Background Osteoarthritis (OA) is the most prevalent chronic joint disorder worldwide and is associated with significant pain and disability. Objectives To assess the effects of viscosupplementation in the treatment of OA of the knee. The products were hyaluronan and hylan derivatives (Adant, Arthrum H, Artz (Artzal, Supartz), BioHy (Arthrease, Euflexxa, Nuflexxa), Durolane, Fermathron, Go-On, Hyalgan, Hylan G-F 20 (Synvisc Hylan G-F 20), Hyruan, NRD-101 (Suvenyl), Orthovisc, Ostenil, Replasyn, SLM-10, Suplasyn, Synject and Zeel compositum). Search strategy MEDLINE (up to January (week 1) 2006 for update), EMBASE, PREMEDLINE, Current Contents up to July 2003, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched. Specialised journals and reference lists of identified randomised controlled trials (RCTs) and pertinent review articles up to December 2005 were handsearched. Selection criteria RCTs of viscosupplementation for the treatment of people with a diagnosis of OA of the knee were eligible. Single and double-blinded studies, placebo-based and comparative studies were eligible. At least one of the four OMERACT III core set outcome measures had to be reported (Bellamy 1997). Data collection and analysis Each trial was assessed independently by two reviewers for its methodological quality using a validated tool. All data were extracted by one reviewer and verified by a second reviewer. Continuous outcome measures were analysed as weighted mean differences (WMD) with 95% confidence intervals (CI). However, where different scales were used to measure the same outcome, standardized mean differences (SMD) were used. Dichotomous outcomes were analyzed by relative risk (RR). Main results Seventy-six trials with a median quality score of 3 (range 1 to 5) were identified. Follow-up periods varied between day of last injection and eighteen months. Forty trials included comparisons of hyaluronan/hylan and placebo (saline or arthrocentesis), ten trials included comparisons of intra-articular (IA) corticosteroids, six trials included comparisons of nonsteroidal anti-inflammatory drugs (NSAIDs), three trials included comparisons of physical therapy, two trials included comparisons of exercise, two trials included comparisons of arthroscopy, two trials included comparisons of conventional treatment, and fifteen trials included comparisons of other hyaluronans/hylan. The pooled analyses of the effects of viscosupplements against 'placebo' controls generally supported the efficacy of this class of intervention. In these same analyses, differential efficacy effects were observed for different products on different variables and at different timepoints. Of note is the 5 to 13 week post injection period which showed a percent improvement from baseline of 28 to 54% for pain and 9 to 32% for function. In general, comparable efficacy was noted against NSAIDs and longer-term benefits were noted in comparisons against IA corticosteroids. In general, few adverse events were reported in the hyaluronan/hylan trials included in these analyses. Authors' conclusions Based on the aforementioned analyses, viscosupplementation is an effective treatment for OA of the knee with beneficial effects: on pain, function and patient global assessment; and at different post injection periods but especially at the 5 to 13 week post injection period. It is of note that the magnitude of the clinical effect, as expressed by the WMD and standardised mean difference (SMD) from the RevMan 4.2 output, is different for different products, comparisons, timepoints, variables and trial designs. However, there are few randomised head-to-head comparisons of different viscosupplements and readers should be cautious, therefore, in drawing conclusions regarding the relative value of different products. The clinical effect for some products, against placebo, on some variables at some timepoints is in the moderate to large effect-size range. Readers should refer to relevant tables to review specific detail given the heterogeneity in effects across the product class and some discrepancies observed between the RevMan 4.2 analyses and the original publications. Overall, the analyses performed are positive for the HA class and particularly positive for some products with respect to certain variables and timepoints, such as pain on weight bearing at 5 to 13 weeks postinjection. In general, sample-size restrictions preclude any definitive comment on the safety of the HA class of products; however, within the constraints of the trial designs employed no major safety issues were detected. In some analyses viscosupplements were comparable in efficacy to systemic forms of active intervention, with more local reactions but fewer systemic adverse events. In other analyses HA products had more prolonged effects than IA corticosteroids. Overall, the aforementioned analyses support the use of the HA class of products in the treatment of knee OA.

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Viscosupplementation for the treatment of osteoarthritis of the knee

The importance and implications of aseptic techniques during regional anesthesia

Objective. This systematic review assessed the available published evidence on the efficacy and safety of using trigger point injection (TPI) to treat patients with chronic non-malignant musculoskeletal pain that had persisted for at least 3 months.

Methods.  All published systematic reviews or randomized controlled trials detailing the use of TPI in patients with chronic, non-malignant musculoskeletal pain (persisting for >3 months) were identified by systematically searching literature databases and the Websites of various health technology assessment agencies, research registers, and guidelines sites up to July 2006.

Results.  Although no systematic reviews were identified, 15 peer-reviewed randomized controlled trials met the inclusion criteria. However, deficiencies in reporting, small sample sizes, and marked inter-study heterogeneity precluded a definitive synthesis of the data. TPI is a safe procedure when used by clinicians with appropriate expertise and training. It relieved symptoms when used as a sole treatment for patients with chronic head, neck, shoulder, and back pain or whiplash syndrome, regardless of the injectant used, and may be a useful adjunct to intra-articular injection in the treatment of osteoarthritis pain. Although the addition of TPI to stretching exercises augments treatment outcomes, this was also true of other therapies such as ultrasound and laser.

Conclusion.  The efficacy of TPI is no more certain than it was a decade ago as, overall, there is no clear evidence of either benefit or ineffectiveness. The only advantage of injecting anesthetic into trigger points may be to reduce the pain of the needling process, which may not be an insignificant benefit.

Trigger Point Injections for Chronic Non-Malignant Musculoskeletal Pain: A Systematic Review

Epidural abscess with and without associated meningitis after epidural corticosteroid injections for radicular back pain is a rarely reported complication. We report the occurrence of an epidural abscess and meningitis in a 70-year-old man after 2 epidural corticosteroid injections for treatment of acute radicular lumbar back pain. At the time of diagnosis, cerebrospinal fluid cultures grew Staphylococcus aureus, and the patient was treated with intravenous antibiotics. Possible predisposing factors for the development of an epidural abscess and meningitis in this patient include a 2-year history of neutropenia and an accidental dural puncture that occurred during performance of the first epidural injection. A literature search identified 11 reported cases of epidural abscess, 2 of epidural abscess and meningitis, and 1 of meningitis attributed to epidural corticosteroid injections. Eight of the 14 reported patients were immunocompromised, and 8 (67%) of the 12 in whom cultures of blood, cerebrospinal fluid, or epidural pus were performed had results positive for S aureus. Antibiotic prophylaxis for S aureus should be considered for immunocompromised patients undergoing epidural corticosteroid injections.

Epidural abscess and meningitis after epidural corticosteroid injection.

Musculoskeletal pain affects a significant proportion of the general population. The myofascial trigger point is recognized as a key factor in the pathophysiology of musculoskeletal pain. Ultrasound is commonly employed in the treatment and management of soft tissue pain and, in this study, we set out to investigate the segmental antinociceptive effect of ultrasound. Subjects (n=50) with identifiable myofascial trigger points in the supraspinatus, infraspinatus and gluteus medius muscles were selected from an outpatient rehabilitation clinic and randomly assigned to test or control groups. Test subjects received a therapeutic dose of ultrasound to the right supraspinatus trigger point while control groups received a sham (null) exposure. Baseline pain pressure threshold (PPT) readings were recorded at the ipsilateral infraspinatus and gluteus medius trigger-point sites prior to ultrasound exposure. The infraspinatus point was chosen due to its segmental neurologic link with the supraspinatus point; the gluteus medius acted as a segmental control point. Following the ultrasound intervention, PPT readings were recorded at 1, 3, 5, 10 and 15 min intervals at both infraspinatus and gluteus medius trigger points; the difference between infraspinatus and gluteus medius PPT values, PPT seg, represents the segmental influence on the PPT. The ultrasound test group demonstrated statistically significant increases in PPT seg (decreased infraspinatus sensitivity) at 1, 3 and 5 min, when compared with PPT seg in the sham ultrasound group. These results establish that low-dose ultrasound evokes short-term segmental antinociceptive effects on trigger points which may have applications in the management of musculoskeletal pain.

Stimulation of myofascial trigger points with ultrasound induces segmental antinociceptive effects: a randomized controlled study.

https://rapm.bmj.com/content/rapm/28/5/389.full.pdf

Is skin disinfection with 10% povidone iodine sufficient to prevent epidural needle and catheter contamination?

Nervus intermedius neuralgia: an uncommon pain syndrome with an uncommon etiology.

Background and objectives: The purpose of this study was to investigate whether injection of trigger points with lidocaine combined with intra-articular hyaluronic acid injection would be more effective in pain reduction and assisting daily activities of patients with knee osteoarthritis then hyaluronic acid injection alone. Methods: Thirty-four, female, osteoarthritis patients were randomly assigned into two groups (hyaluronic acid group, n = 17; trigger point group, n = 17). Patients in the trigger point group received intraarticular 2 ml Na-hyaluronate injections and trigger point injections, three times with one-week intervals. The hyaluronic acid group received only hyaluronic acid injections. Before the treatment and 7 days after the third injection, the same physician who was blind to the treatment, assessed the intensity of pain at rest or during normal daily activities, activity restrictions, and joint range of motion. Results: A significant improvement of pain and reduction of activity ...

E. Alp Yentür

Papers

Is skin disinfection with 10% povidone iodine sufficient to prevent epidural needle and catheter contamination?

Nervus intermedius neuralgia: an uncommon pain syndrome with an uncommon etiology.

The role of trigger point therapy in knee osteoarthritis