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Steroid Injections: What You Should Know

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Steroid injections have become a common recommendation in the case of pain or injury. They are most often used to treat inflammation, especially when it has become chronic. Just like so many other things in medicine, these injections have potential benefits, as well as potential side-effects. And, recently, there has been new research that may change how often these injections are even recommended in the first place for use in joints.

We thought it would be important to talk a little bit more about it, since this treatment has become so commonplace and new research has come out.

About Steroid Injections – General Info

This treatment is used for pain and inflammation. It is injected to treat the joint, bursa, tendons or ligaments.

The procedure is most often done in a physician’s office and takes just a few minutes. The area is first cleaned and is often numbed with a topical anesthetic (spray or cream). Depending upon what area is being treated, the physician uses ultrasound to determine placement of the needle. The injection itself will either be the corticosteroid alone, or it may be a mixture that also contains a local anesthetic to help numb the treated area for a few hours. It is typical to have some aching in the treated area for 1-3 days.

Most physicians recommend getting an injection no more than 3-4 times per year, if indicated. It’s typically recommended to wait at least 4-6 weeks if another injection is warranted.

Results can vary person to person, and even between body regions for the same person. Some sources state that pain can be reduced for 6 weeks to 6 months. According to what we’ve heard from our own patients over the years, they’ve experienced relief anywhere between 1 week and 1 year.

Injections may not be recommended if you:

  • are on blood thinners, as it can cause additional bleeding at the injection site;
  • have diabetes, as the medication injected can affect blood sugars;
  • are dealing with an active infection, as it can make recovery from the infection more difficult;
  • have a joint that is already severely damaged, injections likely won’t be helpful.

After treatment, it is recommended to slowly increase activity. If you’ve gotten good relief, it can be tempting to jump right back into normal activities. However, this can be too much, too fast – so pace yourself!

Potential Side-Effects

In the past, many sources have reported that steroid injections have few side effects and none of them are very common, especially in response to a single injection. Worst-case scenario is that nothing changes and the patient gets no benefit.

Side effects include infection, allergic reactions, allergic reaction, skin discoloration, and tendon rupture. Some people may also experience something called post-injection flare. This flare occurs when the inflamed area is aggravated by a reaction to the injection.

Repeated use in one area can increase the likelihood of side effects. One concern is particular to treatments of tendon or ligament. Over time, repeated treatment can contribute to tissue damage. It can even contribute to tendon rupture. There is also a theory that repeated treatments can result in decreased benefit.

New Research

One research group did a meta-analysis in 2015 regarding knee arthritis, reviewing 27 different research articles on the topic. They determined that the benefits of steroid injections for knee arthritis are inconclusive and unclear.

In 2017, an article published in the Journal of the American Medical Association (JAMA) showed some interesting findings. Researchers worked with patients with knee arthritis. One group received the typical steroid injection and another group received an injection of saline. People reported the same result, regardless if they received the steroid or the saline. In addition, they found that more of those that received the steroid injection saw more erosion of the cartilage in the joint after treatment.

A new study published in October of 0291, by the Boston University School of Medicine, suggests that steroid injections can actually speed up destruction of a joint, leading to things like earlier total knee and total hip replacements. They’ve found an increase in problems like stress fractures, joint collapse, and progression of osteoarthritis.

So What Does This Mean?

First of all, research doesn’t quite know what to make of the injections. They may or may not actually help. They potentially have more significant side effects than originally thought.

In either case, one of the most important things to consider if you are thinking about getting steroid injections is that they are meant to treat the symptoms of pain and inflammation. Steroid injections do not “cure” the problem. If the symptoms were caused by injury or overuse, for example, other things will need to be addressed to have long-term results.

A steroid injection should be just one part of a larger treatment plan. Physicians may recommend NSAIDs (non-steroidal anti-inflammatory medications) or use of a brace. Hopefully, they also recommend physical and/or occupational therapy. The best recommendations, especially in the case of early osteoarthritis, include exercise, weight loss, and lifestyle changes.

