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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 7
| Issue : 2 | Page : 149-154 |
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Ultrasound-tailored treatment of subacromial shoulder pain: Exploring the role of platelet-rich plasma versus steroids
Shailesh Kumar Mishra1, Depinder Kaur2, Manjeet Singh Dhanda3
1 Department of Blood Transfusion, SHKM Government Medical College, Nuh, Haryana, India
2 Department of Anesthesia, SHKM Government Medical College, Nuh, Haryana, India
3 Department of Orthopedics, SHKM Government Medical College, Nuh, Haryana, India
| Date of Submission | 07-Mar-2022 |
| Date of Decision | 29-Jul-2022 |
| Date of Acceptance | 10-Aug-2022 |
| Date of Web Publication | 5-Nov-2022 |
Correspondence Address:
Shailesh Kumar Mishra
Department of Blood Transfusion, SHKM Government Medical College, Nuh, Haryana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/gjtm.gjtm_20_22
Background and Objectives: Subacromial shoulder pain is the most common cause of shoulder pain consultation in musculoskeletal practice. Partial supraspinatus tendon tears have frequently been treated using a subacromial corticosteroid injection or surgery. The clinical use of a platelet-rich plasma (PRP) injection is an alternative treatment method for the condition, despite the paucity of evidence of its efficacy. The objective of the study was to assess the clinical effectiveness of autologous PRP in comparison to steroid injection in terms of pain relief and functional restoration in subacromial shoulder pathology. Methodology: All the patients above 18 years of either sex presenting with complaints of shoulder pain and painful abduction and elevation of arm for more than 6 weeks and not received any steroid injection in the previous 6 months were included in the study. In intra-articular PRP (IA-PRP), i.e., test group, 20 patients received 3 ml of single IA PRP injection, and in the steroid group (control group), 20 patients received 1 ml of intra-articular corticosteroid (IA CS) into glenohumeral joint under ultrasound (US) guidance. All patients were prospectively followed for 6 months. Results: There were no differences in visual analog scale (VAS) and disability scores between the PRP and corticosteroid groups at 1-month follow-up. However, the PRP group had better scores than the corticosteroid group on both the VAS and disability scores at 3- and 6-month follow-up. The VAS and disability scores did not change significantly at 6-month follow-up in the corticosteroid group; however, the PRP group showed continued improvement in both VAS and disability scores between 1- and 6-month follow-up. The PRP group had better scores than the corticosteroid group on shoulder range of motion after postintervention follow-up after 1 month. There were no complications in either group. Conclusion: Both subacromial PRP and corticosteroid injections had a positive clinical response in the treatment of shoulder pain. In view of the reached results, it may be assumed that steroid injections may provide symptomatic relief but not promote healing which makes PRP injection a good alternative as it is simple, easy to use, easily available, prepared from patient's own blood, and cost-effective. US-guided injections may increase the efficacy of accurately targeted injections.
Keywords: Adhesive capsulitis, corticosteroid, intra-articular, platelet-rich plasma, shoulder pain, ultrasound
How to cite this article:
Mishra SK, Kaur D, Dhanda MS. Ultrasound-tailored treatment of subacromial shoulder pain: Exploring the role of platelet-rich plasma versus steroids. Glob J Transfus Med 2022;7:149-54 |
How to cite this URL:
Mishra SK, Kaur D, Dhanda MS. Ultrasound-tailored treatment of subacromial shoulder pain: Exploring the role of platelet-rich plasma versus steroids. Glob J Transfus Med [serial online] 2022 [cited 2023 Mar 28];7:149-54. Available from: https://www.gjtmonline.com/text.asp?2022/7/2/149/360477 |
| Introduction | |  |
Subacromial shoulder pain is the most common cause of shoulder pain consultation in musculoskeletal practice. Subacromial impingement syndrome (SAIS) is a spectrum of rotator cuff lesions from impingement and bursitis to partial- and full-thickness rotator cuff tear. The challenge lies in early diagnosis and providing pain relief with functional restoration of shoulder movements.
