Journal Club January 2017: Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections: A Prospective, Double-Blind, Randomized Controlled Study

Article Title: Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections: A Prospective, Double-Blind, Randomized Controlled Study

Author: Yetsa A. Tuakli-Wosornu, MD, MPH Alon Terry, MD, Kwadwo Boachie-Adjei, BS, CPH, Julian R. Harrison, BS, Caitlin K. Gribbin, BA, Elizabeth E. LaSalle, BS, Joseph T Nguyen, MPH, Jennifer L. Solomon, MD, Gregory E Lutz, MD

Journal: PM R. 2016 Jan;8(1):1-10; quiz 10. doi: 10.1016/j.pmrj.2015.08.010. Epub 2015 Aug 24.

Discussion:

Musculoskeletal complaints are the second most common cause for doctor visits in the United States. The overwhelming odds indicate that these complaints are of low back pain (LBP). In fact, more than 80% of American adults experience at least one episode of LBP during their lifetime. Various structures within the human body can cause LBP and the intervertebral disk (IVD) accounts for more than 40% of cases of chronic LBP. Being the largest avascular structure in the human body, the IVD has poor inherent healing potential. Therefore, it is necessary to develop a recipe for a healing cascade to address the numerous pathologies associated with the IVD. Platelet Rich Plasma (PRP) can provide the essential ingredients for the body to address these pathoanatomic processes and help treat LBP.

PRP is thought to provide the necessary growth factors that are lacking at injurious sites, especially ones with a scarcity of vasculature like the IVD. Placing a high concentration of growth factors (PDGF, VEGF, TGF-Beta, IGF etc.) directly at the site of collagen injury or degeneration can help restore the integrity of the structures via a healing response. In addition, the cytokines in PRP act as humoral mediators to induce the natural healing cascade. In comparison to surgery, PRP is readily available and cost-effective.

In this study, Tuakli-Wosornu et al 2016 investigated whether a single intradiskal injection of PRP delivered to symptomatic degenerative IVD(s), would be clinically beneficial for individuals with chronic diskogenic LBP. This was a prospective, double-blind, randomized controlled trial. A single independent observer randomized 47 participants into two treatment groups (29 in the treatment and 18 in the control). PRP or contrast agent was used under standardized protocol as the injectate for either group. Only disk levels that elicited pain with evidence of incomplete annular disruption were injected. Four internationally validated surveys were used as outcome measures over the 8 weeks of follow-up: the FRI, the NRS, the SF-36, and the modified NASS Outcome Questionnaire.

Participants who received intradiskal PRP injections experienced significantly greater improvements in FRI, NRS-Best Pain, and NASS satisfaction scores compared with those who received contrast agent alone over 8 weeks. Moreover, the improvement in FRI scores lasted for up to 1 year or more for the PRP group. Consequently, this study highlights that intradiskal PRP can be considered a viable option to alleviate pain and restore function for a universally common complaint of low back pain.

Discussion Author: Altamash Raja, OMS-IV, Lincoln Memorial University-DeBusk College of Osteopathic Medicine

Discussion Points:

  1. What are the most common causes of chronic low back pain? Which causes are more prevalent in the various age groups? Young adults (18-35)? Middle aged (35-60)? Elderly (>60)?
  2. What therapeutic objectives should techniques for diskogenic low back pain aim to achieve?
  3. Describe some of the current limitations regarding PRP injections.
  4. How does PRP compare to other interventional treatment options such as facet joint injections, epidural steroid injections etc.? What are the pros? Cons?
  5. What other orthobiologics can be utilized for treatment of musculoskeletal complaints? Where does the future go?
  6. What are some osteopathic techniques for the treatment of low back pain that should be explored further?
  7. When is surgery the preferred treatment option, even in the eyes of a non-operative expert?

LEARN MORE by downloading the article:

Journal Article Summary and Discussion Questions January 2017

Journal Article January 2017

 

Journal Club December 2016: The Impact of Trunk Impairment on Performance-Determining Activities in Wheelchair Rugby

Article Title: The Impact of Trunk Impairment on Performance-Determining Activities in Wheelchair Rugby

Author: V. C. Altmann, B. E. Groen, A. L. Hart, Y. C. Vanlandewijck, J. van Limbeek, N. L.W. Keijsers

Journal: Scandinavian Journal of Medicine & Science in Sports

Discussion:

Imagine the game of rugby, one of the rougher contact sports played worldwide. Now imagine that each of those rugby athletes are tetraplegic and are in a wheelchair, but don’t tone down the contact. Wheels screeching, chairs crashing, crowds roaring! This is the adaptive sport known as wheelchair rugby.

