Is local subacromial corticosteroid injection beneficial in subacromial impingement syndrome?

A manual physical therapy approach versus subacromial corticosteroid injection for treatment of shoulder impingement syndrome: a protocol for a randomised clinical trial

INTRODUCTION

Corticosteroid injections (CSI) are a recommended and often-used first-line intervention for shoulder impingement syndrome (SIS) in primary care and orthopaedic settings. Manual physical therapy (MPT) offers a non-invasive approach with negligible risk for managing SIS. There is limited evidence to suggest significant long-term improvements in pain, strength and disability with the use of MPT, and there are conflicting reports from systematic reviews that question the long-term efficacy of CSI. Specifically, the primary objective is to compare the effect of CSI and MPT on pain and disability in subjects with SIS at 12 months.

DESIGN

This pragmatic randomised clinical trial will be a mixed-model 2×5 factorial design. The independent variables are treatment (MPT and CSI) and time with five levels from baseline to 1 year. The primary dependent variable is the Shoulder Pain and Disability Index, and the secondary outcome measures are the Global Rating of Change and the Numeric Pain Rating Scale. For each ANOVA, the hypothesis of interest will be the two-way group-by-time interaction.

METHODS AND ANALYSIS

The authors plan to recruit 104 participants meeting established impingement criteria. Following examination and enrollment, eligible participants will be randomly allocated to receive a pragmatic approach of either CSI or MPT. The MPT intervention will consist of six sessions, and the CSI intervention will consist of one to three sessions. All subjects will continue to receive usual care. Subjects will be followed for 12 months.

DISSEMINATION AND ETHICS

The protocol was approved by the Madigan Army Medical Center Institutional Review Board. The results may have an impact on clinical practice guidelines. This study was funded in part by the Orthopaedic Physical Therapy Products Grant through the American Academy of Orthopaedic Manual Physical Therapists. Trial Registration http://clinicaltrials.gov/ NCT01190891.

Effect of prescribed sleep surfaces on back pain and sleep quality in patients diagnosed with low back and shoulder pain

The purpose of this study was to assess sleep quality and comfort of participants diagnosed with low back pain and stiffness following sleep on individually prescribed mattresses based on dominant sleeping positions. Subjects consisted of 27 patients (females, n=14; males, n=13; age 44.8 yrs ± SD 14.6, weight 174 lb. ± SD 39.6, height 68.3 in. ± SD 3.7) referred by chiropractic physicians for the study. For the baseline (pretest) data subjects recorded back and shoulder discomfort, sleep quality and comfort by visual analog scales (VAS) for 21 days while sleeping in their own beds. Subsequently, participants' beds were replaced by medium-firm mattresses specifically layered with foam and latex based on the participants' reported prominent sleeping position and they again rated their sleep comfort and quality daily for the following 12 weeks. Analysis yielded significant differences between pre- and post means for all variables and for back pain, we found significant (p<0.01) differences between the first posttest mean and weeks 4 and weeks 8-12, thus indicating progressive improvement in both back pain and stiffness while sleeping on the new mattresses. Additionally, the number of days per week of experiencing poor sleep and physical discomfort decreased significantly. It was concluded that sleep surfaces are related to sleep discomfort and that is indeed possible to reduce pain and discomfort and to increase sleep quality in those with chronic back pain by replacing mattresses based on sleeping position.

Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials

BACKGROUND

Few evidence-based treatment guidelines for tendinopathy exist. We undertook a systematic review of randomised trials to establish clinical efficacy and risk of adverse events for treatment by injection.

METHODS

We searched eight databases without language, publication, or date restrictions. We included randomised trials assessing efficacy of one or more peritendinous injections with placebo or non-surgical interventions for tendinopathy, scoring more than 50% on the modified physiotherapy evidence database scale. We undertook meta-analyses with a random-effects model, and estimated relative risk and standardised mean differences (SMDs). The primary outcome of clinical efficacy was protocol-defined pain score in the short term (4 weeks, range 0-12), intermediate term (26 weeks, 13-26), or long term (52 weeks, ≥52). Adverse events were also reported.

