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      Subacromial corticosteroid injection versus subcutaneous 5% dextrose in patients with chronic rotator cuff tendinopathy: A short-term randomized clinical trial

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          Abstract

          Aim

          The aim of this study is to compare subcutaneous 5% dextrose versus subacromial corticosteroid injection for the treatment of chronic rotator cuff tendinopathy.

          Methods

          We carried out a randomized clinical trial with two parallel groups at a university hospital. Overall, 57 (32 women) were included in two groups of corticosteroid ( n = 29) and dextrose ( n = 28). The mean pain score was 6.6 (1.0). We used a visual analog scale for pain and goniometry for the range of motion. The measurements were repeated 1 month after the interventions. For corticosteroid, a single injection of triamcinolone and 1% lidocaine, and for dextrose, a mixture of 5% dextrose and 2% lidocaine three times weekly were prescribed.

          Results

          Both interventions were effective in decreasing pain compared to the baseline (both p < 0.001). The difference in pain between the two groups was nearly significant 1-month post-intervention ( p = 0.052). The comparison of the two groups in considerable pain reduction (≥2.8) was in favor of dextrose ( p = 0.046). The differences in the range of motion were not conclusive. None of the participants reported an important adverse effect.

          Conclusion

          The 5% dextrose treatment is at least as effective as corticosteroid for reducing pain in patients with rotator cuff tendinopathy.

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          Most cited references26

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          A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain

          OBJECTIVE The aim of this study was to systematically review dextrose (d-glucose) prolotherapy efficacy in the treatment of chronic musculoskeletal pain. DATA SOURCES Electronic databases PubMed, Healthline, OmniMedicalSearch, Medscape, and EMBASE were searched from 1990 to January 2016. STUDY SELECTION Prospectively designed studies that used dextrose as the sole active prolotherapy constituent were selected. DATA EXTRACTION Two independent reviewers rated studies for quality of evidence using the Physiotherapy Evidence Database assessment scale for randomized controlled trials (RCTs) and the Downs and Black evaluation tool for non-RCTs, for level of evidence using a modified Sackett scale, and for clinically relevant pain score difference using minimal clinically important change criteria. Study population, methods, and results data were extracted and tabulated. DATA SYNTHESIS Fourteen RCTs, 1 case–control study, and 18 case series studies met the inclusion criteria and were evaluated. Pain conditions were clustered into tendinopathies, osteoarthritis (OA), spinal/pelvic, and myofascial pain. The RCTs were high-quality Level 1 evidence (Physiotherapy Evidence Database ≥8) and found dextrose injection superior to controls in Osgood–Schlatter disease, lateral epicondylitis of the elbow, traumatic rotator cuff injury, knee OA, finger OA, and myofascial pain; in biomechanical but not subjective measures in temporal mandibular joint; and comparable in a short-term RCT but superior in a long-term RCT in low back pain. Many observational studies were of high quality and reported consistent positive evidence in multiple studies of tendinopathies, knee OA, sacroiliac pain, and iliac crest pain that received RCT confirmation in separate studies. Eighteen studies combined patient self-rating (subjective) with psychometric, imaging, and/or biomechanical (objective) outcome measurement and found both positive subjective and objective outcomes in 16 studies and positive objective but not subjective outcomes in two studies. All 15 studies solely using subjective or psychometric measures reported positive findings. CONCLUSION Use of dextrose prolotherapy is supported for treatment of tendinopathies, knee and finger joint OA, and spinal/pelvic pain due to ligament dysfunction. Efficacy in acute pain, as first-line therapy, and in myofascial pain cannot be determined from the literature.
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            Subacromial injection of autologous platelet-rich plasma versus corticosteroid for the treatment of symptomatic partial rotator cuff tears.

