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Yes / Cortico-steroid Injections (CSI) are commonly used to treat patients with Greater Trochanteric Pain Syndrome (GTPS) but it is unclear which patients will experience improvements in pain Objectives: To identify factors that influence improvements in pain for patients with GTPS treated with CSI Design: Systematic review Methods: A search was undertaken of AMED, CINAHL, Cochrane Library, EMBASE, Medline and PEDro databases. Studies were eligible for inclusion of they investigated factors that influenced changes in pain experienced by patients who received a CSI. Studies needed to include relevant summary statistics and tests of clinical significance. Risk Of Bias in Non-randomised Trials Of Interventions (ROBINS-I) and Risk of Bias 2 (ROB2) tools were used to assess bias. Results: The search identified 466 studies, 8 were included in the final review with a total of 643 participants. There was no association between demographic variables such as age, sex, symptom duration or obesity and pain outcomes post-CSI. Having a co-existing musculoskeletal (MSK) condition such as knee osteoarthritis or sacroiliac/lumbar spine pain was associated with less pain reduction post-CSI. Injections into the Trochanteric Bursa were associated with longer lasting pain reduction than Gluteus Medius Bursa or extra-bursal injections. Image guidance of CSI maintained lower pain scores at six months but did not increase the duration of the therapeutic effect past six months. The presence of specific ultrasound scan features was not associated with differences in pain scores. Conclusions: Patients with co-existing MSK conditions may not respond to CSI as well as those without. Injections into the Greater Trochanteric Bursa may have longer lasting benefit. Further research is needed on the use of USS imaging findings and image guidance. / This work was completed as part of a pre-doctoral fellowship funded by the National Institute of Health Research [NIHR301938, 2021].

The supraspinatus tendon is an important structure of the rotator cuff. Subacromial impingement is a common reason for shoulder pain. Despite extensive scientific work in this field, the cause of impingement syndrome is still not fully understood. The general aim of the present thesis was to generate new knowledge with respect to pathogenesis and treatment of impingement syndrome. A combination of animal and clinical studies were performed. Different methods were used such as histology, immunohistochemistry, development and assessment of a novel measuring device and clinical and radiological assessment. Thirty rats were injected with triamcinolone or saline into the subacromial bursa. After five corticosteroid injections, we found focal inflammation, degradation and fragmentation of collagen bundles in the supraspinatus tendon, whereas the control specimens were normal (p=0.035). Subacromial bursitis was induced by injections of carrageenan into the subacromial space (n=28). Fibrocartilaginous metaplasia and bony metaplasia were found in the supraspinatus tendon. Even in specimens with no histologic changes of the collagen bundles the staining for fibronectin was significantly increased. The distance between the anterolateral acromion and the supraspinatus tendon was measured in patients with impingement syndrome intraoperatively (n=30) and in controls (instability, n=15). The mean value of the subacromial distance in controls was 16 mm, the 95% mean confidence limits between 14 and 18 mm. The mean value in the group of patients with impingement syndrome was 8 mm before and 16 mm after the decompression. Fifty patients were reviewed after arthroscopic subacromial decompression. Twenty-five showed calcific deposits in the rotator cuff on radiographs preoperatively. In 13 patients the calcific deposits totally disappeared postoperatively. In another six patients the calcifications had decreased in size. Four patients still showed calcifications, which were 5 mm or greater in size. The postoperative results measured by the Constant score were almost identical in the calcific and the non-calcific groups. Tillander 010916 8 Human surgical supraspinatus tendon specimens were studied from patients with impingement (n=16), ruptured supraspinatus tendons (n=7) and controls (n=10). Degradation of tendinous tissue and fibrin were found only in some specimens from ruptures. The difference in fibronectin staining was significant between controls and patients with a rupture (p=0.002). Fibrosis and thinning of fascicles seemed to be a more non-specific finding, appearing in control, impingement and rupture specimens. In conclusion, subacromial corticosteroid injections may cause rupture of the supraspinatus tendon. Metaplasia of the supraspinatus tendon may play a role in the pathogenesis of impingement and rupture of the supraspinatus tendon. The subacromial distance can be measured intraoperatively and was shown to be lower in patients with impingement than in patients with instability. Calcifications disappear or decrease in size after arthroscopic subacromial decompression and do not seem to influence the postoperative outcome in patients with impingement. Degradation of tendon tissue, fibrin and fibronectin appear to be signs of tendon degeneration, whereas fibrosis and thinning of fascicles were found also in controls.

