Hyaluronic Acid, Platelet-Rich Plasma – Positions, and Exposition

January 25, 2023

Opening The Gait

It’s the middle of January in Colorado and we are on the tail-end of three separate cold fronts that dumped a decent amount of snow. The kids are back to school after a few weeks at home for Winter Break and I am settling back into the weekly routine of school drop-off, work, and after-school activities.

If I haven’t mentioned that I’m a runner yet – well, I’m a runner. And if you’re a runner, you know that when you see other runners… running… that there’s a level of respect as well as a little pang of jealousy that wells deep inside because you are not actively running. It’s a thing. Kind of like when motorcyclists give other motorcyclists the nod when they pass. We’re all little instinctual beings who notice our own kind. (I digress.)

So, in my neighborhood, there’s a younger woman who I see running maybe 3-4 mornings a week around the same time that I drop the kiddos off at school. This woman. Oh my… I adore seeing her. She has the most unique gait. Like ever. Like Phoebe Buffey style on the 90’s television show Friends. The content creators wrote an entire episode dedicated to Phoebe’s boisterous running gait. She is joyous and free, without a care in the world. Additionally, I frequently see an older woman walking on the neighborhood sidewalks. She’s usually out once or twice a day, a true creature of habit. She’s got a bit of a shuffle as she walks but her gait is strong and she certainly displays endurance. These two women lift me up every time I see them because they are consistently outside, breathing, living, and moving.

I’ll get back to my ‘secret’ girl crushes on the 60-something-year-old walker and my happy runner, Phoebe, because the main thing that I notice about each individual is their gait. Stick a pin in that.

Where Things Stand Or Don’t – Demystification

The other evening, a colleague sent me an article regarding the American College of Rheumatology’s (ACoR) position statement for hyaluronic acid (HA) gel and platelet-rich plasma (PRP) therapy used in the treatment of osteoarthritis. In their position statement, the ACoR strongly advises against hyaluronic acid and platelet-rich plasma injections. As you would imagine, this is a topic that is near and dear to my heart, as I am a Nurse Practitioner who focuses on an integrated approach to health and wellness. HA and PRP knee injections are part of a robust plan of care (including physical therapy, bracing, and metabolic disease management) to facilitate our patients with pain, weight loss, and mobility.

I’m also going to preface the next few paragraph’s with my respect for our medical colleagues and professionals. Physicians, researchers and nurse practitioners have all dedicated a robust amount of time and energy to their chosen fields of practice. By the time an individual becomes “specialized”; that person should be respected for their expert understanding of that topic. Therefore, those of us who are not experts in those fields need to both respect their research but also recognize the natural bias that these position statements hold.

This is where the waters can get muddy.
So, in an effort to demystify some of the content of that article, I’d like to point out a few concepts and sentences to interpret for you from a broader perspective.

The specific position statement is titled, 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee.2 The authors of the study received consulting fees from major pharmaceutical companies such as Pfizer, Noavartis, Serono, Bristol-Meyers Squibb etc…

Additionally, the article clearly states, “We focused on management options that are available in the US and, for pharmacologic therapies, we additionally focused on agents that are available in pharmaceutical-grade formulations, thus eliminating most nutraceuticals”.2

The article goes on to make clear recommendations for weight loss, exercise, surgical intervention and utilizing pharmaceuticals to manage pain for patient’s with osteoarthritis. There is a breakdown of numerous different pharmaceuticals with the risk/benefit structure.

To further summarize the recommendation against hyaluronic acid and platelet-rich plasma; the ACoR and the Arthritis Foundation findings note that HA injections do not show consistent benefit over placebo with clear instruction for glucocorticoid steroid injections researched to provide pain relief (which they do… for only so long).

PRP injections are a non-pharmaceutical intervention that currently is concerning to the ACoR and Arthritis Foundation because is has a lack of heterogeneity and a lack of standardization and therefore the outcomes cannot be controlled.2

I’m going to reiterate that this position statement is based on expert specialists in the fields of rheumatology and pharmacology.

Additional Considerations

As a well-rounded medical provider, it is important that I understand this context and also consider the expert specialists in the fields of orthopedics, physical therapy, exercise physiologists and metabolic weight loss. Osteoarthritis is a multi-factorial disease process, involving chronic inflammation, environmental factors and genetics; it will span many specialties.

Any medical provider can get behind the concept of weight loss and exercise to manage most disease processes but osteoarthritis poses the problem of chronic pain; specifically joint pain.

Unfortunately, by the time the joints have started to break down enough to cause pain, the disease process has progressed to at least a Stage 2 or 3 on a scale of 0 to 4. A person’s natural response to pain is to stop using that joint, creating immobility, a more sedentary lifestyle and weight gain.

So, yes, corticosteroid injections can address pain for a short time but current research also suggests that repeat corticosteroid use in a joint will continue to compromise and degrade the tissues.3,4

Platelet-rich plasma injections are a process of drawing an individual’s blood, spinning it down in a centrifuge so that the platelet-rich plasma is separated from the red blood cells, and re-injecting the platelets into an injured joint or tendon. Re-introducing the body’s natural healing cells (platelets) to an injured area is not a new concept and has been well researched for decades.

