0:00

Stirring

0:06

injections definitely have a place

0:08

in our MSK2 box. It's

0:10

not the one and only treatment

0:13

and it's definitely not the first line of

0:15

treatments. I think that's something we

0:17

bear in mind. But if we can use in the right

0:19

patient at the right timing and right diagnosis,

0:22

that is brilliant because we give

0:24

our patient a window opportunity to

0:26

rehab.

0:29

Music

0:30

Welcome to Physio Explained. In today's

0:32

episode, we're joined by Dr. Sharon Chan-Braddock.

0:35

Sharon completed her professional doctorate in physiotherapy

0:37

in 2016 and brings over

0:39

14 years of experience in postgraduate

0:42

musculoskeletal education. She is

0:44

the MSC module lead for injection

0:46

therapy and developing professional practice

0:49

with the Society of Musculoskeletal Medicine,

0:51

the SOM, and holds a distinction of being

0:53

the first physiotherapist in the UK and

0:56

internationally to achieve both SOM fellowship

0:58

and MACP membership. in

1:00

this episode we cover everything from what

1:03

corticosteroid injections aim to achieve

1:06

how effective they really are in clinical practice

1:08

And we look at the evolution and changes in practice

1:10

over the last 15 years. And then

1:13

finally, we look at patient selection and

1:15

timing, when we should consider utilising

1:18

corticosteroid injections. This is

1:20

a fascinating discussion packed with insights

1:22

for any clinician considering or

1:24

using corticosteroid injections in their practice.

1:27

I'm James Armstrong, and this is Physio

1:29

Explained. sharon

1:35

it's great to have you on the podcast today

1:38

thank you so much for joining us

1:40

Thank you for having me today. So

1:41

we're going to be talking about a really interesting topic,

1:43

particularly interesting for me as well. It's

1:45

about corticosteroid injections and we're going

1:48

to get dive straight into the up-to-date

1:50

sort of clinical reasoning, the evidence and

1:52

how we should be using them at the moment. I

1:54

thought what better way to kick this off with

1:57

what are corticosteroid injections aiming

1:59

to do and how are they aiming

2:01

to work in the body, Sharon?

2:03

So steroid injections have been used

2:05

in musculoskeletal medicine for a long time,

2:08

since 1960. So

2:10

the main properties of steroid injections

2:13

is anti-inflammatory medications,

2:15

but also has its immunosuppressive

2:18

effects. And the main indication

2:20

to use an MSK practice is to

2:22

reduce pain and inflammation,

2:24

and therefore it facilitates

2:27

that patient's rehab

2:30

and loading program. Majority

2:32

of the steroid injections will be used in

2:34

conjunction with other managements. So

2:37

it's fairly, it's used as a standalone

2:39

treatment. And therefore we always

2:41

have to think about that wrap around

2:44

care, personalized care. So

2:47

ingestions are often best used as

2:49

a total management of the plan.

2:52

So for example, if someone's pain

2:54

is the main barrier to prevent

2:56

them from rehab or pain

2:58

really disturbed their sleep or affect

3:01

their function, like their work

3:03

and their hobbies, then that

3:06

could be the indications of using

3:08

pain. steroid injections to give them a window

3:10

of opportunity to be able to engage

3:13

with rehab and physiotherapy. So

3:15

in terms of how steroids work, your buddy

3:17

is very clever. So steroids is

3:20

a liposoluble hormone and

3:22

it interacts with one of the biological

3:24

targets, which is the receptors. So

3:26

basically the receptors bind

3:29

with the glucocorticoid

3:31

receptors and it's diffused

3:34

into the cyprism and this

3:36

will trigger a number of events in the

3:38

nucleus And that's

3:41

how they create the anti-inflammatory

3:43

effects of your body. So that's

3:45

basically how it works. Wonderful.

3:47

In terms of steroid injections, obviously, we

3:50

use them around the body in different areas. Do

3:52

we know sort of how long they tend to

3:54

work for?

