Systemic corticosteroids in treatment of common Rheumatological and MSK conditions
NHS England (2020) paper on the management of patients with musculoskeletal and rheumatic conditions offer that when RA is “active” (i.e., before starting drug treatment or during a disease flare in established RA), one-off administration of high-dose corticosteroid (CS), often by intramuscular (IM) injection, is recommended in clinical guidelines (e.g., American College of Rheumatology (ACR), European League against Rheumatism (EULAR), British Society for Rheumatology (BSR), and NICE Clinical Guidelines 79, 2009). Used to control a disease flare up compromising the patients ability to function, and consider using lower doses (max 120mg methylprednisolone). Physiotherapy practitioners deliver I/M gluteal injections as independent prescribers or under directive in Rheumatology departments.
The use of intramuscular gluteal injections for the relief of Musculoskeletal conditions has a long history, Valtonen (1976) offered benefit over placebo for supraspinatus tendon pain in 180 patients. Equally, Ekeberg et al (2009) found that in 106 patients no important differences in short term outcomes were found between local ultrasound guided corticosteroid injection into rotator cuff versus systemic gluteal corticosteroid injection, offering a clinical pathway to preserve tendon integrity.
Qiuke Wang (2022) compared Intra-articular (IA) glucocorticoid injection in patients with knee osteoarthritis (OA), with Intramuscular (IM) glucocorticoid injection with 145 patients with symptomatic knee osteoarthritis and found intramuscular injection of the glucocorticoid triamcinolone acetonide could present an inferior effect in reducing pain at 4 weeks compared with the intra-articular injection, but noninferiority of an intramuscular injection was observed at 8 and 24 weeks after injection, offering an alternative pain relief to repetitive intraarticular injection therapy which is suspected to degrade joints. Further trials are in
Dorleijn et al (2018) placebo blinded trial delivered just one I/M injection of 40mg or triamcinolone to the gluteal region of 52 hip osteoarthritis patients, showing significant benefit in pain scores at 2 weeks and 12 week follow ups, with functional improvements also seen using WOMAC outcomes. This offers an alternative to expensive and resource dependent intraarticular therapy.
Green (1975) delivered I/M dexamethasone for 7 days in disc herniation patients (n=100), who reported prompt relief of pain. That trial was of low quality. Hedeboe et al (1982) trial with placebo blinding (n=39) found nearly twice as many patients had benefit in the dexamethasone (n=13) group compared to the placebo (n=7), but concluded that as 50% of improved patients in either group had recurrences of pain, so at 3 months the benefit of Dexamethasone did not exceed that of placebo.
Friedman et al (2008) randomized, double-blind, placebo-controlled trial of patients with radicular low back pain (n= 133) and positive straight leg raise, who present to an emergency department (ED) were provided I/M 160mg methylprednisolone, results were in favour of the treatment group for pain (p=0.10), required analgesia and functional disability. This paper offers a suggestion of benefit and concludes further studies are required. Friedman et al (2006) found some benefits with a population of non-radicular low back pain ED patients (n=86) at 1 month post I/M injection, but this difference was not clinically significant.
In Abdel Shaheed et al (2020) systematic review and meta-analysis on the efficacy and harms of orally, intramuscularly or intravenously administered glucocorticoids for sciatica, there was low quality evidence from one study [n = 78] of moderate reduction in disability and small reduction in pain with single intramuscular administration of methylprednisolone. A commentary on this review by Bhatia (2020) offers epidural and nerve root injections are the commonest route for treatment for sciatica, which require resources and expertise, so clinicians in primary care setting resort to prescribing steroids orally or intramuscularly to treat sciatica. The literature published by Abdel Shaheed (2020) did not consider important factors such as comparison against recommended pharmacological treatments for neuropathic pain, from which many patients suffer side effects. Further research is underway.
