Glucocorticoid Injection Research Articles

Electrical Dry Needling Plus Corticosteroid Injection for Osteoarthritis of the Knee: A Randomized Controlled Trial

ObjectiveTo investigate the effects of electrical dry needling (DN) plus corticosteroid injection (CSI) on pain, physical function, and global change in patients with osteoarthritis of the knee (KOA). DesignA prospective, single-blinded, randomized controlled trial. SettingPain treatment clinic. ParticipantsSixty patients with KOA were randomly assigned to the electrical dry needling plus corticosteroid injection (electrical-DN+CSI) group or CSI group. InterventionsThe CSI group received glucocorticoid injection only once during the trial, and the electrical-DN+CSI group received glucocorticoid injection combined with 4 sessions of electrical-DN. Main Outcomes MeasuresThe primary outcome was the numerical rating scale at 3 months. The secondary outcomes were the Western Ontario and McMaster Universities Osteoarthritis Index, the time to complete the Timed Up and Go test, and the score of the global rating of change scale at 3 months. A generalized linear mixed-effects model was used to analyze the repeated measurement data. ResultsBaseline characteristics and measurements were similar in the 2 groups. The group by time interaction effect was significant for all variables (P<.05). The electrical-DN+CSI group obtained a more significant reduction in pain intensity and more significant improvement in dysfunction than the CSI group at 3 months (P<.05). The median global rating of change score for the CSI group was +3 (somewhat better), and that for the electrical-DN+CSI group was +4 (moderately better). ConclusionElectrical-DN therapy at myofascial trigger points combined with CSI is more effective at alleviating pain, improving dysfunction, and creating global change than CSI alone for patients with KOA. Electrical-DN may be an essential part of treatment for KOA rehabilitation.

Is image-guided glucocorticoid injection better than blind injection for shoulder pain? A Cochrane Review summary with commentary.

Is image-guided glucocorticoid injection better than blind injection for shoulder pain? A Cochrane Review summary with commentary.

Cost-effectiveness of Physical Therapy vs Intra-articular Glucocorticoid Injection for Knee Osteoarthritis

Physical therapy and glucocorticoid injections are initial treatment options for knee osteoarthritis, but available data indicate that most patients receive one or the other, suggesting they may be competing interventions. The initial cost difference for treatment can be substantial, with physical therapy often being more expensive at the outset, and cost-effectiveness analysis can aid patients and clinicians in making decisions. To investigate the incremental cost-effectiveness between physical therapy and intra-articular glucocorticoid injection as initial treatment strategies for knee osteoarthritis. This economic evaluation is a secondary analysis of a randomized clinical trial performed from October 1, 2012, to May 4, 2017. Health economists were blinded to study outcomes and treatment allocation. A randomized sample of patients seen in primary care and physical therapy clinics with a radiographically confirmed diagnosis of knee osteoarthritis were evaluated from the clinical trial with 96.2% follow-up at 1 year. Physical therapy or glucocorticoid injection. The main outcome was incremental cost-effectiveness between 2 alternative treatments. Acceptability curves of bootstrapped incremental cost-effectiveness ratios (ICERs) were used to identify the proportion of ICERs under the specific willingness-to-pay level ($50 000-$100 000). Health care system costs (total and knee related) and health-related quality-of-life based on quality-adjusted life-years (QALYs) were obtained. A total of 156 participants (mean [SD] age, 56.1 [8.7] years; 81 [51.9%] male) were randomized 1:1 and followed up for 1 year. Mean (SD) 1-year knee-related medical costs were $2113 ($4224) in the glucocorticoid injection group and $2131 ($1015) in the physical therapy group. The mean difference in QALY significantly favored physical therapy at 1 year (0.076; 95% CI, 0.02-0.126; P = .003). Physical therapy was the more cost-effective intervention, with an ICER of $8103 for knee-related medical costs, with a 99.2% probability that results fall below the willingness-to-pay threshold of $100 000. A course of physical therapy was cost-effective compared with a course of glucocorticoid injections for patients with knee osteoarthritis. These results suggest that, although the initial cost of delivering physical therapy may be higher than an initial course of glucocorticoid injections, 1-year total knee-related costs are equivalent, and greater improvement in QALYs may justify the initial higher costs. ClinicalTrials.gov Identifier: NCT01427153.