Role of ultrasound
MRI is the gold standard imaging and crucial in determining the further course of action for shoulder pain patients. Advancements in the image quality and portability of ultrasound (US) have expanded the role of US in diagnosing extra-articular soft-tissue shoulder pathology.[1],[2] Furthermore, dynamic US examination coupled with high clinical suspicion can confirm the presence of impingement syndrome with a positive predictive value of 0.96.[3] One of the biggest advantages for pain physicians of using US as compared to MRI is portability, easy availability, and cost-effectiveness. US has its role not only in image-guided injections but also in the screening of patients for interventions.
Role of steroids
Corticosteroid injections are commonly administered in tendinous lesions.[4] Subacromial application is considered a cheap and effective therapeutic option, but the side effects of corticosteroids cause concern in clinical practice. Tendinous ruptures following local injections of corticosteroids have also been found, in the repetition of the treatment or even after a single application.[5] In addition, other noninfectious complications may occur, including nerve atrophy, hypopigmentation of the skin, dystrophic calcification around the joint capsule, hyperglycemia, and inhibition of the pituitary–adrenal axis.
Role of platelet-rich plasma
The concept of pain biologics and regenerative medicine is coming in a bigger way in pain management. The logic behind platelet-rich plasma (PRP) is that platelets are the first to arrive at the site of injury and thus have the potential to release growth factors that play a critical role in tissue healing. PRP[6] injection stimulates natural healing through growth factors in the platelets. PRP accelerates the physiological healing process, provides support for the connection of cells, reduces pain, and has an anti-inflammatory and antibacterial effect.[7]
SAIS is the most common disorder of the shoulder, accounting for 44% to 65% of all complaints of shoulder pain, and results from an inflammation and degeneration of the anatomic structures in the subacromial space.
There are two types of treatment for SAIS: nonsurgical and surgical. Some of the nonsurgical treatment options that are recommended include exercise therapy, subacromial corticosteroid injection, rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical modalities.[8]
There is a uniform consensus that a patient should have exhausted a course of adequate nonoperative or conservative management lasting a minimum of 3 months before surgery is considered. However, no standard definition of adequate non operative treatment”exists, nor can one assume that what is adequate for one patient is adequate for another. As there is no consensus regarding adequate nonoperative treatment, it is often overlooked as an effective, noninvasive, and economical treatment option for patients with a chronic, symptomatic, full-thickness rotator cuff tear.[9],[10],[11],[12],[13],[14],[15],[16] PRP, an autologous blood concentrate, has gained popularity in orthopedics cases in comparison to steroid injection[17] in shoulder pain management. Categorized as a minimally manipulated tissue and autologous blood component, PRP has avoided regulatory hurdles of extensive preclinical and clinical testing resulting in widespread use.
However, a high degree of variability in the preparation of PRP to its injection without any image guidance further complicates its effectiveness. Therefore, keeping in mind the safety and broad spectrum of the healing potential of this autologous blood component, we planned a prospective study to assess its efficacy in our shoulder pain patients.
Aims and objective
The aim of this study was to assess the clinical effectiveness of PRP in comparison to steroid injection in terms of pain relief and functional restoration in subacromial shoulder pathology.
| Materials and Methods | | |
Study design
This study was done at SHKM GMC, Nalhar, after obtaining approval from Institutional Ethics Committee (IEC approval letter no.-SHKM/IEC/2020/117, dated- November 21, 2020). All the patients attending the orthopedics outpatient department for subacromial shoulder pain were referred to pain clinic after 6 weeks of failed conservative treatment for the diagnostic US of the affected shoulder by an experienced pain physician using a standardized protocol and criteria for subacromial pathology. Only those patients were recruited in the study that fulfilled the inclusion criteria and gave their informed consent. Participants enrolled in the study were randomized into two groups by simple randomization. Randomization is based on a single sequence of random assignments.