            Rotator cuff tears are one of the most common causes of chronic shoulder pain and disability. They significantly affect the quality of life. Reduced pain and improved function are the goals of conventional therapy, which includes relative rest, pain therapy, physical therapy, corticosteroid injections and surgical intervention. Tendons have a relative avascular nature; hence, their regenerative potential is limited. There is some clinical evidence that the application of autologous platelets may help to revascularize the area of injury in rotator cuff pathologies.
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              Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis

              Background The ability of injection of corticosteroids into the subacromial space to relieve pain ascribed to rotator cuff tendinosis is debated. The number of patients who have an injection before one gets relief beyond what a placebo provides is uncertain. Questions/purposes We asked: (1) Do corticosteroid injections reduce pain in patients with rotator cuff tendinosis 3 months after injection, and if so, what is the number needed to treat (NNT)? (2) Are multiple injections better than one single injection with respect to pain reduction at 3 months? Methods We systematically searched seven electronic databases for randomized controlled trials of corticosteroid injection for rotator cuff tendinosis compared with a placebo injection. Eligible studies had at least 10 adults and used pain intensity as an outcome measure. The Hedges’s g as adjusted pooled standardized mean difference (SMD) (which expresses the size of the intervention effect in each study relative to the total variability observed among pooled studies) and NNT were calculated at assessment points less than 1 month, 1–2 months, and 2–3 months. The protocol of this study was registered at the international prospective register of systematic reviews. Eleven studies of 726 patients satisfied our criteria for data pooling. Three studies containing 292 patients used repeat injections. A random effects model was used owing to substantial heterogeneity among studies. The funnel plot indicated the possibility of some missing studies, but Orwin’s fail-safe N and Duval and Tweedie’s trim and fill suggested that missing studies would not significantly affect the results. Results Corticosteroid injection did not reduce pain intensity in adult patients with rotator cuff tendinosis more than a placebo injection at the 3-month assessment. A small transient pain relief occurred at the assessment between 4 and 8 weeks with a SMD of 0.52 (range, 0.27–0.78) (p < 0.001). At least five patients must be treated for one patient’s pain to be transiently reduced to no more than mild. Multiple injections were not found to be more effective than a single injection at any time. Conclusions Corticosteroid injections provide—at best—minimal transient pain relief in a small number of patients with rotator cuff tendinosis and cannot modify the natural course of the disease. Given the discomfort, cost, and potential to accelerate tendon degeneration associated with corticosteroids, they have limited appeal. Their wide use may be attributable to habit, underappreciation of the placebo effect, incentive to satisfy rather than discuss a patient’s drive toward physical intervention, or for remuneration, rather than their utility. Level of Evidence Level I, therapeutic study. Electronic supplementary material The online version of this article (doi:10.1007/s11999-016-5002-1) contains supplementary material, which is available to authorized users.
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                Author and article information

                Journal
                imas
                1646
                Interventional Medicine and Applied Science
                IMAS
                Akadémiai Kiadó (Budapest )
                2061-1617
                2061-5094
                11 November 2019
                :
                :
                : 1-7
                Affiliations
                [ 1 ]Department of Physical Medicine and Rehabilitation, School of Medicine, Baqiyatallah University of Medical Sciences , Tehran, Islamic Republic of Iran
                [ 2 ]Exercise Physiology Research Center, Baqiyatallah University of Medical Sciences , Tehran, Islamic Republic of Iran
                Author notes
                [* ]Corresponding author: Mahsa Asheghan; Exercise Physiology Research Center, Baqiyatallah University of Medical Sciences, Mollasadra St., Tehran 1437773787, Islamic Republic of Iran; Phone/Fax: +98 21 8126 2112; E-mail: m_asheghan@ 123456bmsu.ac
                Article
                10.1556/1646.11.2019.18
                eeb4f8d3-8600-4a14-bdc5-a9cb25fcbb23
                © 2019 The Author(s)

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium for non-commercial purposes, provided the original author and source are credited, a link to the CC License is provided, and changes – if any – are indicated.

                History
                : 20 February 2019
                : 31 May 2019
                : 16 June 2019
                Page count
                Figures: 1, Tables: 3, Equations: 0, References: 26, Pages: 7
                Funding
                Funding sources: The authors did not receive any financial support from any public or private sources.
                Categories
                ORIGINAL PAPER

                Medicine,Immunology,Health & Social care,Microbiology & Virology,Infectious disease & Microbiology
                joint,shoulder,rotator cuff tendinopathy,prolotherapy,dextrose,corticosteroid injection

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