Treatment

 

Mobilisation and Manipulation

Musculoskeletal practitioners may use mobilisation or manipulation to help with pain and improved range of movement. The idea is that joints are meant to move, and helping a joint through its range of movement, or to the end of its range will help to restore the natural movement and function. Techniques can include gliding, mobilisation, or a quick targeted thrust which achieves a popping sound.

Prolotherapy

Prolotherapy is a safe, effective injection treatment which provides increased strength in joints, ligaments and tendons by making new connective tissue. It can eliminate even chronic longstanding back, neck and joint pain. The solution used is usually 20% glucose or less, mixed with a local anaesthetic called lignocaine. It was developed by a USA surgeon, Dr George Hackett in the 1940s and has been refined and researched by many other doctors since then.

If strained ligaments fail to heal properly, injections of strong glucose can be used to restart the healing cascade. Mobility increases because stiffness is often due to protective muscle spasm, and once the pain from the ligaments is relieved the muscles relax.

Tendinopathy: When tendons are overused they become painful and occasionally fail to heal. The swollen or torn tissue can be seen on ultrasound. The usual treatment for tendinopathy in knees, Achilles tendon and elbows is rest, then very slow increase in exercise. This can take months or years. The glucose in the prolotherapy solution allows the healing to occur much more quickly. Best results occur when special exercises are performed as well.

Neuropathic pain is where the pain is due to the nerve itself. The pain is often sharp, burning and occurs in lines that are very tender to touch. A weak glucose solution allows healing in the nerve itself and the tissues it supplies. This new technique was developed by Dr John Lyftogt in NZ and is called Neural Prolotherapy or Perineural Injection therapy. It is done with very fine short needles as the nerves are cutaneous nerves, close to the skin.

Osteoarthritis: If its ligaments are strained and loose, the joint slips and slides out of its track, and the cartilage becomes worn causing osteoarthritis. Prolotherapy for worn joints (knees, hips, fingers and shoulders) involves treatment of the ligaments around the joint and usually injection into the joint, as it also stimulates regrowth of cartilage. This has been seen on xray in some knees, in Dr Dean Reeves research on prolotherapy in knee osteoarthritis.

The solution is injected to where the pain is coming from. Usually many different points are injected. The local anaesthetic relieves pain for a short time. This can be useful diagnostically; especially if there has been some doubt where the pain is coming from. Then inflammation begins – and pain may occur and may last up to 2 days. Pain relief is used if necessary.

Research has shown that this treatment is significantly more effective for low back pain than local anaesthetic or cortisone. An Australian study of very chronic back pain found that 20% became free of pain and over 40% had at least 50% reduction in pain. Many more reports of success have been published for other joints – knees, whiplash neck, fibromyalgia, jaw joint, pubic symphysis, fingers and thumb joints.

Exercises

To maintain optimum function, the body must move, and work. Exercise keeps cartilage, bone, and muscles strong by continually remodeling and building structure. Much harm is done by a couch potato lifestyle.

When some part of the musculoskeletal system becomes painful or loses range of movement, lack of use creates a cycle of weakness. Often the user then favours another part of the body, which can in turn create problems there. Sometimes the sufferer fears that exercise will harm them, and they restrict their activities further, inadvertently making the problem even worse.

Exercises help build strength, flexibility, symmetry, and muscle balance, and to restore function. Specific exercises can be given to aid specific problems, either by the musculoskeletal doctor or by working together with an exercise physiologist or physiotherapist.

Exercise can be done at every age, and by everybody. Other benefits include improved mood, stress reduction, improved brain function, improved immunity, weight control, and higher energy levels.

Perineural Injection Therapy

In Neural Prolotherapy, the subcutaneous (under the skin) nerves are recognised as a source of pathology. These nerves in a pathologic state can cause neurogenic inflammation and pain. The pain is often burning, sharp and the areas of pain are very tender. Common nerves to cause this are the cluneal nerves over the buttocks, an often overlooked cause of low back pain.

Ligaments, tendons and joints have special C pain fibre innervation. When these C fibres are irritated anywhere along their length they transmit impulses in both forward and reverse directions. The forward direction of the nerve signal causes pain perception as the signal travels up to the brain. It also has a local reflex action out to the muscles, causing a reflex muscle spasm. The reverse signal goes down the nerve where substance P is released causing swelling and pain. The swollen painful nerves become self-perpetuating, especially when compressed, for example when lying on the hips at night. Dr John Lyftogt in New Zealand has discovered that 5% glucose relieves this pain and if applied a few times the pain, when it recurs, is less each time, and can eventually go away altogether.

Cognitive Behavioural Therapy (CBT)

CBT is a method of pain management used by many musculoskeletal medicine practitioners. There is good evidence that it is an effective form of treatment for chronic pain sufferers, especially when combined with other treatments, such as physical therapy and medication.

It is based on an understanding that pain is real (and not just “in the head”) and that there is triggering of specific emotions, thoughts, memories and behaviours (many of which are negative) when pain signals are processed by the brain. Similarly, negative thoughts, beliefs and emotions can influence the way pain is felt by people, often increasing muscle tension and activating more pain signals, and leading people to behave in a way that reduces their enjoyment of life.

CBT involves talking with a practitioner to develop skills to identify and change these negative thoughts and behaviours and to think more realistically and healthily about pain. This can help people gain a greater sense of control of their pain, reducing pain levels and use of pain medications and improving their overall functioning.

CBT can be performed as part of a pain management consultation or by referral to a psychologist. To learn more about this worthwhile approach, the book “Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain (3rd Edition)” by Dr Michael Nicholas is an excellent starting point.

