Is local subacromial corticosteroid injection beneficial in subacromial impingement syndrome?

Randomized feasibility study of an autologous protein solution versus corticosteroids injection for treating subacromial pain in the primary care setting - the SPiRIT trial

Aims

The primary aim of this study was to assess the feasibility of recruiting and retaining patients to a patient-blinded randomized controlled trial comparing corticosteroid injection (CSI) to autologous protein solution (APS) injection for the treatment of subacromial shoulder pain in a community care setting. The study focused on recruitment rates and retention of participants throughout, and collected data on the interventions' safety and efficacy.

Methods

Participants were recruited from two community musculoskeletal treatment centres in the UK. Patients were eligible if aged 18 years or older, and had a clinical diagnosis of subacromial impingement syndrome which the treating clinician thought was suitable for treatment with a subacromial injection. Consenting patients were randomly allocated 1:1 to a patient-blinded subacromial injection of CSI (standard care) or APS. The primary outcome measures of this study relate to rates of recruitment, retention, and compliance with intervention and follow-up to determine feasibility. Secondary outcome measures relate to the safety and efficacy of the interventions.

Results

A total of 53 patients were deemed eligible, and 50 patients (94%) recruited between April 2022 and October 2022. Overall, 49 patients (98%) complied with treatment. Outcome data were collected in 100% of participants at three months and 94% at six months. There were no significant adverse events. Both groups demonstrated improvement in patient-reported outcome measures over the six-month period.

Conclusion

Our study shows that it is feasible to recruit to a patient-blinded randomized controlled trial comparing APS and CSI for subacromial pain in terms of clinical outcomes and health-resource use in the UK. Safety and efficacy data are presented.

A scoping review and best evidence synthesis for treatment of partial-thickness rotator cuff tears

BACKGROUND

Rotator cuff disorders include a broad spectrum of pathological conditions including partial-thickness and full-thickness tears. Studies have shown partial-thickness rotator cuff tear (PTRCT) prevalence to be twice that of full-thickness tears. In the working population, PTRCTs are one of the most common causes of shoulder pain and often result in occupational disability due to pain, stiffness, and loss of shoulder function. Treatment of PTRCTs remains controversial. The purpose of this study was to consolidate the existing high-quality evidence on best management approaches in treating PTRCTs using both nonoperative and operative approaches.

METHODS

A scoping review with best evidence synthesis was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. MEDLINE (OVID), EMBASE (OVID), Cochrane Library (Wiley), SCOPUS, Web of Science Core Collection, CINAHL Plus with Full Text (EBSCOhost), PubMed Central, and Science Direct were searched from 2000 to March 3, 2023. Level 1 studies, and systematic reviews and meta-analyses that included level 1 and 2 studies, were included.

RESULTS

The search yielded 8276 articles. A total of 3930 articles were screened after removing 4346 duplicates. Application of inclusion criteria resulted in 662 articles that were selected for full-text review. Twenty-eight level 1 studies, 1 systematic review, 4 meta-analyses, and 1 network meta-analyses were included in the best evidence synthesis. Nonoperative strategies included injections (ie, platelet-rich plasma, corticosteroid, prolotherapy, sodium hyaluronate, anesthetic, and atelocollagen), exercise therapy, and physical agents. Operative interventions consisted of débridement, shaving of the tendon and footprint, transtendon repair, and traditional suture anchor repair techniques with and without tear completion. Both nonoperative and operative strategies demonstrated effectiveness at managing pain and functional outcome for PTRCTs. The evidence supports the effectiveness of surgical intervention in treating PTRCTs regardless of arthroscopic technique.

CONCLUSION

The results of this scoping review do not support superiority of operative over nonoperative management and suggest that both strategies can be effective at managing pain and functional outcome for PTRCTs. Surgery, however, is the most invasive and costly approach, with the highest risk of complications such as infection. Other variables such as patient expectation, treating practitioner bias, or preference may change which modalities are offered and in what sequence.

Nonsteroidal Anti-Inflammatory Drug Injections versus Steroid Injections in the Management of Upper and Lower Extremity Orthopedic Conditions: A Systematic Review with Meta-Analysis

BACKGROUND

Although corticosteroid injections are an effective treatment for musculoskeletal pathologies, they may not be suitable for all patients. The purpose of this systematic review was to compare clinical outcomes between patients who received NSAID and corticosteroid injections for various orthopedic conditions.

METHODS

Medline, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched, and meta-analyses were performed using a random-effects model for outcomes presented in three or more studies. Other studies were qualitatively analyzed.

RESULTS

A total of 28 articles with 2113 patients were included. A meta-analysis of five studies in patients with shoulder impingement syndrome demonstrated that there was no significant difference in the pain visual analogue scale (VAS) between subacromial NSAID injections and corticosteroid injections at 1 month [weighted mean difference (WMD) -0.244; 95% CI, -1.232 to 0.745; I2, 94.5%]. For patients with knee osteoarthritis, a meta-analysis of three studies demonstrated that there was no significant difference between intraarticular NSAID injections and corticosteroid injections in pain VAS at 1 month (WMD 0.754; 95% CI, -0.413 to 1.921; I2, 90.2%) and 3 months (WMD-0.089; 95% CI, -0.345 to 0.166; I2, 0%). A review of the studies assessing pain outcomes for hip osteoarthritis, adhesive capsulitis, and plantar fasciitis showed no significant differences between the NSAID and corticosteroid groups.

CONCLUSION

NSAID injections may be safe and effective alternatives to steroid injections, especially in shoulder impingement syndrome and knee osteoarthritis.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Effectiveness of lyophilized growth factors injection for subacromial impingement syndrome: a prospective randomized double-blind placebo-controlled study

BACKGROUND

Platelet-derived lyophilized growth factors (L-GFs) use a standardized number of allogenic pathogen-free platelets instead of autologous platelets used in PRP as a source of growth factors. This study aimed to evaluate the efficacy of L-GF injection versus placebo in subacromial impingement (SIS) treatment.

METHODS

The current randomized double-blind placebo-controlled study included sixty patients (40 females and 20 males, aged between 24 and 75 years) diagnosed with SIS (both clinically and sonographically). Patients were randomly assigned to two equal groups. Under ultrasound guidance, group 1 received subacromial saline injection, and group 2 received L-GF injection. Clinical examination, pain visual analogue scale (VAS), shoulder pain and disability index (SPADI) and shoulder ultrasound were performed before and at the 8th week after injection.

RESULTS

Follow-up assessment showed statistically significant improvement in the L-GF group regarding active flexion, active and passive internal rotation and extension, SPADI-disability scale, VAS and thickness of the supraspinatus tendon by US. Regression analysis showed that group 1 was approximately 30 times more likely than the L-GF group to experience painful arc at follow-up. Both groups showed statistically significant improvement in SPADI-pain scale and SPADI-total, flexion and abduction (still the mean value of abduction was significantly higher in the L-GF group).

CONCLUSIONS

L-GF injection resulted in clinically significant reductions in pain and functional disability outcomes in patients with SIS. An objective significant reduction in the thickness of the supraspinatus tendon, measured by ultrasound, in the L-GF group hopefully encourages proper healing and functioning in SIS.

TRIAL REGISTRATION

The identification number is NCT04330027, date of first registration (01/04/2020). Unique on 21/11/2019, Protocol ID: 0106178.

Editorial Commentary: Arthroscopic Treatment Should No Longer Be Offered to People With Subacromial Impingement

Arthroscopic treatment should no longer be offered to people with subacromial impingement. In many people, subacromial impingement (or subacromial pain syndrome) is self-limiting and may not require any specific treatment. This is evident by the fact that almost 50% of people with new-onset shoulder pain consult their primary care doctor only once. The best-available evidence from randomized controlled trials indicates that glucocorticoid injection provides rapid, modest, short-term pain relief. Exercise therapy has also been found to provide no added benefit over glucocorticoid injection. Subacromial decompression (bursectomy and acromioplasty) for subacromial pain syndrome provides no important benefit on pain, function, or health-related quality of life. Acromioplasty does not improve the outcomes of rotator cuff repair.

