Contemporary medical interventions

Medical technology continues to improve at an amazing pace – just when it seems one new “magical” cure is available, there seems to be another “magical” cure that has been developed to replace it.  Thankfully in today’s “evidence based” world, we are very wary of many of these new developments, and there is an expectation that there is some evidence to show that the technique actually does have merit. Having said that, sometimes evidence is just not available readily, as many of these techniques rely on medium to long term follow up to prove if they actually are effective. So whilst evidence is very important, sometimes we rely on anecdotal evidence to help us decide the worthiness of a technique. Well known Sports Physician Dr Peter Larkins makes a great point when he says “Absence of proof of an effect is not the same as proof of absence of an effect”.

There are many different techniques beyond standard physiotherapy interventions that we often turn to for difficult conditions and chronic pain. In this article we explain some of the newest (and not so new) “miracle” cures that have come on the market, and that often gain great exposure through their use at elite sports level.

Local Anaesthetic

• Most local anaesthetic injections are given for short term purposes. They are often used as a diagnostic tool, with the injection guided into a structure that is thought to be causing pain, and the resulting effect recorded. If a patient receives significant pain relief following an injection of local anaesthetic, we can assume that the tissue injected was actually the cause of the patient’s pain. If the patient has minimal or no effect from the local, then it is likely that another structure is the cause of the pain. Using a local anaesthetic is a way to ensure that bigger procedures (such as Cortisone and surgery) are not used on a structure that is not actually a cause of the patient’s pain.
• This is the main injection used in competitive sport, however many people mistakenly believe that it is Cortisone that is given as pre competition injections. Cortisone does not act fast enough to have any purpose immediately before competition – it is the local anaesthetic that “deadens” the area, therefore often resulting in further damage by the end of a game, as the athlete cannot feel the damage they are doing.

Cortisone

• This is probably the most well-known of the injections that are used in contemporary medicine. Cortisone is a synthetic product that mimics the steroid hormones that are produced in our adrenal gland. Steroids are involved in a wide range of our physiological systems, including assisting with our stress response, metabolism, immune responses, inflammatory regulation and general behaviour, just to name a few!
• Cortisone is most commonly prescribed for its effect on chronic inflammatory conditions, including asthma, and can be given orally for widespread or inaccessible inflammation (but there are increased side effects of this method) or more commonly via injection for more specific areas of pain.
• Cortisone has received a bad name over the years for a few reasons – firstly, it has probably been an overused intervention over the years, and has been used on many conditions that we now know don’t respond well to cortisone. For example, many tendon conditions can actually respond poorly (and have increased risk of rupture) following a cortisone injection. Thankfully we now have a much better idea of what does respond tocortisone, so it is used less, but with more accuracy and effect. Secondly, as mentioned above, many people blame “cortisone” for the damage caused with pre game injections, when it is in fact just a local anaesthetic that is being injected, and not cortisone at all.
• Cortisone is successfully used for joint problems and impingements syndromes particularly around the shoulder and ankle.
• Cortisone does come with some pretty significant potential side effects however, particularly when taken orally and over long periods, so doctors are usually very specific with their dosages when prescribing oral cortisone.

Prolotherapy

• Prolotherapy gained notoriety some years ago, but seems to have taken a back seat again pretty quickly. This involves a series of injections of glucose which is aimed at inducing a local inflammatory reaction (in other words it is supposed to create pain and local tissue damage) and therefore results in a flare up of pain, swelling, and bruising. The whole idea is that the inflammation results in an increased blood flow which stimulates the tissue to repair itself.
• Injections are at fortnightly intervals and generally patients need a minimum of four series of injections, but can have up to 10.
• The main use for prolotherapy is for tendon and ligament conditions. The evidence for prolotherapy is variable, and you will not find it commonly recommended as a part of main stream medicine.

