Steroid injection vs. physiotherapy for RCRSP
Article review of Daghiani et al., (2022)
Paper title and link to paper:
The effectiveness of comprehensive physiotherapy compared with corticosteroid injection on pain, disability, treatment effectiveness, and quality of life in patients with subacromial pain syndrome: a parallel, single-blind, randomized controlled trial (Daghiani et al., 2022)
Overview of the paper:
Steroid injection has been a topic of interest of mine. My bias within a rotator cuff related shoulder pain (RCRSP) population is to avoid, if possible, a steroid injection. The two main reasons for this bias include the following:
Five patients are needed to be injected with steroid for one patient’s pain to be transiently reduced to what a patient would describe as mild (Mohamadi et al., 2017)
Steroids seems to dampen down any healing response with an increase seen in unwanted glutamate receptors linked to excitotoxic damage to the tendon (Dean et al., 2014)
“Excitotoxicity is a phenomenon that describes the toxic actions of excitatory neurotransmitters, primarily glutamate, where the exacerbated or prolonged activation of glutamate receptors starts a cascade of neurotoxicity that ultimately leads to the loss of neuronal function and cell death. (Armada-Moreira et al., 2020)”
The GRASP trial and questions leading to the present study
This bias was slightly hit by the GRASP trial (Hopewell et al., (2021) which was published in the Lancet. Although providing no long-term benefit for having a steroid injection, the authors did note that best practice advice (one physio session) with the addition of a steroid injection was the most cost-effective treatment. This was despite no steroid injection and a progressive exercise (multiple physio sessions) intervention also being available within their 2 x 2 factorial study design.
What about just giving a patient a steroid and leaving them be? Would this be just as good? Do patients really need to do physiotherapy? The following paper tries to answer this.
Daghiani et al., (2022) looked at two groups with patients with RCRSP. They were randomised into either a comprehensive physiotherapy (CP) group or a subacromial corticosteroid injection (SCI) group. The SCI group had an unguided steroid injection into the subacromial bursa. They were discouraged from seeking any further support. The CP group involved three, face to face 45 minutes session a week, for four weeks. This involved ‘strengthening’ around the rotator cuff and scapular muscles, motor control exercises, and manual therapy. The intervention is shown below:
The study managed to recruit 25 patients in each group but with drop outs for various reasons, they ended up with 21 patients in the CP group and 23 patients in the SCI group. Following the initial assessment, outcomes of VAS, QuickDASH, SPADI, WORC, were reviewed at 4 weeks, 3 months and 6 months. GRC was also reviewed at 4 weeks.
Results
An ANOVA indicated a significant interaction between group and time for SPADI and WORC but not for the QuickDASH or VAS. As for the independent t-tests, patients in the CP group had statistically significantly lower SPADI, WORC and QuickDASH scores. No statistical significance was seen for VAS.
As for the GRC scores, 86% of patients in the CP group reported either ‘complete recovery’ or ‘very much improved’ for function at 4 weeks. This was compared to 40% in the SCI group. As for pain, 68% of the patients in the CP group reported either ‘complete recovery’ or very much improved’ at the 4-week mark. This was 36% in the SCI group.
What do we need to consider when looking at these results?
Small sample size with no power calculations (would a larger sample strengthen or weaken the findings?)
Younger population with no patient above the age of 65 (would older patients have worse outcomes?)
Symptom duration of the patients had an average of 5-6 months (would patients with a more chronic presentation have worse outcomes?)
Feasibility of doing the CP intervention in real practice (would 12 sessions over 4 weeks be feasible in a busy outpatient department?)
Adherence rates for exercise therapy may be higher than in normal practice with the patient being called routinely to make sure they did their exercise (how feasible and potentially annoying is this to keep calling patients)
No cost benefit analysis (is CP cost effective?)
What I did really like about this paper is that in their discussion they were open and honest about the findings and bringing caution to their interpretation. For example, in the results of the QuickDASH outcome measure (see below), the lower end of the mean confidence intervals did not reach the minimal clinically important difference (MCID). For the case of the QuickDASH outcome measure, this is 8 points (Mintken et al., 2009). So, although the confidence interval did not cross the line of no effect (i.e. 0), the true effect of treatment may be under the minimal clinically important difference. For further detail on confidence intervals read this concise paper by Steven Kamper.
What are the take away points from this paper?
Having a steroid injection alone produces similar pain-relieving effects to a comprehensive physiotherapy programme
A comprehensive physiotherapy programme without a steroid injection seems to be more effective in improving patient function and reducing disability than a steroid injection
Final thoughts
This paper may be helpful in some clinical situations when having discussions about treatment options for RCRSP. Something along the lines of…
“Having a steroid injection may be an option to give you pain relief. If you are wanting another option which may require more effort from yourself, a physiotherapy programme could help your pain and the functional limitations and disability that this problem has had on you. This is done without compromising your tissue health which is thought to occur with a steroid injection”
As always, if anyone has any comments, further reading or suggestions on this topic please feel free to fire them at me on here or on my Twitter. I am always learning and any discrepancies on what I have written is thoroughly encouraged.