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Poenaru D, Potcovaru CG, Sandulescu MI, Constantinovici M, Cinteza D. Injectables in the Therapy of Mid-Portion Achilles Tendinopathy, a Descriptive Review. Life (Basel) 2025; 15:824. [PMID: 40430250 PMCID: PMC12113072 DOI: 10.3390/life15050824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2025] [Revised: 05/16/2025] [Accepted: 05/19/2025] [Indexed: 05/29/2025] Open
Abstract
Achilles mid-portion tendinopathy is defined as a painful thickening of the tendon, identified also on different imagistic examinations, occurring in sport people as well in inactively middle-aged individuals. The chronic and/or relapsing evolution interfere with daily living and alter the quality of life. Eccentric physical exercise is a cornerstone in her management and several injectable agents are used in clinical settings to reduce pain and improve function. According to the presumed pathogenic mechanisms, many classes of agents are in use: corticosteroids, protease inhibitors, sclerosing agents, pro-inflammatory agents, autologous products. The modalities of administration, either intra- or peritendon, the timing and number of sessions are displayed. Practical approach of chronic mid-portion Achilles tendinopathy consists of rest, tendon protection, eccentric exercise and therapeutical injections. The clinicians must choose between a spectrum of agents active on different pathogenic mechanisms, with benefits in the short and medium term. Future research may be focused on comparison between the different agents and on long term evolution.
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Affiliation(s)
- Daniela Poenaru
- Rehabilitation Department, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.G.P.); (M.I.S.); (M.C.); (D.C.)
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Biedermann BM, Fathi A, Kotlier JL, Lamb CJ, Ahmad A, Bolia IK, Mayfield C, Petrigliano FA, Liu JN. Results of Randomized Controlled Trials of Platelet-Rich Plasma in Lower-Extremity Tendinopathy Are Not Influenced by Industry Sponsorship. Arthroscopy 2025; 41:848-856. [PMID: 38703920 DOI: 10.1016/j.arthro.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 03/22/2024] [Accepted: 04/02/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE To determine whether industry affiliation influences the results of randomized controlled trials (RCTs) studying the use of platelet-rich plasma (PRP) for the treatment of patellar or Achilles tendinopathy. METHODS The PubMed, Scopus, Cochrane, and MEDLINE databases were searched in July 2023 for RCTs investigating PRP for the treatment of patellar or Achilles tendinopathy published between 2009 and July 2023. Industry affiliation was determined by analyzing each study's funding or conflict-of-interest section. Author disclosures were searched in the American Academy of Orthopaedic Surgeons disclosure database and the Centers for Medicare & Medicaid Services open payments database. An industry-affiliated (IA) designation was given if an author had a relevant disclosure or if the company that funded the study manufactured PRP. Otherwise, a non-industry-affiliated (NIA) designation was given. Fisher exact analysis was used to determine whether PRP had a favorable effect, no significant effect, or an unfavorable effect on outcome. RESULTS Analysis was performed on 22 studies (10 IA and 12 NIA), with 17 studies (77.3%) reporting a conflict of interest or funding for the research, 4 (18.2%) reporting no conflict of interest, and 1 (4.5%) with no reporting. Of the 22 included studies, 8 (36.4%) reported favorable outcomes regarding PRP use and 14 (63.6%) reported no significant effect. Favorable outcomes were found in 4 of the 10 IA studies (40.0%), whereas no significant effect was reported in 6 (60.0%). The 12 NIA studies included 4 (33.3%) with favorable results and 8 (66.7%) with no significant effect. The comparison between industry affiliation and results reported was not statistically significant (P > .999). CONCLUSIONS The results of RCTs evaluating the use of PRP in lower-extremity tendinopathy were not influenced by industry sponsorship. CLINICAL RELEVANCE Most biomedical research is funded through industry sponsorship. Although this relation is necessary as technologies are developed, it is important to scrutinize studies for evidence of industry bias to understand how this bias may be affecting study results published in the literature.
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Affiliation(s)
- Brett M Biedermann
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A..
| | - Amir Fathi
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Jacob L Kotlier
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Chris J Lamb
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Aamir Ahmad
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Ioanna K Bolia
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Cory Mayfield
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Frank A Petrigliano
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Joseph N Liu
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
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Wigham L, Richardson A, Moore K, Martin M. Implementing group consultations in a lower limb musculoskeletal outpatient service to improve efficiency and maintain positive patient outcomes. BMJ Open Qual 2024; 13:e002924. [PMID: 39581636 PMCID: PMC11590858 DOI: 10.1136/bmjoq-2024-002924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Accepted: 11/03/2024] [Indexed: 11/26/2024] Open
Abstract
BACKGROUND Group consultations (GCs) in healthcare have been shown to improve clinical outcomes with greater efficiency. This project aimed to develop a more efficient musculoskeletal (MSK) physiotherapy-led GC approach for common lower limb problems. This was to help manage an anticipated increase in demand while maintaining high patient satisfaction and ensuring clinical effectiveness. METHODS Three 'Plan-Do-Study-Act' (PDSA) cycles were undertaken to test out the new approach of virtual group consultations (VGCs) and face-to-face GCs with MSK patients. These two approaches were tested and refined on four common lower limb conditions: patellofemoral pain syndrome, Achilles tendinopathy, plantar fasciopathy and knee osteoarthritis. We measured the number of patients seen, staff time, patients' experience and patient outcome scores. RESULTS Each patient used 45 min of physiotherapy time via the traditional one-to-one physiotherapy consultation approach, this was reduced to 22 min in the VGCs and 12 min for the face-to-face GCs. We found a significant increase in EQ-5D scores (PDSA 1: +0.19, p=0.004 and PDSA 2: +0.17, p=0.002) and the Visual Analogue Score for Pain (PDSA 1: -1.95, p=0.001 and PDSA 2: -2.6, p=0.007) from the first to the second virtual GC sessions. CONCLUSION GCs were shown to be an efficient way of providing physiotherapy to patients with lower limb conditions. Feedback from patients attending GCs has shown a good level of effectiveness and patient satisfaction. This alternative way to review and treat patients has yielded a reduction in physiotherapist contact time per patient, improving the efficiency of our MSK service. We did not compare these groups to the one-to-one face-to-face consultations, therefore whether they are better, is unknown.
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Affiliation(s)
- Lisa Wigham
- Physiotherapy, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Annette Richardson
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Kathryn Moore
- Physiotherapy, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Michael Martin
- Physiotherapy, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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Kenyon M, Driver P, Mallows A, Stephens G, Bryant M, Al Dawoud M, O'Neill S. Characteristics of patients seeking national health service (NHS) care for Achilles tendinopathy: A service evaluation of 573 patients. Musculoskelet Sci Pract 2024; 74:103156. [PMID: 39270530 DOI: 10.1016/j.msksp.2024.103156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 07/30/2024] [Accepted: 07/31/2024] [Indexed: 09/15/2024]
Abstract
BACKGROUND Achilles tendinopathy is a common condition that is often still symptomatic 10 years after onset. Much of the available research has focussed on active populations, however our experience is patients seeking care in the UK's National Health Service (NHS) may be different. OBJECTIVES To determine the characteristics of patients receiving NHS care for Achilles tendinopathy (AT). To describe the utilisation of resources and the effectiveness of AT management in the NHS. METHODS A data extraction tool was developed and used to retrospectively extract the characteristics of 573 patients diagnosed with Achilles tendinopathy. RESULTS NHS Achilles tendinopathy patients averaged 57 years old, had a Body Mass Index of 31, and 69% had at least one other long-term health condition. These included musculoskeletal complaints (59%), hypertension (30%), Chronic Obstructive Pulmonary Disease or asthma (17%), cardiovascular disease (13%) and diabetes (13%). Subsequently medication usage was higher than the general population and included drugs that have been linked to the pathogenesis of tendinopathy. On average, healthcare providers conducted 3.8 therapy sessions and 26% of patients had radiological investigations. Outcome measures were commonly absent with Visual Analog Scale (VAS) scores documented in 51% of records, and patient-reported outcome measures like VISA-A only appearing in 3% of cases. Reports on psychosocial factors were seldom documented. CONCLUSION Individuals diagnosed with Achilles tendinopathy through NHS services exhibit distinct characteristics that diverge considerably from those currently represented in the published research used to develop clinical guidelines. NHS Achilles tendinopathy patients have multiple long-term health conditions and higher medication usage.
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Affiliation(s)
- Matt Kenyon
- Integrated Musculoskeletal Pain and Rheumatology Service, East Lancashire Hospitals Trust, Blackburn, UK.
| | - Phil Driver
- Integrated Musculoskeletal Pain and Rheumatology Service, East Lancashire Hospitals Trust, Blackburn, UK
| | - Adrian Mallows
- School of Health and Human Sciences, University of Essex, Colchester, UK
| | | | - Michael Bryant
- Integrated Musculoskeletal Pain and Rheumatology Service, East Lancashire Hospitals Trust, Blackburn, UK
| | - Marwan Al Dawoud
- Integrated Musculoskeletal Pain and Rheumatology Service, East Lancashire Hospitals Trust, Blackburn, UK
| | - Seth O'Neill
- School of Healthcare, University of Leicester, Leicester, UK
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Ling SKK, Mak CTK, Lo JPY, Yung PSH. Effect of Platelet-Rich Plasma Injection on the Treatment of Achilles Tendinopathy: A Systematic Review and Meta-analysis. Orthop J Sports Med 2024; 12:23259671241296508. [PMID: 39611122 PMCID: PMC11603511 DOI: 10.1177/23259671241296508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/02/2024] [Indexed: 11/30/2024] Open
Abstract
Background Achilles tendinopathy is a common condition without a reproducible and timely treatment modality. Platelet-rich plasma (PRP) injection has been proposed as an enticing treatment option, but there is no consensus regarding its effectiveness. Purpose To pool the available data and evaluate the evidence of the effect of PRP injections on Achilles tendinopathy. Study Design Systematic review; Level of evidence, 1. Methods This review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. CINAHL via EBSCOhost, Cochrane Library, and PubMed databases were searched for randomized controlled trials comparing PRP injection with nonoperative treatment, with the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire score or maximal Achilles tendon (AT) thickness on ultrasound as outcome measures. Risk-of-bias assessment was performed of the included studies, and meta-analyses compared differences in outcome measures between PRP injection and control at the short-term (3-month), intermediate-term (6-month), and long-term (12-month) follow-ups. Results Of 409 publications, 6 publications (N = 422 patients with chronic midportion Achilles tendinopathy) were identified from the literature search. Risk-of-bias assessment revealed 2 studies were low risk, 1 was of some concern, and 3 were high risk of bias. Meta-analysis revealed no significant differences between PRP injection and control at any time point for both VISA-A score (short term: P = .29; intermediate term: P = .42; long term: P = .57) and maximal AT thickness (short term: P = .60; intermediate term: P = .20; long term: P = .55). Conclusion Our review demonstrated that although recent trends have shown an increasing popularity of PRP injection, no solid evidence has been established. The heterogenicity of the tendinopathy pathology and the PRP injection content and methodology should be controlled by better-designed clinical trials. Further research is needed before it should be recommended as a standard treatment.
