Síndrome miofascial: comparação entre o tratamento com infiltração de trigger points e medicação oral (ciclobenzaprina)

Objetivo: Comparar os efeitos da infiltração de trigger points com xilocaína a 1% com o uso da ciclobenzaprina no tratamento a curto prazo da síndrome miofascial (SMF) de trapézio. Material e métodos: Estudo prospectivo controlado randomizado com avaliador “cego” em 38 pacientes com SMF de trapézio. Intervenção realizada no grupo teste (IF) (n = 18): infiltração com xilocaína a 1% em, no máximo, 06 trigger points de trapézio; no grupo-controle (CB) (n = 20) foi fornecido 10 mg/dia de ciclobenzaprina por 15 dias. Os pacientes foram avaliados no tempo zero (T0), em sete (T7), quinze (T15) e trinta dias (T30). Instrumentos de avaliação: escala visual analógica de dor global (EVA de dor global), escala visual analógica de dor à compressão digital de trigger points (EVA de dor à compressão), questionário resumido para dor de McGill. Foi realizada a avaliação da reprodutibilidade interobservador (RI) para EVA de dor à compressão digital. Resultados: Os pacientes apresentaram na avaliação inicial a média de trigger points de 2,0 (+ 0,5), taut band de 3,05 (+ 0,8) e tender spots de 4,64 (+ 1,15). A RI para EVA à compressão mostrou-se boa (pearson > 0,8). Observou-se tendência (p > 0,05) a maior variação do escore de dor (McGill) no grupo-teste, maior variação do tipo de dor e maior incidência de efeitos colaterais no grupo-controle. Ambos os grupos melhoraram ao término do acompanhamento (p < 0,05). A média das variações da EVA de dor global no T7 (-24,2% (+62,8 CB X -40% + 50,9 IF p = 0,19), T15 (-37,6% + 48,4 CB X -50% + 44,8 IF p = 0,3) e T30 (-50% + 60 CB X -70,8% +44,7 IF p = 0,14) foi maior no grupo-teste porém sem significância estatística. Esta tendência também se observou na média das variações da EVA de dor à compressão digital no T7 (-26,8% + 35,34 CB X - 46,5% ( 44,4 IF p = 0,24), no T15 (-38,8% + 38,2 CB X -56,2% + 34,3 IF p = 0,44) e no T30 (-46,6% + 38 CB X -53% + 34,4 IF – p = 0,38), porém mais uma vez sem significância estatística. Conclusão: A semelhança do efeito da ciclobenzaprina com o da infiltração de trigger points permite a indicação da primeira no tratamento de pacientes com SMF de trapézio e questiona a indicação invariável da infiltração de trigger points.Objective: To compare the effects of the infiltration of “trigger points” with lidocaine at 1% with the use of cyclobenzaprine in the short term treatment of trapezius myofascial syndrome (SMF). Material and methods: Randomized controlled prospective study with a “blind” evaluating 38 patients with trapezius SMF. Intervention accomplished in the test group (IF) (n = 18): infiltration with lidocaine at 1% in at the most 06 trapezius ”trigger points”; in the control group (CB) (n = 20) 10 cyclobenzaprine mg/dia was supplied for 15 days. The patients were appraised in the time zero (T0), in seven (T7), fifteen (T15) and thirty days (T30). Evaluation instruments: visual analogue scale of global pain (VAS of global pain), visual analogue scale of pain to the digital compression of “trigger points” (VAS of pain to the compression), short-form McGill pain questionnaire. The evaluation of the interobserver reprodutibility (RI) was accomplished for VAS of pain to the digital compression. Results: The patients presented, in the initial evaluation, AN average of “trigger points” of 2,0 (± 0,5), “taut band” of 3,05 (± 0,8) and to “tend spots” of 4,64 (± 1,15). The RI for VAS to the compression was shown satisfactory (pearson > 0,8). It was observed the largest variation (p > 0,05) of the pain score (McGill) in the IF, larger variation of the type pain and larger incidence of side effects in the CB. Both groups showed improvement at the end of the evaluation (p < 0,05). The average of the variations of VAS of global pain in T7 (-24,2% ± 62,8 CB X -40% ± 50,9 IF p = 0,19), T15 (- 37,6% ± 48,4 CB X -50% ± 44,8 IF p = 0,3) and T30 (-50% ± 60 CB X -70,8% ± 44,7 IF p = 0,14) it was higher in the IF, however without statistical significe. This tendency was also observed in the average of VAS variations of pain to the digital compression on T7 (-26,8% ± 35,34 CB X -46,5% ± 44,4 IF p = 0,24), on T15 (-38,8% ± 38,2 CB X -56,2% ± 34,3 IF p = 0,44) and on T30 (-46,6% ± 38 CB X -53% ± 34,4 IF - p = 0,38), however, once again without statistical significance. Conclusion: The similarity between the effect of the cyclobenzaprine an the infiltration of the trigger points allows the indication of the first in the patients’ treatment with trapezius SMF and it questions the invariable indication of the infiltration of trigger points

