to the hyaluronic acid group at six months, both of which assist in mediating an inflammatory state (Bansal et al., 2021). If you would like to read more about the role of these cytokines in osteoarthritis, we have an additional blog post discussing just that.
Collectively, this trial, along with several others, demonstrate the efficacy of PRP, specifically with an absolute count of ten billion platelets, in achieving a long sustained chondroprotective effective in arthritis.
*The WOMAC represents an osteoarthritis index and measures a patients’ physical function, pain, and stiffness over a 48 hour period. The IKDC, on the other hand, gives an indication of a patients’ condition, containing questions on knee symptoms, overall function, and sports activities. The scoring system ranges from zero to one hundred, with zero representing the lowest level of function and the highest level of symptoms.

Chronic tennis elbow

A study by Mishra et al. (2014) evaluated the clinical value of tendon needling with PRP in 230 patients with chronic tennis elbow compared with an active control group. Patient outcomes were followed for up to 24 weeks, with the findings revealing several beneficial results at this mark. In those treated with PRP, a significant improvement of 71.5% was observed in their pain scores. Moreover, the percentage of patients reporting significant elbow tenderness notably decreased over this time. This demonstrates the clinical efficacy of PRP in the treatment of chronic tennis elbow on a larger scale (Mishra et al., 2014).

References

Bansal, H., Leon, J., Pont, J. L., Wilson, D. A., Bansal, A., Agarwal, D. & Preoteasa, I. 2021. Platelet-rich plasma (PRP) in osteoarthritis (OA) knee: Correct dose critical for long term clinical efficacy. Scientific Reports, 11, 3971. Mishra, A. K., Skrepnik, N. V., Edwards, S. G., Jones, G. L., Sampson, S., Vermillion, D. A., Ramsey, M. L., Karli, D. C. & Rettig, A. C. 2014. Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med, 42, 463-71.

Related reading

Platelet rich plasma injections for tendonitis

Platelet rich plasma injections for tendonitis

17 February 2024

Clinician in gloves giving an injection into a patient's upper arm

Platelet rich plasma treatment(PRP)
represents a promising approach to therapy for a range of conditions, including torn tendons, arthritis, muscle injuries, and tendonitis. We have already looked at the process of PRP and the underlying scientific evidence in our previous posts. Now, we are going to look specifically at the use of PRP in the treatment of tendonitis. But first, what is tendonitis, and how does it affect a person?

Tendonitis is a term used to define inflammation and pain following a tendon injury. This usually causes significant pain, stiffness and alters how the tendon can move. The most common areas that are affected by tendonitis are the rotator cuff, the elbow, and the Achilles tendon, with an overall prevalence of an estimated 11.6% in the general population. Although most cases of tendonitis resolve themselves within two to three weeks with relative rest of the area, icing, and strengthening exercises, a number of cases require medical intervention if they persist.

PRP therapy for tendonitis generally involves three injections, given at two to three week intervals; however, in certain cases, further injections may be needed to complete your journey. But do not worry; our doctors at Opus will discuss this and the treatment protocol with you throughout the process. The procedure itself follows three stages:

    1. The plasma, the liquid where the platelets reside, is drawn from your body through the blood.
    2. This is then placed in a machine to separate the PRP from the rest of your blood.
    3. The PRP is then injected into the area where you are experiencing tendonitis.

    Once the platelets are in the target area, they will break down, releasing growth factors. These growth factors are the pivotal component of PRP and are the reason that this treatment has shown great promise in conditions such as tendonitis. Growth factors are important proteins that stimulate cell growth, differentiation, survival, inflammation, and tissue repair; collectively, triggering your body’s healing process. Specifically, in the treatment of tendonitis, growth factors play an important role in the tendon healing process. Not only are they directly involved in tendon tissue engineering, but they have also been shown to stimulate the action of mesenchymal stem cells. To understand the role of these stem cells in regenerative medicine, we discuss them in more detail here.

    If you or someone you know are suffering from tendonitis, book an appointment today to speak to one of our team at Opus on the next steps to reduce your pain and improve your everyday function.

    Related reading

    Osteoporosis prevention and management

    Osteoporosis prevention and management

    8 February 2024

    Osteoporosis is a common condition characterised by a reduction in bone density and quality, leading to an increased  risk of fractures. As per the Royal Orthopaedic Society, risk factors for developing Osteoporosis include; smoking, too much alcohol and low body weight. We also know the females, particularly post menopausal females, are at higher risk of being diagnosed.

