Background
- 126 million Americans reported to have a musculoskeletal or musculotendinous pathology in 20121
- Combined direct and indirect cost of these injuries in 2015 was $874 billion1
- Corticosteroid injections have been the mainstay of invasive management after conservative methods fail Long-term effects of corticosteroids   Intra-articular injections for knee osteoarthritis resulted in cartilage volume loss10 Harm to flexor tendons, neurovascular structures, and compromised integrity7, 11 
- Platelet Rich Plasma   Sample patient blood --\u3e Centrifuge --\u3e Separate plasma and platelets from other blood products --\u3e Reconcentrate the platelets into the plasma Platelets release growth factor beta, vascular endothelial growth factor, platelet derived growth factor, transforming growth factor12, 13 Reproduction of cells and regeneration of tissue New application in the management of musculoskeletal and musculotendinous pathologies 
- The goal of this literature review is to discuss possible improved outcomes and patient satisfaction when combining platelet rich plasma with corticosteroids in the management of musculoskeletal and musculotendinous pathologies in adults 18 years or older, versus the use of PRP or corticosteroid injections alone.https://jdc.jefferson.edu/mspas_capstones/1013/thumbnail.jp

Stoudt, Mikayla

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Thomas Jefferson University Jefferson Digital Commons Master of Science in Physician Assistant Studies Capstone Presentations (Center City) Department of Health Science & Clinical Practice 8-16-2023 The Combination of Platelet Rich Plasma and Corticosteroids in Musculoskeletal and Musculotendinous Pathologies Mikayla Stoudt Thomas Jefferson University, mikayla.stoudt@students.jefferson.edu Follow this and additional works at: https://jdc.jefferson.edu/mspas_capstones  Part of the Pathology Commons Let us know how access to this document benefits you Recommended Citation Stoudt, Mikayla, "The Combination of Platelet Rich Plasma and Corticosteroids in Musculoskeletal and Musculotendinous Pathologies" (2023). Master of Science in Physician Assistant Studies Capstone Presentations (Center City). 13. https://jdc.jefferson.edu/mspas_capstones/13 This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Master of Science in Physician Assistant Studies Capstone Presentations (Center City) by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: JeffersonDigitalCommons@jefferson.edu. Background Results DiscussionLimitations:• Lack of standardization between preparations of PRP and different types of local anesthetics and corticosteroids• Small variety of musculoskeletal and musculotendinous pathologies were included in this literature review• Small sample sizesConclusions:• All studies revealed that platelet rich plasma injections provided patients with superior pain control, functional status, and satisfaction over the long-term while corticosteroids were the superior injection for the same outcomes over the short-term• The protective effects of PRP against the degenerative effects of corticosteroids highlights the potential benefit of the combination of these two treatment modalities• The combination of PRP and corticosteroids for the treatment of musculoskeletal or musculotendinous pathologies may decrease morbidity for patients with such conditions• It is important for physician assistants practicing in orthopedics to understand the risks and benefits of these injections and be up to date on the ever-evolving practice guidelinesFurther Direction• Prospective randomized control trials on the combination of PRP and corticosteroids for adults with a musculoskeletal or musculotendinous pathology• Researchers must determine if the combination of these injections can be given in one injection or given in a series over time• Pain → VAS• Function → Validated tool specific to the particular pathology• Sample sizes greater than 100 patients• A treatment that provides pain relief while simultaneously improving function and extending time until physiologic breakdown should be the standard of careReferences1. Lezin N, Watkins-Castillo S. The Impact of Musculoskeletal Disorders on Americans - Opportunities for Action. Burd Musculoskelet Dis U S Prevelance Soc Econ Cost. 2016;(3). Accessed April 6, 2023. https://boneandjointburden.org/docs/BMUS%20Executive%20Summary%203rd%20Edition.pdf2. Shetty SH, Dhond A, Arora M, Deore S. Platelet-Rich Plasma Has Better Long-Term Results Than Corticosteroids or Placebo for Chronic Plantar Fasciitis: Randomized Control Trial. J Foot Ankle Surg. 2019;58(1):42-46. doi:10.1053/j.jfas.2018.07.0063. Gupta PK, Acharya A, Khanna V, Roy S, Khillan K, Sambandam SN. PRP versus steroids in a deadlock for efficacy: long-term stability versus short-term intensity—results from a randomised trial. Musculoskelet Surg. 2020;104(3):285-294. doi:10.1007/s12306-019-00619-w4. Barman A, Mukherjee S, Sahoo J, et al. Single Intra-articular Platelet-Rich Plasma Versus Corticosteroid Injections in the Treatment of Adhesive Capsulitis of the Shoulder: A Cohort Study. Am J Phys Med Rehabil. 