Diagnosis and inclusion criteria were based on the combination of physical examination, radiological findings, and diagnostic US.
Inclusion criteria
- All the patients above 18 years presenting with complaints of shoulder pain and painful abduction and elevation of arm for more than 6 weeks
- Neer test, Hawkins–Kennedy test positive
- Patients who had not received any steroid injection in previous 6 months
- Patients who had not consumed NSAIDS in previous 7 days
- Patients with finding of subacromial effusion, bursitis supraspinatus tendinosis, and partial-thickness tear.
Exclusion criteria
- Patients with glenohumeral joint instability and arthropathy
- Patients with drop arm test and lift off test positive
- Patients with US findings of full-thickness tear
- Patients with signs of systemic infection and those who refused for intervention
- X-ray shoulder suggesting Grade 2 or 3 acromion pathology were excluded from the study in view of external impingement.
Sample size – 40 study subjects (20 in each group).
Sample size was calculated as follows:
N = Z2×p×q/d2
N = Minimum sample size
Z = level of confidence (at 95% confidence interval z = 1.95)
p = prevalence rate of subacromial shoulder pain[18]
q = 1-p
d = desired degree of accuracy or tolerated margin of error
Interventions
Platelet-rich plasma group
An aliquot of 25 mL of venous blood was collected from each patient using a syringe containing 2.5 mL of anticoagulant citrate-dextrose solution. The samples were projected into a TubexAutotube System (MOOHAN Enterprise) and again centrifuged at 1300 rpm for 10 min. The separated plasma was subsequently centrifuged at 2770 rpm for 8 min, and finally, 3 mL of PRP was prepared. Obtained PRP injected to the patient in the PRP group under sterile conditions without any activator within 30 min of centrifugation. More specifically, 2 mL of PRP was injected into the partial tear in the tendon or, in the case of patients with tendinopathy, into hypoechogenic areas using an 18-gauge catheter guided by a 10-MHz US machine (Sonosite). The other 1 mL was injected into the subacromial space under US guidance by a trained pain physician.
Postprocedure instructions
Instructions were given:
- To avoid ice packs and excessive use of their shoulder joint within 48 h after injection
- Not to take NSAIDs or aspirin for 12 days, starting from 1 week before the injection, and ending on the 5th day after injection.
Steroid group
Triamcinolone 40 mg diluted with 0.25% bupivacaine 1 ml along with 1 ml of normal saline was injected in subacromial space under US guidance. Patients were advised not to use excessive use of shoulder joint for the next 48 h. Both the groups were advised to exercise therapy for 6 months.
Outcome measures
Demographic variables such as age, gender, dominant hand, and profession in terms of weight lifting were analyzed.
To evaluate the therapeutic response, we used patient-reported improvement, in pain relief by Visual Analog Scale (VAS) score and functional restoration by disability score, and physician assessment of range of motion at every visit of the patient. The patients were evaluated before the procedure, and after 1 month, 3 months, and 6 months of the intervention. All patients were enquired regarding possible side effects throughout the follow-up period.
Data analysis
The statistical analysis was carried out using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA, version 25.0 for Windows). Scores were presented as mean ± standard deviation, median, and interquartile range. Qualitative or categorical variables (e.g., age and gender) were described as frequencies and proportions. Normality of quantitative data was checked by the measures of Kolmogorov–Smirnov tests of normality. Independent t-test was applied for the comparison of age of two groups (PRP and steroid). Mann–Whitney U-test was used for the statistical analysis of scores. Proportions were compared using the Chi-square or Fisher's exact test whichever was applicable. Correlation and regression tests applied wherever needed. All statistical tests were two-sided and were performed at a level of α = 0.05.
| Results | | |
This study included 40 patients with complaints of shoulder pain with painful abduction and elevation of arm for more than 6 weeks. The patients were randomized into two groups, the PRP group (Group I) and the steroid group (Group II). The two groups were statistically matched regarding demographic profile sex [Table 1] and age [Table 2].