Do your research. Ask your physician questions. Ask what your options are. Talk to a physical therapist to learn what can be done. Try exercise and changing your lifestyle.

Physical Therapy as an Option

So how does physical therapy play into all of this?

Your physical therapist will do an evaluation to see what all needs attention. Quite often, those with arthritis benefit from working on strength, balance, and stretches. PTs will also show you different ways to do things that will decrease stress on your body and joints. We have so many options to help, so give us a call! If you have more questions, contact us at Back in Step Physical Therapy.

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Total Joint Replacements: What You Should Know (Part 3)

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Here we are – the final part of our three part series on total joint replacements. We’ve already talked about how to prepare before you even get the surgery done, and then what to expect while in the hospital. Let’s talk about what to expect as a whole during the rehabilitation process.

 

What to Expect During Your Recovery from Total Joint Replacements

This is where the road to recovery will vary more depending upon whether you’ve had a total hip replacement or a total knee replacement. It will also vary person to person, even with the same type of surgery being completed.

Exercises: Typically, you will start with some exercises that appear to be pretty basic. When you actually start performing them, however, they will seem more challenging than you realize. These exercises are important to help build a good strong foundation before you continue through the rehab process.

Precautions: In some cases, particularly in the case of total hip replacements, you may have certain restrictions of movements you can do until you’ve reached a certain point in healing. These restrictions or precautions are temporary, and it is important that they are followed to make sure that your body can heal as quickly and easily as possible. Your physical therapist will develop an exercise program that both meets your recovery needs and respects any restrictions that are in place. The PT will also guide you through the process of returning to normal movement and activities once your precautions are lifted.

Pain Management: As you may expect after ANY surgery, it is normal to experience some pain and discomfort after a total joint replacements. Everyone has their own tolerance level and perception of their pain. Your physician will help you with pain management from the perspective of pain medication. Your physical therapists will also help with pain management.  Recommendations from your physical therapist may include the following:

  • Ice – Regardless of your total joint replacements, ice helps to decrease swelling and inflammation, which will help to decrease your pain. In all cases, make sure to have at least one layer of fabric between your skin and your method of icing – this will protect your skin.
    • Ice pack (my personal favorite is this one): A moldable ice pack is easiest, because it can better reach any areas that need attention. Make sure to ice for about 20 minutes at a time, unless otherwise directed by your therapist.
    • Bag of peas: This is a popular cheap alternative to a moldable ice pack; however, this method doesn’t get as cold. If you choose to use a bag of peas, make sure that you mark the bag “do not eat” – because of the repeated freezing and thawing, there is an increased risk of growing bacteria that you don’t want to eat!
    • Ice compression unit: These units are seen predominantly in the hospital, but can be rented or purchased for home use. I find that patients who have had a total knee replacement really like these. They ice and provide compression at the same time, which promotes further decreases in swelling. You can also safely use these for longer than 20 minutes, but follow the recommendations of your therapist.
  • Movement – As one my professors and colleagues loves to say, “Motion is lotion” (thank you, Sharon!). And this statement is so true! Movement helps to keep our joint lubricated and muscles loose. People are typically most stiff and sore first thing in the morning, because you’ve been resting in bed all night and things have gotten tight. The same feeling will occur if you spend a lot of time during your day sitting or lying down. If you are able to incorporate small rounds of movement throughout your day, it can decrease your overall pain levels.
  • Positioning – It can seem difficult to get comfortable after surgery. Your PT can help you figure out some other options for sitting and lying down, and can give you guidance for making other tasks or activities easier or less uncomfortable.

As you can see, there are many things to consider as you prepare for your surgery, a variety of options of how to start your recovery process after the surgery is done, and a long list of ways that a physical therapist will help you along the way.  I hope this has been a helpful guide for all of you that are either considering surgery or already have it scheduled. If you’ve already had the surgery, share with us any other ideas that you’ve tried!