2019;98(7):549-557. doi:10.1097/PHM.00000000000011445. Malahias MA, Roumeliotis L, Nikolaou VS, Chronopoulos E, Sourlas I, Babis GC. Platelet-Rich Plasma versus Corticosteroid Intra-Articular Injections for the Treatment of Trapeziometacarpal Arthritis: A Prospective Randomized Controlled Clinical Trial. CARTILAGE. 2021;12(1):51-61. doi:10.1177/19476035188052306. Fawcett R, Grainger A, Robinson P, Jafari M, Rowbotham E. Ultrasound-guided subacromial–subdeltoid bursa corticosteroid injections: a study of short- and long-term outcomes. Clin Radiol. 2018;73(8):760.e7-760.e12. doi:10.1016/j.crad.2018.03.0167. Weber S, Chahal J. Management of Rotator Cuff Injuries: J Am Acad Orthop Surg. 2020;28(5):e193-e201. doi:10.5435/JAAOS-D-19-004638. Graham B, Peljovich AE, Afra R, et al. The American Academy of Orthopaedic Surgeons Evidence-Based Clinical Practice Guideline on: Management of Carpal Tunnel Syndrome. J Bone Jt Surg. 2016;98(20):1750-1754. doi:10.2106/JBJS.16.007199. Brophy RH, Fillingham YA. AAOS Clinical Practice Guideline Summary: Management of Osteoarthritis of the Knee (Nonarthroplasty), Third Edition. J Am Acad Orthop Surg. 2022;30(9):e721-e729. doi:10.5435/JAAOS-D-21-0123310. McAlindon TE, LaValley MP, Harvey WF, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA. 2017;317(19):1967-1975. doi:10.1001/jama.2017.528311. Management of Carpal Tunnel Syndrome: Evidence-Based Clinical Practice Guideline.12. Mishra A, Tummala P, King A, et al. Buffered Platelet-Rich Plasma Enhances Mesenchymal Stem Cell Proliferation and Chondrogenic Differentiation. Tissue Eng Part C Methods. 2009;15(3):431-435. doi:10.1089/ten.tec.2008.053413. Mejia HA, Bradley JP. The Effects of Platelet-Rich Plasma on Muscle: Basic Science and Clinical Application. Oper Tech Sports Med. 2011;19(3):149-153. doi:10.1053/j.otsm.2011.04.00214. Durant TJS, Dwyer CR, McCarthy MBR, Cote MP, Bradley JP, Mazzocca AD. Protective Nature of Platelet-Rich Plasma Against Chondrocyte Death When Combined With Corticosteroids or Local Anesthetics. Am J Sports Med. 2017;45(1):218-225. doi:10.1177/0363546516664161The Combination of Platelet Rich Plasma and Corticosteroids in Musculoskeletal and Musculotendinous PathologiesMikayla Stoudt, PA-SThomas Jefferson University Physician Assistant Program@ResearchAtJeffhttps://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2960709-X/fulltextMethods• 126 million Americans reported to have a musculoskeletal or musculotendinous pathology in 20121• Combined direct and indirect cost of these injuries in 2015 was $874 billion1• Corticosteroid injections have been the mainstay of invasive management after conservative methods fail• Long-term effects of corticosteroids• Intra-articular injections for knee osteoarthritis resulted in cartilage volume loss10• Harm to flexor tendons, neurovascular structures, and compromised integrity7, 11• Platelet Rich Plasma• Sample patient blood → Centrifuge → Separate plasma and platelets from other blood products → Reconcentrate the platelets into the plasma• Platelets release growth factor beta, vascular endothelial growth factor, platelet derived growth factor, transforming growth factor12, 13• Reproduction of cells and regeneration of tissue• New application in the management of musculoskeletal and musculotendinous pathologies• The goal of this literature review is to discuss possible improved outcomes and patient satisfaction when combining platelet rich plasma with corticosteroids in the management of musculoskeletal and musculotendinous pathologies in adults 18 years or older, versus the use of PRP or corticosteroid injections alone.Inclusion Criteria: Corticosteroid injections, platelet rich plasma injections, musculoskeletal and musculotendinous pathologies, short and long-term effects, pain, function, mobility, strength, and satisfactionExclusion Criteria: Articles with patient populations under 18 years old, articles that did not address a musculoskeletal/musculotendinous pathology, outcomes besides those mentioned aboveSearch Engines: Scott Memorial Library and PubMedSearch Terms: “PRP vs Corticosteroid”, “platelet rich plasma versus corticosteroids”, “platelet rich plasma AND corticosteroid”, “long-term effects of corticosteroid injections”, “PRP combined with corticosteroids”, “platelet rich plasma”Filters: Article type for clinical trials, meta-analysis, randomized control trials, systematic review, peer-reviewed journals only, publication date within the past five yearsArticle 1: Platelet-Rich Plasma Has Better Long-Term Results than Corticosteroids or Placebo for Chronic Plantar Fasciitis: Randomized Control Trial2• Three-arm randomized control trialArticle 2: PRP versus Steroids in a Deadlock for Efficacy: Long-term Stability versus Short-Term Intensity – Results from a Randomised Trial3• Randomized control trialArticle 3: Single Intra-Articular Platelet-Rich Plasma versus Corticosteroid Injections in the Treatment of Adhesive Capsulitis of the Shoulder: A Cohort Study4• Cohort studyArticle 4: