orthopaedic surgeon consultation

Interventional Treatments for Osteoarthritis & Tendinopathy

Resolution Physiotherapy is excited to team up with Orthopaedic Surgeon, Dr. Raaj Vora, who will be offering intra-articular joint and musculotendinous injections with the goal of reducing pain, improving function, and delaying the need for surgical interventions for our clients.

If you have OA pain or chronic tendinopathy that is slowing you down, contact us today so we can help get you back to life with increased function and less pain!

Interventional Treatments available at Resolution

nSTRIDE - Autologous Protein Solution

nSTRIDE is an exciting new treatment developed with the goal of reducing pain, increasing function, as well as slowing the progression of cartilage breakdown and delaying the need for surgery with Osteoarthritis.

nSTRIDE uses an Autologous Protein Solution (APS) which is created using a client’s own blood. The blood is then processed using the unique nStride system which, in a matter of minutes, creates a solution that has an extremely high concentration of good anti-inflammatory proteins.

When nSTRIDE APS is then injected directly into the knee joint, it alters the ratio of proteins within the joint, resulting in a significantly higher concentration of anti-inflammatory and beneficial proteins in the joint. In laboratory testing, it has been shown that these anti-inflammatory proteins can block and slow the degradation of cartilage which occurs with Osteoarthritis.

“Up until now, there have been no OA treatments which have changed the course of the disease.” (Kon 2018)

nSTRIDE is the first interventional treatment for OA that could potentially alter the course of the disease progression (van Drumpt 2016) in addition to significantly reducing pain and improving function for clients with Osteoarthritis.

nSTRIDE APS has been shown to:

• Significantly reduce pain associated with Knee OA for up to 2 years with a single injection (70% of those injected experienced a 70% reduction in pain) (Kon 2018, Kon 2017, van Drumpt 2016, King 2016)

• Significantly improve function in the knee joint associated with OA (Kon 2018, Kon 2017, van Drumpt 2016, King 2016)

• To be safe and effective for patients with mild to moderate OA following a single injection (Kon 2018, Kon 2017, van Drumpt 2016, King 2016)

• Protect cartilage in a meniscal-tear model (King 2017)

• Stimulate cartilage cell proliferation (Matsuka 2013)

• Inhibit pro-inflammatory proteins production and catabolic destruction of cartilage, thereby protecting cartilage tissue (King 2017, Matsuka 2013)

• Produce a serum with a much higher ratio of anti-inflammatory to pro-inflammatory proteins (1000:1) so that there is a much higher amount of anti-inflammatory proteins - this balance is theorized to contribute to long-term pain relief due to the “potential disease-modifying properties of APS improving joint homeostasis and cartilage quality” (vanDrumpt 2016)

Hyaluronic Acid

In a healthy knee, there is a thick, slippery substance called synovial fluid inside the joint that provides lubrication, allowing bones to glide easily against one another. This lubrication helps reduce wear and tear by keeping the bones slightly apart from one another and acting as a shock absorber.

In individuals with osteoarthritis, hyaluronic acid (HA), which is an important component of synovial fluid breaks down and is no longer produced at a rate high enough to keep the joint properly lubricated. This reduction of hyaluronic acid can lead to joint pain and stiffness.

HA injections have been shown to:

• produce a small, statistically significant improvements in knee pain and knee function (Miller 2020)

• be more effective than Corticosteroid injection for reducing knee pain and improving function with knee OA at 6 months (He 2017)

• produce the same effect as Corticosteroid injection for reducing knee pain and improving function with knee OA at 3 months (He 2017)

• have less risk of adverse events in the form of gastrointestinal concerns when compared with oral NSAIDs (Miller 2020, Bannuru 2014)

Given the favorable safety profile of HA over NSAIDs, HA may be a viable alternative to NSAIDs in knee OA care, especially for older patients at greater risk for systemic adverse events. (Bannuru 2014) HA will also produce longer term pain relief than Corticosteroid injection (He 2017).

