Category Archives: Musculoskeletal

Do you need a cortisone shot?

I presented this article at our recent Rheumatology journal club: “Exercise therapy after corticosteroid injection for moderate to severe shoulder pain: large pragmatic randomised trial” from BMJ (2010).

It is available full text via the link above. In a nutshell, this was a study of 232 people over 40 with unilateral shoulder pain. People with prior  surgery or underlying conditions such as prior surgery or known arthritic conditions like RA were excluded (along with several other exclusion criteria). Patients were randomized into steroid injection (20mg triamcinolone) AND physical therapy or physical therapy only. Response was assessed at weeks 1, 6, 12 and 24. From the article text:

What is already known on this topic

  • Shoulder pain is common, persistent, and often caused by subacromial impingement syndrome

  • Exercise, manual therapy, and corticosteroid injections are common interventions in primary care for this condition

What this study adds

  • Steroid injection combined with exercise is of similar effectiveness to exercise only at 12 weeks

  • A third of patients treated with exercise and manual therapy alone do not improve sufficiently by 12 weeks and will opt for a steroid injection

  • Earlier improvement in pain and function is seen with corticosteroid injection combined with exercise and manual therapy

Will this change how patients with shoulder pain are treated? Probably not, but it is reinforcement of what we do typically see in practice – shoulder pain usually improves by 3 months whether you get a steroid shot or do PT, but it will improve faster with an injection. However, there are complications to injections so if patients are nervous about that, needle phobic or just willing to do a course of PT then there certainly is not a need to absolutely do an injection. There was no arm of people who JUST did an injection and didn’t do PT (which is probably the more likely scenario for people who get injections) and I’d like to know how they compared with the other groups. Thoughts?


“Weathering” your arthritis

Is it spring where you live? There’s a wind chill close to 20 degrees in Massachusetts today, the last week of March! Sadly, these flowers are from last year and this year’s are only just thinking about popping up.

While “spring cleaning” some backlogged blog files I came across this post about how weather affects arthritis. Bottom line,

As we have learned, whether weather is a contributing factor in arthritic pain can not be stated definitively. Even though the literature is filled with contradicting studies, one of the largest, multi-site studies conducted to date has recently demonstrated an association between the two. To quote Robert Ripley, “believe it or not.”

Now I’m just angry!

High on the list of things making me angry is the weather. A foot of snow each week? Really, Mother Nature? Really? Global warming or not, it’s wearing on us. I’ve tried making idle threats against the earth, which go something like this – “Make the snow stop or I swear I’ll never recycle anything ever again! Look at me holding this peanut butter jar! It’s going in the TRASH. That not enough for ya? OK, I can do better. Here’s a laundry detergent bottle! OOOOH all that plastic, bobbing around in your oceans. Gonna stop the snow now???” Yeah, well, I think all the snow is making me loopy. Not to mention that we’ve had so many snow days causing patient cancellations that it’s really fouling up everyone’s schedules.

What else makes me angry? An article with the headline “Docs Don’t Follow OA Guidelines.” Why so accusatory? In my mind that headline assumes there’s a bunch of guys smoking cigars sitting around a table saying, “To hell with guidelines! We don’t care about guidelines! We’re doing what we want!” (I don’t know why it’s like a 1920’s mobster scene, but that’s my vision here).

Here’s the first paragraph:

Physicians are apparently disregarding standard guidelines to manage osteoarthritis — relying on painkillers and surgery rather than on steps like exercise and weight loss that could help reduce morbidity — adding to the soaring costs of treating OA, researchers argued.

Let’s think about that for a minute. A patient comes in with osteoarthritic knee pain. Usually it hurts when getting up after sitting for a while, hurts going up and down stairs. Maybe they’re already active and it hurts when exercising. Maybe it used to respond to an OTC analgesic but isn’t anymore.