Drug levels, anti-drug antibodies and B-cell counts were not predictive of response in rheumatoid arthritis patients on (ultra-)low-dose rituximab.

The REDO trial (REtreatment with Rituximab in RhEumatoid arthritis: Disease Outcome after Dose Optimisation) showed that ultra-low-dose rituximab (500 mg or 200 mg) was similarly effective to a 1000 mg dosage in the majority of RA patients. This pre-planned secondary analysis investigated (1) associations between rituximab dosage, drug levels, anti-drug antibodies (ADAs) and B-cell counts and (2) the predictive value of pharmacokinetic and pharmacodynamic parameters, and of patient, disease and treatment characteristics in relation to response to ultra-low-dose rituximab. For 140 RA patients from the REDO trial, differences in drug levels, ADAs and B-cell counts were examined at baseline, and at 3 and 6 months after dosing. Treatment response was defined as absence of flare and no extra rituximab or >1 glucocorticoid injection received during follow-up. The association between potential predictors and response was investigated using logistic regression analyses. Lower doses of rituximab resulted in lower drug levels but did not significantly affect ADA levels or B-cell counts, and 3 (10.7%), 12 (20.7%) and 7 (13.0%) patients failed to meet the response criteria in, respectively, the 1000 mg, 500 mg and 200 mg dosage groups. Drug levels, ADAs, B-cell counts, and patient, disease and treatment characteristics were not predictive for response to ultra-low-dose rituximab. The results of this study further support the hypothesis that continued treatment with 500 or 200 mg rituximab is similarly effective to a 1000 mg dosage in RA patients doing well on rituximab. These results, combined with lack of finding a clinical dose-response relationship in the original REDO study, suggest that 200 mg rituximab is not yet the lowest effective rituximab retreatment dose in RA.

Comparative analysis of various modes of preconditioning to increase high altitude tolerance

Hypoxic preconditioning (HPC) represents an effective tool to increase high altitude tolerance but requires rather severe conditions of hypoxic interventions. We aim to investigate the possibility to reduce the intensity of the HPC factor without losing its effectiveness. Adult male rats were divided as follows: one group was subjected to severe hypoxia (SH); other groups before SH were treated with: three trials of HPC at 5,000 m “altitude” for 2 hours daily (originally proven effective mode); HPC with three trials at 5,000 m “altitude” for 1 hour; HPC with three trials at 3,500 m for 2 hours; HPC with one trial at 5,000 m for 2 hours; HPC with one trial at 5,000 m “altitude” for 2 hours on the background of glucocorticoid administration. In addition, the effects of the non-hypoxic preconditioning with two injections of sodium valproate (a histone deacetylase inhibitor) were studied in a separate group. The survival rate of animals, neuronal loss, neurological status, and behavioral and hormonal reactions were assessed. It was found that all tested modes improved the survival of the rats and their neurological status to a varying degree, but only one trial of HPC in combination with glucocorticoid injection was comparable in efficacy with the original mode of preconditioning proposed by us earlier and produced no side effects. Based on the experimental findings, we suggest a new effective mode of HPC based on a single exposure to the altitude of 5,000 m combined with an injection of dexamethasone.

2021 clinical practice guidelines for the diagnosis, treatment, and follow-up of patients with peripheral spondyloarthritis. Colombian Association of Rheumatology

