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Author Topic: NYT: Cortisone  (Read 1414 times)
Crafty_Dog
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« on: October 27, 2010, 01:05:03 PM »

Do Cortisone Shots Actually Make Things Worse?
By GRETCHEN REYNOLDS
In the late 1940s, the steroid cortisone, an anti-inflammatory drug, was first synthesized and hailed as a landmark. It soon became a safe, reliable means to treat the pain and inflammation associated with sports injuries (as well as other conditions). Cortisone shots became one of the preferred treatments for overuse injuries of tendons, like tennis elbow or an aching Achilles, which had been notoriously resistant to treatment. The shots were quite effective, providing rapid relief of pain.

Then came the earliest clinical trials, including one, published in 1954, that raised incipient doubts about cortisone’s powers. In that early experiment, more than half the patients who received a cortisone shot for tennis elbow or other tendon pain suffered a relapse of the injury within six months.

But that cautionary experiment and others didn’t slow the ascent of cortisone (also known as corticosteroids). It had such a magical, immediate effect against  pain. Today cortisone shots remain a standard, much-requested treatment for tennis elbow and other tendon problems.

But a major new review article, published last Friday in The Lancet, should revive and intensify the doubts about cortisone’s efficacy. The review examined the results of nearly four dozen randomized trials, which enrolled thousands of people with tendon injuries, particularly tennis elbow, but also shoulder and Achilles-tendon pain. The reviewers determined that, for most of those who suffered from tennis elbow, cortisone injections did, as promised, bring fast and significant pain relief, compared with doing nothing or following a regimen of physical therapy. The pain relief could last for weeks.

But when the patients were re-examined at 6 and 12 months, the results were substantially different. Overall, people who received cortisone shots had a much lower rate of full recovery than those who did nothing or who underwent physical therapy. They also had a 63 percent higher risk of relapse than people who adopted the time-honored wait-and-see approach. The evidence for cortisone as a treatment for other aching tendons, like sore shoulders and Achilles-tendon pain, was slight and conflicting, the review found. But in terms of tennis elbow, the shots seemed to actually be counterproductive. As Bill Vicenzino, Ph.D., the chairman of sports physiotherapy at the University of Queensland in Australia and senior author of the review, said in an e-mail response to questions, “There is a tendency” among tennis-elbow sufferers “for the majority (70-90 percent) of those following a wait-and-see policy to get better” after six months to a year. But “this is not the case” for those getting cortisone shots, he wrote. They “tend to lag behind significantly at those time frames.” In other words, in some way, the cortisone shots impede full recovery, and compared with those ‘‘adopting a wait-and-see policy,” those getting the shots “are worse off.” Those people receiving multiple injections may be at particularly high risk for continuing damage. In one study that the researchers reviewed, “an average of four injections resulted in a 57 percent worse outcome when compared to one injection,” Dr. Vicenzino said.

Why cortisone shots should slow the healing of tennis elbow is a good question. An even better one, though, is why they help in the first place. For many years it was widely believed that tendon-overuse injuries were caused by inflammation, said Karim Khan, M.D., Ph.D., a professor at the School of Human Kinetics at the University of British Columbia and the co-author of a commentary in The Lancet accompanying the new review article. The injuries were, as a group, given the name tendinitis, since the suffix “-itis” means inflammation. Cortisone is an anti-inflammatory medication. Using it against an inflammation injury was logical.

But in the decades since, numerous studies have shown, persuasively, that these overuse injuries do not involve inflammation. When animal or human tissues from these types of injuries are examined, they do not contain the usual biochemical markers of inflammation. Instead, the injury seems to be degenerative. The fibers within the tendons fray. Today the injuries usually are referred to as tendinopathies, or diseased tendons.

Why then does a cortisone shot, an anti-inflammatory, work in the short term in noninflammatory injuries, providing undeniable if ephemeral pain relief?  The injections seem to have “an effect on the neural receptors” involved in creating the pain in the sore tendon, Dr. Khan said. “They change the pain biology in the short term.” But, he said, cortisone shots do “not heal the structural damage” underlying the pain. Instead, they actually “impede the structural healing.”

Still, relief of pain might be a sufficient reason to champion the injections, if the pain “were severe,” Dr. Khan said. “But it’s not.” The pain associated with tendinopathies tends to fall somewhere around a 7 or so on a 10-point scale of pain. “It’s not insignificant, but it’s not kidney stones.”

So the question of whether cortisone shots still make sense as a treatment for tendinopathies, especially tennis elbow, depends, Dr. Khan said, on how you choose “to balance short-term pain relief versus the likelihood” of longer-term negative outcomes. In other words, is reducing soreness now worth an increased risk of delayed healing and possible relapse within the year?

