Effects of intralesional platelet-rich plasma in the patients with lateral epicondylitis of elbow

Abstract

Lateral epicondylitis (tennis elbow) is a major cause of musculoskeletal pain involving common extensor origin of the forearm. This study was done to determine the effects of platelet-rich plasma on 15 patients with lateral epicondylitis. Selected patients were given intralesional platelet-rich plasma injection, activity of daily living instructions and paracetamol. Patients were assessed every 14 days interval by visual analogue scale, and the patient rated tennis elbow evaluation. Treatment response according to visual analogue scale and patient rated tennis elbow evaluation tool, the difference of improvement was found in respect to time, from pretreatment W1 (just before 1^st Intervention) score to W11 score in every alternate week (p<0.005). This indicates that intralesional platelet-rich plasma is effective in patients with lateral epicondylitis of elbow.

Introduction

One of the most common causes of musculo-skeletal pain is the lateral epicondylitis, which involves common extensor origin of the forearm. Its incidence and prevalence are 1-3% and 10% respectively on general population among working people aged over 45 years old with high-risk jobs (strenuous for the arms).^{1, 2} It arises due to repetitive manual work invol-ving overexertion of wrist and finger extensors and imparts significant disability in terms of quality of daily life activities. Clinically, it expresses both direct and indirect tenderness at the lateral epicondyle.^{1, 2}Although the diagno-sis of lateral epicondylitis is quite straight forward, the optimal management strategy has no consensus.³ However, non-surgical treatment includes rest, physiotherapy, epicondylar counterforce braces, non-steroidal anti-inflammatory drugs, corticosteroid injection, autologous blood injection, platelet-rich plasma injection, percutaneous radiofrequency thermal treatment, extracorporal shock wave therapy, use of low-level laser therapy, acupuncture and botulinum toxin A injection.^4-7

A systematic review and meta-analysis showed the effect of a range of physical interventions like non-electrotherapeutic interventions such as exercise, manipulation technique, orthotics and taping, acupuncture and electrotherapeutic interventions such as laser, ultrasonic therapy with phonophorosis, electromagnetic field therapy, on various outcomes for lateral epicondylitis and failed to explicate any long term favorable effects over that of a placebo group.⁸Local steroid injection has been proven to provide consistent and predictable short-term pain relief but no action on reparative process.⁹ New treatment options include local injection of platelet-rich plasma, autologous blood, prolotherapy and extracorporeal shock wave therapy.^10-12 Platelet-rich plasma is a concentrate of platelets derived from the patient’s own blood. Platelets in platelet-rich plasma contain numerous growth factors and build-up reparative processes.

In lateral epicondylitis, there may be complex changes in the tendon in addition to an inflammatory process. Therefore, platelet-rich plasma owing to its high content of various growth factors may be more efficacious as a healing agent.^13-15 Treatment of patients with chronic lateral epicondylitis with platelet-rich plasma not only reduces pain but also increases function significantly, exceeding the effect of corticosteroid injection even after a follow-up of 2 years.¹⁶In another study, an injection of platelet-rich plasma improves the pain and function in patients suffering from lateral epicondylitis where conservative management has failed.¹⁷ In another study, the effectiveness of a single injection of platelet-rich plasma, after 3 months, showed that the pain and disability of lateral epicondylitis was not adequately reduced.¹⁸ So, infiltration with autologous blood, buffered platelet‐rich plasma or auto-logous growth factors seem promising, but require further investigation.¹⁹

Due to angiogenesis, increase growth factor expression and cell proliferation, platelet-rich plasma therapy is used to increase the reparative process and tensile strength in chronic tendinopathies.²⁰ Some studies showed that platelet-rich plasma therapy decreases pain and increases functional improvement^{16, 17}whereas other studies showed inconclusive results.^{18, 15, 21-22} Hence, this study was conducted to find out the efficacy of platelet-rich plasma in terms of pain relief and functional improvement.

Materials and Methods

A cross-sectional descriptive study was designed involving the final year cadets of Armed Forces Medical College, Dhaka Cantonment. The study was conducted during the period from July to December 2018. Regularly passed cadets of phase IV were included in the study and the response was collected in the first week of October 2018 (3 weeks prior to the beginning of University level summative examination). The purpose and the process of data collection were explained to the cadets and a structured questionnaire was distributed to the volunteers of the target population only. The foreign students were excluded from the study. A total of 63 students (33 males and 30 females) participated in the study. Validated structured set of a questionnaire (Medical student stressor questionnaire - MSSQ)⁸ was selected for the study. For better and easy understanding, questions were translated into the local language (Bangla) and were slightly modified for better adaptation to the topic of the study. Collected data was analyzed in Microsoft Excel and SPSS 19.