Physical Therapy Combined With Subacromial Cortisone Injection Is a First-Line Treatment Whereas Acromioplasty With Physical Therapy Is Best if Nonoperative Interventions Fail for the Management of Subacromial Impingement: A Systematic Review and Network Meta-Analysis

PURPOSE

To construct an algorithm to optimize clinical outcomes in subacromial impingement based on current, high-level evidence.

METHODS

A systematic review of all clinical trials on subacromial impingement published from 1999 to 2020 was performed. Demographic, clinical, range of motion (ROM), and patient-reported outcome measure (PROM) data were collected. Interventions were compared via arm-based Bayesian network meta-analysis in a random-effects model and treatments ranked via surface under the cumulative ranking curves with respect to 3 domains: pain, PROMs, and ROM.

RESULTS

A total of 35 studies comprising 3,643 shoulders (42% female, age 50 ± 5 years) were included. Arthroscopic decompression with acromioplasty ranked much greater than arthroscopic decompression alone for pain relief and PROM improvement, but the difference in absolute PROMs was not statistically significant. Corticosteroid injection (CSI) alone demonstrated inferior outcomes across all 3 domains (pain, PROMs, and ROM) with low cumulative rankings. Physical therapy (PT) with CSI demonstrated moderate-to-excellent clinical improvement across all 3 domains whereas PT alone demonstrated excellent ROM and low-moderate outcomes in pain and PROM domains. PT with nonsteroidal anti-inflammatory drugs or alternative therapies ranked highly for PROM outcomes and moderate for pain and ROM domains. Finally, platelet-rich plasma injections demonstrated moderate outcomes for pain, forward flexion, and abduction with very low-ranking outcomes for PROMs and external rotation.

CONCLUSIONS

Arthroscopic decompression with acromioplasty and PT demonstrated superior outcomes whereas CSI demonstrated poor outcomes in all 3 domains (pain, PROMs, and ROM). For patients with significant symptoms, the authors recommend PT with CSI as a first-line treatment, followed by acromioplasty and PT if conservative treatment fails. For patients with symptoms limited to 1 to 2 domains, the authors recommend a shared decision-making approach focusing on treatment rankings within domains pertinent to individual patient symptomatology.

LEVEL OF EVIDENCE

I, systematic review and network meta-analysis of Level I studies.

Nonsteroidal Anti-inflammatory and Corticosteroid Injections for Shoulder Impingement Syndrome: A Systematic Review and Meta-analysis

CONTEXT

To determine optimal treatment strategies for shoulder impingement syndrome (SIS).

OBJECTIVE

To compare subacromial nonsteroidal anti-inflammatory injections (SNIs) and subacromial corticosteroid injections (SCIs) on pain relief and functional improvement in individuals with SIS. Second, to perform a cost analysis of the 2 injections.

DATA SOURCES

MEDLINE, SPORTDiscus, CINAHL, Embase, Web of Science, and SCOPUS databases were searched for randomized controlled trials using several keywords.

STUDY SELECTION

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized, and 10 studies comparing changes in pain or function in humans with SIS receiving SNIs or SCIs were included. Quality and risk of bias were assessed using the Consolidated Standards of Reporting Trials (CONSORT) 2010 scale and the Cochrane Collaboration tool.

STUDY DESIGN

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level 1.

DATA EXTRACTION

Baseline and follow-up scores of the visual analog, Constant-Murley, and University of California Los Angeles shoulder scales were extracted to calculate effect sizes (ESs), represented as Cohen d. Metaregression and publication bias analyses were performed. Procedural and medication costs were extracted from Medicare guidelines.

RESULTS

A total of 7 high and 3 good quality studies were included, with a mean score of 21.1. Only 1 study had a high risk of bias. The meta-analyses produced pooled ESs of 0.05 (P = 0.83), 0.12 (P = 0.71), and 0.07 (P = 0.79) for each scale, respectively, with CIs crossing 0. Procedural costs were equal between groups, whereas ketorolac was the least costly medication ($0.47). There was no significant difference in side effects between the 2 injections.

CONCLUSION

SNIs are as effective as SCIs for short-term pain relief and improving function in patients with subacromial impingement syndrome. In addition, they are less expensive and cause no major difference in complications, providing a viable, cost-effective alternative for injection therapy in patients with SIS.

Mattress Coil Spring Fatigue and Weight-Bearing Support: Comparison of Weight-Bearing and Non-Weight-Bearing Springs

OBJECTIVE

The purpose of this study was to compare the firmness of used mattress coil springs from the areas bearing greatest body weight versus areas subjected to little compression.

METHODS

Weight-bearing springs (WBS) extracted from the center of the mattresses (N = 32), and non-weight-bearing springs (NWBS) extracted from the head/foot were of the same mattresses. To determine spring weakness, a 1296-g ingot was placed on the coil, and the compression distance was measured (cm). In addition, a gauge was used to measure the amount of pressure required to compress the coil springs a distance of 2 cm. Comparison between WBS and NWBS data were statistically treated using independent t tests and a 1-way analysis of variance.

RESULTS

There were no significant group differences in weight or height in unloaded coils. However, there were significant (P < .05) differences in coil spring compression distance under load (WBS = 2.78 ± 0.34 cm; NWBS = 1.52 ± 0.39 cm) and force gauge compression (WBS = 1090.51 ± 88.42 g; NWBS = 1213.12 ± 71.38 g) between groups.

CONCLUSION

This study found that WBSs were weaker when compressed than the NWBS from used mattresses, and such characteristics may not be visually apparent in a mattress when not in use. Thus, coil springs in bedding systems may eventually fail to provide the initial structural support after use. Such sagging may compromise sleep posture with accompanying poor sleep quality and quantity.

MRI findings in atraumatic shoulder pain-patterns of disease correlated with age and gender

BACKGROUND

The rotator cuff is a group of muscles and tendons which support the shoulder joint. Rotator cuff disease is a frequent cause of morbidity in adulthood.

AIMS

The aims of his study are to determine the prevalence and patterns of rotator cuff derangement in symptomatic patients using MRI and to attempt to correlate identified patterns of disease with age and gender METHODS: Five hundred ninety-seven patients attending for MRI of the shoulder with atraumatic shoulder pain were included for study. Patients' age and gender was recorded. Record was made of the presence or absence of rotator cuff derangement and of degenerative change in the AC and glenohumeral joints. Correlation was made between age and gender.

RESULTS

There were 358 males (60%) and 239 females (40%) with a mean age of 49.4 ± 17.1 years. Subacromial bursitis was identified in 517 patients. A normal supraspinatus tendon was identified in 219 patients and supraspinatus full thickness tearing was identified in 102 patients. A normal AC joint was identified in 267 patients while degenerative AC joint changes were identified in 370 patients. A significant correlation was identified between age and rotator cuff derangement (p < .001) and between age and AC joint derangement (p < .001). No significant difference was identified between gender and patterns of cuff derangement CONCLUSION: The extent of rotator cuff and AC joint derangement increases with ageing. Impingement appears to trigger a cascade of events in sequence, from isolated subacromial bursitis through to supraspinatus tendon tearing. Patterns of rotator cuff derangement are similar in men and women.

Publication Trends and Hot Spots in Subacromial Impingement Syndrome Research: A Bibliometric Analysis of the Web of Science Core Collection

Background

In recent years, the research on subacromial impingement syndrome (SIS) has gradually increased. Although the research directions are diverse, the overall research status and trend are not clear.

Objective

The aim of our study was to use bibliometric analysis to identify the trends in SIS-related research and to analyze the most highly cited scientific publications on SIS.

Methods

All data were retrieved from the Web of Science Core Collection database, and the year of publications, countries, journals, institutions and total number of citations were extracted and analyzed. The results related to countries, institutions and keywords were then analyzed using VOSviewer software and bibliometrics online analysis platform. And, we also identified the 100 most cited articles on SIS.