BackgroundPeripheral spondyloarthritis is a chronic inflammatory disease in which clinical presentation is related to the presence of arthritis, enthesitis and/or dactylitis. This term is used interchangeably with some of its subtypes such as psoriatic arthritis, reactive arthritis, and undifferentiated spondyloarthritis. ObjectiveTo develop and formulate a set of specific recommendations based on the best available evidence for the diagnosis, treatment and monitoring of adult patients with peripheral spondyloarthritis. MethodsA working group was established, clinical questions were formulated, outcomes were graded, and a systematic search for evidence was conducted. The guideline panel was multidisciplinary (including patient representatives) and balanced. Following the formal expert consensus method, the GRADE methodology “Grading of Recommendations Assessment, Development and Evaluation” was used to assess the quality of the evidence and generate the recommendations. The Clinical Practice Guideline includes ten recommendations; related to monitoring of disease activity (n = 1) and treatment (n = 9). ResultsIn patients with peripheral spondyloarthritis, the use of methotrexate or sulfasalazine as the first line of treatment is suggested, and local injections of glucocorticoids is recommended conditionally. In patients with failure to cDMARDs, an anti TNFα or an anti IL17A is recommended. In case of failure to bDMARDs, it is suggested to use another bDMARD or JAK inhibitor. In patients with peripheral spondyloarthritis associated to inflammatory bowel disease, it is recommended to start treatment with cDMARDs; in the absence of response, the use of an anti TNFα over an anti-IL-17 or an anti-IL-12-23 is recommended as a second line of treatment. In patients with psoriatic arthritis, the combined use of methotrexate with bDMARD is conditionally recommended for optimization of dosing. To assess disease activity in Psoriatic Arthritis, the use of DAPSA or MDA is suggested for patient monitoring. ConclusionsThis set of recommendations provides an updated guide on the diagnosis and treatment of peripheral spondyloarthritis.

Analysis of Some Immunological Aspects of Joint Infections Developed as a Result of Intra-Articular Glucocorticoid Injection

Summary. The work is devoted to the studies of immune status of patients with infectious complications after local glucocorticoid injections.&#x0D; Objective: to assess the state of the immune system of patients with infectious complications after local glucocorticoid injections, to monitor the dynamics of immunological parameters before and after sanitizing surgical treatment, and to reveal factors that are important for predicting the course of the disease and treatment results.&#x0D; Materials and Methods. The immune status of 26 patients with purulent inflammatory processes after local glucocorticoid injections in rheumatoid arthritis, deforming osteoarthritis, and chronic synovitis was studied. Immunological, hematological, and statistical research methods were used.&#x0D; Results. Changes of immunity factors as well as hematological parameters were revealed: a decrease in the content of T-lymphocytes (CD3+), T-helpers (CD4+), T-suppressors / cytotoxic lymphocytes (CD8+), immunoglobulins of classes A, M, and G; an increase in the levels of circulating immune complexes (СIC), the number of thrombocytes, erythrocyte sedimentation rate (ESR), and the reaction of the neutrophil leukocytes. It has been shown that the improvement of the immune status and the decrease in the level of inflammatory reactions after the sanitizing surgical intervention occurs slowly, which requires the inclusion of immunocorrective therapy in the treatment of such patients.&#x0D; Conclusions. Primary examination of patients before surgery for the purpose of sanitizing the infection showed that the local inflammatory process in the bones and joints occurs against the background of altered immunological and hematological parameters. Dynamic follow-up showed that we are dealing not only with a local process, but also with a systemic inflammatory response. A variant of the laboratory criterion for the course of infectious complications and the effectiveness of the treatment can be the determination in the dynamics of the content of T-lymphocytes and their subpopulations, the levels of the CIC, platelets and ESR.

Intra-articular glucocorticoid injection site: best practice guidelines

The article presents modern recommendations for the use of systemic administration of glucocorticoids. It is indicated that there is a clear tendency to minimize the doses and timing of the appointment of systemic glucocorticoids in rheumatoid arthritis, and in seronegative spondyloarthropathies (ankylosing spondylitis, psoriatic arthritis), in accordance with both foreign and domestic recommendations, systemic therapy with glucocorticoids is not carried out. It is emphasized that at the present stage, the role of local administration of glucocorticoids will increase as an effective way to reduce the activity of arthritis in any nosologically form. The mechanisms of action of locally administered glucocorticoids leading to anti-inflammatory and analgesic effects are described. The comparative characteristics of locally administered glucocorticoids with different duration of action according to their effectiveness and safety are presented. Predictors of the effectiveness of local therapy with glucocorticoids are described. The data on the evaluation of the duration of the anti-inflammatory and analgesic effects of various local glucocorticoids, including in comparison with the intra-articular administration of hyaluronic acid preparations, which showed the advantages of betamethasone over triamcinolone acetate, are presented. The differences in the crystal structure of betamethasone and triamcinolone acetate are described. It is indicated that the 2.5-fold smaller size of betamethasone crystals compared to triamcinolone acetate crystals and the absence of betamethasone crystals makes it possible to use betamethasone in the treatment of inflammatory processes in periarticular tissues, as well as in crystalline arthritis (gout, pseudogout). The data on the safety of the use of intra-articular injection of glucocorticoids are presented. It is indicated that the registration in the Russian Federation of a new form of betamethasone in pre-filled syringes makes it even more possible to avoid infectious complications of this type of therapy. Rare cases of complications of local therapy with glucocorticoids are described.