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Affiliation(s)
- Samuel Ka-Kin Ling
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong (CUHK), Hong Kong SAR, China
| | - Clarence Tsz-Kit Mak
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong (CUHK), Hong Kong SAR, China
| | - Jasmine Pui-Yin Lo
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong (CUHK), Hong Kong SAR, China
| | - Patrick Shu-Hang Yung
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong (CUHK), Hong Kong SAR, China
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Rajkumar CA, Thomas KE, Foley M, Ganesananthan S, Evans H, Simader F, Syam S, Nour D, Beattie C, Khan C, Reddy RK, Ahmed-Jushuf F, Francis DP, Shun-Shin M, Al-Lamee RK. Placebo Control and Blinding in Randomized Trials of Procedural Interventions: A Systematic Review and Meta-Regression. JAMA Surg 2024; 159:776-790. [PMID: 38630462 PMCID: PMC11024757 DOI: 10.1001/jamasurg.2024.0718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 01/13/2024] [Indexed: 04/20/2024]
Abstract
Importance Unlike medications, procedural interventions are rarely trialed against placebo prior to becoming accepted in clinical practice. When placebo-controlled trials are eventually conducted, procedural interventions may be less effective than previously believed. Objective To investigate the importance of including a placebo arm in trials of surgical and interventional procedures by comparing effect sizes from trials of the same procedure that do and do not include a placebo arm. Data Sources Searches of MEDLINE and Embase identified all placebo-controlled trials for procedural interventions in any specialty of medicine and surgery from inception to March 31, 2019. A secondary search identified randomized clinical trials assessing the same intervention, condition, and end point but without a placebo arm for paired comparison. Study Selection Placebo-controlled trials of anatomically site-specific procedures requiring skin incision or endoscopic techniques were eligible for inclusion; these were then matched to trials without placebo control that fell within prespecified limits of heterogeneity. Data Extraction and Synthesis Random-effects meta-regression, with placebo and blinding as a fixed effect and intervention and end point grouping as random effects, was used to calculate the impact of placebo control for each end point. Data were analyzed from March 2019 to March 2020. Main Outcomes and Measures End points were examined in prespecified subgroups: patient-reported or health care professional-assessed outcomes, quality of life, pain, blood pressure, exercise-related outcomes, recurrent bleeding, and all-cause mortality. Results Ninety-seven end points were matched from 72 blinded, placebo-controlled trials (hereafter, blinded) and 55 unblinded trials without placebo control (hereafter, unblinded), including 111 500 individual patient end points. Unblinded trials had larger standardized effect sizes than blinded trials for exercise-related outcomes (standardized mean difference [SMD], 0.59; 95% CI, 0.29 to 0.89; P < .001) and quality-of-life (SMD, 0.32; 95% CI, 0.11 to 0.53; P = .003) and health care professional-assessed end points (SMD, 0.40; 95% CI, 0.18 to 0.61; P < .001). The placebo effect accounted for 88.1%, 55.2%, and 61.3% of the observed unblinded effect size for these end points, respectively. There was no significant difference between unblinded and blinded trials for patient-reported end points (SMD, 0.31; 95% CI, -0.02 to 0.64; P = .07), blood pressure (SMD, 0.26; 95% CI, -0.10 to 0.62; P = .15), all-cause mortality (odds ratio [OR], 0.23; 95% CI, -0.26 to 0.72; P = .36), pain (SMD, 0.03; 95% CI, -0.52 to 0.57; P = .91), or recurrent bleeding events (OR, -0.12; 95% CI, -1.11 to 0.88; P = .88). Conclusions and Relevance The magnitude of the placebo effect found in this systematic review and meta-regression was dependent on the end point. Placebo control in trials of procedural interventions had the greatest impact on exercise-related, quality-of-life, and health care professional-assessed end points. Randomized clinical trials of procedural interventions may consider placebo control accordingly.
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Affiliation(s)
| | - Katharine E. Thomas
- Division of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
| | - Michael Foley
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Holli Evans
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Florentina Simader
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Sharan Syam
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Daniel Nour
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Catherine Beattie
- Royal Free London National Health Service Foundation Trust, London, United Kingdom
| | - Caitlin Khan
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Rohin K. Reddy
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Fiyyaz Ahmed-Jushuf
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Darrel P. Francis
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Matthew Shun-Shin
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Rasha K. Al-Lamee
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Desouza C, Dubey R, Shetty V. Platelet-rich plasma in chronic Achilles tendinopathy. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3255-3265. [PMID: 37225947 DOI: 10.1007/s00590-023-03570-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/05/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Achilles tendinopathy [AT] is a functional problem characterised by swelling and pain above the Achilles tendon insertion region. In individuals with AT, PRP or platelet-rich plasma can be used as an alternative modality of treatment with an aim to lessen the discomfort and enhance functional recovery. We assessed the available data supporting the effectiveness of PRP in treating chronic AT. MATERIALS AND METHODS We did a literature search for randomised controlled trials [RCTs] that contrasted the effectiveness of PRP with that of eccentric exercise and placebo injections as treatment for AT in databases such as the Cochrane Library, Web of Science, PubMed, and EMBASE. The Visual analogue scale [VAS] score, Victorian Institute of Sports Assessment-Achilles [VISA-A] score, and Achilles tendon thickness were used to measure the results. We used the RevMan 5.3.5 software for statistical analysis. RESULTS We included five RCTs in this meta-analysis. There was no significant difference in the VISA-A between the PRP and placebo groups at 12 weeks, 24 weeks and 1 year after treatment. However, at 6 weeks after treatment, PRP exhibited better efficacy than the placebo treatment. Two studies in our meta-analysis included VAS scores and tendon thickness. There was no significant difference in VAS scores at 6 weeks and 24 weeks after treatment. However, VAS scores at 12 weeks and tendon thickness were significantly different. CONCLUSION PRP injection is an effective treatment for chronic AT. It has a unique potential for increasing function and reducing discomfort in AT patients.
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Affiliation(s)
- Clevio Desouza
- Saanvi Orthopaedics, 2003, Sorrento High Street, Hiranandani Gardens, Powai, Mumbai, Maharashtra, 400076, India.
- DR. L.H. Hiranandani Hospital, Powai, Mumbai, Maharashtra, India.
| | - Rishabh Dubey
- DR. L.H. Hiranandani Hospital, Powai, Mumbai, Maharashtra, India
| | - Vijay Shetty
- Saanvi Orthopaedics, 2003, Sorrento High Street, Hiranandani Gardens, Powai, Mumbai, Maharashtra, 400076, India
- DR. L.H. Hiranandani Hospital, Powai, Mumbai, Maharashtra, India
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Cooper K, Alexander L, Brandie D, Brown VT, Greig L, Harrison I, MacLean C, Mitchell L, Morrissey D, Moss RA, Parkinson E, Pavlova AV, Shim J, Swinton PA. Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness. Health Technol Assess 2023; 27:1-389. [PMID: 37929629 PMCID: PMC10641714 DOI: 10.3310/tfws2748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Background Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy. Review questions (i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies? Methods A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021. Results Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship. Limitations Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made. Conclusion The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence. Future work There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes. Study registration This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review). Funding This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kay Cooper
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Lyndsay Alexander
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - David Brandie
- Sportscotland Institute of Sport, Airthrey Road, Stirling, UK
| | | | - Leon Greig
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Isabelle Harrison
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Colin MacLean
- Library Services, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Laura Mitchell
- NHS Grampian, Physiotherapy Department, Ellon Health Centre, Schoolhill, Ellon, Aberdeenshire, UK
| | - Dylan Morrissey
- William Harvey Research Institute, School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, Bancroft Road, London, UK
| | - Rachel Ann Moss
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Eva Parkinson
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | | | - Joanna Shim
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Paul Alan Swinton
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
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Merry K, MacPherson M, Vis-Dunbar M, Whittaker JL, Grävare Silbernagel K, Scott A. Identifying characteristics of resistance-based therapeutic exercise interventions for Achilles tendinopathy: A scoping review. Phys Ther Sport 2023; 63:73-94. [PMID: 37536026 DOI: 10.1016/j.ptsp.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE This scoping review describes resistance-based therapeutic exercise intervention characteristics for Achilles tendinopathy (AT) treatment (e.g., therapeutic dose, underlying mechanisms targeted by exercise) and assesses participant reporting characteristics. METHODS Seven electronic databases were searched; studies delivering a resistance exercise-focused treatment for individuals with AT were included. The Template for Intervention Description and Replication (TIDieR) and the ICON 2019 'Recommended standards for reporting participant characteristics in tendinopathy research' checklists framed data extraction, and study quality was assessed using the Mixed Methods Appraisal Tool 2018 version. RESULTS 68 publications (describing 59 studies and 72 exercise programs) were included. Results demonstrate that therapeutic exercise interventions for AT are well reported according to the TIDieR checklist, and participant characteristics are well reported according to the ICON checklist. Various underlying therapeutic mechanisms were proposed, with the most common being increasing tendon strength, increasing calf muscle strength, and enhancing collagen synthesis. CONCLUSIONS While evidence suggests that resistance-based therapeutic exercise interventions are effective in treating AT, more reporting on program fidelity, adherence, and compliance is needed. By summarizing currently published AT exercise programs and reporting key intervention characteristics in a single location, this review can assist clinicians in developing individualized resistance training programs for people with AT.
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Affiliation(s)
- Kohle Merry
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Megan MacPherson
- Virtual Health Team, Fraser Health Authority, Surrey, BC, Canada.
| | - Mathew Vis-Dunbar
- Library, The University of British Columbia, Kelowna, British Columbia, Canada.
| | - Jackie L Whittaker
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada; Arthritis Research Canada, Vancouver, BC, Canada.
| | | | - Alex Scott
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada.
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Huang D, Vithran DTA, Gong HL, Zeng M, Tang ZW, Rao ZZ, Wen J, Xiao S. Effectiveness of platelet-rich plasma in the treatment of Achilles tendon disease. World J Orthop 2023; 14:485-501. [PMID: 37377997 PMCID: PMC10292057 DOI: 10.5312/wjo.v14.i6.485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/28/2023] [Accepted: 04/20/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND The effectiveness of Platelet-Rich Plasma (PRP) in the treatment of patients with Achilles tendon rupture (ATR) and Achilles tendinopathy (AT) has been controversial. AIM To assess PRP injections' effectiveness in treating ATR and AT. METHODS A comprehensive review of relevant literature was conducted utilizing multiple databases such as Cochrane Library, PubMed, Web of Science, Chinese Science and Technology Journal, EMBASE, and China Biomedical CD-ROM. The present investigation integrated randomized controlled trials that assessed the effectiveness of platelet-rich plasma injections in managing individuals with Achilles tendon rupture and tendinopathy. The eligibility criteria for the trials encompassed publications that were published within the timeframe of January 1, 1966 to December 2022. The statistical analysis was performed utilizing the Review Manager 5.4.1, the visual analogue scale (VAS), Victorian Institute Ankle Function Scale (VISA-A), and Achilles Tendon Thickness were used to assess outcomes. RESULTS This meta-analysis included 13 randomized controlled trials, 8 of which were randomized controlled trials of PRP for AT and 5 of which were randomized controlled trials of PRP for ATR. PRP for AT at 6 wk [weighted mean difference (WMD) = 1.92, 95%CI: -0.54 to 4.38, I2 = 34%], at 3 mo [WMD = 0.20, 95%CI: -2.65 to 3.05, I2 = 60%], and 6 mo [WMD = 2.75, 95%CI: -2.76 to 8.26, I2 = 87%) after which there was no significant difference in VISA-A scores between the PRP and control groups. There was no significant difference in VAS scores between the PRP group and the control group after 6 wk [WMD = 6.75, 95%CI: -6.12 to 19.62, I2 = 69%] and 6 mo [WMD = 10.46, 95%CI: -2.44 to 23.37, I2 = 69%] of treatment, and at mid-treatment at 3 mo [WMD = 11.30, 95%CI: 7.33 to 15.27, I2 = 0%] after mid-treatment, the PRP group demonstrated better outcomes than the control group. Post-treatment patient satisfaction [WMD = 1.07, 95%CI: 0.84 to 1.35, I2 = 0%], Achilles tendon thickness [WMD = 0.34, 95%CI: -0.04 to 0.71, I2 = 61%] and return to sport [WMD = 1.11, 95%CI: 0.87 to 1.42, I2 = 0%] were not significantly different between the PRP and control groups. The study did not find any statistically significant distinction between the groups that received PRP treatment and those that did not, regarding the Victorian Institute of Sport Assessment - Achilles scores at 3 mo [WMD = -1.49, 95%CI: -5.24 to 2.25, I2 = 0%], 6 mo [WMD = -0.24, 95%CI: -3.80 to 3.32, I2 = 0%], and 12 mo [WMD = -2.02, 95%CI: -5.34 to 1.29, I2 = 87%] for ATR patients. Additionally, no significant difference was observed between the PRP and the control groups in improving Heel lift height respectively at 6 mo [WMD = -3.96, 95%CI: -8.61 to 0.69, I2 = 0%] and 12 mo [WMD = -1.66, 95%CI: -11.15 to 7.83, I2 = 0%] for ATR patients. There was no significant difference in calf circumference between the PRP group and the control group after 6 mo [WMD = 1.01, 95%CI: -0.78 to 2.80, I2 = 54%] and 12 mo [WMD = -0.55, 95%CI: -2.2 to 1.09, I2 = 0%] of treatment. There was no significant difference in ankle mobility between the PRP and control groups at 6 mo of treatment [WMD = -0.38, 95%CI: -2.34 to 1.58, I2 = 82%] and after 12 mo of treatment [WMD = -0.98, 95%CI: -1.41 to -0.56, I2 = 10%] there was a significant improvement in ankle mobility between the PRP and control groups. There was no significant difference in the rate of return to exercise after treatment [WMD = 1.20, 95%CI: 0.77 to 1.87, I2 = 0%] and the rate of adverse events [WMD = 0.85, 95%CI: 0.50 to 1.45, I2 = 0%] between the PRP group and the control group. CONCLUSION The use of PRP for AT improved the patient's immediate VAS scores but not VISA-A scores, changes in Achilles tendon thickness, patient satisfaction, or return to sport. Treatment of ATR with PRP injections alone improved long-term ankle mobility but had no significant effect on VISA-A scores, single heel lift height, calf circumference or return to sport. Additional research employing more extensive sampling sizes, more strict experimental methods, and standard methodologies may be necessary to yield more dependable and precise findings.