Platelet-Rich Plasma versus Corticosteroid Intra-Articular Injections for the Treatment of Trapeziometarcarpal Arthritis: A Prospective Randomized Controlled Clinical Trial5• Prospective randomized control trialArticle 5: Ultrasound-Guided Subacromial-Subdeltoid Bursa Corticosteroid Injections: A Study of Short- and Long-Term Outcomes6• Prospective, longitudinal, analytical studyArticle 6: Protective Nature of Platelet-Rich Plasma Against Chondrocyte Death when Combined with Corticosteroids or Local Anesthetics14• Controlled laboratory studyTitle Groups Outcomes Timeline FindingsPlatelet-Rich Plasma Has Better Long-Term Results than Corticosteroids or Placebo for Chronic Plantar Fasciitis: Randomized Control Trial2PRP vs Corticosteroid vs Placebo90 patient’s aged 18 and older who failed conservative treatment for chronic plantar fasciitisPain: Visual analogue Scale (VAS)Pain and Function: Roles and Maudsley Score (R&M)Patient Satisfaction: Short Form-12 Score• Baseline• 1 week• 3 weeks• 3 months• 6 months• 12 months• 18 monthsPatients in the corticosteroid group had greatest improvement in VAS score, R&M score, and Short Form-12 score from baseline to three weeks Patients in the PRP group had greatest improvement in VAS score, R&M score, and Short Form-12 Score from 3 months to 18 monthsPatients had better outcomes for pain, function, and satisfaction with the corticosteroids over the short-term while PRP had better outcomes over the long-termPRP versus Steroids in a Deadlock for Efficacy: Long-Term Stability versus Short-Term Intensity – Results from a Randomised Trial3PRP vs Corticosteroid80 patients 18 years and older who failed conservative treatment for lateral epicondylitis (LE)Pain: Visual Analogue Scale (VAS)Function: Disabilities of the arm, shoulder, and hand (DASH) score + Mayo elbow performance score (MEPS) + grip strength score (GSS)• Baseline• 6 weeks• 3 months• 12 monthsPatients in the corticosteroid group had less pain and better function at 6 weeks post injectionPatients in the PRP group had less pain and better function at 3 and 12 months post injectionEx: Mean VAS for CS at 6 weeks was 13.5 but worsened to 22.75 at 3 monthsSingle Intra-Articular Platelet-Rich Plasma versus Corticosteroid Injections in the Treatment of Adhesive Capsulitis of the Shoulder: A Cohort Study4PRP vs Corticosteroid60 patients with adhesive capsulitis of the shoulderPain: Visual Analogue Scale (VAS)Disability: Shoulder Pain and Disability Index (SPADI) scoreFunction: Range of motion with goniometrySatisfaction: Interval scale “satisfied”, “partly satisfied”, or “not satisfied”• 3 weeks• 6 weeks• 12 weeksNo statistically significant difference between groups for mean VAS at 3 weeks post-injection (p=0.06)Statistically significant difference between groups for mean VAS at 6 weeks (p=0.01) and 12 weeks (p=0.001)Statistically significant difference between groups for SPADI score at 12 weeks (p=0.002)75% of patients in PRP group reported “satisfied”, 52% of patients in corticosteroid group reported “satisfied”Platelet-Rich Plasma versus Corticosteroid Intra-Articular Injections for the Treatment of Trapeziometacarpal Arthritis: A Prospective Randomized Controlled Clinical Trial5PRP vs Corticosteroid33 patients with TMJ arthritisPain: Visual Analogue Scale (VAS)Function: Shortened disabilities of the arm, shoulder, and hand questionnaire (Q-DASH) scoreSatisfaction: “yes” or “no”• Baseline• 3 months• 12 monthsAt 3 months, both the PRP and corticosteroid groups had a statistically significant difference from the mean VAS baseline value (p=0.004 and p=0.001)At 12 months, the PRP group continued to have a statistically significant VAS compared to baseline (p=0.005) while the CS group did not (p=0.105)At 3 months both the PRP and CS groups had statistically significant differences in Q-DASH score compared to baseline (p=0.002 and p=0.014)At 12 months, only the PRP group continued to have a statistically significant Q-DASH score when compared to baseline (p=0.002, p=0.06)At 3 months, patients in corticosteroid group were more satisfiedAt 12 months, patients in the PRP group were more satisfiedProtective Nature of Platelet-Rich Plasma Against Chondrocyte Death when Combined with Corticosteroids or Local AnestheticsMethylprednisolone alone vs PRP alone vs PRP plus methylprednisolone vs Depo-Medrol alone vs PRP plus Depo-MedrolHuman articular chondrocytesCell viabilityCell proliferationViability: 0, 5, 10, and 30 minutesProliferation: 4 daysChondrocyte proliferation for PRP was significantly greater than the separate proliferation of corticosteroids.Chondrocytes that were treated only with a corticosteroid had worse cell viability and proliferation compared to when it was combined with PRP

The Combination of Platelet Rich Plasma and Corticosteroids in Musculoskeletal and Musculotendinous Pathologies

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The Combination of Platelet Rich Plasma and Corticosteroids in Musculoskeletal and Musculotendinous Pathologies

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