1. Introductions

2. Learning outcomes for day • To apply knowledge of anatomy in needle placement of injections of the shoulder, knee and foot • To understand the pharmacology of injectates • To understand the current evidence base supporting the use of joint injections, and where evidence is lacking • To apply knowledge of the evidence in practical decision making regarding injections • To understand the indications for, and procedure of hydro dilation in adhesive capsulitis

4. Frozen shoulder/ Adhesive Capsulitis • What is it – define? • Who gets it (M:F, age?) / what are the risk factors • How common is it? • Typical clinical presentation • What investigations are relevant and what would they demonstrate? • What is the management?

5. Evidence for Intra-articular Injections for RA, OA & various Soft Tissue Diseases Dr Zoe Paskins Clinical Lecturer and Honorary Consultant Rheumatologist

6. Q - What is evidence based medicine?

7. ‘The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’. Sackett et al, BMJ 1996

8. Hollander Arthritis and Allied Conditions 1972 “…since…1951 we have administered intrasynovial injections of steroids over 250,000 times into more than 8,000 patients who had inflamed joints, bursae or tendon sheaths. The generally favourable response in symptomatology… has been confirmed in more than 100 reports in the literature.”

9. Treatment of rheumatoid joint inflammation with intrasynovial triamciniolone hexacetonide McCarty et al J Rheumatol 1995;22:1631-5 • Historical review • 140 patients with RA • 956 injections with Triamcinolone hexacetonide • Joint immobilisation post injection • eg crutch-walking for 4 weeks • Mean follow up 7 years • “Sustained clinical remission” in 75% of injected joints • Side effects: No infections; 2 tendon ruptures

10. Polyarticular corticosteroid injection versus systemic administration in treatment of RA patientFurtado, Oliveira and Natour J Rheumatol 2005;32:1691-8 • 75 patients with RA • Randomised to multiple concomitant IA triamcinolone injections or equivalent IM dose (minimum 160mg) • Outcome • ACR improvement criteria at baseline 1,4,12,24 weeks • Any adverse effects

11. Furtado et al 2005 Fewer side effects in IA group

12. Importance of synovial fluid aspiration when injecting intra-articular corticosteroidsWeitoft and Uddenfeldt Ann Rheum Dis 2000;59:233-235 • 147 patients (191 knees) with RA • Patients randomised to arthrocentesis or no arthrocentesis • All were injected with triamcinolone • Outcome: relapse of inflammation in the injected joint

13. Weitoft and Uddenfeldt 2000

14. Cochrane review Wallen and Gillies 2006 • Efficacy of IACS in adult RA and JIA • 5 RCTs included IACS knee in adult RA • Concluded that effect on range of movement (up to 12 weeks), pain, knee swelling (up to 6 weeks), morning stiffness. • No harm identified • Effects appear to be dose dependant

15. JIA • Retrospective case review of 220 patients • Multiple (>3) IACS associated with ‘sustained joint remission in a substantial proportion of patients’ • 66% flared • 33% remission post IAC Papadopoulou et al, 2013 Arthritis Care Res

16. OA RCT evidence

17. OA: RCT evidence *Bellamy et al, Cochrane 2005 Atchia, Robinson, Qvistagard, ** Kullenberg 2004, Lambert 2007 ***Bahadir, 2009

18. OA: predictors of response of IACS • Effusion • Synovitis • Pain • BMI • Gender • Illness beliefs • Radiographic severity • Age • USGI

19. OA knee: predictors of response of IACS Maricar, 2013 • Effusion • Absence of Synovitis • Pain • BMI • Gender • Illness beliefs • Radiographic severity • Age • USGI

20. OA hip: predictors of response of IACS Atchia, 2011 Robinson, 2007 Desmukh, 2011 • Effusion • Synovitis • Pain • Lower BMI • Gender • Illness beliefs • Radiographic severity • Age • USGI

21. Why might the evidence not align with our clinical impressions?

22. Limitations of Studies of IACS • N = Small • Different injectates, different doses • Different controls • Population of severe disease?

23. Soft Tissue • Plantar fasciitis • USGI reduces pain at 4/52 (McMillan 2012) • Recommended in NICE CKS after conservative treatment • Achilles tendonitis • 1: 40 rupture. Do not inject • Tennis Elbow • In patients with symptoms for >6/52, CSI resulted in higher rate of recurrence at 12/12 (Coombes 2013)

24. Is the effectiveness of ultrasound guided joint injections supported by evidence?

25. The evidence • Does accuracy improve efficacy? • YES (Jones, 1993) • Does ultrasound improve accuracy? • YES* • Does ultrasound improve efficacy? • Yes, in some joints • shoulders in RA, 6/52 pain and function (Naredo 2003) • Are USGI clinically effective? • Are USGI cost effective? *although knee accuracy 87% unblinded

26. Summary • Evidence based medicine uses the best available evidence • Systematic review/ RCTs do support the clinical effectiveness of IACS in RA, OA knee and hip • Caution with soft tissue injections for tennis elbow and achilles tendonitis.. poorer clinical outcomes

27. Questions?

28. Acknowledgements (Plus any other acknowledgements you may have)