Exploring Patients’ Motivations in Using Platelet-Rich Plasma as Their Primary Care Therapy for Managing Knee Osteoarthritis: A Focus Group Discussion

Abstract

Knee osteoarthritis (KOA) is a degenerative disease that causes pain and burden in patients. Aside from surgery, clinicians tout the potential use of platelet-rich plasma. This study explores motivation in terms of perceptions, experiences, and recommendations of KOA patients who received platelet-rich plasma (PRP) as primary care therapy. A qualitative approach via focus group discussion was conducted. Data were analyzed using thematic analysis and visualized using MAXQDA. Patients’ motivation for the use of PRP was based on three factors: (1) their perception of PRP as a therapy, (2) their lived experiences post-PRP therapy, and (3) their willingness to recommend PRP to others as a primary care therapy. The elements of each theme were identified and ranked based on how often the patients expressed the same thought, with willingness (f=5), alternative therapy (f=7), and pain (f=27) ranking highest. Physicians’ recommendations, preference for a non-surgical approach, and later on, reduced pain and improved quality of life made them believe in the effectiveness of PRP as primary care therapy to alleviate KOA symptoms.

Introduction

Knee osteoarthritis (KOA) is a degenerative disease causing joint deformations and severe disability. It is characterized by progressive pain on the affected knees triggered by activities such as walking and bending, resulting in a limited range of motion. ¹ Some patients with KOA experienced bone deformity over time with intense pain. Over the past two decades, the prevalence of KOA among the global population has been relatively high, particularly among Asian countries. ² In the Philippines, about four million Filipinos are affected by KOA, and the number continues to increase. ³

Current KOA management includes pharmacological, non-pharmacological, and surgical approaches. The Philippine Rheumatology Association (PRA) has identified the following non-pharmacological interventions as recommended management for KOA: awareness of the disease, lifestyle modifications, and strength and conditioning. Clinical evidence has demonstrated that these interventions positively impact the management of KOA, significantly improving pain outcomes and overall quality of life. On the other hand, pharmacological interventions, such as analgesics prescribed to alleviate pain, have also been widely recommended by clinicians to lessen the burden of the condition. Furthermore, emerging pharmaceutical treatments have exhibited encouraging outcomes, potentially enhancing the management of KOA to a greater extent.^4,5 These new therapies include but are not limited to genetic modification techniques, cell-derived vesicles that promote tissue regeneration, and natural substance-based treatments, such as mesenchymal stem cells, growth factor therapy, and platelet-rich plasma (PRP) have emerged as promising alternatives to conventional treatment for KOA. ⁶

In this study, the use of PRP will be given importance focusing on perceptions and outlooks on the treatment through participant perceptions, experiences, and recommendations. To our knowledge, patient-reported qualitative evaluation of the outcomes of PRP knee injection is limited; thus, this study aims to explore motivations in terms of the perceptions, experiences, and recommendations of selected individuals with KOA in receiving PRP as a therapy.

Methods

Study Design and Setting

This study used a phenomenological approach based on Collaizi's methodology to qualitatively explore consciousness perception in individuals with KOA. ⁷ Participants were selected for the focus group discussion (FGD) using the convenience sampling method. These were Filipino citizens aged 50 years old and above, clinically diagnosed with osteoarthritis by a physiatrist following the American College of Rheumatology criteria, which include symptoms of persistent knee pain, morning stiffness, functional limitation, signs of crepitus, and observable signs of bony enlargement, including radiographic evidence who underwent PRP injection, who a shared physician with expertise in rehabilitative medicine referred. They were approached directly and mutually established the most convenient time for the interview. They were instructed to cease using non-steroidal anti-inflammatory drugs (NSAIDs) for at least 24 h before and 72 h after the procedure. Institution-specific protocols for post-PRP management included non-NSAID pain relief, weight-bearing restrictions, physical therapy, and activity adjustments, all tailored to the patient's preferences. A virtual meeting was organized following the distribution of invitations and the receipt of consent, ensuring that all participants could engage in a supportive atmosphere conducive to the exchange of insights and concerns.

Instrumentation and Data Collection

Before the interview, the study was approved by an ethics committee, and informed consent was obtained from the participants. A total of five (5) participants were successfully recruited and took part in one (1) FGD held virtually in February 2023. They were encouraged to engage actively, share their thoughts, and provide candid opinions and responses about the topics being discussed. Demographic data were also collected, including names, addresses, and other contact information. A semi-structured interview was initiated and facilitated by a skilled moderator, covering key topics including the participants’ backgrounds, the duration of their experience with KOA, their personal encounters with the condition, their motivations for utilizing PRP therapy, the factors influencing their decision-making, their experiences following PRP treatment, and their reasons for recommending PRP injections to others. The discussion lasted over an hour and was recorded for transcription.

