Original papers
DOI: 10.11152/mu.2013.2066.152.rb1vy2Abstract
Aim: Professional athletes require faster recovery after trauma. The aim of our study was to evaluate the efficacy of ultra- sound guided platelets rich plasma (PRP) treatment for acute muscle injury comparing with traditional conservative therapy.
Materials and methods: Thirty consecutive men (mean age 24 years old) professional athletes with acute local muscle injury were enrolled. All patients underwent US and sonoelastography examination. Patients were randomly assigned to 2 groups: group A received targeted PRP injection under US guidance and additionally conservative treatment and group B received conventional conservative treatment only. The pain was assessed according to visual analogue scale (0 to 10), muscle function according to pain on resisted flexion or strength, and range of motion. Both groups were further evaluated in the days 1, 7, 14, 21, and 28 after treat- ment starting. US criteria for regeneration were considered to be the disappearance of hypoechoic areas of muscle damage, fibrous tissue more stiff on sonoelastography, and neovascularity appearances. Results: The pain relief was more important in group A compared to group B starting from day 1 and continuing in the next 3 evaluation sessions (p<0.05). At the end of observation (28 day), 93 % of pain regression was declared by patients in group A vs 80 % of regression of pain in group B (p>0.05). Assess- ing the physical evolution in the 7th and 14th days significant changes in strength (p<0.05) and range of motion (p<0.05) for PRP treatment group was observed. After 28 days no significant differences between groups were observed concerning the pain on resisted flexion and strength (p>0.05) but the range of movement improved better in group A compared with group B (p< 0.05).
Subjective global function scores improved significantly in group A compared with group B on the 28th day (p<0.05). The mean time for the physical recovery movement volume and the ability to practice sport was 10±1.2 days in group A and 22±1.5 days in group B. Conclusions: Injections of PRP under ultrasound guidance had asignificantly higher level of pain relief, physical recov- ery, and faster regeneration compared with conventional conservative treatment in acute muscle trauma in professional athletes
Keywords: muscle trauma, athletes, ultrasound, platelets rich plasma,
Ultrasound guided injections of Platelets Rich Plasma for muscle injury in professional athletes. Comparative study.
Rostyslav Bubnov
1, Viacheslav Yevseenko
2, Igor Semeniv
21 Centre of Ultrasound Diagnostics and Interventional Sonography, 2 Centre for Orthopedics, Traumatology and Sport medicine, Clinical Hospital ”Pheophania“ of State Affairs Department, Kyiv, Ukraine
Received 05.02.2013 Accepted 22.03.2013 Med Ultrason
2013, Vol. 15, No 2, 101-105
Corresponding author: Rostyslav Bubnov
Clinical Hospital “Pheophania”
21 Zabolotny str, 03680 Kyiv,Ukraine Tel. +380442596237, Fax +380442596959 E-mail: [email protected]
Introduction
According to the World Health Organization (WHO), musculoskeletal injuries are the most common cause of severe long-term pain and physical disability, and affect hundreds of millions of people worldwide [1]. Introduc- tion of the platelets rich plasma (PRP) therapy, prepared from autoblood containing its own growth factors, is con-
sidered to be a promising solution to accelerate the heal- ing process of the injured soft tissue [1-5]. This need is especially important in professional athletes who require a faster recovery after trauma. PRP contains growth fac- tors and bioactive proteins that influence the healing of tendons, ligaments, muscles, and bones.
In 1981 Antoniades [2] identified two types of platelet-derived growth factors (PDGF I and II). These growth factors are small proteins that stimulate cellu- lar proliferation, migration, differentiation, and matrix synthesis, influence the metabolism of chondrocytes, chondrogenesis, and improve the healing of tendons and muscles in vivo.
Musculoskeletal ultrasound (US) provides clinicians with sufficient data about the muscle injury [3,4]. Also,
US technique is the most effective method for guiding the puncture of soft tissues [5,6].
Currently, most studies on PRP therapy are anecdo- tal, nonrandomized, or involve insufficient sample sizes and are underpowered [6]. Recently, there is emerging literature on the beneficial effects of PRP for chronic, non-healing tendon injuries including lateral epicondyli- tis and plantar fasciitis [6-8]. However, at present, there are limited studies documenting the safety and efficacy of PRP use in degenerative process as e.g., knee osteo- arthritis (OA). There are publications about PRP admin- istration under ultrasound guidance for the treatment of lateral epicondylitis [9-11] or treatment of adductor lon- gus muscle damage [12,13]. Sanchez et al reported the use of platelet growth factors for the treatment of articu- lar cartilage avulsion [14]. Also Sanchez et al compared PRP and hyaluron acid administration into osteoarthritic knees and showed better pain relief with PRP [15].
