INTRODUCTION: Platelet Rich Plasma (PRP) is a blood component therapy with a supraphysiological concentration of platelets derived from allogenic or, more commonly, autologous blood. PRP has been used in different non-transfusion indications due to its role in the promotion of tissue repair and healing, in fields such as Traumatology, Dermatology and Dentistry.
OBJECTIVE: To provide a synthesis of the efficacy of PRP for different clinical situations.
METHODS: Systematic searches were carried out in MEDLINE, Embase, Cochrane Library and LILACS in July 2018 to identify systematic reviews (SRs) of randomized controlled trials (RCTs) focusing on PRP for non-transfusion use. Two authors independently screened all retrieved references in two stages (titles and abstracts at a first stage and full texts at a second stage). The methodological quality of SRs that met the eligibility criteria was appraised by AMSTAR 2. Conclusions were based on the most recent SRs with highest quality.
RESULTS: 1,240 references were retrieved. After checking the inclusion criteria, 29 SRs of RCTs related to three different fields (wound care, Orthopedics and Dentistry) were included. Results suggest benefit of PRP for different clinical situations, such as diabetic wounds, acute lesions of musculoskeletal system, rotator cuff lesions, tendinopathies, knee and hip osteoarthritis, total knee arthroplasty, allogenic bone graft for dental implants, and periodontal intrabony defects.
CONCLUSION: There is low to moderate quality evidence supporting the efficacy of PRP for specific clinical situations. The low quality of the evidence limits the certainty of these findings. Well-planed and well-conducted RCTs are still needed to further assess the efficacy of PRP. This article is protected by copyright. All rights reserved.
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
OBJECTIVES: Massage therapy has been proposed for painful conditions, but it can be difficult to understand the breadth and depth of evidence, as various painful conditions may respond differently to massage. The authors conducted an evidence mapping process and generated an "evidence map" to visually depict the distribution of evidence available for massage and various pain indications to identify gaps in evidence and to inform future research priorities.
DESIGN: The authors searched PubMed, Embase, and Cochrane for systematic reviews reporting pain outcomes for massage therapy. The authors assessed the quality of each review using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) criteria. The authors used a bubble plot to depict the number of included articles, pain indication, effect of massage for pain, and strength of findings for each included systematic review.
RESULTS: The authors identified 49 systematic reviews, of which 32 were considered high quality. Types of pain frequently included in systematic reviews were cancer pain, low back pain, and neck pain. High quality reviews concluded that there was low strength of evidence of potential benefits of massage for labor, shoulder, neck, low back, cancer, arthritis, postoperative, delayed onset muscle soreness, and musculoskeletal pain. Reported attributes of massage interventions include style of massage, provider, co-interventions, duration, and comparators, with 14 high-quality reviews reporting all these attributes in their review.
CONCLUSION: Prior reviews have conclusions of low strength of evidence because few primary studies of large samples with rigorous methods had been conducted, leaving evidence gaps about specific massage type for specific pain. Primary studies often do not provide adequate details of massage therapy provided, limiting the extent to which reviews are able to draw conclusions about characteristics such as provider type.
La artrosis es la enfermedad articular crónica que presenta mayor prevalencia, en la cual el dolor es uno de los principales síntomas y el mayor determinante de la pérdida de funcionalidad. Se han planteado múltiples opciones terapéuticas, entre ellas la glucosamina, pero su real utilidad aún no ha sido claramente establecida. Utilizando la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en múltiples bases de datos, identificamos 11 revisiones sistemáticas que en conjunto incluyen 35 estudios aleatorizados que responden la pregunta de este resumen. Extrajimos la información relevante, realizamos un metanálisis y preparamos tablas de resumen de los resultados utilizando el método GRADE. Concluimos que no está claro que la glucosamina disminuya el dolor o mejore la funcionalidad en la artrosis porque la certeza de la evidencia es muy baja.
BACKGROUND & AIMS: Musculoskeletal pain, the most common cause of disability globally, is most frequently managed in primary care. People with musculoskeletal pain in different body regions share similar characteristics, prognosis, and may respond to similar treatments. This overview aims to summarise current best evidence on currently available treatment options for the five most common musculoskeletal pain presentations (back, neck, shoulder, knee and multi-site pain) in primary care.
METHODS: A systematic search was conducted. Initial searches identified clinical guidelines, clinical pathways and systematic reviews. Additional searches found recently published trials and those addressing gaps in the evidence base. Data on study populations, interventions, and outcomes of intervention on pain and function were extracted. Quality of systematic reviews was assessed using AMSTAR, and strength of evidence rated using a modified GRADE approach.
