“I’m not going to be able to get a massage for a few weeks because I’m getting saline injections done”.
For some reason I’ve been hearing this a lot lately, mostly from patients who have been in a car accident.
I get the feeling it’s being promoted as a “cure all” when I talk to patients about it, especially for those who are experiencing pain from a complicated issue (ie: car accident) for the first time.
So far I have seen patients who are experiencing chronic pain (a year or two post accident) to those who are only a few weeks/months after, who are giving this a try.
It has been described a few different ways as well, saline injections, sugar injections and nerve blocking but could never make heads or tails as to what was actually going on, or whether it actually works.
Some patients have had the therapy done and I don’t see them again for ages, while others are back within weeks for more massage.
So I figured it was time to take a hard look at what’s happening.
Saline Injections And Prolotherapy
Like most of you I’m sure, the first I heard of saline injections was from the Travell & Simons textbooks we got in school to learn trigger point therapy.
Most of what I remember in those books were images of trigger point injections with referral patterns etc., and as we know our understanding of what trigger points are has changed.
But the use of saline injections is still being used and has developed into further applications called Prolotherapy.
Turns out there are three different types of Prolotherapy:
- Growth factor injection: injecting a growth factor (plasma) to stimulate growth of certain cells.
- Growth factor stimulation: injecting something in the body that produces growth factors.
- Inflammatory prolotherapy: inject something that causes inflammation and tricks the body into thinking there is an injury and begin healing again.
From looking into research and checking things out online, it looks as though Prolotherapy is used more to work on ligaments and tendons (is also being used with osteoarthritis), compared to trigger point therapy which is focusing more on muscle.
So my question is whether these kinds of therapy are actually effective for the patients who are being referred out to have it done?
Well, like so many other things in therapy…it depends.
Low Back Pain And Whiplash
There are frequent statements in the research I could find that mentioned the effectiveness of these treatments as “unclear”, and tough to find any resounding positive studies to prove the effectiveness of injections.
One systematic review showed that in the case of whiplash, symptoms were better when sterile water was used compared to saline and was more effective in the short term (3 months) compared to long term (8 months).
It showed that trigger point injection was successful at reliving symptoms when used as the sole treatment, but could be better used as something to augment additional therapy like stretching. But since there wasn’t an additional study group that did stretching alone, it is hard to determine how much of a difference trigger point injection would make.
One study showed that intracutaneous injections of sterile water was beneficial both in pain reduction and improving function in patients with acute low back pain.
The study ruled out anyone who had any major back injury or condition like fracture, stenosis or osteoporosis as it would be inappropriate. Another study with the same exclusion criteria showed that saline injections are not recommended for patients with chronic low back pain due to nerve issues.
Those with chronic non-specific low back pain there can be a reduction in pain when injections are made into ligaments, but it does not appear to matter if saline or another prolotherapy solution is used.(1)
When an epidural is done to manage spinal pain, a saline injection is shown to have a lack of effectiveness when compared to using local anesthetic alone and when local anesthetic is used in conjunction with steroid. (2)
However research has been done to show that saline injections are equally as effective as conventional drugs for treating low back pain and other myofascial pain syndromes in a hospital emergency room setting.(3)
Now I know this is a lot of different types of low back pain to discuss, but research is showing that sterile water and saline injections are helpful in acute stages of injury, but not as effective in chronic conditions.
Tendinopathy And Arthritis
The best information I could find was for treatment of tennis elbow as far as a tendinopathy.
One study compared the use of a saline injection against a corticosteroid. It showed that in the short term there was better pain reduction with the corticosteroid, but after 24 weeks the saline injections were working better.
In a comparison between corticosteroid, autologous blood injection and saline for tennis elbow, there was no real improvement compared to the placebo saline injections.
When it comes to arthritis, I found a study and a systematic review on the affect of saline injections for knee Osteoarthritis.
The study said that using a saline injection did not significantly reduce pain in the knee compared to a saline placebo. (4)
Whereas the systematic review makes the argument that due to the pain relief shown in the studies, we should be considering the effectiveness of saline injections.
32 studies involving 1705 patients showed improvement in short term knee pain from saline injections. And 19 studies involving 1445 patients showed improvement in long term knee pain.
While saline injections were originally used as a control or placebo in studies, research is starting to challenge that it does have a therapeutic benefit. Most of the studies cited in this post argued that in the acute stages there is a pain relief and functional benefit to using saline injections. While this isn’t something we are going to be doing as massage therapists, it is important for us to know what could be happening with some of our patients. Any one of our patients who is dealing with chronic pain, whiplash, osteoarthritis or a tendinopathy could be referred by their doctor to have some of these treatments done. It is important for us to understand what and how this is done, so we can better support and stay informed with our patients. Remember, one of the studies showed that trigger point injection might be better as a way to augment additional therapy…like maybe massage therapy!?
- Yelland M, Glasziou P, Bogduk N, Schluter P, McKernon M. Prolotherapy injections, saline injections, and exercises for chronic low-back pain: a randomized trial. Spine [serial on the Internet]. (2004, Jan 1), [cited December 12, 2016]; 29(1): 9-16. Available from: MEDLINE with Full Text.
- Manchikanti L, Nampiaparampil D, Manchikanti K, Falco F, Singh V, Hirsch J, et al. Comparison of the efficacy of saline, local anesthetics, and steroids in epidural and facet joint injections for the management of spinal pain: A systematic review of randomized controlled trials. Surgical Neurology International [serial on the Internet]. (2015, May 7), [cited December 12, 2016]; 6(Suppl 4): S194-S235. Available from: MEDLINE with Full Text.
Bakunas C, Bayona A, Roldan C, Rehrer S, Leoni J, Hu N, Banuelos R/ University of Texas Health Science Center at Houston, Houston, TX
- Lundsgaard C, Dufour N, Fallentin E, Winkel P, Gluud C. Intra-articular sodium hyaluronate 2 mL versus physiological saline 20 mL versus physiological saline 2 mL for painful knee osteoarthritis: a randomized clinical trial. Scandinavian Journal Of Rheumatology [serial on the Internet]. (2008, Mar), [cited December 12, 2016]; 37(2): 142-150. Available from: MEDLINE with Full Text.