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Affiliation(s)
- Dan Huang
- Department of Pediatric Orthopedics, Hunan Provincial People’s Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha 410013, Hunan Province, China
| | - Djandan Tadum Arthur Vithran
- Department of Orthopaedics, Xiangya Hospital of Central South University, Changsha 410013, Hunan Province, China
| | - Hao-Li Gong
- Department of Pediatric Orthopedics, Hunan Provincial People’s Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha 410013, Hunan Province, China
| | - Ming Zeng
- Department of Pediatric Orthopedics, Hunan Provincial People’s Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha 410013, Hunan Province, China
| | - Zhong-Wen Tang
- Department of Pediatric Orthopedics, Hunan Provincial People’s Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha 410013, Hunan Province, China
| | - Zhou-Zhou Rao
- Department of Physiology, Hunan Normal University School of Medicine, Changsha 410005, Hunan Province, China
| | - Jie Wen
- Department of Pediatric Orthopedics, Hunan Provincial People’s Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha 410013, Hunan Province, China
- Department of Anatomy, Hunan Normal University School of Medicine, Changsha 410005, Hunan Province, China
| | - Sheng Xiao
- Department of Pediatric Orthopedics, Hunan Provincial People’s Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha 410013, Hunan Province, China
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The Efficacy of Platelet-Rich Plasma Injection Therapy in the Treatment of Patients with Achilles Tendinopathy: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12030995. [PMID: 36769643 PMCID: PMC9918262 DOI: 10.3390/jcm12030995] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/21/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Over the past few years, many studies have been conducted to evaluate the effectiveness of platelet-rich plasma (PRP) in treating musculoskeletal conditions. However, there is controversy about its benefits for patients with Achilles tendinopathy. OBJECTIVE This study aimed to investigate whether platelet-rich plasma injections can improve outcomes in patients with Achilles tendinopathy. METHODS A comprehensive literature search was conducted in PubMed, Embase, Cochrane Library, Web of Science, China Biomedical CD-ROM, and Chinese Science and Technology Journal databases to identify randomised controlled clinical trials that compared the efficacy of PRP injection in patients with Achilles tendinopathy (AT) versus placebo, published between 1 January 1966 and 1 December 2022. Review Manager 5.4.1 software was used for the statistical analysis, and the Jadad score was used to assess the included literature. Only 8 of the 288 articles found met the inclusion criteria. RESULTS Our work suggests that: The PRP treatment group had a slightly higher VISA-A score than the placebo group at 6 weeks [MD = 1.92, 95% CI (-0.54, 4.38), I2 = 34%], at 12 weeks [MD = 0.20, 95% CI (-2.65 3.05), I2 = 60%], and 24 weeks [MD = 2.75, 95% CI (-2.76, 8.26), I2 = 87%]). However, the difference was not statistically significant. The Achilles tendon thickness was higher at 12 weeks of treatment in the PRP treatment group compared to the control group [MD = 0.34, 95% CI (-0.04, 0.71), p = 0.08], but the difference was not statistically significant. The VAS-improvement results showed no significant difference at 6 and 24 weeks between the two groups, respectively (MD = 6.75, 95% CI = (-6.12, 19.62), I2 = 69%, p = 0.30), and (MD = 10.46, 95% CI = (-2.44 to 23.37), I2 = 69%, p = 0.11). However, at 12 weeks of treatment, the PRP injection group showed a substantial VAS improvement compared to the control group (MD = 11.30, 95% CI = (7.33 to 15.27), I2 = 0%, p < 0.00001). The difference was statistically significant. The return to exercise rate results showed a higher return to exercise rate in the PRP treatment group than the placebo group [RR = 1.11, 95% CI (0.87, 1.42), p = 0.40]; the difference was not statistically significant. CONCLUSION There is no proof that PRP injections can enhance patient functional and clinical outcomes for Achilles tendinopathy. Augmenting the frequency of PRP injections may boost the outcomes, and additionally, more rigorous designs and standardised clinical randomised controlled trials are needed to produce more reliable and accurate results.
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12
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Tendinopathy. Regen Med 2023. [DOI: 10.1007/978-3-030-75517-1_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Boksh K, Elbashir M, Thomas O, Divall P, Mangwani J. Platelet-Rich Plasma in acute Achilles tendon ruptures: A systematic review and meta-analysis. Foot (Edinb) 2022; 53:101923. [PMID: 36037774 DOI: 10.1016/j.foot.2022.101923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/13/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Platelet Rich Plasma (PRP) is known to exert multi-directional biological effects favouring tendon healing. However, conclusions drawn by numerous studies on its clinical efficacy for acute Achilles tendon rupture are limited. We performed a systematic review and meta-analysis to investigate this and to compare to those without PRP treatment. METHODS The Cochrane Controlled Register of Trials, Pubmed, Medline and Embase were used and assessed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ('plasma' OR 'platelet-rich' OR 'platelet-rich plasma' or 'PRP') AND ('Achilles tendon rupture/tear' OR 'calcaneal tendon rupture/tear' OR 'tendo calcaneus rupture/tear'). Data pertaining to biomechanical outcomes (heel endurance test, isokinetic strength, calf-circumference and range of motion), patient-reported outcome measures (PROMs) and incidence of re-ruptures were extracted. Meta-analysis was performed for same outcomes measured in at least three studies. Pooled outcome data were analysed by random- and fixed-effects models. RESULTS After abstract and full-text screening, 6 studies were included. In total there were 510 patients of which 256 had local PRP injection and 254 without. The average age was 41.6 years, mean time from injury to treatment 5.9 days and mean follow-up at 61 weeks. Biomechanically, there was similar heel endurance, isokinetic strength, calf circumference and range of motion between both groups. In general, there were no differences in patient reported outcomes from all scoring systems used in the studies. Both groups returned to their pre-injured level at a similar time and there were no differences on the incidence of re-rupture (OR 1.13, 95% CI, 0.46-2.80, p = 0.79). CONCLUSION PRP injections for acute Achilles tendon ruptures do not improve medium to long-term biomechanical and clinical outcomes. However, future studies incorporating the ideal application and biological composition of PRP are required to investigate its true clinical efficacy.
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Affiliation(s)
- Khalis Boksh
- Academic Team of Musculoskeletal Surgery, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK.
| | - Mohamed Elbashir
- Academic Team of Musculoskeletal Surgery, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Owain Thomas
- Academic Team of Musculoskeletal Surgery, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Pip Divall
- Academic Team of Musculoskeletal Surgery, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Jitendra Mangwani
- Academic Team of Musculoskeletal Surgery, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
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Ryan D, O’Donoghue G, Rio E, Segurado R, O’Sullivan C. The effect of combined Action Observation Therapy with eccentric exercises in the treatment of mid-portion Achilles-tendinopathy: a feasibility pilot randomised controlled trial. BMC Sports Sci Med Rehabil 2022; 14:201. [PMID: 36447250 PMCID: PMC9706872 DOI: 10.1186/s13102-022-00594-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 11/18/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Mid-portion Achilles Tendinopathy (AT) is a common musculoskeletal condition with varying rehabilitation success rates. Despite the prevalence of this condition, a considerable proportion of individuals experience persisting pain and functional deficits. Current treatment approaches bias the biomedical model which emphasises physically treating and loading the tendon. Overall, there is a lack of consideration for the central nervous system that is commonly implicated in chronic injuries. The aim of this pilot study was to explore the feasibility of combining Action Observation Therapy (AOT), a treatment technique which targets central changes and influences motor learning, with eccentric exercises in the treatment of mid-portion AT. AOT involves the observation of movements and is commonly followed by the physical performance of these same movements. METHODOLOGY This was a double-blinded randomised controlled pilot feasibility study. All participants underwent the 12-week Alfredson eccentric training protocol. The intervention group watched videos of the exercises prior to performing these exercises, whilst the control group watched nature videos before performing the same exercises. Study feasibility was the primary outcome measure, with the Victorian Institute of Sports Assessment- Achilles (VISA-A) selected as the primary clinical outcome measure. RESULTS Thirty participants were recruited, reflecting a 75% eligibility rate and 100% of eligible participants enrolled in the study. The retention rate at week 12 was 80%. At week six the mean VISA-A score improved by 18.1 (95% CI 10.2-26.0) in the intervention group and 7.7 (95% CI 0.3-14.9) in the control group, and 75% and 33% of participants in the intervention and control group respectively exceeded the minimal clinically important difference (MCID). At week 12 the mean VISA-A score from baseline improved by 22.25 (95% CI 12.52-31.98) in the intervention group and 16.5-(95% CI 8.47-24.53) in the control group, equating to 75% and 58% in each group respectively exceeding the MCID. CONCLUSION The positive feasibility outcomes and exploratory data from the clinical outcome measures suggest that a larger scaled RCT is warranted to further investigate the impact of AOT in the rehabilitation of mid-portion AT. Trial registration ISRCTN58161116, first registered on the 23/12/2020.
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Affiliation(s)
- Deirdre Ryan
- grid.7886.10000 0001 0768 2743UCD School of Public Health, Physiotherapy and Sports Science, UCD, Dublin, Ireland
| | - Gráinne O’Donoghue
- grid.7886.10000 0001 0768 2743UCD School of Public Health, Physiotherapy and Sports Science, UCD, Dublin, Ireland
| | - Ebonie Rio
- grid.1018.80000 0001 2342 0938School of Allied Health, La Trobe University Melbourne, Melbourne, Australia
| | - Ricardo Segurado
- grid.7886.10000 0001 0768 2743UCD School of Public Health, Physiotherapy and Sports Science, UCD, Dublin, Ireland
| | - Cliona O’Sullivan
- grid.7886.10000 0001 0768 2743UCD School of Public Health, Physiotherapy and Sports Science, UCD, Dublin, Ireland
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Xu AL, Ortiz-Babilonia C, Gupta A, Rogers D, Aiyer AA, Vulcano E. The Statistical Fragility of Platelet-Rich Plasma as Treatment for Chronic Noninsertional Achilles Tendinopathy: A Systematic Review and Meta-analysis. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221119758. [PMID: 36051864 PMCID: PMC9424894 DOI: 10.1177/24730114221119758] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Randomized controlled trial (RCT) outcomes reaching statistical significance,
frequently determined by P <.05, are often used to guide
decision making. Noted lack of reproducibility of some RCTs has brought
special attention to the limitations of this approach. In this
meta-analysis, we assessed the robustness of RCTs evaluating platelet-rich
plasma (PRP) for the treatment of chronic noninsertional Achilles
tendinopathy (AT) by using fragility indices. Methods: The present study was a systematic review and meta-analysis of RCTs comparing
outcomes after PRP injection vs alternative treatment in patients with AT.
Representative data sets were generated for each reported continuous outcome
event using summary statistics. Fragility indices refer to the minimal
number of patients whose status would have to change from a nonevent to an
event to turn a statistically significant result into a nonsignificant
result, or vice versa. The fragility index (FI) and continuous FI (CFI) were
determined for dichotomous and continuous outcomes, respectively, by
manipulating each data set until reversal of significance (a=0.05) was
achieved. The corresponding fragility quotient (FQ) and continuous FQ (CFQ)
were calculated by dividing FI/CFI by sample size. Results: Of 432 studies screened, 8 studies (52 outcome events) were included in this
analysis. The 12 dichotomous outcomes had a median FI of 4.5 (FQ: 0.111),
and the 40 continuous outcomes had a median CFI of 5 (CFQ: 0.154). All 52
outcome events included lost-to-follow-up data, and 12 (23.1%) indicated a
greater number of patients lost to follow-up than the FI or CFI. Conclusion: Our findings suggest that RCTs evaluating PRP for AT therapy lack statistical
robustness, because changing only a small number of events may alter outcome
significance. Level of Evidence: Level II, therapeutic study.