Autologous Blood Injections (ABI)

• Apart from stem cells, “blood injections” are one of the newest techniques available for patients. Autologous (meaning taken from yourself) Blood Injections involve blood being taken from a patient’s vein and reinjected immediately back into the area of concern.
• There is a low risk of immune reaction with blood injections and they are relatively inexpensive.
• Their main use is in areas that have a naturally poor blood supply, and therefore we see blood injections used most commonly for tendon pathology, in particular around the elbow (“tennis elbow”), and for gluteal, hamstring, patella and achilles tendons. Results are variable and the evidence level is low regarding their value.

Platelet Rich Plasma (PRP)

• This is basically the same as blood injections, except a larger amount of blood is withdrawn and the blood is then spun down for about 15 minutes in a centrifuge which spins at the rate of many thousand times a minute. This causes the cells in the blood to separate from the fluid component of the blood (plasma) and the cells, or platelets, can then be selectively removed resulting in the extraction of growth factor rich platelets (approximately 8-10 times the concentration of platelets compared to ABI).
• PRP is permitted in athletes as no performance enhancement occurs.
• PRP is used for soft tissue conditions but is also starting to be trialled for bone and joint problems, and costs approximately$200 per injection, with 2 – 4 treatments generally required, at intervals of about 3-4 weeks between injections.
• At the moment there is also little supporting evidence to show that PRP is more effective than ABI, however theoretically at least PRP sounds like it should have a better chance of promoting healing!
• Orthokine Therapy has also received some publicity in AFL circles this year – this is a form of ABI, using individual proteins derived from a patient’s blood and incubated. It is thought to be better for joint pain and back pain, rather than tendon pathology, however once again there is little supporting literature or evidence to proof it’s effects or benefits.

Synvisc

• Hyaluron is part of the synovial fluid, or natural lubricant, which is formed within normal joints. Osteoarthritic and degenerative joints have synovial fluid that lacks elasticity and viscosity (thickness) and therefore these joints have less lubrication and shock absorbing capacity. Synvisc is an injection of a thick gel like fluid that is mainly derived from hyaluron, and the aim of this technique is to restore the natural elasticity and lubricating properties of synovial fluid.
• Synvisc used to be given in three separate injections but is now given in one, and an average of 70% of people respond positively to synvisc with an average of 12 months relief of symptoms. The main use currently for synvisc is in mid to late stages of joint degeneration or arthritis, particularly knees.
• The only precaution with synvisc is for those with bird/egg allergies and there is about a 2% risk of significant infective reaction.
• Of all the interventions mentioned in this article, Synvisc, along with cortisone when used correctly, is probably the one that is showing the greatest effect, relief of pain, and improvement in function for patients.

Stem Cell Therapy

• Stem Cell therapy is the most exciting and potentially beneficial technique on the market at the moment. Stem cells are “growth” cells – they make things happen. The idea behind stem cell therapy is to replenish injured cells and maintain a normal turnover of cells. There are 200 types of adult stem cells, but the source used for therapy are mainly:
  • Adipose tissue (vessels in fat)
  • Bone marrow (the richest source of stem cells)
  • Blood (PRP may have stem cells in it)
• The excitement with stem cell therapy comes from the fact that it is thought that stem cells can:
  • Reduce inflammation by controlling the immune system.
  • Inhibit scar formation which results from injury and damage.
  • Suppress cell death.
  • Stimulate new blood vessels to injury sites.
  • Promote wound healing via the secretion of growth factors.
  • Stimulate cell division and growth of new cells
• It is early days yet and therefore no clear idea of how stem cells could and should be used. Issues originally came as stem cells were taken from embryos, however they are now taken from adult stem cells. The excitement of stem cell therapy is tempered at the moment by two significant drawbacks: Firstly, one of the big current risks of stem cells is that undifferentiated stem cells can make tumors/cancers and it is this possibility that needs further investigation. The second drawback is cost: stem cell therapy costs between $8,000 to $9,000 per treatment!

So as you can see, there are quite a few options that may be recommended or suggested to you to help manage an injury or condition, however many of these require a bit more time and testing until we determine the true effects and benefits. Stay tuned!