Results

Baseline characteristic of the patients and analysis of the pain were described in Table I.

Treatment response in relation to weeks according to VAS

There was significant improvement. In respect to time, improvement was started to occur in pretreatment W1 (just before 1^st Intervention) score vs W3 score which was 6.2 ± 2.1 vs 4.0 ± 1.6 respectively (p=0.000). Then, W3 vs W5 score was 4.0 ± 1.6 vs 3.0 ± 1.3 respectively (p=0.001). Then, W5 vs W7 (just before 2^nd Intervention) score 3.0 ± 1.3 vs 2.7 ± 1.0 respectively (p=0.096). Then, W7 (just before 2^nd Intervention) vs W9 score 2.7 ± 1.0 vs 1.4 ± 0.6 respectively ( p=0.000). Then, W9 vs W11 score was 1.4 ± 0.6 vs 0.5 ± 0.5 respectively (p=0.000). This indicates that intralesional platelet-rich plasma was effective in lateral epicondylitis of elbow (Table II).

Treatment response in relation to weeks according to PRTEE

There was also significant improvement. In respect to time, improvement was started to occur in pretreatment W1 (just before 1^st Intervention) vs W3 score which was 52.2 ± 13.3 vs 42.4 ± 12.9 respectively (p=0.000). Then W3 vs W5 score was 42.4 ± 12.9 vs 34.2 ± 11.5 respectively (p=0.000). Then, W5 vs W7 (just before 2^nd Intervention) score was 34.2 ± 11.5 vs 24.1 ± 7.8 respectively (p=0.000).

Then W7 (just before 2^nd Intervention) vs W9 score 24.1 ± 7.8 vs 12.9 ± 5.5 respectively (p=0.000). Then W9 vs W11 score was 12.9 ± 5.5 vs 4.2 ± 3.1 respectively (p=0.000). This indicates that intralesional platelet-rich plasma was effective in lateral epicondylitis of elbow (Table II).

Discussion

The present study showed that the subjective and objective measures of pain as well as functional parameters were improved following administration of intralesional platelet-rich plasma.

The difference of improvement was found in respect to time, from pretreatment W1 (just before 1st inter-vention) to W11 score in every alternate week which was statistically significant. Patient’s pain was decreased due to subsiding inflammatory process and healing of the diseased tendon by various growth factors secreted from platelets.^13-15 In a similar study, it was found intralesional platelet-rich plasma showed significant improvement in pain scores using visual analogue scale than placebo at 12 and 24 weeks (p value <0.001).²³ Therefore, platelet-rich plasma was effective as it reduces subjective measures of pain.

In the present study, the difference of improvement was found in respect to time, from pretreatment W1 (just before 1st Intervention) to W11 score in every alternate week. Patient’s pain and functional para-meters were improved due to subsiding inflammation, tissue regeneration and increase tensile strength.^{13-15, 20}

In another study, it was found that intalesional platelet-rich plasma injection showed significant pain relief and gain in function as well as quality of life 6 months after intervention by using patient rated tennis elbow evaluation tool, even with a single platelet-rich plasma injection. Where they showed that the mean baseline to 6-month follow-up scores of the patient rated tennis elbow evaluation questionnaires improved significantly from 54.0 to 63.0.²⁵So that the mean platelet-rich plasma was effective as it reduces pain and improves patient’s functional improvement.

Hence, treatment response according to visual analogue scale and patient rated tennis elbow evaluation, the difference of improvement was found in respect to time, from pretreatment W1 (just before 1st Intervention) to W11 score in every alternate week, which was supported by other studies.^25-28

Conclusion

Intralesional platelet-rich plasma showed significant improvement in patients with lateral epicondylitis of elbow.

Ethical Issue

The protocol was approved by the Institutional Review Board of the University (BSMMU/2016/2380).

Conflict of Interest

Authors declare no conflict of interest.

Acknowledgement

We are grateful to the Department of Transfusion Medicine for their kind co-operation.

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