IA Steroid Knee Injections and Exercise

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drusso

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http://archinte.jamanetwork.com/article.aspx?articleid=2210887

Would ultrasound guidance changed this results?


Evaluation of the Benefit of Corticosteroid Injection Before Exercise Therapy in Patients With Osteoarthritis of the KneeA Randomized Clinical Trial

Marius Henriksen, PT, MSc, PhD1; Robin Christensen, PhD1; Louise Klokker, MSc1; Cecilie Bartholdy, MSc1; Elisabeth Bandak, MSc1; Karen Ellegaard, PhD1; Mikael P. Boesen, PhD1,2; Robert G. Coumine Riis, MD1,2; Else M. Bartels, PhD1; Henning Bliddal, DMSc1
[+] Author Affiliations
JAMA Intern Med. 2015;175(6):923-930. doi:10.1001/jamainternmed.2015.0461.

ABSTRACT | INTRODUCTION | METHODS | RESULTS | DISCUSSION | CONCLUSIONS |ARTICLE INFORMATION | REFERENCES
Importance Osteoarthritis (OA) of the knee is the most frequent form of arthritis and a cause of pain and disability. Combined nonpharmacologic and pharmacologic treatments are recommended as the optimal treatment approach, but no evidence supports the recommendation.

Objective To assess the clinical benefits of an intra-articular corticosteroid injection given before exercise therapy in patients with OA of the knee.

Design, Setting, and Participants We performed a randomized, blinded, placebo-controlled clinical trial evaluating the benefit of intra-articular corticosteroid injection vs placebo injection given before exercise therapy at an OA outpatient clinic from October 1, 2012, through April 2, 2014. The participants had radiographic confirmation of clinical OA of the knee, clinical signs of localized inflammation in the knee, and knee pain during walking (score >4 on a scale of 0 to 10).

Interventions Participants were randomly allocated (1:1) to an intra-articular 1-mL injection of the knee with methylprednisolone acetate (Depo-Medrol), 40 mg/mL, dissolved in 4 mL of lidocaine hydrochloride (10 mg/mL) (corticosteroid group) or a 1-mL isotonic saline injection mixed with 4 mL of lidocaine hydrochloride (10 mg/mL) (placebo group). Two weeks after the injections, all participants started a 12-week supervised exercise program.

Main Outcomes and Measures The primary outcome was change in the Pain subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire (range, 0-100; higher scores indicate greater improvement) at week 14. Secondary outcomes included the remaining KOOS subscales and objective measures of physical function and inflammation. Outcomes were measured at baseline, week 2 (exercise start), week 14 (exercise stop), and week 26 (follow-up).

Results One hundred patients were randomized to the corticosteroid group (n = 50) or the placebo group (n = 50); 45 and 44 patients, respectively, completed the trial. The mean (SE) changes in the KOOS Pain subscale score at week 14 were 13.6 (1.8) and 14.8 (1.8) points in the corticosteroid and placebo groups, respectively, corresponding to a statistically insignificant mean difference of 1.2 points (95% CI, −3.8 to 6.2; P = .64). We found no statistically significant group differences in any of the secondary outcomes at any time point.

Conclusions and Relevance No additional benefit results from adding an intra-articular injection of 40 mg of corticosteroid before exercise in patients with painful OA of the knee. Further research is needed to establish optimal and potentially synergistic combinations of conservative treatments.

Trial Registration clinicaltrialsregister.eu Identifier: 2012-002607-18; clinicaltrials.gov Identifier: NCT01945749

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Would US guidance change the results? Don't know. Removing the P.T., D.P.T. as the lead author sure would though.
 
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Members don't see this ad :)
JAMA is changing the game.
But thank god for progress and the scientific method.
If we are not leading the discussion, we're following it. Where do you want to be?
 
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Would US guidance change the results? Don't know. Removing the P.T., D.P.T. as the lead author sure would though.
Change all three. Guidance would eliminate the 15% of the time blind joint injections miss their target. PT as lead author with inherent bias, which leads to #3- should use 80 mg of Depo/kenalog, not 40mg.

