Kurt T. Hegmann, MD, MPH
Does adding local corticosteroid injection to exercise plus manual mobilization therapy reduce shoulder pain and disability in the subacromial impingement syndrome?
Randomized controlled trial (RCT). Current Controlled Trials ISRCTN25817033, EudraCT No 2005-003628-20.
Primary care referrals to a musculoskeletal service in England, UK.
232 patients ≥ 40 years of age (mean age 56 y, 55% women) who had unilateral, moderate, or severe shoulder pain with a noncapsular pattern of restriction; ≤ 25% loss of lateral rotation compared with the opposite shoulder; and a positive Neer or Hawkins impingement sign. Exclusion criteria included blood coagulation disorders; referred pain from the cervical spine or internal organs; history of inflammatory arthritis conditions; neurologic diagnosis with shoulder involvement; previous fracture, dislocation, or surgery to the shoulder, upper limb, neck, or thorax; and steroid injections or physiotherapy for the symptomatic shoulder in the past 6 months.
Subacromial corticosteroid injection (triamcinolone acetonide, 20 mg, mixed with 4.5 ml 1% lidocaine) plus individualized, progressive exercises and manual mobilization techniques (n = 115) or exercise and manual mobilization therapy alone (n = 117), each delivered by physiotherapists. A second injection for ongoing moderate-to-severe pain could be given in the injection group after 6 weeks.
Change in self-reported shoulder pain and disability index (SPADI) total score and pain and disability subscale scores (score range 0 to 100, 100 = severe pain or disability) at 12 weeks. Other outcomes included change in SPADI scores at 1, 6, and 24 weeks. The trial had 80% power to detect a ≥ 10-point difference in SPADI score between groups.
83% (intention-to-treat analysis).
Adding corticosteroid injection to exercise and manual mobilization therapy reduced shoulder pain and disability total scores at 1 and 6 weeks but not at 12 or 24 weeks (Table). Results were similar for pain and disability subscale scores.
In patients with the subacromial impingement syndrome, adding corticosteroid injection to exercise plus manual mobilization therapy reduced pain and disability in the short term but not in the long term.
Subacromial corticosteroid injection plus exercise and manual mobilization therapy (combination) vs exercise and manual mobilization therapy alone in the subacromial impingement syndrome†
†SPADI = Shoulder Pain And Disability Index; other abbreviations defined in Glossary.
‡Scores transformed using Rasch analysis to provide interval scaling. Lower scores = less pain and disability.
Hegmann KT. Adding steroid injection to exercise and manual mobilization did not reduce shoulder pain and disability over the long term. Ann Intern Med. ;153:JC5–6. doi: 10.7326/0003-4819-153-10-201011160-02006
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Published: Ann Intern Med. 2010;153(10):JC5-6.
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