3:55

Yeah, that's a really good question

3:57

because our evidence is so important

4:00

to inform our practice. And part

4:02

of the important part to

4:05

give our patient informed choice or consent

4:07

is we are able to give our patients

4:09

treatment options. And that's when

4:12

we have to have the understanding about

4:14

the risks versus benefits for our patients,

4:17

understanding about the possible

4:19

risks and complications. There

4:21

is so much research out there in

4:23

corticosteroid injections, but the

4:25

general themes in terms of joint,

4:28

for example, arthritis, the

4:30

general themes is short to moderate

4:33

benefit. So it could be between a few

4:35

weeks to a few months effectiveness,

4:38

and there is no evidence to suggest

4:40

any long-term benefits. In

4:42

terms of tendinopathy, it's short-term

4:45

benefit only. We know steroids is

4:47

not the best for tendinopathy,

4:49

but that That could give some patients

4:52

a window of opportunity for them to rehab

4:54

or for that loading program. So

4:57

those are the general themes of evidence.

5:00

Obviously, we have evidence on individual

5:03

lesions that you can look into that. I

5:06

suppose with the evidence, it brings us probably really

5:08

nicely on to a topic that we were talking about

5:10

just before we started recording, and that's

5:12

how things have changed. We talked about

5:14

this. Corticosteroid injections have been used for a long

5:17

time. How have things changed over the years,

5:19

Sharon?

5:20

So I've been doing injections for 15

5:22

years. So when I trained doing steroid

5:24

injections, using local

5:26

anesthetic was a default. So

5:29

we know some risks associated with

5:31

local anesthetic. in our

5:33

central nervous system, cardiovascular system,

5:36

and allergic reactions such as anaphylactic

5:38

reactions. So we very much focus

5:40

on those. And we don't really question

5:43

why you use local anesthetic in every

5:45

single injection in those days. But

5:47

in the last 10 years, practice

5:50

has been changed because there are increasing

5:52

amount of evidence to suggest

5:55

steroids is not great for our

5:57

articular cartilage and tendons. So

5:59

we understand, we know the systemic

6:02

effects. But in terms of locally,

6:04

evidence suggests steroids

6:07

can cause chondrotoxicity.

6:09

So basically, it's toxicity

6:12

to our chondrocytes, which is cells

6:14

in articular cartilage, but also

6:17

tenotoxicity, which is toxicity

6:19

to tendon cells. And you can see

6:21

these deleterious changes very,

6:23

very similar to the natural

6:26

process of arthritis and tendinopathy.

6:29

So the question is, Do

6:31

we need to use local anesthetic

6:34

if there's not good clinical reasoning?

6:36

So the use of local anesthetic should be

6:39

used when there is, for example,

6:41

a diagnostic purpose. So you can use

6:43

local anesthetic when you want to

6:46

aid that differential diagnosis. So for

6:48

example, between cervical

6:51

reflopping and the subchromic impingement,

6:53

you want to help that differential diagnosis. or

6:55

you want to give your patients some relief, like

6:58

a pain relief, a short-term pain relief, usually

7:01

local anesthetic like the common one like

7:03

Lidocaine lasts for 90

7:05

to 120 minutes. So it's

7:08

not a short-term benefit, a

7:10

long-term benefit that you can cover

7:13

that post-injection flare, which can last

7:15

for a few days, or it doesn't

7:17

bridge that gap until the steroids work

7:19

after 24, 36 hours. So

7:22

if you are confident with your diagnosis,

7:25

and you don't need a diagnostic purpose,

7:28

then the question is, are you adding

7:30

more benefits to give your patient local

7:32

anesthetic? So the change of practices,

7:35

we become much more careful in

7:37

terms of the selection of our

7:39

use of local anesthetic. So I

7:42

think that is down to clinical reasoning,

7:45

case-by-case basis, always

7:47

thinks about that risk versus benefits

7:50

of our patients and informed choice

7:52

to our patients first. when you're utilizing

7:54

steroid injections.

7:56

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8:26

for That's

8:33

quite important, isn't it? Because I think some individuals

8:35

may be working under a

8:37

patient group directive or things like that, but whereby the

8:41

local anaesthetic is already

8:43

mixed and that's not

8:45

necessarily giving clinical reasoning

8:47

as to whether you're using it or not then, is it? You're

8:50

taking that clinical reasoning away from the

8:52

clinician?

8:53

Yeah, and I think that is a very, very common

8:55

question people are being asked when

8:58

we're teaching. And sometimes I

9:00

think we just need to go back to our services

9:02

and ask about, can we have other options?