The study was designed to fail,.,,,, by a PT
 
Change all three. Guidance would eliminate the 15% of the time blind joint injections miss their target. PT as lead author with inherent bias, which leads to #3- should use 80 mg of Depo/kenalog, not 40mg.

The study was designed to fail,.,,,, by a PT

2/3 ain't bad. I use fluoro for tough knees.
 
No control group?
Why isnt their placebo group (1-mL isotonic saline injection mixed with 4 mL of lidocaine hydrochloride (10 mg/mL) an adequate control?
 
The article doesnt carve out those with the presence of effusion, withdrawal of fluid from the knee, severity of disease, absence of synovitis, injection delivery under US guidance and greater symptoms at baseline. These are the factors that may all improve the likelihood of response to IASI (http://www.ncbi.nlm.nih.gov/pubmed/23264554).
 
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Lateral midpatellar is not where most guys go, so the other 25-29% missed rates are probably more realistic. But this was one guy, ortho.....i bet family practice or other probably miss closer to 35%+.

Wow 80mg of steroid into an arthritic joint?....that remaining cartilage is toast.
 
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Prof. Jackson was probably the most important knee arthroscopist in the past generation. To not follow his recommendation would be foolish.

Bedrock suggested that guidance would eliminate the injections that were not intra-articular. If you think FP's would be competent to use fluoro or US guidance, I'd like to talk to you about a bridge I'd be interested in selling.
 
Lateral midpatellar is not where most guys go, so the other 25-29% missed rates are probably more realistic. But this was one guy, ortho.....i bet family practice or other probably miss closer to 35%+.

Wow 80mg of steroid into an arthritic joint?....that remaining cartilage is toast.

again with this?

ill try to inject goat placenta or rabbit semen next time. it will "enhance the immune response"
 
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Prof. Jackson did that study in 2002, and one has to wonder about procedural bias if he was the sole and only proceduralist who is writing up a study to discuss a particular method of doing procedures. would he have published that article if they were all equally good (or bad, as it were)?

Even he had 29% miss rate on first try with the lateral approach, which is most commonly taught.

at the time of my original quote, i was thinking about how insurers are trying to cut back on all procedural intervention. the study specifically addresses whether steroids help, and are not taken in the context of any injection helping. i do not doubt however that i will read some LCD that uses this study as a basis to deny all intrarticular injections - steroid or no.
 
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again with this?

ill try to inject goat placenta or rabbit semen next time. it will "enhance the immune response"

Why did u think it was directed at you? Smh.....keep using marcaine too
 
Why is a physician-centered journal publishing a study by a non-physician? Internal medicine is an intense medical specialty that should be protected and furthered by physicians. JAMA should be ashamed.
 
Not sure why you would assume that just because the lead author is a PT he would be automatically biased against IA injections. I'm not arguing that the study design doesn't have flaws but I don't see too many PTs as anti-injection.

Is 80mg considered standard of care for injecting patients who have OA related knee pain? Are there physicians in other specialties such as Rhuem or ortho that would consider a 40mg injection as standard of care?
 
Not sure why you would assume that just because the lead author is a PT he would be automatically biased against IA injections. I'm not arguing that the study design doesn't have flaws but I don't see too many PTs as anti-injection.

Just about every P.T. here thinks they have the answer and generic exercises combined with dry needling is it. And if those fine treatment methods don't work a person needs surgery.
 
Just about every P.T. here thinks they have the answer and generic exercises combined with dry needling is it. And if those fine treatment methods don't work a person needs surgery.
Ugh. That's a sad state of affairs down there.
 
Just about every P.T. here thinks they have the answer and generic exercises combined with dry needling is it. And if those fine treatment methods don't work a person needs surgery.

"Generic exercises" as in reduced variability in practice pattern for the same diagnosis? Last time I checked the same or similar exercises/POC is encouraged for the hypothetical same or similar patient. The last thing we need is more "progression" to "do something different." I personally as I know jesspt does customize for every patient. I don't dry needle and rarely mention/recommend it. Sometimes TKA's are indicated, but those are even done way to often (not because the PT says they "just need a little surgery").
 
PT's are allowed to dry needle in some states, and there is some evidence that it works.
 
i love how pmrmd has a vendetta against PTs. im serious, i get a kick out of it.

PT for intra-articular processes ( hip or knee OA, facet arthropathy, labral tears) is a waste of time in my opinion.
 
i love how pmrmd has a vendetta against PTs. im serious, i get a kick out of it.

PT for intra-articular processes ( hip or knee OA, facet arthropathy, labral tears) is a waste of time in my opinion.

Well, there is some research which shows that PT can be as efficacious as arthoscopic surgery for degenerative meniscus tears and OA. And I think the lead author is an MD.
 
i love how pmrmd has a vendetta against PTs. im serious, i get a kick out of it.

PT for intra-articular processes ( hip or knee OA, facet arthropathy, labral tears) is a waste of time in my opinion.

On a case by case basis physical therapy can be helpful for all these so that generalization is false. We see these all day long and probably rival or supercede the outcomes of other treatments/professions with less cost and less risk. Guess what common surgeries for these conditions require often post operatively for a good outcome? Why is "prehab" helpful if it's a "waste of time"?
 
On a case by case basis physical therapy can be helpful for all these so that generalization is false. We see these all day long and probably rival or supercede the outcomes of other treatments/professions with less cost and less risk. Guess what common surgeries for these conditions require often post operatively for a good outcome? Why is "prehab" helpful if it's a "waste of time"?

We see all day long people saying they did P.T. and got nothing out of it. Delve a bit deeper and you find out that people were told to ride an exercise bike. Do pulleys. Left bends. Right bends. Everyone says the same thing. It doesn't matter if the pain is right sided or left--the treatment protocols are the same. No wonder the outcomes of P.T. are average. If you approach something randomly, you cannot expect anything better than an average outcome. There is no risk with therapy, true, because it does and accomplishes very little. As far as cost, I suggest you look at things beyond the EOB. I see people every day doing P.T. for 4-6 weeks for radicular pain. That's about 12 or more copays to them. Gas money. Time off work. And the patient is still symptomatic. That is far more than the expense of a single epidural that is more for efficacious than anything you do.
Agree with ssdoc regarding IA processes. I would include radiculopathy as well.
 
I see patients all day long who have been to physician after physician, big deal. It doesn't prove anything. Pain physicians predominantly see chronic pain don't they? Don't you think that would make all these "PT failures" skewed? As in you see the patients often times after they have failed many treatment appraches. As far as they poor quality of care you describe, I know this is not based on evidence and not anything close to what I've observed (thousands of combined hours in many different outpatient clinics). I don't know you should just write off a profession that you've "mastered" because it doesn't belong in your clique. And in what way are you qualified to judge a physical therapy POC quality anyway? You don't even know that a "P.T., D.P.T" and PT, MSc, PhD are not one in the same. Patients are unable to discern if a physical therapy POC is quality, the same is true of physicians like you IMO.
 
You don't even know that a "P.T., D.P.T" and PT, MSc, PhD are not one in the same.


they sort of are.


look, there is a role for PT. nobody is arguing that. but you have to know your limitations. you have to be able to say: PT is not going to help this patient. can you do that?
 
I see patients all day long who have been to physician after physician, big deal. It doesn't prove anything. Pain physicians predominantly see chronic pain don't they?

A) No. I see acute pain all the time, every day.

Don't you think that would make all these "PT failures" skewed?

B) Chronic pain was acute at some time, and all those patients had therapy. What was the benefit? Does acute pain need P.T. to resolve? Nope. Note I believe P.T.s play a vital role in true rehabilitation of SCI/TBI/CVA folks.

As in you see the patients often times after they have failed many treatment appraches. As far as they poor quality of care you describe, I know this is not based on evidence and not anything close to what I've observed (thousands of combined hours in many different outpatient clinics).

