Musculoskeletal Injections: A Review of the EvidenceApplies to the following strengths: The intra articular steroid injection dosage at Drugs. Always trenbolone acetate ?? your doctor or pharmacist. Doses should be individualized based on the disease and lesion being treated Intra-Articular IA Administration: Every 3 to 4 weeks; injection should be as infrequent as possible to avoid possible joint destruction Periarticular Injection: Use care to ensure injection into tendon sheath rather than tendon substance -Epicondylitis: May treat by infiltrating into area of greatest tenderness Comments:
Musculoskeletal Injections: A Review of the Evidence - American Family Physician
Conaghan; Clinical effectiveness and dose response of image-guided intra-articular corticosteroid injection for hip osteoarthritis, Rheumatology , Volume 46, Issue 2, 1 February , Pages —, https: To assess symptomatic change after intra-articular corticosteroid IAST injection at 2 doses in hip osteoarthritis OA , and to examine dose response and predictors of response. WOMAC scores, body mass index BMI , conventional radiographic grade Kellgren and Lawrence scoring and ultrasound measures including capsular thickness and osteophyte assessments were recorded at baseline.
Change in WOMAC scores from baseline to weeks 6 and 12 were calculated for each dose and then dose comparisons were made. Imaging findings did not relate to severity of symptoms or response to IAST. Comparison of the two dose groups provided some evidence of a dose response.
Intra-articular corticosteroid IAST injection is a commonly recommended pharmacological treatment in the medical management of large joint osteoarthritis OA although a specific dose is not advised [ 1—3 ]. However, the majority of series evaluating this treatment have addressed its effectiveness in knee OA, which may be because intra-articular injection of this joint can be performed easily and safely in the outpatient clinic [ 4—6 ]. There have been relatively few studies in hip OA, where anatomical landmarks are less reliable.
Therefore, radiology input is usually required to perform hip injection under image guidance to ensure appropriate intra-articular placement [ 3 , 7—9 ]. Importantly, clinical or imaging predictors of response to injection have also not been clearly identified [ 4 , 5 , 7 ]. One study has shown that atrophic hip radiograph appearances correlate with a poor response, while other authors believe synovitis or joint effusion should improve the chance of response to injection [ 3 , 4 , 7 ].
The aim of this study was to investigate and compare two cohorts of patients with hip OA referred for image-guided IAST injection. The study aimed to monitor response by evaluating patient pain, stiffness and disability and also investigate if response was related to dose, imaging or demographic features. All patients gave informed consent prior to entry into the study and injection treatment.
All patients were referred by orthopedic surgeons and rheumatologists with a clinical diagnosis of hip OA and symptoms greater than 4 months duration.
Patients with a previous history of inflammatory arthritis or intra-articular injection within the previous 16 weeks were excluded. Prior to injection a conventional radiograph was taken and graded 0—4 by an experienced musculoskeletal radiologist using the system of Kellgren—Lawrence K-L [ 11 ]. An assessment of intra-observer reproducibility was made with a second reading, using a random sample of 30 radiographs, at least 6 months after the original scoring.
Ultrasound Sonosite , Sonosite Inc. The maximal anterior capsular thickness in millimeters was measured in the longitudinal plane of the femoral neck from the anterior femoral cortex to the outer margin of the capsule [ 12 ].
The capsule was also assessed by colour power Doppler for blood flow recorded as absent or present [ 13 ]. The presence of a hip effusion was defined as hypoechoic or anechoic fluid along the femoral neck deep to the capsule and was recorded as present or absent.
Iliopsoas bursal fluid was defined as fluid associated with the iliopsoas tendon and was recorded as present or absent. An additional semi-quantitative assessment of the degree of capsular thickness and anterior femoral head osteophytes was made and scored as normal 0 , mild 1 , moderate 2 or severe 3 abnormality Fig. An assessment of intra-observer reproducibility was made with a second reading, using a random sample of 12 ultrasound images, at least 6 months after the original scoring.
Ultrasound scoring system for anterior capsular thickness: All patients underwent fluoroscopically guided injection of the hip using an anterior approach and a gauge spinal needle with the patient in a supine position. All patients were blinded to the steroid dose injected. All WOMACs were administered by research assistants who were blinded to steroid dose and imaging assessment.
WOMAC has been designed for use in knee and hip OA populations [ 10 ] and has demonstrated appropriate construct validity [ 14 ], reliability [ 15 , 16 ] and responsiveness to change [ 14 , 17 , 18 ]. It has been commonly used in OA clinical trials [ 19—22 ] and has been validated for administration by telephone [ 23 ]. Data was explored and evaluated for parametric and non-parametric analysis. Those patients lost to follow-up were recorded but not included in the statistical analysis.
WOMAC raw scores were evaluated for their distribution using visual inspection and statistical testing Kolmogorov—Smirnov test and found to be significantly skewed. Differences between doses were analysed using the chi-square test. Patients were also categorized into two groups based on ultrasound capsular thickness grading and compared with WOMAC scores: The aim of this strategy was to take factors that were found to be statistically significant in the univariate analyses, or those that had been reported to be of significance in the literature, and then enter these into a forward, stepwise, logistical regression model.
The baseline characteristics of subjects from both phases of the study are demonstrated in Table 1. Looking at the combined cohorts, conventional radiograph and ultrasound scores did not correlate with baseline WOMAC scores. No fluid was aspirated from any of the hip joints. Joint effusion, iliopsoas bursa and capsular vascularity on power Doppler were absent in all cases. To account for these differences, dose effects were compared using percentage change from baseline rather than raw scores for the WOMAC domains for the dose—response data.