The following study by Altmann et al. 2016 observed the impact of the severity of an individual’s trunk impairment on their performance in wheelchair rugby. They assessed the relationship between the Trunk Impairment Classifications (TIC) system with wheelchair activities that determine the performance in the sport of wheelchair rugby. Typically the lower the TIC score, the more physically impaired an individual is.

The study took 55 athletes with a variety of TIC scores and put them through a series of tests. Specifically, they looked at four activities that they thought would be really affected by trunk impairment, including: a 10-m sprint test, a turn test, a tilt test and a maximal initial acceleration test. Each athlete performed three trials per test. Two athletes participated simultaneously during each test, to ensure some competitiveness.

Ultimately the performance of a wheelchair rugby athlete is determined by three separate items: (1) how they avoid a hit (maneuverability and acceleration), (2) how well they hit (acceleration, peak speed and impulse of hit) and (3) how well they free themselves from being held by the opposing player’s chair (impulse and tilting). They better they performed on the four assigned activities, the better they would perform in a real-life athletic setting of a wheelchair rugby match.

As a result, the study showed that the players with higher TIC scores were better athletes in wheelchair rugby than those with lower TIC scores.

Discussion by James Meiling, OMS-II, Texas College of Osteopathic Medicine

Discussion Points:

  1. Why is it important to rank paraolympic athletes by severity of disability?
  2. Describe the terms hitting and tilting when related to wheelchair rugby.
  3. How would a larger sample size aid the committees that designed the Trunk Impairment Classification (TIC) guidelines?
  4. Athletes with which health conditions participated in this study? Additionally, how would each health condition affect the performance of each athlete?
  5. Why was it important to test two athletes at the same time? How would the results of the study have differed if they ran each test individually, one at a time?
  6. Can these results be used to determine effectiveness of an athlete in other adaptive sports?
  7. Why do guidelines differ from one adaptive sport to another?
  8. How could future studies improve upon the Trunk Impairment Classification system?
  9. With the results of this study, what implications does this have for the future athletes you see within your practice?

LEARN MORE by downloading the article:

Journal Discussion Questions December 2016

Journal Article December 2016

Journal Club November 2016: Older Age as a Prognostic Factor of Attenuated Pain Recovery After Shoulder Arthroscopy

Article Title: Older Age as a Prognostic Factor of Attenuated Pain Recovery After Shoulder Arthroscopy

 

Author: Simon CB, Riley III JL, Coronado RA, Valencia C, Wright T, Moser M, Farmer K, George SZ

 

Journal: PM R. 2016 Apr;8(4):297-304. doi: 10.1016/j.pmrj.2015.09.004. Epub 2015 Sep 12.

 

Discussion:

 

Shoulder injuries, pain, and subsequent shoulder surgeries are common among the older adults.   It is estimated that up to 30% of adults older than 50 years of age have been affected by shoulder pain, a major indicator for shoulder surgery and in particular, arthroscopic rotator cuff repair.  Due to the widespread prevalence of shoulder pain and surgery in the community, Simon et.al conducted a prospective cohort study looking at the variance between postoperative outcomes in younger, middle-aged, and older adults.  The article was originally published in the American Journal of Physical Medicine and Rehabilitation in April 2016 and obtained via the online journal for review.

 

Inclusion criteria included age (between 20 to 79 years of age), pain in the anterior, lateral, or posterior shoulder, a diagnosis of musculoskeletal dysfunction based on imaging and clinical assessment, and having been scheduled for an arthroscopic shoulder procedure.  Exclusion criteria included pain for more than 3 months in other regions, prior shoulder surgery in the past year, shoulder-related fractures, tumor, or infections, and current or previous chronic pain disorders, psychiatric management or gastrointestinal or renal diseases.  A total of 139 participants were recruited with 30 older adults, 57 younger adults, and 52 middle aged adults.

