INTRODUCTION:

Platelet rich plasma is an autologous blood derivative that has been used in different medical fields, ranging from dermatology to ophthalmology and orthopedic surgery, with the aim of stimulating tissue healing through the local administration of the milieu of platelet derived growth factors and other bioactive molecules⁽¹⁾

The articular cartilage is highly specialized connective tissue in mobile joints, whose main function is to provide an articular surface with low friction and efficient support for mechanical loads. It is a tissue that is devoid of blood vessels, lymphatic vessels and nerve endings. So its intrinsic regenerative ability is low.

Biological changes including biomechanical and metabolic ones as well as traumas can lead to a loss in cartilage homeostasis, which significantly increases with age. This results in an accelerated reduction of the articular surface, which cause osteoarthritis.

Clinically, this decrease is characterized by joint pain, stiffness, motion restriction and variable degree of swelling, Treatment of osteoarthritis range of techniques that only relieve pain, such as arthroscopy and an initial pharmacological treatment with analgesics and anti-inflammatory drugs. In knee osteoarthritis, platelet rich plasma injection aim to promote cartilage repair and relieve osteoarthritic symptoms, potentially delaying the need for joint replacement surgery⁽²⁾.

In the orthopedic practice its main application is in sports medicine^(2,3) and in the treatment of degenerative disorders in the particular osteoarthritis⁽⁴⁾. Due to its intrinsic features, platelet rich plasma is believed to play a beneficial role in joint tissue homeostasis, exerting a positive modulation on all the articular tissues involved in the osteoarthritis degenerative process. ie, cartilage, menisci and synovia⁽⁵⁾

Some studies have reported a reduction in platelet rich plasma efficacy in moderate and advanced (Kellegren Lawrence grade 3-4) knee osteoarthritis as this group of patients have higher pain and functional impairment, which require more medical attention. Grade 4 osteoarthritis generally requires surgical treatments such as tibial osteotomy and total knee replacement^(6,7).

In the present study the effects of plasma rich protein administration to control the disease activity of the subjects with grade 3 knee osteoarthritis were investigated and compared with the subjects who have not received platelet rich plasma and only treated with drugs.

METHODOLOGY:

Patients in the age range of 45-75 years who visited our physical medicine and rehabilitation outpatient clinic because of the single knee pain for a minimum six months were recruited for this study.

Osteoarthritis was diagnosed according to the American College of Rheumatology (ACR) criteria. Radiological assessment was conducted by standing anteroposterior and lateral knee radiography according to Kellegren Lawrence grading system.

A total of thirty patients identified with grade 3 knee osteoarthritis (with multiple osteophytes, definite joint space narrowing, sclerosis and bony deformity) were studied.

The exclusion criteria were bilateral symptomatic knee osteoarthritis; age older than 75 years; intra articular steroid; recent history of severe trauma of the affected knee; active infection; tumor existence around the knee; history of diabetes mellitus, severe cardiovascular diseases, coagulopathies, malignant, immunosuppressive, collagen vascular or auto immune disorders, pregnancy or breastfeeding.

Only the subjects who signed a written consent form were included in the study. Study participants attended a screening visit that included recording of medical history, physical examination, laboratory testing and a survey of medication use.

Platelet rich plasma is a sterile condition was injected by a physician using a classic lateral approach with a 22G needle with the subjects in a supine position with the knee in full extension. After the injections patients were told to actively were told to actively flex and extend their knees a few times to allow the platelet rich plasma to spread throughout the joint before swelling. The subjects were discharged to home after 15-20 minutes of rest with instructions to have rest to limit weight bearing and to use cold packs 3-4 times a day.

Patients were evaluated before the procedure and after the procedure with a Visual Analog Scale (VAS) for pain, the Western Ontario and Mc Master Universities Arthritis Index (WOMAC).

PROCEDURE:

Thirty subjects were selected based on the inclusion and exclusion criteria. Subjects were divided into 2 groups as Group A(15) and Group B (15).

For Group A subjects physiotherapy treatment such as stretching and strengthening exercises for quadriceps was given after the platelet rich plasma procedure from the day of surgery.

0-3 DAYS AFTER PROCEDURE:

· Immobilisation of affected joints

· Gentle AROM exercise out of the immobilizing device.

3 DAYS TO 10-14 DAYS AFTER PROCEDURE:

· Continue with AROM out of the device 3 times a day for 5mins a session

· Upper body exercise are allowed

14 DAYS AFTER PROCEDURE TO 6-8 WEEKS AFTER PROCEDURE

· Stretching exercise for quadriceps at least once a day 3-4 repetitions holding for 20-30 secs.

· Joint mobilization as needed to restore normal joint mechanics

· Stretching exercise: concentric activities initially and with progression (single press) eccentric.

6-8 WEEKS AFTER PROCEDURE:

· Continued strengthening of the affected area with increases in resistance repetition.

· Impact control exercise with progression from single plane to multi planar landing and agility drills with progression increase in velocity and amplitude.