Mode of Analysis

Before the FGD with participants, a pilot discussion took place in December 2022 through semi-structured interviews with expert physicians in the field. Two (2) experts from different healthcare institutions provided their professional insights on managing patients undergoing PRP treatment. Their responses, based on extensive clinical experience, emphasized various aspects such as the benefits and drawbacks of the treatment, user-friendliness, preferred PRP brands, patient backgrounds, levels of patient receptiveness, treatment modification, patient experiences after PRP, and the overall efficacy of the treatment. The authors reviewed the transcript multiple times, engaging in iterative readings to understand how the conversation evolved and to recognize the contributions made by each participant. The transcribed material was divided into portions to produce a single interview arrangement for each participant via a Microsoft Excel worksheet. Responses reflecting similar ideas from the pilot discussion in 2022 were gathered and organized according to their relevance to specific topics within the context of PRP utilization. The transcribed responses of each participant were uploaded to MAXQDA software, where a ground-up coding analysis was conducted. This involved identifying patterns or themes and extracting relevant data from the interviews. Prominent and frequently mentioned words in several discussion areas were tagged in the coding system and were used in concept mapping analysis using MAXMap. A visual tool incorporated within MAXQDA, which illustrates the correlation between the themes, the frequency of codes, and the overall experiences of each respondent with PRP.

Results

Participants’ responses highlighted common factors in their perceptions, experiences, and recommendations on PRP for KOA. The synthesized codes were extracted to identify the discussion themes, as shown in Figure 1. These themes were subsequently investigated to identify variations or comparisons among different users.

Figure 1.

Codification of PRP treatment to KOA based on user's perceptions, experiences, and recommendations (MAXMap).

Theme 1: User's Perception of PRP as Therapy for KOA

The PRA's clinical guidelines state that clinicians view surgery as a last resort for KOA when conservative treatments fail to alleviate pain and deformities. Despite the availability of surgical interventions for their condition, a majority of the participants have expressed skepticism towards undergoing such treatment, as shown in the participant's responses:

As for me, [PRP] looks like [the best option], since I am scared to undergo surgery. (R1)

There are other doctors who recommend surgery, but I dislike undergoing operations. (R4)

because I don't like to be operated again. (R3)

Participants shared their views on choosing PRP and their expectations during the discussion. All respondents considered this treatment option viable based on their physician's advice, thus, “Physician Recommendation” significantly influenced all participants’ choice to undergo PRP. As the physician explained the benefits of PRP to the participants, they consented to undertake the procedure without hesitation, as evidenced by their statements:

That's why I consulted [my doctor], and then she recommended the introduction of plasma into my right knee. (R3)

[My doctor] actually gave a very clear explanation. So I was right away convinced. (R2)

The doctor suggested to me to try PRP. But I don't know. Nobody told me what was administered to me specifically. She just took charge. (R5)

Most participants had long-term care from a shared medical professional, fostering strong trust in their provider for managing health conditions and achieving treatment goals. The high level of trust observed is crucial for their willingness to accept PRP as their recommended treatment, as indicated by their statements:

So why PRP? Number one, because of [my doctor]. (R1)

[My doctor] really knows my knee. Actually, she handled all of my injury cases. That's why whatever Doc is recommending, I comply because I trust her, because she has been taking care of me for a long time. (R4)

Theme 2: The Collective Experience of PRP Treatment

The overall feedback of the participants on their PRP experience centered on the treatment's efficacy in alleviating their predicament. Figure 1 shows that pain outcomes are the most frequently reported responses, highlighting the significant impact of pain on participants after therapy. Pain outcomes exist in two categories: (1) recurrence and (2) absence of pain. Participants strongly believed that PRP relieved their symptoms, with most reporting significant improvements in their quality of life, enabling them to resume their daily activities:

After the first PRP, I performed normal activity for around two and half years. (R1)

But when the pain has gradually subsided, maybe because of the [PRP] injection, it seems like I am completely satisfied because it's not the slightest pain that I felt, but it felt nothing. It felt as if I did not undergo PRP injection at all. It felt like I did not experience OA in the past. (R2)

The pain has subsided, [from a scale of 1 to 10 (painful)] zero pain. (R4)

