Pain is a pain…am I right?!
As a musculoskeletal specialist, I see people with pain from all sorts of problem areas that are limiting to their activity. Once they are sitting in front of me, the objective is clear…they want to get rid of the pain…as fast as possible…and for as long as possible.
So how do we do that? There has been a greater push for more conservative management approaches, such as physical therapy or other modalities, for which I am an advocate. However, when patients are experiencing activity-limiting pain, they do not always want to invest the time and effort necessary to get outcomes from these approaches. Or, the pain simply limits their ability to engage in these treatments.
The typical “quick fix” has been to inject the affected area, usually with a mixture of high-dose corticosteroid and anesthetic. Tapering doses of corticosteroids taken orally are also commonly prescribed. Pain relief is usually immediate or within the first few days. So, because these types of procedures fast pain relief and have been performed for decades that must make them ok, right? Well, maybe not as ok as we thought.
The problem is that there is now mounting evidence showing that when high-dose corticosteroids are utilized, they are doing more harm than good over time. Now, effects associated with both oral and intraarticular corticosteroids are raising concerns across the board in the medical community.
Let’s look at the pitfalls. Corticosteroid treatments on average provide short-term relief (maybe 3-6 months). Now that might sound relatively good if you’re experiencing pain, but the treatment will likely need to be repeated. With repeat exposure, steroid injections have been shown to break down cartilage faster and also hinder the stem cell response needed to heal the area appropriately. Further breakdown of the tissue requires injections to be performed more frequently for more pain, and the negative cycle continues. Injections into tendons also cause further damage, resulting in more pain and increased risk of rupture. Spine injections can speed up degenerative change and increase risk for fractures. On a systemic level, repeated exposure to oral and injected steroids speeds up bone demineralization and osteoporosis. Also, hormonal interruptions can cause problems with systemic cortisol regulation and adrenal insufficiency…no one wants that.
It’s pretty clear…routine high-dose corticosteroid exposure, whether injection or oral, is not good for the body. Still, in many cases, the desire for fast-acting pain relief and the coverage by insurance often will outweigh the concern over risks. But is this the right thing to do for patients? Usually when increasing evidence shows that the negative effects of a medication/procedure begin to outweigh the potential for benefit, most companies/practitioners will remove that treatment as an option for patients. The problem is that there aren’t many other good interventional options under the insurance coverage umbrella. Hyaluronic acid injections (“rooster” or “gel” shots) are a relatively good alternative to basically lubricate the joint. Still, these give a variable response, which also diminishes as arthritis worsens over time.
So, then what do we do? Luckily there are still a few options if we venture to think outside the proverbial insurance box. Regenerative treatments using platelets from patients’ blood and stem cells from their bone marrow (not from umbilical or amniotic sources) are showing tremendous outcomes in treating musculoskeletal issues. The focus with these treatments is more on healing tissue for longer-term benefit. In recent research, treatments using a patient’s own blood platelets (PRP) have shown superiority over both corticosteroids and hyaluronic acid in both symptom relief and longevity of relief. These treatments are also showing great results in treatment for both arthritic pain in the spine and nerve entrapments. Plus, there are no significant degenerative or hormonal effects from these treatments, which is great for long term use! If these treatments were covered by insurances, I feel like this would be a no-brainer in most cases…it would just be the go-to.