Contact us at Back in Step Physical Therapy:

  • If you have questions in preparation for an upcoming surgery,
  • If you want to get scheduled for “pre-hab”,
  • If you are needing physical therapy following a surgery,
  • or if you have other aches and pains, feel limited in your activities, or want to avoid future injury or surgery.

 

 

Article author, Alyssa Arms, PT, DPT, OCS holds a Doctor of Physical Therapy (DPT) degree from the University of Colorado Anschutz Medical Campus, and later obtained a Board Certification as an Orthopedic Clinical Specialist (OCS). She is also the President and Owner of Back in Step Physical Therapy in Centennial, Colorado, and is an instructor at her PT alma mater.

Total Joint Replacement: What You Should Know (Part 2)

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In Part 1 of our 3 part series, we talked about how to get yourself prepared for an upcoming total joint replacement surgery. In this post, we’re going to discuss what to expect during your hospital stay and immediately afterwards.

Your Hospital Stay

For the typical total joint replacement, it’s pretty common to check in to the hospital anywhere from the early morning to early afternoon, depending on the time that your surgery is scheduled to start.

In many hospitals, it is now typical to be seen by physical therapy later in the same day as surgery. It may seem counterintuitive, but research shows better outcomes for patients that are able to get up the same day, as opposed to waiting a day or two. This, of course, is done in whatever way is safe and appropriate for you as the patient. If you can only make it to sitting on the edge of the bed – great! If you can get up and walk 200 feet with a walker – great!

Anything and everything counts.  Protocol is different at every hospital, so find out what to expect at the location that you’ve chosen. I’ve worked in a couple of hospitals, and patients after a total joint replacement are seen once on the day of surgery, and then twice per day while in the hospital until you are discharged. In addition, you will likely be seen by an occupational therapist, who will make sure that you can get yourself dressed, manage in the bathroom, do your grooming tasks safely, and may recommend some of the pieces of equipment listed above.

Physical Therapy Options after the Hospital

One big discussion that always comes up while in the hospital is “discharge planning” – in other words, where do you go and what do you need once you leave the hospital? When it comes to discharge planning, you have several options.  Your therapists will work with you to determine what is your best and safest option, depending on how you are doing during your hospital stay. If your therapist thinks that you need some extra time before you head home, they will recommend transferring to another facility for additional physical and/or occupational therapy. It may be because you can’t yet walk safe, functional distances without help, like to get to the bathroom. It may be because you’re having difficulty getting out of bed, and you don’t have a situation where you have someone at home that can help you in that way. There are many factors and scenarios that are considered when making these recommendations, because we realized that it’s always nice to go home – but we also need to make sure that it’s safe for both you and for anyone who is helping you at home.

Acute Rehab: After your stay at the hospital, you transfer to another facility that exclusively specializes in “acute rehab”. There are not as many options for this kind of place, typically, and you need to “qualify” to get in. During acute rehab, the goal is to have a total of 3 hours of therapy per day, and can include physical, occupational, and/or speech therapy. You have a schedule for the day, including rest breaks, and you often have therapy every day of the week.

Sub-acute Rehab: Again, you go to another facility immediately after the hospital. You still have frequent therapy throughout the week, but it would not be at the same 3 hours a day as in acute rehab. If the idea of 3 hours of therapy a day seems too intense to you, sub-acute rehab may be a good option.

If your therapist sees that you’re doing well with walking and can manage sufficiently and safely, they will recommend that you go home. But your therapy doesn’t stop there! They will recommend one of the following options.

Home Health PT: Your therapists come to you at your home. The great thing about this option is that they get to see you in your “natural habitat” – your layout, the equipment you have, etc. They work with what you already have, and give you recommendations of what to do as your routine. They typically come about twice a week. In some cases, they may only come to your home for 1-2 weeks; in other cases, it may be over a month. It all depends on what they’re seeing and how you’re doing.

Out-Patient PT: Eventually, no matter what option you choose from all those listed above, you will almost always end up in out-patient PT. You will now travel to a clinic of your choosing, and will often go 2-3 times per week, unless your therapist recommends otherwise.

