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Improvement in wrist pain with ultrasound-guided glucocorticoid injections: a meta-analysis of individual patient data |
Dubreuil M, Greger S, LaValley M, Cunnington J, Sibbitt WL, Kissin EY |
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CRD summary This review concluded that there was a significant benefit from ultrasound-guided intra-articular glucocorticoid injections, over palpation-guided injections, in the reduction of wrist pain and achievement of a minimal clinically important improvement, for patients with inflammatory arthritis or osteoarthritis. The authors acknowledged the poor evidence, which could affect the reliability of their conclusions. Authors' objectives To assess the effectiveness of ultrasound-guided intra-articular glucocorticoid injections for wrist pain in patients with inflammatory arthritis or osteoarthritis. Searching Five electronic databases, including MEDLINE and The Cochrane Library, were searched for articles from 2006 to June 2011. Search terms were reported. Abstracts from the American College of Rheumatology and relevant reference lists were handsearched, and experts were contacted for additional data. Study selection Eligible for inclusion were prospective or retrospective studies, or case studies comparing the effectiveness of a single ultrasound-guided long-acting intra-articular glucocorticoid injection versus a standard palpation-guided injection for adult patients. Eligible patients had inflammatory arthritis, crystalline arthritis or arthropathy, or osteoarthritis. The primary outcome was the mean change in wrist pain from the start to one-to-six weeks after treatment, as assessed on a visual analogue scale or by the Health Assessment Questionnaire. The secondary outcome was the proportion of patients who attained a minimal clinically important improvement (as defined in the review). In the included studies, where reported, the mean age of patients ranged from 48.3 to 61.0 years; most patients were women. Patients received triamcinolone acetonide (20 to 60mg) or triamcinolone hexacetonide (10 or 30mg). Different visual analogue scales were used to measure pain. Three studies had only one treatment arm – only the comparative studies are discussed here. Two reviewers independently screened studies for inclusion, with disagreements resolved by a third reviewer. Assessment of study quality Study quality was assessed according to eight criteria: clear inclusion and exclusion criteria, randomisation, blinding, clinician experience, description of injection methods, drug regimen, and description of activity restrictions after injection. The authors did not state how many reviewers assessed quality. Data extraction Means and standard deviations for visual analogue scale or Health Assessment Questionnaire scores were extracted for the start and the last follow-up, to calculate the mean differences and their 95% confidence intervals. The proportion of patients achieving a minimal clinically important improvement was extracted to calculate odds ratios and their 95% confidence intervals. Study authors were contacted for missing data and for individual patient data. Two reviewers independently extracted the data. Methods of synthesis A fixed-effect model was used to combine odds ratios, with their 95% confidence intervals; relative risks and 95% confidence intervals were calculated. A random-effects model was used to combine the mean differences and 95% confidence intervals; patients with initial pain scores of zero were excluded from the analyses. Statistical heterogeneity was assessed using Cochran's Q, I², and the Breslow-Day test. Sensitivity analysis was performed by excluding patients, who had an initial visual analogue scale score of below three, from the minimal clinically important improvement analysis. Results of the review Four comparative studies (202 patients; range 29 to 83) were included. Follow-up ranged from two to four weeks. One comparative study met five of the eight quality criteria, and three met six or more criteria. There was a statistically significant reduction in pain score for patients receiving ultrasound-guided injection versus palpation-guided injection (MD 1.0, 95% CI 0.3 to 1.7; four studies). A statistically significant higher number of patients achieved a minimal clinically important improvement using ultrasound-guided injection, compared with palpation-guided injection (OR 3.1, 95% CI 1.2 to 8.3; three studies). The sensitivity analysis did not significantly alter these findings, and the relative risks were consistent. There was no evidence of statistical heterogeneity for either outcome. Authors' conclusions There was a statistically and clinically significant benefit with ultrasound-guided injections, over palpation-guided injections, in reduction in wrist pain and achievement of a minimal clinically important improvement. CRD commentary The review question and supporting inclusion criteria were clearly defined. A satisfactory search of the literature was undertaken, and this included attempts to identify unpublished data. Study quality was assessed, and the results suggested that the included studies had some quality issues. It was unclear whether quality was assessed by two people, which means that reviewer error and bias cannot be ruled out. The authors used individual patient data, but the patient and study details were sparse. The confidence intervals for the pain scores were only just significant, and those for a minimal clinically important improvement were wide, which indicated that the results were not robust. The samples in the four studies were small. The authors acknowledged the poor evidence, which could affect the reliability of their conclusions. Implications of the review for practice and research Practice: The authors stated that their findings were the first steps towards developing an outcome-based approach for the use of ultrasound guidance. Research: The authors stated that further research was needed to examine the relationship between patient and intervention characteristics, and outcome, and to assess the joint-specific cost-effectiveness of ultrasound-guided injections. Bibliographic details Dubreuil M, Greger S, LaValley M, Cunnington J, Sibbitt WL, Kissin EY. Improvement in wrist pain with ultrasound-guided glucocorticoid injections: a meta-analysis of individual patient data. Seminars in Arthritis and Rheumatism 2013; 42(5): 492-497 Indexing Status Subject indexing assigned by NLM MeSH Arthralgia /pathology /physiopathology /prevention & Glucocorticoids /administration & Humans; Injections, Intra-Articular; Pain Management /methods; Pain Measurement; Treatment Outcome; Ultrasonography, Interventional; Wrist Joint /pathology /physiopathology /ultrasonography; control; dosage AccessionNumber 12013030472 Date bibliographic record published 18/06/2013 Date abstract record published 19/03/2014 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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