Results

A total of 548 articles related to AIS were identified. The frequency of publication on SIS has increased substantially over time. Among all countries, Turkey has contributed the most publications on SIS (n=118). The institution with the most articles was Istanbul University (n=17). Journal of Shoulder and Elbow Surgery topped the list of journals and has published 19 SIS-related publications. The hotspot of research changed from the former arthroscopic surgery to physical therapy and rehabilitation.

Conclusion

The scientific research on SIS has rapidly expanded in recent years. This study represents the first bibliometric analysis of SIS, gives us a systematic and comprehensive summary into the development of SIS.

Physiotherapy after ultrasound-guided percutaneous irrigation in rotator cuff calcific tendinopathy

BACKGROUND

Rotator cuff calcific tendinopathy (RCCT) is a very frequent and debilitating disease often treated with Ultrasound-guided percutaneous irrigation (UGPI) followed by physiotherapy.

OBJECTIVE

A multicenter observational clinical study was designed to assess the effects of physiotherapy after UGPI on the functional recovery of the shoulders of patients suffering from RCCT.

METHOD

One hundred sixty-six patients (mean age 50.7± 7.6 years), 121 women, with painful RCCT were treated with UGPI and assessed at the day of UGPI (T0), and at one (T1), 3 (T2) and 6 (T3) months after treatment by the Constant- Murley Score (CMS), Oxford Shoulder Scale (OSS) and Numerical Rating Scale (NRS). Patients were divided into 2 groups, Physiotherapy (PT+) and not Physiotherapy (PT-) according to the performance of the rehabilitation program based on personal decision.

RESULTS

A significant improvement at T1 in all outcomes in both groups and between T1 and T3 for NRS during movement and OSS was found, but not for NRS at rest and CMS. There was no difference between groups for all outcome measures. In 27,1% of patients symptoms recurred in an average of 13 ± 8 weeks.

CONCLUSIONS

Results suggest that post-UGPI not-standardized physiotherapy might not provide additional clinical benefits in short and medium term. Further studies could assess the effectiveness of physiotherapy performed after three months in patients with recurrence of pain.

Impingement on the internet: evaluating the quality and readability of online subacromial impingement information

Patients increasingly access the internet to learn about their orthopaedic conditions. Despite this, online information may be unregulated, of questionable quality and difficulty to read.

OBJECTIVES

Therefore, this study aimed to evaluate the readability and quality of the online information concerning subacromial impingement syndrome.

METHODS

A search using Australia's three most popular online search engines was undertaken using the search terms 'subacromial impingement syndrome' and 'shoulder impingement'. The first 15 websites for each term were evaluated. Duplicates, advertisements and sponsored links were removed.The quality and readability of each website were calculated using the DISCERN and Flesch-Kincaid Reading Ease (FKRE) tools, respectively. The differences in quality and readability between each website type (healthcare/academic, commercial, news outlet, charitable/not-for-profit, layperson, government) was assessed using analysis of variance. The correlation between quality and readability was assessed using the Pearson correlation coefficient.

RESULTS

The majority of 35 unique websites analysed were of 'poor'/'fair' quality (determined via the DISCERN instrument) and 'difficult' readability (per the FKRE tool), with no correlation established between the scores. There was no statistically significant difference in quality across website types, however layperson, news outlet and government websites were found to be significantly more readable than alternate website categories (p<0.05).

CONCLUSIONS

We determined that much of the online information concerning subacromial impingement syndrome may be difficult to read and/or of poor quality. By recognising the shortcomings of information accessed by patients online, it is hoped clinicians may be prompted to better educate their patients.

Comparison of ultrasound-guided platelet-rich plasma, prolotherapy, and corticosteroid injections in rotator cuff lesions

BACKGROUND

Injections are a good alternative to conventional treatment-resistant cases with rotator cuff (RC) lesions before operation. Currently, different injection methods are used in RC lesions.

OBJECTIVE

To evaluate the efficacy of different injection methods (platelet-rich plasma [PRP], corticosteroid [COR] and prolotherapy [PRO]) in RC tendon lesions.

METHODS

One hundred and twenty-nine patients were divided into 4 groups as PRP, COR, PRO and the lidocaine group. Subacromial injection was applied to all groups. They were evaluated using the Visual Analogue Scale (VAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Western Ontario Rotator Cuff Index (WORC) at 3, 12 and 24 weeks post-injection.

RESULTS

In the COR group in the 3rd week, VAS and WORC scores were significantly lower than the other groups (p< 0.01 and p< 0.05 respectively). In the PRP group in the 24th week, VAS and WORC scores were found to be significantly lower than the COR group (p< 0.01 and p< 0.05 respectively). In the COR group in the 3rd week the ASES score was found to be significantly higher than the PRP and PRO group (p< 0.01).

CONCLUSION

In patients with RC lesions, corticosteroid injection provides short-term relief for pain, function, and quality of life, while PRP injection works for long-term wellbeing. For all types of applied injections, improvement in pain, function and quality of life were observed.

Addition of corticosteroids to local anaesthetics for chronic non-cancer pain injections: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Despite common use, the benefit of adding steroids to local anaesthetics (SLA) for chronic non-cancer pain (CNCP) injections is uncertain. We performed a systematic review and meta-analysis of English-language RCTs to assess the benefit and safety of adding steroids to local anaesthetics (LA) for CNCP.

METHODS

We searched MEDLINE, EMBASE, and CENTRAL databases from inception to May 2019. Trial selection and data extraction were performed in duplicate. Outcomes were guided by the Initiative in Methods, Measurements, and Pain Assessment in Clinical Trials (IMMPACT) statement with pain improvement as the primary outcome and pooled using random effects model and reported as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CIs).

RESULTS

Among 5097 abstracts, 73 trials were eligible. Although SLA increased the rate of success (42 trials, 3592 patients; RR=1.14; 95% CI, 1.03-1.25; number needed to treat [NNT], 13), the effect size decreased by nearly 50% (NNT, 22) with the removal of two intrathecal injection studies. The differences in pain scores with SLA were not clinically meaningful (54 trials, 4416 patients, MD=0.44 units; 95% CI, 0.24-0.65). No differences were observed in other outcomes or adverse events. No subgroup effects were detected based on clinical categories. Meta-regression showed no significant association with steroid dose or length of follow-up and pain relief.

CONCLUSIONS

Addition of cortico steroids to local anaesthetic has only small benefits and a potential for harm. Injection of local anaesthetic alone could be therapeutic, beyond being diagnostic. A shared decision based on patient preferences should be considered. If used, one must avoid high doses and series of steroid injections.

CLINICAL TRIAL REGISTRATION

PROSPERO #: CRD42015020614.

[Electro-acupuncture promotes repair of rotator cuff injury in rats]

OBJECTIVE

To observe the therapeutic effect of electro-acupuncture on tendon healing and functional recovery of rotator cuff injury in rats and explore the therapeutic mechanism of electro-acupuncture.

METHODS

Ninety SD rats were randomly divided into electro-acupuncture group, model group and blank control group, and models of rotator cuff injury were established in the former two groups.The rats in electro-acupuncture group was treated with electro-acupuncture after the operation, and those in the other two groups received no treatment.The right forefoot thermal withdrawal latency (TWL), the contents of IL-1β, IL-6 and TNF-α in the synovial fluid and the maximum tension load of supraspinatus tendon were measured at 2, 4 and 8 weeks after the operation.

RESULTS

TWL in the model group was significantly lower than that in the blank control group and electro-acupuncture group at 2, 4 and 8 weeks after the operation (P < 0.05).At all these time points, the contents of IL-1β, IL-6 and TNF-α in the synovial fluid were significantly higher in the model group than in the blank control group and electro-acupuncture group (P < 0.05).At 2 weeks, the maximum load in electro-acupuncture group and model group were significantly lower than that in the blank control group (P < 0.05).At 4 and 8 weeks after the operation, the maximum pull load was significantly greater in electro-acupuncture group than in the model group (P < 0.05).

CONCLUSIONS

Electro-acupuncture treatment not only effectively reduces the expression of inflammatory factors to relieve pain, but also promotes the repair of damaged tissue to improve the biomechanical properties of rotator cuff in the rat models.