Though PRP does not claim to ‘cure’ osteoarthritis it has shown to be very effective for pain management, which is the most important factor to facilitate an individual’s participation with physical therapy, exercise and weight loss. In clinical trials, platelet-rich plasma, as a non-pharmacologic treatment intervention for pain, has proven very safe with management of pain for up to 12 months.6

The American Academy of Orthopedic Surgeons, in consideration of PRP therapy for osteoarthritis note, “Even though the success of PRP therapy is still questionable, the risks associated with it are minimal: There may be increased pain at the injection site, but the incidence of other problems — infection, tissue damage, nerve injuries — appears to be no different from that associated with cortisone injections.”1

Proven Practice Preferences Win Out

The conundrum here lies in the fact that there are many modalities to manage pain but no one treatment to, in essence, heal or reverse osteoarthritis. Once diagnosed with osteoarthritis, the disease will advance without intervention. My personal view is to avoid utilizing pharmaceuticals that have the capacity to accelerate that degeneration. I also seek to support a patient to prevent surgical intervention for as long as physically possible.

Two more quick points I’d like to point out are the facts that good medical providers operate ahead of research and well rounded providers will collaborate with specialists outside of their scope to develop sound medical advice. When seeking care for any condition, it is important to always consider your sources as well as considering a person’s inherent bias (including your own).

In consideration of my bias, as a metabolic specialist (meaning my focus is on medical health maintenance as a whole-body approach to managing disease), I seek to support patients with their pain management, mobility, blood sugar management, nutrition and weight loss. All in an effort to slow the progression of osteoarthritis. I would recommend utilizing steroid joint injections sparingly and focusing on stabilizing the joint with bracing, hyaluronic acid and platelet-rich plasma injections in order to provide pain relief for mobility and a window of time to slowly heal some of the damage already accrued in the tissues of the joint.

Closing The Gait

Back to our two friends I mentioned at the beginning of this exposition. I saw the 60ish year old woman the other morning while out walking my dog. We exchanged hellos and walked together for a short while. She tells me she is in her late 60’s and has struggled with arthritic pain for years. She walks twice daily, in spite of her pain, in order to continue to balance her lifestyle. She’s taken Ibuprofen and Tylenol in the past but has mostly decided to continue to muscle through the pain. She is a motivated woman who seeks to avoid surgery but worries that it is on the horizon. If I could help relieve her pain, brace those joints, and keep her walking for years to come; I most certainly would.

My friend the Phoebe-style runner; well, I’ve yet to meet her. But every morning she runs by me, it brings the biggest smile to my face and I silently wish her many years of health and joy in her running outlet. If she should ever need support for joint pain or physical therapy for gait analysis; I hope she finds our group. We will take excellent care of her too.

References:

    1. Alaia, M.J., Kelly, F.B. (2020). Platelet-rich plasma. OrthoInfo from the Academy of Orthopedic. Retrieved from https://orthoinfo.aaos.org/en/treatment/platelet-rich-plasma-prp/
    2. Kolasinski, S. L., Neogi, T., Hochberg, M. C., Oatis, C., Guyatt, G., Block, J., … & Reston, J. (2019). American College of Rheumatology/Arthritis Foundation guideline for the Management of Osteoarthritis of the hand, hip, and knee. Arthritis Rheumatol. 2020; 72 (2): 220–33. Updated evidence-based recommendations for the management of hand, hip and knee osteoarthritis based on systematic review of published randomized clinical trials.
    3. Kompel, A. J., Roemer, F. W., Murakami, A. M., Diaz, L. E., Crema, M. D., & Guermazi, A. (2019). Intra-articular corticosteroid injections in the hip and knee: perhaps not as safe as we thought?. Radiology, 293(3), 656-663.
    4. McAlindon, T. E., LaValley, M. P., Harvey, W. F., Price, L. L., Driban, J. B., Zhang, M., & Ward, R. J. (2017). Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. Jama, 317(19), 1967-1975.
    5. McMullen, C. (2020). Platelet-Rich Plasma in the Treatment of Osteoarthritis: Grand Rounds Presentation. Retrieved from https://rheumatology.uw.edu/grand-rounds/platelet-rich-plasma-treatment-osteoarthritis
    6. Moen, M., Weir, A., Bakker, E., Rekers, M., & Laudy, G. (2016). Efficacy of platelet-rich plasma injections in osteoarthritis of the knee: an updated systematic review and meta-analysis. Osteoarthritis and Cartilage, 24, S520-S521.
    7. Xuan, Z., Yu, W., Dou, Y., & Wang, T. (2020). Efficacy of platelet-rich plasma for low back pain: a systematic review and meta-analysis. Journal of Neurological Surgery Part A: Central European Neurosurgery, 81(06), 529-534.