Risk factors, painful site involved, and the baseline US findings at the start of the study were statistically analyzed [Table 3],[Table 4],[Table 5].
VAS pain scores were significantly lower in the PRP groups as compared to the steroid group at 1-month, 3-month, and 6-month follow-up postintervention [Table 6].
The difference in disability scores between the two groups depicts that the PRP group had significantly lower disability scores at 3- and 6-month follow-up postintervention [Table 7].
The VAS and disability scores did not change significantly at 6-month follow-up in the corticosteroid group; however, the PRP group showed continued improvement in both VAS and disability scores between 1- and 6-month follow-up.
The PRP group had better scores than the corticosteroid group on shoulder range of motion after postintervention follow-up [Table 8]. | Table 8: Comparison of range of movement between platelet-rich plasma group and steroid group
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When the range of motion of shoulder was compared between the two groups, shoulder abduction was significantly better in the PRP group at 3 months postintervention.
Shoulder active flexion was significantly better in the PRP group at 1 month and 3 months postintervention.
Range of active shoulder internal rotation was statistically better in the PRP group at 3 months and 6 months postintervention.
Range of active shoulder external rotation was significantly better in the PRP group at 6 months postintervention.
There were no complications in either group.
| Discussion | | |
PRP is considered at present as an investigational drug because there is insufficient data to support the use of PRP to relieve pain. Regenerative medicine has opened a new emerging window for the restoration of tissues with severe injuries using PRP.
Several studies had investigated the usefulness of PRP in treatment of rotator cuff treatment administered either as an adjuvant to surgical repair[19] or as a primary treatment,[20] however, results remain inconclusive,[21] making it difficult to conclude if PRP injections are an effective treatment.
In this study, we compared the clinical effectiveness of PRP in comparison to steroid injection in terms of pain relief and functional restoration in subacromial shoulder pathology.
The results from the current study showed that PRP had more beneficial effects than corticosteroids for the treatment of subacromial shoulder pain. A comparison of the two groups at the 1-month time point indicated that there was no significant difference between them in terms of pain and function. However, at the 3-month time point, the differences were statistically significant, reflecting the extended effects of PRP compared to the corticosteroid.
Many studies have shown similar results on the relative efficacy of PRP,[22] but others have found no overall significant effects of PRP on functional outcomes and repair integrity.[5],[23],[24],[25] A review by Chen et al.[26] reported that leukocyte-poor PRP appeared to significantly reduce the retear rate compared with the control and may improve tendon-to-bone healing based on significant differences in the failure-to-heal rate along with improving patient pain scores.
Platelets are known for their importance in clotting. Furthermore, platelet products represent an enriched autologous source of platelets containing growth factors at higher concentrations than normal physiological levels. These factors augment revascularization of the injury areas and promote tendon healing, resulting in the improvement of pain and function.[27] Many animal models have proven the beneficial effects of growth factors in PRP on tendon healing.[28]
In another randomized trial by Rha et al.,[5] PRP injection and dry needling were used in two groups of 17 patients for the treatment of RC diseases. In this study, PRP injection and dry needling were performed twice with a 4-week interval between injections. They showed that PRP is more effective than dry needling (dry needling is a procedure where nonmedicated needles are inserted into painful tissues, with the goal of releasing trigger points, mini muscle spasms that can cause pain and limit the functional range of motion.) in the treatment of both intra-articular and bursal surface tendinopathy. These findings are similar to the result of our study.
