MEDSCAPE ORTHOPAEDICS IV

ATTACKING THE CONFUSION: INJECTION THERAPIES

“Candy is Dandy But liquor is quicker.”

Reflections on Ice-Breaking

Ogden Nash

Principia Primum – Fundamentals First

Cortisone injections and the controversy.

Recent revelations (to me with very practical current importance) of little attended yet vital information concerning cortisone for health and in disease treatment.

Prolotherapy. And its relationship to cortisone

The injectionists in pain management. The rush promoting fluoroscopic selective nerve blocks, epidurals etc.

(Please be advised that, for some, this will test sphincter and/or rage control)

CORTISONE INJECTIONS

There is a current folklore that condemns the use of cortisone injections in the treatment of musculoskeletal conditions. The controversy is so generalized that many of my current patients immediately express wariness if I suggest it, but whatever its source it is misinformation, misperception and confusion largely the result of scarred memories from its historic misuse for decades with its predictable iatrogenic sequellae.

While Descartes’ aphorism “The truth lies in small distinctions” also applies here, the comprehensive concept of cortisone usage is supported by a pervasively basic truth

that appropriate cortisone supplementation may be essential, fundamental therapy throughout medicine. This discussion will clarify orthopaedic issues and introduce the broader application.

As a prime example of cortisone’s sometimes irreplaceable importance, adhesive capsulitis is an orthopaedic medical emergency, a major inflammatory, possibly totaling disabling condition of often cryptic etiology that well deserves the reputation that if not aborted, “six months into the valley of hell, six months through the valley of hell, and – maybe – six months out of the valley of hell but often accompanied by major impairment (for which, incidentally, the primary use of a shoulder wheel is indefensible torture).

Dr. James Cyriax’s “Capsular Pattern” concept is one of his most valuable contributions and makes the diagnosis of adhesive capsulitis fast and easy. In my experience, the earliest sign of adhesive capsulitis is the restriction of passive external rotation of the shoulder component, associated with inability to passively abduct the humerus to approximately 90 degrees with the scapula tethered (Scapulohumeral abduction) - and distinct tenderness over the anterior shoulder capsule that is greater than at the Coracoid Process. From my dissection research I concluded that the subscapularis tendon and bursa have to be injected as well as the glenohumeral joint and the subacromial space. Specific mobilization is almost always performed. (described in Release From Pain)

Cortisol is obviously one of the body’s major hormones and is essential to life. Impairment of its production is initially accompanied by sometimes subtle abnormalities that can progress to a broad spectrum of frank diseases and to life threatening Addison’s disease. In specific areas of need (such as the tissues involved in adhesive capsulitis), cortisone’s concentration can totally relieve. A brief visit to the underlying history of the confusion will, I hope, restore common sense.

The “miracle” of cortisone’s commercialization in the 50’s (while I was in medical school) soon became a nightmare. The magical disappearance of symptoms so dramatically illustrated in rheumatologic disease was a temporariness of medical ecstasy that soon soured from the careless overindulgence that set the stage for a reflexively rigid “sour grapes” mindset. But the fundamental physiology never changed. So the penalties of cortisone’s misapplication should have been anticipated.

A societal responsibility is to recognize logical and safe parameters for actions that affect its citizens, such as safe driving speeds. And, when sound sense is discarded and the predictable happens, to recognize the cause and effect. However in cortisone’s case, which has the same requirements, the complications were compounded by the expedient (and self-protective) condemnation of the therapy rather than its abuse.

So let’s logically rethink. Inflammation can become a self-perpetuating destructive process. Interrupting the cycle can restore healing. Cortisone is a specific anti-inflammatory. At the same time, pharmaceutical doses cause temporary tissue weakness (and certainly never strengthens the tissues as Prolotherapy does). Illogically, the weakening is one of the major criticisms for disparaging cortisone.

When effects are not desired, they are termed side effects. All potent drugs have such properties. That appreciation, such as the constipation that accompanies the use of codeine preparations, is rationally countered with appropriate recommendations. The use of cortisone should be no different. I have injected it for almost five decades. I have followed many of my patients for years and have never had cause for regret. I have no recollection of having produced complications. If the procedure was successful, and I have had very few failures, likely because I select my patient carefully, my patients have soon returned to normal activities.