RESULTS: Moderate to strong evidence suggests that exercise therapy and psychosocial interventions are effective for relieving pain and improving function for musculoskeletal pain. NSAIDs and opioids reduce pain in the short-term, but the effect size is modest and the potential for adverse effects need careful consideration. Corticosteroid injections were found to be beneficial for short-term pain relief among patients with knee and shoulder pain. However, current evidence remains equivocal on optimal dose, intensity and frequency, or mode of application for most treatment options.
CONCLUSION: This review presents a comprehensive summary and critical assessment of current evidence for the treatment of pain presentations in primary care. The evidence synthesis of interventions for common musculoskeletal pain presentations shows moderate-strong evidence for exercise therapy and psychosocial interventions, with short-term benefits only from pharmacological treatments. Future research into optimal dose and application of the most promising treatments is needed.
La artrosis es la enfermedad articular crónica que presenta mayor prevalencia, en la cual el dolor es uno de los principales síntomas y el mayor determinante de la pérdida de funcionalidad. Se han planteado múltiples opciones terapéuticas, entre ellas el condroitín sulfato, pero su real utilidad aún no ha sido claramente demostrada. Para aclarar esta interrogante utilizamos la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en múltiples fuentes de información. Identificamos 13 revisiones sistemáticas que en conjunto incluyen 50 estudios aleatorizados que responden la pregunta de este resumen. Extrajimos la información relevante, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. Concluimos que no está claro si el uso de condroitín sulfato produce una mejoría en el dolor o la funcionalidad en la artrosis porque la certeza de la evidencia es muy baja.
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
Numerous meta-analyses have been conducted aiming to compare hyaluronic acid (HA) and placebo in treating knee osteoarthritis (OA). Nevertheless, the conclusions of these meta-analyses are not in consistency. The purpose of the present study was to perform a systematic review of overlapping meta-analyses investigating the efficacy and safety of HA for Knee OA and to provide treatment recommendations through the best evidence. A systematic review was conducted based on the PRISMA guidelines. The meta-analyses and/or systematic reviews that compared HA and placebo for knee OA were identified. AMSTAR instrument was used to evaluate the methodological quality of individual study. The information of heterogeneity within each variable was fetched for the individual studies. Which meta-analyses can provide best evidence was determined according to Jadad algorithm. Twelve meta-analyses met the eligibility requirements. The Jadad decision making tool suggests that the highest quality review should be selected. As a result, a high-quality Cochrane review was included. The present systematic review of overlapping meta-analyses demonstrates that HA is an effective intervention in treating knee OA without increased risk of adverse events. Therefore, the present conclusions may help decision makers interpret and choose among discordant meta-analyses.
La artrosis de rodilla es una enfermedad crónica, invalidante, de evolución progresiva e irreversible. Los corticoides intraarticulares han sido comúnmente utilizados con el fin de disminuir sus síntomas y retrasar la resolución quirúrgica. Sin embargo, hasta el día de hoy, existe debate sobre su eficacia y seguridad. Utilizando la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en 30 bases de datos, se identificaron 12 revisiones sistemáticas que en conjunto incluyen 41 estudios que contestan la pregunta de interés, entre los cuales se cuentan 40 estudios aleatorizados. Realizamos un metanálisis y tablas de resumen de los resultados utilizando el método GRADE. Concluimos que los corticoides intraarticulares probablemente llevan a una leve disminución del dolor a corto plazo, hacen poca o ninguna diferencia a mediano plazo y podrían no tener ningún efecto a largo plazo.
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
Revista»Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association
OBJETIVO: Realizar una revisión sistemática de la superposición de los meta-análisis comparando el tratamiento de la osteoartritis de rodilla (OA) con viscosuplementación intraarticular (ácido hialurónico intraarticular [IA-HA]) frente a los fármacos anti-inflamatorios no esteroides orales (AINE), intra corticosteroides articulares (IA-corticosteroides), plasma rico en plaquetas intraarticular (IA-PRP), o placebo intraarticular (IA-placebo) para determinar qué metanálisis proporcionan la mejor evidencia actual e identificar las posibles causas de discordancia.
MÉTODOS: Literatura búsquedas se realizaron para meta-análisis examinando el uso de IA-HA frente a AINE, IA-corticoides, IA-PRP o IA-placebo. Los datos clínicos se obtuvieron, y la calidad metanálisis se evaluó. El algoritmo de Jadad se aplicó para determinar qué meta-análisis proporciona el más alto nivel de evidencia.