Corticosteroid and Local Anesthetic Use Trends for Large Joint and Bursa Injections: Results of a Survey of Sports Medicine Physicians

BACKGROUND

Physician decision-making surrounding choices for large joint and bursa injections is poorly defined, yet influences patient safety and treatment effectiveness.

OBJECTIVE

To identify practice patterns and rationale related to injectate choices for large joint and bursal injections performed by physician members of the American Medical Society for Sports Medicine (AMSSM).

DESIGN

An electronic survey was sent to 3400 members of the AMSSM. Demographic variables were collected: primary specialty (residency), training location, practice location, years of clinical experience, current practice type, and rationale for choosing an injectate.

PARTICIPANTS

A total of 674 physicians responded (minimum response rate of 20%).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Outcomes of interest included corticosteroid type and dose, local anesthetic type, and total injectate volume for each large joint or bursa (hip, knee, and shoulder).

RESULTS

Most respondents used triamcinolone (50% to 56% of physicians, depending on injection location) or methylprednisolone (25% to 29% of physicians), 21 to 40 mg (53% to 60% of physicians), diluted with lidocaine (79% to 87%) for all large joint or bursa injections. It was noted that 36.2% (244/674) of respondents reported using >40 mg for at least one injection type. Most (90.5%, 610/674) reported using an anesthetic other than ropivacaine for at least one type of joint or bursa injection. Physicians who reported lidocaine use were less likely to report that their injectate choice was based on the literature that they reviewed (odds ratio [OR] 0.41 [0.27-0.62], P < .001). Respondents predominantly used 5 to 7 mL of total injectate for all large joints or bursae (45% to 54% of respondents), except for the pes anserine bursa, where 3-4 mL was more common (51% of physicians).

CONCLUSIONS

It appears that triamcinolone and methylprednisolone are the most commonly used corticosteroids for sports medicine physicians; most physicians use 21 to 40 mg of corticosteroid for all injections, and lidocaine is the most-often used local anesthetic; very few use ropivacaine. Over one-third of respondents used high-dose (>40 mg triamcinolone or methylprednisolone) for at least one joint or bursa.

Ultrasound-guided versus palpation-guided corticosteroid injections for tendinosis of the long head of the biceps: A randomized comparative study

PURPOSE

To compare accuracy, patient discomfort, and clinical outcome of ultrasound-guided versus palpation-guided corticosteroid injections to the bicipital groove in patients with long head of biceps (LHB) tendinosis.

MATERIALS AND METHODS

Forty-four patients with primary LHB tendinosis were randomized into two groups (group A, n = 22; group B, n = 22). All patients underwent treatment with a single corticosteroid injection to the bicipital groove. Injections in group A were performed under ultrasound-guidance, while in group B using a palpation-guided technique. The duration of each procedure was recorded. To assess accuracy, ultrasound examination was performed in both groups after injection. Patient discomfort was evaluated with visual analogue scale (VAS) for pain. The clinical outcome was assessed comparing the VAS, the Single Assessment Numeric Evaluation (SANE) score and the QuickDASH score before treatment and after 4 weeks and 6 months.

RESULTS

The mean duration of the procedure was 64 ± 6.87 s in group A and 81.91 ± 8.42 s in group B (p < 0.001). Injection accuracy in group A was 100% and in group B 68.18%. Discomfort was lower in group A, as compared to group B (22.10 vs. 35.50; p < 0.001). Symptoms, as measured by VAS, SANE and QuickDASH scores, improved in both groups at 4 weeks and 6 months (p < 0.05). Superior clinical improvement was recorded in group A in both time points (p < 0.05).

CONCLUSIONS

Corticosteroid injections are an effective treatment for primary LHB tendinosis. Under ultrasound guidance, injections to the bicipital groove are faster and produce lower discomfort. Superior accuracy and clinical outcomes can be achieved using the ultrasound-guided technique.

LEVEL OF EVIDENCE

Level II; Prospective Randomized Comparative Study.

A comparison of the effectiveness of lateral versus posterior approach to shoulder injection in patients with subacromial impingement syndrome: A pragmatic randomized controlled trial

OBJECTIVE

The aim of the study was to determine the effectiveness of the lateral approach to subacromial injection, compared with the posterior approach, for the treatment of subacromial impingement syndrome.

METHOD

A pragmatic randomized controlled trial was carried out in an outpatient community musculoskeletal service. The sample comprised 80 adults, aged 18 years or over, with subacromial impingement syndrome. The intervention group received a single subacromial injection, using a 21-gauge green needle, of 40 mg/ml triamcinolone acetonide (Kenalog) and 4 ml 1% lignocaine using a lateral approach. The control group received identical treatment, with the exception that the injection was given using a posterior approach. The outcome measures were pain measured using 0-10 numerical pain scale and shoulder pain and disability index (SPADI) scores at 8 and 12 weeks' follow-up.

RESULT

A moderate but statistically and clinically significant difference in improvement in daytime pain (mean change in score) occurred in favour of the lateral group (mean = 4.0) compared with the posterior group (mean = 2.0) between weeks 0 and 8 (1.4 points [95% confidence interval 0.3, 2.6; p = 0.018]). However, there were no statistically significant differences between the groups in night-time pain, shoulder function and SPADI scores. There was a statistically and clinically significant difference (p = 0.001) within the groups for all clinical outcomes between weeks 0 and 8, and between weeks 0 and 12.

CONCLUSION

There were no significant differences in the treatments; however, both forms of treatment were associated with a significant improvement in shoulder pain, function and disability.

Screening of the cervical spine in subacromial shoulder pain: A systematic review

BACKGROUND

Subacromial shoulder pain is a common clinical presentation with much diagnostic uncertainty. Some of this uncertainty relates to the involvement of the cervical spine as a source or contribution to subacromial shoulder pain. Currently, there is no accepted method of screening of the cervical spine in the presence of subacromial shoulder pain, which risks patients receiving misguided and/or ineffective interventions.

OBJECTIVE

To evaluate approaches used to screen the cervical spine in patients with subacromial shoulder pain.

DESIGN

Systematic review of randomized controlled trials.

METHODS

Electronic searches of PEDro and MEDLINE to December 2016 were conducted. Randomized controlled trials evaluating the effectiveness of interventions within the current scope of physiotherapy comprising of adult patients complaining of subacromial shoulder pain were included. Data relating to the method of cervical spine screening were extracted and synthesized categorically.

RESULTS

One hundred and two studies were included. Twenty-six (25.5%) were categorized as "No method of screening undertaken or reported," 49 (48.0%) were categorized as "Localized cervical spine symptoms and/or radiculopathy/radicular pain," nine (8.8%) were categorized as "Cervical examination," two (2.0%) were categorized as "Manual testing," two (2.0%) were categorized as "History of cervical surgery," and 14 (13.7%) were categorized as using "Combined approaches."

CONCLUSION

Examination of the cervical spine in patients with subacromial shoulder pain is variable in randomized controlled trials. In many instances, no or minimal attempts to screen were undertaken or reported. This has potential research and management implications and further research is indicated to facilitate development of this aspect of examination.

The relationship between joint hypermobility and subacromial impingement syndrome and adhesive capsulitis of the shoulder

OBJECTIVE:

Joint hypermobility (JH) is a clinical condition in which the joints move beyond the expected physiological range of motion. JH can be accompanied by many musculoskeletal complaints. One of the common causes of musculoskeletal pain is shoulder pain. The aim of this study was to investigate the relationship between subacromial impingement syndrome (SAIS), shoulder adhesive capsulitis (AC), and JH in patients with shoulder pain.

METHODS:

Patients aged between 18 and 70 years who presented at the physical medicine and rehabilitation outpatient clinic and who were diagnosed with SAIS or AC in a clinical and physical examination were included in the study. Patients in the same age group without musculoskeletal system pain were included in a control group. All of the cases were assessed for hypermobility using the Beighton score for generalized joint hypermobility (GJH), and the revised 1998 Brighton criteria for benign joint hypermobility syndrome (BJHS).