But from the first, I informed each patient that a part of the anti-inflammatory response is that, indeed, there is temporary weakening. I illustrate with well known stories of cortisone’s injection to relieve Achilles tendonitis, sometimes with total rupture because of precipitous strenuous exercise during the illusory immediate period of what appears to be another dramatic cure. I insist the patient realize that the early asymptomatic healing phase categorically requires a period of commensurate rest: I emphasize that the often dramatic response does not mean they are healed and that they must intensely respect that if they misbehave there may be hell to pay. So, as stated, my patients don’t have such complications, and I have often experienced the gratification of terminating what had been a prolonged period of impairment with just one injection: An outstanding illustration I describe in Release From Pain was a man who continued to subject himself to almost two years of inappropriate chiropractic care for a shoulder tendonitis. (The chiropractors who follow my writing are well aware that this factual story is not a generic prejudicial statement any more than my comments generally condemn medical practitioners.)

To summarize, while inflammation is essential defense, its purposeless presence prevents healing – and – as well, it can be a bodily stressor that fatigues the inherent hormonal homeostasis. Under such circumstances, inflammation’s termination is an essential for which cortisone injections remain among the most important in our therapeutic armamentarium. Another essential is how it is used.

Dr. Jimmy Cyriax, legitimately the father of orthopaedic medicine as well as his being justifiably controversial (I knew him well), declared the issue in the first sentence of his paper on cortisone published in the 50’s. I know it by heart: “Cortisone works but only where it is put.” Obviously, considerable else has to be established, that the diagnosis, dosage and decision concerning number of injections, and scheduling, have been carefully considered.

If you are interested in another fascinatingly painful story of how far unsubstantiated but popular information can cause, in this case, the death of millions, here is another, the full expression of the universal ‘Law of Unintended Consequences.’ We forget so easily that human grasp is very limited, and flawed, and too easily manipulated ~ American Thinker: Rachel Carson and the Deaths of Millions

Still on the subject of cortisol, in the past year I was exposed to a vastness of its controversy that, as I initially stated, pervades the therapies. I will briefly discuss it here and provide the links for your entering another world of essential cortisol in physiologic, in contrast to gross pharmaceutical and the applicability of the rationale.

Independently and for decades, two clinicians, a veterinarian and physician proved through intensive clinical research that impairment of the pituitary/adrenal/thyroid axis is the foundation for a host of disease states. They conclusively demonstrated that physiological (small) doses of hormones are successful in restoring and sustaining health in a host of conditions.

My initial exposure was through: Michael E. Platt, M.D. A few months ago, I was in the Palm Springs area visiting family. My sister asked me to look at a book written by Michael E. Platt, M.D., a Harvard trained internist, The Miracle of Bio-Identical Hormones. My skepticism faded by the third page when I realized that here was a kindred spirit advocating another face of fundamental therapy in the perspective of thinking about cortisone’s pervasive influence on bodily function.

The axis, including estrogen, progesterone and testosterone influences an entire spectrum of health. From many challenges, including age, toxic exposure, other stressors, adrenal output of cortisol can diminish. As I alluded, physiological supplementation doses may dramatically improve health.

Dr. Platt practices close to Palm Springs, in Palm Desert, and I had the pleasure of visiting him, and he is, indeed, a kindred spirit. The knowledge he provides in his book from his vast experience is important reading.

Back in Israel, I discussed the information with a friend, Moshe Rogosnitzky, Director of Research, MedInsight Research Institute and learned about William Jefferies, M.D., now a retired professor from the University of Virginia and Alfred J. Plechner, D.V.D. veterinarian, who, as I stated, independently supportively concluded about the benefits of physiologic hormone supplements.

From Dr. Plechner’s available monograph, “Endocrine-Immune Mechanisms in Animals and Human Health Implications,” page 13, “William Jefferies, M.D. of the University of Virginia, has described the safe and effective use of physiologic dosages of cortisone for decades in human patients with “adrenocortical deficiency.” He has reported improvement among patients with allergies, autoimmune disorders, and chronic fatigue yet the medical community has largely ignored his research. The reason, he states, relates to the “unique situation in which a normal hormone, one that is essential for life, has developed such a bad reputation that many physicians and patients are afraid to use it under any circumstances.” This comment accurately describes my experience in veterinary medicine. At pharmacologic dosages, cortisone does indeed create side effects. Practitioners shudder at the suggestion of long-term cortisone, even small physiologic doses acting as a hormone replacement for deficient cortisol.”

The addresses of the clinicians are:

William Jefferies, M.D.

Alfred J. Plechner, D.V.M.

Concluding, hydrocortisone didn’t develop the bad reputation. Iatrogenic misuse was responsible. The medical edifice preferred to blame the therapy. In the same way, cervical traction didn’t develop a bad reputation. Doctors have used a hazardous apparatus for decades and then discredited a valuable concept because of allegiance to the method. Please read Release From Pain.