The participants initially experienced a reduction in pain; however, most of them subsequently encountered “pain recurrence.” This resurgence was attributed to exacerbation from ongoing trauma or lifestyle factors associated with their return to work:

Now I’m beginning to experience some pain again. I’d like to think that this was also aggravated by the fact that a year before Christmas time, I think that was December 29, 2021, I almost stumbled. (R2)

It was okay then. I can partially run on the treadmill. But after a while, the pain came back. It was painful again. (R3)

I received PRP treatment last June. However, the pain is still there when I’m walking. (R5)

Many individuals who have undergone PRP treatment should seek additional remedies, such as medication or rehabilitation exercises, to complement the therapy due to the likelihood of pain recurrence. The physician attending to the participants required a combination of additional therapy to relieve the discomfort the participants were enduring:

That's why when it [KOA] is painful, of course I take Arcoxia. And then at night, if it is too painful, I topically apply Fastum. (R3)

But what I do is swimming. I swim. That's where I perform stretching. But I still do continuous exercises every day at home. I bought rubber. I bought weights, something like that. (R4)

Even though the participants had a pain recurrence, their status with KOA significantly improved following PRP therapy. Pain reduction has allowed a return to daily activities, leading some participants to feel that PRP completely relieved their discomfort and expressed interest in another dose, given their overwhelmingly positive experience:

It probably would really help me if I undergo PRP at least once a year. (R2)

What I’m thinking now is maybe to repeat the procedure [PRP]. I think that if the procedure is repeated, there is a better chance of improvement. (R3)

Theme 3: Recommending PRP as a Treatment

The cost of medical care is a crucial element affecting an individual's decision. The cost of PRP therapy varies depending on the individual. The price is insignificant for other participants as they reap advantages from their line of work.

So as for the price [of PRP], also, I have no idea because we have privileged benefits from the hospital. So it was charged from there. (R1)

I did not even bother to ask, maybe because I am confident that it was covered by my privilege in UST. Then, when I found out, I told myself, it's not very costly. (R2)

I don't know, because I did not witness the payment made by the community, because as you know, it is being charged from our common fund. (R3)

Contrarily, some view PRP treatment as expensive but acknowledge its potential to relieve pain:

But if it is too costly, it is costly. But if you have PhilHealth [insurance], it can be partially covered. Yes. I recommend PRP because I already had two (2) injections already. (R4)

Yes. I recommend PRP, though they say it is expensive. (R5)

Convenience is crucial in healthcare. Participants’ experiences with PRP preparation procedures indicate a positive relationship with their feedback:

No, it did not take too long. In fact, it [PRP procedure] was just for a short time. (R3)

The [PRP] procedure was quick. It took only one afternoon, maybe a very little time; it's not that long. (R1)

Discussion

Most KOA patients face considerable discomfort to the extent that even the performance of ordinary and essential tasks appears excessively challenging. While conservative treatment has shown short-term effectiveness in reducing pain, it is necessary to consider a surgical approach for managing persistent symptoms of KOA when conventional treatment fails to provide relief. ⁸ Surgical intervention for KOA offers clear advantages and successful outcomes, making it a leading treatment option for individuals with advanced stages of the condition. Despite the promising nature of these surgical interventions, it is essential to note that specific medical procedures, such as osteotomy and arthroscopic debridement, like other conventional methods, merely offer a temporary solution and do not fundamentally modify the consequences of KOA. ⁹ Moreover, their utilization may severely impact an individual's cost of living. ¹⁰ These factors may contribute to the respondents’ fear and doubtfulness about surgery despite its implications. Thus, they believe that alternative treatments may still be available before surgery.

Alternatively, PRP represents one of the emerging treatment modalities in regenerative medicine. There have been notable discoveries regarding the utilization of PRP in enhancing pain relief and improving the overall quality of life for individuals with musculoskeletal disorders. However, the need for standardized preparation has sparked ongoing discussions about its clinical use. Many healthcare experts believe PRP could be a valuable alternative for patients avoiding surgery. The participants in this study disclosed that PRP therapy had been proposed to them as an alternative to surgery, and they expressed willingness to explore the potential benefits of this treatment. A significant proportion of the participants are currently undergoing long-term medical care under the supervision of their clinicians, which has fostered a strong sense of trust in their clinical proficiency. All participants openly acknowledged that their contemplation of PRP treatment was greatly influenced by the recommendations provided by their physicians. Interestingly, it is found that the trust relationship between patients and doctors is a significant factor that can lead to improved treatment outcomes and overall satisfaction. ¹¹ It is also notable to consider how an individual's background can significantly impact building trust with others. Based on our findings, participants view their physicians’ professional opinions as trustworthy and well-established. Furthermore, owing to a positive rapport established between the physician and the patient, various communication channels have emerged to enhance their relationship. This facilitates the expression of their concerns, enables them to seek additional information regarding medical procedures, and clarifies specific aspects of their treatment. Apart from this, the variability in outcomes associated with PRP treatment has led to doubts among numerous clinicians regarding its application, particularly in surgical contexts. This doubt is significant when advising patients about PRP as a viable treatment option for managing KOA, especially for those under long-term care who have developed a strong trust in their healthcare providers. Such uncertainty can influence patients’ decision-making processes as they seek to select the most suitable treatment for their condition. Notwithstanding, trust constitutes a fundamental instrument in fostering a favorable perception of the treatment regimen.