Background: Intra-articular corticosteroid injections (IACI) are a commonly used treatment for painful knee osteoarthritis (OA). Response to treatment varies the reason for which is unclear. Further there are no data concerning the impact of accuracy of injection and psychological factors including illness perceptions, pain catastrophizing and depression on outcome following IACI.Objectives: i) to undertake a systematic review looking at predictors of response to IACI in patients with symptomatic knee OA and, ii) to determine the role of psychological factors and accuracy of injection in predicting response to IACI.Methods: A systematic review was conducted using electronic databases for randomised trials and observational studies looking at predictors of response to IACI in knee and hip OA. An observational study of 141 consenting patients (105 primary OA and 36 secondary OA in the context of well controlled rheumatoid arthritis) receiving routine IACI as part of clinical care for knee OA was conducted including baseline assessment and outcome assessments at 3 and 9 weeks. Response was defined as at least 40% reduction of pain from baseline, using the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Assessment included ultrasound (US) for features of synovial inflammation), radiographs, and assessment of psychological factors including the revised illness perception questionnaire (IPQR). Accuracy of injection was assessed using US. Characteristics of responders and non-responders to IACI at 3 and 9 weeks were determined using univariate statistics and significant factors entered into logistic regression models. Results: The systematic review found no consistent evidence for any disease or non-disease related predictor of response and no systematic exploration of the effects of psychological factors or accuracy of injection on treatment response. In the observational study, 83 (53%) of 141 subjects were responders to IACI at 3 weeks and 56 (44%) at 9 weeks. In univariate analysis, responders to treatment had higher scores for the IPQR domain treatment control and lower scores for IPQR consequences, depression and pain catastrophizing at both 3 and 9 weeks. Physical and patient related factors, including accuracy of injection and US features, were not associated with outcome, with the exceptions of higher baseline pain and previous experience of injection being associated with non-response at 9 weeks. In multiple regression, treatment control was the only independent predictor of response at 3 weeks. At 9 weeks, treatment control, consequences and depression were independent predictors of treatment outcome. Conclusion: In this observational study illness perceptions and depression predicted the outcome of IACI at 3 and 9 weeks. By contrast, physical factors including accuracy of injection did not influence outcome. Further work is needed to replicate these findings and elucidate mechanisms for these effects.

Although glucocorticoids are often used as an adjunct to epinephrine to treat anaphylactic shock, glucocorticoids can also be a rare cause of anaphylactic shock. Only through the administration of a challenge dose of different glucocorticoids and different substrates that glucocorticoids are delivered in can the determination be made about which glucocorticoid or accompanying solvent may be the culprit which caused the anaphylactic reaction. These challenge tests should only be performed in a controlled environment as repeat anaphylaxis is a risk, especially if the patient has a history of glucocorticoid-induced anaphylaxis.

Bakgrund: Subakromiell smärta är ett vanligt förekommande muskuloskeletalt besvär. Behandlingen består ofta av antingen styrketräning, kortisoninjektion eller en kombination av behandlingsformerna.  Syfte: Att undersöka effekten av kombinerad behandling (styrketräning och kortisoninjektion) jämfört med enbart styrketräning som behandling för subakromiell smärta samt att utföra en kvalitetsgranskning och en bedömning av den sammanvägda tillförlitligheten. Metod: En systematisk litteraturöversikt utifrån formulerat PICO. Systematiska sökningar utfördes i databaserna AMED, CINAHL, PEDro, PubMed och Web of Science. Genomförande av kvalitetsgranskning enligt granskningsmallen PEDro och bedömning av den sammanvägda tillförlitligheten enligt ”Bedömning av den sammanvägda tillförlitligheten i systematiska översikter”. Resultat: Motstridiga resultat visades gällande effekten av kombinerad behandling. Totalt 8 studier inkluderades till kvalitetsgranskningen där resultatet varierade från medel till hög kvalitet. Av dessa bedömdes den sammanvägda tillförlitligheten i 6 studier. För funktion var den måttligt hög till att ingen effekt kan ses av interventionen. För smärta och rörelseomfång var tillförlitligheten låg respektive mycket låg till att effekt ses av interventionen. Konklusion: Det har inte varit möjligt att fastslå vilken effekt en kombinerad behandling jämfört med styrketräning har på smärta, funktion och rörelseomfång på kort sikt då resultaten har varit motstridiga. Inga långsiktiga effekter har observerats. Tillförlitligheten för funktion var måttligt hög till att ingen effekt ses av interventionen. För smärta bedömdes den som låg och för rörelseomfång som mycket låg till att effekt ses av interventionen. Framtida forskning bör fokusera på att utföra studier med mer likvärdiga interventioner för att kunna utvärdera effekten av kombinerad behandling jämfört med styrketräning för personer med subakromiell smärta. / Background: Subacromial pain syndrome is a common musculoskeletal condition. The treatment consists of either physiotherapy, corticosteroid injection or a combination of the two. Objective: To research the effects of a combined treatment compared to exclusively resistance training in individuals with subacromial pain syndrome and to assess the quality of the evidence as well as the overall reliability.  Method: A systematic review. Systematic searches were conducted using the databases AMED, CINAHL, PEDro, PubMed and Web of Science. The quality of the evidence was assessed using the PEDro scale. The overall reliability was assessed using “Bedömningen av den sammanvägda tillförlitligheten i systematiska översikter”.  Results: Contradictory results were found regarding the effect of combined treatment. A total of 8 studies were included in the quality assessment, with results varying from moderate to high quality. Of these, the overall reliability was assessed in 6 studies. The reliability for the outcome measure of function was assessed as moderately high that no effect of the intervention could be observed. Effects from the intervention on pain and range of motion were found to have low and very low reliability, respectively.  Conclusion: It has not been possible to determine the effect of combined treatment compared to resistance training on pain, function and range of motion in the short term, as the results have been conflicting. No long term effects have been observed. Overall reliability for the outcome measure of function was assessed as moderately high that no effect could be seen from the intervention. Effects on pain and range of motion from the intervention were found to have low and very low reliability, respectively. Future research should focus on conducting studies with more comparable interventions to evaluate the effect of combined treatment compared to resistance training for individuals with subacromial pain.