Incidentally, if you are not familiar, a new book, “How Doctors Think” by Jerome Groopman, M.D. just came out. Again I was skeptical, but he well addresses the difficulties of the medical mindset that closes down early and tends not to extend its thinking beyond the early impression. A wise physician once commented to me, “First, you have to decide the principle. Then you can decide what to do about it.” The problem is us.

PROLOTHERAPY

There is now an exponentially proliferating presence of Prolotherapy on the Internet. Entire practices are developing around it, and some are imaginatively recommending its use for an expanding list of applications. It appears that prolotherapy’s time has finally come.

I will only synopsize my considerations here because more is on my website and certainly in Release From Pain.

I became aware of Prolotherapy, in London in 1972 when I was visiting Jimmy Cyriax. It is the extension of ancient therapies when bowed tendons of horses were scarified with red hot irons, when sclerosant injections were (disastrously) injected to treat hernia and other (mis)adventures. My first personal experience was in my teens when I had a hydrocele. The urologist aspirated the fluid, injected another and almost ran to the door. As I raised my head from the table to ask why he was leaving, my breath was suddenly, so agonizingly sucked back I couldn’t scream, and only when I began to contemplate that maybe I just might live he reentered the room. He told me the hydrocele wouldn’t likely recur, but my main worry was did I still have a testicle. It worked, and I wasn’t one of the sterilized. Sclerosant solutions have been employed for varicose veins, esophageal varices, even snoring, but its primary place in the treatment of musculoskeletal pain conditions was long ignored by general medicine for many reasons, high on the list being that orthopedic surgeons operate. And, the clearly established properties of damaged ligaments are usually ignored.

Ligaments are bloodless and nourished by the flow of body fluids in the “wetlands” of the circulation. When ligaments are injured, the capillary network opens to provide a brief time of first intention healing. But the duration of capillary flow is not contingent on healing but on time. The capillary bed closes in less than two weeks, and ligament laxity left is ligament laxity and weakness that persists. Someone with a floppy ankle after a poorly treated sprain has a weak ankle liable to further injury in the future.

When George Hackett, M.D., a general surgeon practicing in Canton, Ohio first began to experiment with Prolotherapy after learning of it from, as I recall, a dentist who learned about it from a veterinarian, he used an exceedingly caustic solution. The “rep” it developed was to do all the injecting you could the first time because the patient would never come back. Regardless, Dr. Hackett made genuine contribution. The procedure was initially largely picked up by “fringe” osteopaths who called it “sclerotherapy.” Otherwise, it was largely ostracized, at least ignored in traditional circles in the U.S. but spread in England and Europe particularly Germany before it returned to its homeland.

Weakened ligaments persistently impair the normal function of any joint. Like a sloppy door that keeps opening when it is shut, the loss of tension integrity about a joint makes it easily vulnerable to dysfunction. While joint manipulation is (also) essential therapy, I believe that it is misused when the practitioner is committed to repeatedly employing it when it is clear that there is no inherent stability to maintain the adjustment. When ligaments are weak, prolotherapy is indicated.

Each area of application has its rules. In the treatment of recurrent spinal dysfunction, I don’t accept that anyone has the wisdom to closely restrict the injection area. I have concluded that my task is to provide a ‘field of healing’ within which the body’s wisdom will then operate.

For more you may visit my website, read Release From Pain &/and visit the thousands of pages now available on the Internet.

SPINAL AND SELECTIVE NERVE BLOCK INJECTIONS

And so we come to trench warfare education concerning the wild fire of “Selective Nerve Blocks.”

Arguably the trinity in the development of this technology is Dr. Nik Bogduk, Dr. Rick Derby and Dr. Charlie Aprill. They are all good men and excellent clinicians, and Dr. Bogduk has, of course, well deserved international reputation. But I have serious contention with the use of what they have pioneered, and I must express it, and for that I must qualify my conclusions through the authority of very personal experience because none of this issue is remote from my convictions about the current state of Orthopaedic Medicine.

I first learned of fluoroscopically directed spinal injections in 1984 when, along with Nik, I was invited to teach for a week at The New Zealand Society of Musculoskeletal Medicine annual meeting. Nik and I shared the podium. I was obviously impressed with him and his work while I never thought at that time that I would be doing it. In his turn, Nik had hours to hear me plead for the preeminence of careful clinical examination and application of the manual therapies as the prerequisite to professional medical practice. We didn’t see each other again for years.

I met Rick Derby and Charlie Aprill in Las Vegas at one of the meetings of The International Spinal Injection Society in 1999, which I had just joined. Rick practices in Daly City, near San Francisco, and Charlie practices in New Orleans. Nik was there, and we’d remembered our previous collaboration. So I was all the more startled when during one of the discussions he’d suddenly burst out to the general meeting that finally, with the use of the injections, the injectionists had essentially become the masters of pain (for the first time in medical history).