I am fairly certain that most doctors almost always if not always counsel patients with OA about diet and exercise. I’ve given the “even a little bit of weight loss would help take some pressure off your knees” talk so many times I wouldn’t be surprised if I say it in my sleep. But here’s the clincher – diet and exercise are the PATIENT’S responsibility. I can’t go home with you and cook your food (though I can help you find some great internet resources for healthy eating) and I can’t take you to the gym. I have enough trouble getting myself out to exercise and to avoid the lure of the office candy bowl! But when patients come to the doctor they expect us to DO something. Dieting and exercise are slow. They’re hard to do. Your knee still hurts when you’re exercising. Painkillers, injections and even surgery can help you feel better as youre working on healthier lifestyle modifications. So please don’t tell me that I’m “disregarding guidelines” by recommending other treatment options. I’m just trying to help.

Back Pain

Much of the country is digging out from a massive winter storm and news stories about protecting your back while shoveling are everywhere. This story from talks about why MRIs are often unnecessary in the assessment of back pain.

Osteoporosis Review

This is a good summary article in The Boston Globe about osteoporosis diagnosis and managment. I haven’t had any patients mention it to me, which I find a little surprising.

I’ll take my gin without raisins, please.

Did you read my recent post on use of cherries as a gout treatment? Let’s continue the theme of wacky food treatments with the good old “gin-soaked raisins” treatment. Just do an internet search and you’ll find many sites that discuss this. Apparently you’re supposed to soak golden raisins in good gin (one post debated good gin vs cheap gin, though I know some people who’d say any gin is good gin) and eat 9 a day. No one knows why this helps with arthritis pain. There are no scholarly articles. I could not find any discussion on the science behind it. I don’t think that 9 gin-soaked raisins a day is enough to give you much of an alcohol effect, but I guess that depends on how plumped up they get. I wonder what one’s blood alcohol level would be after eating these raisins. I’m not recommending this. I just wanted to see if I could find out a little more info regarding something patients continually ask me about. It’s right up there with the idea that putting a bar of soap under your sheets will help with night time leg cramps. I don’t really feel like commenting on that one. Have you used the gin raisins? Have patients asked you about it? What do you think?

Gout: A bowl of cherries?

Did you know that I write a health blog for the Worcester Telegram and Gazette? The latest one was about patients asking me about cherry juice as a gout treatment. Keep in mind these are short, general purpose blog entries for the newspaper site.  Here is a reprint:

Maybe it is because the grocery stores are fully stocked with beautiful cherries this time of year, but several patients in the last few weeks have come in touting the merits of cherries as a gout treatment. Yes, I’d heard this before and no, I didn’t really know why. Some patients eat cherries, some drink the juice and some take special cherry juice extract pills they purchase through a vitamin store. My first reaction to the patient who claimed eating a pound of cherries a day cured his gout was, “wow, you must spend a lot of time in the bathroom!” But I digress . . .

Why cherries? I searched good old google and found mainly advertisements or websites trying to sell juice or extracts. I turned to google scholar and to PubMed, which is an internet database of the US National Library of Medicine and National Institutes of Health, or a site where you can search for what we call “scholarly articles” or scientific research printed in medical journals. I did find some articles talking more specifically about the chemicals in cherries. Some of them were sports-medicine related and discussed cherry juice for post-workout recovery following intense exercise, like marathons. There is an article loaded with very “science-y” words in a journal called Plant Foods for Human Nutrition called “Improved antioxidant and Anti-Inflammatory Potential in Mice Consuming Sour Cherry Juice.” I wonder how well the mice liked the cherry juice?? (According to the article the food pellets incorporated the juice). An article in the Journal of Nutrition was titled “Consumption of Bing Sweet Cherries Lowers Circulating Concentrations of Inflammation Markers in Healthy Men and Women.”

I did skim a few more articles and overall it seems there are some anti-inflammatory chemicals in cherries that may have a benefit in inflammatory conditions, like gout. Bottom line? If your gout isn’t that bad and you find eating cherries or drinking juice daily prevents attacks, great! If you feel cherries can prevent a gout attack when you feel one coming on, also great! Remember that cherries and especially juices have calories and sugar. Overdoing it can lead to weight gain or high blood sugars for diabetics. Also, we’re talking tart cherries, bing cherries or dark sweet cherries. Stay away from the bright red ones in the jar! Remember that uncontrolled gout can lead to a chronic and deforming arthritis, so be sure to discuss your condition and what you’re doing for it with your doctor. It is possible your condition may require a prescription gout medication.