For pain that is persisting and not responding to the usual rest, stretching, manual therapy and anti-inflammatory medications, injections may be used to reduce pain and inflammation or encourage healing. Injections by themselves are rarely an instant cure, but they can assist in recovery in conjunction with other modalities. Here is a brief overview of some of the more common types of injection therapies available at Brighton Spine and Sports Clinic:
Cortisone is a synthetically manufactured drug which mimics certain functions of the natural hormones that appear in the body. These natural hormones include glucocorticoids which regulate sugar metabolism within the body, adrenal corticoids which regulate fluid balance within the body, and androgenic hormones which are one class of sex hormones within the body, but its main effect is as a powerful regulator of the immune system, reducing inflammation. Cortisone injections are used to provide a localised concentration of the drug into areas of excessive inflammation. They are typically used to settle nerve pain and swelling in the spine in cases of disc prolapse (hypertext to link to disc prolapse page). They are also useful in settling joint inflammation in the short term – to provide a “window” where other treatments can be introduced. Recent research suggested cortisone is not helpful long term for tendon or ligament sprains as they settle the inflammation but don’t encourage strengthening and healing of weakened tissues.
Sclerosing or prolotherapy injections were first proposed by Hackett, an orthopaedic surgeon, in the 1950s. Early injections included various solutions of local anaesthetic, dextrose (sugar), phenol and glycerol. The solution was designed to create an inflammatory reaction initiating the proliferation of scar tissue (collagen) in the tissues injected. The idea was to cause thickening, tightening and strengthening of the tissues through scarring. Studies confirmed that treatment lead to about a 40% increase in collagen fibre strength and cross sectional area of tendons and ligaments. More recent trends have led to the use of less irritant solutions of 5% to 25% dextrose and 0.5% Xylocaine – a very tolerable and safe injection. Other theories on how the injections work include:
- dextrose may also act as an oxygen radical scavenger – soaking up molecules that are thought to cause tissue damage, possibly having some anti-inflammatory value as well.
- repeated injections into tender points seem to de-sensitize these tissues or block pain leading to some new theories about affecting the capsaicin pain receptors around nerves in the subcutaneous tissue.
Usually a course of 3-4 injections is given spaced about 2-3 weeks apart leading to progressive lessening of pain and strengthening of tissues. Research trials on dextrose prolotherapy show about 50% improvement in pain in 50% of chronic lower back pain patients, with about 20% rendered pain free.
PLATELET RICH PLASMA ( PRP)
PRP is a fraction of whole blood containing concentrated growth factors and proteins which appear to enhance soft tissue healing. The number of basic science, animal, and human investigations of PRP for tendon and muscle injuries worldwide has risen sharply in recent years. These studies are helping clinicians better understand the mechanisms of PRP and are guiding novel treatment protocols.
Currently PRP is being used clinically in the following areas:
- healing skin in chronic leg ulcers
- enhancing bone strength in dental implants
- enhancing tendon repair in chronic conditions such as tennis elbow and jumpers knee
- enhancing bone healing in fractures
What does it involve?
Firstly blood is taken from the arm and then placed in small test tubes which are then placed in a centrifuge and spun for 10 minutes. This separates out the red blood cells from the clear serum ( plasma). A portion of the plasma rich in growth factors and stem cells (about 2 to 3 mls) is then drawn from the tubes in injected into the damaged area. Depending on the injury a course of 3 injections is given about 3 weeks apart.
PENTOSAN POLYSULPHATE SODIUM ( PPS )
PPS therapy has been in the news recently showing impressive improvements in footballers with crippling knee osteoarthritis. It is still an experimental drug and only available from Paradigm Biopharma – an Australian listed company as part of the clinical trials program they are running. Dr Victor Wilk of this clinic is involved in the running of some of these trials. The trials consist of twice weekly subcutaneous injections of PPS for a period of 6 weeks. Current results indicate a likely improvement in the order of 50% relief of pain with improvement in function. Trials at present are restricted to knee osteoarthritis and modic type 1 inflammation of the discs of the lower back. There are certain eligibility criteria that patients must fulfil and the first step in assessment is to make an initial appointment with Dr Wilk.
STEM CELL THERAPIES
Stem cell therapies are available for knee osteoarthritis – but at present do not show any superior benefit over PRP injections and are still classed as an experimental therapy. The cost of such injections at present is prohibitive and thus not recommended for routine treatment.
TRIGGER POINT INJECTIONS
The majority of patients complaining of chronic pain will have areas of muscle tightness throughout their body. In some cases these areas of muscle tightness are the primary cause of pain. In other cases the muscles tighten up in reaction to an underlying joint or nerve system problem. Where the muscle is the primary source and cause of the pain, a simple injection into a tender spot in the muscle can relax a tight band in the muscle, (otherwise known as a trigger point) resulting in relief of pain.
A trigger point can be described as a taut band within the muscle, which when stimulated, causes pain locally and also may cause pain to spread to nearby areas. Examples of trigger points which may cause headaches include tender spots within the trapezius muscle at the base of the neck, sending pain up the back of the neck to the base of the skull. The strap muscles at the front of the neck (sternomastoid) can cause pain that spreads up to the side of the face, the temple region and around the eye.