RESULTS:

Of the 124 cases included in the study, 71 (57.3%) were female and 53 (42.7%) were male. There was no case of GJH in the AC group. There were 2 (4.50%) cases in the SAIS group and 3 (7.5%) in the control group. BJHS was found in 4 (10%) cases in the AC group, 6 (13.63%) in the SAIS group, and 2 (5%) cases in the control group. There was no statistically significant difference between groups in terms of JH (p>0.05). The Beighton scores of the AC group were statistically lower those of the control group (p<0.05).

CONCLUSION:

The results of this study indicated no significant difference between the SAIS group, the AC group, and the control group in terms of GJH and BJHS. The fact that Beighton scores were lower in the AC group than in the control group suggests that the probability of developing AC in those with JH may be lower.

Efficacy and Safety of Subacromial Corticosteroid Injection in Type 2 Diabetic Patients

Purpose

In type 2 diabetic patients affected by chronic shoulder pain, subacromial injection with corticosteroid could be an effective treatment. The aim of this study was to measure the risk-benefit ratio of this treatment.

Methods

Twenty patients with well-controlled diabetes were included in a prospective study. In a first preinjection phase, patients were asked to measure glycemia for 7 days, before breakfast and dinner, and then 2 hours after lunch and dinner. Baseline data including Constant Score (CS), Subjective Shoulder Value (SSV), and Numerical Rating Scale (NRS) for pain were collected. Patients were treated with subacromial injection with 40 mg of Methylprednisolone Acetate and 2 ml of Lidocaine. At discharge, patients were asked to remeasure glycemia for the following week.

Results

The overall pain improved and patients graded their shoulder as "greatly improved". At 30-day follow-up, the SSV and the CS improved, considering pain but not ROM. The average daily glycemia was 136 mg/dl before injection, 161 mg/dl the day of the injection (p<0.001), and 170 mg/dl one day after injection (p<0.001). Glycemia was not statistically different 3 days after injection.

Conclusion

Subacromial injection is an effective short-term treatment in type 2 diabetic patients affected by shoulder pain, but a closed follow-up is recommended in all these patients. This trial is registered with NCT03652480. The Protocol ID is SHOULDERDM2013.

Comparative Effectiveness of Injection Therapies in Rotator Cuff Tendinopathy: A Systematic Review, Pairwise and Network Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To compare the effectiveness of diverse injections in patients with rotator cuff tendinopathy using pairwise and network meta-analysis.

DATA SOURCES

PubMed, EMBASE, Scopus, and Cochrane Library were searched for studies published up to September 31, 2017.

STUDY SELECTION

We included all published or unpublished randomized controlled trials (RCTs) comparing diverse injections including corticosteroid, nonsteroidal anti-inflammatory drugs, hyaluronic acid, botulinum toxin, platelet-rich plasma (PRP), and prolotherapy in patients with rotator cuff tendinopathy. Among the 1495 records screened, 18 studies were included in the meta-analysis.

DATA EXTRACTION

The quality of RCTs was assessed with Cochrane Risk of Bias Tool by 2 independent raters. The primary outcome was pain reduction, and the secondary outcome was functional improvement.

DATA SYNTHESIS

Standardized mean difference (SMD) was used for pairwise and network meta-analysis. In pairwise meta-analysis, corticosteroid was more effective only in the short term in both pain reduction and functional improvement. Network meta-analysis indicated that prolotherapy significantly reduced pain compared with placebo in the long term (over 24wk; SMD: 2.63; 95% confidence interval [CI], 1.88-3.38); meanwhile PRP significantly improved shoulder function compared with placebo in the long term (over 24wk; SMD: 0.44; 95% CI, 0.05-0.84).

CONCLUSIONS

For patients with rotator cuff tendinopathy, corticosteroid plays a role in the short term (3-6wk) but not in long-term (over 24wk) pain reduction and functional improvement. By contrast, PRP and prolotherapy may yield better outcomes in the long term (over 24wk). On account of heterogeneity, interpreting these results with caution is warranted.

Injection Therapies for Rotator Cuff Disease

Rotator cuff disease affects a large proportion of the overall population and encompasses a wide spectrum of pathologies, including subacromial impingement, rotator cuff tendinopathy or tear, and calcific tendinitis. Various injection therapies have been used for the treatment of rotator cuff disease, including corticosteroid, prolotherapy, platelet-rich plasma, stem cells, and ultrasound-guided barbotage for calcific tendinitis. However, the existing evidence for these therapies remains controversial or sparse. Ultimately, improved understanding of the underlying structural and compositional deficiencies of the injured rotator cuff tissue is needed to identify the biological needs that can potentially be targeted with injection therapies.

Ultrasound guided versus landmark guided corticosteroid injection in patients with rotator cuff syndrome: Randomised controlled trial

OBJECTIVE

Impingement syndrome is the most common differential in a patient presenting to an orthopaedic OPD with shoulder pain. Impingement syndrome is often managed with subacromial corticosteroid injection, which can be instilled using either landmark guided (LMG) approach or with the assistance of ultrasound (US). This study was envisaged to enquire whether ultrasound assistance improves the accuracy, efficacy or safety profile of the injection.

METHODS

60 patients of rotator cuff syndrome underwent diagnostic ultrasound. They were randomly assigned to receive subacromial injection of 2 ml (40 mg/ml) methylprenisolone and 2 ml of 1% lignocaine combination either by US assistance (n = 30) or using LMG assistance (n = 30). The patients were evaluated before injection and on follow up visits at day 5, week 3, week 6 and 3rd month by a single assessor. The assessor was blinded of the treatment group to which patient belonged. Clinical assessment included demographic and clinical data, accuracy of injection, VAS (0-100) for pain, Constant score with goniometer evaluation of range of motion, patient's self assessment proforma and post injection side effects if any.

RESULTS

Initial demographic, clinical and US findings in the groups exhibited no significant differences. The accuracy of US guided injections (100%) was more when compared from LMG injection (93.3%). Both VAS and Constant score showed significant improvement following steroid injection up to 3 months of follow up. However the differences in the two groups were not significant suggesting comparable efficacy of the two approaches. (Mean VAS score decrease: 27.23 for US and 25.16 for LMG, p < 0.05: Mean constant score change: 14.73 for US and 15.00 for LMG, p < 0.05). The safety profile in both groups was comparable.

CONCLUSION

Although US guided injections have a higher accuracy of drug placement in the subacromial bursa, there is no difference in terms of clinical outcomes or safety profile of either of the method. Hence US guided injections seems to be unjustified, when compared to equally efficacious and cost effective LMG steroid injection.

Are corticosteroid injections more beneficial than anaesthetic injections alone in the management of rotator cuff-related shoulder pain? A systematic review

Objective

To compare the effectiveness of corticosteroid injections to local anaesthetic injections in the management of rotator cuff-related shoulder pain (RCRSP).

Design

Systematic review with best evidence synthesis.

Data sources

The Cochrane, PubMed, CINAHL Plus, PEDro and EMBASE electronic databases were searched (inception until 8 June 2017). Reference lists of included articles were also hand searched.

Eligibility criteria

Two reviewers independently evaluated eligibility. Randomised controlled trials (RCTs) were included if they compared subacromial injections of corticosteroid with anaesthetic injections. Two reviewers independently extracted data regarding short-term, midterm and long-term outcomes for pain, self-reported function, range of motion and patient-perceived improvement.

Results

Thirteen RCTs (n=1013) were included. Four trials (n=475) were judged as being at low risk of bias. Three studies of low risk of bias favoured the use of corticosteroid over anaesthetic-only injections in the short term (up to 8 weeks). There was strong evidence of no significant difference between injection types in midterm outcomes (12–26 weeks). There was limited evidence of no significant difference between injection types in long-term outcomes.

Conclusion

Corticosteroid injections may have a short-term benefit (up to 8 weeks) over local anaesthetic injections alone in the management of RCRSP. Beyond 8 weeks, there was no evidence to suggest a benefit of corticosteroid over local anaesthetic injections.

