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?