FINDINGS

3824 trials were identified and 41 met inclusion criteria, providing data for 2672 participants. We showed consistent findings between many high-quality randomised controlled trials that corticosteroid injections reduced pain in the short term compared with other interventions, but this effect was reversed at intermediate and long terms. For example, in pooled analysis of treatment for lateral epicondylalgia, corticosteroid injection had a large effect (defined as SMD>0·8) on reduction of pain compared with no intervention in the short term (SMD 1·44, 95% CI 1·17-1·71, p<0·0001), but no intervention was favoured at intermediate term (-0·40, -0·67 to -0·14, p<0·003) and long term (-0·31, -0·61 to -0·01, p=0·05). Short-term efficacy of corticosteroid injections for rotator-cuff tendinopathy is not clear. Of 991 participants who received corticosteroid injections in studies that reported adverse events, only one (0·1%) had a serious adverse event (tendon rupture). By comparison with placebo, reductions in pain were reported after injections of sodium hyaluronate (short [3·91, 3·54-4·28, p<0·0001], intermediate [2·89, 2·58-3·20, p<0·0001], and long [3·91, 3·55-4·28, p<0·0001] terms), botulinum toxin (short term [1·23, 0·67-1·78, p<0·0001]), and prolotherapy (intermediate term [2·62, 1·36-3·88, p<0·0001]) for treatment of lateral epicondylalgia. Lauromacrogol (polidocanol), aprotinin, and platelet-rich plasma were not more efficacious than was placebo for Achilles tendinopathy, while prolotherapy was not more effective than was eccentric exercise.

INTERPRETATION

Despite the effectiveness of corticosteroid injections in the short term, non-corticosteroid injections might be of benefit for long-term treatment of lateral epicondylalgia. However, response to injection should not be generalised because of variation in effect between sites of tendinopathy.

FUNDING

None.

Positive outcomes with intra-articular glenohumeral injections are independent of accuracy

BACKGROUND

Shoulder pain is a common, costly, and recalcitrant affliction. One treatment for shoulder pain is intra-articular injection of corticosteroid. Clinical opinion is that injection guided by palpation is accurate and effective, and there is some evidence to support a positive effect of injection on pain. However, great controversy exists as to the accuracy of injection by palpation, whether or not accuracy is important, and what the effect is of accuracy on pain.

METHODS

We used a blinded, longitudinal observational design of effectiveness in an effort to determine the accuracy of intra-articular injections and the effect of that accuracy on pain and functional outcomes in patients with various shoulder pathologies.

RESULTS

Injection accuracy data were captured on 103 patients. Of the 103 blinded injections, 54 received injections that were identified by fluoroscopy as "in" the capsule, whereas 49 were identified as "outside" the capsule; an accuracy rate of 52.4%. In the 4-week follow up, regardless of group assignment or accuracy of the injection, patients improved significantly (P < .01) from pre- to post-injection. Improvement was typically over by 2.5 points in the Numeric Pain Rating Scale (NPRS) categories, over 8 points on the Short-Form McGill Pain Questionnaire (SFMPQ), and over by 13 points on the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH).

DISCUSSION

Our accuracy rate was within the range reported in the literature. Improvements in all subjects with regard to pain and self-reported function occurred even in light of a wide variance in subject duration of symptoms, multiple injectors with varied training, a blinded approach to injection, and multiple injection approaches.

CONCLUSIONS

The accuracy of the injection does not appear to depend on the experience of the physician and may be irrelevant in treating shoulder pain of multiple origins.

Correlation between rotator cuff tears and repeated subacromial steroid injections: a case-controlled study

INTRODUCTION

Concern exists regarding potential damage to the rotator cuff from repeated corticosteroid injections into the subacromial space.

PATIENTS AND METHODS

In this retrospective, case-controlled study, 230 consecutive patients presenting to three orthopaedic units with subacromial impingement and investigated as an end-point with magnetic resonance imaging (MRI) of the shoulder were divided into groups having received less than three or three or more subacromial injections of corticosteroids.

RESULTS

With no significant difference in age and sex distribution, analysis by MRI showed no significant difference between the two groups in the incidence of rotator cuff tear (P < 1.0).

CONCLUSIONS

This suggests that corticosteroid use in patients with subacromial impingement should not be considered a causative factor in rotator cuff tears.

