Journal-based CME article
Comparison of High- and Low-Dose Corticosteroid in Subacromial Injection for Periarticular Shoulder Disorder: A Randomized, Triple-Blind, Placebo-Controlled Trial

https://doi.org/10.1016/j.apmr.2011.06.033Get rights and content

Abstract

Hong JY, Yoon S-H, Moon DJ, Kwack K-S, Joen B, Lee HY. Comparison of high- and low-dose corticosteroid in subacromial injection for periarticular shoulder disorder: a randomized, triple-blind, placebo-controlled trial.

Objective

To determine whether subacromial injection with high-dose corticosteroid in patients with periarticular shoulder disorders is better than low-dose corticosteroid or placebo in improving pain, function, and active range of motion (AROM).

Design

Multicenter, randomized, triple-blind, placebo-controlled trial.

Setting

Primary (n=2) and university-affiliated (n=1) tertiary-care hospitals.

Participants

Volunteers (N=79) with periarticular shoulder disorders with at least 1 month's duration of pain.

Intervention

Participants were randomly assigned to receive ultrasound-guided subacromial injection with triamcinolone acetonide, 40 or 20mg, or placebo. After a single injection, participants were followed up for 8 weeks.

Main Outcome Measures

Visual analog scale (VAS) of average shoulder pain level during the past 1 week, Shoulder Disability Questionnaire (SDQ), and angles of shoulder AROM (including flexion, abduction, external rotation, internal rotation) pre- and posttreatment at weeks 2, 4, and 8.

Results

There were no significant differences among the 3 groups (triamcinolone acetonide, 40mg, group 1, n=27; triamcinolone acetonide, 20mg, group 2, n=25; placebo, group 3, n=27) in terms of demographic and clinical characteristics at baseline. (1) Within-group comparison: VAS score, SDQ score, and AROM for groups 1 and 2 significantly improved at weeks 2, 4, and 8 (P<.0167). However, there was no difference in VAS score, SDQ score, and AROM scores for group 3. (2) Between-group comparison: significant differences in VAS score, SDQ score, and abduction, external rotation, and internal rotation of AROM were shown between groups 1 and 2 and group 3 at weeks 2, 4, and 8 (P<.05).

Conclusions

This was the first study to assess the efficacy of corticosteroid according to 2 different doses, which are the most widely used in subacromial injection for participants with periarticular shoulder disorders. This study showed no significant differences between the high- (triamcinolone acetonide, 40mg) and low-dose (20mg) corticosteroid groups, indicating preferred use of a low dose at the initial stage.

Section snippets

Program Overview

Shoulder pain accounts for 33.2% of physician office visits for musculoskeletal pain in the United States. The prevalence of shoulder pain is 7% to 27% for adults and is increasing for women and older individuals. The most frequent cause of shoulder pain is subacromial impingement syndrome (SIS), which includes a number of pathological entities: rotator cuff syndrome, tendonitis and bursitis in the shoulder. SIS occurs when the soft tissues of the glenohumeral joint between the coracoacromial

Accreditation Statement

This journal-based activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the sponsorship of the Elsevier Office of Continuing Medical Education (EOCME). The EOCME is accredited by the ACCME to provide continuing medical education (CME) for physicians.

Credit Designation Statement

The EOCME designates this journal-based activity for a maximum of 3.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity. All other health care professionals completing continuing education credit for this activity will be issued a certificate of participation.

Educational Objectives

To support the attainment of knowledge, competence, and performance, the learner should be able to achieve the following objective:

  • 1

    Describe the evidence-base supporting the effectiveness of corticosteroid injections for subacromial impingement syndrome

  • 2

    Demonstrate their ability to develop a treatment plan based on current evidence

Planning Committee

Ji Yeon Hong, MD, Seung-Hyun Yoon, MD, PhD, Do Jun Moon, MD, Kyu-Sung Kwack, MD, PhD, Bohyun Joen, MD, Hyun Young Lee, MS, Tania Dickson, PhD.

Faculty Profiles & Disclosure Information

As a sponsor accredited by the ACCME, it is the policy of the EOCME to require the disclosure of anyone who is in a position to control the content of an educational activity. All relevant financial relationships with any commercial interests and/or manufacturers must be disclosed to participants at the beginning of each activity. The faculty of this educational activity discloses the following:

Ji Yeon Hong, MD

Department of Physical Medicine and Rehabilitation

Ajou University School of Medicine and Ajou University Hospital, Suwon

Republic of Korea

Disclosures: Has nothing to disclose.

Seung-Hyun Yoon, MD, PhD

Department of Physical Medicine and Rehabilitation

Ajou University School of Medicine and Ajou University Hospital, Suwon

Republic of Korea

Disclosures: Has nothing to disclose.

Do Jun Moon, MD

Department of Physical Medicine and Rehabilitation

Goyang Healings Hospital, Goyang

Republic of Korea

Disclosures: Has nothing to disclose.

Kyu-Sung Kwack, MD, PhD

Department of Radiology

Ajou University School of Medicine and Ajou University Hospital, Suwon

Republic of Korea

Disclosures: Has nothing to disclose.

Bohyun Joen, MD

Department of Physical Medicine and Rehabilitation

Ajou Good Hospital, Suwon

Republic of Korea

Disclosures: Has nothing to disclose.

Hyun Young Lee, MS

Regional Clinical Trial Center

Ajou University School of Medicine and Ajou University Hospital, Suwon

Republic of Korea

Disclosures: Has nothing to disclose.

