Dr. Kevin Most: Pain
We all have aches and pains, many are self-inflicted from over exercising, injuries during activities and slips and falls. We have talked many times in the past about the treatment for these injuries. We all know the acronym RICE Rest, Ice, Compression and Elevation. The goal is to get the injury to heal as quickly as possible. We also often will encourage the use of anti-inflammatory medication to help minimize swelling and thus pain. One of the recent goals has been to minimize the use of opiate medications for minor to moderate pain relief. Because of the chance of addiction the prescription of these meds has decreased and will continue to.
For the vast majority of injuries this treatment plan of RICE works and although it may not be as fast as we want the recovery to occur it does as the body heals itself. In some individuals the condition lingers and often worsens. This can be due to many reasons, continued over use, anatomical issues and repetitive trauma are some. In these patients the treatment needs to be expanded and may include surgery, physical therapy, ultrasound therapy or other treatments.
One goal is to also minimize the need for any opiate medications as the concern for addiction has skyrocketed along with the number of overdoses from the abuse of these drugs. Because of this we are starting to see more novel or resurrection of other pain treatment options arise.
You all have recently seen the advertising on TV for the electric pads that attach to the skin and send electric impulse to the area of discomfort, often the low back. Until recently this therapy was mainly done in Physical therapy units and not readily available over the counter at reasonable pricing. Now we see TENS units being sold by many companies for pain relief.
TENS stands for Transcutaneous electrical nerve stimulation. It is essentially low voltage current that is sent to your muscles and nerves. The thought is that this unit stops the pain signals from those nerves from reaching the brain. It is also thought that these units increase the production of natural painkillers called Endorphins.
These units can be purchased on Amazon for under $50, other higher quality units like those used in PT departments can cost thousands of dollars. The units are fairly easy to use and are fairly safe. The data on these units is actually pretty decent for muscular injuries of the back.
You also may notice an increase in advertising for other pain relief treatments. Common ones that are making a comeback are topical medications such as Salon Pas, Icy Hot and Execedrin Cooling Packets. These are all OTC medications that actually are some what irritants to the skin and when applied to the skin cause a reaction on the skin that minimizes the pain signals to the brain. An easy way to think about these items is they are essentially a chemical TENS unit.
Musculoskeletal and joint pain are also treated in a few different ways with many becoming more popular. Steroids are used frequently. You may be given something called a Medrol Dose Pak, this is a dose of steroids that you take orally and it has a taper dosing schedule, so you take a large dose on the first day and then the dose is tapered over the next 5-10 days. This allows for a strong anti inflammatory drug to get into your system quickly. It allows for the inflamation to decrease and thus decrease the amount of pain due to swelling. The dose is tapered as the body will naturally make its own steroids and if the body notes that it has enough steroids it will stop making steroids which can be very dangerous, so make sure you take them as prescribed.
Doctors may also consider giving a shot of steroids in a specific inflamed area, often a joint. This allows for a high dose of the medication to go immediately to the area it is needed most. Think about it, oral steroids are absorbed into the blood and distributed thru the body where the steroid shot makes sure all of the medication gets to the area where it is needed the most.
Another modality that is being tried and studied is one call Platelet Rich Plasma. Essentially this is an injection into the area of concern with the individuals own blood that has been manipulated to contain a high concentration of platelets. We have talked about platelets in the past, essentially they are material in our blood that allows and helps us stop bleeding after an injury. We all have platelets as they are needed to clot blood. Platelets also contain growth factors. These growth factors found in platelets help with wound healing and regenerative process.
Here is a quick description of how this occurs, blood is drawn from the individual, it is them centrifuged down which allows for the blood to separate into its components, Plasma, Red Blood cells, White Blood Cells and platelets. The platelets are removed and placed with some additional blood. This allows the concentration of the platelets to be 5 – 10 times higher than standard blood.
This blood is then injected into the area of discomfort. As it is the patients’ blood there is no concern of rejection or reaction.
The thought is that the components of the PRP will help speed recovery and healing. As with all treatments the first few questions should be, is it safe and does it work. It appears that it is very safe and the risks are pretty low, infection being one.
Now the more important question is does it work? Well the jury is out on that as are the researchers. Although this is being done around the world there are very few studies that show it is very effective. We talk about athletes making us aware of treatments, this is no different. Tiger Woods , Brian Urlacher, Matt Forte are just a few of the many athletes who are reported to have used PRP in the past to speed up recovery from an injury.
However, there are no studies that have shown statistically that this works at a high rate of success. There are studies going on but many skeptics are out there currently. One of the reasons is that they are having a tough time figuring out exactly how it works.
It is being tried in many orthopedic issues, including tendonitis, muscle strains and arthritis.
One of the concerns here or benefits is the placebo effect. This is a great placebo possibly. Why?
1. People expect that shots are strong medicine, stronger than any pills
2. People are influenced by what professional athletes are doing and the results they are getting
3. It is “natural” so no foreign chemicals are used
4. It is high tech and cutting edge
Each of these lead to the benefit of a placebo.
Another problem with it is the cost, although it is much less expensive than other possible treatments, insurance companies are not paying for its use. It is deemed by almost all of them to be unproven and still experimental, so for that reason patients will often need to pay out of pocket.
Now, I want to be clear, I am not saying it does not work. We have many ortho docs who recommend it and have had success with it. I am just not able to go to a great study that shows it works. Patients may still want to try it as they may be frustrated with the lack of response from traditional treatments. In those patients a course of this may prove to be helpful.