C) How about I dig up the last 5 P.T. evaluations for different patients and post just the plan of care. You won't see any differences. I don't RF the L4-5 joint for every back ache. Your colleagues do the same thing for everyone. Thankfully you don't though

I don't know you should just write off a profession that you've "mastered" because it doesn't belong in your clique. And in what way are you qualified to judge a physical therapy POC quality anyway? You don't even know that a "P.T., D.P.T" and PT, MSc, PhD are not one in the same. Patients are unable to discern if a physical therapy POC is quality, the same is true of physicians like you IMO.

D) I know because a decade of seeing the benefits of P.T. tells me so. I'm qualified because Rehabilitation is my field, but your unwillingness to recognize that is noted. Try to realize you people have started your own programs to give yourselves more letters behind your names. I really don't give a ****. Letters don't matter because the disease process doesn't change.

With that, I'm unsubscribed
 
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they sort of are.


look, there is a role for PT. nobody is arguing that. but you have to know your limitations. you have to be able to say: PT is not going to help this patient. can you do that?


PT, DPT and PT, MSc, PhD are significantly different in my mind. One is a clinical doctorate that often practices physical therapy , the other is a academic doctorate that often teaches or researches physical therapy.

I definitely have limitations as a physical therapist but as a general rule my practice is not useless in the management of the conditions as you suggest. Can I say I am unable to help a particular patient? Yes. Can the referring physician defer that determination is another thing. Can the business owner with numerous conflicts of interest? When it comes down to purely clinical decision making of the average PT in determining the physical therapy prognosis or to just D/C, we'd do a lot better without all the pressures.
 
A) No. I see acute pain all the time, every day.



B) Chronic pain was acute at some time, and all those patients had therapy. What was the benefit? Does acute pain need P.T. to resolve? Nope. Note I believe P.T.s play a vital role in true rehabilitation of SCI/TBI/CVA folks.



C) How about I dig up the last 5 P.T. evaluations for different patients and post just the plan of care. You won't see any differences. I don't RF the L4-5 joint for every back ache. Your colleagues do the same thing for everyone. Thankfully you don't though



D) I know because a decade of seeing the benefits of P.T. tells me so. I'm qualified because Rehabilitation is my field, but your unwillingness to recognize that is noted. Try to realize you people have started your own programs to give yourselves more letters behind your names. I really don't give a ****. Letters don't matter because the disease process doesn't change.

With that, I'm unsubscribed

A) Sure but you still see a majority of chronic pain don't you?

B) Not all patients "had therapy." Benefit varies depending on lots of factors (not "PT" doesn't work, or the POC's were all the same). Physical therapy in the rehibilitation of neurological conditions is responsible for ~ 5-10% of the outcome, time is the main factor there.

C) Please post me the POC's, then if you're right I'll report all those PT's to their state board.

D) You are a physical medicine and rehabilitation physician. There some over lap with physical therapy but you are not a physical therapist or an expert in physical therapy.
 
Wow. Then lets use your expert opinion and reshape healthcare. 5-10% of the outcome does not justify the expense of an acute rehabilitation unit. I should correspond with the medical director of my residency program and all the other acute rehab hospital medical directors across this land and tell them to close up shop, the 5boy says people can be 90-95% better without their services. These patients can bide their time at home with a little PT-A coming for an hour. Its only 5%, right? I bet the CEOs of every insurance company would love to learn from you to direct these patients home with a family member where they can languish for the rest of their days. On second thought, lets not. You are a physical therapist. There is some overlap but you are not an expert in rehabilitation.
 
Wow. Then lets use your expert opinion and reshape healthcare. 5-10% of the outcome does not justify the expense of an acute rehabilitation unit. I should correspond with the medical director of my residency program and all the other acute rehab hospital medical directors across this land and tell them to close up shop, the 5boy says people can be 90-95% better without their services. These patients can bide their time at home with a little PT-A coming for an hour. Its only 5%, right? I bet the CEOs of every insurance company would love to learn from you to direct these patients home with a family member where they can languish for the rest of their days. On second thought, lets not. You are a physical therapist. There is some overlap but you are not an expert in rehabilitation.