The organization was largely composed of, and certainly dominated by, anesthesiologists. There were physiatrists, physicians taking fellowships in “Pain Medicine,” numbers capitalizing of the rapidly emerging popularity of “Pain Management,” but nowhere was there a perceivable presence of clinicians who had the slightest understanding of the principles of Orthopaedic Medicine. They were fully willing to dive in with a needle at what seemed the slightest provocation.

The exhibit hall was a vast spread of technology and sales people selling everything from C-Arms to all the (expensive) paraphernalia that was accumulating around this new and aggressive and aggressively exploited industry. Like the core that eventually cracked and destroyed the medicine that I treasure as a memory from the 50’s, who could doubt that again a big mouth was being born that would also self perpetuate its gluttony.

During the course, when I became more personally familiar with Rick and Charlie, I had lunch with them and gently related what I was observing. I had just finished another revision of Relief From Pain (then called Pain Pandemic), and they were genuinely interested in reading it. I was honored. I placed only one proviso. They had to promise me that they would communicate their impressions, which they very willingly agreed to do. After the meeting, I never heard from them again. They would not respond to my letters, my emails, my phone calls. It was a very telling time for me.

During that time, Rick had told me that he knew the value of Prolotherapy. He had done it, and he knew it worked and is important. When I asked him why he stopped, he told me candidly it was a matter of economics. He had a huge investment in his C-Arm fluoroscopes, in all the requirements of a large budget office, and he simply couldn’t afford to. He is a consultant. He does not do primary care. He has no obligation to provide any therapy. But the economic factors that can limit an invaluable therapy are important to recognize.

A few years later, I was in the Rancho Mirage area, near Palm Springs, where my sister and one of my daughters live. My daughter had met a nurse at a pain facility adjacent to Eisenhower Medical Center. She talked about her father, and I was invited to meet the physician, an anesthesiologist who, as Rick Derby, had a hugely invested office. He appeared excited to meet me as a preliminary to a possible association to provide more comprehensive care than he was providing. He asked me to bring some of my writing. As I watched him begin reading it was like watching some movie comedy when I was a kid. Within a few minutes, the hair literally raised on his neck and head. It was almost comical, but his expression wasn’t funny at all when I was literally shown the door.

Absolutely, the advent of precision that can place the point of a needle mere millimeters from a nerve root, or perform an epidural with objectification of the area of perfusion is more than remarkable. To the hundreds of epidural and caudal epidural injections I did before, and the few that I gratefully received, I can add the near hundred I did with the new technology. But my cases were selected, and the decision to inject was part of a logical hierarchy of priorities so that the major cost was justified. In the general scheme of this, as I have alluded, no such priority is at least acknowledged. That is the issue. The injectionists recognize no impetus for the desperately needed systems review that will reveal the fallacies of precipitous injecting at costs that can approximate $1000 an injection.

So what is my point through all this admittedly very personal history? Nothing can replace defining principles! Defining truths are the only substantial foundations for anything, especially what is required for societies to survive. Today, we are in an extraordinarily dangerous place in medicine. The worship of technology is one more layer that obfuscates and corrupts medicine’s essentials.

We corrupted ourselves for decades and prepared the masters of scientific greed to rape health care for unimaginable wealth. We did it to ourselves. Then, we continued to ignore fundamental truths for the glitz of remote therapies – and further lost and again ignored the essentials of the hands-on therapies. Now injectionists capitulate to self deceiving temptation to inject ‘anything that moves’ the way we accused chiropractic of ‘cracking every back’ for mean profit. And now we are under almost undefeatable threat from the “Evidence Based Medicine (EBM)” scam in which the “sacred” computer model for deciding therapeutic validity for Orthopaedic Medicine doesn’t even exist, the issue comprehensively exposed in: American Thinker: Medicine at Gunpoint: The Sicko Crowd's Deadly Rx for America

In all this general medical quagmire, clinicians continue to see people in pain. Medicine, in the end, is a one-on-one encounter in which individual ethics, intent, pride, skill – professionalism – is all the honest and seeking practitioner can offer. Only G-d knows what will happen next in the increasingly dangerous world, but each day is a blessing and an opportunity for fulfill what each of us has been given to do. Being caught up in agonizing about ultimate results of what we set in motion is recipe for defeatism and a wasted life. We each have purpose and have been given time to fulfill it. This is all philosophy - but it is the substance of what we need to be about, practitioners who consciously, willfully restore our art.

Be well,

Paul H. Goodley, M.D.