The median percentage change from baseline to week 6 pain scores was While there was an improvement in each group for the stiffness domain at week 6 Fig. There were no significant differences between the doses at either time point. Forty three of the 75 The baseline characteristics of the responders and the non-responders are presented in Table 3.
The only difference between responders and non-responders at week 6 was BMI: However, with Bonferronni corrections, this difference was not considered significant.
At week 12, while the non-responders tended to have a higher BMI, this did not reach statistical significance. While the responders appeared to have less severe imaging findings lower K-L score compared with the non-responders at week 12, this was not statistically significant.
While the limitations of this pragmatic, clinical study need to be acknowledged, this study informs an area that has had only limited previous research.
Previous studies of IAST injection in knee and hip OA have shown a very limited response in terms of pain reduction [ 2 ]. Evaluation of knee OA studies has demonstrated significant reductions in visual analogue pain scores of 3—6 weeks duration [ 4—6 ]. However, statistical evaluation was not presented and there was potential for bias as patients were told they would be fast-tracked for hip replacement surgery if they had a poor response [ 8 ]. There are very few studies evaluating the effect of IAST on hip function.
One study that compared steroid and anesthetic injection also assessed hip range of motion by physiotherapist examination and function on a semi-quantitative scale [ 9 ]. Range of movement was only assessed once after injection 3 weeks but showed a significant improvement in the steroid group compared with baseline. Functional assessment showed a statistically significant improvement in only the steroid group at 3 and 12 weeks [ 9 ]. Another study of steroid injection including 27 patients with OA measured hip range of motion by goniometer and function using a self developed questionnaire [ 7 ].
Internal rotation was significantly improved at 2 weeks but was no longer significant at 12 weeks. There was no significant improvement in the function scores at any point. Radiographic severity does not seem to correlate with symptoms or response although atrophic radiographic appearances in the hip may indicate a poor response to injection [ 5 , 7 ]. A letter reviewing patients with hip OA described a poor response in patients with severe radiographic changes.
However, statistical evaluation was not presented and outcome was assessed by the patient stating if the pain had or had not improved 8 weeks after injection [ 26 ]. In this current series, radiographic severity did not correlate with the severity of symptoms or with any of the outcome measures evaluated.
Although IAST injection is recommended for both inflammatory and mechanical arthritides, it might seem more intuitive that it should be effective where there is more synovial inflammation [ 1 , 2 ]. Certainly, synovitis is a common component of the whole-organ damage seen in OA, and steroids have a beneficial effect in reducing this [ 3 , 27 , 28 ]. The fact that previous studies have not defined predictors of response to injection may be due to lack of definition of what constituted response, lack of sustained symptomatic response or the absence of significant inflammation.
There are conflicting reports on whether clinical signs of inflammation can predict response to injection [ 4 , 5 ].
Ultrasound was performed in all patients and evaluated anterior osteophytes, joint effusion and capsular Doppler signal as well as grading and measuring capsular thickness. A previous study showed increased hip capsule vascularity on Doppler correlated with vascularity on histological examination [ 29 ]. The patients studied included those with a diagnosis of rheumatoid arthritis, and higher scores were seen in this group.
We hypothesized that increased capsular thickness on ultrasound may have been an indicator of chronic synovitis but no effusions or increased vascularity on Doppler were detected in association with this feature.
However, anterior capsular thickening and the other ultrasound features which may have indicated cartilage damage osteophytes also showed no correlation with response or severity of symptoms. The result of this study must be considered in light of its limitations. This study was a pragmatic, cohort study, where patients were not randomized to treatment nor was the clinician blinded to the treatment dose.
Certainly, a limitation of this study was the lack of a placebo group; however, this was not considered ethical as the patients would have required fluoroscopic exposure as well as injection to remain truly blinded. While the attrition rate within the two arms of the study was consistent between each of the two groups, we did not attempt to include those lost to follow-up in the analysis.
While it is possible to undertake statistical modelling to estimate the profile of such people, we considered this to be inappropriate in an observational study of this size.
Clearly the profile of such patients needs further consideration. Indeed, one of the main conclusions to be drawn from this study is that further research, including a double-blinded, randomized control trial is necessary in order to address the limitations associated with this pragmatic trial method.
The duration of follow-up in our patient group was relatively short; however, the previous literature had not demonstrated any benefit past 12 weeks. Only one other study has assessed patients for a longer duration but this involved a considerably smaller series 30 patients for 26 weeks [ 7 ]. Another limitation was that image assessment was conducted by a single observer. As well, the ultrasound system employed here had a relatively low flow sensitivity compared with Doppler evaluation by larger systems, and may have been insensitive to low levels of inflammation.
No imaging ultrasound or radiographic features predicted response. Although many radiologists utilize this treatment in OA, the results of this study provide some evidence for steroid dose selection and provide evidence for the limited duration of response.
Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Close mobile search navigation Article navigation. Clinical effectiveness and dose response of image-guided intra-articular corticosteroid injection for hip osteoarthritis P. Rheumatology , Volume 46, Issue 2, 1 February , Pages —, https: Osteoarthritis , Hip , Corticosteroid , Radiography , Ultrasound.
View large Download slide. Baseline characteristics for responders vs non-responders group. Recommendations for the medical management of osteoarthritis of the hip and knee: