Tag Archives: journal club

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?

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Journal Club

What we discussed at this month’s Rheumatology Journal Club with our residents:

deVos et al. Platelet-Rich Plasma Injection for Chronic Achilles Tendinopathy. JAMA 2010; 303:2. PRP injection was no better than saline injection.

Merrill et al. Efficacy and Safety of Rituximab in Moderately-to-Severely Active Systemic Lupus Erythematosus. Arthritis and Rheumatism 2010; 62:1. No difference between placebo and Rituximab.

Peters et al. Does Rheumatoid Arthritis Equal Diabetes Mellitus as an Independent Risk Factor for Cardiovascular Disease? A Prospectove Study. Arthritis and Rheumatism 2009; 61:11. The risk of cardiovascular disease in patients with RA is elevated compared with the general population. Consider risk factor modification similar to diabetics.

Rheumatology Journal Club

Most months we have a couple residents rotating with us on a Rheumatology elective.  As part of that month, we hold a journal club where each resident and the teaching attending presents an article. Here is what we discussed this month:

Askling et al. Cancer Risk in Patients With Rheumatoid Arthritis Treated with Anti-Tumor Necrosis Factor Alpha Therapies. Arthritis and Rheumatism. 2009; 60:11.

  • Chosen by the attending. Supports the observations against increasing cancer risk over time with these medications.

Woodburn et al. A Randomized Controlled Trial of Foot Orthoses in Rheumatoid Arthritis. The Journal of Rheumatology. 2002; 29:7.

  • Chosen by the podiatry resident. Orthotics are very helpful in RA but they need to be worn (pts wore them avg of 6 hours/day) and it is helpful to ensure someone skilled in orthotics and gait is fitting them.

Daimon et al. Nonspecific Interstitial Pneumonia Associated with Collagen Vascular Disease: Analysis of CT Features to Distinguish the Various Types. Internal Medicine. 2009; 48.

  • Chosen by the prelim radiology resident. It’s hard to diagnose Rheumatologic conditions just by a CT scan. Score one for the H&P! However, CT can be an important piece of the equation.