Real-world experience of treating frozen shoulder using active manipulation under local anesthetic: A retrospective study.

Currently, there is limited evidence to guide treatment and no standard management guidelines exist for treating frozen shoulder (FS). A general management approach consists of initial evaluation, range of motion (ROM) exercises, intra-articular injection of glucocorticoid, home exercise program (HEP), and/or physical therapies. However, the general approach lacks detail and has limited evidence of its effectiveness. This retrospective cohort study evaluates the short-term recovery of near-full to full-ROM technique followed by an instructed HEP for strengthening and coordinating shoulder girdle muscle group for FS management. This study details our experiences following a general approach to managing FS and aims to fill this knowledge void, providing additional context of the efficacy of FS management in the real-world. Seven-two adult patients with FS (46 females, 26 males; mean age of 66; standard deviation of 15.1; range 23–87) from an orthopedic and physical medicine and sport medicine office between 2014 and 2018 were included in this study. Following general management of FS, patients received a glucocorticoid–lidocaine mixture injection administered to the respective shoulder at the glenohumeral joint space and/or subacromial separately. Immediately, patients underwent active manipulation of the affected shoulder in 3 directions: forward flexion, abduction, and extension in the sagittal plane. Lastly, patients were instructed to perform movements similar to the active manipulation protocol as a HEP. The abduction and forward flexion ROM showed significant improvements with the described protocol. Following treatment, there was a 90.20° and 77.33° increase in average shoulder abduction and forward flexion ROM, respectively (P < .05). The immediate goal of this protocol was to gain maximum ROM in different directions of shoulder mobility. Following the general management of FS, active manipulation under local anesthetic was a highly effective treatment modality for adhesive capsulitis that was time-saving and cost-effective.

A clinical model for predicting knee replacement in early-stage knee osteoarthritis: data from osteoarthritis initiative.

Knee osteoarthritis (OA) progresses in a heterogeneous way, as a majority of the patients gradually worsen over decades while some undergo rapid progression and require knee replacement. The aim of this study was to develop a predictive model that enables quantified risk prediction of future knee replacement in patients with early-stage knee OA. Patients with early-stage knee OA, intact MRI measurements, and a follow-up time larger than 108months were retrieved from the Osteoarthritis Initiative database. Twenty-five candidate predictors including demographic data, clinical outcomes, and radiographic parameters were selected. The presence or absence of knee replacement during the first 108months of the follow-up was regarded as the primary outcome. Patients were randomly divided into derivation and validation groups in the ratio of three to one. Nomograms were developed based on multivariable logistic regressions of derivation group via R language. Those models were further tested in the validation group for external validation. A total of 839 knees were enrolled, with 98 knees received knee replacement during the first 108months. Glucocorticoid injection history, knee OA in the contralateral side, extensor muscle strength, area of cartilage deficiency, bone marrow lesion, and meniscus extrusion were selected to develop the nomogram after multivariable logistic regression analysis. The bias-corrected C-index and AUC of our nomogram in the validation group were 0.804 and 0.822, respectively. Our predicting model provided simplified identification of patients with high risk of rapid progression in knee OA, which showed adequate predictive discrimination and calibration. • Knee OA progresses in a heterogeneous way and rises to a challenge when making treatment strategies. • Our predicting model provided simplified identification of patients with high risk of rapid progression in knee OA.

Repeated exposure with short-term behavioral stress resolves pre-existing stress-induced depressive-like behavior in mice

Chronic stress induces adaptive changes in the brain via the cumulative action of glucocorticoids, which is associated with mood disorders. Here we show that repeated daily five-minute restraint resolves pre-existing stress-induced depressive-like behavior in mice. Repeated injection of glucocorticoids in low doses mimics the anti-depressive effects of short-term stress. Repeated exposure to short-term stress and injection of glucocorticoids activate neurons in largely overlapping regions of the brain, as shown by c-Fos staining, and reverse distinct stress-induced gene expression profiles. Chemogenetic inhibition of neurons in the prelimbic cortex projecting to the nucleus accumbens, basolateral amygdala, or bed nucleus of the stria terminalis results in anti-depressive effects similarly to short-term stress exposure, while only inhibition of neurons in the prelimbic cortex projecting to the bed nucleus of the stria terminalis rescues defective glucocorticoid release. In summary, we show that short-term stress can reverse adaptively altered stress gains and resolve stress-induced depressive-like behavior.