On a global scale, the average cost of PRP is approximately $3700 for a 6-month appointment, including additional charges such as office visits, professional fees, and other necessary supplies. ¹² This factor significantly affects the ability of average Filipino patients to access medical care, as the expense associated with PRP may exceed their monthly revenue. Given that PRP is categorized as an experimental treatment, insurance plans may impose restrictions on the coverage of associated hospital expenses. This situation presents a challenge for both healthcare providers and patients regarding the direction of their treatment alternatives. While cost is a consideration, three participants deem the financial burden of PRP minimal due to employer support, and two participants thought PRP was too costly compared to other therapies, such as steroids and hyaluronic acid. Despite the cost, they were confident in PRP's efficacy and chose it over alternative therapies. The product's effectiveness and quality over time define a medical treatment's cost-effectiveness. PRP therapy for KOA has gained considerable attention in various scholarly publications due to its remarkable success in alleviating pain. All of the participants provided accounts of their experiences before receiving PRP injections, which were based on the range of pain levels they had experienced. These included difficulties with walking, reliance on mobility aids, insomnia and fatigue, and limitations in performing their usual daily activities. ¹³ Following PRP injections, the participants expressed positive feedback regarding the impact on their affected knees and the subsequent improvement in their overall quality of life. However, our findings indicate that PRP effectiveness in pain management can vary among individuals. The effectiveness of PRP in pain relief has led numerous participants to report feelings of satisfaction, fulfillment, joy, and excitement upon resuming their daily activities shortly after the procedure. Some have re-engaged in various aerobic exercises, utilized the treadmill, and engaged in recreational activities and travel. However, this engagement in activities has resulted in a recurrence of pain, primarily due to insufficient supportive exercises following the injection. Previous cases show that physical exercise may enhance PRP treatment effectiveness and improve outcomes. ¹⁴ Additionally, it has been observed that repetitive mechanical stress resulting from overuse and post-therapy traumas may require time to manifest and yield quicker positive results. ¹⁵ One of the participants observed the minimal pain reduction experienced post-PRP injection after noticing that the pain resurfaces following a series of aerobic exercises. The reduced response to PRP injections among older individuals is likely due to mechanical stress from overuse and a lower number of active, viable cells available to interact with growth factors. ¹⁶ The recurrence of pain experienced by the participants has prompted the desire for another PRP injection.

Conclusion

KOA has significantly decreased the functionality and the quality of life of the participants, mainly due to the debilitating pain symptoms. Their ongoing discomfort prompted them to consult healthcare professionals for therapy. The established confidence and expertise of their physicians were key in choosing PRP, despite the known effectivity of surgery. The alleviation of pain achieved through PRP treatment resulted in satisfaction, fulfillment, excitement, and joy among patients, enabling them to resume their daily activities in a shorter timeframe than anticipated. This outcome was perceived as a substantial enhancement in their quality of life. Consequently, this level of satisfaction motivates them for additional injections to attain optimal relief. Although the procedure is costly and not widely accessible, they believe that the treatment is valuable and merits recommendations to both their peers and family members.

This study represents significant limitations. Initially, the fact that participants received care exclusively from a single provider may lead to the presence of selection bias. Since the researchers used convenience sampling for participant selection, they relied solely on the availability and willingness of participants living within Metro Manila in the Philippines, comprising a very small representation of the country. Furthermore, the data presented in this study exclusively reflects the experiences of the participants engaged in this discussion regarding the use of PRP as the primary treatment for KOA. It does not encompass the broader societal perspectives. Other perspectives may arise from different participants or various FGDs; hence, it is recommended to encourage discussion among diverse participants to evaluate their perspectives and experiences with PRP treatment for managing KOA.