However, little has been published about the use of growth factors in acute muscle damage. Recent studies indicate the feasibility of the combination of dry-nee- dling and the introduction of growth factors as an effec- tive conservative treatment tendinopathies [16].
Autologous PRP has emerged as a treatment option for tendinopathies and chronic wounds. In addition to the release of growth factors, PRP also promotes concentrat- ed anti-inflammatory signals including interleukin-1ra, which has been a focus of emerging treatments for os- teoarthritis [17].
The aim of our study was to evaluate the efficacy of ultrasound guided PRP treatment for acute muscle injury compared with traditional conservative therapies in pro- fessional athletes.
Material and methods
Thirty consecutive men patients, mean age 24 years old, professional athletes, with acute local muscle injury, diagnosed clinically and confirmed by ultrasonography were enrolled. All patients underwent US examination using 12 MHz linear probes of US machines Sonosite Turbo and Hitachi HV 900 with sonoelastography func- tion in the day of injuries.
Muscle injuries were visualized as areas of alteration in the normal structure of the muscles, hypoechoic areas, small haematomas, or interruption of the continuity of the muscle fibers. Sonoelastography was used to identify local changes in the muscle elasticity.
Patients were randomly assigned to 2 types of treat- ment. Patients of group A received targeted PRP injection under US guidance in the lesion and additionally conserv- ative treatment (including immobilization, general physio-
therapy, and anti-inflammatory therapy). Patients in group B received only conventional conservative treatment.
The 2 groups were assessed on the day of presentation, after 24 h (1st day) and in the 7th, 14th, 21th, and 28th days after treatment starting (6 evaluations). The pain was evaluated according to the visual analogue scale data (VAS): 0- no pain, 10- the worst possible pain. Physical assessment con- sisted of assessing the muscle function according to pain on resisted flexion, strength, and range of motion - extension, pronation, or supination of injured muscle. Patient’s self- evaluation consisted of subjective global function scores, using a scale from 0 to 100 (with 100 representing healthy, preinjury function). The US criteria for regeneration of the injured muscle of tissue recurrence were the disappearance of hypoechoic areas of muscle damage, the replacement of the hematoma by fibrous tissue, fibrous tissue more stiff on sonoelastography, and neovascularity appearance.
For the PRP preparation approximately 40 cm3 of the patient’s venous blood was collected. The blood was buffered with trisodium citrate and was placed into a centrifuge. After centrifugation, the platelets and plasma were separated from the red and white blood cells. The 2 cm3 plasma fraction located just above the sedimented red blood cells together with the buffy coat fraction, were collected. The PRP was then loaded into a 5-mL syringe with a 22-gauge needle. After US identification of the in- jury and aspiration of hematomas, the freshly prepared PRP was injected under US control.
The medical Ethics Committee of the Clinical hospi- tal “Pheophania” of State Affairs Department approved the study and written informed consent was obtained from all participants.
Statistical method: The Student t-test was applied to perform the comparison between the groups; the Spear- man’s rank correlation coefficient R for study relation- ship between two variables of outcome in both groups was used.
Results
In the thirty patients included in the study, we regis- tered 34 lesions: two patients of group A had thigh and ankle trauma and similarly two patients in group B had same kind of combined trauma of the lower limb (table I).
Table I. Types of trauma founded in the study groups.
Place of injury Group A Group B
thigh trauma 10 8
foot and ankle trauma 5 5
shoulder trauma 2 4
Total 17 17
Pain relief (fig 1) was observed starting from day 1, 24 hours after procedure: 28% pain relief according to VAS scores were seen in group A compared to 10% in group B (p<0.05); the same statistical signification in pain reduc- tion was observed in the next 3 evaluation session (p<0.05).
After 28 days, 93 % of pain regression was declared by patients in group A vs 80 % of regression of pain in group B. The difference was not statistically significant (p>0.05).
The physical assessment evolution is presented in fig 2 for group A and in fig 3 for group B. On the 1st day no significant differences between groups was observed concerning the muscle function (pain on resisted flexion, Fig 2. Physical assessment evolution in group A (days 1 to 28) Fig 1. Quantification of the pain using VAS during the 6 evalu- ation sessions
Fig 3. Physical assessment evolution in group B (days 1 to 28)
Fig 4. A professional football player, 22 years old. Postrauma hematoma of the left thigh: a) hematoma aspiration under ultra- sound guidance, longitudinal scan; b) PRP administration; c) sonoelastography on 7th day – the hematoma was replaced by heterogeneous tissue with a predominance of dense component corresponding to fibrosis; d) sonoelastography on 14th day- the elasticity of the regenerating tissue is growing comparing with 7th day examination
strength, and range of motion, all p>0.05). On the 7th day significant changes in strength (p<0.05) and range of mo- tion (p<0.05) for PRP treatment group were found. After 14 days the improvement in physical assessment in group A group was significantly superior according to all param- eters (p<0.05). After 28 days the pain on resisted flexion and strength were quite similar in the two groups (p>0.05) but the range of motion improved, better in PRP treatment group compared with standard treated patients (p< 0.05).
