Synvisc for shoulders?

[Ludicolo]

I'm seeing a referral tomorrow specifically for "Synvisc injection for shoulder pain". The patient has a history of breast cancer, post-mastectomy pain syndrome, with secondary adhesive capsulitis. She can't tolerate physical therapy. She's had corticosteroid injections in the past - no benefit. Her shoulder MRI shows minor DJD, tendons intact, no tumors. I'm going to need to examine her to determine if her pain is truly coming from the shoulder, but if it is - has anyone injected Synvisc (or anything similar) into the shoulder?

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[PMR 4 MSK]

I've been asked to try it by ortho, but have not had an insurance company approve it yet. Medicare won't pay for it. Patients haven't wanted to pay cash. I believe it's been cleared for use in Europe for the shoulder.

Before considering it, I would do a lidocaine challenge into the glenohumeral joint under fluoro to see if the pain goes away. If not, I wouldn't do it.

 

[rehab_sports_dr]

When I was a resident at UMDNJ, there was a clinical trial looking at Hylgan v Placebo for AC-joint arthropathy. I don't have the data in front of me, but my memory was that there was not a significant difference

That is for AC-joint

As for glenohumeral joint, I have no data

My personal belief system (not necessarily supported by data, and perhaps incorrect)
1. To confirm that you are truly in the glenohumeral joint, you need some form of imaging guidance- the miss rate is too high blind for the glenohumeral joint. (the miss rate is actually non-trivial even for AC joint and subacromial bursa)

2. While it probably doesn't matter too much if you are off a bit with steroid/local anasthetic, because the medications can diffuse, viscosupplements are probably too viscous to permeate across the synovial membrane. Again, this requires, in my opinion, some form of imaging guided injection- either fluoroscopy or ultrasound (I've only done fluoroscopy myself)

3. I agree that a trial with local anasthetic should be performed prior to verify that the glenohumeral joint is indeed the pain generator

4. Once that has been done, I could understand the rationale for a trial with viscosupplementation, letting the patient know that is an off label usage. I have never been in the position of having to petition an insurance company for coverage. An argument could be made for it being a potentially surgery sparing treatment option

5. For most other joints, injections in conjunction with therapy tends to be better than either in isolation. Therefore, recommend therapy to offload the joint, including scapular mobilization as part of the therapy program (including targeted lower trapezius and serratus anterior strengthening to promote external rotation and posterior rotation of the scapula)

 

[SCIronMike]

I have put Supartz into the glenohumeral joint ONCE before here at UC Irvine at the VA. We had an extra Hyalgan and a patient with severe GH DJD. We put it in blind, and there was no appreciable benefit for the patient. Now, we have a Philips HD3 ultrasound machine in our department at the VA (where we do almost all our outpt. clinics) for diagnostic MSK ultrasound and ultrasound guided injections. Might be useful in the future if the right patient comes along that can benefit from an injection.

 

[lobelsteve]

N=1

Fluoro guided contrast enhanced IA injection of the GH Joint for moderate to severe OA shoulder.

I used a 25G 3.5" needle and put it on the humeral head well within the capsular reflection. After 5cc Omnipaque and comfortable that I was IA, I did a series of 3 Synvisc injections (1 week apart).

Pain relief has been 50%. I think a large part is the fact her OA was too severe for Synvisc. She has declined surgery as shoulder replacement.

I wrote an RX for Synvisc and it was covered by her pharmacy benefit for $25. I only billed for arthrocentesis and non-spinal fluoro withno J-code for Synvisc at time of procedure.

N of one is as good as an N of none.

 

[Ludicolo]

N=1

Fluoro guided contrast enhanced IA injection of the GH Joint for moderate to severe OA shoulder.

I used a 25G 3.5" needle and put it on the humeral head well within the capsular reflection. After 5cc Omnipaque and comfortable that I was IA, I did a series of 3 Synvisc injections (1 week apart).

Pain relief has been 50%. I think a large part is the fact her OA was too severe for Synvisc. She has declined surgery as shoulder replacement.

I wrote an RX for Synvisc and it was covered by her pharmacy benefit for $25. I only billed for arthrocentesis and non-spinal fluoro withno J-code for Synvisc at time of procedure.

N of one is as good as an N of none.

