|Ahead of print publication
Intra-articular injections for musculoskeletal pain in a cancer rehabilitation clinic: A cross-sectional study
Victor F Leite1, Jesuel Padro-Guzman2
1 Physical Medicine and Rehabilitation, A.C.Camargo Cancer Center, São Paulo, SP, Brazil
2 Rehabilitation Medicine Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
|Date of Submission||27-Feb-2020|
|Date of Decision||07-May-2020|
|Date of Acceptance||28-May-2020|
|Date of Web Publication||24-Jul-2020|
Victor F Leite,
A.C.Camargo Cancer Center, Rua Professor Antônio Prudente, 211, Liberdade, São Paulo, SP
Source of Support: None, Conflict of Interest: None
Objective: The objective of this study is to describe the individuals that undergo intraarticular injections for musculoskeletal pain in a cancer rehabilitation clinic, as well as the safety of those procedures. Materials and Methods: Retrospective cross-sectional study from July 2017 to May 2018. Results: We included 157 individuals in the study. Participants underwent a total of 546 injections, with a median of two injections per individuals. Osteoarthritis was the most common indication for injections (82.1%). Most injections were guided by ultrasound (62.2%). There were six AEs in our study: four procedure-related, none serious. Conclusions: Intraarticular injections were safe in the short-term in this population.
Keywords: Injections, intra-articular, musculoskeletal pain, neoplasms, safety, pain
|How to cite this URL:|
Leite VF, Padro-Guzman J. Intra-articular injections for musculoskeletal pain in a cancer rehabilitation clinic: A cross-sectional study. J Int Soc Phys Rehabil Med [Epub ahead of print] [cited 2021 Apr 14]. Available from: https://www.jisprm.org/preprintarticle.asp?id=290574
| Introduction|| |
Pain is frequent in individuals with cancer and often impacts their functionality.,, Musculoskeletal pain (MSP) is a common cause for pain in this population and is more prevalent than in individuals without cancer. MSP can be caused or aggravated both by cancer and by cancer treatments.
As part of the treatment of MSP, intraarticular injections are frequently necessary,,, particularly in cases refractory to patient education, oral medication, and physical rehabilitation. Our objective is to describe a population that underwent intraarticular injections for MSP in a cancer rehabilitation clinic, as well as its safety.
| Materials and Methods|| |
Reporting of this study followed the STROBE guidelines, as suggested by the EQUATOR network. This research was approved by the Institutional Review Board and is in accordance with the requirements of the declaration of Helsinki.
Retrospective electronic health record review was conducted at the Physical Medicine and Rehabilitation outpatient clinic at Memorial Sloan Kettering Cancer Center, from July 2017 to May 2018. Records for all individuals that underwent any procedure at the clinic (e.g., trigger point injection, electromyography, and intraarticular injections) from January 2012 to May 2017 were screened.
Individuals were included if presenting all the following criteria:
- Underwent an intraarticular injection for MSP (e.g., osteoarthritis [OA] and adhesive capsulitis) in our clinic from January 2012 to May 2017
- Presented with active cancer (radiological or laboratory confirmation of persistence of disease) or on current active cancer treatment at the time of injection.
In this descriptive study, we assessed individuals' demographics, information related to cancer and its treatment. We also assessed etiology of MSP, and information related to the intra-articular injection. Adverse events (AEs) after the injection were defined as procedure-related AEs and serious AEs. Procedure-related AEs were defined as those probably caused by the injection. Serious AEs were defined as procedure-related AEs, resulting in life-threatening situation, hospitalization, permanent disability, or death. Classification into those strata was determined by the consensus between the researchers. The follow-up visit was considered valid if conducted ≥7 days after injection, by any clinic in the hospital, and if there was a clear description of either the presence or absence of AEs after the injection.
Preprocedure laboratory examinations were considered if they were performed ≤30 days before the procedure. Altered values were defined by the following thresholds:
- Absolute neutrophil count ≤1.5 × 103/μL
- Platelets ≤100 × 103/μL
- International normalized ratio for prothrombin time ≥1.5.
| Results|| |
The records of 910 individuals were assessed, and a total of 157 individuals were included in the study. At the time of the injection, 84% of participants were on active cancer treatment. Participants underwent a total of 546 injections, with a median of 2 injections per individual [Table 1]. OA was the indication for 82.1% of injections [Table 2]. Most injections were guided by ultrasound (US) (62.2%), followed by the landmark-guided (18.5%) and fluoroscopy (16.3%). Most injected medications were hyaluronic acid (52.6%), corticosteroid combined with local anesthetic (31.7%), and corticosteroid combined with hyaluronic acid (13.7%). Time of follow-up was <30 days in 75.7% of the injections [Table 3]. No individuals presented with altered laboratory values.