Subjective global function scores improved from 55 (group A) and 53 (group B) at baseline to 92 (group A) and 74 (group B) respectively in 28th day (p<0.05).
Regenerative process was diagnosed on ultrasonog- raphy at 7 days after treatment starting 3 patients (20 %) from group A compared to 0 patients in group B (p<
0.05) and on the 14th day in 12 patients from group A (80
%) compared with 3 patients (20 %) from group B, (p
< 0.01). After 21 days all the patients from group A and 11 patients from group B had regenerative changes on ul- trasonography (p>0.05). On the 28th day the regenerative processes were identified in all patients.
We found a strong correlation in assessing regres- sion between regenerative process and all parameters of physical assessment were observed (the Spearman’s rank correlation coefficient r was 0.94 for all measurements).
The mean time for the physical recovery movement volume and the ability to practice sport was 10±1.2 days in group A and 22±1.5 days in group B.
In figure 4 we illustrated one of the cases included in group A.
Discussion
Our findings confirm that the pain relief was faster in group A after PRP treatment; however, difference with traditional therapy was insignificant in the late outcome.
Also we observed significant changes in strength, range of motion, and pain on resisted flexion that were signifi- cantly higher after 1-2 weeks of PRP treatment. Range of motion recovery was registered as the most beneficial result.Assessing the regenerative process we found sig- nificantly better results from the early stages in the PRP treated group, which is crucial for the athletes’ recovery.
A strong correlation between ultrasound and clinic find- ings was observed.
Thus, the early pain relief lead us to conclude that PRP therapy is effective for pain treatment. In combina- tion with effective physical restoration and high subjec- tive global function scores it can initiate an early reha- bilitation and decrease the mean time of treatment.
We have not found published comparative studies be- tween standard conservative treatment and PRP adminis- tration in acute muscle injury, but faster pain relief was reported by many authors after steroid therapy [10,18,19].
Comparing the data dedicated to PRP and steroid admin- istration [10] we assume that steroid injections may pro- vide symptomatic relief, but no evidence was provided that steroids promote healing. Steroids decrease the in- flammatory process (but this is not always present in injuries) and have also specific side effects. Moreover, in the study of Gosens et al comparing PRP versus cor- ticosteroid injection for lateral epicondylitis treatment, the patients from the PRP group were more often treated successfully compared with the corticosteroid group. The
PRP group had worse DASH scores before treatment and better ones after 26 weeks of the initial treatment [18].
Preliminary results have shown that PRP treatment led to a significantly better outcome than hyaluronic acid administration for the management of osteochondral le- sions of the talus [19].
PRP regenerative activity can be explained due to the secretion from the activated platelets aggregated into a clot of a variety of cytokines including adhesive proteins and growth factors [4,20-23]. These cytokines play im- portant roles in cell proliferation, chemotaxis, cell dif- ferentiation, and angiogenesis. Also the cytokines are capable of inducing an expression of new genes [24] and have antibacterial properties [25] that may also improve the results of treatment. The PRP could be potentially used in any part of an injured muscle, tendon, or liga- ment: shoulder pain, rotator cuff tear, knee pain or tendon tears, knee meniscus tear, foot pain, plantar fasciitis, hip pain, lower back pain, etc. In arthritis or osteoarthritis the treatment using PRP has not yet been considered due to the effect of the growth factors on the cartilage loss, subchondral bone deterioration, alterations in synovium, ligaments, capsule, or menisci [6,22]. The majority of recently proposed therapeutic modalities for OA has the foundation of attempting to address the cytokine imbal- ance [6-12,20-23].
Limitations of the study
The main limitations of the study are the small num- ber of patients/lesions and the lack of the double blinded protocol.
Conclusions
Injections of PRP under ultrasound guidance had significantly higher level of pain relief, physical recov- ery, and faster regeneration compared with conventional conservative treatment in acute muscle trauma of profes- sional athletes.
Conflict of interest: none Acknowledgment
We acknowledge Prof. Igor Zazirny for his kind ad- vices in study design.
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