Trigger injections: is it a duck? Please reply

[Suezoled]

I'm thinking there's a difference between legit "trigger point injections" that use things like lidocaine, cortisone, etc, and this "trigger injection" thing being brought forth by people like
http://www.rawtimes.com/HaroldDSteinberg/

This treatment has been around for a long time, but was mostly abandoned by orthopedic surgeons. Dr. Steinberg has made a caring career of perfecting this technique, for which his time-honed skills can mean the difference between a happy pain free life, and conventional medical failure.

Trigger injections, aka "prolotherapy" isnt' even considered a legit medical procedure in the US!

But am I wrong in thinking it's quacky?

 

[TruthSeeker]

Take this with a grain of salt, but I've been a pain researcher for about 10 years and I've never heard of this. In fact, it sounds potentially dangerous and contrary to much of our thinking about the mechanisms of pain.

For instance:

The discomfort of prolotherapy, because it is an artificial injury, is an important signal that healing is underway. The pain, swelling, heat and the redness caused by the injections are all signs that the underlying cellular and chemical processes of 200 million years of evolution are safely underway. The body's pain signals can be listened to, and as the pain decreases the joint movement can increase.

I would change this to suggest that the pain, swelling heat and redness caused by the injections are all signs that inflammation, hyperalgesia and central sensitization are underway. We know that prolonged hyperalgesia can lead to neurotoxic changes and reorganization throughout the central nervous system that may be the underlying mechanism for chronic pain. Research is focussed on preventing these changes (e.g. by blocking various steps in the inflammatory or hyperalgesic response) and we know that subsequent injuries to already reorganized nervous systems tend to be more painful, more difficult to heal. Trying to reverse central sensitization by producing further injury is like curing amnesia with a second hit to the head.

As for the body listening to pain signals...well...I don't really know what that means. The body and the brain don't just passively wait around for pain signals to interpret. They are actively involved in their generation and interpretation at every step of the process. This is basic Gate Control Theory.

So, all this to say I hear some quacking.

 

[Suezoled]

Thank you Truthseeker.

Anyone else?

(Oh and by the way Truthseeker: if you want anyone to inflict pain to, um, test... you know, thresh-holdy stuff, I'll be happy to volunteer to do some inflicting...erm, participate in research...)

 

[TeaBag420]

Are they really talking about gating?

 

[TruthSeeker]

Are they really talking about gating?

No...sorry to be unclear. They are talking as if Gate Control Theory did not exist in terms of how "pain signals" travel.

 

[TruthSeeker]

(Oh and by the way Truthseeker: if you want anyone to inflict pain to, um, test... you know, thresh-holdy stuff, I'll be happy to volunteer to do some inflicting...erm, participate in research...)

Excellent, my pretty

 

[Goshawk]

This treatment has been around for a long time, but was mostly abandoned by orthopedic surgeons. Dr. Steinberg has made a caring career of perfecting this technique...

Well, speaking just as a consumer, and a skeptic, I'd have to wonder about someone who has chosen to specialize in something that the rest of his profession has long since discarded as ineffective or pointless.

Quackwatch on prolotherapy, which is on their "Index of Questionable Treatments".

http://www.quackwatch.org/01QuackeryRelatedTopics/prolo.html

The practice of sclerotherapy or prolotherapy to produce dense fibrous tissue in an effort to strengthen the attachment of ligaments and tendons is not new. Forms of this therapy apparently date back to Hippocrates, however, prolotherapy recently found favor with osteopaths following the teachings of George Hackett, MD, who in 1939 began using a local injectable irritant to initiate the healing process. It was Dr. Hackett who coined the term "prolotherapy" because sclerotherapy implied scar formation, which, according to Dr. Hackett, did not occur with prolotherapy. Nevertheless, both processes use trigger point injections to form new cells in an effort to support weakened muscles. Although the method has been in use for some time, to date there is no strong clinical evidence to support the efficacy of the treatment.

http://www.aetna.com/cpb/data/PrtCPBA0207.html

Aetna considers prolotherapy experimental and investigational for any indications because there is inadequate evidence of its effectiveness.
Aetna considers Sarapin, an herbal extract that has been used as a sclerosant in prolotherapy, experimental and investigational because there is inadequate evidence of its effectiveness.