I said physical therapy is responsible for 5-10% of the outcome, and this would be on average. I did not say a inpatient rehab stay is responsible for 5-10%. I do not think you grasp, among other things, that physical therapy is a separate and distinct profession and service from occupational therapy, speech therapy, medicine, nursing, etc, etc, family support, CNA services, etc etc. I think the medical community would jump up and down for a service that on average improves outcomes by 5-10%. Time is still the main factor in the outcome.
 
PT in the chronic pain setting is for one reason, primarily: It's a stall tactic by insurance companies. They're just stalling so that a few of the acute pain exacerbations get better on their own from time alone, and therefore don't cost them money on MRIs or procedures, or cost them money in some other way. It's not about the PT; it's about placing a "roadblock of time" between the patient and more expensive treatments.

I am happy to have PT as an alternative option in patients requesting an unnecessary drug dose escalation. I'm also happy to put patients through a course of PT, especially if they've had it before and strongly believe in it. But once a chronic painer gets to me, PT is rarely a game changer.
 
What I don't understand is how the insurance companies evaluate cost. How is it that many will approve pt at infinitum but have an issue approving my mri/epidural? I totally understand the buying time argument but has anyone done a real cost analysis or is it even possible?
 
you're right, but only in that they are both worthless (http://www.ncbi.nlm.nih.gov/pubmed/12110735)

Well, according to the study that started this thread, your injection isn't any better than saline. Are you going to stop using IA with steroids?

Given the relatively high prevalence of these types of conditions in the asymptomatic population, I think non-invasive treatments such as PT have a place in the treatment of patients with knee pain that also have imaging indicating degenerative disease. There is also some data indicating that it can reduce symptoms. I give my patients with knee pain 2-3 visits to show improvement (6 minute walk test and Lower Extremity Functional Scale) and if it isn't happening, they get referred elsewhere. I don't think that this is an unrealistic or irresponsible approach - it doesn't drive up costs, make unnecessary demands on a patient's time or $$, and it doesn't prevent the patient from seeking other care if PT interventions aren't resulting in symptom reduction. I usually suggest Pain Management if referral is required, but they're harder to find and take longer to get into around here than several orthopods who are conservative in their approach and aren't scalpel-happy, so often they end up at ortho.
 
What I don't understand is how the insurance companies evaluate cost. How is it that many will approve pt at infinitum but have an issue approving my mri/epidural? I totally understand the buying time argument but has anyone done a real cost analysis or is it even possible?


I don't know what insurance company(s) you're referring to, but where I practice, PT just isn't approved forever. Many have now taken to using third-party administrators to manage MSK c/o, such as Ortho-Net. I get 4-6 visits initially whether the patient has had an amputation, an ACL reconstruction, or stubbed their toe.
 
I give my patients with knee pain 2-3 visits to show improvement (6 minute walk test and Lower Extremity Functional Scale) and if it isn't happening, they get referred elsewhere.

thats great. well done.

but you are clearly an outlier. 2-3 visits is not the norm
 
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Well, according to the study that started this thread, your injection isn't any better than saline. Are you going to stop using IA with steroids?

Given the relatively high prevalence of these types of conditions in the asymptomatic population, I think non-invasive treatments such as PT have a place in the treatment of patients with knee pain that also have imaging indicating degenerative disease. There is also some data indicating that it can reduce symptoms. I give my patients with knee pain 2-3 visits to show improvement (6 minute walk test and Lower Extremity Functional Scale) and if it isn't happening, they get referred elsewhere. I don't think that this is an unrealistic or irresponsible approach - it doesn't drive up costs, make unnecessary demands on a patient's time or $$, and it doesn't prevent the patient from seeking other care if PT interventions aren't resulting in symptom reduction. I usually suggest Pain Management if referral is required, but they're harder to find and take longer to get into around here than several orthopods who are conservative in their approach and aren't scalpel-happy, so often they end up at ortho.
GIGO

Might want to rad the entire thread, not just the initial post
 
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