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Does ultrasound guidance improve outcomes for steroid joint injections?
A Patients yes, at least in the short term. Ultrasound-guided (USG) injections of triamcinolone into the shoulder improve function more than palpation-guided (PG) steroid injections over 6 weeks (strength of recommendation [SOR]: B, 2 small randomized, controlled trials [RCTs]).
USG steroid injections are also less painful than PG injections (SOR: A, multiple RCTs). They reduce pain more than PG injections in arthritic joints (shoulder, elbow, wrist, hand, hip, knee, or ankle) over 2 weeks (SOR: B, lower quality RCTs with some inconsistent results) but possibly not at 6 weeks (SOR: B, multiple RCTs with conflicting results).
EVIDENCE SUMMARY
A prospective RCT found that USG steroid joint injections improved shoulder function more than PG injections in patients with shoulder pain unresponsive to nonsteroidal anti-inflammatory drugs (NSAIDs).1 Investigators randomized 60 patients (mean age 52.5 years) to either USG or PG injections of triamcinolone 40 mg given by a rheumatologist. They used a 10-point visual analog scale (VAS) to assess pain and evaluated joint function at 6 weeks using a validated 100-point scale for shoulder function,2 with high scores indicating better function.
The USG group showed greater improvement from baseline in pain (TABLE)1,3-7 and function scores than the PG group (32 vs 12 points; P<.05).1 Investigators didn’t control for a possible placebo effect from ultrasound in this trial (or any trial described here). Another RCT found that USG steroid joint injections improved shoulder function more than PG injections in patients with rheumatoid arthritis and at least one month of shoulder pain unresponsive to NSAIDs.3 Investigators randomized 41 rheumatology clinic patients (mean age 52.4 years) to USG or PG injections of 20 mg triamcinolone.
They assessed function at 6 weeks with a validated 70-point shoulder function assessment tool designed for patients with rheumatoid arthritis,8 which evaluates pain with motion, range of motion, and activities of daily living (higher scores indicate better shoulder function), and used a 100-point VAS to assess pain.3 Function scores showed greater improvement from baseline in the USG group than the PG group (15 vs 6 points; P=.012), as did pain scores (TABLE).
Ultrasound injections hurt less than palpation-guided injections
Three RCTs, all using triamcinolone, found that USG joint injections were less painful than PG joint injections (TABLE).4-6 Three of 4 studies found that USG injections also were associated with lower pain scores 2 weeks after injection, as measured with a standardized VAS.1,3-7 A common weakness of the 3 studies demonstrating a difference at 2 weeks was that they compared end scores rather than the magnitude of change from baseline between groups.
Two of 3 RCTs found that USG injections produced a greater reduction in the VAS pain score at 6 weeks, although the negative study was larger than the other 2 combined—184 patients, compared with a total of 285 patients for all 3 studies.1,3,7
Recommendations
The American College of Radiology’s practice guidelines for musculoskeletal ultrasound examination recommend using ultrasound to guide interventional procedures.9 However, no consensus statements comment on the use of ultrasound as opposed to palpation for guiding steroid joint injections.
1. Ucuncu F, Capkin E, Karkucak M, et al. A comparison of the effectiveness of landmark-guided injections and ultrasonography-guided injections for shoulder pain. Clin J Pain. 2009;25:786-789.
2. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214:160-164.
3. Naredo E, Cabero F, Beneyto P, et al. A randomized comparative study of short term response to blind injection versus sonographic-guided injection of local corticosteroids in patients with painful shoulder. J Rheumatol. 2004;31:308-314.
4. Sibbitt WL Jr, Kettwich LG, Band PA, et al. Does ultrasound guidance improve the outcomes of arthrocentesis and corticosteroid injection of the knee? Scand J Rheumatol. 2012;41:66-72.
5. Sibbitt W Jr, Band PA, Kettwich LG, et al. A randomized controlled trial evaluating the cost-effectiveness of sonographic guidance for intra-articular injection of the osteoarthritic knee. J Clin Rheumatol. 2011;17:409-415.
6. Sibbitt WL Jr, Peisajovich A, Michael AA, et al. Does sonographic needle guidance affect the clinical outcome of intraarticular injections? J Rheumatol. 2009;36:1892-1902.
7. Cunnington J, Marshall N, Hide G, et al. A randomized, double-blind, controlled study of ultrasound-guided corticosteroid injection into the joints of patients with inflammatory arthritis. Arthritis Rheum. 2010;62;1862-1869.
8. van Den Ende CH, Rozing PM, Dijkmans BA, et al. Assessment of shoulder function in rheumatoid arthritis. J Rheumatol. 1996;23:2043-2048.
9. ACR-AIUM-SPR-SRU practice guideline for the performance of the musculoskeletal ultrasound examination. Updated 2012. American College of Radiology; 2007, updated 2012. Available at: http://amclc.acr.org/LinkClick.aspx?fileticket=z6ih9CEE6_w%3D&tabid=61. Accessed August 3, 2012.