Trial registration number

PROSPERO CRD42016033161.

Effectiveness of Kinesiotaping and Subacromial Corticosteroid Injection in Shoulder Impingement Syndrome

OBJECTIVE

The aim of this study was to investigate whether kinesiotaping or subacromial corticosteroid injection provides additional benefit when used with nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with shoulder impingement syndrome.

DESIGN

Patients with shoulder impingement syndrome were divided into 3 groups as follows: NSAID group (n = 33), kinesiotaping group (kinesiotaping + NSAID) (n = 33), and injection group (subacromial corticosteroid injection + NSAID) (n = 33). Outcome measures including visual analog scale, shoulder ranges of motion, Shoulder Disability Questionnaire, and University of California-Los Angeles (UCLA) scale were evaluated before and after the treatment (fourth week).

RESULTS

A total of 99 patients (21 male and 78 female patients) were enrolled in this study. Demographic and baseline clinical characteristics of the groups (except for body mass index and visual analog scale at night, both P = 0.05) were similar between the groups (all P > 0.05). Clinical parameters were found to have improved in the 3 groups (all P < 0.001). While the kinesiotaping and injection groups showed similar improvements (all P > 0.05), each group had better outcome than did the NSAID group as regards pain (activity visual analog scale), ranges of motion, and Shoulder Disability Questionnaire and UCLA scale scores (all P < 0.05).

CONCLUSIONS

Addition of kinesiotaping or subacromial corticosteroid injection to NSAID treatment seems to have better/similar effectiveness in patients with shoulder impingement syndrome. Therefore, kinesiotaping might serve as an alternative treatment in case (injection of) corticosteroids are contraindicated.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES:: Upon completion of this article, the reader should be able to: (1) Delineate appropriate treatment options for shoulder impingement syndrome; (2) Identify treatment benefits of kinesiotaping and corticosteroid injections in shoulder impingement syndrome; and (3) Incorporate kinesiotaping and corticosteroid injections into the treatment plan for patients with shoulder impingement syndrome.

LEVEL

Advanced

ACCREDITATION

: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this activity for amaximumof 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

A Review of Systematic Reviews of the Effectiveness of Conservative Interventions for Rotator Cuff Tendinopathy

Background

Rotator cuff tendinopathy is common and a wide range of conservative interventions are currently used to treat this problem. The purpose of this review is to systematically review the systematic reviews that evaluate the effectiveness of conservative interventions for rotator cuff tendinopathy.

Methods

An electronic search of PEDro, MEDLINE and the Cochrane Library was undertaken and supplemented by hand and citation searching. The AMSTAR checklist was adopted for quality appraisal and a narrative synthesis was undertaken.

Results

Twenty-six systematic reviews were retrieved. Methodological quality was variable. Exercise and multimodal physiotherapy appear to confer superior outcomes over no treatment or placebo, although the clinical significance of these results remains unclear. Surgery does not confer an additional benefit over exercise alone or multimodal physiotherapy. Combining manual therapy with exercise is not currently supported, neither is the use of corticosteroid injections or acupuncture. Other commonly prescribed interventions lack evidence of effectiveness.

Conclusions

Exercise and multimodal physiotherapy might be effective interventions for rotator cuff tendinopathy, although the clinical significance of this effect is unclear. This interpretation is drawn from systematic reviews comprising mainly small randomized controlled trials that frequently measure outcome in a heterogeneous manner, limiting the strength of any conclusions.

Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis

BACKGROUND

The ability of injection of corticosteroids into the subacromial space to relieve pain ascribed to rotator cuff tendinosis is debated. The number of patients who have an injection before one gets relief beyond what a placebo provides is uncertain.

QUESTIONS/PURPOSES

We asked: (1) Do corticosteroid injections reduce pain in patients with rotator cuff tendinosis 3 months after injection, and if so, what is the number needed to treat (NNT)? (2) Are multiple injections better than one single injection with respect to pain reduction at 3 months?

METHODS

We systematically searched seven electronic databases for randomized controlled trials of corticosteroid injection for rotator cuff tendinosis compared with a placebo injection. Eligible studies had at least 10 adults and used pain intensity as an outcome measure. The Hedges's g as adjusted pooled standardized mean difference (SMD) (which expresses the size of the intervention effect in each study relative to the total variability observed among pooled studies) and NNT were calculated at assessment points less than 1 month, 1-2 months, and 2-3 months. The protocol of this study was registered at the international prospective register of systematic reviews. Eleven studies of 726 patients satisfied our criteria for data pooling. Three studies containing 292 patients used repeat injections. A random effects model was used owing to substantial heterogeneity among studies. The funnel plot indicated the possibility of some missing studies, but Orwin's fail-safe N and Duval and Tweedie's trim and fill suggested that missing studies would not significantly affect the results.

RESULTS

Corticosteroid injection did not reduce pain intensity in adult patients with rotator cuff tendinosis more than a placebo injection at the 3-month assessment. A small transient pain relief occurred at the assessment between 4 and 8 weeks with a SMD of 0.52 (range, 0.27-0.78) (p < 0.001). At least five patients must be treated for one patient's pain to be transiently reduced to no more than mild. Multiple injections were not found to be more effective than a single injection at any time.

CONCLUSIONS

Corticosteroid injections provide-at best-minimal transient pain relief in a small number of patients with rotator cuff tendinosis and cannot modify the natural course of the disease. Given the discomfort, cost, and potential to accelerate tendon degeneration associated with corticosteroids, they have limited appeal. Their wide use may be attributable to habit, underappreciation of the placebo effect, incentive to satisfy rather than discuss a patient's drive toward physical intervention, or for remuneration, rather than their utility.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Effect of corticosteroid injections versus physiotherapy on pain, shoulder range of motion and shoulder function in patients with subacromial impingement syndrome: A systematic review and meta-analysis

Background

Subacromial impingement syndrome (SIS) is one of the most common causes of shoulder pain. Limited research has been conducted into the efficacy of corticosteroid injections (CSIs) compared to physiotherapy in the management of SIS.

Objective

To critically appraise and establish the best available evidence for the effectiveness of CSI in comparison with physiotherapy for the management of pain, shoulder range of motion (ROM) and shoulder function in patients with SIS.

Methodology

Seven databases were searched from inception to February 2016, namely PubMed, Science Direct, EBSCO Host: SPORTDiscus, EBSCO Host: CINAHL, Cochrane, Scopus and PEDro. The main search terms were shoulder impingement syndrome and/or subacromial impingement syndrome, corticosteroid injections and/or steroid injections, physical therapy and/or physiotherapy. Only randomised controlled trials (RCTs) were considered for inclusion. The articles were appraised according to the PEDro scale. The Revman^© Review Manager Software was used to combine the results of shoulder function and the data were illustrated in forest plots.

Results

The PEDro scores of the three RCTs that qualified for this review ranged from 7 to 8/10. There is Level II evidence suggesting that besides a significant improvement in shoulder function in favour of CSI at 6–7 weeks follow-up (p < 0.0001), no evidence was found for the superiority of CSIs compared with physiotherapy for pain, ROM and shoulder function in the short- (1–3 months), mid- (6 months) and long term (12 months).

Conclusion

In patients with SIS only a short term significant improvement in shoulder function was found in favour of CSIs.

Local anesthetic injections with or without steroid for chronic non-cancer pain: a protocol for a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Steroids are often combined with local anesthetic (LA) and injected to reduce pain associated with various chronic non-cancer pain (CNCP) complaints. The biological rationale behind injection of a steroid solution is unclear, and it is uncertain whether the addition of steroids offers any additional benefits over injection of LA alone. We propose to conduct a systematic review and meta-analysis to summarize the evidence for using steroids and LA vs. LA alone in the treatment of CNCP.