Trigger Points

A trigger point is a portion of the muscle that has become a source of pain and spasm. It usually can be felt as a tender nodule or band and may cause pain elsewhere. Dr Janet Travell showed that trigger points occur in predictable patterns for every muscle in the body. Two (2) common ones are trapezius and piriformis.
Hence, injecting a trigger point can help to eliminate it. Without injection, it may last weeks, months or become chronic.

What is the injection like?

While the trigger point is being injected, you may briefly experience the same pain that has been aching. This pain may be quite sharp, but very brief. Immediately afterward, there’s often a marked reduction in the typical pain pattern. There may also be more freedom of movement of the involved muscles with less stiffness. It may need a series of injections to eliminate it completely.

Massage or exercises to stretch the involved muscle/s are also beneficial.

Are there any side effects?

Overall, this is a procedure with minimal risks, although no invasive procedure is totally risk free. Potential adverse effects include temporary muscle soreness, infection, bleeding, weakness in the injected muscles up to 45 minutes (rare), or partial collapse of the lung (extremely rare) when the injected muscle is near the lung.

Epidural Steroid Injection

Lumbar caudal epidural blocks for low back and leg pain

The covering over the nerve roots in the spine is called the dura. The epidural space is a fat filled ‘sleeve’ that surrounds the dura providing cushioning for the nerves and spinal cord. Nerves from the spine travel through this epidural space before travelling to the legs. These nerves can become inflamed due to irritation from a damaged disc, bony spurs (osteophytes), ligamentous thickening and other rarer causes. Inflammation of these nerves can cause low back, hip, buttock and leg pain. Epidural steroid Injections are a method of treating inflammation associated with low back related leg pain. Cortisone placed into the epidural space has a very potent anti-inflammatory action that can decrease pain and allow patients improved function. Recent studies have shown that 60-70% of patients with leg pain due to spinal stenosis will have significant improvement in their pain for up to 6 months.

Although cortisone does not change the underlying condition, it can break the cycle of pain and inflammation and allow the body to better compensate for the condition. In this way, the injections can provide benefits that outlast the effects of the steroid itself. There are various ways of injecting cortisone into the epidural space, each with their own pros and cons. For patients with multi-level disease the caudal approach is often the best as the cortisone is able to spread over several levels. The epidural space extends all the way down to the very end of your spine. There is a small hole at the base of the sacrum (the sacral hiatus) through which the cortisone can be injected.

What to expect?

You may have some partial numbness in your buttocks or legs due to the local anaesthetic which is injected with the cortisone. You should arrange to be driven home and to take things quietly for the rest of the day. Many doctors will request you keep a daily pain diary to assist in assessing the success of the cortisone block. Take your regular medication and on the following day you may resume your regular activities (specific instructions regarding blood thinning medications and diabetes may be given by your doctor). Further follow-up will be arranged with your treating doctor.

Joint injections

Joint injections can be an effective way of treating some disorders of joints and ligaments that are caused by inflammation such as osteoarthritis, inflammatory arthritis (eg: gout), and shoulder or hip bursitis.

Various injectable medications can be used depending on the exact circumstances. The most common medication used is cortisone which will relieve the pain, swelling and stiffness by its direct anti-inflammatory effects within only a couple of days. However, pain relief from cortisone also diminishes rapidly within a month or so. Furthermore, overuse of cortisone injections can have a catabolic effect – that is, it could cause the cartilage and connective tissue to break down and deteriorate further.

More recently hyaluronic acid injections (called viscosupplements) have been used in the treatment of knee osteoarthritis. A recent review of the medical literature shows an average reduction in pain of 28-54% when using this particular type of injection. In contrast to cortisone, it takes about five weeks, on average, before a patient experiences the full benefits of hyaluronic acid. Whilst in some patients this benefit can last up to two years, in others there may be little or no benefit. The medication is NOT PBS subsidized currently.

It should be noted that in November 2013 the Australian Federal Government withdrew funding for joint injections unless done under ultrasound control (increasing the cost by > $130).

Neural Therapy

Neural therapy is a German technique involving the injection of local anesthetics into scars, based on the theory that scars can produce long-standing pain and malfunction. Scar tissue can have an electric charge of up to 1.5 volts difference to the rest of the body. This abnormal electrical signaling disturbs the nervous system as a whole, causing pain, sometimes at distant sites. So if you have continuing pain since an operation, local anaesthetic injection may help.

How does neural therapy work?

It is not really known, but local anaesthetic has a beneficial effect on the nerve endings in the skin that register chronic pain, by reducing inflammatory chemicals, and can often break a self perpetuating pain cycle. Sometimes one treatment will resolve the pain problem for good. More often, only a partial improvement follows each treatment. Three to six treatments is average. The period of pain relief usually doubles each time.

Neural therapy is widely used in Europe, the Soviet Union, and South America but is not well known here as much of the research is only reported in German and in old journals. Modern research is difficult and expensive, and there is no research money for old drugs like local anaesthetics. Also neural therapy does not lend itself to a double-blind study. Each patient with pain needs to be treated in a different way with careful history taking and appropriate injections.

Nerve Blocks

When discs or osteoarthritic facet joints press on a spinal nerve as it emerges from the spine, the nerve is irritated and swells up causing severe pain that is usually felt down the buttock or leg (sciatica). A cortisone injection placed with xray guidance will often relieve the swelling and settle the pain within 2-3 days. Risks or side effects are:

  • pain flare up in first 24-48 hours
  • red flushed face for 2-7 days
  • diabetes temporarily worse for 2-7 days

Acupuncture

For more detail on acupuncture see the website of the Australian Acupuncture and Chinese Medicine Association http://www.acupuncture.org.au/Health_Services/Acupuncture.aspx

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