A Cochrane systematic review by Chou et al (2022) discusses the limitations on the current evidence for radicular low back pain treated with systematic corticosteroids; yet includes 13 studies. Concluding moderate confidence about positive effects on short term pain and function and long term function, benefiting quality of life. They also offer that they have few side effects and harms, are of low cost and are widely available. Optimum dose is unknown, but avoiding repeating higher doses will reduce risk of harms. The review suggests that the systemic corticosteroids anti-inflammatory properties relieve pain by reducing swelling and thus pressure on nerves from discs narrowing of the foramen and inflammation in spinal joints narrowing the spinal canal.
The chartered society of physiotherapy public liability scheme 2023 covers all individual physiotherapy work: within the scope of physiotherapy practice – there is no list of ‘included’ activities but the treatment of animals, some professional footballers, spinal injection therapy, nerve blocks and acupuncture when used for fertility treatment are excluded. “Therapeutic injection therapy used as part of physiotherapy practice is covered by the CSP PLI scheme for members” CSP Information paper online (July 2023). The scheme provides (amongst other things) cover for claims of clinical negligence which arise from your individual physiotherapy work where you fail to provide a reasonable standard of care, causing harm to your patients that is proven to be wholly, or in part, from your negligence (CSP PLI scheme).
According to CSP clinical services online (2023) In advanced practice there are the three types of GP contract used in England by NHS commissioners for provision of overarching medical services that may include, for example, first contact practitioner (FCP), urgent care, minor injuries, and Out Of Hours services. These services are increasingly being offered by GP practice businesses which engage physiotherapists to deliver some of the clinical care as part of these services under these contracts. However, individual physiotherapists may have the individual capabilities to work in some of the roles offered as part of these contracts for example, FCP physiotherapy roles in MSK services. The Clinical Negligence Scheme for GPs (CNSGP) is a state-backed indemnity scheme in England, set up to indemnify these types of ‘medical services’ delivered under these contract types in Primary Care. This means that CSP members’ work in these services may be covered by the CNSGP, providing that you provide your clinical services directly to the contract service provider.
The CSP Practice guidance for Physiotherapy Prescribers PD026 Nov (2018) 8.1 you should prescribe according to the best available evidence in conjunction with clinical decision-making based on an individual’s circumstances when making prescribing decisions.
References
NHS England (2020). Management of patients with musculoskeletal and rheumatic conditions who: are on corticosteroids; require initiation of oral/IV corticosteroids; require a corticosteroid injection. 16 June 2020. © BSR BOA BASS RCGP BSIR FPM BPS CSP 16th June 2020
Valtonen EJ: Double acting betamethasone (Celestone Chronodose) in the treatment of supraspinatus tendinitis: a comparison of subacromial and gluteal single injections with placebo. J Int Med Res. 1978, 6 (6): 463-467.
Ekeberg OM, Bautz-Holter E, Tveita EK, Juel NG, Kvalheim S, Brox JI: Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: randomised double blind study. BMJ. 2009, 338: a3112-10.1136/bmj.a3112.
Dorleijn, D.M., Luijsterburg, P.A., Reijman, M. et al. Effectiveness of intramuscular corticosteroid injection versus placebo injection in patients with hip osteoarthritis: design of a randomized double-blinded controlled trial. BMC Musculoskelet Disord 12, 280 (2011). https://doi.org/10.1186/1471-2474-12-280
Qiuke Wang, MD, MSc1; Marianne F. Mol, MD1; P. Koen Bos, MD, PhD2; et al (April 5, 2022): Effect of Intramuscular vs Intra-articular Glucocorticoid Injection on Pain Among Adults With Knee Osteoarthritis. The KIS Randomized Clinical Trial. JAMA Netw Open. 2022;5(4):e224852. doi:10.1001/jamanetworkopen.2022.4852
Mol, M.F., Runhaar, J., Bos, P.K. et al. Effectiveness of intramuscular gluteal glucocorticoid injection versus intra-articular glucocorticoid injection in knee osteoarthritis: design of a multicenter randomized, 24 weeks comparative parallel-group trial. BMC Musculoskelet Disord 21, 225 (2020). https://doi.org/10.1186/s12891-020-03255-9
Dorleijn DMJ, Luijsterburg PAJ, Reijman M, Kloppenburg M, Verhaar JAN, Bindels PJE, Bos PK, Bierma-Zeinstra SMA. Intramuscular glucocorticoid injection versus placebo injection in hip osteoarthritis: a 12-week blinded randomised controlled trial. Ann Rheum Dis. 2018 Jun;77(6):875-882. doi: 10.1136/annrheumdis-2017-212628. Epub 2018 Mar 7. PMID: 29514801.