RESULTADOS: Catorce metanálisis cumplen los criterios de elegibilidad y se extendieron en la calidad del nivel I al IV pruebas. En los estudios que informaron el número de pacientes, hubo un total de 20.049 pacientes: 13.698 que reciben IA-HA, 355 recibieron AINE, 294 recibieron IA-corticosteroides y 5702 recibieron IA-placebo. Diez estudios examinaron los efectos de IA-HA frente IA-placebo; de estos, 5 encontraron que IA-HA mejoró el dolor y encontró que 4 IA-HA función mejorada. No se encontraron diferencias clínicamente relevantes en la eficacia de la IA-HA frente a los AINE sobre el dolor y la función. En cuanto a IA-HA frente IA-PRP, función de la rodilla mejorada IA-HA a los 2 y 6 meses después de la inyección, pero los efectos fueron menos robustos que los de IA-PRP. En cuanto a IA-HA frente IA-corticoides, los efectos positivos de IA-HA fueron mayores a las 5 a 13 semanas y persistieron durante un máximo de 26 semanas. Después de la aplicación del algoritmo de Jadad, se seleccionaron 2 de alta calidad meta-análisis concordantes y ambos mostraron que IA-HA proporcionado mejoras clínicamente relevantes en el dolor y la función en comparación con IA-placebo.
Conclusiones: Esta revisión sistemática de los meta-análisis que comparan IA-HA con otras modalidades de tratamiento no quirúrgico para la OA de rodilla superposición muestra que el nivel más alto de la evidencia actual sugiere que el IA-HA es una opción viable para la OA de rodilla. Sus resultados en el uso de las mejoras en el dolor y la función de la rodilla que puede persistir por hasta 26 semanas. IA-HA tiene un buen perfil de seguridad, y su uso debe ser considerado en pacientes con artrosis de rodilla temprano.
Nivel de evidencia: Nivel IV, revisión sistemática de Nivel I a IV estudios.
OBJETIVO: Desarrollar,,, directrices concisas, hasta a la fecha centradas en el paciente basada en la evidencia de expertos de consenso para el manejo de la artrosis de rodilla (OA), destinada a informar a los pacientes, médicos y otros profesionales sanitarios de todo el mundo.
MÉTODO: Trece expertos de disciplinas médicas pertinentes (atención primaria, reumatología, ortopedia, fisioterapia, medicina física y rehabilitación, y la medicina basada en la evidencia), tres continentes y diez países (EE.UU., Reino Unido, Francia, Países Bajos, Bélgica, Suecia, Dinamarca , Australia, Japón y Canadá) y un representante de los pacientes comprendían las Directrices del Grupo de Desarrollo osteoartritis (OAGDG). Sobre la base de las directrices OA anteriores y una revisión sistemática de la literatura OA, 29 modalidades de tratamiento fueron considerados para su recomendación. La evidencia publicada con posterioridad a las directrices OARSI 2010 se basó en una revisión sistemática realizada por la OA Sociedad Internacional de Investigación (OARSI) equipo de pruebas del Centro Médico Tufts, Boston, EE.UU.. Medline, EMBASE, Google Scholar, Web of Science, y el Registro Cochrane Central de Ensayos Controlados se buscaron inicialmente en el primer trimestre de 2012 y el pasado buscó en marzo de 2013. Incluye pruebas se evaluó la calidad mediante la Evaluación de Múltiples Revisiones Sistemáticas (AMSTAR) los criterios, y la crítica publicada de pruebas incluidas también se consideró. Para proporcionar recomendaciones para las personas con una amplia gama de perfiles de salud y la carga OA, fueron estratificados recomendaciones de tratamiento en cuatro sub-fenotipos clínicos. Recomendaciones de consenso fueron producidos utilizando el proceso de votación RAND / UCLA Adecuación Método y Delphi. Los tratamientos se recomiendan como adecuado, incierto, o no apropiada, para cada uno de los cuatro sub-fenotipos clínicos y acompañados de 1-10 puntuaciones de riesgo y beneficio.
RESULTADOS: modalidades de tratamiento apropiados para todas las personas con artrosis de rodilla incluyen intervenciones biomecánicas, corticosteroides intraarticulares, ejercicio, auto-gestión (con base en tierra y al agua) y de educación, entrenamiento de fuerza y de control de peso. Tratamientos adecuados para sub-fenotipos clínicos específicos incluyen el acetaminofeno (paracetamol), balneoterapia, la capsaicina, la caña (bastón), duloxetina, orales no esteroides anti-inflamatorios medicamentos (AINE; COX-2 selectivos y no selectivos) AINE, y tópicos . Tratamientos de adecuación incierto para sub-fenotipos clínicos específicos incluyen la acupuntura, unsaponfiables soja aguacate, condroitina, muletas, diacereína, glucosamina, ácido hialurónico intraarticular, opioides (oral y transdérmica), rosa mosqueta, la estimulación nerviosa eléctrica transcutánea y la ecografía. Tratamientos votaron no apropiado incluido risedronato y electroterapia (estimulación eléctrica neuromuscular).