Influence of Glucocorticoids on Cellular Senescence Hallmarks in Osteoarthritic Fibroblast-like Synoviocytes.

Osteoarthritis (OA) is recognized as being a cellular senescence-linked disease. Intra-articular injections of glucocorticoids (GC) are frequently used in knee OA to treat synovial effusion but face controversies about toxicity. We investigated the influence of GC on cellular senescence hallmarks and senescence induction in fibroblast-like synoviocytes (FLS) from OA patients and mesenchymal stem cells (MSC). Methods: Cellular senescence was assessed via the proliferation rate, β-galactosidase staining, DNA damage and CKI expression (p21, p16INK4A). Experimental senescence was induced by irradiation. Results: The GC prednisolone did not induce an apparent senescence phenotype in FLS, with even higher proliferation, no accumulation of β-galactosidase-positive cells nor DNA damage and reduction in p21mRNA, only showing the enhancement of p16INK4A. Prednisolone did not modify experimental senescence induction in FLS, with no modulation of any senescence parameters. Moreover, prednisolone did not induce a senescence phenotype in MSC: despite high β-galactosidase-positive cells, no reduction in proliferation, no DNA damage and no CKI enhancement was observed. Conclusions: We provide reassuring in vitro data about the use of GC regarding cellular senescence involvement in OA: the GC prednisolone did not induce a senescent phenotype in OA FLS (the proliferation ratio was even higher) and in MSC and did not worsen cellular senescence establishment.

Focal myopathy following local glucocorticoid injection

Abstract Introduction: Few cases of local subcutaneous atrophy after corticosteroid injection have been described previously. Here, we report 2 patients who had weakness of hip extension and atrophy of the gluteus maximus after several intramuscular triamcinolone acetonide injections in the buttocks. Patient concerns: A 50-year-old woman presented with hand eczema and received biweekly intramuscular triamcinolone acetonide injections in the gluteus maximus. After 12 weeks, she experienced difficulty getting up from the armchair and walking upstairs, and noted asymptomatic, oval, gently sloped depressions of the bilateral hips around the injection sites. The other patient was a 45-year-old woman with a medical history of allergic rhinitis. One and a half years before admission, she received weekly intramuscular triamcinolone acetonide injections in the gluteus maximus for 4 weeks for seasonal allergic rhinitis allergic attacks. Six months before admission, she noted depressions in the bilateral hips around the injection sites. Diagnosis: Physical examination of both patients showed normal muscle strength, except for bilateral hip extension. Magnetic resonance imaging of the thigh revealed atrophy and fatty infiltration of the bilateral gluteus maximus. Interventions: The 2 patients started rehabilitation therapy. Outcomes: Six months later, their weakness and atrophy remained unchanged. Conclusions: The patients in this case report had weakness and atrophy secondary to the use of triamcinolone acetonide. Glucocorticoid-induced myopathy chiefly affects limb-girdle muscles, the focal form of which needs to be recognized.

For people with shoulder pain, how does image-guided glucocorticoid injection compare with landmark-guided or systemic injection?

For people with shoulder pain, how does image-guided glucocorticoid injection compare with landmark-guided or systemic injection?

Autologous blood and platelet-rich plasma injection therapy for lateral elbow pain.

Autologous blood and platelet-rich plasma injection therapy for lateral elbow pain.

