Common Approaches to Pain Management/ The Dirty on Tainted Steroid Injections causing Fungal Meningitis (Part 2)
Last week I discussed the tainting of a common steroid injection that has infected hundreds of people with fungal meningitis- many in the Twin Cities area- that left us questioning the health care delivery system.
We’ll build on that this week with some information on steroids, their usefulness and introduce a possible shift to your action plan for painful conditions.
It is a most common scenario. Something hurts, beyond the “usual”pain, so we go in to seek care from our doctor. The more severe, short term pain patients get pain killers and possibly muscle relaxers, are told to rest, ice and it will improve. For longer, nagging injuries, patients are offered a steroid injection to decrease inflammation and get them immediately out of pain- with the hope that relief will continue long term. X-rays and/or MRIs are ordered as needed. Of course, severe conditions may wind up in surgery but that’s a whole other discussion.
Studies show that this scenario is being played out more in doctor’s offices today than ever before. Recent studies on back pain, our most common complaint, document a 629% increase in Medicare expenditures for epidural steroid injections; a 423% increase in expenditures for opioids for back pain; a 307% increase in the number of lumbar magnetic resonance images (MRIs); and a 220% increase in spinal fusion surgery rates. This is in spite of the face that these increases have not been accompanied by population-level improvements in patient outcomes or disability rates1. Particularly, US Medical Expenditure Panel Survey showed that self-reported functional limitations, mental health, work limitations, and social limitations were worse among people reporting such problems in 2005 than in 1997.2
The current scenario is not working. Patients do not improve substantially nationwide utilizing the common medical approach to pain.
Let us look a little deeper at steroid injections (since this is the main topic). Their main use is to curb inflammation in the local area of pain. But why does it occur in the first place? Simply put, inflammation is initiated when something tears or rips or presses on something else the wrong way. To decrease the use of a damaged area and give it time to heal, the area swells up and a cascade reaction is initiated to clean up debris and set an atmosphere for rebuilding. Pain comes from the swelling, the torn tissue and the nervous system’s increased sensitivity in the area- used as a protective mechanism.
As providers, it is our job to help this process along so it ends in a timely manner and our patients can function again. In this light, steroids have gained incredibly popularity. Get rid of the inflammation and we see immediate improvement. But what about the cause? What have we done to change the thing that tears, rips or presses on something the wrong way?
Is this a short term benefit at the expense of lasting results?
Recent literature seems to corroborate this notion, often showing short-term improvements in symptoms with few long-term benefits. For instance, both European and American guidelines, based on systematic reviews, conclude that corticosteroids do not reduce the rate of subsequent surgery.1 Furthermore, facet joint injections with corticosteroids seem no more effective than saline injections.1
Research repeatedly shows that conditions such as plantar fasciitis, tennis elbow (lateral epicondylitis), jumper’s knee (patellar tendonitis), rotator cuff tendonitis (swimmer’s shoulder), and runner’s knee (IT band tendonitis) ARE NOT inflammatory conditions. The above mentioned conditions are misnamed as the last letters -itis, which stands for inflammation, should be switched to -osis, which means degenerative change to soft tissues. Poor mechanics places undue stress on our tissues so they degenerate more quickly than the norm.
So, if we can see pain in terms of poor mechanics, we get a sense that a different approach is needed. How do we fix poor mechanics? At Modern Point, we measure posture and change it accordingly using a unique and vital acupuncture method called Sports Medicine Acupuncture. Patients see relief begin in just a few visits, though, like building muscle in the gym, continual care over a few months may be necessary for more chronic conditions. Notice that I didn’t say a few years; acupuncture does not have the reputation for short term benefits that necessitate years of care for all but the most severe conditions. We then combine acupuncture with postural therapy, techniques to balance an overactive nervous system and assure a constructive atmosphere systemically for healing to take place.
A September 2012 study financed by the National Institutes of Health found acupuncture outperformed standard care when used by people suffering from osteoarthritis, migraines and chronic back, neck and shoulder pain. Published in the Archives of Internal Medicine, the six-year study used data from about 18,000 patients and show solid evidence of the efficacy of acupuncture for pain relief.5
Modern Point Acupuncture offers hope to hundreds of Minnesotans looking for pain relief when conventional approaches have failed them. It is my hope that you will see us as a first response to sub-acute and chronic conditions in light of the fact that current approaches are not working and research shows significant benefits of acupuncture over large populations for our most common painful conditions.
2. Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingworth W, Sullivan SD. Expenditures and health status among adults with back and neck problems. JAMA 2008; 299: 656–64.
3. Hay EM, Paterson SM, Lewis M, et al. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ 1999;319(7215):964–8.
4. Barr S, Cerisola FL, Blanchard V. Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis: a systematic review. Physiotherapy 2009;95(4):251– 65.
5. Arch Intern Med. 2012;172(19):1444-1453.