The N=1 is helpful for the 1. Not so much for the doctor.

In any case, your N=1 beats my N=0. My patient no showed

I appreciate all of the anecdotes though.

PMR 4 MSK - Curious...Ortho asked you to try it? Because of the fluoro guidance?

 

[lobelsteve]

The N=1 is helpful for the 1. Not so much for the doctor.

In any case, your N=1 beats my N=0. My patient no showed

I appreciate all of the anecdotes though.

PMR 4 MSK - Curious...Ortho asked you to try it? Because of the fluoro guidance?

Because they knew it would lose money as the can't bill out the J-code.

Synvisc can be put anywhere- butgetting somebody to pay for it is another thing.

Have your staff call the patient and find out what's going on. I've had my nurse call folks up to get the skinny and we've made minor practice changes to greatly reduce no shows.

 

[Rehab India]

N=30,

During my PM&R residency in INDIA, currently a neurorehab fellow and will be starting PM&R pgy-1 july 2008. I presented a poster on this topic at AAPMR 2007, Boston, abstract was published in subsequent online archives of PM&R.

Breifly, I did a study to compare efficacy of hyalgan in adhesive capsulitis with conservative management, what I did, was I gave 5 injections a week apart and then follow up all the patients over 3 and 6 months, P<0.05 for pain, and has a carryover effect, did not acheive statistical significance in terms of ROM and Overall functional status. I also used it for resistant cases, those who failed 6-8wks of conservative treatment -- definitely good results but no data or statistics to support this.

I didn't used any radiological evidence to support, I got support for these costly injections as most of my patients are hospital employees and covered under Employee State Insurance. I want to conduct this study furthur in US at montefiore where I will be doing my residency.

I attended annual Canadian PM&R annual meeting and some rheumatologist was presenting on using hyalgan for multiple musculoskeletal conditions not sure about shoulder.

I hope this helps

 

[SSdoc33]

N=30,

During my PM&R residency in INDIA, currently a neurorehab fellow and will be starting PM&R pgy-1 july 2008. I presented a poster on this topic at AAPMR 2007, Boston, abstract was published in subsequent online archives of PM&R.

Breifly, I did a study to compare efficacy of hyalgan in adhesive capsulitis with conservative management, what I did, was I gave 5 injections a week apart and then follow up all the patients over 3 and 6 months, P<0.05 for pain, and has a carryover effect, did not acheive statistical significance in terms of ROM and Overall functional status. I also used it for resistant cases, those who failed 6-8wks of conservative treatment -- definitely good results but no data or statistics to support this.

I didn't used any radiological evidence to support, I got support for these costly injections as most of my patients are hospital employees and covered under Employee State Insurance. I want to conduct this study furthur in US at montefiore where I will be doing my residency.

I attended annual Canadian PM&R annual meeting and some rheumatologist was presenting on using hyalgan for multiple musculoskeletal conditions not sure about shoulder.

I hope this helps

you sure you need to do a residency, rehabindia? sounds like you're a bit ahead of the game. well done.

 

[PMR 4 MSK]

PMR 4 MSK - Curious...Ortho asked you to try it? Because of the fluoro guidance?

Yeah, as above, unless you're sure you're intra-articular, it won't likely do anything. I do a lot of shoulder injections, diagnostic and therapeutic for the ortho's, also do contrast injection for MRI's.

 

[ampaphb]

Yeah, as above, unless you're sure you're intra-articular, it won't likely do anything. I do a lot of shoulder injections, diagnostic and therapeutic for the ortho's, also do contrast injection for MRI's.

PMR works in a different practice model - his group owns the c-arm, owns the MRI, and as a result, is maximizing its financial return by sending those injections to him

 

[Rehab India]

you sure you need to do a residency, rehabindia? sounds like you're a bit ahead of the game. well done.

Yes, I don't have formal training in various advanced aspects of PM&R, like no experience of spinal injections, poor electrodiagnostics, and moreover I aspire to be an interventional spine physiatrist and practise in US, I can't do that without american board certification. I appreciate your response, now I will be a regular in all discussion forums...

 

[Ludicolo]

Rehab India - Thanks for the abstract.

Good luck in your new residency. Hopefully your new attendings will appreciate the experience you bring to the table.