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Affiliation(s)
- Amy L. Xu
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carlos Ortiz-Babilonia
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Orthopaedic Surgery, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - Arjun Gupta
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Davis Rogers
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amiethab A. Aiyer
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ettore Vulcano
- Department of Orthopaedic Surgery, Columbia University Mount Sinai Medical Center, Miami, FL, USA
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Burton I, McCormack A. Assessment of the reporting quality of resistance training interventions in randomised controlled trials for lower limb tendinopathy: A systematic review. Clin Rehabil 2022; 36:831-854. [PMID: 35311606 DOI: 10.1177/02692155221088767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES 1. To describe what exercises and intervention variables are used in resistance training interventions in randomised controlled trials for lower limb tendinopathy 2. To assess completeness of reporting as assessed by the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier framework. 3. To assess the implementation of scientific resistance training principles. 4. To assess therapeutic quality of exercise interventions with the i-CONTENT tool. DATA SOURCES We searched MEDLINE, CINAHL, AMED, EMBase, SPORTDiscus, and the Cochrane library databases. REVIEW METHODS Systematic review of randomised controlled trials that reported using resistance exercises for lower limb tendinopathies. RESULTS We included 109 RCTs. Eccentric heel drops were the most common exercise (43 studies), followed by isotonic heel raises (21), and single leg eccentric decline squats (18). Reporting of exercise descriptor items from the Toigo and Boutellier framework ranged from 0-13, with an average score of 9/13, and only 7 studies achieved a full 13/13. Reporting of items from the CERT ranged from 0-18, with an average score of 14/19. No study achieved a full 19/19, however 5 achieved 18/19. Scoring for resistance training principles ranged from 1-10, with only 11 studies achieving 10/10. Reporting across studies for the i-CONTENT tool ranged from 2-7, with an average score of 5 across included studies. A total of 19 studies achieved a full 7/7 score. Less than 50% of studies achieved an overall low risk of bias, highlighting the methodological concerns throughout studies. CONCLUSION The reporting of exercise descriptors and intervention content was generally high across RCTs for lower limb tendinopathy, with most allowing exercise replication. However, reporting for some tendinopathies and content items such as adherence was poor, limiting optimal translation to clinical practice.
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Affiliation(s)
- Ian Burton
- Specialist Musculoskeletal Physiotherapist, MSK Service, Fraserburgh Physiotherapy Department, Fraserburgh Hospital, 1015NHS Grampian, Aberdeen
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Burton I, McCormack A. Resistance Training Interventions for Lower Limb Tendinopathies: A Scoping Review of Resistance Training Reporting Content, Quality, and Scientific Implementation. TRANSLATIONAL SPORTS MEDICINE 2022; 2022:2561142. [PMID: 38655173 PMCID: PMC11023730 DOI: 10.1155/2022/2561142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 01/26/2022] [Accepted: 02/11/2022] [Indexed: 04/26/2024]
Abstract
The objectives of this scoping review were as follows: (1) to describe what exercises and intervention variables are used in resistance training interventions for lower limb tendinopathy, (2) to assess the completeness of reporting as assessed by the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier framework, and (3) to assess the implementation of scientific resistance training principles. We searched MEDLINE, CINAHL, AMED, Embase, SPORTDiscus, and Cochrane Library databases. Randomized controlled trials, cohort studies, case series, case reports, and observational studies that reported using resistance exercises for lower limb tendinopathies were considered for inclusion, with 194 studies meeting the inclusion criteria. Completeness of the reporting of exercise descriptors and programme variables was assessed by the CERT and the Toigo and Boutellier framework. Reporting of exercise descriptor items from the Toigo and Boutellier framework ranged from 0 to 13, with an average score of 9/13, with only 9 studies achieving a full 13/13. Reporting of items from the CERT ranged from 0 to 18, with an average score of 13/19. No study achieved a full 19/19; however, 8 achieved 18/19. Scoring for resistance training principles ranged from 1 to 10, with only 14 studies achieving 10/10. Eccentric heel-drops were the most common exercise (75 studies), followed by isotonic heel raises (38), and single-leg eccentric decline squats (27). The reporting of exercise descriptors and intervention content was high across studies, with most allowing exercise replication, particularly for Achilles and patellar tendinopathy. However, reporting for some tendinopathies and content items such as adherence was poor, limiting optimal translation to clinical practice.
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Affiliation(s)
- Ian Burton
- MSK Service, Fraserburgh Physiotherapy Department, Fraserburgh Hospital, NHS Grampian, Aberdeen, UK
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Grävare Silbernagel K, Malliaras P, de Vos RJ, Hanlon S, Molenaar M, Alfredson H, van den Akker-Scheek I, Antflick J, van Ark M, Färnqvist K, Haleem Z, Kaux JF, Kirwan P, Kumar B, Lewis T, Mallows A, Masci L, Morrissey D, Murphy M, Newsham-West R, Norris R, O'Neill S, Peers K, Sancho I, Seymore K, Vallance P, van der Vlist A, Vicenzino B. ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy. Sports Med 2022; 52:613-641. [PMID: 34797533 PMCID: PMC8891092 DOI: 10.1007/s40279-021-01588-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated. OBJECTIVE To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains. DESIGN Systematic review. DATA SOURCES Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series. RESULTS 9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain. CONCLUSION 233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures. PROSPERO REGISTRATION CRD42020156763.
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Affiliation(s)
- Karin Grävare Silbernagel
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA.
| | - Peter Malliaras
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, VIC, Australia
| | - Robert-Jan de Vos
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Zuid-Holland, The Netherlands
| | - Shawn Hanlon
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA
| | - Mitchel Molenaar
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Håkan Alfredson
- Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, Sweden
| | - Inge van den Akker-Scheek
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jarrod Antflick
- Department of Bioengineering, School of Engineering, Imperial College, London, UK
| | - Mathijs van Ark
- Department of Physiotherapy, School of Health Care Studies, Hanze University of Applied Sciences and Peescentrum, Centre of Expertise Primary Care Groningen (ECEZG), Groningen, The Netherlands
| | | | - Zubair Haleem
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
- Arsenal Football Club, London, UK
| | - Jean-Francois Kaux
- Department of Physical and Rehabilitation Medicine and Sports Traumatology, University and University Hospital of Liège, Liège, Belgium
| | - Paul Kirwan
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Bhavesh Kumar
- Institute of Sport Exercise and Health (ISEH), University College London, London, UK
| | - Trevor Lewis
- Aintree University Hospital, Liverpool Foundation Trust, Liverpool, UK
| | - Adrian Mallows
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, UK
| | - Lorenzo Masci
- Institute of Sport Exercise and Health (ISEH), University College London, London, UK
| | - Dylan Morrissey
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
| | - Myles Murphy
- National School of Nursing, Midwifery, Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, WA, Australia
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - Richard Newsham-West
- School of Allied Health, Department of Physiotherapy, La Trobe University, Melbourne, VIC, Australia
| | - Richard Norris
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
- Liverpool University Hospitals, NHS Foundation Trust, Liverpool, UK
| | - Seth O'Neill
- School of Allied Health, University of Leicester, Leicester, UK
| | - Koen Peers
- Department of Physical and Rehabilitation Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Igor Sancho
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
- Physiotherapy Department, University of Deusto, San Sebastian, Spain
| | - Kayla Seymore
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA
| | - Patrick Vallance
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Clayton, VIC, Australia
| | - Arco van der Vlist
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Bill Vicenzino
- School of Health and Rehabilitation Sciences: Physiotherapy, The University of Queensland, Brisbane, QLD, Australia
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19
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Van Schaik KD, Lee KS. Orthobiologics: Diagnosis and Treatment of Common Tendinopathies. Semin Musculoskelet Radiol 2021; 25:735-744. [PMID: 34937114 DOI: 10.1055/s-0041-1735475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Orthobiologics, including platelet-rich plasma, prolotherapy, and mesenchymal stem cells, are seeing increasing use in the treatment of osteoarthritis (OA), muscle injury, and tendinopathy. This article reviews the biology and applications of orthobiologics in tendons, muscles, and joints, and focuses on platelet-rich plasma (PRP). Clinical evidence-based literature related to the use of PRP in the treatment of rotator cuff injury, lateral epicondylosis, Achilles tendinopathy, plantar fasciitis, knee OA, and acute muscle injury are discussed.
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Affiliation(s)
- Katherine D Van Schaik
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kenneth S Lee
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.,Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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20
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Abate M, Di Carlo L, Salini V. To evaluate the outcomes of PRP treatment in Achilles tendinopathy: An intriguing methodological problem. Orthop Traumatol Surg Res 2021; 107:102787. [PMID: 33333266 DOI: 10.1016/j.otsr.2020.102787] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 11/03/2019] [Accepted: 02/27/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Assessing the outcomes of Platelet Rich Plasma (PRP) treatment in Achilles Tendinopathy (AT) may prove difficult due to several methodological reasons. For example, given that the simple mean of VISA-A score is just the result of positive, negative or null values, this may provide incomplete information, and therefore the size of individual changes can remain unknown. On the contrary, calculating the score changes in each subject after treatment would allow a more appropriate evaluation of the clinical results. However, this method has been applied only to few small-scale studies. Therefore we performed a retrospective study aiming to determine: (1) are the percentages of positive outcomes of the present research comparable to those of previous studies performed in different settings? (2) Is there a relationship between the size of increase of the clinical score and the patient satisfaction? HYPOTHESES The percentages of positive outcomes of the present research are comparable to those of previous studies performed in different settings. MATERIAL AND METHODS This is a retrospective observational study. Eighty-four patients submitted to PRP treatment for mid-portion AT were enrolled. Pain and function were evaluated by means of VISA-A scale. Besides the mean, in each subject the pre- and post-treatment difference of VISA-A score was computed and the outcome was defined clinically no detectable, detectable and evident according to the increasing values of the score (0 to 9 points, 10 to 19, and≥20 points change, respectively). The Likert's scale for the patients satisfaction was also used. RESULTS The mean VISA-A increased significantly after treatment (from 50.1±9.1 at baseline to 63.7±13.8 at 3 months (p=0.00001) and 67.2±14.1 at 6 months (p=0.00001)). At 3 and 6 months the subjects belonging to the prefixed categories were 15, 45, 24 and 19, 36, 29, respectively. Moreover, large discrepancies were observed between the size of increase of the clinical score and patients satisfaction, mainly for intermediate increases of the score. DISCUSSION The percentages of positive outcomes found in this study are slightly lower than those reported in literature. The different patients expectations about the efficacy of the therapy can explain the discrepancies between the size of increase of the clinical score and the individual satisfaction. In comparison to the simple mean, the individual changes of VISA-A score allow a proper evaluation of the outcomes. The research shows that discrepancies can be present in the percentage of positive clinical outcomes between different studies. The size of increase of the clinical score does not always match patient satisfaction. LEVEL OF PROOF IV retrospective study without control group.
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Affiliation(s)
- Michele Abate
- Department of Medicine and Sciences of Aging, University "G. d'Annunzio" Chieti-Pescara, Via dei Vestini 31, 66013, Chieti Scalo (CH), Italy.
| | - Luigi Di Carlo
- Department of Medicine and Sciences of Aging, University "G. d'Annunzio" Chieti-Pescara, Via dei Vestini 31, 66013, Chieti Scalo (CH), Italy
| | - Vincenzo Salini
- Division of Orthopedics and Traumatology, San Raffaele Hospital, Milan, Italy
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21
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Chen J, Wan Y, Jiang H. The effect of platelet-rich plasma injection on chronic Achilles tendinopathy and acute Achilles tendon rupture. Platelets 2021; 33:339-349. [PMID: 34346853 DOI: 10.1080/09537104.2021.1961712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Several clinical trials exploring the effect of platelet-rich plasma (PRP) on Achilles tendon rupture (ATR) or Achilles tendinopathy (AT) have been published. However, current evidence is limited to small-sized trials. This study aims to evaluate whether PRP improves the outcomes of ATR or AT. PubMed, Web of Science, EMBASE, and Cochrane Library databases were searched to identify randomized controlled trials comparing PRP injection versus placebo for ATR or AT. Eleven studies with 574 patients were included. Quantitative synthesis suggested that compared with placebo, AT patients in PRP group had higher VISA-A score improvement at six-week follow-up (mean difference (MD) = 2.64; 95% CI) = 1.12 to 4.15). However, there was no significant difference between two groups for VISA-A score improvement at three-month follow-up (MD = 0.93; 95% CI = -2.75 to 4.62), or 6-month follow-up (MD = 5.46; 95% CI = -1.19 to 12.11). In ATR patients, quantitative synthesis suggested that no significant difference was seen between PRP and control group at 3-month, 6-month, and 1-year follow-up. In addition, no significant difference was detected between the two groups in improving tendon thickness and pain for AT patients, and no significant difference was seen in improving heel-rise work, maximum heel-rise height, dorsal and plantar flexion, rate of returning to sports activities, and complication for ATR patients. To conclude, no evidence indicates that PRP injection can improve the patient-reported/clinical/functional outcomes of AT or ATR. The increasing times of PRP injection could improve the outcomes, and further clinical randomized controlled trials are expected to be conducted to verify this hypothesis.