Platelet Rich Protein (PRP)

Platelet-rich plasma, or PRP, is a substance that’s thought to promote healing when injected. PRP is produced from a client’s own blood that is centrifuged so that the blood separates into components. Plasma is the component that is isolated with PRP and it contains special “factors,” or proteins, that help your blood to clot. PRP also contains proteins that support cell growth.

PRP is used in orthopaedic and sports medicine practices to treat bone, tendon and ligament injuries (O’Connell 2019).

The use of PRP in the treatment of degenerative knee OA has increased in recent years due to it being a relatively safe treatment and that it is easily produced in a clinical environment.

Studies on PRP have shown that:

• Intra-articular PRP injections in active patients with knee OA show significant improvements in pain reduction, improved symptoms and quality of life at 6 and 12 months post-injection (O’Connell 2019, Meheux 2016)

• At 6 months post injection, PRP and HA had similar effects with respect to pain relief and functional improvement in knee OA (Dai 2017)

• At 12 months PRP is more effective than HA for improving pain and knee joint function in all stages of knee OA (O’Connell 2019, Dai 2017)

• Three injections per month yielded significantly better outcomes in the short-term (Huang 2017)

• PRP injection can increase patellofemoral articular cartilage volume (Raeissadat 2020)

• Younger and more active patients with a low degree of cartilage degradation achieved better results following PRP treatment (Meheux 2016)

PRP is a better option than HA for longer term pain relief and functional improvement with OA but the higher cost and risk for adverse events with PRP over HA must also be taken into consideration. Despite the apparent positivity in the use of PRP for treatment of knee OA, the lack of standardization of PRP has made it difficult to generalize the effectiveness of PRP treatment (O’Connell 2019).

At Resolution, we strive to deliver the best product available. We extract high density platelets to ensure the patient is receiving the best treatment available. 

Corticosteroid Injection

Corticosteroids is a cost effective treatment that has both anti-inflammatory and immunosuppressive effects, but their mechanism of action is complex. Corticosteroids act directly on steroid receptors and interupt the inflammatory response related to OA. This leads to rapid decreases in swelling and pain in inflamed osteoarthritic joints.

Corticosteroid injection has been shown to:

• reduce pain and inflammation and pain over a short duration (1-6 weeks) (Kijowski 2019, Law 2015, Ayhan 2014)

• have low risk of adverse events on the short term (Kijowski 2019)

• have a higher risk of adverse events including possibly increasing the rate of progression of OA, increased cartilage degeneration and bone loss over the long term (Kijowski 2019)

• the beneficial effects of IA corticosteroid appear rapid but may be of short duration (Kijowski 2019, Law 2015, Ayhan 2014)

Corticosteroid injection is a cost effective option for rapid reduction of inflammation and pain in OA but consideration must be made regarding the risk of long term adverse events and that HA or PRP may yield longer lasting effects.

References:

Altman, Roy, et al. "Anti-inflammatory effects of intra-articular hyaluronic acid: a systematic review." Cartilage 10.1 (2019): 43-52.

Ayhan, Egemen, Hayrettin Kesmezacar, and Isik Akgun. "Intraarticular injections (corticosteroid, hyaluronic acid, platelet rich plasma) for the knee osteoarthritis." World journal of orthopedics 5.3 (2014): 351.

Bannuru, Raveendhara R., et al. "Relative efficacy of hyaluronic acid in comparison with NSAIDs for knee osteoarthritis: a systematic review and meta-analysis." Seminars in arthritis and rheumatism. Vol. 43. No. 5. WB Saunders, 2014.

Dai, Wen-Li, et al. "Efficacy of platelet-rich plasma in the treatment of knee osteoarthritis: a meta-analysis of randomized controlled trials." Arthroscopy: The Journal of Arthroscopic & Related Surgery 33.3 (2017): 659-670.

Gwynne-Jones, Julia, et al. "The outcomes of non-operative management of patients with hip and knee osteoarthritis triaged to a physiotherapy-led clinic at minimum 5-year follow-up and factors associated with progression to surgery." The Journal of Arthroplasty (2020).