    Recent research has suggested that resistance training can be highly beneficial for individuals with osteoporosis (Zhang et. al 2022). (3)

    Resistance training involves placing stress on bones, which stimulates bone remodelling and increases bone density. This can help counteract the bone loss associated with osteoporosis, making bones stronger and more resistant to fractures. Resistance training targets not only bones but also muscles. Strengthening muscles can improve balance, stability, and coordination, which are important for reducing the risk of falls and fractures, particularly in older adults with osteoporosis. Regular resistance training has numerous other health benefits, including improved cardiovascular health, better insulin sensitivity, and enhanced mood and well-being. These benefits contribute to overall better health and may indirectly help in managing osteoporosis.

    The LIFTMOR trial 2017 (2) shows that targeting large multi joint strength exercises is an effective way of enhancing – or at least limiting a reduction in bone density. Through the use of 4 fundamental exercises; deadlifts, overhead presses, back squats and a chin up landing drill, positive results were shown.

    The frequency of resistance training for individuals with osteoporosis can vary depending on factors such as your current fitness level, overall health, and goals. However, general recommendations suggest aiming for resistance training exercises at least 2-3 times per week with a day of rest between sessions to allow for muscle recovery. This frequency was also tested and shown to be efficacious and superior to previous programs for enhancing bone at clinically relevant sites, as well as stature and functional performance of relevance to falls in postmenopausal women with low to very low bone mass. (Watson et al 2017) (2)

    Another important component in the management and prevention of Osteoporosis is nutrition (Garach et. al 2020). (1). The correct nutritional changes to your diet can support bone health, especially when combined with resistance training. Some key components to consider include:

    • Calcium: Adequate calcium intake is essential for maintaining bone health. Good dietary sources of calcium include dairy products (such as milk, yogurt, and cheese), leafy green vegetables (such as kale and broccoli), tofu, almonds, and fortified foods (such as fortified plant-based milk alternatives and breakfast cereals). Aim for the recommended daily intake of calcium, which varies depending on age and sex.
    • Vitamin D: Vitamin D helps the body absorb calcium and plays a crucial role in bone health. Sources of vitamin D include sunlight exposure, fatty fish (such as salmon and mackerel), fortified foods (such as fortified dairy products and cereals), and supplements. Consider getting your vitamin D levels tested and talk to your healthcare provider about supplementation if necessary.
    • Protein: Protein is important for maintaining muscle mass and supporting bone health. Include sources of lean protein in your diet, such as poultry, fish, beans, lentils, tofu, eggs, and dairy products. 
    • Magnesium: Magnesium is involved in bone formation and metabolism. Good dietary sources of magnesium include nuts, seeds, whole grains, leafy green vegetables, and dairy products. 
    • Vitamin K: Vitamin K plays a role in bone metabolism and may help reduce the risk of fractures. Include foods rich in vitamin K, such as leafy green vegetables (such as kale, spinach, and Swiss chard), broccoli, Brussels sprouts, and fermented foods in your diet. Limit Sodium and Caffeine: High sodium intake can increase calcium excretion in the urine, potentially weakening bones. Limit your intake of high-sodium processed foods and try to minimize added salt in your diet. Excessive caffeine intake may also negatively impact calcium absorption, so moderate your consumption of caffeinated beverages. 
    • Maintain a Healthy Weight: Being underweight can increase the risk of osteoporosis and fractures. Aim for a balanced diet that supports a healthy weight and includes a variety of nutrient-rich foods.

    We are proud to be able to assist all of our patients at Opus who require assistance in the prevention or management of osteoporosis through a full MDT approach including our Sports Medicine physician – Dr Porter, physiotherapy team and nutritionist. Through our expertise we are able to implement the important points made above into the patient’s package of care.