Worsening of pain and swelling following triamcinolone hexacetonide intra-articular injection: a prospective study in a cohort of patients with rheumatic diseases

Div Rheumatol, São Paulo, BrazilUniversidade Federal de São Paulo, São Paulo, BrazilUniversidade Federal de São Paulo, São Paulo, BrazilWeb of Scienc

Effectiveness of Radiation Synovectomy with Samarium-153 Particulate Hydroxyapatite in Rheumatoid Arthritis Patients with Knee Synovitis: A Controlled Randomized Double-Blind Trial

OBJECTIVES: The aim of the present study was to investigate the effectiveness of Samarium153-particulate hydroxyapatite radiation synovectomy in rheumatoid arthritis patients with chronic knee synovitis. METHODS: Fifty-eight rheumatoid arthritis patients (60 knees) with chronic knee synovitis participated in a controlled double-blinded trial. Patients were randomized to receive either an intra-articular injection with 40 mg triamcinolone hexacetonide alone (TH group) or 40 mg triamcinolone hexacetonide combined with 15 mCi Samarium153-particulate hydroxyapatite (Sm/TH group). Blinded examination at baseline (T0) and at 1 (T1), 4 (T4), 12 (T12), 32 (T32), and 48 (T48) weeks post-intervention were performed on all patients and included a visual analog scale for joint pain and swelling as well as data on morning stiffness, flexion, extension, knee circumference, Likert scale of improvement, percentage of improvement, SF-36 generic quality of life questionnaire, Stanford Health Assessment Questionnaire (HAQ), Lequesne index, use of non-steroidal anti-inflammatory drugs or oral corticosteroids, events and adverse effects, calls to the physician, and hospital visits. RESULTS: The sample was homogeneous at baseline, and there were no withdrawals. Improvement was observed in both groups in relation to T0, but no statistically significant differences between groups were observed regarding all variables at the time points studied. The Sm/TH group exhibited more adverse effects at T1 (p<0.05), but these were mild and transitory. No severe adverse effects were reported during follow-up. CONCLUSION: Intra-articular injection of Samarium153-particulate hydroxyapatite (15 mCi) with 40 mg of triamcinolone hexacetonide is not superior to triamcinolone hexacetonide alone for the treatment of knee synovitis in patients with rheumatoid arthritis at 1 y of follow-up

Is painless synovitis different from painful synovitis? A controlled, ultrasound, radiographic, clinical trial

OBJECTIVE: This study compares the clinical, ultrasonography, radiography, and laboratory outcomes of painless and painful chronic synovitis in patients with established rheumatoid arthritis. METHODS: This cross-sectional study involved 60 patients with rheumatoid arthritis and synovitis in the metacarpophalangeal joints; 30 of the patients did not experience pain, and 30 had experienced pain for at least 6 months prior to the study. The radiocarpal, distal radioulnar, and metacarpophalangeal joints were evaluated using the ultrasound gray scale, power Doppler, and radiography. Past and present clinical and laboratory findings were also evaluated. RESULTS: There were no statistically significant differences between the groups for most of the outcomes. The group with pain scored worse on the disease activity indices (e.g., DAS 28 and SDAI), function questionnaires (HAQ and Cochin), and pinch strength test. A logistic regression analysis revealed that the use of an immunobiological agent was associated with a 3-fold greater chance of belonging to the group that experienced pain. The painless group had worse erosion scores in the second and fifth metacarpophalangeal with odd ratios (ORs) of 6.5 and 3.5, respectively. The painless group had more cartilage with grade 4 damage in the third metacarpophalangeal. CONCLUSIONS: The rheumatoid arthritis patients with both painless and painful synovitis exhibited similar disease histories and radiographic and ultrasound findings. However, the ultrasonography evaluation revealed worse scores in the second and fifth metacarpophalangeal of the synovitis patients who did not experience pain.Fundacao de Amparo a Pesquisa do Estado de Sao PauloUNIFESP communityHospital do Servidor Publico Estadual (IAMSPE)Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Disciplina de ReumatologiaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de Diagnostico por ImagemUNIFESP, EPM, Disciplina de ReumatologiaUNIFESP, EPM, Depto. de Diagnostico por ImagemFAPESP - 2012/04867-6SciEL

Intra-articular triamcinolone hexacetonide injections in hands osteoarthritis ‒ A double-blinded randomized controlled trial with a one year follow-up