Randelli et al. stated that all their patients had a reduction in pain, functional improvement, with no adverse effect when using PRP for the augmentation of arthroscopy in the treatment of cuff repairs. This was shown by the improvement in the constant score at 12 weeks following the repair.[29]
Saltzman et al. concluded that there is an improvement in pain and reduction in the rehabilitation period in cases, where PRP augmentation was done intraoperatively during arthroscopy for patients with rotator cuff tear. When PRP is used to augment rotator cuff repair, it resulted in decreased retear rates, early going back to day-to-day activity, and improvement in pain.[19]
Ilhanli et al. compared between PRP therapy and physiotherapy in the treatment of supraspinatus tendinopathy and conclude that PRP therapy is a well-tolerated therapeutic application that showed encouraging clinical results in patients with chronic tendinopathy and may be as effective as physiotherapy.[30] Parada et al. suggested that surgery, as a classic option for treating these cases, has risks such as infection and damage to surrounding nerves and blood vessels with up to 6 months of recovery period depending on the severity of the injury. Stiffness, weakness, chronic pain, or incomplete healing after surgery can occur.[31]
| Conclusion | | |
Both subacromial PRP and corticosteroid injections had a positive clinical response in the treatment of shoulder pain. In view of the reached results, it may be assumed that steroid injections may provide symptomatic relief but not promote healing which makes PRP injection a good alternative as it is simple, easy to use, easily available, prepared from patient's own blood, and cost-effective, PRP is considered a safe therapy that promotes healing, decreases inflammation while avoiding possible adverse effects associated with the use of corticosteroid injection. US-guided injections may increase the efficacy of accurately targeted injections.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | de Jesus JO, Parker L, Frangos AJ, Nazarian LN. Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: A meta-analysis. AJR Am J Roentgenol 2009;192:1701-7.  |
| 2. | Ottenheijm RP, Jansen MJ, Staal JB, van den Bruel A, Weijers RE, de Bie RA, et al. Accuracy of diagnostic ultrasound in patients with suspected subacromial disorders: A systematic review and meta-analysis. Arch Phys Med Rehabil 2010;91:1616-25. |
| 3. | Read JW, Perko M. Shoulder ultrasound: Diagnostic accuracy for impingement syndrome, rotator cuff tear, and biceps tendon pathology. J Shoulder Elbow Surg 1998;7:264-71. |
| 4. | Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev 2003;2003(1):CD004016. |
| 5. | Rha DW, Park GY, Kim YK, Kim MT, Lee SC. Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease: A randomized controlled trial. Clin Rehabil 2013;27:113-22. |
| 6. | Lynch SE, Nixon JC, Colvin RB, Antoniades HN. Role of platelet-derived growth factor in wound healing: Synergistic effects with other growth factors. Proc Natl Acad Sci U S A 1987;84:7696-700. |
| 7. | Scarpone M, Rabago D, Snell E, Demeo P, Ruppert K, Pritchard P, et al. Effectiveness of platelet-rich plasma injection for rotator cuff tendinopathy: A prospective open-label study. Glob Adv Health Med 2013;2:26-31. |
| 8. | Rhon DI, Boyles RB, Cleland JA. One-year outcome of subacromial corticosteroid injection compared with manual physical therapy for the management of the unilateral shoulder impingement syndrome: A pragmatic randomized trial. Ann Intern Med 2014;161:161-9. |
| 9. | Goldberg BA, Nowinski RJ, Matsen FA 3 rd. Outcome of nonoperative management of full-thickness rotator cuff tears. Clin Orthop Relat Res 2001;(382):99-107. |
| 10. | Hawkins RH, Dunlop R. Nonoperative treatment of rotator cuff tears. Clin Orthop Relat Res 1995;321:178-88. |
| 11. | Wirth MA, Basamania C, Rockwood CA Jr. Nonoperative management of full-thickness tears of the rotator cuff. Orthop Clin North Am 1997;28:59-67. |
