Do intra-articular steroid injections work for treating rheumatoid arthritis and should people rest after the injections?
Seven moderate quality studies were reviewed and provide the best evidence we have today. The studies tested 346 adults with rheumatoid arthritis. They compared people who had a steroid injection, a fake injection or aspiration/washout of their knees or wrists to each other. Two studies tested whether people should rest their joints after injections.
What is rheumatoid arthritis and how might steroid injections help?
Rheumatoid arthritis is a disease in which the body's immune system attacks its own healthy tissues. The attack happens mostly in the joints of the hands and feet and causes redness, pain, swelling and heat around the joints. Intra-articular steroid injections into a joint can be used to decrease pain and swelling quickly. People may have steroid injections to delay starting steroid pills or arthritis drugs, or when drugs are not controlling pain enough. It is not clear if steroid injections work and if people should rest their joints after injections.
What did the studies show?
One of two studies show that people who had steroid injections had less pain the first day than people who had fake injections.
Pain decreased by about 15 points on a 0-100 scale with a steroid injection and 7 points with a fake injection.
The change in pain, however, was the same after 1 or 7 to 12 weeks with or without steroid injections.
Studies show that people who had steroid injections could bend and straighten their leg better/farther and had less swelling around their knee than people with fake injections. Morning stiffness also did not last as long with steroid injections. But one study shows that people could walk faster with steroid injections while another study shows they could not.
People had less pain, stiffness, swelling, and could walk faster if they rested their knees after steroid injections to their knees. But after steroid injections to their wrists, people felt the same whether they rested their wrists or not - but more had a relapse when they rested.
How safe are steroid injections?
No side effects due to injections were reported.
What is the bottom line?
The level of quality of the evidence is 'silver'. Intra-articular steroid injections can improve pain, movement, stiffness and swelling and are safe in adults with rheumatoid arthritis. There is no evidence to say whether this is true for children.
Knees should be rested after a steroid injection, but wrists should not.
There is some evidence to support the use of IA steroid injections and resting a knee following injections but that wrists should not be rested following injections. The included studies involved adult participants so any conclusions can only cautiously applied to children. Further research is required to examine the use and type of rest and the differential responses of different joints following injections.
Resting or immobilizing a joint to enhance outcomes following intra-articular (IA) steroid injection is generally advocated. This systematic review aimed to determine the efficacy of IA steroid injections and the influence of post-injection rest.
1. Compare IA steroid injections versus no treatment or placebo.
2. Determine the effects of rest following IA steroid injection in rheumatoid or juvenile idiopathic arthritis.
The Cochrane Central Register of Controlled Trials (CENTRAL- Issue 4, 2003), Cochrane Database of Systematic Reviews (CDSR - Issue 4, 2003), Database of Abstracts of Reviews of Effectiveness (DARE - searched 8.1.04), MEDLINE (1966 to August Week 2 2004), EMBASE (1980 to August Week 2 2004) , CINAHL (1982 to December Week 2 2003), Clinical Trials site of the National Institute of Health, (USA - searched 8.1.04), OTseeker (Occupational Therapy Systematic Evaluation of Evidence - searched 8.1.04) and PEDro (Physiotherapy Evidence Database - searched 8.1.04) were searched. Journals and reference lists were hand searched.
Eligible were randomised controlled trials of IA steroid injections or of rest following IA steroid injections in rheumatoid or juvenile idiopathic arthritis.
Potentially relevant references were evaluated and all data extracted by two independent reviewers.
Five trials (n=346) examining IA steroid injection in the knee joint were included. It was not possible to pool data as outcome measures, timing of follow up and the methods of data reporting differed between trials. There was inconclusive conflicting evidence from two trials that walking time was reduced. There was evidence from one moderate quality trial that pain was reduced at 1-day post-injection (0-100 VAS from 28.33 to 13.46; McGill Pain Scale from 8.89 to 3.96) but not at 1 week or 7-12 weeks post-injection. There is some evidence that IA injections improved knee flexion (by 14 degrees) and reduced knee extension lag (by 20 degrees), knee circumference (median reduction = 0.3 cm) and morning stiffness (reduced from 60 mins to 7.6 mins). One trial (n=91) examined the effects of rest following injection in the knee. The rested group achieved significant improvement in pain, stiffness, knee circumference, and walking time when compared with the non-rested group (no point estimates provided). One trial evaluated rest following injection of the wrist (n=117). Relapse rate was higher in the rested group (rest relapse rate = 24/58, no-rest group = 14/59); but there were no differences between the rested and non-rested groups on pain, joint circumference, wrist function, grip strength or ROM.