A Patients yes, at least in the short term. Ultrasound-guided (USG) injections of triamcinolone into the shoulder improve function more than palpation-guided (PG) steroid injections over 6 weeks (strength of recommendation [SOR]: B, 2 small randomized, controlled trials [RCTs]).
USG steroid injections are also less painful than PG injections (SOR: A, multiple RCTs). They reduce pain more than PG injections in arthritic joints (shoulder, elbow, wrist, hand, hip, knee, or ankle) over 2 weeks (SOR: B, lower quality RCTs with some inconsistent results) but possibly not at 6 weeks (SOR: B, multiple RCTs with conflicting results).
EVIDENCE SUMMARY
A prospective RCT found that USG steroid joint injections improved shoulder function more than PG injections in patients with shoulder pain unresponsive to nonsteroidal anti-inflammatory drugs (NSAIDs).1 Investigators randomized 60 patients (mean age 52.5 years) to either USG or PG injections of triamcinolone 40 mg given by a rheumatologist. They used a 10-point visual analog scale (VAS) to assess pain and evaluated joint function at 6 weeks using a validated 100-point scale for shoulder function,2 with high scores indicating better function.
The USG group showed greater improvement from baseline in pain (TABLE)1,3-7 and function scores than the PG group (32 vs 12 points; P<.05).1 Investigators didn’t control for a possible placebo effect from ultrasound in this trial (or any trial described here). Another RCT found that USG steroid joint injections improved shoulder function more than PG injections in patients with rheumatoid arthritis and at least one month of shoulder pain unresponsive to NSAIDs.3 Investigators randomized 41 rheumatology clinic patients (mean age 52.4 years) to USG or PG injections of 20 mg triamcinolone.
They assessed function at 6 weeks with a validated 70-point shoulder function assessment tool designed for patients with rheumatoid arthritis,8 which evaluates pain with motion, range of motion, and activities of daily living (higher scores indicate better shoulder function), and used a 100-point VAS to assess pain.3 Function scores showed greater improvement from baseline in the USG group than the PG group (15 vs 6 points; P=.012), as did pain scores (TABLE).
Ultrasound injections hurt less than palpation-guided injections
Three RCTs, all using triamcinolone, found that USG joint injections were less painful than PG joint injections (TABLE).4-6 Three of 4 studies found that USG injections also were associated with lower pain scores 2 weeks after injection, as measured with a standardized VAS.1,3-7 A common weakness of the 3 studies demonstrating a difference at 2 weeks was that they compared end scores rather than the magnitude of change from baseline between groups.
Two of 3 RCTs found that USG injections produced a greater reduction in the VAS pain score at 6 weeks, although the negative study was larger than the other 2 combined—184 patients, compared with a total of 285 patients for all 3 studies.1,3,7
Recommendations
The American College of Radiology’s practice guidelines for musculoskeletal ultrasound examination recommend using ultrasound to guide interventional procedures.9 However, no consensus statements comment on the use of ultrasound as opposed to palpation for guiding steroid joint injections.
A Patients yes, at least in the short term. Ultrasound-guided (USG) injections of triamcinolone into the shoulder improve function more than palpation-guided (PG) steroid injections over 6 weeks (strength of recommendation [SOR]: B, 2 small randomized, controlled trials [RCTs]).
USG steroid injections are also less painful than PG injections (SOR: A, multiple RCTs). They reduce pain more than PG injections in arthritic joints (shoulder, elbow, wrist, hand, hip, knee, or ankle) over 2 weeks (SOR: B, lower quality RCTs with some inconsistent results) but possibly not at 6 weeks (SOR: B, multiple RCTs with conflicting results).
EVIDENCE SUMMARY
A prospective RCT found that USG steroid joint injections improved shoulder function more than PG injections in patients with shoulder pain unresponsive to nonsteroidal anti-inflammatory drugs (NSAIDs).1 Investigators randomized 60 patients (mean age 52.5 years) to either USG or PG injections of triamcinolone 40 mg given by a rheumatologist. They used a 10-point visual analog scale (VAS) to assess pain and evaluated joint function at 6 weeks using a validated 100-point scale for shoulder function,2 with high scores indicating better function.
The USG group showed greater improvement from baseline in pain (TABLE)1,3-7 and function scores than the PG group (32 vs 12 points; P<.05).1 Investigators didn’t control for a possible placebo effect from ultrasound in this trial (or any trial described here). Another RCT found that USG steroid joint injections improved shoulder function more than PG injections in patients with rheumatoid arthritis and at least one month of shoulder pain unresponsive to NSAIDs.3 Investigators randomized 41 rheumatology clinic patients (mean age 52.4 years) to USG or PG injections of 20 mg triamcinolone.