Contexte Un objectif important de la prise en charge de l'arthrite juvénile oligoarticulaire serait d'altérer le cours de la maladie à l'aide d'une thérapie hâtive. Nous avons étudié l'effet des injections intra-articulaires de corticostéroïdes hâtives sur les chances d'atteindre un décompte d'articulation active de zéro et une maladie inactive. Méthode Les données démographiques, cliniques et thérapeutiques des patients avec oligoarthrite juvénile enrôlés dans une étude prospective longitudinale pancanadienne ont été collectées pendant 2 ans. Une injection hâtive était définie comme étant reçue dans les 3 premiers mois suivant le diagnostic. Les équations d'estimation généralisées ont été utilisées pour l'analyse statistique. Résultats Trois cent dix patients ont été inclus. Cent onze (35.8%) ont reçu une injection hâtive. Ces derniers avaient une maladie plus active lors de l'entrée dans l'étude. Les patients exposés à une injection hâtive avaient une chance similaire d'obtenir un décompte d'articulation active de zéro, OR 1.52 (IC95% 0.68-3.37), p=0.306 mais étaient significativement moins à risque d'avoir une maladie inactive, OR 0.35 (IC95% 0.14-0.88), p=0.026. Interprétation Dans cette cohorte de 310 patients avec oligoarthrite juvénile, les injections hâtives de corticostéroïdes n'ont pas mené à une probabilité plus élevée d'atteindre un décompte d'articulation active de zéro ou une maladie inactive. Des problématiques méthodologiques intrinsèques à l'utilisation de données observationnelles pour fins d'estimation d'effets thérapeutiques auraient pu biaiser les résultats. Nous ne pouvons affirmer avec certitude que les injections hâtives n'améliorent pas le décours de la maladie. Des études prospectives adressant les limitations soulevées seront requises pour clarifier la question. / Background One of the goals in oligoarticular juvenile idiopathic arthritis would be to alter the disease course with early therapy. We examined the association between early intra-articular corticosteroid injections and the achievement of an active joint count of zero and inactive disease during the first two years after study enrollment. Methods We included oligoarticular juvenile idiopathic arthritis patients enrolled into a prospective longitudinal cohort across Canada. Demographic, clinical and treatment-related information were collected. Early intra-articular corticosteroid injections was defined as having received the first injection within 3 months of diagnosis. Generalized estimating equations were used for data analysis. Results A total of 310 patients were included, of whom 111 (35.8%) received an early injection. Participants who received an early injection had more severe disease at baseline. Patients exposed to early injections had a similar chance to achieve an active joint count of zero, OR 1.52 (95%CI 0.68-3.37), p=0.306 but were significantly less likely to achieve inactive disease, OR 0.35 (95%CI 0.14-0.88), p=0.026. Interpretation In this cohort of 310 oligoarticular juvenile idiopathic arthritis patients, early intra-articular corticosteroid injections did not result in an increased risk of achieving an active joint count of zero or inactive disease. Methodological issues encountered when estimating treatment effect using observational data might have biased the estimates obtained. Firm conclusion on the inefficacy of early injections in improving outcomes in this population cannot be drawn from this study. Prospective studies addressing the limitations raised will be needed to clarify if early injections can alter the disease course.