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Affiliation(s)
- Jianguo Chen
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yingying Wan
- Xi Yuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Haiyue Jiang
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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22
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Kearney RS, Ji C, Warwick J, Parsons N, Brown J, Harrison P, Young J, Costa ML. Effect of Platelet-Rich Plasma Injection vs Sham Injection on Tendon Dysfunction in Patients With Chronic Midportion Achilles Tendinopathy: A Randomized Clinical Trial. JAMA 2021; 326:137-144. [PMID: 34255009 PMCID: PMC8278266 DOI: 10.1001/jama.2021.6986] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Platelet-rich plasma injections are used as a treatment for chronic midportion Achilles tendinopathy, but evidence for this treatment is limited. OBJECTIVE In adults with midportion Achilles tendinopathy, to assess the effects of a single platelet-rich plasma injection, compared with sham injection, on the outcome of the Victorian Institute of Sport Assessment-Achilles (VISA-A) score (a single composite measure of Achilles tendinopathy severity). DESIGN, SETTING, AND PARTICIPANTS A participant-blinded, multicenter randomized clinical trial that included 240 people from 24 sites assigned to either a platelet-rich plasma injection or a sham injection between April 2016 and February 2020. Final follow-up was July 2020. Participants were older than 18 years with midportion Achilles tendon pain for more than 3 months as confirmed by ultrasound, magnetic resonance imaging, or both. INTERVENTIONS A single intratendinous platelet-rich plasma injection (n = 121) or a single sham injection (insertion of a subcutaneous dry needle not entering the tendon) (n = 119). MAIN OUTCOMES AND MEASURES The primary outcome was the VISA-A score, measured 6 months after treatment allocation. The VISA-A score contains 8 questions that cover 3 domains of pain, function, and activity, analyzed as a composite score (range, 0 [worst symptoms] to 100 [no symptoms]; minimal clinically important difference in score, 12 points). The primary analysis was adjusted for laterality, age, sex, and baseline VISA-A score. RESULTS Among 240 patients assigned to a platelet-rich plasma or sham injection (mean age, 52 years; 138 [58%] women), 221 (92%) completed the trial. At 6-month follow-up, mean VISA-A score values in the plasma-rich plasma group vs the sham injection group were 54.4 vs 53.4 (adjusted mean difference, -2.7 [95% CI, -8.8 to 3.3]). The most common adverse events compared between patients in the platelet-rich plasma group vs the sham group were injection site discomfort (97 vs 73 patients), swelling (56 vs 52 patients) and bruising (48 vs 49 patients). CONCLUSIONS AND RELEVANCE Among patients with chronic midportion Achilles tendinopathy, treatment with a single injection of intratendinous platelet-rich plasma, compared with insertion of a subcutaneous dry needle, did not reduce Achilles tendon dysfunction at 6 months. These findings do not support the use of this treatment for chronic midportion Achilles tendinopathy. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN13254422.
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Affiliation(s)
- Rebecca S. Kearney
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- University Hospitals of Coventry and Warwickshire, Coventry, United Kingdom
| | - Chen Ji
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Jane Warwick
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Nicholas Parsons
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Jaclyn Brown
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Paul Harrison
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Jonathan Young
- University Hospitals of Coventry and Warwickshire, Coventry, United Kingdom
| | - Matthew L. Costa
- Oxford Trauma and Emergency Care, Nuffield Department of Rheumatology, Musculoskeletal and Orthopaedic Sciences, University of Oxford, Oxford, United Kingdom
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23
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Nauwelaers AK, Van Oost L, Peers K. Evidence for the use of PRP in chronic midsubstance Achilles tendinopathy: A systematic review with meta-analysis. Foot Ankle Surg 2021; 27:486-495. [PMID: 32798020 DOI: 10.1016/j.fas.2020.07.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/14/2020] [Accepted: 07/25/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Platelet-rich plasma (PRP) injections have been proposed as an additional therapy in the treatment of chronic midsubstance Achilles tendinopathy (AT). The use of PRP injections as pharmacological treatment added to a conservative approach has gained growing interest, but the efficacy remains highly debated. The varying methodological quality of the available studies may contribute to these contradictory results. The aim of this systematic review with meta-analysis was to establish the existing evidence of PRP injections for chronic midsubstance AT on the functional outcome, with a risk of bias assessment of each included study. METHODS According to the PRISMA guidelines systematic searches were performed in Embase, the Cochrane library and Pubmed on June 12, 2020 for relevant literature. Only clinical trials comparing PRP injections with placebo, additional to an eccentric training program, in midsubstance AT were included. The primary outcome was Victorian Institute of Sport Assessment - Achilles (VISA-A) score at 3, 6 and 12 months post-injection. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials (Rob 2). As secondary outcome we assessed reported changes in tendon structure after PRP injections. RESULTS A total of 367 studies were identified with the initial database search. Finally, four randomized controlled trials (RCTs) met inclusion criteria for systematic review and meta-analysis with data of 170 patients available for pooling. Results showed no difference in clinical outcome between the PRP and placebo group at different points in time using the VISA-A score as outcome parameter (3 months 0.23 (CI -0.45, 0.91); 6 months 0.83 (CI -0.26, 1.92); 12 months 0.83 (CI -0.77, 2.44)). The bias analysis showed a low or intermediate risk of bias profile for all studies which supports the good methodological quality of each included article. Finally, it is unclear whether PRP injections cause an improvement in tendon structure. However, no direct relationship between tendon structure and clinical presentation of AT could be found. CONCLUSION PRP has no clear additional value in management of chronic midsubstance Achilles tendinopathy and therefore should not be used as a first-line treatment option.
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Affiliation(s)
- An-Katrien Nauwelaers
- Faculty of Medicine KU Leuven, Department: Physical medicine and rehabilitation, Herestraat 49, 3000 Leuven Belgium
| | - Loïc Van Oost
- Faculty of Medicine KU Leuven, Department: Physical medicine and rehabilitation, Herestraat 49, 3000 Leuven Belgium.
| | - Koen Peers
- Faculty of Medicine KU Leuven, Department: Physical medicine and rehabilitation, Herestraat 49, 3000 Leuven Belgium
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24
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Burton I, McCormack A. The implementation of resistance training principles in exercise interventions for lower limb tendinopathy: A systematic review. Phys Ther Sport 2021; 50:97-113. [PMID: 33965702 DOI: 10.1016/j.ptsp.2021.04.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 04/25/2021] [Accepted: 04/27/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The primary purpose of this systematic review is to examine the literature on resistance training interventions for lower limb tendinopathy to evaluate the proportion of interventions that implemented key resistance training principles (specificity, progression, overload, individualisation) and reported relevant prescription components (frequency, intensity, sets, repetitions) and reported intervention adherence. METHODS Two reviewers performed a systematic review after screening titles and abstracts based on eligibility criteria. Identified papers were obtained in full text, with data extracted regarding the implementation of resistance training principles. Included articles were evaluated by the Cochrane risk of bias tool, with a scoring tool out of 10 used for implementation and reporting of the 5 key principles. Scientific databases were searched in November 2020 and included Medline, CINAHL, AMED, and Sportsdiscus. RESULTS 52 randomised controlled trials investigating resistance training in five different lower limb tendinopathies were included. Although most studies considered the principles of progression (92%) and individualisation (88%), only 19 studies (37%) appropriately described how this progression in resistance was achieved, and only 18 studies (35%) reported specific instruction on how individualisation was applied. Adherence was considered in 27 studies (52%), with only 17 studies (33%) reporting the levels of adherence. In the scoring criteria, only 5 studies (10%) achieved a total maximum score of 10, with 17 studies (33%) achieving a maximum score of 8 for implementing and reporting the principles of specificity, overload, progression and individualisation. CONCLUSION There is meaningful variability and methodological concerns regarding the application and reporting of resistance training principles, particularly progression and individualisation, along with intervention adherence throughout studies. Collectively, these findings have important implications for the prescription of current resistance training interventions, including the design and implementation of future interventions for populations with lower limb tendinopathies.
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Affiliation(s)
- Ian Burton
- MSK Service, Fraserburgh Physiotherapy Department, Fraserburgh Hospital, NHS Grampian, Aberdeen, United Kingdom.
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25
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Cole BJ, Gilat R, DiFiori J, Rodeo SA, Bedi A. The 2020 NBA Orthobiologics Consensus Statement. Orthop J Sports Med 2021; 9:23259671211002296. [PMID: 34017878 PMCID: PMC8114275 DOI: 10.1177/23259671211002296] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/14/2020] [Indexed: 12/26/2022] Open
Abstract
This 2020 NBA Orthobiologics Consensus Statement provides a concise summary of available literature and practical clinical guidelines for team physicians and players. We recognize that orthobiologic injections are a generally safe treatment modality with a significant potential to reduce pain and expedite early return to play in specific musculoskeletal injuries. The use of orthobiologics in sports medicine to safely reduce time loss and reinjury is of considerable interest, especially as it relates to the potential effect on a professional athlete. While these novel substances have potential to enhance healing and regeneration of injured tissues, there is a lack of robust data to support their regular use at this time. There are no absolutes when considering the implementation of orthobiologics, and unbiased clinical judgment with an emphasis on player safety should always prevail. Current best evidence supports the following: Key Points There is support for the use of leukocyte-poor platelet-rich plasma in the treatment of knee osteoarthritis. There is support for consideration of using leukocyte-rich platelet-rich plasma for patellar tendinopathy. The efficacy of using mesenchymal stromal cell injections in the management of joint and soft tissue injuries remains unproven at this time. There are very few data to suggest that current cell therapy treatments lead to any true functional tissue regeneration. Meticulous and sterile preparation guidelines must be followed to minimize the risk for infection and adverse events if these treatments are pursued.Given the high variability in orthobiologic formulations, team physicians must stay up-to-date with the most recent peer-reviewed literature and orthobiologic preparation protocols for specific injuries.Evidence-based treatment algorithms are necessary to identify the optimal orthobiologic formulations for specific tissues and injuries in athletes.Changes in the regulatory environment and improved standardization are required given the exponential increase in utilization as novel techniques and substances are introduced into clinical practice.
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Affiliation(s)
- Brian J Cole
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Ron Gilat
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA.,Department of Orthopaedic Surgery, Shamir Medical Center and Tel Aviv University, Tel Aviv, Israel
| | - John DiFiori
- Hospital for Special Surgery, New York, New York, USA
| | - Scott A Rodeo
- Hospital for Special Surgery, New York, New York, USA
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
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26
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Altink JN, Kerkhoffs GMMJ. Emerging Biological Treatment Methods for Ankle Joint and Soft Tissue Conditions: Clinical Applications as Alternative or Adjuvant. Foot Ankle Clin 2021; 26:225-235. [PMID: 33487242 DOI: 10.1016/j.fcl.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In the past 2 decades, there has been a rapid expansion of clinical studies investigating the safety and efficacy of biological treatment methods for a wide range of diseases. These biological treatment methods increasingly are used in clinical practice based on limited available evidence. This article provides an overview of evidence on biological treatment methods for foot and ankle pathologies, including ankle osteoarthritis, osteochondral lesions of the talus, and Achilles tendinopathy.
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Affiliation(s)
- J Nienke Altink
- Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, K1-208, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands; Academic Center for Evidence Based Sports Medicine (ACES); Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center
| | - Gino M M J Kerkhoffs
- Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, K1-208, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands; Academic Center for Evidence Based Sports Medicine (ACES); Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center.
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27
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Fares MY, Khachfe HH, Salhab HA, Zbib J, Fares Y, Fares J. Achilles tendinopathy: Exploring injury characteristics and current treatment modalities. Foot (Edinb) 2021; 46:101715. [PMID: 33039245 DOI: 10.1016/j.foot.2020.101715] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 06/19/2020] [Accepted: 07/03/2020] [Indexed: 02/04/2023]
Abstract
Achilles tendinopathy is a prevalent overuse injury to the Achilles tendon causing prominent pain and reduction in quality of life. Several biomechanical and anatomical properties govern the pathology of the Achilles tendinopathy, and as a result, choosing the optimal treatment option is challenging. The aim of this review is to study the anatomical and biomechanical characteristics of this injury and explore the available treatment options in order to extrapolate the most suitable option with the best prognosis. Treatment modalities for Achilles tendinopathy vary and include non-operative and operative options. Non-operative treatment modalities include physical therapy, extracorporeal shockwave therapy, injectable agents, and bracing and taping. Operative treatment modalities include surgical procedures, both percutaneous and open. Treatment should be catered to the individual patient. Further research is required in order to confirm the efficacy of the available treatment options, test the viability of novel techniques and approaches, and discover possible new therapeutic modalities.