According to a study published in Australia in 2017, patients who underwent uncomplicated total knee replacements did just as well with home health physical therapy as those who went to 10 days of in-patient rehab, even looking at information 26 weeks out from surgery and considering that someone may be alone at home. Now, this study lets us know that the appropriate people can benefit equally from the two options, but it’s still up to your therapist and the rest of the medical team to help you determine what is the best option for you and your situation.  Regardless of the choice you make for what to do once you leave the hospital, the goals of physical therapy are the same. In physical therapy terms, it’s increasing your range of motion and strength, and decreasing pain and swelling. More importantly for you as the patient, it is to get you back to moving the way that you want to, so that you can return to activities that you enjoy and so that you can return to interacting with your friends and family in the ways that important to you!

Read our last installment of the three part series to find out more about the rehabilitation process itself.

 

Have more questions about a total joint surgery? Contact us at Back in Step Physical Therapy!

Check out Part 1 and Part 3 of this blog topic too!

 

 

 

Article author, Alyssa Arms, PT, DPT, OCS holds a Doctor of Physical Therapy (DPT) degree from the University of Colorado Anschutz Medical Campus, and later obtained a Board Certification as an Orthopedic Clinical Specialist (OCS). She is also the President and Owner of Back in Step Physical Therapy in Centennial, Colorado, and is an instructor at her PT alma mater.

Total Joint Replacement: What You Should Know (Part 1)

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So you’re getting a total joint replacement, particularly of the knee or hip? You’re either already scheduled, or at least thinking about taking that next step.

Up to this point, you have probably been dealing with regular pain, difficulty with certain movements, and not getting to enjoy hobbies, work, or play in the same way. You may have noticed that your walking pattern has changed. Maybe you now rely on a cane to help you get around. You may have noticed some ached and pains in other areas, like your low back or feet, as a result of moving differently. Your doctor is recommending a total joint replacement.

Now what? Throughout our 3 part series about total joint replacement, we will be talking about:

  • “Pre-Hab” or Rehab before surgery – why it can be a great option to help with better recovery after surgery.
  • Recommendations for setting up your home to make things easier once you’re back from surgery.
  • Common recommendations for equipment that can make walking and normal self-care tasks easier.
  • What to anticipate during your hospital stay.
  • Options for physical therapy and rehabilitation after discharging from the hospital.
  • What to expect during your recovery.
  • and other general recommendations.

We hope these next few blog posts are helpful to you!

Now let’s get started….  

“Pre-Hab” or Rehab Before Surgery

First of all, doing some physical therapy prior to surgery can be a great option for most people. It gives you an opportunity to build up as much muscle strength and stamina going as possible before going into your surgery. It often helps people do better during the recovery process. Doing some prep work can also help to minimize any other aches and pains that have developed prior to surgery, so you don’t have to worry about them afterwards. All in all, it gets you going on a good start.

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A study published in 2014 by the American Academy of Orthopedic Surgeons took data gathered via Medicare claims from nearly 5,000 people who had had either a total knee or total hip replacement. They compared information for overall use of therapies and their cost. They found that those that did pre-habilitation showed a 29 percent reduction in post-operative care use, saving an average of $1,215 per person. Most individuals that used pre-hab only needed a couple of visits to meet their needs. Your doctor may already recommend this option to you, or you can ask him or her about it.

You may also hear about a variety of other options before surgery, with the hopes of delaying that surgery. Options may include corticosteroid injections, hyaluronic acid injections, non-steroidal anti-inflammatory medications (NSAIDs), braces, insoles, etc. According to a 2017 study by the American Academy of Hip and Knee Surgeons (AAHKS), only three pre-surgical options were recommended for use. These included NSAIDs, tramadol, and physical therapy. This same study found that if people stuck to these three recommendations, rather than trying many others on the list, people could find up to 45% overall cost savings for the treatment of knee osteoarthritis.

Home Set Up & Making Arrangements

It’s also a good idea to get things set up before you go into surgery. This can include arranging your home in a more mobility-friendly way, picking up supplies and equipment, and scheduling help at home.