Background

Prolotherapy refers to the injection of sclerosing solutions into joints, muscles, or ligaments. The effectiveness of prolotherapy has not been verified by scientifically controlled studies. As early as 1978, the Medical Procedures Appropriateness Program of the Council of Medical Specialty Services (CMSS), based on input from the American Academy of Orthopedic Surgeons, the American Association of Neurological Surgeons, and the American College of Physicians, concluded that prolotherapy had not been shown to be effective. Furthermore, the clinical practice guideline on “Acute Low Back Problems in Adults” by the Agency for Health Care Policy and Research does not recommend ligamentous and sclerosant injections in the treatment of patients with acute low back pain. In a recent report, Yelland et al (2004) concluded that prolotherapy is no more effective than saline injections for the treatment of chronic low back pain. Additionally, the Canadian Coordinating Office for Health Technology Assessment (2004) stated that “evidence from further controlled clinical trials of prolotherapy is clearly needed.”

http://www.drweil.com/u/QA/QA316482/

Although prolotherapy has been around for a long time, there are very few studies of its safety and efficacy and no proof that the theory that underlies it is scientifically sound. I have no first hand experience with prolotherapy although I have heard positive reports from a few patients who have tried it.

One of the most recent studies, published in the May/June 2003 issue of Alternative Therapy Health Medicine, tested prolotherapy on 16 patients who had had knee pain and instability for six months or more. The patients were treated for a total of 36 months after which the researchers found an improvement of 45 percent in pain at rest, a 43 percent improvement in pain with walking, and a 35 percent improvement in pain with stair use. I’ve found no studies comparing prolotherapy to total hip replacement.

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=PubMed&list_uids=15100629&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=PubMed&dopt=Abstract&list_uids=14699269

 

[Dr. Imago]

Excellent reply, Goshawk.

I have personally seen trigger-point injections administered - and work, but because (as Suezoled suggests) the anti-inflammatory properties of the steroid. The lidocaine is mostly used to reduce the pain from the actual injection, and not necessarily the pain from the trigger point. A trigger point, though, can be effectively treated (albeit more prolonged and involved therapeutically) with such things as massage, posture improvement, specialized stretching exercises, focused relaxation techniques, etc. But, of course the "quick fix" is often more appealing to the patient.

As far as prolotherapy goes, I have not personally seen it used. And, it would seem a bit counterintutive to me. If you create a inflammatory damage with a sclerotic agent in a particular area, that process becomes basically irreversible after a fibrotic scar forms . If you screw it up, there's really no turning back. At least with a trigger-point injection, even if it doesn't work it's still a temporary treatment with no longterm sequelae.

-TT

 

[Suezoled]

I see. It seems that "trigger injections" and trying to disguise itself as an aspect of "trigger point injections." Or distance itself by calling itself "prolotherapy."

I was hoping to find a bit of peer reviewed lit on trigger point injections. Trigger injections does seem terribly quacky.

 

[Eos of the Eons]

I'm having a hard time finding articles. It is considered a form of accupuncture in most places. Some call it "westernized accupuncture" of all things.

I tried BMJ Search

 

[Dr. Imago]

I was hoping to find a bit of peer reviewed lit on trigger point injections. Trigger injections does seem terribly quacky.

Here's are good resources explaining (in lay terms) TPI. All of these are peer-reviewed, so to speak, before they are published:

http://www.neurologychannel.com/tpi/

http://www.cinn.org/workinjury/services/triggerpointinjections.html

Here's one that's a little more technical...

http://www.empireblue.com/physician...licies/surgery/trigger_point_injections.shtml

And, finally, here's the latest on prolotherapy, which seems to be a bastardization of the real thing...

There was no evidence that prolotherapy injections alone were more effective than control injections alone.

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=15106234

Lastly, there was nothing in Harrison's online (the Bible of medicine) specifically on "prolotherapy" or "trigger injections".