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Affiliation(s)
- Mohamad Y Fares
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon; College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, Scotland, UK.
| | - Hussein H Khachfe
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Hamza A Salhab
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Jad Zbib
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Youssef Fares
- Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Jawad Fares
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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28
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Edwards S, Sivan M. High volume distension injection (HVDI) for chronic mid-portion Achilles tendinopathy: A service evaluation of clinical outcomes. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2020. [DOI: 10.1177/2210491720979321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose: High Volume Distension Injection (HVDI) is a treatment adjunct in chronic mid-portion Achilles tendinopathy. This study analysed whether HVDI is safe and effective in an outpatient clinic setting. Methods: Retrospective service evaluation of 18 participants over 18 months. Ultrasound-guided saline, corticosteroid and bupivacaine was injected to disrupt vasculo-neural ingrowth, with post-procedure eccentric exercises. Mean follow-up was 8 weeks. Outcomes used were Numeric rating Scale (NRS) of pain, tendon thickness and Modified Ohberg score (MOS) of neovascularisation measured on Ultrasound and Doppler imaging. Results: Mean reduction in NRS was 5.30 ± 2.53 ( P < 0.001). Mean tendon thickness reduction was 0.21 ± 0.17 cm ( P < 0.001). Median MOS improved from 2.00 ± 2.00 to 1.00 ± 3.00 ( P = 0.009). No complications occurred. 11 participants had successful primary HVDI, 3 responded to a second injection. Two non-responders were referred for surgery and two referred for alternative therapy by patient preference. Conclusion: Significant reduction in pain, tendon thickness and neovascularity was observed in 78% of patients. Recurrence in 39%. HVDI with eccentric training is safe and effective intervention in outpatient clinic setting.
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Affiliation(s)
- Samuel Edwards
- Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Manoj Sivan
- Leeds Institute of Rheumatology and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Musculoskeletal Service, Leeds Community Healthcare NHS Trust, UK
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29
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Auliffe SM, Korakakis V, Hilfiker R, Whiteley R, O'Sullivan K. Participant characteristics are poorly reported in exercise trials in tendinopathy: A systematic review. Phys Ther Sport 2020; 48:43-53. [PMID: 33360409 DOI: 10.1016/j.ptsp.2020.12.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/11/2020] [Accepted: 12/13/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the reporting of eligibility criteria and baseline participant characteristics in randomised controlled trials investigating the effects of exercise interventions in tendinopathy. METHODS Randomised controlled trials investigating the effects of exercise therapy compared to a non-exercising intervention in upper and lower limb tendinopathy were included. Data extraction was categorised into the following domains: participant demographics, tendinopathy descriptors, general health, participant recruitment and eligibility criteria. RESULTS The review included the following tendinopathies: Achilles (n = 9), gluteal (n = 2), lateral elbow tendinopathy (n = 15), patellar (n = 3) plantar (n = 3), and rotator cuff (n = 13). Age, sex, duration of symptoms and symptom severity were commonly reported across the review, while prior history of tendinopathy was poorly reported (6/45). Variables such as physical activity level (17/45), sleep (0/45), psychological factors (2/45), medication at baseline (8/45), co morbid health complaints (10/45) and sociodemographic factors (11/45) were poorly reported across the included studies. Substantial variation existed between studies in the specific eligibility criteria used. CONCLUSION The findings of this systematic review demonstrate that participant characteristics are poorly reported in exercise trials in tendinopathy. To improve effectiveness of exercise interventions in tendinopathy, improved reporting of participant characteristics may allow better comparisons and targeted interventions for specific subgroups.
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Affiliation(s)
- Seán Mc Auliffe
- Department of Physical Therapy & Rehabilitation Science, College of Health Sciences, Qatar University, Doha, Qatar.
| | | | - Roger Hilfiker
- School of Health Sciences, HES-SO Valais-Wallis, University of Applied Sciences and Arts Western Switzerland Valais, Leukerbad, Switzerland
| | - Rodney Whiteley
- Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - Kieran O'Sullivan
- School of Allied Health, University of Limerick, Limerick, Ireland; Ageing Research Centre, University of Limerick, Limerick, Ireland
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30
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Escriche-Escuder A, Casaña J, Cuesta-Vargas AI. Load progression criteria in exercise programmes in lower limb tendinopathy: a systematic review. BMJ Open 2020; 10:e041433. [PMID: 33444210 PMCID: PMC7678382 DOI: 10.1136/bmjopen-2020-041433] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE The objective of this study is to summarise and analyse the current literature about what progression criteria are applied in loading exercise programmes in lower limb tendinopathies and their evidence and effectiveness. DESIGN Systematic review. METHODS PubMed, Embase, Scopus and PEDro were searched from inception to 24 September 2020. The inclusion criteria were randomised controlled trials that included patients with midportion Achilles, patellar or gluteal tendinopathy; assessed function, pain or performance; included at least one group where progressive physical exercise was administered as monotherapy; included at least a control group. We excluded studies that included subjects with previous tendon surgical treatment; studies with control group that conducted a supplemented modality of the exercise performed in the intervention group. A narrative synthesis was conducted. Cohen's d and the percentage of change of main clinical and performance outcomes were obtained. Methodological quality was assessed using the PEDro scale. RESULTS Thirty studies that described progression criteria were included. Six types of criteria grouped in two categories were identified and included in a new classification proposal: pain as a primary criterion (evoking and avoid-pain based), and pain and symptom control as a secondary criterion (conditioning stages, fatigue-based, subjective perception and temporary linear increase). Most of the studies applied a pain-based criterion. Criteria based on conditioning stages were also commonly applied. Other criteria such as fatigue, a temporary linear increase, or the subjective perception of the patient's abilities were occasionally applied. CONCLUSIONS There is a predominant use of pain-based criteria, but the utilisation of these criteria is not supported by strong evidence. This review evidences the need for studies that compare the same exercise programme using different progression criteria. A new classification of the existing progression criteria is proposed based on the use of pain as the primary or secondary criterion. PROSPERO REGISTRATION NUMBER CRD42018110997.
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Affiliation(s)
- Adrian Escriche-Escuder
- Department of Physiotherapy, University of Málaga, Malaga, Spain
- Grupo Clinimetría (F-14), Instituto de Investigación Biomédica de Málaga (IBIMA), Malaga, Spain
| | - Jose Casaña
- Department of Physiotherapy, University of Valencia, Valencia, Spain
| | - Antonio I Cuesta-Vargas
- Department of Physiotherapy, University of Málaga, Malaga, Spain
- Grupo Clinimetría (F-14), Instituto de Investigación Biomédica de Málaga (IBIMA), Malaga, Spain
- Health, Queensland University of Technology-QUT, Brisbane, Queensland, Australia
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Neph A, Schroeder A, Enseki KR, Everts PA, Wang JHC, Onishi K. Role of Mechanical Loading for Platelet-Rich Plasma-Treated Achilles Tendinopathy. Curr Sports Med Rep 2020; 19:209-216. [PMID: 32516191 DOI: 10.1249/jsr.0000000000000719] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
There is no consensus on the optimal rehabilitation protocol after platelet-rich plasma (PRP) treatment for tendinopathy despite basic science studies showing the critical role of mechanical loading in the restoration of tendon structure and function posttreatment. In this article, we will review tendon mechanobiology, platelet biology, and review levels I and II Achilles tendon clinical studies paying particular attention to the role of mechanical loading in rehabilitation of injured tendons. Animal studies emphasize the synergistic effect of mechanical tendon loading and PRP to treat tendon injury while clinical studies described minimal details on loading protocols.
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Affiliation(s)
- Alyssa Neph
- Department of Physical Medicine and Rehabilitation at University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Allison Schroeder
- Department of Physical Medicine and Rehabilitation at University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Keelen R Enseki
- University of Pittsburgh Medical Center Centers for Rehab Services, Pittsburgh, PA
| | - Peter A Everts
- Scientific and Research Department at Gulf Coast Biologics, Fort Myers, FL
| | - James H-C Wang
- Department of Orthopedic Surgery at University of Pittsburgh School of Medicine, Pittsburgh, PA
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Rhim HC, Kim MS, Choi S, Tenforde AS. Comparative Efficacy and Tolerability of Nonsurgical Therapies for the Treatment of Midportion Achilles Tendinopathy: A Systematic Review With Network Meta-analysis. Orthop J Sports Med 2020; 8:2325967120930567. [PMID: 32728589 PMCID: PMC7366412 DOI: 10.1177/2325967120930567] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/10/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Achilles tendinopathy (AT) is a common cause of overuse injury in both
athletes and nonactive individuals, especially at older ages. Due to the
limited number of direct comparisons among interventions, determining the
best treatment option can be difficult. Purpose: To evaluate the comparative efficacy and tolerability of nonsurgical
therapies for midportion AT. Study Design: Systematic review; Level of evidence, 1. Methods: PubMed, MEDLINE, EMBASE, and Google Scholar were searched from database
inception through June 20, 2019. Randomized controlled trials investigating
the effect of nonsurgical therapies for midportion AT using the Victorian
Institute of Sports Assessment–Achilles (VISA-A) assessment were eligible
for inclusion. Primary outcome was mean change in VISA-A score from
baseline. Comparisons between interventions were made through use of
random-effects network meta-analysis over the short term (≤3 months) and
longer term (>3 to <12 months). A safety profile was defined for each
intervention by rate of all-cause discontinuation (dropout) during
follow-up. Relative ranking of therapies was assessed by the
surface-under-the–cumulative ranking possibilities. Results: A total of 22 studies with 978 patients met the inclusion criteria. In
short-term studies, high-volume injection with corticosteroid (HVI+C) along
with eccentric exercise (ECC) significantly improved the change of VISA-A
score compared with that of ECC alone (standardized mean difference [SMD],
1.08; 95% CI, 0.58-1.58). Compared with ECC, acupuncture showed benefits
over both the short term (SMD, 1.57; 95% CI, 1.00-2.13) and longer term
(SMD, 1.23; 95% CI, 0.69-1.76). In longer-term studies, the wait-and-see
approach resulted in unfavorable outcomes compared with ECC (SMD, −1.51; 95%
CI, −2.02 to −1.01). Improvement was higher when ECC was combined with HVI+C
(SMD, 0.53; 95% CI, 0.05-1.02) and extracorporeal shockwave therapy (ESWT)
(SMD, 0.99; 95% CI, 0.48-1.49). All interventions had a similar safety
profile. Conclusion: From available high-level studies, HVI+C and ESWT may be possible
interventions to add along with ECC to improve longer-term outcomes.
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Affiliation(s)
- Hye Chang Rhim
- Department of Orthopedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Min Seo Kim
- Korea University College of Medicine, Seoul, Republic of Korea
| | - Seungil Choi
- Department of Biostatistics, University of Pittsburg, Pittsburg, Pennsylvania, USA
| | - Adam S Tenforde
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
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Madhi MI, Yausep OE, Khamdan K, Trigkilidas D. The use of PRP in treatment of Achilles Tendinopathy: A systematic review of literature. Study design: Systematic review of literature. Ann Med Surg (Lond) 2020; 55:320-326. [PMID: 32566217 PMCID: PMC7298400 DOI: 10.1016/j.amsu.2020.04.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/22/2020] [Accepted: 04/27/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Chronic Achilles Tendinopathy is a common condition that can be challenging to treat. There are many modalities used as treatment ranging from physiotherapy, injections, shockwave therapy to surgical intervention. Platelet Rich Plasma (PRP) has increased in popularity recently as a treatment option for Achilles Tendinopathy. It contains growth factors that might accelerate healing and speed up the recovery of this condition. Many studies have been conducted in the last few years to assess the effectiveness of this treatment method. However, there was controversy as to whether PRP had a beneficial effect on chronic Achille tendinopathy. AIM This systematic review of the literature was conducted to ascertain the efficacy of Platelet Rich Plasma (PRP) as a treatment option in chronic Achilles tendinopathy. METHODS PRISMA reporting item for systematic review has been used to conduct the selection, Electronic databases included PubMed, EMBASE, Cochrane collaborate, Google scholar, the web of science and Cochrane Library were searched for all RCT, prospective and retrospective studies conducted between January 2010 to February 2019. The quality of each study was evaluated using the Oxford CEBM tool to assess the articles for validity, relevance, and applicability of the results. A total number of 288 were found, and only 11 met the inclusion criteria. RESULTS 5 Randomised control trials, 4 prospective and 2 retrospective cohort study were included in this systematic review. A total number of 406 patients were treated for non-insertional Achilles tendinopathy of which 230 patients had PRP local injection under Ultrasound guide. CONCLUSION Although many of the retrospective studies suggested an advantage of using PRP, the higher level of evidence studies do not support a significant efficacy. This systematic review showed very promising results from the use of Platelet Rich Plasma demonstrated by a significant improvement in the VAST-A score, but we certainly need decent size randomised control trials to show better and more accurate results.
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Affiliation(s)
- Mr Imad Madhi
- Trauma and Orthopaedics Surgery, Wythenshawe Hospital, Manchester, UK
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Mariani E, Pulsatelli L. Platelet Concentrates in Musculoskeletal Medicine. Int J Mol Sci 2020; 21:ijms21041328. [PMID: 32079117 PMCID: PMC7072911 DOI: 10.3390/ijms21041328] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/29/2020] [Accepted: 02/06/2020] [Indexed: 12/02/2022] Open
Abstract
Platelet concentrates (PCs), mostly represented by platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) are autologous biological blood-derived products that may combine plasma/platelet-derived bioactive components, together with fibrin-forming protein able to create a natural three-dimensional scaffold. These types of products are safely used in clinical applications due to the autologous-derived source and the minimally invasive application procedure. In this narrative review, we focus on three main topics concerning the use of platelet concentrate for treating musculoskeletal conditions: (a) the different procedures to prepare PCs, (b) the composition of PCs that is related to the type of methodological procedure adopted and (c) the clinical application in musculoskeletal medicine, efficacy and main limits of the different studies.