Huang, Po-Hua, et al. "Short-term clinical results of intra-articular PRP injections for early osteoarthritis of the knee." International Journal of Surgery 42 (2017): 117-122.

He, Wei-wei, et al. "Efficacy and safety of intraarticular hyaluronic acid and corticosteroid for knee osteoarthritis: A meta-analysis." International Journal of Surgery 39 (2017): 95-103.

Heidari, Behzad. "Knee osteoarthritis prevalence, risk factors, pathogenesis and features: Part I." Caspian journal of internal medicine 2.2 (2011): 205.

Kijowski, Richard. "Risks and Benefits of Intra-articular Corticosteroid Injection for Treatment of Osteoarthritis: What Radiologists and Patients Need to Know." (2019): 664-665.

King, William, et al. "Human blood‐based anti‐inflammatory solution inhibits osteoarthritis progression in a meniscal‐tear rat study." Journal of Orthopaedic Research 35.10 (2017): 2260-2268.

King W, van der Weegen W, Van Drumpt R, Soons H, Toler K, Woodell-May J, “White bloodcell concentration correlates with increased concentration of IL-1ra and improvement in WOMAC pain scores in an open-label safety study of autologous protein solution.” Journal of Experimental Orthopaedics. 2016;3:9.

Kon E, Engebretsen L , Peter Verdonk P, Nehrer S and Filardo G. “Clinical Outcomes of Knee Osteoarthritis Treated with an Autologous Protein Solution. A1-year Pilot Double-Blinded Randomized Control Trial. American Journal of Sports Medicine, Oct. 2017.

Kon E, Engebretsen L , Peter Verdonk P, Nehrer S and Filardo G. “Two-year Clinical Outcomes of An Autologous Protein Solution Injection For Knee Osteoarthritis.” ICRS 14th World Congress, presented, 2018.

Law, Tsun Yee, et al. "Current concepts on the use of corticosteroid injections for knee osteoarthritis." The Physician and sportsmedicine 43.3 (2015): 269-273.

Matuska, Andrea, et al. "Autologous solution protects bovine cartilage explants from IL‐1α‐and TNFα‐induced cartilage degradation." Journal of Orthopaedic Research 31.12 (2013): 1929-1935.

McAlindon, Timothy E., et al. "OARSI guidelines for the non-surgical management of knee osteoarthritis." Osteoarthritis and cartilage 22.3 (2014): 363-388.

Meheux, Carlos J., et al. "Efficacy of intra-articular platelet-rich plasma injections in knee osteoarthritis: a systematic review." Arthroscopy: The Journal of Arthroscopic & Related Surgery 32.3 (2016): 495-505.

Miller, Larry E., Michael Fredericson, and Roy D. Altman. "Hyaluronic Acid Injections or Oral Nonsteroidal Anti-inflammatory Drugs for Knee Osteoarthritis: Systematic Review and Meta-analysis of Randomized Trials." Orthopaedic Journal of Sports Medicine 8.1 (2020): 2325967119897909.

O’Connell, Brendan, Nicholas Martin Wragg, and Samantha Louise Wilson. "The use of PRP injections in the management of knee osteoarthritis." Cell and tissue research 376.2 (2019): 143-152.

Raeissadat, Seyed Ahmad, et al. "MRI Changes After Platelet Rich Plasma Injection in Knee Osteoarthritis (Randomized Clinical Trial)." Journal of Pain Research 13 (2020): 65.

Richmond, Sarah A., et al. "Are joint injury, sport activity, physical activity, obesity, or occupational activities predictors for osteoarthritis? A systematic review." journal of orthopaedic & sports physical therapy 43.8 (2013): 515-B19.

van Drumpt, Rogier AM, et al. "Safety and treatment effectiveness of a single autologous protein solution injection in patients with knee osteoarthritis." BioResearch open access 5.1 (2016): 261-268.