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Injections for pain relief are growing in popularity. Traditionally, corticosteroid injections are used to alleviate symptoms. However, research has highlighted ongoing concerns about the use of corticosteroids increasing the rate of future joint degeneration. Some contemporary studies promote a new class of regenerative injections that have a much different effect—to stimulate inflammation. There is also new data showing that injections using placebo (saline) may provide equivocal results. In this blog, we will dive deeper into non-spinal injections, and possibly add another alternative to your toolbox.

Saline

Gazendam et al. (2020) provides a systematic review and network meta-analysis finding that intra-articular hip saline injections performed as well as all other injectable options in the management of hip osteoarthritis for pain and functional outcomes. There are many injectable options available for patients with hip OA. “Although some theoretical and in vitro regenerative potential has been demonstrated with some of the above treatments, at present time all are aimed at symptom relief rather than disease reversal.” (10)

Eleven randomized controlled trials (1353 patients) studying patients with hip osteoarthritis at both 2–4 and 6 months. Interventions including: local anaesthetics, corticosteroids, hyaluronic acid, platelet-rich plasma, and mesenchymal stem cells DID NOT outperform placebo injections for both pain relief and functional outcomes.

Corticosteroids

Corticosteroids down-regulate immune function and reduce the number of inflammatory cells and mediators, such as lymphocytes, macrophages, and mast cells. (1)

Essentially, corticosteroid injections minimize pain.

The Positives

  • Down-regulate immune function through the reduction of inflammatory cells and mediators. (lymphocytes, macrophages and mast cells) (1)
  • Reduce pain caused by inflammation

The Negatives

  • Increase protein catabolism, decrease type I collagen and glycosaminoglycan syntheses, and therefore slow the healing process (1)
  • Inhibition of collagen repair leading to accelerated joint degeneration (1,9)
  • Bone loss, breakdown, and potential fracture (9)
  • Traditionally overutilized in cases of tendinosis

Common Applications

  • Intra-articular injections for conditions such as osteoarthritis
  • Extraarticular injections for short-term pain relief associated with tendinitis (2)

The vast majority of current and past research supports the use of steroids for short-term pain relief and reduction of inflammation. These medications provide patients with exactly what they are looking for—quick symptom reduction. Unfortunately, pain relief and the anti-inflammatory properties are short-lived, and symptoms often return. Steroids also delay tissue healing, which can lead to an extended period of disability. 

Conclusion: steroids may be used sparingly for these non-spinal purposes; however, long-term use is discouraged. 

Orthobiologic Regeneratives

Autologous blood injections involve performing a peripheral blood draw to extract blood from a distal site then injecting it directly into the affected tendon. 

Platelet-rich plasma (PRP) is a biological blood product derived from centrifuged whole blood to extract concentrated platelets. They are injected directly into the site of injury to promote tissue healing. (3)

The Positives

  • Introduce blood and platelet products to initiate maturation and proliferation. (4)
  • “Stimulate cellular activity to initiate a healing response by increasing growth factors by increasing platelets or aseptic inflammation to trigger the reparative process of tendons.”(5)

The Negatives

  • Most insurers do not cover PRP injections. Cash prices range from $800–1200 per dose with typically 1–2 injections providing significant relief of pain and improvement in physiologic tissue recovery. (6)
  • There are few condition-specific standardized protocols. (7) 

Common Applications

  • Treat musculoskeletal injuries by facilitating tissue regeneration and healing. (8)
  • Often included in a multimodal approach to treatment, including rehabilitation exercises and possibly instrument-assisted soft tissue manipulation.

Regenerative injection therapy is a conservation treatment designed to stimulate healing. Barnett et al. (2019) found that: “Individuals receiving these injections had long-term pain relief and increased self-perceived upper limb use. The results also suggest that doses of whole autologous blood, as well as platelet-rich plasma, are useful to decrease pain and increase self-rated upper limb use in individuals with lateral epicondylitis. An additionally important consideration is that the regenerative injections were helpful in the acute as well as chronic stages of lateral epicondylitis.” (5)

Conclusion: PRP and autologous blood injections may be used to promote a healing response in both the acute and chronic phases of disease; however, they do come at a higher out-of-pocket cost to patients.

When a chiropractic trial of care results in failure, you and your patients are left to consider other options. When assessing injections, first ask yourself the intent of the medication. Injections are designed to either suppress or catalyze an inflammatory reaction, so choose the diagnosis-specific desired cellular response.  While most chiropractic physicians do not perform injections in office, developing relationships with local physical medicine providers may benefit your patients.

As a fellow Chiropractor, I realize that’s not always the easiest thing to do. However, with ChiroUp, you have access to the step-by-step process on how exactly you can build relationships with the medical providers in your area.

It’s the same recipe that Dr. Bertelsman and I use, and it pays off to the tune of over 300 MD new patient referrals every year. You can find this entire step-by-step recipe under the new MD Relationships “BOOST” tab in your ChiroUp account.

Working closely with medical physicians in your area will not only increase your number of referrals but also further your reputation in the community as the authority on chiropractic care. Building these kinds of relationships with physicians will take time and energy, but the outcome will be worth the effort. Log in now to check out the entire BOOST breakdown for building MD relationships.

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References
  1. MacMahon PJ, Eustace SJ, Kavanagh EC. Injectable corticosteroid and local anesthetic preparations: a review for radiologists. Radiology. 2009;252:647–61. 11.
  2. Cole BJ, Schumacher RH Jr. Injectable corticosteroids in modern practice. JAAOS-J Am Acad Orthop Surg. 2005;13:37–46. 
  3. Saucedo JM, Yaffe MA, Berschback JC, Hsu WK, Kalainov DM. Platelet-rich plasma. J Hand Surg. 2012;37:587–9.
  4. Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev. 2014;:CD010071. https://doi.org/10.1002/14651858.CD010071.pub3. 
  5. Barnett J, Bernacki MN, Kainer JL, Smith HN, Zaharoff AM, Subramanian SK. The effects of regenerative injection therapy compared to corticosteroids for the treatment of lateral Epicondylitis: a systematic review and meta-analysis. Archives of Physiotherapy. 2019 Dec 1;9(1):12.
  6. Mlynarek R, Kuhn A, Bedi A. Platelet-rich plasma (PRP) in orthopedic sports medicine. Am J Orthop. 2016;45:290–326. 
  7. Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-rich plasma: from basic science to clinical applications. Am J Sports Med. 2009; 37:2259–72.
  8. Reeves KD, Fullerton BD, Topol G. Evidence-based regenerative injection therapy (prolotherapy) in sports medicine. In: The sports medicine resource manual. Philadelphia: Saunders (Elsevier); 2008. p. 611–9.
  9. Kompel AJ, Roemer FW, Murakami AM, Diaz LE, Crema MD, Guermazi A. Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Safe as We Thought?. Radiology. 2019 Oct 15:190341.
  10. Gazendam A, Ekhtiari S, Bozzo A, et alIntra-articular saline injection as effective as corticosteroids, platelet-rich plasma and hyaluronic acid for hip osteoarthritis pain: a systematic review and network meta-analysis of randomised controlled trialsBritish Journal of Sports Medicine Published Online First: 22 August 2020. doi: 10.1136/bjsports-2020-102179

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