The Group B subjects were observed who have not received physiotherapy exercises after platelet rich plasma procedure and treated only with drugs(acetaminophen).

RESULT:

From the statistical analysis made with the quantitative data revealed statistically significant difference between the Group A and B, and also within the group. Comparison of post test results of visual analogue scale for Group A and Group B is shown in table 1.Both Groups A and B post-test values of visual analogue scale were compared in the Graph 2 which shows that Group A is greater significant than Group B with the p=0.001.

Table 1: Comparison of post test values of visual analog scale between Group A and Group B

Visual analog scale

Test

Mean

Standard deviation

t value

p value

Group A

Group B

Post test

2.790

3.52

0.63

0.64

3.148

<0.001

Graph 1: Comparison of mean post test score of body mass index between Group A and Group B

Table 2: Comparison of post test values of WOMAC-Pain between Group A and Group B

WOMAC-Pain

Test

Mean

Standard deviation

t value

p value

Group A

Group B

Post test

6.04

7.01

0.82

3.2396

<0.001

Graph 2: Comparison of mean post test score of WOMAC-Pain between Group A and Group B

Table 3: Comparison of post test values of WOMAC-Stiffness between Group A and Group B

WOMAC-Stiffness

Test

Mean

Standard deviation

t value

p value

Group A

Group B

Post test

2.55

3.09

0.60

0.47

2.7440

<0.001

Graph 3: Comparison of mean post test score of WOMAC-Stiffness between Group A and Group B

Table 4: Comparison of post test values of WOMAC-Reduction of Physical function between Group A and Group B

WOMAC-Reduction of Physical function

Test

Mean

Standard deviation

t value

p value

Group A

Group B

Post test

30.53

31.40

4.610

4.010

0.5515

0.04

Graph 4: Comparison of mean post test score of WOMAC-Reduction of Physical function between Group A and Group B

Post values of WOMAC-Pain were compared between Group A and B is shown in Table 2.The post test mean values of WOMAC-Pain of both Group A and Group B were compared in the Graph 2 which shows that Group A is greater significant than Group B with the p<0.001. Table 3 shows the comparison of post tests results between Group A and Group B of WOMAC-Stiffness. The post test mean values of WOMAC-Stiffness of both Group A and Group B were compared in the Graph 3 which shows that Group A is greater significant than Group B with the p<0.001.

Post values of WOMAC-Reduction of Physical function were compared between Group A and B is shown in Table 4.The post test mean values of WOMAC-Reduction of Physical function of both Group A and Group B were compared in the Graph 4 which shows that Group A is greater significant than Group B with the p<0.001.

Statistical analysis shows that there is a significant difference between pre and post values in both Group A and B. Group A being highly significant with a greater difference in pre and post tests values with a p<0.0001 for Visual analogue scale, WOMAC-Pain, stiffness and reduction of physical function.

DISCUSSION:

One of the major result of the study was the effectiveness of platelet rich plasma treatment for pain and physical function in grade 3 knee osteoarthritis. In this study, during the follow up period, significant improvements were observed in the Visual analogue scale, WOMAC values compared to their pre-injection values.

According to the study of kon et al, which examined platelet rich plasma effectiveness on the knee joint, better results were achieved in patients with a low degree of cartilage degeneration⁽¹⁰⁾. There is not enough data regarding the effectiveness of platelet rich plasma in the regeneration of substantial and irreversible bone and cartilage damage⁽¹⁴⁾. In the studies conducted so far, the lack of standardization of platelet rich plasma dosing regimens makes it difficult to compare outcomes of studies for the evaluation of clinical effectiveness.

The amount and effectiveness of platelet concentration and the growth factors related to platelets in platelet rich plasma content will vary according to platelet rich plasma preparation techniques. The follow up period in many studies was short term and there were no control groups^(9,15). The strength of this study was the prospective randomized design. The absence of a control group and the relatively small patients numbers were the limitations of the study.

This minimally invasive injection procedure appears to be safe and effective and since platelet rich plasma injections biologically change the articular cartilage, they may be a worthwhile treatment option even in moderate knee osteoarthritis. Further studies are required with larger sample sizes with longer follow-ups and objective outcomes measures. In conclusion, this study shows that the physiotherapy interventions are effective when it is given after the platelet rich plasma procedure by decreasing pain, stiffness and improving the patients physical functions when compared to that of the patients followed with only medical management.

Hence this study proves to introduce the benefits of physiotherapeutic effects along with that of platelet rich plasma therapy in treating subjects with grade 3 osteoarthritis of knee.

CONCLUSION:

This study concludes that the physiotherapy interventions are effective when it is given after the platelet rich plasma procedure by decreasing pain, stiffness and improving the patient’s physical functions when compared to that of the patients followed with only medical management. Hence this study proves to introduce the benefits of physiotherapeutic effects along with that of PRP therapy in treating subjects with Grade 3 osteoarthritis of knee

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

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Received on 08.12.2018 Modified on 11.03.2019

Research J. Pharm. and Tech 2020; 13(5):2065-2068.

DOI: 10.5958/0974-360X.2020.00371.6