Wednesday, February 23, 2011
Many people with chronic pain find their way to my office because they are given a difficult choice by their doctor: cortisone injections or surgery. Neither option guarantees results or is a pleasant choice. In addition, many patients are reporting a lack of adequate information regarding possible side effects from the injections. As a service to my patients, I decided to wade through the medical jargon and make an easily understood outline of cortisone injection therapy and how that would compare to acupuncture treatments.
Cortisol, a glucocorticoid, is a naturally occurring steroid hormone in our bodies that is secreted by the adrenal glands. Cortisol exerts a wide range of effects in the body that include regulation of metabolism, cardiovascular function, growth, and immunity. The amount in our blood stream is tightly regulated by the central nervous system. In a normal adult, in the absence of stress, 10-20 mg of cortisol is released daily and follows our circadian rhythm. It is commonly associated with the ‘fight or flight’ mechanism that helps us deal with stress. When we need to ‘run’ or make things happen quickly, cortisol is released and energy is shunted from our normal body processes to accommodate our quick actions. Thus, one could say that injecting cortisone mimics constant stress and will kick our bodies into the stress state unnecessarily. Glucocorticoids also increase glucose levels in the blood thus stimulating insulin release and inhibiting muscles from taking in glucose. This increase in insulin leads to a net increase in fat deposition combined with muscle starvation. Higher than normal amounts of glucocorticoids in the body leads to decreased muscle mass, weakness and osteoporosis. In children, it can retard growth.
On the flip side, cortisol can dramatically reduce inflammation. Simply put, it does this by cleaning up the mess that white blood cells make when they infiltrate an inflamed area. It also moderates the chemical messengers associated with the inflammatory response. Some of these same chemical messengers are involved in the immune response, thus cortisol decreases our immune response, which is helpful in organ transplants, but detrimental in preventing illness. In disorders where the inflammatory response is the cause of the major manifestation of the disease, cortisone injections may be helpful. However, in instances where the inflammatory and immune responses are important in controlling the pathological process, cortisone therapy may be dangerous and needs very close monitoring.
To summarize, the anti-inflammatory and immunosuppressive effects can be therapeutically useful, but are also responsible for some of their most serious side effects. For example, long term use suppresses the release of important hormones in our body. Large doses have been associated with peptic ulcers, fat redistribution, and can antagonize the effect of Vitamin D on calcium absorption. In addition, increased amounts of glucocortiocoids in the body often induce behavioral changes in humans, including insomnia, euphoria, and depression.
For cortisone injections specifically, the highest risks are for muscle atrophy and weakness and bone degeneration and these are more likely with more than one injection. Also, long term use will inhibit the bodies own production of these hormones and lead to syndromes associated with cortisol deficiencies. Since cortisone therapy in not usually a cure, the pathological process may continue to progress while the clinical manifestations are suppressed. Therefore, chronic therapy with glucocorticoids should be undertaken with great care and only for serious conditions. Kruse et al. (2008) reported that “the available research demonstrates a short term reduction in pain with corticosteroid injection and is indicated for patients who don’t respond to nonpharmecological or analgesic or NSAID treatment”. If it is decided that cortisone injection is the best form of treatment, certain diet modifications should be considered. These include an increase in dietary potassium and a decrease in sodium, caloric management, and a high protein intake.
A few of my patients have received cortisone injections. One patient had a complete resolution of symptoms for five years now. Another patient had a very bad flare up of pain for three days post injection with a moderate reduction in pain afterwards. A flare up is common after treatment, but often this is not discussed with the patient. Here is a link to patient discussions on their experience with cortisone injections.
So what role does acupuncture play in pain management? Acupuncture has received a lot of recognition as a viable alternative for pain management. As an acupuncturist, the mechanism of action makes sense when discussed in terms of Chinese theory. But these terms are difficult to translate into Western medical definitions and researchers have been working hard at demystifying acupuncture and how it works. A recent study published in the September issue ofNeuroImage reported that acupuncture increases the binding availability of opiod centers in the brain that process and weaken pain signals. This will help strengthen the body’s ability to manage pain long term.
There are numerous other studies on different pain syndromes and how they respond to acupuncture, but there is still a need for more research. The National Institutes of Health generally recognize the efficacy of acupuncture in the treatment of low back pain and osteoarthritis of the knee. Since cortisone injections are used in the treatment of both of these conditions, it is reasonable to assume a course of acupuncture would be a viable alternative to the injections. In addition, the side effects of acupuncture are minimal and the other health benefits are numerous. Pain can cause sleeplessness, low energy, and poor mood, all of which can be treated with acupuncture while also treating the pain. This is due to acupuncture’s ability to open up areas that are blocked and congested, getting the energy that is naturally inherent in the body to move more freely, thereby decreasing pain and increasing energy and mood.
A normal course of treatment with acupuncture is between six to ten sessions. Most people will notice a decrease in their symptoms by the third treatment, some as early as the first. Symptoms may also change or move location with treatment. This is a good sign because it demonstrates your body is responsive to treatment. Once things begin to move, the blockages can be cleared and normal health restored.
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