introductions
DESCRIPTION
Introductions. Learning outcomes for day. To apply knowledge of anatomy in needle placement of injections of the shoulder, knee and foot To understand the pharmacology of injectates To understand the current evidence base supporting the use of joint injections, and where evidence is lacking - PowerPoint PPT PresentationTRANSCRIPT
To apply knowledge of anatomy in needle placement of injections of the shoulder, knee and foot
To understand the pharmacology of injectates
To understand the current evidence base supporting the use of joint injections, and where evidence is lacking
To apply knowledge of the evidence in practical decision making regarding injections
To understand the indications for, and procedure of hydro dilation in adhesive capsulitis
Learning outcomes for day
1. What is it – define?2. Who gets it (M:F, age?) / what are the risk
factors3. How common is it?4. Typical clinical presentation5. What investigations are relevant and what
would they demonstrate?6. What is the management?
Frozen shoulder/ Adhesive Capsulitis
Arthritis Research UK Primary Care CentreWinner of the Queen’s Anniversary Prize For Higher and Further Education 2009
Evidence for Intra-articular Injections for RA, OA &
various Soft Tissue DiseasesDr Zoe Paskins
Clinical Lecturer and Honorary Consultant Rheumatologist
‘The conscientious, explicit and judicious use of current best evidence in making decisions
about the care of individual patients’. Sackett et al, BMJ 1996
Hollander Arthritis and Allied Conditions 1972
“…since…1951 we have administered intrasynovial injections of steroids over 250,000 times into more than 8,000 patients who had inflamed joints, bursae or tendon sheaths. The generally favourable response in symptomatology… has been confirmed in more than 100 reports in the literature.”
Treatment of rheumatoid joint inflammation with intrasynovial triamciniolone hexacetonide
McCarty et al J Rheumatol 1995;22:1631-5
Historical review 140 patients with RA 956 injections with Triamcinolone hexacetonide Joint immobilisation post injection
- eg crutch-walking for 4 weeks Mean follow up 7 years “Sustained clinical remission” in 75% of injected
joints Side effects: No infections; 2 tendon ruptures
Polyarticular corticosteroid injection versus systemic administration in treatment of RA patient
Furtado, Oliveira and Natour J Rheumatol 2005;32:1691-8
75 patients with RA Randomised to multiple concomitant IA
triamcinolone injections or equivalent IM dose (minimum 160mg)
Outcome- ACR improvement criteria at baseline 1,4,12,24
weeks- Any adverse effects
Furtado et al 2005IM group (%) IA group (%)
ACR 20 at 1 wk 10 21 *
ACR 20 at 4 wks
15 25 **
ACR 20 at 12 wks
12 16
ACR 50 at 1 wk 2 10 **
ACR 50 at 4 wks
7 15 *
ACR 50 at 12 wks
4 8Fewer side effects in IA group
Importance of synovial fluid aspiration when injecting intra-articular corticosteroids
Weitoft and Uddenfeldt Ann Rheum Dis 2000;59:233-235
147 patients (191 knees) with RA Patients randomised to arthrocentesis or no
arthrocentesis All were injected with triamcinolone Outcome: relapse of inflammation in the
injected joint
Efficacy of IACS in adult RA and JIA- 5 RCTs included IACS knee in adult RA- Concluded that effect on range of movement
(up to 12 weeks), pain, knee swelling (up to 6 weeks), morning stiffness.
- No harm identified - Effects appear to be dose dependant
Cochrane review Wallen and Gillies 2006
Retrospective case review of 220 patients Multiple (>3) IACS associated with
‘sustained joint remission in a substantial proportion of patients’
66% flared 33% remission post IAC
Papadopoulou et al, 2013 Arthritis Care Res
JIA
Joint Duration of improvement
Pain Function
Knee 2-3* -
Hip 8-12/52** 8
CMC 6/12*** (not RCT) 6/12
AC joint -
1st MTP -
OA: RCT evidence
*Bellamy et al, Cochrane 2005Atchia, Robinson, Qvistagard, ** Kullenberg 2004, Lambert 2007***Bahadir, 2009
OA: predictors of response of IACS
Effusion Synovitis Pain BMI Gender Illness beliefs Radiographic severity Age USGI
OA knee: predictors of response of IACS
Effusion Absence of Synovitis Pain BMI Gender Illness beliefs Radiographic severity Age USGI
Maricar, 2013
OA hip: predictors of response of IACS
Effusion Synovitis Pain Lower BMI Gender Illness beliefs Radiographic severity Age USGI
Atchia, 2011Robinson, 2007Desmukh, 2011
N = Small Different injectates, different doses Different controls Population of severe disease?
Limitations of Studies of IACS
Plantar fasciitis- USGI reduces pain at 4/52 (McMillan 2012)- Recommended in NICE CKS after conservative
treatment Achilles tendonitis
- 1: 40 rupture. Do not inject Tennis Elbow
- In patients with symptoms for >6/52, CSI resulted in higher rate of recurrence at 12/12 (Coombes 2013)
Soft Tissue
Does accuracy improve efficacy?- YES (Jones, 1993)
Does ultrasound improve accuracy?- YES*
Does ultrasound improve efficacy?- Yes, in some joints
- shoulders in RA, 6/52 pain and function (Naredo 2003)
Are USGI clinically effective? Are USGI cost effective?*although knee accuracy 87% unblinded
The evidence
Evidence based medicine uses the best available evidence
Systematic review/ RCTs do support the clinical effectiveness of IACS in RA, OA knee and hip
Caution with soft tissue injections for tennis elbow and achilles tendonitis.. poorer clinical outcomes
Summary