Objective: to evaluate the effectiveness of triamcinolone Hexacetonide (TH) Intra-Articular Injection (IAI) in hand Interphalangeal Joints (IP) of Osteoarthritis (OA) patients to improve pain and joint swelling; improve function, goniometry, and grasping force, and assess IAI influence on radiographic evolution over&nbsp;1-year. Methods: A randomized, double-blind study. 60&nbsp;patients who underwent IAI at the most symptomatic IP joint were randomly assigned to receive TH+Lidocaine (LD) (TH/LD group) or just LD (LD group). Patients were assessed blindly for&nbsp;1-year, at baseline and&nbsp;1,&nbsp;4,&nbsp;8,&nbsp;12, and&nbsp;48&nbsp;weeks. The following variables were assessed: articular pain and swelling, AUSCAN and COCHIN functional questionnaires, grip and pinch strength, goniometry, perception of improvement, acetaminophen consumption, and simple radiography. Repeated-measures ANOVA test was used to analyze the intervention response. Results: Sixty patients completed the follow-up. There were nine missed assessments. 97%&nbsp;were women; mean age&nbsp;of 61-years (SD&nbsp;=&nbsp;8.2), and approximately&nbsp;5-years of disease (SD&nbsp;=&nbsp;3.6). Half of the patients present radiographic classification Kellgren and Lawrence (KL) grades&nbsp;I&nbsp;and&nbsp;II, and the other half grades&nbsp;III&nbsp;and&nbsp;IV. The two groups evolved similarly at&nbsp;48-weeks. TH/LD group had a better evaluation in joint swelling and acetaminophen consumption (p&nbsp;=&nbsp;0.04 and p &lt; 0.001, respectively) at&nbsp;48-weeks. Radiographically there was no statistical difference between groups (KL, p&nbsp;=&nbsp;0.564; erosive OA, p&nbsp;=&nbsp;0.999; worsening, p&nbsp;=&nbsp;0.573). Conclusion: The IAI IP hands OA is effective for the improvement of joint swelling and decrease of analgesic consumption and does not influence the radiographic evolution of the injected joint

Is painless synovitis different from painful synovitis? A controlled, ultrasound, radiographic, clinical trial

OBJECTIVE: This study compares the clinical, ultrasonography, radiography, and laboratory outcomes of painless and painful chronic synovitis in patients with established rheumatoid arthritis. METHODS: This cross-sectional study involved 60 patients with rheumatoid arthritis and synovitis in the metacarpophalangeal joints; 30 of the patients did not experience pain, and 30 had experienced pain for at least 6 months prior to the study. The radiocarpal, distal radioulnar, and metacarpophalangeal joints were evaluated using the ultrasound gray scale, power Doppler, and radiography. Past and present clinical and laboratory findings were also evaluated. RESULTS: There were no statistically significant differences between the groups for most of the outcomes. The group with pain scored worse on the disease activity indices (e.g., DAS 28 and SDAI), function questionnaires (HAQ and Cochin), and pinch strength test. A logistic regression analysis revealed that the use of an immunobiological agent was associated with a 3-fold greater chance of belonging to the group that experienced pain. The painless group had worse erosion scores in the second and fifth metacarpophalangeal with odd ratios (ORs) of 6.5 and 3.5, respectively. The painless group had more cartilage with grade 4 damage in the third metacarpophalangeal. CONCLUSIONS: The rheumatoid arthritis patients with both painless and painful synovitis exhibited similar disease histories and radiographic and ultrasound findings. However, the ultrasonography evaluation revealed worse scores in the second and fifth metacarpophalangeal of the synovitis patients who did not experience pain

Intra-articular injection with triamcinolone hexacetonide in patients with rheumatoid arthritis: prospective assessment of goniometry and joint inflammation parameters

Objectives: To evaluate local joint variables after intra-articular injection (IAI) with triamcinolone hexacetonide (HT) in rheumatoid arthritis (RA) patients. Methods: We blindly and prospectively (baseline, 1, 4, 12 and 24 weeks) evaluated metacarpophalangeal (MCP), wrist, elbow, shoulder, knee and ankle joints after HT IAI by the following outcome measures: Visual analogue scale 0-10 cm (VAS) for rest pain (VASR)VAS for movement pain (VASM)VAS for joint swelling (VASSw)flexion (FlexG) and extension (ExtG). Results: 289 patients (635 joints) were studied. VASSw (p < 0,001) and VASR (0,001< p < 0.016) improved from TO to T4, T12 and T24 for all joints. VASM improved from TO-T4 (p < 0.021) for all jointsTO-T12 (p < 0.023) for MCF and kneeTO-T24 (p < 0.019) only for MCF and knee. FlexG improved from TO-T4 (p < 0.001) for all jointsTO-T12 (p < 0.001) and TO-T24 (p < 0.02) only for MCF and knee. ExtG improved from TO-T4 (p < 0.001) for all joints except for elbowTO-T12 (p = 0.003) for wrist, MCP and kneeand TO-T24 (p = 0.014) for MCF and knee. Conclusion: VASSw responded better at short and medium term after IAI with HT in our sample of RA patients. (C) 2016 Published by Elsevier Editora Ltda.Univ Fed Sao Paulo, Disciplina Reumatol, Sao Paulo, SP, BrazilUniv Fed Sao Paulo, Disciplina Reumatol, Sao Paulo, SP, BrazilWeb of Scienc