CONCLUSIÓN: Estas recomendaciones de consenso basadas en la evidencia proporcionan orientación a los pacientes y los profesionales sobre los tratamientos aplicables a todas las personas con artrosis de rodilla, así como terapias que pueden ser considerados de acuerdo a las necesidades del paciente y las preferencias individuales.
Osteoarthritis refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life. It is the most common form of arthritis, and one of the leading causes of pain and disability worldwide. The most commonly affected peripheral joints are the knees, hips and small hand joints. Although pain, reduced function and effects on a person’s ability to carry out their day-to-day activities can be important consequences of osteoarthritis, pain in itself is of course a complex biopsychosocial issue, related in part to person expectations and self-efficacy, and associated with changes in mood, sleep and coping abilities. There is often a poor link between changes on an X-ray and symptoms: minimal changes can be associated with a lot of pain and modest structural changes to joints oftencan occur without with minimal accompanying symptoms. Contrary to popular belief, osteoarthritis is not caused by ageing and does not necessarily deteriorate. There are a number of management and treatment options (both pharmacological and non-pharmacological), which this guideline addresses and which offer effective interventions for control of symptoms and improving function. Osteoarthritis is characterised pathologically by localised loss of cartilage, remodelling of adjacent bone and associated inflammation. A variety of traumas may trigger the need for a joint to repair itself. Osteoarthritis includes a slow but efficient repair process that often compensates for the initial trauma, resulting in a structurally altered but symptom-free joint. In some people, because of either overwhelming trauma or compromised repair, the process cannot compensate, resulting in eventual presentation with symptomatic osteoarthritis; this might be thought of as ‘joint failure’. This in part explains the extreme variability in clinical presentation and outcome that can be observed between people, and also at different joints in the same person. There are limitations to the published evidence on treating osteoarthritis. Most studies have focused on knee osteoarthritis, and are often of short duration using single therapies. Although most trials have looked at single joint involvement, in reality many people have pain in more than one joint, which may alter the effectiveness of interventions. This guideline update was originally intended to include recommendations based on a review of new evidence about the use of paracetamol, etoricoxib and fixed-dose combinations of NSAIDs plus gastroprotective agents in the management of osteoarthritis. Draft recommendations based on the evidence reviews for these areas were presented in the consultation version of the guideline. Stakeholder feedback at consultation indicated that the draft recommendations, particularly in relation to paracetamol, would be of limited clinical application without a full review of evidence on the pharmacological management of osteoarthritis. NICE was also aware of an ongoing review by the MHRA of the safety of over-the-counter analgesics. Therefore NICE intends to commission a full review of evidence on the pharmacological management of osteoarthritis, which will start once the MHRA’s review is completed, to inform a further guideline update. Until that update is published, the original recommendations (from 2008) on the pharmacological management of osteoarthritis remain current advice. However, the GDG would like to draw attention to the findings of the evidence review on the effectiveness of paracetamol that was presented in the consultation version of the guideline. That review identified reduced effectiveness of paracetamol in the management of osteoarthritis compared with what was previously thought. The GDG believes that this information should be taken into account in routine prescribing practice until the intended full review of evidence on the pharmacological management of osteoarthritis is published (see the NICE website for further details).
Platelet Rich Plasma (PRP) is a blood component therapy with a supraphysiological concentration of platelets derived from allogenic or, more commonly, autologous blood. PRP has been used in different non-transfusion indications due to its role in the promotion of tissue repair and healing, in fields such as Traumatology, Dermatology and Dentistry.
OBJECTIVE:
To provide a synthesis of the efficacy of PRP for different clinical situations.
METHODS:
Systematic searches were carried out in MEDLINE, Embase, Cochrane Library and LILACS in July 2018 to identify systematic reviews (SRs) of randomized controlled trials (RCTs) focusing on PRP for non-transfusion use. Two authors independently screened all retrieved references in two stages (titles and abstracts at a first stage and full texts at a second stage). The methodological quality of SRs that met the eligibility criteria was appraised by AMSTAR 2. Conclusions were based on the most recent SRs with highest quality.
RESULTS:
1,240 references were retrieved. After checking the inclusion criteria, 29 SRs of RCTs related to three different fields (wound care, Orthopedics and Dentistry) were included. Results suggest benefit of PRP for different clinical situations, such as diabetic wounds, acute lesions of musculoskeletal system, rotator cuff lesions, tendinopathies, knee and hip osteoarthritis, total knee arthroplasty, allogenic bone graft for dental implants, and periodontal intrabony defects.
CONCLUSION:
There is low to moderate quality evidence supporting the efficacy of PRP for specific clinical situations. The low quality of the evidence limits the certainty of these findings. Well-planed and well-conducted RCTs are still needed to further assess the efficacy of PRP. This article is protected by copyright. All rights reserved.
Síntesis amplia»Revisión panorámica de revisiones sistemáticas