METHODS

An experienced librarian will perform a comprehensive search of EMBASE, MEDLINE, and the Cochrane Central Registry of Controlled Trials (CENTRAL) databases with search terms for clinical indications, LA, and steroid agents. We will review bibliographies of all relevant published reviews in the last 5 years for additional studies. Eligible trials will be published in English and randomly allocate patients with CNCP to treatment with steroid and LA injection therapy or injection with LA alone. We will use the guidelines published by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) to inform the outcomes that we collect and present. Teams of reviewers will independently and in duplicate assess trial eligibility, abstract data, and assess risk of bias among eligible trials. We will prioritize intention to treat analysis and, when possible, pool outcomes across trials using random effects models. We will report our findings as risk differences, weighted mean differences, or standardized mean differences for individual outcomes. Further, to ensure interpretability of our results, we will present risk differences and measures of relative effect for pain reduction based on anchor-based minimally important clinical differences. We will conduct a priori defined subgroup analyses and use the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to evaluate the certainty of the evidence on an outcome-by-outcome basis.

DISCUSSION

Our review will evaluate both the effectiveness and the adverse events associated with steroid plus LA vs. LA alone for CNCP, evaluate the quality of the evidence using the GRADE approach, and prioritize patient-important outcomes guided by IMMPACT recommendations. Our results will facilitate evidence-based management of patients with chronic non-cancer pain and identify key areas for future research.

TRIAL REGISTRATION

PROSPERO CRD42015020614.

Rotator Cuff Tendinopathy: Navigating the Diagnosis-Management Conundrum

Synopsis The hallmark characteristics of rotator cuff (RC) tendinopathy are pain and weakness, experienced most commonly during shoulder external rotation and elevation. Assessment is complicated by nonspecific clinical tests and the poor correlation between structural failure and symptoms. As such, diagnosis is best reached by exclusion of other potential sources of symptoms. Symptomatic incidence and prevalence data currently cannot be determined with confidence, primarily as a consequence of a lack of diagnostic accuracy, as well as the uncertainty as to the location of symptoms. People with symptoms of RC tendinopathy should derive considerable comfort from research that consistently demonstrates improvement in symptoms with a well-structured and graduated exercise program. This improvement is equivalent to outcomes reported in surgical trials, with the additional generalized benefits of exercise, less sick leave, a faster return to work, and reduced costs to the health care system. This evidence covers the spectrum of conditions that include symptomatic RC tendinopathy and atraumatic partial- and full-thickness RC tears. The principles guiding exercise treatment for RC tendinopathy include relative rest, modification of painful activities, an exercise strategy that initially does not exacerbate pain, controlled reloading, and gradual progression from simple to complex shoulder movements. Evidence also exists for a specific exercise program being beneficial for people with massive inoperable tears of the RC. Education is an essential component of rehabilitation, and attention to lifestyle factors (smoking cessation, nutrition, stress, and sleep management) may enhance outcomes. Outcomes may also be enhanced by subgrouping RC tendinopathy presentations and directing treatment strategies according to the clinical presentation and the patient's response to shoulder symptom modification procedures outlined herein. There are substantial deficits in our knowledge regarding RC tendinopathy that need to be addressed to further improve clinical outcomes. J Orthop Sports Phys Ther 2015;45(11):923-937. Epub 21 Sep 2015. doi:10.2519/jospt.2015.5941.

Perspectives in ultrasound-guided musculoskeletal interventions

Ultrasonography (USG) is a safe, easily available, and cost-effective modality, which has the additional advantage of being real time for imaging and image-guided interventions of the musculoskeletal system. Musculoskeletal interventions are gaining popularity in sports and rehabilitation for rapid healing of muscle and tendon injuries in professional athletes, healing of chronic tendinopathies, aspiration of joint effusions, periarticular bursae and ganglia, and perineural injections in acute and chronic pain syndromes. This article aims to provide an overview of the spectrum of musculoskeletal interventions that can be done under USG guidance both for diagnostic and therapeutic purposes.

Treatments for shoulder impingement syndrome: a PRISMA systematic review and network meta-analysis

Many treatments for shoulder impingement syndrome (SIS) are available in clinical practice; some of which have already been compared with other treatments by various investigators. However, a comprehensive treatment comparison is lacking. Several widely used electronic databases were searched for eligible studies. The outcome measurements were the pain score and the Constant-Murley score (CMS). Direct comparisons were performed using the conventional pair-wise meta-analysis method, while a network meta-analysis based on the Bayesian model was used to calculate the results of all potentially possible comparisons and rank probabilities. Included in the meta-analysis procedure were 33 randomized controlled trials involving 2300 patients. Good agreement was demonstrated between the results of the pair-wise meta-analyses and the network meta-analyses. Regarding nonoperative treatments, with respect to the pain score, combined treatments composed of exercise and other therapies tended to yield better effects than single-intervention therapies. Localized drug injections that were combined with exercise showed better treatment effects than any other treatments, whereas worse effects were observed when such injections were used alone. Regarding the CMS, most combined treatments based on exercise also demonstrated better effects than exercise alone. Regarding surgical treatments, according to the pain score and the CMS, arthroscopic subacromial decompression (ASD) together with treatments derived from it, such as ASD combined with radiofrequency and arthroscopic bursectomy, showed better effects than open subacromial decompression (OSD) and OSD combined with the injection of platelet-leukocyte gel. Exercise therapy also demonstrated good performance. Results for inconsistency, sensitivity analysis, and meta-regression all supported the robustness and reliability of these network meta-analyses. Exercise and other exercise-based therapies, such as kinesio taping, specific exercises, and acupuncture, are ideal treatments for patients at an early stage of SIS. However, low-level laser therapy and the localized injection of nonsteroidal anti-inflammatory drugs are not recommended. For patients who have a long-term disease course, operative treatments may be considered, with standard ASD surgery preferred over arthroscopic bursectomy and the open surgical technique for subacromial decompression. Notwithstanding, the choice of surgery should be made cautiously because similar outcomes may also be achieved by the implementation of exercise therapy.

Low-level laser and local corticosteroid injection in the treatment of subacromial impingement syndrome: a controlled clinical trial

Objective:

To investigate the effectiveness of low-level laser treatment and local corticosteroid injection in patients with subacromial impingement syndrome.

Design:

Controlled clinical trial.

Setting:

Physical Medicine and Rehabilitation outpatient clinic.

Subjects:

One hundred thirty-five patients with subacromial impingement syndrome.

Intervention:

The patients were allocated to three groups: local corticosteroid injection (group I); sham laser treatment (group II); and low-level laser treatment (group III). Low-level laser treatment was performed three times per week for a total of nine sessions. Local corticosteroid injections were administered twice, with an interval of 10 days between each. The patients were assessed at pre-treatment, post-treatment and three and six months after the first visit.

Main measures:

The primary outcome of the study was pain intensity (visual analog scale) during activity and at rest. The secondary outcomes were, shoulder functional status and quality of life measured by the University of California at Los Angeles rating score (UCLA) and Nottingham Health Profile (NHP) scale respectively.

Results:

Significant differences were observed between groups I and II and between groups II and III regarding pain during activity and at rest scores at all of the visits ( p<0.05). Nevertheless, significant improvement was observed between groups I and III regarding pain during activity only at post-treatment ( p=0.013). The UCLA scores were significantly changed in all three study groups at all of the visits ( p<0.05).

Conclusion:

The effectiveness of low-level laser treatment was similar to that of local corticosteroid injection in patients with subacromial impingement syndrome. We concluded that both low-level laser treatment and corticosteroid injection were more effective than sham laser treatment.

Corticosteroids injection in rotator cuff tears in elderly patient: pain outcome prediction

AIM

The aim of this prospective study was to evaluate the effect of corticosteroids intra-articular injections on pain in patients with rotator cuff tear (RCT), and to identify predictors for pain outcomes.

METHODS

A total of 60 patients with RCT were enrolled. All patients underwent rehabilitation; 20 patients received a single intra-articular injection of 40 mg triamcinolone acetonide and 20 patients had a repeat injection at a 21-day interval. Backward stepwise regression analysis was used to predict effectiveness and improvement of pain. The independent variables were age, sex, symptom duration, tear size, passive range of motion (ROM), active ROM, non-steroidal anti-inflammatory drugs request, pain at rest, number of triamcinolone injections and severity of osteoarthritis at admission.