 

The study observed both subjective and objective measures of dysfunction and pain utilizing self-reported pain duration and intensity, disability levels, and current medications together with movement-evoked pain and experimental pain response physical testing.  Each utility was assessed pre-operatively, and three and six months post-operatively.  Univariate analysis was used to examine the difference between preoperative physical testing with 3 and 6 month measures postoperatively.  Influence of age group on pain outcomes were performed using a multivariate regression analyses, accounting for prognostic factors preoperative (movement-evoked pain, pain duration, and pain catastrophizing), intraoperatively (arthroscopic procedure), and postoperatively (analgesic use).

 

Results revealed that older adults had significantly higher movement-evoked pain intensity and experimental pain response at 3 months postoperatively compared to young and middle-aged adults.  Older age is a positive predictor for movement-evoked pain at 3 and 6 months and experimental pain at 3 months.  However, there were no age-group related differences in outcomes.  These results provide data for older age contributing to poorer pain outcomes after shoulder arthroscopy and further age-related studies on managing pain among older adults were recommended.

 

Discussion Points:

 

  1. What is the study’s objective?
  2. What is the main rationale behind investigating the objective?
  3. What methodological approach (statistical analysis, design) was used and why was it used?
  4. Was the sample size adequate?
  5. Are there any other factors that can be considered for inclusion or exclusion criteria in the study?
  6. What were the main results of the study?
  7. What were the strengths and weakness of the study?
  8. What biologic factors do you think accounts for the variance in movement-evoked pain intensity between older adults and middle age/young adults?
  9. What recommendations can you make to future older age patients who present with shoulder pain?  Would you change your conversation based on the results found in this article?
  10. What OMM techniques could be utilized in the management of shoulder pain and at what stage of the treatment do you think these techniques will benefit the patients, regardless of age?

LEARN MORE by downloading the article:

Journal Discussion Questions November 2016

Journal Article November 2016

Journal Club October 2016: Impact of Needle Diameter on Long-Term Dry Needling Treatment of Chronic Lumbar Myofascial Pain Syndrome

Whether it is in the inpatient or outpatient setting, myofascial pain is a common problem that all physiatrists will eventually see in their medical career. The following study conducted by Wang et al. 2016 examined the impact of needle diameter on lumbar myofascial pain. Specifically, the researchers were looking to identify whether the diameter of a dry-needle had an effect on myofascial pain. The article was originally published in the American Journal of Physical Medicine and Rehabilitation. Through a web search, on the database PUBMED, the article was obtained to read.

This was a double-blinded study. Wang et al. 2016 separated 48 patients with a history of lumbar myofascial pain into one of three groups. Each group corresponded to a specific dry-needle diameter. The three groups examined were: 0.25 mm, 0.5mm, and 0.9mm.

The primary outcomes used were the visual analog score (VAS) and the short form health survey (SF-36). Patients rated their pain before treatment and three months after treatment. Secondary outcomes examined included: pain intensity after treatment and whether the patient would consider undergoing the same treatment again if needed.

The researchers determined that dry-needling as a practice improved patient’s pain scores over a three month period regardless of needle diameter. They also determined that the efficacy of the larger diameter needle (0.9mm) improved over the course of three months in comparison to the other two diameter sizes. Patient’s willingness to return for another treatment improved as time went on with the larger diameter needle.

In conclusion, dry-needling and the diameter of the needle both play an important role in the treatment of myofascial pain.  

Discussion Points:

1) What is myofascial pain syndrome? How is it diagnosed?

2) What is dry needling therapy? Can you think of any other forms of alternative medicine that have been used to treat myofascial pain?

3) What is the difference between a tender point and a trigger point? Could dry needling also be used as a treatment modality for tender points?

4) Do you think the diameter of the needle could play a role in other treatment modalities (trigger points, nerve blocks, etc.) for chronic pain?

5) Do you think the VAS score is an accurate way to measure pain? Do you think another scale could be used or designed to better measure a patient’s pain level?

6) How can this study be used to further improve treatment for myofascial pain?

7) What type of future research could be designed based on this new study?

8) With this new information, how will you incorporate this information into your own medical practice?

LEARN MORE by downloading the article:

Journal Article October 2016

Journal Discussion Questions October 2016