They assessed function at 6 weeks with a validated 70-point shoulder function assessment tool designed for patients with rheumatoid arthritis,8 which evaluates pain with motion, range of motion, and activities of daily living (higher scores indicate better shoulder function), and used a 100-point VAS to assess pain.3 Function scores showed greater improvement from baseline in the USG group than the PG group (15 vs 6 points; P=.012), as did pain scores (TABLE).
Ultrasound injections hurt less than palpation-guided injections
Three RCTs, all using triamcinolone, found that USG joint injections were less painful than PG joint injections (TABLE).4-6 Three of 4 studies found that USG injections also were associated with lower pain scores 2 weeks after injection, as measured with a standardized VAS.1,3-7 A common weakness of the 3 studies demonstrating a difference at 2 weeks was that they compared end scores rather than the magnitude of change from baseline between groups.
Two of 3 RCTs found that USG injections produced a greater reduction in the VAS pain score at 6 weeks, although the negative study was larger than the other 2 combined—184 patients, compared with a total of 285 patients for all 3 studies.1,3,7
Recommendations
The American College of Radiology’s practice guidelines for musculoskeletal ultrasound examination recommend using ultrasound to guide interventional procedures.9 However, no consensus statements comment on the use of ultrasound as opposed to palpation for guiding steroid joint injections.
1. Ucuncu F, Capkin E, Karkucak M, et al. A comparison of the effectiveness of landmark-guided injections and ultrasonography-guided injections for shoulder pain. Clin J Pain. 2009;25:786-789.
2. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214:160-164.
3. Naredo E, Cabero F, Beneyto P, et al. A randomized comparative study of short term response to blind injection versus sonographic-guided injection of local corticosteroids in patients with painful shoulder. J Rheumatol. 2004;31:308-314.
4. Sibbitt WL Jr, Kettwich LG, Band PA, et al. Does ultrasound guidance improve the outcomes of arthrocentesis and corticosteroid injection of the knee? Scand J Rheumatol. 2012;41:66-72.
5. Sibbitt W Jr, Band PA, Kettwich LG, et al. A randomized controlled trial evaluating the cost-effectiveness of sonographic guidance for intra-articular injection of the osteoarthritic knee. J Clin Rheumatol. 2011;17:409-415.
6. Sibbitt WL Jr, Peisajovich A, Michael AA, et al. Does sonographic needle guidance affect the clinical outcome of intraarticular injections? J Rheumatol. 2009;36:1892-1902.
7. Cunnington J, Marshall N, Hide G, et al. A randomized, double-blind, controlled study of ultrasound-guided corticosteroid injection into the joints of patients with inflammatory arthritis. Arthritis Rheum. 2010;62;1862-1869.
8. van Den Ende CH, Rozing PM, Dijkmans BA, et al. Assessment of shoulder function in rheumatoid arthritis. J Rheumatol. 1996;23:2043-2048.
9. ACR-AIUM-SPR-SRU practice guideline for the performance of the musculoskeletal ultrasound examination. Updated 2012. American College of Radiology; 2007, updated 2012. Available at: http://amclc.acr.org/LinkClick.aspx?fileticket=z6ih9CEE6_w%3D&tabid=61. Accessed August 3, 2012.
1. Ucuncu F, Capkin E, Karkucak M, et al. A comparison of the effectiveness of landmark-guided injections and ultrasonography-guided injections for shoulder pain. Clin J Pain. 2009;25:786-789.
2. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214:160-164.
3. Naredo E, Cabero F, Beneyto P, et al. A randomized comparative study of short term response to blind injection versus sonographic-guided injection of local corticosteroids in patients with painful shoulder. J Rheumatol. 2004;31:308-314.
4. Sibbitt WL Jr, Kettwich LG, Band PA, et al. Does ultrasound guidance improve the outcomes of arthrocentesis and corticosteroid injection of the knee? Scand J Rheumatol. 2012;41:66-72.
5. Sibbitt W Jr, Band PA, Kettwich LG, et al. A randomized controlled trial evaluating the cost-effectiveness of sonographic guidance for intra-articular injection of the osteoarthritic knee. J Clin Rheumatol. 2011;17:409-415.
6. Sibbitt WL Jr, Peisajovich A, Michael AA, et al. Does sonographic needle guidance affect the clinical outcome of intraarticular injections? J Rheumatol. 2009;36:1892-1902.
7. Cunnington J, Marshall N, Hide G, et al. A randomized, double-blind, controlled study of ultrasound-guided corticosteroid injection into the joints of patients with inflammatory arthritis. Arthritis Rheum. 2010;62;1862-1869.
8. van Den Ende CH, Rozing PM, Dijkmans BA, et al. Assessment of shoulder function in rheumatoid arthritis. J Rheumatol. 1996;23:2043-2048.
9. ACR-AIUM-SPR-SRU practice guideline for the performance of the musculoskeletal ultrasound examination. Updated 2012. American College of Radiology; 2007, updated 2012. Available at: http://amclc.acr.org/LinkClick.aspx?fileticket=z6ih9CEE6_w%3D&tabid=61. Accessed August 3, 2012.
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