Shoulder impingement: relationship of clinical symptoms and imaging criteria

OBJECTIVE

To establish, in patients with subacromial impingement syndrome, (1) the relationship between pain and shoulder function, as determined by the Constant score, and morphological findings, as determined by radiographs and magnetic resonance imaging (MRI) and (2) the relationship between acromial shape and minimum acromiohumeral distance (AHD).

DESIGN

Cross-sectional study.

SETTING

Tertiary care center.

PATIENTS

Forty-seven patients (33 males and 14 females; mean age, 51.7 years) with unilateral subacromial impingement syndrome who had failed to respond to conservative therapy for at least 6 months.

INTERVENTIONS

The Constant score was determined preoperatively; acromial shape (type I, flat; type II, curved; and type III, hooked) was evaluated on preoperative outlet view radiographs and oblique sagittal T1-weighted MRIs; AHD was evaluated on preoperative anteroposterior radiographs and oblique coronal T1-weighted MRIs.

MAIN OUTCOME MEASURES

Correlation coefficients and the simple kappa statistic were calculated. Student t test and mean differences with 95% confidence limits were reported for group comparisons.

RESULTS

The Constant score was fairly correlated with AHD (r = 0.39, P < 0.01) but not with acromial shape. Patients with an AHD < or =7 mm on MRI scored significantly lower than those with an AHD >7 (mean difference, 18.5; P < 0.01). Acromial shape and AHD were not correlated, neither on radiographs nor on MRI.

CONCLUSIONS

AHD seems to better reflect the clinical status of patients with subacromial impingement, but without rotator cuff tears, than acromial shape. Acromial shape is not a good descriptor of subacromial space narrowing.

Changes in back pain, sleep quality, and perceived stress after introduction of new bedding systems

OBJECTIVE

This study compared sleep quality and stress-related symptoms between older beds (>/=5 years) and new bedding systems.

METHODS

A convenience sample of healthy subjects (women = 30; men = 29) with minor musculoskeletal sleep-related pain and compromised sleep, but with no clinical history of disturbed sleep, participated in the study. Subjects recorded back discomfort and sleep quality upon waking for 28 consecutive days in their own beds (baseline) and for 28 consecutive days (post) on a new bedding system using visual analog scales. Following baseline measures, participant's beds were replaced by new, medium-firm beds, and they again rated their sleep quality and back discomfort. Stress was assessed by a modified stress questionnaire.

RESULTS

Repeated-measures analysis of variance was used to treat sleep quality and efficiency and factored responses of the stress items. Results indicated that the subjects' personal bedding systems average 9.5 years old and were moderately priced. Significant (P < .01) improvements were found between pre- and posttest mean values in sleep quality and efficiency. Continued improvement was noted for each of the 4-week data gathering period. Stress measures yielded similar positive changes between pre- and posttest mean values.

CONCLUSION

Based on these data, it was concluded that, in this population, new bedding systems increased sleep quality and reduced back discomfort, factors that may be related to abatement of stress-related symptoms.

Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials

Objectives:

To assess the efficacy and safety of steroid injections for patients with tendonitis of the shoulder or elbow.

Methods:

A systematic review of the literature using PubMed, EMBASE, the Cochrane library and manual searches was performed until April 2008. All randomised controlled trials (RCTs) reporting the efficacy on pain or functional disability, and/or the safety of steroid injections, versus placebo, non-steroidal anti-inflammatory drugs (NSAIDs) or physiotherapy in patients with tendonitis were selected. Pooled effect size (ES) was calculated by meta-analysis using the Mantel–Haenszel method.

Results:

In all, 20 RCTs were analysed (744 patients treated by injections and 987 patients treated by controls; 618 shoulders and 1113 elbows). The pooled analysis indicated only short-term effectiveness of steroids versus the pooled controls for pain and function (eg, pain at week 1–3 ES = 1.18 (95% CI 0.27 to 2.09), pain at week 4–8 ES = 1.30 (95% CI 0.55 to 2.04), pain at week 12–24 ES = −0.38 (95% CI −0.85 to 0.08) and pain at week 48 ES = 0.07 (95% CI −0.60 to 0.75)). Sensitivity analyses indicated similar results whatever the localisation, type of steroid and type of comparator except for NSAIDs: steroid injections were not significantly better than NSAIDs in the short-term. Steroid injections appeared more effective than pooled other treatments in acute or subacute tendonitis. The main side effects were transient pain after injection (10.7% of corticosteroid injections) and skin modification (4.0%).