One helpful idea is removing any throw rugs that you have. When you’re still new to the method of walking after your surgery, you don’t want to have to worry about tripping on a rug.  Also make sure that you have a cleared path along any major routes through your house, like to your bedroom, bathroom and kitchen. You will likely be relying on a walker or crutches, so each path should be wide enough to accommodate walking with a device.

If you have stairs inside your home, be prepared to have a back-up plan for staying on your main level, in case you have difficulty with stairs. Many people are able to practice stairs while still in the hospital so that you feel confident with them before going home.

It’s never a bad idea to think of your options ahead of time, so that you’re not left scrambling when you’re getting sent home from the hospital.

Helpful Equipment

Lastly, there are various types of equipment that you may find beneficial once you’re at home after your total joint replacement. Most items are available for rent or purchase. I always recommend purchase, because you never know if you or a family member will need the same thing in the future!

  • Walking aides: First of all, most people after a hip or knee replacement will rely on a walker, if only for a short time. Some people are able to progress to crutches before they head home from the hospital. 
    • Front-wheeled walkers or crutches may be covered by your insurance company, although many companies will only cover one device every 5 years. Most insurance also see items like a four-wheeled walker as a “luxury item”, and will not cover them at all. 
    • If your insurance will pay for something when you have your surgery, there is often someone at the hospital, like a physical therapist or case manager, who can order one for you.
  • Bedside commode or raised toilet seat:
    • It’s amazing how challenging it can feel to get up and down from the toilet after these surgeries! This device helps bring the seat up to you, so that you’re not having to work so hard.

  • Grab bars:
    • It’s important to think about an extra level of safety when it comes to getting in and out of the shower after surgery. It’s also great if you’re having trouble putting a lot of your weight through your leg, or if you’re just not allowed to because of the surgery done.
    • The bar will give you something sturdy to hang on to, whether you have a walk-in shower or a tub/shower combo.
  • Shower chair: 
    • This device is particularly helpful if you have a tub/shower combo, but can be helpful with a walk-in shower as well. It’s not unusual for people to initially feel like it takes a lot of extra energy to bathe after these surgeries.
    • This type of seat will allow you to be safe in a seated position, will allow you to have a seated break if you’re getting tired or feel like your balance isn’t great, and can make a transition over the edge of a tub a bit easier.
  • Detachable shower head: 
    • Another device to help you with bathing while you aren’t as mobile as normal.
    • This is particularly helpful if you’re using a shower chair.
  • Sock aide: 
    • One of the simple things that we often don’t think about when going into a total knee or hip replacement surgery is how we’re going to get socks and shoes on.
      • If you’re having difficulty bending your knee or hip, this device can be a life-saver. It can spare your helper at home from needing to get down low to help you.
    • There are several kinds of sock aides, including the style included on the link here. There is another style that just sits on the floor, and you push your foot through. I’ve had several patients say that they prefer the style with the ropes to pull on, as pictured.
  • Reacher: 
    • This is often helpful for things like get pants and underwear on. It can also be used to reach for things that you’ve dropped.
    • This should not be used for large or heavy items. You also need to be careful with using this for anything overhead, unless it is something like a light piece of clothing.
  • Long shoe horn: 
    • Again, getting shoes on can be a challenge, and this helps bridge that gap.
  • Shower sponge: 
    • This helps you reach your lower body in particular, which can be a challenge with limited mobility immediately following surgery. 

We’ve talked about how to prepare before going in to surgery for a total joint replacement. Our next blog will talk about what to expect during your hospital stay and options for after you discharge from the hospital.

 

 

 

Article author, Alyssa Arms, PT, DPT, OCS holds a Doctor of Physical Therapy (DPT) degree from the University of Colorado Anschutz Medical Campus. She later obtained a Board Certification as an Orthopedic Clinical Specialist (OCS). She is also the President and Owner of Back in Step Physical Therapy in Centennial, Colorado, and is an instructor at her PT alma mater.