    Reference List

     

    • Muñoz-Garach, A., García-Fontana, B. and Muñoz-Torres, M. (2020). Nutrients and Dietary Patterns Related to Osteoporosis. Nutrients, [online] 12(7), p.1986. doi:https://doi.org/10.3390/nu12071986.
    • Sl, W., Bk, W., Lj, W., At, H., Sa, H. and Br, B. (2018). High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. [online] Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. Available at: https://pubmed.ncbi.nlm.nih.gov/28975661/.
    • Zhang, L., Zheng, Y.-L., Wang, R., Wang, X.-Q. and Zhang, H. (2022). Exercise for osteoporosis: A literature review of pathology and mechanism. Frontiers in Immunology, 13. doi:https://doi.org/10.3389/fimmu.2022.1005665.
    Athlete performing a sprint drill against a wall outdoors

    Injury Prevention for Skiing

    Injury Prevention for Skiing

    31 January 2024

    There are many risk factors that could cause injury when skiing which include equipment, technique, experience, education, awareness and snow related injuries (Hebert-Losier and Holmberg,2016). Research has shown that ski equipment (highly shaped, short and wide skis) has the most impact when preventing injuries (Spörri et. Al, 2017). Nevertheless, it is important to ensure professional and amateur skiers meet the physical demands of skiing to further reduce the risk of injury; this can be achieved through endurance training and strength and conditioning (Hebert-Losier and Holmberg,2016).

    Sport specific strength training is key for improving technique and delay in muscle fatigue (Sandbakk, 2018). In order to formulate a ski specific strength programme, it is important to understand the most common injuries caused by skiing.  Spörri et. all established 80% of injuries occur while the skier is turning and 19% when landing. Upper limb injuries are caused by crashes (96%) and knee injuries are the most common in skiing (83%). Hewett et. al used a screening method to assess the valgus loading of the knee to predict the risk of ACL injuries. The athletes who sustained ACL injury had a higher valgus angle compared to the uninjured athletes (Spörri et. al 2017).  In order to reduce the valgus angle in the knee, it is important to focus on strengthening hip abductors, hip external rotators (Dix et. al 2019) and quadriceps to support the knee within the sagittal plane when skiing (Morrissey et. Al 1987). Additionally, recent studies have shown the importance of core strengthening exercises in preventing ACL injuries in alpine skiing. Raschner et. all found athletes with reduced core strength or core strength imbalance had an increased risk for an ACL injury (Spörri et. Al, 2017). Therefore, a strength training programme focusing on core and lower limb strengthening is key to reducing the risk of injury in skiers.

    Endurance training for alpine skiing is crucial for performance (Neumayr et. Al 2003) and in reducing the risk of fatigue. The traditional recommendation for cardiovascular endurance training is a minimum of 20 minutes within 70%-80% of maximum heart rate (Morrissey et. Al 1987). However more recent research has shown high intensity interval training (HIIT) is also an effective method of improving endurance for skiers. Sandbakk et. al found aerobic HIIT improves endurance and ‘oxygen uptake at the ventilatory threshold’ (Sandbakk et. al 2013) in junior cross-country skiers. Furthermore, active on-hill recovery within training has shown to ‘optimize blood lactate clearance’(Spörri et. al 2017) and ‘increase run completion rate’ (Spörri et. al 2017) therefore highlighting the importance of endurance training in the prevention of injury.

    Neuromuscular training for skiers is key to preventing falls. Jacopo et. al established that including a neuromuscular warm- up programme for skiers had a positive impact on dynamic balance by improving their lower limb awareness and control (Jacobi et. al 2018). However recent studies show neuromuscular training programs reduce the risk of ACL injuries apart from alpine ski racing. This is likely due to ski boots further challenging the athletes’ balance (Spörri et. al 2017).

    Reference List

     

    • Dix, J., Marsh, S., Dingenen, B. and Malliaras, P. (2018). The relationship between hip muscle strength and dynamic knee valgus in asymptomatic females: A systematic review. Physical Therapy in Sport, 37. doi:https://doi.org/10.1016/j.ptsp.2018.05.015.

    • Hébert-Losier, K. and Holmberg, H.-C. (2013). What are the Exercise-Based Injury Prevention Recommendations for Recreational Alpine Skiing and Snowboarding? Sports Medicine, 43(5), pp.355–366. doi:https://doi.org/10.1007/s40279-013-0032-2.

    • Morrissey, M.C., Seto, J.L., Brewster, C.E. and Kerlan, R.K. (1987). Conditioning for Skiing and Ski Injury Prevention. Journal of Orthopaedic & Sports Physical Therapy, 8(9), pp.428–437. doi:https://doi.org/10.2519/jospt.1987.8.9.428.

