Knee OA: Corticosteroid Shot Does Not Boost Exercise Benefit

Troy Brown, RN

March 31, 2015

Adding an intra-articular injection of 40 mg corticosteroid before exercise in patients with painful knee osteoarthritis (OA) provided no extra benefit, results from a new randomized trial show.

Exercise has been shown to provide relief of knee OA symptoms, as have intra-articular injections, but no studies to date have evaluated the two treatments in combination.

Therefore, Marius Henriksen, PT, PhD, from Parker Institute, Department of Rheumatology, Copenhagen University Hospital at Bispebjerg and Frederiksberg, Denmark, and colleagues conducted a randomized, blinded, placebo-controlled clinical trial to evaluate the benefit of intra-articular corticosteroid injection vs placebo before exercise therapy in patients with painful knee OA.

They recruited patients through an OA outpatient clinic between October 1, 2012, and April 2, 2014. At enrolment, all patients had OA confirmed by radiography, clinically evident inflammation, and knee pain when walking (score >4 on a scale of 0 to 10).

The researchers randomly assigned patients either to the corticosteroid group, which received an intra-articular 1 mL injection with methylprednisolone acetate (Depo-Medrol, Pharmacia and Upjohn Company), 40 mg/mL, dissolved in 4 mL lidocaine hydrochloride (10 mg/mL), or to the placebo group, which received a 1-mL isotonic saline injection mixed with 4 mL lidocaine hydrochloride (10 mg/mL).

The participants began a 12-week supervised exercise program 2 weeks after the injections.

Of the 50 patients who were assigned to each of the two trial groups, 45 in the corticosteroid group and 44 in the placebo group completed the study, researchers report in an article published online March 30 in JAMA Internal Medicine.

At the 14-week follow-up evaluation, the researchers found no statistically significant differences between the groups in the Pain subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire, which was the primary outcome measure. Specifically, the mean changes in the KOOS Pain subscale were 13.6 in the corticosteroid group and 14.8 in the placebo group, for a statistically insignificant mean difference of 1.2 points (95% confidence interval, −3.8 to 6.2; P = .64).

Similarly, the groups did not differ significantly in any of the secondary objectives, including in the KOOS subscales (Symptoms, Function in Daily Living, Function in Sport and Recreation, and Knee-Related Quality of Life), physical function, and inflammation.

"Our findings should be considered in therapeutic decision making. Intra-articular corticosteroid injection and exercise are highlighted in recommendations and guidelines," the authors conclude. "However, our results do not support the superiority of intra-articular injection of corticosteroid compared with saline and lidocaine before an exercise intervention."

This study was supported by a grant from the Danish Council for Independent Research, Medical Science, and by the Oak Foundation, Association of Danish Physiotherapists, Lundbeck Foundation, and Capital Region of Denmark. Dr Henriksen is associated with the Danish Association of Physiotherapists, which could benefit from wide uptake of this publication. One coauthor is involved in many healthcare initiatives and research that could benefit from wide uptake of this publication (including Cochrane, Outcome Measures in Rheumatology, and the Grading of Recommendations Assessment, Development, and Evaluation Working Group). The other authors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online March 30, 2015. Abstract

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