Conclusions:

Steroid injections are well tolerated and more effective for tendonitis in the short-term than pooled other treatments, though similar to NSAIDs. No long-term benefit was shown.

Treatment of tendinopathy: what works, what does not, and what is on the horizon

Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions. Thus, traditional treatment modalities aimed at controlling inflammation such as corticosteroid injections and nonsteroidal antiinflammatory medications (NSAIDS) may not be the most effective options. We performed a systematic review of the literature to determine the best treatment options for tendinopathy. We evaluated the effectiveness of NSAIDS, corticosteroid injections, exercise-based physical therapy, physical therapy modalities, shock wave therapy, sclerotherapy, nitric oxide patches, surgery, growth factors, and stem cell treatment. NSAIDS and corticosteroids appear to provide pain relief in the short term, but their effectiveness in the long term has not been demonstrated. We identified inconsistent results with shock wave therapy and physical therapy modalities such as ultrasound, iontophoresis and low-level laser therapy. Current data support the use of eccentric strengthening protocols, sclerotherapy, and nitric oxide patches, but larger, multicenter trials are needed to confirm the early results with these treatments. Preliminary work with growth factors and stem cells is promising, but further study is required in these fields. Surgery remains the last option due to the morbidity and inconsistent outcomes. The ideal treatment for tendinopathy remains unclear.

LEVEL OF EVIDENCE

Level II, systematic review.

Grouped comparisons of sleep quality for new and personal bedding systems

The purpose of this study was to compare sleep comfort and quality between personal and new bedding systems. A convenience sample (women, n=33; men, n=29) with no clinical history of disturbed sleep participated in the study. Subjects recorded back and shoulder pain, sleep quality, comfort, and efficiency for 28 days each in their personal beds (pre) and in new medium-firm bedding systems (post). Repeated measures ANOVAs revealed significant improvement between pre- and post-test means for all dependent variables. Furthermore, reduction of pain and stiffness and improvement of sleep comfort and quality became more prominent over time. No significant differences were found for the groupings of age, weight, height, or body mass index. It was found that for the cheapest category of beds, lower back pain was significantly (p<0.01) more prominent than for the medium and higher priced beds. Average bed age was 9.5yrs. It was concluded that new bedding systems can significantly improve selected sleep variables and that continuous sleep quality may be dependent on timely replacement of bedding systems.

[Ultrasound guided interventional radiology]

Ultrasound is a valuable imaging technique for musculoskeletal pathology. It is increasingly used for image-guided procedures such as aspiration of superficial or deep collections, injection of drugs, or biopsies. Ultrasound guidance is an interesting alternative to procedures performed either blindly or under fluoroscopic or CT guidance. Advantages of US-guided procedures include the absence of ionizing radiation, real-time monitoring during needle placement, decreased risk of injury to neighboring structures (namely vessels and nerves), real time confirmation of procedure success (injection, drainage, biopsy). Minor inconveniences relate to the proper conditions for performance of ultrasound. Complications are rare and can be avoided by using proper sterile technique and evaluate for potential contra-indications to the procedure. As with any other image guided procedure, informed consent is required.

Subacromial corticosteroid injections

The use of subacromial injections to treat shoulder pain has remained one of the most common procedures for the practicing orthopedist, rheumatologist, and general practitioner. Despite this, many prospective studies have questioned the efficacy of corticosteroid injections compared with nonsteroidal anti-inflammatory drugs or injections of local anesthetics alone, or both, when used for the treatment of symptomatic rotator cuff disease. Accurate diagnosis of the etiology of a patient's shoulder pain and proper injection technique are important in achieving satisfactory clinical outcomes. Both extrinsic as well as intrinsic etiologies for rotator cuff disease should be considered and must be elucidated with appropriate physical examination techniques. Although subacromial injections appear straightforward, more recent cadaveric, radiographic, and clinical studies have demonstrated variable accuracy rates using the two common techniques. In addition, absolute sterile technique must be used because infections of the subacromial space after injections, although uncommon, have generally led to debilitating conditions. This article reviews the etiology and pathophysiology of rotator cuff disease and the indications and techniques for subacromial corticosteroid injections.