    • Neumayr, G., Hoertnagl, H., Pfister, R., Koller, A., Eibl, G. and Raas, E. (2003). Physical and Physiological Factors Associated with Success in Professional Alpine Skiing. International Journal of Sports Medicine, 24(8), pp.571–575. doi:https://doi.org/10.1055/s-2003-43270.

    • Sandbakk, Ø. (2018). PRACTICAL IMPLEMENTATION OF STRENGTH TRAINING TO IMPROVE THE PERFORMANCE OF WORLD-CLASS CROSS-COUNTRY SKIERS. Kinesiology, [online] 50(1), pp.155–162. Available at: https://hrcak.srce.hr/ojs/index.php/kinesiology/article/view/6420 [Accessed 26 Jan. 2024].

    • Sandbakk, Ø., Sandbakk, S.B., Ettema, G. and Welde, B. (2013). Effects of Intensity and Duration in Aerobic High-Intensity Interval Training in Highly Trained Junior Cross-Country Skiers. Journal of Strength and Conditioning Research, 27(7), pp.1974–1980. doi:https://doi.org/10.1519/jsc.0b013e3182752f08.

    • Spörri, J., Kröll, J., Gilgien, M. and Müller, E. (2016). How to Prevent Injuries in Alpine Ski Racing: What Do We Know and Where Do We Go from Here? Sports Medicine, [online] 47(4), pp.599–614. doi:https://doi.org/10.1007/s40279-016-0601-2.

    • Vitale, J.A., La Torre, A., Banfi, G. and Bonato, M. (2018). Effects of an 8-Week Body-Weight Neuromuscular Training on Dynamic Balance and Vertical Jump Performances in Elite Junior Skiing Athletes. Journal of Strength and Conditioning Research, 32(4), pp.911–920. doi:https://doi.org/10.1519/jsc.0000000000002478.

    • White, G.E. and Wells, G.D. (2015). The Effect of On-Hill Active Recovery Performed Between Runs on Blood Lactate Concentration and Fatigue in Alpine Ski Racers. Journal of Strength and Conditioning Research, 29(3), pp.800–806. doi:https://doi.org/10.1519/jsc.0000000000000677.

    Athletes training with battle ropes in a gym

    Antibodies and the Immune System

    Antibodies and the Immune System

    20 December 2023

    Vial labelled COVID-19 vaccine on a pink and blue background
    Photo by Artem Podrez from Pexels

    We have already looked at the role of antibody testing in the fight against COVID-19; however, there was just too much information to discuss in one post. Therefore, this post is aimed at diving into a bit more detail on antibody testing for SARS-CoV-2 and looking at misconceptions surrounding this.

    When taking an antibody test, we are looking for anti-SARS-CoV-2 antibodies, which can be found in your blood as early as ten days after experiencing COVID-19 symptoms. Therefore, not only is antibody testing useful on its own, when combined with PCR testing, these detection methods minimise the likelihood of receiving a false-negative test. Moreover, antibody tests for SARS-CoV-2 are based primarily on the detection of antibodies against specific proteins. But, what does this mean? The novel coronavirus has four main structural proteins, the nucleocapsid (N), the spike (S), the membrane (M), and the envelope (E), as seen in the image below. However, antibody testing solely focuses on the detection of the S protein, consisting of S1 and S2 subunits, and the N protein, as these are the main immunogens of this virus.

    The S protein of SARS-CoV-2 is located on the surface of the virus and is highly immunogenic. Each subunit of this protein plays a different role, with the S1 protein containing the receptor binding domain, a key target of neutralising antibodies. The N protein, on the other hand, plays a crucial role in the replication of viral RNA, enabling the virus to survive in our system. Its role in transcription enables the virus’s genome to be packaged into virions and also inhibits the cell cycle process of our cells. During infections, the N protein is vastly expressed and possesses high immunogenic activity.

    Labelled diagram of the SARS-CoV-2 virus showing the spike, matrix, nucleocapsid and envelope proteins binding to a host cell

    Image taken from: https://www.invivogen.com/covid-19-related-genes

    Although antibody testing is focused on detecting antibodies against either the S or N protein of SARS-CoV-2, it has been recommended that a testing method that detects antibodies against both proteins be used to gain the most accurate results. This method has been adopted across the UK, and the antibody testing at Opus is no exception to this.