EOCME Staff

Tania Dickson, PhD

Disclosures: Has nothing to disclose

Resolution of Conflict of Interest

The EOCME has implemented a process to resolve conflict of interest for each CME activity. In order to help ensure content objectivity, independence, and fair balance, and to ensure that the content is aligned with the interest of the public, the EOCME has resolved the conflict by external content review.

Unapproved/Off-Label Use Disclosure

The EOCME requires CME faculty to disclose to the participants:

  • 1

    When products or procedures being discussed are off-label, unlabeled, experimental, and/or investigational (not US Food and Drug Administration [FDA] approved); and

  • 2

    Any limitations on the information presented, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion. Faculty may discuss information about pharmaceutical agents that is outside of FDA-approved labeling. This

Intended Audience

This program is intended for physicians and healthcare professionals responsible for the comprehensive care for individuals with chronic illness and disabilities.

Method of Participation

In order to claim credit, participants must complete the following:

  • 1

    Pre-activity self-assessment questions

  • 2

    Read the activity

  • 3

    Complete the CME Test and Evaluation. Participants must achieve a score of 70% on the CME Test.

Participants can complete the pre-activity self-assessment and CME Test and Evaluation online by logging-on to http://www.elsevierOCME.com/910472-5. Upon successful completion of the online tests and evaluation form, you can instantly download and print your certificate of credit.

CME Inquiries

For all CME certificate inquiries, please contact Sandy Breslow at [email protected].

Release Date of Activity: December 2011

Expiration Date of Activity for

AMA PRA Credit: November 30, 2012

Estimated Time to Complete This Activity: 3.0 hours

Participants

Between October 2009 and September 2010, eligible participants with shoulder pain were recruited by displaying posters in the rehabilitation clinic of a university hospital in Suwon, Korea, and 2 other local outpatient clinics in Suwon and Goyang. All participants underwent a standardized history and physical examination. We also carried out active and passive range of movement and the painful arc test and checked for tenderness and/or swelling of the lesion in the affected shoulder.

The Neer17

Results

Table 1 lists baseline characteristics of study participants, which were similar for all 3 randomization groups, whereas table 2 lists ultrasound findings of the affected shoulder.

Discussion

To our knowledge, this is the first study to assess the efficacy of corticosteroid (triamcinolone acetonide) according to 2 different doses, which are the most widely used in subacromial injection for participants with periarticular shoulder disorders diagnosed clinically and ultrasonographically. Compared with pretreatment (within-group comparisons), the high- (triamcinolone, 40mg) and low-dose corticosteroid (triamcinolone, 20mg) groups showed improvement in pain, disability, and AROM,

Conclusions

This is the first study to assess the efficacy of corticosteroid according to 2 different doses (triamcinolone acetonide, 20mg, 40mg), which are the most widely used in subacromial injection for participants with periarticular shoulder disorders. Initial use of a low dose is encouraged because there was no difference in efficacy according to dose, and the effect of corticosteroid lasted up to 8 weeks.

Suppliers

Acknowledgment

We thank Aeree Park, MA, for translation of the manuscript.

References (60)

  • A. Frost et al.

    The painful shoulder

    Surgery (Oxford)

    (2006)
  • B.K. Coombes et al.

    Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials

    Lancet

    (2010)
  • P. Creamer

    Intra-articular corticosteroid treatment in osteoarthritis

    Curr Opin Rheumatol

    (1999)
  • A. Johansson et al.

    Local corticosteroid application blocks transmission in normal nociceptive C-fibres

    Acta Anaesthesiol Scand

    (1990)
  • J.G. Skedros et al.

    Variations in corticosteroid/anesthetic injections for painful shoulder conditions: comparisons among orthopaedic surgeons, rheumatologists, and physical medicine and primary-care physicians

    BMC Musculoskelet Disord

    (2007)
  • C. Plafki et al.

    Local anaesthetic injection with and without corticosteroids for subacromial impingement syndrome

    Int Orthop

    (2000)
  • A.O. Adebajo et al.

    A prospective double blind dummy placebo controlled study comparing triamcinolone hexacetonide injection with oral diclofenac 50 mg TDS in patients with rotator cuff tendinitis

    J Rheumatol

    (1990)
  • N. Walsh et al.

    Injection procedure

  • S. Saunders

    Injection techniques in orthopaedic and sports medicine

    (2002)
  • M. Kesson et al.

    Musculoskeletal injection skills

    (2003)
  • E. Naredo 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)
  • J.J. Cush et al.

    Rheumatology: diagnosis and therapeutics

    (2005)
  • S. Bianchi et al.

    Ultrasound of the musculoskeletal system

    (2007)
  • B. Blair et al.

    Efficacy of injections of corticosteroids for subacromial impingement syndrome

    J Bone Joint Surg Am

    (1996)
  • R.H. White et al.

    Rotator cuff tendinitis: comparison of subacromial injection of a long acting corticosteroid versus oral indomethacin therapy

    J Rheumatol

    (1986)
  • M. Petri et al.

    Randomized, double-blind, placebo-controlled study of the treatment of the painful shoulder

    Arthritis Rheum

    (1987)
  • F. Ucuncu et al.

    A comparison of the effectiveness of landmark-guided injections and ultrasonography guided injections for shoulder pain

    Clin J Pain

    (2009)
  • B. Arroll et al.

    Corticosteroid injections for painful shoulder: a meta-analysis

    Br J Gen Pract

    (2005)
  • R.J. Hawkins et al.

    Impingement syndrome in athletes

    Am J Sports Med

    (1980)
  • J.L. Leroux et al.

    Diagnostic value of clinical tests for shoulder impingement syndrome

    Rev Rhumatis

    (1995)
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