| 12. | Wolf BR, Dunn WR, Wright RW. Indications for repair of full-thickness rotator cuff tears. Am J Sports Med 2007;35:1007-16. |
| 13. | Ainsworth R, Lewis JS. Exercise therapy for the conservative management of full thickness tears of the rotator cuff: A systematic review. Br J Sports Med 2007;41:200-10. |
| 14. | Bokor DJ, Hawkins RJ, Huckell GH, Angelo RL, Schickendantz MS. Results of nonoperative management of full-thickness tears of the rotator cuff. Clin Orthop Relat Res 1993;294:103-10. |
| 15. | Handelberg FW. Treatment options in full thickness rotator cuff tears. Acta Orthop Belg 2001;67:110-5. |
| 16. | Tanaka M, Itoi E, Sato K, Hamada J, Hitachi S, Tojo Y, et al. Factors related to successful outcome of conservative treatment for rotator cuff tears. Ups J Med Sci 2010;115:193-200. |
| 17. | Say F, Gurler D, Bulbul M. Platelet-rich plasma versus steroid injection for subacromial impingement syndrome. J Orthop Surg (Hong Kong) 2016;24:62-6. |
| 18. | Tangrood ZJ, Gisselman AS, Sole G, Ribeiro DC. Clinical course of pain and disability in patients with subacromial shoulder pain: A systematic review protocol. BMJ Open 2018;8:e019393. |
| 19. | Saltzman BM, Jain A, Campbell KA, Mascarenhas R, Romeo AA, Verma NN, et al. Does the use of platelet-rich plasma at the time of surgery improve clinical outcomes in arthroscopic rotator cuff repair when compared with control cohorts? A systematic review of meta-analyses. Arthroscopy 2016;32:906-18. |
| 20. | Kesikburun S, Tan AK, Yilmaz B, Yaşar E, Yazicioğlu K. Platelet-rich plasma injections in the treatment of chronic rotator cuff tendinopathy: A randomized controlled trial with 1-year follow-up. Am J Sports Med 2013;41:2609-16. |
| 21. | 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;26:1984-99. |
| 22. | Mautner K, Colberg RE, Malanga G, Borg-Stein JP, Harmon KG, Dharamsi AS, et al. Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: A multicenter, retrospective review. PM R 2013;5:169-75. |
| 23. | Schwitzguebel AJ, Kolo FC, Tirefort J, Kourhani A, Nowak A, Gremeaux V, et al. Efficacy of platelet-rich plasma for the treatment of interstitial supraspinatus tears: A double-blinded, randomized controlled trial. Am J Sports Med 2019;47:1885-92. |
| 24. | Shams A, El-Sayed M, Gamal O, Ewes W. Subacromial injection of autologous platelet-rich plasma versus corticosteroid for the treatment of symptomatic partial rotator cuff tears. Eur J Orthop Surg Traumatol 2016;26:837-42. |
| 25. | Tantisiriwat N, Wongmatikul V, Jaroenarpornwatana A, Janchai S. Validation and reliability of the Thai version of the Oxford shoulder score. J Med Assoc Thai 2018;101:509-15. |
| 26. | Chen X, Jones IA, Togashi R, Park C, Vangsness CT Jr. Use of platelet-rich plasma for the improvement of pain and function in rotator cuff tears: A systematic review and meta-analysis with bias assessment. Am J Sports Med 2020;48:2028-41. |
| 27. | Lange S. Are Platelet-Rich Plasma Injections a Better Choice Compared to Glucocorticoid Injections for the Treatment of Rotator Cuff Tendinopathy in Adult Patients? Thesis. Augsburg University; 2018. Available from: https://idun.augsburg.edu/cgi/viewcontent.cgi?article¼1347. [Last accessed on 2021 Aug 24]. |
| 28. | Mei-Dan O, Carmont MR. The role of platelet-rich plasma in rotator cuff repair. Sports Med Arthrosc Rev 2011;19:244-50. |
| 29. | Randelli P, Arrigoni P, Ragone V, Aliprandi A, Cabitza P. Platelet rich plasma in arthroscopic rotator cuff repair: A prospective RCT study, 2-year follow-up. J Shoulder Elbow Surg 2011;20:518-28. |
| 30. | Ilhanli I, Guder N, Gul M. Platelet-Rich of complications after rotator cuff surgery. Curr Rev Musculoskelet Med 2015;8:40-52. |
| 31. | Parada SA, Dilisio MF, Kennedy CD. Management of complications after rotator cuff surgery. Curr Rev Musculoskelet Med 2015;8:40-52. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]
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