9:05

Because it really depends on

9:07

the patients and the lesions. I'm not saying

9:09

steroid, local anesthetic definitely

9:11

have a place. And in some cases,

9:13

we may use pre-mix. In some places, we

9:16

may use a steroids plus

9:18

local anesthetic. In some cases,

9:20

we may use steroids alone. So it really

9:22

depends on the lesions we're dealing

9:24

with, but also patient's factors as well.

9:27

Definitely. And that leads us really nicely

9:29

onto sort of when we should be using

9:31

these. We've talked already, haven't we, really about patient

9:34

selection. And I think we could probably

9:36

dive into that a little bit more now in terms of some

9:38

of the conditions and types of patients

9:41

that we know the steroid injections

9:43

are good for. And we also potentially

9:46

with the evidence emerging now on where we, when

9:48

they might now not be so much used.

9:51

Can you talk to us a bit more about that, Sharon?

9:53

Yeah. So usually steroid injections

9:56

used in joint, so such as arthritis.

9:59

So it could be degenerated, traumatic

10:02

or inflammatory arthritis. It

10:04

could be used in tendinopathy, bursitis

10:08

and some nerve entrapments such as carpal

10:10

tunnel injections. In terms of when

10:12

we're going to use it, as everything

10:14

else in MSK management, we often

10:17

adopt that step approach. So

10:19

we want to be the least invasive

10:22

to start with and self-management,

10:25

physiotherapy, exercise, medications.

10:28

If people fail to respond

10:30

to dose and pain still are

10:32

barriers for them to engage

10:34

with rehab and physiotherapy and affecting

10:37

their function, then you may consider

10:39

steroid injections can be an option.

10:42

So often it's really important

10:44

for patients to understand about

10:46

what are they having. So it's your job

10:48

to discuss the intended benefit

10:51

and risk. But also it's really

10:53

important for people to understand this is just

10:55

part of their rehab. It's not a

10:57

one-off. It's not the end of it. It's the

10:59

start of their rehab. So

11:02

the aftercare is really important. So

11:04

you give them appropriate aftercare advice.

11:07

At the moment, we're drafting a guidance

11:09

document in terms of aftercare in

11:12

injection therapy. And also think about

11:14

the rehab pen hose injections

11:17

as well. I would probably say the one-off

11:19

that you may never see a patient again, it

11:21

could be trigger finger or trigger thumb, but

11:24

the rest of everything, you often

11:27

have to thing about rehab and patients

11:29

need to engage in terms of

11:32

relatively rest for two weeks after injections

11:35

and then go back to engage with the physiotherapy

11:37

and rehab afterwards so

11:40

it's kind of agreement and a contract

11:42

with your patients that they have to understand

11:44

those to get the maximum benefits of

11:46

it.

11:47

I suppose that's where our patient education comes

11:49

in we need the patient to understand the

11:51

process and quite a lot really about what's

11:54

happening and why we're doing it to then

11:56

engage with that process don't we really?

11:58

Yeah because like I said that is when

12:01

your evidence come along like

12:03

it lasts for a few weeks to a few months but

12:06

it doesn't mean after a few months you have your

12:08

pain coming back again because if

12:10

you can give your patients some short-term

12:13

relief they will be able to go back to their

12:15

normal function they will have better

12:17

sleep they will feel happier

12:20

and they can engage with

12:22

their rehab better and all this just break

12:25

that visual circle and on

12:27

the top of other management and self-management,

12:30

then that gives them a more sustainable

12:33

effect.

12:34

Definitely. What are your thoughts around

12:37

repeat injections? Because we

12:39

might see a patient who we think, right, okay,

12:41

they're not sleeping. They're struggling to engage

12:43

with rehabilitation and actually an injection

12:45

here. They've tried our over-the-counter

12:48

medications. They've got that stepwise approach.

12:50

We're thinking, right, give them the injection. And

12:52

they get some relief. They undertake the rehab

12:55

alongside it. They do everything we're asking. But

12:57

that relief is quite short term. We know

12:59

that sometimes it can be. What

13:02

are your thoughts around repeating that injection?