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Affiliation(s)
- Erminia Mariani
- Laboratorio di Immunoreumatologia e rigenerazione tissutale, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy;
- Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum-University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
- Correspondence: ; Tel.: +39-051-6366803
| | - Lia Pulsatelli
- Laboratorio di Immunoreumatologia e rigenerazione tissutale, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy;
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Kearney RS, Parsons N, Ji C, Warwick J, Brown J, Young J, Costa ML. Platelet rich plasma versus placebo for the management of Achilles tendinopathy: protocol for the UK study of Achilles tendinopathy management (ATM) multi-centre randomised trial. BMJ Open 2020; 10:e034076. [PMID: 32051317 PMCID: PMC7044811 DOI: 10.1136/bmjopen-2019-034076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION In the UK, 150 000 people every year experience mid-substance Achilles tendinopathy. Typically patients are offered a range of treatment options such as exercise, electrotherapy, injections and surgery. With large variations in current practice, there is a pressing need to establish which treatments are effective and which are not. This is the protocol for a multi-centre randomised trial of platelet rich plasma (PRP) versus placebo injection for patients with Achilles tendinopathy. METHODS AND ANALYSIS Adult patients with mid-substance Achilles tendinopathy for longer than 3 months will be screened. Randomisation will be on a 1:1 basis, stratified by centre and bilateral presentation. Participants will be allocated to either a single PRP injection or placebo injection. A minimum of 240 patients will be recruited into the study; this number will provide 90% power to detect a difference of 12 points in Victorian Institute of Sport Assessment-Achilles score at 6 months. Quality of life, pain and complications data will be collected at baseline, 2-week, 3-month and 6-month post-randomisation. The differences between treatment groups will be assessed on an intention-to-treat basis. ETHICS, REGISTRATION AND DISSEMINATION This trial was funded by Versus Arthritis and commenced on 1 September 2015 (Versus Arthritis 20831). National Research Ethic Committee approved this study on 30 October 2015 (15/WM/0359). It was registered on the International Standard Randomised Controlled Trial Number (ISRCTN) registry with reference number ISRCTN 13254422 on 28 October 2015. The first site opened to recruitment on 27 April 2016 and the trial was in active recruitment at the point of submitting the protocol paper. The results of this trial will be submitted to a peer-reviewed journal and will inform clinical practice with regard to the treatment of Achilles tendinopathy.
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Affiliation(s)
| | - Nicholas Parsons
- Statistics and Epidemiology Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Chen Ji
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jane Warwick
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jaclyn Brown
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jonathan Young
- Trauma and Orthopaedic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Matthew L Costa
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Heitkamp HSJ, Kapitza C. [The Management of Mid-Portion Achilles Tendinopathy from a Physiotherapeutic Point of View: A Systematic Review]. SPORTVERLETZUNG-SPORTSCHADEN 2019; 35:24-35. [PMID: 31639830 DOI: 10.1055/a-0877-3407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Tendinopathy of the mid-portion of the Achilles tendon is common in athletes and non-athletes. From a physiotherapeutic view, calf muscle training is the most recommended kind of treatment. However, there is no current systematic review evaluating the efficacy of physiotherapy in due consideration of the entire spectrum of therapeutic options. A systematic review of the literature in several databases and journals revealed 19 relevant studies. Good evidence was found for eccentric training compared to no therapy, satisfactory evidence for eccentric training compared to concentric training, satisfactory to good evidence for the same effect by using eccentric training and heavy slow resistance training, poor evidence for the same effect by using eccentric training and stretching, and poor to good evidence that eccentric training may have the same effect as several therapies applied by physicians. The Alfredson protocol and heavy slow resistance training may be the most recommendable types of calf muscle training. There is no high-quality evidence for the efficacy of other hands off or hands on treatment options.
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Affiliation(s)
| | - Camilla Kapitza
- Prof.-Grewe-Schule, Hochschule Osnabrück, Fakultät Wirtschafts- und Sozialwissenschaften, Osnabrück, Deutschland
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Abate M, Di Carlo L, Salini V. Platelet rich plasma compared to dry needling in the treatment of non-insertional Achilles tendinopathy. PHYSICIAN SPORTSMED 2019; 47:232-237. [PMID: 30427252 DOI: 10.1080/00913847.2018.1548886] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The efficacy of platelet rich plasma in the treatment of Achilles tendinopathy is controversial. Despite positive results observed in open studies, randomized controlled trials failed to show difference against saline or rehabilitation. Aims of this retrospective observational study were to compare the efficacy of platelet-rich plasma and dry needling and to assess possible differences age and sex-related. METHODS Groups of 46 and 38 patients with non-insertional Achilles tendinopathy were treated with platelet-rich plasma and dry needling (once a week for 3 weeks), respectively. At baseline, 3 and 6 months, pain and function scores and the percentage of satisfactory outcomes were evaluated. Sub-group analyses were performed according to age and sex. RESULTS At 3 and 6 months no differences in terms of pain and function between groups were observed, but the percentage of subjects reporting satisfactory results, at 6 months, was higher in platelet rich plasma group. Better results were observed in younger subjects, with a greater reduction of pain, improvement of function, and accordingly of the percentage of positive outcomes. A trend toward better results was also observed in males. CONCLUSION Beneficial effects of platelet rich plasma and dry needling in non-insertional Achilles tendinopathy have been observed only in some subjects, but not in others; platelet rich plasma shows a slight superiority against dry needling, mainly in younger persons; finally, a gender difference in the therapeutic response can be hypothesized.
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Affiliation(s)
- Michele Abate
- a Department of Medicine and Science of Aging , University G. d'Annunzio , Chieti Scalo , Italy
| | - Luigi Di Carlo
- a Department of Medicine and Science of Aging , University G. d'Annunzio , Chieti Scalo , Italy
| | - Vincenzo Salini
- a Department of Medicine and Science of Aging , University G. d'Annunzio , Chieti Scalo , Italy
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38
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Liu CJ, Yu KL, Bai JB, Tian DH, Liu GL. Platelet-rich plasma injection for the treatment of chronic Achilles tendinopathy: A meta-analysis. Medicine (Baltimore) 2019; 98:e15278. [PMID: 31008973 PMCID: PMC6494278 DOI: 10.1097/md.0000000000015278] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Platelet-rich plasma (PRP) is used as an alternative therapy to reduce pain and improve functional restoration in patients with Achilles tendinopathy (AT). We evaluated the current evidence for the efficacy of PRP as a treatment for chronic AT. METHODS The PubMed, Embase, Web of Science, and The Cochrane Library databases were searched for articles on randomized controlled trials (RCTs) that compared the efficacy of PRP with that of with placebo injections plus eccentric training as treatment for AT. The articles were uploaded over the establishment of the databases to May 01, 2018. The Cochrane risk of bias (ROB) tool was used to assess methodological quality. Outcome measurements included the Victorian Institute of Sports Assessment-Achilles (VISA-A), visual analog scale (VAS) and Achilles tendon thickness. Statistical analysis was performed with RevMan 5.3.5 software. RESULTS Five RCTs (n = 189) were included in this meta-analysis. Significant differences in the VISA-A were not observed between the PRP and placebo groups after 12 weeks [standardized mean difference (SMD) = 0.2, 95% confidence interval (95% CI): 0.36 to 0.76, I = 71%], 24 weeks (SMD = 0.77, 95% CI: -0.10-1.65, I = 85%) and 1 year (SMD = 0.83, 95% CI: -0.76-2.42, I = 72%) of treatment. However, PRP exhibited better efficacy than the placebo treatment after 6 weeks (SMD = 0.46, 95% CI: 0.15-0.77, I = 34%). Two studies included VAS scores and tendon thickness. VAS scores after 6 weeks (SMD = 1.35, 95% CI: -0.1.04-3.74, I = 93%) and 24 weeks (SMD = 1.48, 95% CI: -0.1.59-4.55, I = 95%) were not significantly different. However, VAS scores at the 12th week (SMD = 1.10, 95% CI: 0.53-1.68, I = 83%) and tendon thickness (SMD = 1.51, 95% CI: 0.39-2.63, I = 53%) were significantly different. CONCLUSION PRP injection around the Achilles tendon is an option for the treatment of chronic AT. Limited evidence supports the conclusion that PRP is not superior to placebo treatment. These results still require verification by a large number of well designed, heterogeneous RCT studies.
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Affiliation(s)
- Chun-jie Liu
- Department of Orthopedics, Tangshan Workers Hospital, Tangshan City
| | - Kun-lun Yu
- Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang
| | - Jiang-bo Bai
- Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang
| | - De-hu Tian
- Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang
| | - Guo-li Liu
- Department of Orthopedics, The Second Hospital of Tangshan, Tangshan City Hebei Province, PR China
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Efficacy of platelet-rich plasma injections for treating Achilles tendonitis. DER ORTHOPADE 2019; 48:784-791. [DOI: 10.1007/s00132-019-03711-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Abstract
Tendinopathy carries a large burden of musculoskeletal disorders seen in both athletes and aging population. Treatment is often challenging, and progression to chronic tendinopathy is common. Physical therapy, nonsteroidal anti-inflammatory drugs, and corticosteroid injections have been the mainstay of treatment but are not optimal given that most tendon disorders seem to involve degenerative changes in addition to inflammation. The field of regenerative medicine has taken the forefront, and various treatments have been developed and explored including prolotherapy, platelet rich plasma, stem cells, and percutaneous ultrasonic tenotomy. However, high-quality research with standardized protocols and consistent controls for proper evaluation of treatment efficacy is currently needed. This will make it possible to provide recommendations on appropriate treatment options for tendinopathy.
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Murphy M, Travers M, Gibson W, Chivers P, Debenham J, Docking S, Rio E. Rate of Improvement of Pain and Function in Mid-Portion Achilles Tendinopathy with Loading Protocols: A Systematic Review and Longitudinal Meta-Analysis. Sports Med 2018; 48:1875-1891. [PMID: 29766442 DOI: 10.1007/s40279-018-0932-2] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Mid-portion Achilles tendinopathy is prevalent within both the athletic and non-athletic populations and loading protocols for Achilles tendinopathy are effective over time, though the rate of symptom change throughout rehabilitation is unknown. OBJECTIVE The objective of this study was to determine the rate of change in pain and function over time in patients while completing a loading protocol for mid-portion Achilles tendinopathy. METHODS A systematic review and longitudinal meta-analysis was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The databases PubMed, CINAHL (Ovid) and CINAHL (EBSCO) were searched for articles published from inception until 31 July, 2017. Our search focused on clinical trials and cohort studies examining changes in pain and function when completing a loading protocol for mid-portion Achilles tendinopathy. The primary outcome measure assessing pain and function was the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire. RESULTS A total of 31 separate cohorts (24 studies) were eligible, with follow-up ranging from 2 weeks to 6 months. The data were pooled to create the mean (standard deviation) of change from baseline at each time point. The data demonstrated an improvement in pain and function as early as 2 weeks that appeared to peak at 12 weeks with a mean (standard deviation) of 21.11 (6.61) points of change on the VISA-A. CONCLUSION The improvement in pain and function during rehabilitation suggests future research should be directed toward investigating contributing mechanisms as tendon structure on imaging does not change within 2 weeks and muscular hypertrophy is not seen for at least 4 weeks following the inception of a loading protocol. Systematic Review Registry: PROSPERO registration number: CRD42017062737 ( https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=62737 ).
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Affiliation(s)
- Myles Murphy
- School of Physiotherapy, University of Notre Dame Australia, 19 Mouat Street, PO Box 1225, Fremantle, WA, 6959, Australia.
- SportsMed Subiaco, St John of God Health Care, Subiaco, WA, Australia.
