Posts tagged injections
Utilization of Platelet Rich Plasma (PRP) for Tendon Pain
boulder-PRP-treatment-tendon-pain-tendonitis

Overuse injuries to the upper and lower extremity tendons remains a common source of pain and lost activity for patients at our Boulder Physical Therapy practice.   Tendon injuries can be challenging to treat, but these injuries have been shown to respond to exercise interventions designed to appropriately load and promote healing (remodeling) of the injured tissue.  Often patients ask about additional interventions to accelerate the healing of injured tendons including platelet rich plasma (PRP).

PRP remains the most common biological injection provided by physicians to treat the injured tendon.  In short, blood is taken and spun (centrifuged) to concentrate the blood's platelets which are subsequently injected into the injured tendon in an effort to heal the injured tissue.  The effectiveness of this treatment is still being researched.  Authors have reported improvements in tissue structure, mainly in animal models, after PRP injections but improvements in clinical outcomes are less clear.  Improvements in tissue healing and remodeling may or may not correlate to improvements in patient's pain and function.  Further, multiple trials have not shown an additional clinical benefit of pain or improved function over a placebo injection.      

In short, more research is needed to compare PRP to placebo as well as comparing PRP to proven treatments for tendon injury including strengthening exercise.  The injections remain an expensive treatment option for patients and require more scientific inquiry before being used on a widespread basis.

No Evidence to Support Use of Stem Cells for Tendon Injuries
stem cells-injections-treatment-tendon-injury

The use of platelet rich plasma (PRP) and stem cell injections continue to rise and outpace the medical research supporting their use.  Often these expensive injections are not covered by medical insurance due in part to their unproven effectiveness in human trials against placebo or control/natural history groups.  

A recent review article in the British Journal of Sports Medicine examined the available literature on the utilization of stem cell therapy injections (Pas et al. 2017).  The authors reviewed the applicable trials on tendon injuries, including tendinopathy, tendinitis, and tendinosis, across multiple body regions.  The authors examined the available articles and found no evidence to support the use of stem cell injections on tendon conditions and concluded stem cell injections is not advised for clinical practice.  

Patients are encouraged to utilize their local Physical Therapist to implement more evidence based interventions including exercise therapy to assist in their recovery from tendon symptoms.

Hyaluronic Acid vs. Corticosteroid for Knee Osteoarthritis

Knee Osteoarthritis is a common condition affecting many middle aged adults which leads to pain, loss of range of motion, and decreased function.  Physical Therapy remains the primary choice for conservative treatment, but often these treatments are combined with injections to the knee joint.  Corticosteroids are an inexpensive injection designed to reduce pain and inflammation in the knee, but Hyaluronic Acid injections such as Synvisc are also on the rise.  These injections claim to cushion and lubricate the knee joint leading to reduced pain and improved function.  One downside of these injections is their cost ($250-$1000 per injection) which is often not covered by insurance.  In addition, the research on these injections has been compared to saline (placebo) injections instead of a head to head comparison with the corticosteroid.

Recently an article in the Journal of Bone and Joint Surgery examined the impact of a single corticosteroid or hyaluronic acid injection on 99 patients with knee osteoarthritis (Tammachote et al. 2016).  Patients were randomized to receive one of the two injections then followed over 6 months.  As you can see from the graph above both groups demonstrated similar outcomes in pain, function, and range of motion at 6 months.  Differences were noted in the short term with decreased pain and improved function noted in the first two weeks in the patients receiving the corticosteroid.  The authors called into question the cost of these expensive injections compared to the less expensive corticosteroid.  

Injections for Knee Osteoarthritis

Knee osteoarthritis is a common condition in aging adults leading to pain and reduced performance of daily and recreational activities.  Manual therapy and exercise remain a hallmark of conservative care for this condition and have been shown to delay or prevent the need for a total knee replacement.  In addition to exercise, corticosteroid injections are often proposed to patients in order to reduce pain and improve patient participation.  A recent study in the Journal of the American Medical Association examined the impact of these injections in patients with knee arthritis.

Henriksen and colleagues studied 100 patients and randomized them to either a corticosteroid injection or a placebo injection prior to undergoing Physical Therapy 3 days a week for 12 weeks.  These patients all had evidence of knee arthritis on x ray and reported pain with daily activities including walking.  All patients improved through the course of the study, but no significant differences were noted at 2, 14, or 26 weeks between the group receiving a corticosteroid injection or a placebo.   The authors concluded there was no additional clinical benefit of a steroid injection and Physical Therapy compared to Physical Therapy alone.  Thus, Physical Therapy was the main reason for the patient's improvement.   

Patients with knee osteoarthritis are encouraged to seek out a local Physical Therapist to implement an effective rehabilitation program.  

Lateral Elbow Pain (tennis elbow) and Physical Therapy Treatments
Lateral elbow pain and boulder physical therapy treatments

Lateral Elbow Pain and Lateral Epicondylalgia

Lateral epicondylalgia, also known as tennis elbow, is an overuse injury involving the common origin tendon of the wrist and finger extensors. Patients with this condition often report pain in the lateral elbow exacerbated by gripping, lifting, or manipu- lating objects with their hands.

Previously thought to be a condition of inflammation (lateral epicondylitis), new research shows a lack of inflammatory cells in this condition. Instead, lateral epicondylalgia is considered a degenerative condition and one of dysfunctional, immature healing of the tendon(5,6). Tendons have been shown to remodel and heal along the lines of stress from exercise and appropriate loading(7).

4-7 cases per 1000 patients experience the condition and lateral epicondylalgia has a 1-3% incidence within the general population(1,2).