13:04

That's a good question too. It could

13:07

be case by case basis. So

13:09

repeated injections

13:12

is normally not recommended. If your first

13:14

injection, it doesn't work because the

13:17

first thing you think about is, is

13:19

this the right diagnosis? So you

13:21

need to think about differentiated diagnosis. There

13:23

are also many factors. It's

13:26

not necessarily your ingestion techniques

13:28

or your diagnosis, but a lot

13:30

of other factors, patient factors. For example,

13:33

someone have a background of

13:35

chronic pain, sensitizations,

13:38

referral pain. So again,

13:41

it's go back to that diagnosis

13:43

and consider any, like, is there any other

13:46

pathologies causing it? It could be, is that

13:48

they're engaging their rehab? So

13:50

again, In terms of guidelines, for

13:53

example, NICE guidelines suggest a

13:55

weight-bearing joint should not be injected

13:57

more than four to six months. So

14:00

you really should not have more than two

14:02

or three times a year for knee injections.

14:05

So if someone comes to me, for example,

14:07

the third time of the year wanting

14:09

a steroid injection of the knee, then

14:12

I would consider whether

14:15

it's too severe that they may need to consider

14:17

surgery. Are we having a great diagnosis

14:20

here? Or is there any other

14:22

factors may causing this ongoing

14:25

pain? And sometimes it's

14:27

not just MSK issues. It's maybe

14:29

you need to think about outside the box.

14:32

People may have diabetes. Would that be

14:35

like diabetic neuropathy? Would

14:37

that be some kind of vitamin

14:40

deficiency? It's got to

14:42

be outside the box as well. Particularly

14:44

many of us now were as First

14:47

contact practitioner, which you

14:49

may see those much

14:51

more in primary care. So

14:55

repeated injections need to, again, apply

14:57

that clinical reasoning, case-by-case

14:59

basis, but also study

15:02

that patient individually.

15:04

So it's that reassess,

15:06

think again process. Is your diagnosis correct? Lots

15:09

of that clinical thinking.

15:10

Yeah. But also I need to think about a lot

15:12

like past medical history, the drug

15:15

history, the social history, consider

15:18

all of this. And also it's got to be like a personalized

15:20

care approach as well. So sometimes

15:22

when you prefer someone for rehab or physio,

15:25

but the reality is they are not

15:27

very good at doing their exercise or

15:29

following self-management advice.

15:32

So those may be the reason for failure.

15:34

It's got to be looking

15:37

at various aspects. You are almost

15:39

like a detective when someone fails

15:42

injections or fails any treatments

15:44

because there are so many variables. But

15:47

I think one key thing is we want to be safe.

15:49

So safety in terms of injections.

15:52

So think about are we doing more harm to the patients

15:55

if we give them more injections?

15:58

So always going back to that risk

16:00

versus benefit. And even I've

16:02

been doing this for such a long time now, I

16:05

often still discuss cases with my colleagues.

16:08

We always like learning and every patient is very

16:10

different. So this is how we

16:12

carry on learning and make sure we

16:14

ensure that ongoing capability for

16:17

our practice.

16:19

Absolutely. What would you say some of the takeaways,

16:21

if I was to kind of pin you down and say, what

16:23

are some of the takeaways that you'd really want the

16:25

clinicians listening to this now to take from today's

16:28

episode?

16:29

Stero injections definitely

16:31

have a place in our MSK2 box.

16:33

It's not the one and only

16:35

treatment and it's definitely not the first

16:37

line of treatments. I think that's

16:40

something we bear in mind. But if we can use

16:42

in the right patient at the right timing and

16:44

right diagnosis, that is brilliant because we

16:47

give our patient a window opportunity to

16:49

rehab. So always think about clinical

16:52

reasoning, it's risk versus

16:54

benefit assessments, familiar

16:57

yourself with your local protocols and

16:59

policies, safety,

17:01

and also aftercare as well.

17:03

Because again, injections

17:06

should be used in conjunction with other

17:08

management as a total management approach.

17:10

So that would be my... Take home message for

17:13

everybody.

17:14

Brilliant. Well, that's certainly what I think I've got from this. And it's

17:16

been really, really useful, Sharon. It's

17:18

been great. I really appreciate your time today

17:20

on the episode. We've covered loads in a short space

17:22

of time. It's gone really, really quickly. And I'm

17:25

sure it'd be really great to have you on again

17:27

to talk about maybe this in more detail and

17:29

some of the lots of other things that you do, if that's

17:31

okay with you.

17:32

Yeah, of course. No problem.

17:35

Thank you very much, Sharon. We'll see you again

17:37

soon.

17:39

Bye. Thank

17:43

you.