Green LN. Dexamethasone in the management of symptoms due to herniated lumbar disc. J Neurol Neurosurg Psychiatry. 1975 Dec;38(12):1211-7. doi: 10.1136/jnnp.38.12.1211. PMID: 1219086; PMCID: PMC492190.
Hedeboe J, Buhl M, Ramsing P (1982) Effects of using dexamethasone and placebo in the treatment of prolapsed lumbar disc. Acta Neurologica Scandinavica January 1982 vol 65 issue 1 https://doi.org/10.1111/j.1600-0404.1982.tb03055.x
Friedman BW, Esses D, Solorzano C, Choi HK, Cole M, Davitt M, Bijur PE, Gallagher EJ. A randomized placebo-controlled trial of single-dose IM corticosteroid for radicular low back pain. Spine (Phila Pa 1976). 2008 Aug 15;33(18):E624-9. doi: 10.1097/BRS.0b013e3181822711. PMID: 18665021; PMCID: PMC2597789.
Friedman BW, Holden L, Esses D, Bijur PE, Choi HK, Solorzano C, Paternoster J, Gallagher EJ. Parenteral corticosteroids for Emergency Department patients with non-radicular low back pain. J Emerg Med. 2006 Nov;31(4):365-70. doi: 10.1016/j.jemermed.2005.09.023. PMID: 17046475.
Abdel Shaheed C, Maher CG, Buchbinder R, Ng B, Enke O, Guzowski R, McLachlan AJ, Day RO, Richards B, Latimer J, Lin CC. Efficacy and harms of orally, intramuscularly or intravenously administered glucocorticoids for sciatica: A systematic review and meta-analysis. Eur J Pain. 2020 Mar;24(3):518-535. doi: 10.1002/ejp.1505. Epub 2020 Jan 30. PMID: 31715647.
Bhatia A (2020) Commentary on “Efficacy and harms of orally, intramuscularly or intravenously administered glucocorticoids for sciatica: A systematic review and meta-analysis” by Abdel Shaheed et al European Journal of Pain Volume 24, Issue 3 p. 475-476
Chou R, Pinto RZ, Fu R, Lowe RA, Henschke N, McAuley JH, Dana T. Systemic corticosteroids for radicular and non‐radicular low back pain. Cochrane Database of Systematic Reviews 2022, Issue 10. Art. No.: CD012450. DOI: 10.1002/14651858.CD012450.pub2. Accessed 16 October 2023.
CSP PLI scheme 2023 online: https://www.csp.org.uk/professional-clinical/professional-guidance/insurance/policy-information/csp-pli-scheme
CSP clinical service online (2023) https://www.csp.org.uk/professional-clinical/professional-guidance/insurance/insurance-exclusions/clinical-services
CSP Information paper online (July 2023): Therapeutic injection therapy in physiotherapy practice. 7th edition PD003 https://www.csp.org.uk/system/files/publication_files/PD003_InjectionTherapy_2023.pdf
CSP Practice guidance for Physiotherapy Prescribers PD026 Nov (2018) https://www.csp.org.uk/system/files/publication_files/PD026_PracticeGuidancePrescribing_4thEd_2018.pdf