Early-Stage Primary Anti-inflammatory Therapy Enhances the Regenerative Efficacy of Platelet-Rich Plasma in a Rabbit Achilles Tendinopathy Model

Background: Tendinopathy is a pervasive clinical problem that afflicts both athletes and the general public. Although the inflammatory changes in tendinopathy are well characterized, how the therapeutic effects of platelet-rich plasma (PRP) on tendinopathy are being modulated by the inflammatory environment is not well defined. Purpose/Hypothesis: In this study, we aimed to compare the therapeutic effects of PRP alone versus a combination of PRP with a primary glucocorticoid (GC) injection at the early stage of tendinopathy. We hypothesized that PRP treatment could promote better tendon regeneration through the suppression of inflammation with GC. Study Design: Controlled laboratory study. Methods: The gene expression profile of tendon stem/progenitor cells (TSPCs) cultured with PRP was analyzed with RNA sequencing. To evaluate the cell viability, senescence, and apoptosis of TSPCs under different conditions, TSPCs were treated with 0.1 mg/mL triamcinolone acetonide (TA) and/or 10% PRP in an IL1B–induced inflammatory environment. To further verify the effects of the sequential therapy of GCs and PRP, an early tendinopathy animal model was established through a local injection of collagenase in the rabbit Achilles tendon. The tendinopathy model was then treated with isopycnic normal saline (NS group), TA (TA group), PRP (PRP group), or TA and PRP successively (TA+PRP group). At 8 weeks after treatment, the tendons were assessed with magnetic resonance imaging (MRI), histological examination, transmission electron microscopy (TEM), and mechanical testing. Results: Gene Ontology enrichment analysis indicated that PRP treatment of TPSCs induced an inflammatory response, regulated cell migration, and remodeled the extracellular matrix. Compared with the sole use of PRP, successive treatment with TA followed by PRP yielded similar results in cell viability and senescence but less cell apoptosis in vitro. In vivo experiments demonstrated that the TA+PRP group achieved significantly better tendon regeneration, as confirmed by MRI, histological examination, TEM, and mechanical testing. Conclusion: This study showed that the primary use of GCs did not exert any obvious deleterious side effects on the treated tendon but instead enhanced the regenerative effects of PRP in early inflammatory tendinopathy. Clinical Relevance: The sequential therapy of GCs followed by PRP provides a promising treatment strategy for tendinopathy in clinical practice. PRP combined with the primary use of GCs appears to promote tendon regeneration in early inflammatory tendinopathy.

In adults with de Quervain tendinopathy, do glucocorticoid injections relieve symptoms more than placebo?

University of Kansas School of Medicine—Wichita Family Medicine Residency at Ascension Via Christi Hospitals, Wichita, KS The authors declare no conflicts of interest.

Image-guided glucocorticoid injection versus injection without image guidance for shoulder pain.

Image-guided glucocorticoid injection versus injection without image guidance for shoulder pain.

Lyme arthritis in Western Europe: a multicentre retrospective study.

To characterize Lyme arthritis, with a focus on management, and outcome. Observational retrospective multicentre study in Western France, of all consecutive cases of Lyme arthritis, documented by Borrelia burgdorferi IgG on ELISA serological testing, confirmed by Western blot, with or without positive Borrelia PCR in synovial fluid, with no alternative diagnosis. We enrolled 52 patients (29 males), with a mean age of 43 ± 19.4years. Most patients had monoarthritis (n = 43, 82.7%), involving the knee (n = 51, 98.1%), with a median delay between symptoms onset and Lyme arthritis diagnosis of 5months (interquartile range, 1.5-8). Synovial fluid analysis yielded median white cell count of 16,000/mm3 (9230-40,500), and positive PCR in 16 cases (39%), for B. burgdorferi sensu stricto (n = 5), B. garinii (n = 5), B. afzelii (n = 3), and undetermined (n = 3). All patients received antibiotics, for a median duration of 28days (21-30), with doxycycline (n = 44, 84.6%), ceftriaxone (n = 6, 11.5%), or amoxicillin (n = 2). Twelve patients (23.1%) also received intra-articular injection of glucocorticoids as first-line treatment. Of 47 patients with follow-up, 35 (74.5%) had complete resolution of Lyme arthritis. Lyme arthritis in Western Europe may be due to B. burgdorferi ss, B. afzelii, or B. garinii. Clinical presentation is similar to Lyme arthritis in North America (i.e. chronic knee monoarthritis), with low sensitivity of synovial fluid PCR (39%).

Physical Therapy Is Better than Glucocorticoid Injections for Osteoarthritis of the Knee

Physical Therapy Is Better than Glucocorticoid Injections for Osteoarthritis of the Knee