COMPLICATIONS OF JOINT, TENDON, AND MUSCLE INJECTIONS

Prevention of complications is one of the most important aspects of patient care in pain management. The objective of this study is to review documented complications in medical literature that are associated with interventional pain management, specifically those associated with joint, tendon, and muscle injections. We conducted Medline research from 1966 to November 2006 using keywords complication, injection, radiofrequency, closed claim, facet, zygophyseal joint, sacroiliac joint, shoulder, hip, knee, carpel tunnel, bursa, and trigger point. We found over 35 relevant papers in forms of original articles, case reports, and reviews. The most common complications appear to be infections that have been associated with virtually all of these injections. These infections include spondylodiscitis, septic arthritis, epidural abscess, necrotizing fasciitis, osteomyelitis, gas gangrene, and albicans arthritis. Other complications include spinal cord injury and peripheral nerve injuries, pneumothorax, air embolism, pain or swelling at the site of injection, chemical meningism, granulomatous inflammation of the synovium, aseptic acute arthritis, embolia cutis medicamentosa, skeletal muscle toxicity, and tendon and fascial ruptures. We suggest that many of the infectious complications may be preventable by strict adherence to aseptic techniques and that some of the other complications may be minimized by refining the procedural techniques with a clear understanding of the relevant anatomies.

The efficacy of subacromial corticosteroid injection in the treatment of rotator cuff disease: A systematic review

To investigate whether subacromial corticosteroid injections are effective in the treatment of rotator cuff disease, an evidence-based systematic review was undertaken of nine randomized controlled trials that compared subacromial corticosteroid injection with placebo in patients with rotator cuff disease. Each study was systematically evaluated for biases, and outcome measures were scrutinized for statistical significance and clinical importance. One study demonstrated clinically important differences in pain relief. Two studies showed clinically important improvement in range of motion at final follow-up. This systematic review of the available literature indicates that there is little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease.

Therapeutic effect of pulsed electromagnetic field in conservative treatment of subacromial impingement syndrome

Subacromial impingement syndrome (SIS) is a frequent cause of shoulder pain. Our purpose in this double-blinded, randomized, and controlled study was to demonstrate whether the pulsed electromagnetic field (PEMF) provides additional benefit when used with other conservative treatment modalities in acute phase rehabilitation program of SIS. Forty-six patients with unilateral shoulder pain who had been diagnosed as having SIS were included in this trial. The cases were randomly separated into two groups. All cases received a treatment program for 3 weeks consisting of Codman's pendulum exercises and subsequent cold pack gel application on shoulders with pain 5 times a day, restriction of daily activities that require the hands to be used over the head, and meloxicam tablet 15 mg daily. One group was given PEMF; the other group was given sham PEMF daily, 25 min per session, 5 days per week for 3 weeks. Shoulder pain during rest and activity and which causes disturbance of sleep was evaluated using a visual analogue scale, and total Constant score investigated shoulder function. Daily living activities were evaluated by shoulder disability questionnaire. Results were assessed before and after treatment. When compared with the baseline values, significant improvements in all these variables were observed at the end of the treatment in both groups (p<0.05). No significant difference between treatments was observed for any of these variables (p>0.05). There is no convincing evidence that electromagnetic therapy is of additional benefit in acute phase rehabilitation program of SIS.

[Interventional sonography]

Diagnostic and therapeutic interventional procedures are rapidly expanding and, when guided by imaging, are more efficient then when performed with a blinded technique. Compared to fluoroscopy and CT, ultrasound does not utilize ionizing radiation. It can facilitate needle placement for arthrography, tenography or bursography or it can guide a variety of procedures such as aspiration, arthrocentesis, local steroid injections and needling of tendon calcifications. Technological improvements have increased the precision of ultrasound guidance and have contributed to reduce the risk of complication. Real time scanning allows simultaneous visualization of the target and of needle progression and has diminished the rate of complications, that are infrequent if the operator uses a strict sterile technique and respects the contraindications.