Some people, including physicians, may decide that the answer remains yes. There will always be a longing for a magical pill, the quick fix, especially when the other widely accepted and studied alternatives for treating sore tendons are to do nothing or, more onerous to some people, to rigorously exercise the sore joint during physical therapy. But if he were to dispense advice based on his findings and that of his colleagues’ systematic review, Dr. Vincenzino said, he would suggest that athletes with tennis elbow (and possibly other tendinopathies) think not just once or twice about the wisdom of cortisone shots but  “three or four times.”

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Dr Dog
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« Reply #1 on: October 28, 2010, 11:10:24 AM »

Interesting article. For those who don't know, I am a family physician and do provide steroid injections for various tendonitis conditions. In selected patients, they do work quite well. However they are always my last resort. One thing the article failed to mention is that the steroid is NOT a replacement for rest and healing time. Many of my patients will ask for the steroid exactly BECAUSE they can't/won't give the injury a rest. That leads to problems, and a tendon is temporarily weakened by an injection. People who have had multiple injections usually have a reason - an athlete or a worker who can't take time off like a carpenter with tennis elbow for instance. Some injections work better than others - I love doing tennis elbow and wrist tendonitis, knees and shoulders when appropriate, but I get nervous with the achilles tendon or plantar fascia because of the higher risk of tendon rupture and the lower rate of success.

3 rules I follow have helped tremendously:
1) Try ALL conservative therapies first.
2) Steroids are NOT a replacement for rest and conservative therapies - they are in addition. (This is, IMO, the main reason for the findings listed in the article)
3) Never put a needle in anything that is getting better, even if the progress is slower than the patient wants.

Rick

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Crafty_Dog
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« Reply #2 on: October 28, 2010, 01:25:34 PM »

FWIW there is a book by Linda Lee's second husband (ex-husband too) about the "real" reasons for the death of Bruce Lee.  Working from memory here, he had about three theories which may or may not have been interactive amongst themselves.  IIRC he thought that BL was impressed with the immediate results from cortisone in response to his major back injury and self-medicated or was treated by doctors working with the much lower level of understanding at that time (over 40 years ago).  The discussion then went to the consequences of long term cortisone use and connected it with the idea of steroid use.  BL was uncommonly ripped towards the end and one steroid reputed to promote extreme leanness is deca-durabolin (sp?)-- a possible side-effect of which is aneurisms-- the reputed proximate cause of BL's death.

But I digress , , ,

From my layman's perspective one of my guiding "Self Help Principles" (I forget which number it is) is this:

"Symptoms and their causes are usually in different places."

Thus, by this principle when a tendon is irritated the diagnosis is to look to what (mis)alignment caused it to be overworked/misused in the first place. The teatment of the immediate symptoms and/or the breaking of a negative feedback loop are separate questions.

RRL, does this make sense to you or am I simply "out there"?
« Last Edit: October 29, 2010, 09:17:54 AM by Crafty_Dog » Logged
Dr Dog
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« Reply #3 on: October 28, 2010, 02:06:20 PM »

Woof, Guro -  That makes perfect sense and fits in with the article and my comments. In a nutshell, steroids are great for pain but if you don't fix what's causing the pain it will recur - THAT should be the take-home on the article. It isn't that steroid injections don't work - they do, frequently impressively. You can then take that as a jump start to rehabilitation, correct form or alignment or whatever, and things go great;  OR, like many pro athletes or type A's, you can use that to "train through the pain", so you can keep doing whatever got you in the mess in the first place, in which case I will be seeing you back in my office for the same thing in 3-4 months. Since the studies generally use an "either-or" approach rather than a holistic approach, and never break down by personality type,  they usually won't pick up on this. I deal with this almost daily and it's incredibly obvious to me on a practical level.  Unfortunately for people like us, here's yet another health benefit to being a type B  wink

The need for repeat injections, especially if the initial response was good, is a great clue that SOMETHING is causing this and needs to be corrected. The cause may be local, or it may not - it often is obvious but sometimes is not - every case is different.  Also, even correct or perfect form can be overdone abruptly and cause an injury.

I am not aware of any correlation between steroid overuse and aneurisms, but there are PLENTY of other reasons to avoid overdoing these.
 
Rick
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Crafty_Dog
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« Reply #4 on: October 28, 2010, 04:30:21 PM »

Yes, I sensed harmony in what you were saying and my intuitive sense of things.

Concerning aneurisms, after reading the book by Linda Lee's second husband (tangent:  how the hell must if have felt to be second act to BL as the first act?  But I digress , , ,) I had a doctor friend find me the small print warnings to deca-durabolin and sure enough aneurisms were listed as a possible side effect.
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5RingsFitness
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« Reply #5 on: October 29, 2010, 06:49:58 AM »

he who treats the site of pain is lost
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"Nations have passed away and left no traces, And history gives the naked cause of it - One single simple reason in all cases; They fell because their peoples were not fit."-Rudyard Kipling
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