The condition primarily effects the dominant arm of individuals between 35-54 years old1. Amateur tennis players, patients with poor posture, frequent computer use, and manual tasks involv- ing force and repetition are at greater risk for the condition(2).

The majority of patients reports resolution of their symptoms by 1 year but may range up to 24 months(1).

Physical Therapy interventions have been shown to accelerate this recovery process and have been shown to be more cost effective than a wait and see approach or a corticosteroid injection(9). 

Elbow Pain and Physical Therapy Treatments

elbow pain, manual physical therapy, treatments

Review articles do not support the use of Physical Therapy modalities including ultrasound and iontophoresis in the treatment of lateral epicondylalgia(4).

Corticosteroid injections have been advocated for short term relief by many studies. While experiencing early relief, patients undergoing corticosteroid injections have a higher recurrence rate (72%) compared to a wait and see (10%) or Physical Therapy treatments (4%). (3)

Recent systematic report strong evidence against the utilization of platelet rich plasma (PRP) injections in patients with lateral elbow tendinopathy(12).

Evidence reviews on the topic of lateral elbow pain advocate for a multimodal Physical Therapy treatment model including spinal and extremity joint manipulation/ mobilization, soft tissue treatments, and strengthening exercises(4,13). 

boulder manual physical therapy, elbow pain, mobilization with movement

Physical Therapy Evidence

A manual physical therapy approach combined with exercise has been shown to accelerate a patient’s recovery by reducing pain and disability in the short term. Medical evidence has also shown patients receiving this treatment approach have the lowest recur- rence rate of pain and medication use(10,11).

Conversely, poorer long term outcomes and higher recurrence rates have been documented in patients receiving corticosteroid injections(10).

Bisset et al. reported the utilization of manual therapy and exercise is superior to wait and see and corticosteroid injection at short-term follow up11. It appears PT helps accelerate recovery and is superior to a wait and see approach.

Evidence suggests treatment of the upper quarter including the cervical, thoracic, elbow, and wrist regions may provide positive effects on patient’s pain and function(14). 

physical therapy, wait and see, injection for elbow pain

When to Seek Physical Therapy Care

Patient’s with lateral elbow pain exacerbated by gripping or manipulation of the hand and wrist should be treated with a multimodal Physical Therapy treatment plan to reduce pain and disability. 

References

1. Smidt N, Lewis M, Van Der Windt DA, et al. Lateral epicondylitis in general practice: course and prognostic indicators of outcome. J Rheumatol 2006;33:2053–9.

2. Shiri R, Viikari-Juntura E, Varonen H, et al. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol 2006;164:1065–74.

3. Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006;333:939.

4. Coombes, B. et al. A new integrative model of lateral epicondylalgia. Br J Sports Med 2009;43:252–258

5. Fredberg U, Stengaard-Pedersen K. Chronic tendinopathy tissue pathology, pain mechanisms, and etiology with a special focus on inflammation. Scand J Med Sci Sports 2008;18:3–15.

6. Alfredson H, Ljung BO, Thorsen K, et al. In vivo investiga- tion of ECRB tendons with microdialysis technique--no signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthop Scand 2000;71:475–9.

7. Riley G. Chronic tendon pathology: molecular basis and therapeutic implications. Expert Rev Mol Med 2005;7:1- 25.

8. Smidt N, Assendelft WJ, van der Windt DA, et al. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain 2002;96:23–40.

9. Coombes, B. et al. Economic evaluation favours physiotherapy but not corticosteroid injection as a first-line intervention for chronic lateral epicondylalgia: evidence from a randomised clinical trial. Br J Sp Med. 2015.

10. Coombes, B. Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients With Unilateral Lateral Epicondylalgia A Randomized Controlled Trial. JAMA. 2013. 309(5):461-469.

11. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corti- costeroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939.

12. De Vos, R. et al. Strong evidence against PRP injections for chronic lateral elbow tendinopathy. A systematic review. Br J Sp Med. 2014.

13. Fernandez-Carnero, J. et al. EXAMINATION OF MOTOR AND HYPOALGESIC EFFECTS OF CERVICAL VS THORACIC SPINE MANIPULATION IN PATIENTS WITH LATERAL EPICONDYLALGIA: A CLINICAL TRIAL. J Manipulative Ther Phys. 2011. 34(7):432-440.

14. Vicenzino, B. et al. Joint manipulation in the management of lateral epicondylalgia. A clinical commentary. JMMT. 2007. 15(1):50-56. 

Lumbar Injections for Back and Leg Pain
lumbar epidural injections, back and leg pain

The use of lumbar corticosteroid injections is often utilized for patients with back and leg pain (radicular pain) and/or leg numbness, pins and needles, or nerve root weakness (radiculopathy).  In an older adult these symptoms may be due to a narrowing of the canals in which the lumbar nerve roots exit (lumbar stenosis).  These injections are costly and not without risk including a number of cases of infection in 2013-2014.  A recent review of the available literature published this month in the Annals of Internal Medicine found limited effectiveness of these treatments compared to placebo trials for both lumbar radiculopathy and stenosis.  http://nyti.ms/1hEmCDG.  Chou et al. and colleagues reported injections for radiculopathy may offer a small, short-term effect but long term effectiveness is limited.  In patients with lumbar stenosis the evidence reported little to no effectiveness on pain or function.  Physical Therapy is the first line intervention for patients with these conditions. 

Please visit our website, http://www.mendcolorado.com/mendphysicaltherapyconditions-we-treat/, for more information.