Scenario - ND Center for Nursing



ScenarioA 40 year old white female presented to the clinic for right knee pain with exertion. The pain interfered with her active lifestyle and occupation, which required her to walk up and down steps. She has a known history of osteoarthritis and x-ray reveals progressive disease. The patient requested something be done because current therapy of ice/heat application, ROM exercises, and NSAIDs did not provide substantial relief. She asked if getting a steroid shot in the joint would provide better relief from the pain and wanted to know if this is a good option for her. Clinical QuestionIn patients with osteoarthritis(OA) who currently take NSAIDS for pain relief, does the addition of intraarticular (IA) injection of corticosteroid (such as depomedrol) improve severity of pain compared to patients who do not receive injections?ArticlesBellamy N, Campbell J, Welch V, Gee TL, Bourne R, Wells GA. (2009). Intraarticular corticosteroid for treatment of osteoarthritis of the knee (Review). The Cochrane Library. Issue 2. John Wiley and Sons, Ltd. Leung, A., Liew, D., Lim, J., Page, C., Boukris-Sayag, V., Mundae, M., Wong, M., Choong, P., Dowsey, M., Clemens, L., & Lim, K. (2011). The effect of joint aspiration and corticosteroid injections in osteoarthritis of the knee. International Journal of Rheumatic Disease, 14, 384-389Critical Review of StudyIn attempts to answer the clinical question, two studies were reviewed. The chosen studies include a Cochrane review and a retrospective pilot study. Both authors reviewed pain responses in patients with a diagnosis of OA who received IA injections compared to those who did not. A level 1A evidence study from the Cochrane collaboration was analyzed. Bellamy, Campbell, Welch, Gee, Bourne, and Wells (2009) reviewed results for increased pain management of intraarticular corticosteroid for treatment of OA. Twenty-eight randomized controlled studies were analyzed by the authors with 1973 total patients that met predefined selection criteria including current use of an NSAID, diagnosis of OA, and pain assessment. 13 of the trials the authors chose included comparisons of IA corticosteroid against placebo IA injections (usually saline or a suspending vehicle). The studies they selected in the meta-analysis were parallel-group design. Pain was assessed using several outcome measures that including number of patients reporting pain reduction and number of knees with improved pain. The pain scale utilized included the WOMACOA Index pain scale which includes pain during movement, at rest, at night, under pressure, and with active or passive range of motion. With review, the authors found that there was evidence of pain improvement with IA corticosteroids when compared to placebo at weeks 1-4, but then from weeks 5-24 post injection there was no compelling evidence of benefit. The conclusions were that there are beneficial effects of IA corticosteroids, but they are rapid in onset and may be relatively short lived. Limitations of this review include invested interest among some of the trials included by the authors. Four selected trials had direct sponsorship with pharmaceutical industry, financial support was acknowledge with five trials, and four had authors affiliated with industry. Comparison of different steroid preparations and dosages, as well as comparison to steroid verses synvisc was not reviewed or available. There may exist differences among different types of steroids. The authors also studied the diagnosis of OA only, so with the complication of different diagnosis could possibly come different outcomes. A level 4B retrospective, pilot study involved 110 patients with knee OA from a dedicated OA clinic in a Melbourne tertiary hospital from 2007 to 2009. Population included patients who had completed two Multiple Attribute Prioritization Tool (MAPT) questionnaires within 6 months of the initial review were included. The MAPT was designed to help prioritize patients on orthopedic waiting lists. Three groups were analyzed: patients who had no corticosteroid injection or aspiration, patients who received corticosteroid injections and patients who received joint aspiration with corticosteroid injections. The study found that patients who had both joint aspiration and injection reported an improvement in pain compared with those who had no injection (56.3% vs. 32.2%, P = 0.03). Those who had joint injections also did better than those without injection (62.7% vs. 32.2%, P = 0.001). Reduced analgesia use was noted in 12.5% of patients with aspiration and injection compared with 1.7% with no injection or aspiration ( P = 0.03). Improved walking distance was noted in 22.4% of patients who had injections compared with 8.5% of patients with no injections ( P = 0.03). This pilot study appears to show a beneficial trend in giving corticosteroid injections and to aspirate the knee in OA patients. Limitations include using a small, non-diverse population. The study acknowledges that further research is needed to address other factors like mechanical benefits, quadriceps strengthening and pain reduction with knee aspiration. Also, the effects that different volumes of fluid may have on knee can affect mechanics and symptoms, which this study did not take into account with the findings. Clinical Bottom LineBoth Bellemy, Welch, Campbell, Gee & Wells (2009) and Leung et al (2011) found a correlation with tangible benefits of corticosteroid IA use for patients with OA. The benefits have quick onset and short-lasting duration with minimal side effects and risks. For those patients with extensive disease progression, the steroid will likely not provide long term relief, but may help ease the pain short term and improve functional ability. However, it is important to remember that pain may have a protective role for the affected knee by causing a reduction in weight bearing. Therefore, simply alleviating pain may lead to further joint and cartilage damage. Not every patient will benefit from therapy, but in cases where other more conservative therapies have failed, results from both studies indicate that IA steroid use is a good option to try. Implications for practiceFor those patients not experiencing significant pain, first line of therapy should include NSAID medications. However, if this therapy does not provide substantial relief or progressively less relief, evidence supports that consideration of IA injection may afford much needed pain relief. In cases where there are obvious signs of inflammation, a corticosteroid preparation may offer opportunity for relief of inflammation and short term pain relief. ................
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