RESULTS

At 3 and 6 months, patients who received triamcinolone had higher effectiveness and improvement in pain during activities and pain at night than those of control group. At the 3-month interval post-therapy, active ROM was the only predictor for effectiveness in pain during activity, effectiveness in pain at night and improvement in pain at night. Six months after therapy, active ROM was a predictor for improvement in pain at night. Age was a predictor for effectiveness in pain at night, whereas tear size of RCT was a predictor for effectiveness and improvement in pain during activity.

CONCLUSIONS

Corticosteroids can relieve pain in RCT. Active ROM is the most important predictor of pain outcomes. This finding can be useful to physicians when deciding on the type of patients who might best benefit from intra-articular injections of corticosteroids.

Predictors of success of corticosteroid injection for the management of rotator cuff disease

BACKGROUND

The use of subacromial corticosteroid injection (CSI) to treat rotator cuff tendinopathy is controversial. We hypothesized that characteristics such as activity level, American Shoulder and Elbow Surgeons (ASES) score, duration of symptoms, and status of the rotator cuff may be prognostic factors for resolution of symptoms postinjection.

METHODS

During a 12-month period, consecutive patients with rotator cuff disease were analyzed. Patients received subacromial CSI, oral NSAIDs, and physical therapy. Baseline ASES score, simple shoulder test, an activity scale, and demographic data were recorded. Patients who remained symptomatic and were indicated for surgery were considered failures. Patients that did not undergo surgery were reassessed after a minimum of 1 year.

RESULTS

Forty-nine patients met our criteria. Follow-up was obtained for 81.6%. Sixteen cases (40%) failed conservative treatment at final follow-up (22.4 ± 11 months). CSI were successful in 76.2% of males and 45% of females (p = 0.04). Full-thickness tears were present in 8% of the patients with symptom resolution and 25% of those that failed conservative treatment (p = 0.29). No significant difference was found in age, hand dominance, duration of symptoms, or any of the scoring systems.

CONCLUSION

It is difficult to predict outcomes after CSI. Our treatment strategy showed a 40% failure rate.

Subacromial impingement syndrome: effectiveness of pharmaceutical interventions-nonsteroidal anti-inflammatory drugs, corticosteroid, or other injections: a systematic review

OBJECTIVE

To present an evidence-based overview of the effectiveness of pharmaceutical interventions, including nonsteroidal anti-inflammatory drugs, corticosteroid injections, and other injections, used to treat the subacromial impingement syndrome (SIS). An overview can help physicians select the most appropriate pharmaceutical intervention, and it can identify gaps in scientific knowledge.

DATA SOURCES

The Cochrane Library, PubMed, Embase, PEDro, and CINAHL databases.

STUDY SELECTION

Two reviewers independently selected relevant reviews and randomized clinical trials.

DATA EXTRACTION

Two reviewers independently extracted the data and assessed the methodologic quality.

DATA SYNTHESIS

A best evidence synthesis was used to summarize the results. Three reviews and 5 randomized clinical trials were included. Although we found limited evidence for effectiveness in favor of 2 sessions with corticosteroid injections versus 1 session, for the effectiveness of corticosteroid injections versus placebo, nonsteroidal anti-inflammatory drugs, or acupuncture, only conflicting and no evidence for effectiveness was found. Moderate evidence was found in favor of immediate release oral ibuprofen compared with sustained-released ibuprofen in the short-term. Also, moderate evidence for effectiveness was found in favor of glyceryltrinitrate patches versus placebo patches in the short-term and mid term. Furthermore, injections with disodium ethylene diamine tetraacetic acid plus ultrasound with ethylene diamine tetraacetic acid gel were more effective (moderate evidence) than was placebo treatment in the short- and long-term.

CONCLUSIONS

This article presents an overview of the effectiveness of pharmaceutical interventions for SIS. Some treatments seem to be promising (moderate evidence) to treat SIS, but more research is needed before firm conclusions can be drawn.

The effectiveness of injections of hyaluronic acid or corticosteroid in patients with subacromial impingement

A total of 159 patients (84 women and 75 men, mean age of 53 (20 to 87)) with subacromial impingement were randomised to treatment with subacromial injections using lidocaine with one of hyaluronic acid (51 patients), corticosteroid (53 patients) or placebo (55 patients). Patients were followed up for 26 weeks. The primary outcome was pain on a visual analogue score (VAS), and secondary outcomes included the Constant Murley score, shoulder pain score, functional mobility score, shoulder disability questionnaire and pain-specific disability score. The different outcome measures showed similar results. After three, six and 12 weeks corticosteroid injections were superior to hyaluronic acid injections and only at six weeks significantly better than placebo injections. The mean short-term reduction in pain on the VAS score at 12 weeks was 7% (sd 2.7; 97.5% confidence interval (CI) 0.207 to 1.55; p = 0.084) in the hyaluronic acid group, 28% (sd 2.8; 97.5% CI 1.86 to 3.65; p < 0.001) in the corticosteroid group and 23% (sd 3.23; 97.5% CI 1.25 to 3.26; p < 0.001) in the placebo group. At 26 weeks there was a reduction in pain in 63% (32 of 51) of patients in the hyaluronic acid group, 72% (38 of 53) of those in the corticosteroid group and 69% (38 of 55) of those in the placebo group.

We were not able to show a convincing benefit from hyaluronic acid injections compared with corticosteroid or placebo injections. Corticosteroid injections produced a significant reduction in pain in the short term (three to 12 weeks), but in the long term the placebo injection produced the best results.

Subjective rating of perceived back pain, stiffness and sleep quality following introduction of medium-firm bedding systems

PURPOSE

To compare personal and new bedding systems between subjects with reported high and low base line sleep quality.

METHODS

A convenience sample of healthy subjects (women = 30; men = 29) with no clinical history of disturbed sleep participated in the study. Subjects recorded perceived back discomfort and stiffness, sleep quality and comfort, and sleep efficiency upon waking for 28 consecutive days in their own beds (baseline) and for 28 consecutive days (post) on a new bedding system. Repeated measures analysis of variance was used to treat sleep data.

RESULTS

Analysis revealed significant differences between pre- and post means in all areas for both high and low sleep quality groups. Analysis of sleep efficiency also yielded significant differences between, but not among pre- and post means. Improvement of sleep comfort and quality became more prominent with time (from wk 1 to 4 post observation).

CONCLUSIONS

Similar significant benefits of new, medium- firm bedding systems can occur for those reporting both good and poor current sleep quality and variables such as age, weight, height, and body mass index are independent of such improvements.

Retrospective comparison of freehand and ultrasound-guided shoulder steroid injections

The objective of this study was to assess the clinical benefits and financial feasibility of using ultrasound for steroid injections of the shoulder. A retrospective chart review and telephone survey of patients in a clinical shoulder practice were performed. ICD-9 codes and CPT codes identified patients who received shoulder injections without (2006) and with (2007) ultrasound guidance during 2 consecutive years. Results were assessed by patient assessment of relief and duration of that relief via telephone survey or from chart review. Financial data was assessed by reviewing the patients' accounts. One hundred fifty-seven injections were given in 2006 and 159 in 2007. In 2006, 126 unique patients were injected compared to 99 unique patients in 2007 (P<.001). Clinical data was collected on 272 patients (86.1%). Ultrasound had no significant effect on the amount of pain relief following injection (P=.468). One hundred thirty-six patients (50.0%) reported significant pain relief, 72 (26.5%) reported moderate, 39 (14.3%) reported mild, and 25 (9.2%) reported no pain relief following injection. During both years, 92.4% of patients had subacromial injections with no significant difference in injection sites (subacromial vs glenohumeral) between the 2 years (P=.252). Neither the injection site (subacromial or glenohumeral, P=.152) nor diagnosis (P=.540) had a significant effect on pain relief. Financial collections from injections increased as expected due to the use of ultrasound.Ultrasound guidance did not change the efficacy of steroid injections, the number of injections, or the type of injections. Steroid injections are useful for managing pain in several shoulder conditions and ultrasound guidance may not be necessary.