PRP or Cortisone for Knee Pain and Arthritis?
New 2020 research from the Journal of Orthopaedic Surgery and Research looks into intra-articular joint injections of platelet rich plasma (PRP) versus corticosteroid (cortisone) in the treatment of moderate knee osteoarthritis: randomised controlled study with a 1-year follow up.
Osteoarthritis (OA) is a progressive chronic disorder associated with pain, functional impairment and joint deformity. Previously, OA has been considered a normal sign of aging and was described as a degenerative disorder that mainly causes cartilage loss. However, more recent evidence has shown that that it evolves due to the interaction of multiple complex risk factors affecting the whole joint tissue. Currently, no disease modifying treatment exists which makes joint replacement the only viable solution for these patients. Routine conservative treatments include education and self-management, exercises, weight loss, bracing, heat therapy, acupuncture, biomechanical assistance. Pharmacological treatments include oral non-steroidal anti-inflammatory drugs, intra-articular injections of cortisone, hyaluronic acid injections, and blood-derived products, including platelet-rich-plasma (PRP) (highly recommended when the use of oral analgesics or anti-inflammatories fails to release disease symptoms). Joint injection treatment of corticosteroids provides a short-term reduction in pain. This approach, however, has limited efficacy in delaying disease progression, as well as undesirable potential side effects when administered in high doses and frequency. In this context, PRP is proposed as a potential treatment, capable of improving the clinical condition. Here, we would like to address with biological treatment of PRP in comparison to corticosteroid for the treatment of early/moderate knee OA. This is of fundamental importance, as for successful treatment of cartilage preservation - treatment needs to commence in the early stages.
This study looks to compare the efficacy and clinical benefits of a single intra-articular dose of PRP compared to corticosteroids. It is considered that PRP injection treatment reduces pain in a very short term (1-week follow-up), similar to cortisone, and it leads to an equal or more effective pain relief outcome plus better functional recovery at 1 year follow-up.
Both PRP and CS single injections were effective in reducing pain, and they improved the knee function after the first week of treatment. Pain score changes at 1 year (primary clinical outcome) showed a better improvement in the PRP group than the CS group. Interestingly, the PRP induced pain relief just as fast as CS. In fact, a significant reduction of pain from baseline for both groups was found 1 week after treatment. Furthermore, the pain reduction and the knee functional improvement were not significant between both groups in the very short-term follow-up visit (up to 5 weeks). The highest change in the pain score from the baseline was at 3 months for the PRP group and at 1 month in the CS group.
The pharmacological effect of CS was only short lived, and the pain steadily increased in each follow-up visit. At the same time, the PRP group resulted in a sustained improvement in pain relief up to 30 weeks. For all other outcome scores, there were significant differences between pre-treatment and post-treatment results at any time. Knee function improvement was observed in both groups up to 5–15 weeks with no significant differences between groups, however, the PRP group presented a better significant overall improvement in compared to the CS group, which decreased in effectiveness up to 1 year. No serious adverse side effects occurred.
Discussion This controlled study showed that a single intra-articular injection of PRP was more efficient than CS for treating moderate OA. Many studies are showing that PRP is effective for knee OA when compared to placebo, ozone, or HA in several high-quality, randomised, controlled trials. Many studies now suggest that intra-articular joint treatments of PRP provide measurable benefits for pain relief and functional improvement within short-term and long-term. In this study, a single intra-articular injection of PRP resulted in significant pain relief for up to 12 months, with a maximum pain decrease after 3 months. This difference suggested that the number of PRP injections could be critical for the maintenance of the beneficial effect.
More and more studies are now showing the comparisons of PRP and corticosteroid (CS) injections for treating mild OA, concluding the superiority of PRP. The rapid reduction in pain observed upon treatment with PRP might be attributed to a combined effect of anti-inflammatory activity of PRP on chondrocytes. The variation in pain and knee function in the PRP group contributed to the sustained duration of the overall beneficial effects for up to 30 weeks, whereas in the CS group, a tendency to worsen after 5 weeks was registered. Many PRP studies to date look at the beneficial effects of PRP on stimulating cartilage repair and healing. This clinical trial mainly looked to control of the inflammation of the knee rather than the effect of PRP on cartilage. However, there is evidence that suggests that PRP has other effects on the joints other than the anti-inflammatory and this may probably explain why the group that received PRP had better results than the CS group. Even though the mechanism of action on improving cartilage repair remains unclear, it has been reported in the literature that PRP can induce tissue maturation characterised by increased cell proliferation and tissue stiffness. These cells, in turn, produce more superficial zone protein that functions as a boundary lubricant that helps reduce friction and wear. Moreover, it has been reported that PRP can enhance hyaluronic acid secretion (healthy joint fluid) in arthritic patients, producing a lubricating effect that could reduce the shear stress of the joint.
Administration of CS for treating OA has been controversial because these injections can reduce pain in the short term, but they may not be helpful in the treatment of the underlying arthritic damage. Steroid injection treatment has been reported to have deleterious effects on musculoskeletal tissues such as reduction of collagen synthesis, suppression of cell proliferation, induction of oxidative stress, and impact on cell viability, all ultimately contributing to further joint degradation. This harmful effect could also influence the difference in long-term results between treatment groups in detriment of the CS group. Treatment with PRP injections is also considered safe as severe adverse events or complications I rarely witnessed or reported.
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