This week’s blog has been stimulated by a recent publication in The Journal of the American Medical Association evaluating the use of regular intra-articular corticosteroid injections for symptom management and cartilage volume in osteoarthritis (OA) of the knee ( McAlindon, LaValley, & Harvey, 2017). Previous research had suggested that the inflammatory process in the knee was associated with both pain and progression of cartilage loss, however, this trial clearly demonstrated a greater loss of cartilage after two years of 3 monthly intra-articular triamcinolone injections compared with the same frequency of saline injections.
It seems pretty clear then that we should avoid long-term use of intra-articular steroid within the knee and probably other synovial joints. Previous research, also published in JAMA, indicates that steroid can also have a negative impact in the long term on lateral epicondylalgia (Coombes, Bisset, & Brooks, 2013). Furthermore, a systematic review of the effects of local corticosteroid on tendon clearly concluded that the impact was negative both in vitro and in vivo (Dean, Lostis, & Oakley, 2014).
In shoulder pain it does not seem to matter whether or not the steroid is injected into the presumed target based on imaging, or whether it is injected into the buttock. Moreover, given the anatomical vulnerability of the human supraspinatus tendon and its propensity for destruction with age, combined with the known negative effects of steroid on tendon, it looks as though we should avoid steroid in the shoulder too.
So what do we do if we do not inject steroid into our peripheral sources of musculoskeletal pain? We can try injecting other things. Diclofenac, botulinum toxin or maybe normal saline – the latter seems to do very well when used as a control procedure in trials, in terms of the change from baseline. Having been brought up to accept steroid injection as a standard conventional procedure, it was a major surprise to find that needles alone (dry needling or local acupuncture) in tender muscle appeared to be highly effective. Having got over this surprise I was guided through the process of my first systematic review to find that virtually none of the trials of needling and injection therapies in myofascial trigger point pain demonstrated superiority for any individual technique. Indeed, saline injection (the intended control procedure) proved superior in most outcomes of one particularly good quality trial (Frost, Jessen, & Siggaard-Andersen, 1980).
Despite saline injection being no less effective in terms of pain relief than an ‘active’ comparator, and being associated with clinically meaningful changes from baseline in trials, we do not use it in practice. It has not been tested in a double blind randomized controlled trial, but what would we use in the control group of such a trial? Perhaps the needle without an injection. Then we have the challenge of blinding the practitioner, and we are getting closer to the dilemma of acupuncture research.
Acupuncture needles are less traumatic than hypodermic needles, and carry no risk related to the injected substance. They also carry less from the outside of the organism (skin flora and contaminants) into the internal environment because they lack the hollow bore of a needle for injection. In general we avoid needling into joint spaces with acupuncture needles despite the reduced theoretical risk of carrying in bugs from the outside. The best quality evidence for acupuncture in chronic pain related to osteoarthritis demonstrates and effect size (standardized mean difference) of 0.26 over sham acupuncture (minimal needling in the biggest trials) and an effect size of 0.57 over no acupuncture controls (waiting list, usual care, or guideline-based conventional care) ( Vickers, Cronin, & Maschino, 2012).For comparison, topical non-steroidal anti-inflammatory drugs have an effect size of 0.4 over placebo and oral preparations range from 0.29 to 0.44. So 0.57 looks pretty good if you don’t mind buying a bit of the relatively safe context of acupuncture.
In conclusion, I would recommend the acupuncture, perhaps adding electrical impulses as Jorge Vas did in 2004 (Vas, Mendez, & Perea-Milla, 2004) with an effect size of 1.21 (this was an outlier in the Vickers IPDM, but the only trial to use electro acupuncture (EA) to muscles around the knee compared with non-penetrating sham EA).
— Dr. Lana Moshkovich
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