- Sports Science Sports Medicine Department, Western Australian Cricket Association, East Perth, WA, Australia.
| | - Mervyn Travers
- School of Physiotherapy, University of Notre Dame Australia, 19 Mouat Street, PO Box 1225, Fremantle, WA, 6959, Australia
- School of Physiotherapy and Exercise Science, Curtin University, Bentley, WA, Australia
| | - William Gibson
- School of Physiotherapy, University of Notre Dame Australia, 19 Mouat Street, PO Box 1225, Fremantle, WA, 6959, Australia
| | - Paola Chivers
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, Australia
- Exercise Medicine Research Institute and School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - James Debenham
- School of Physiotherapy, University of Notre Dame Australia, 19 Mouat Street, PO Box 1225, Fremantle, WA, 6959, Australia
| | - Sean Docking
- La Trobe Sports and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, Australia
| | - Ebonie Rio
- La Trobe Sports and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, Australia
- Australian Collaboration for Research into Injury in Sport and its Prevention (ACRISP), Bundoora, Australia
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Abstract
PURPOSE OF REVIEW Platelet-rich plasma has become an increasingly popular treatment option within the orthopedic community to biologically enhance and stimulate difficult-to-heal musculoskeletal tissues. This review evaluates the recent literature on platelet-rich plasma use in the treatment of foot and ankle pathologies. RECENT FINDINGS Recent literature has demonstrated platelet-rich plasma to have a possible benefit in the treatment of Achilles pathology, chronic plantar fasciitis, osteochondral lesions of the talus, ankle osteoarthritis, and diabetic foot ulcers. However, given the lack of standardization of platelet-rich plasma preparations and protocols and the predominance of low-quality studies, no definitive treatment indications exist. Platelet-rich plasma is a promising treatment option, but at present, there is only limited clinical evidence supporting its use in foot and ankle applications.
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Affiliation(s)
- Peter R Henning
- Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee, 1400 S. Germantown Rd, Germantown, 38138, TN, USA
| | - Benjamin J Grear
- Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee, 1400 S. Germantown Rd, Germantown, 38138, TN, USA.
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Efficacy of platelet-rich plasma as conservative treatment in orthopaedics: a systematic review and meta-analysis. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018; 16:502-513. [PMID: 30201082 DOI: 10.2450/2018.0111-18] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 07/16/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this systematic review and meta-analysis was to evaluate the benefit of platelet-rich plasma (PRP) in non-surgical orthopaedic procedures. MATERIAL AND METHODS We searched the Cochrane Wounds Specialized Register, CENTRAL, MEDLINE (through PUBMED), Embase, and SCOPUS. We also searched clinical trials registries for ongoing and unpublished studies and checked reference lists to identify additional studies. RESULTS We found 36 randomised controlled trials (2,073 patients) that met our inclusion criteria. The included studies mostly had small numbers of participants (from 20 to 225). Twenty-eight studies included patients with lateral epicondylitis or plantar fasciitis. PRP was compared to local steroids injection (19 studies), saline injection (6 studies), autologous whole blood (4 studies), local anaesthetic injection (3 studies), dry needling injection (3 studies), and to other comparators (4 studies). Primary outcomes were pain and function scores, and adverse events. On average, it is unclear whether or not use of PRP compared to controls reduces pain scores and functional score at short- (up to 3 months) and medium- (4-6 months) term follow-up. The available evidence for all the comparisons was rated as very low quality due to inconsistency, imprecision, and risk of bias in most of the selected studies. There were no serious adverse events related to PRP injection or control treatments. CONCLUSIONS The results of this meta-analysis, which documents the very marginal effectiveness of PRP compared to controls, does not support the use of PRP as conservative treatment in orthopaedics.
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Lin MT, Wu CH. Author reply to "Regarding 'Meta-analysis Comparing Autologous Blood-Derived Products (Including Platelet-Rich Plasma) Injection Versus Placebo in Patients With Achilles Tendinopathy"'. Arthroscopy 2018; 34:2528-2529. [PMID: 30173792 DOI: 10.1016/j.arthro.2018.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 06/20/2018] [Indexed: 02/02/2023]
Affiliation(s)
- Meng-Ting Lin
- National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chueh-Hung Wu
- National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
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Shimozono Y, Fortier LA, Kennedy JG. Regarding "Meta-analysis Comparing Autologous Blood-Derived Products (Including Platelet-Rich Plasma) Injection Versus Placebo in Patients With Achilles Tendinopathy". Arthroscopy 2018; 34:2526-2528. [PMID: 30173791 DOI: 10.1016/j.arthro.2018.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/20/2018] [Indexed: 02/02/2023]
Affiliation(s)
- Yoshiharu Shimozono
- Hospital for Special Surgery, New York, New York; Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Lisa A Fortier
- Department of Clinical Sciences, Cornell University, Ithaca, New York
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Filardo G, Di Matteo B, Kon E, Merli G, Marcacci M. Platelet-rich plasma in tendon-related disorders: results and indications. Knee Surg Sports Traumatol Arthrosc 2018; 26:1984-1999. [PMID: 27665095 DOI: 10.1007/s00167-016-4261-4] [Citation(s) in RCA: 186] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 08/02/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE Platelet-rich plasma (PRP) is currently the most exploited strategy in the clinical practice to provide a regenerative stimulus for tendon healing. The aim of the present study was to systematically review the available evidence on the treatment of the main tendon disorders where PRP is currently applied. METHODS A systematic review of the literature was performed on the use of PRP as a treatment for tendinopathies focusing on the following sites: Achilles tendon, patellar tendon, rotator cuff tendons, and lateral elbow tendons. The following inclusion criteria for relevant articles were used: clinical trials written in English language up to 21 June 2016 on the use of PRP in the conservative or surgical treatment of the aforementioned tendinopathies. RESULTS The research identified the following clinical trials dealing with the application of PRP in the selected tendons: 19 papers on patellar tendon (6 being RCTs: 4 dealing with PRP conservative application and 2 surgical), 24 papers on Achilles tendon (4 RCTs: 3 conservative and 1 surgical), 29 on lateral elbow tendons (17 RCTs, all conservative), and 32 on rotator cuff (22 RCTs: 18 surgical and 3 conservative). CONCLUSION Patellar tendons seem to benefit from PRP injections, whereas in the Achilles tendon, PRP application is not indicated neither as a conservative approach nor as a surgical augmentation. Lateral elbow tendinopathy showed an improvement in most of the high-level studies, but the lack of proven superiority with respect to the more simple whole-blood injections still questions its use in the clinical practice. With regard to rotator cuff pathology, the vast majority of surgical RCTs documented a lack of beneficial effects, whereas there is still inconclusive evidence concerning its conservative application in rotator cuff disorders. LEVEL OF EVIDENCE Systematic review of level I-IV trials, Level IV.
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Affiliation(s)
- Giuseppe Filardo
- Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Berardo Di Matteo
- I Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy.
| | - Elizaveta Kon
- Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Giulia Merli
- Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Maurilio Marcacci
- Biomechanics and Technology Innovation Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy
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Lin MT, Chiang CF, Wu CH, Hsu HH, Tu YK. Meta-analysis Comparing Autologous Blood-Derived Products (Including Platelet-Rich Plasma) Injection Versus Placebo in Patients With Achilles Tendinopathy. Arthroscopy 2018; 34:1966-1975.e5. [PMID: 29685839 DOI: 10.1016/j.arthro.2018.01.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 01/18/2018] [Accepted: 01/18/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the effectiveness of autologous blood-derived products (ABP) injection with that of placebo (sham injection, no injection, or physiotherapy alone) in patients with Achilles tendinopathy. METHODS Electronic databases, including PubMed, Scopus, EMBASE, and Cochrane Library were searched up to June 2017. All published or unpublished randomized controlled trials (RCTs) were included. Two independent raters assessed the risk of bias of RCTs with the Cochrane Risk of Bias Tool. The primary outcome was Victorian Institute of Sports Assessment-Achilles (VISA-A) score. Weighted mean differences (WMDs) were used for random effect meta-analysis. RESULTS Seven RCTs were enrolled in meta-analysis. The ABP injection and placebo revealed equal effectiveness in VISA-A score improvement at 4 to 6 weeks (short term, WMD 2.29, 95% confidence interval [CI]: -1.69, 6.27), 12 weeks (medium term, WMD 2.63, 95% CI: -1.72, 6.98), 24 weeks (long term, WMD 4.61, 95% CI: -1.25, 10.47), and 48 weeks (very long term, WMD 4.16, 95% CI: -6.82, 15.14). In meta-regression, there was no association between change in VISA-A score and duration of symptoms at 4 to 6 weeks (short term), 12 weeks (medium term), and 24 weeks (long term). CONCLUSIONS This meta-analysis revealed that ABP injection was not more effective than placebo (sham injection, no injection, or physiotherapy alone) in Achilles tendinopathy and that no association was found between therapeutic effects and duration of symptoms. LEVEL OF EVIDENCE Level I, meta-analysis of Level I studies.
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Affiliation(s)
- Meng-Ting Lin
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-Fang Chiang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chueh-Hung Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Hui-Hsuan Hsu
- Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan
| | - Yu-Kang Tu
- Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan
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Murphy M, Rio E, Debenham J, Docking S, Travers M, Gibson W. EVALUATING THE PROGRESS OF MID-PORTION ACHILLES TENDINOPATHY DURING REHABILITATION: A REVIEW OF OUTCOME MEASURES FOR SELF- REPORTED PAIN AND FUNCTION. Int J Sports Phys Ther 2018; 13:283-292. [PMID: 30090686 PMCID: PMC6063067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023] Open
Abstract
INTRODUCTION Management of mid-portion Achilles tendinopathy is a challenge for both clinicians and researchers. Alteration in tendon structure, muscle performance and pain processing mechanisms have been suggested as mechanisms driving improvement in pain and function. However, few trials have used consistent outcome measures to track changes in pain and function. OBJECTIVES 1) To identify all outcomes measures used in trials utilizing exercise-based interventions for mid-portion Achilles tendinopathy (AT) that assess self-reported pain and function and to report on the reliability and validity of the identified measures, and 2) Propose measures to optimally assess self-reported pain and function in patients with AT. DESIGN Literature Review. DATA SOURCES Three major electronic databases were searched from inception until May 2016 for studies using isometric, eccentric or isotonic loading protocols for mid-portion AT. ELIGIBILITY CRITERIA Randomized and non-randomized trials of isometric, eccentric or isotonic loading in people with mid-portion AT. RESULTS Forty-six studies were included and all outcome measures assessing self-reported pain and function were extracted. While a variety of outcome measures have been used, few have provided reliability data. There is evidence to suggest that the Victorian Institute of Sports Assessment- Achilles (VISA-A) is the only valid and reliable measure of self-reported pain and function for people with mid-portion AT. No other outcome measures have been validated in mid-portion AT. CONCLUSION The VISA-A remains the gold standard for assessing pain and function in mid-portion AT. However, while the validity or reliability of the Numerical Rating Scale (NRS) of pain during a functional task has not been established it may be a better measure of immediate treatment effect. LEVEL OF EVIDENCE 5.
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Affiliation(s)
| | | | - James Debenham
- School of Physiotherapy, University of Notre Dame Australia, Fremantle, Australia
| | - Sean Docking
- La Trobe Sports and Exercise Medicine Research Centre, Bundoora, Australia
| | | | - William Gibson
- School of Physiotherapy, University of Notre Dame Australia, Fremantle, Australia
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Sussman WI, Mautner K, Malanga G. The role of rehabilitation after regenerative and orthobiologic procedures for the treatment of tendinopathy: a systematic review. Regen Med 2018. [DOI: 10.2217/rme-2017-0110] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aim: Significant variability exists in the literature, with no clear consensus to the optimal protocol after a regenerative procedure. Given this uncertainty, the authors systematically reviewed the literature cataloging the different variables that may influence outcomes. Methods: Search was limited to randomized clinical trials and prospective cohort studies of regenerative procedures for the treatment of tendinopathy. Variables were predetermined, and included: cyrotherapy, pre- and post-procedure nonsteroidal anti-inflammatory drugs use, recommendations for alternative pain medications, immobilization and duration of rest. Variables were categorized based on the influence of the intervention on the three phases of healing. Results: 749 studies were assessed for eligibility, and 60 studies were included. Significant variability existed in the literature. Conclusion: Despite the importance of rehabilitation after regenerative procedures, there is a paucity of evidence available to guide clinicians and highlights the need for additional validation.
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Affiliation(s)
- Walter I Sussman
- Department of Physical Medicine & Rehabilitation, Tufts University, Boston, MA 02111, USA
- Orthopedic Care Physician Network, N Easton, MA 02356, USA
| | - Ken Mautner
- Department of Physical Medicine & Rehabilitation & Department of Orthopedics, Emory University, Atlanta, GA 30329, USA
| | - Gerard Malanga
- Department of Physical Medicine & Rehabilitation, Rutgers School of Medicine University of Medicine & Density, Newark, NJ 07101, USA
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Moya D, Ramón S, Schaden W, Wang CJ, Guiloff L, Cheng JH. The Role of Extracorporeal Shockwave Treatment in Musculoskeletal Disorders. J Bone Joint Surg Am 2018; 100:251-263. [PMID: 29406349 DOI: 10.2106/jbjs.17.00661] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Daniel Moya
- Buenos Aires British Hospital, Buenos Aires, Argentina
| | - Silvia Ramón
- Hospital Quirón, Barcelona, Fundación García Cugat, Spain
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