There were six AEs in our study: four procedure-related, none serious [Table 4]. The two cases that were considered as nonrelated to the procedure were:
- A 74-year-old male on pomalidomide for multiple myeloma, who received an US-guided knee viscosupplementation for OA, and developed an episode of acute on chronic cholecystitis, treated with intravenous antibiotics;
- A 61-year-old female on trametinib and dabrafenib for metastatic melanoma that underwent an US-guided knee viscosupplementation for OA. She was admitted to the urgent care 39 days after the procedure due to worsening low back pain and was found to have increased widespread metastases, particularly over the spine, leading to her death 15 days after admission.
Incidence of procedure-related AEs was 1.1% of total injections, and 2.5% of total patients. Four cases of AEs were thought to be possibly procedure related:
- A 57-year-old female on tamoxifen for nonmetastatic breast cancer without evidence of current cancer activity who received an US-guided knee injection with combined hyaluronic acid and corticosteroids for OA. She presented with knee swelling and fever, underwent complete blood counts, inflammatory markers, as well as blood and synovial cultures, all of which were negative for infection. The patient was treated with oral antibiotics for 1 week, with the resolution of symptoms
- A 71-year-old male on erlotinib for active lung cancer who received an US-guide knee viscosupplementation for OA. He developed worsening knee pain after the injection, without signs of infections, and underwent a knee replacement surgery
- A 51-year-old female on anastrozole for metastatic breast cancer without evidence of active disease who received an US-guided knee corticosteroid injection for OA. She developed worsening pain without the signs of infection and underwent knee replacement surgery
- A 67-year-old male with active liposarcoma without active treatment who underwent an US-guided knee viscosupplementation injection for OA. He presented with a ruptured hemorrhagic Baker's cyst that improved with anti-inflammatory medication, rest, ice, compression, and elevation of the limb.
Three patients had no follow-up after the procedure, resulting in a loss of follow-up of 1.9% of total patients, and 0.5% of total injections.
| Discussion|| |
In this descriptive study, most individuals that underwent intraarticular injections for MSP pain presented breast cancer, and underwent knee injections due to OA. All AEs occurred after knee injections, which accounted for 80% of total injections. Intraarticular injections were safe in the short-term in our cohort, as the incidence of AEs was 0.7% per injection, and no serious AEs were observed, comparable to other studies.,, In the general population, intraarticular knee and shoulder injections, presented AEs in 13% and 1.9%–11.3% of the cases, respectively., Serious AE in the general population for the knee, shoulder, and hip injections was 0.3%, 0%, and 0.97%, respectively.,,
There are three important points that were not addressed in our study: use of corticosteroids during immunotherapy; injection and anticoagulant ion, and injection and lymphedema.
The use of corticosteroids during immunotherapy is of concern, as recent research shows that glucocorticoids can impair immunotherapy success with doses fewer than 10 mg of prednisolone per day. However, our study was not designed to assess the impact of intraarticular corticosteroids on cancer therapy. Of note, this cohort had 10 individuals on immunotherapy that underwent a total of 34 injections, 50% of which were performed with corticosteroids. Due to recent data on the impact of corticosteroids on the efficacy of immunotherapy, alternatives to corticosteroids should be considered whenever possible. Other potential concerns of using glucocorticoids, such as impairment of glucose homeostasis and adrenal suppression were not addressed in this study.
Intraarticular injections in individuals on anticoagulation are also a common concern when managing pain in individuals with cancer. Our cohort had no patients on anticoagulation. However, a guideline of the American Society of Interventional Pain Physicians suggests that peripheral joint injections are of low risk and could be done on anticoagulation.
Lymphedema was not considered in our study. There is a potential, although anecdotal, risk of aggravating lymphedema when performing injections at those limbs. However, this is controversial, since recent research on the risk blood draws and injections could not establish a higher risk of developing lymphedema.,
The main limitations of our study result from its retrospective design, and the absence of a control group. Although we believe that serious short-term AEs were adequately reported, we cannot ascertain long-term AEs. Impact on immunotherapy, for instance, is of particular concern, and was not assessed. The generalizability of our findings is still limited due to our setting: A comprehensive cancer center, with an established and integrated PM&R Clinic. Prospective studies with structured data collection, as well as data from other centers would be helpful in providing more information and potentially offer external validity to our findings.
| Conclusion|| |
Intraarticular injections for MSP in patients with active cancer (or on active cancer treatment) were safe in the short term in this population. No serious AEs were observed. To our knowledge, this is the first study to assess the characteristics of a significant population of cancer patient that underwent intraarticular injection for MSP.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mulvey MR, Boland EG, Bouhassira D, Freynhagen R, Hardy J, Hjermstad MJ, et al
. Neuropathic pain in cancer: Systematic review, performance of screening tools and analysis of symptom profiles. Br J Anaesth 2017;119:765-74.
Jiang C, Wang H, Wang Q, Luo Y, Sidlow R, Han X. Prevalence of chronic pain and high-impact chronic pain in cancer survivors in the United States. JAMA Oncol 2019;5:1224-6.
van den Beuken-van Everdingen MH, Hochstenbach LM, Joosten EA, Tjan-Heijnen VC, Janssen DJ. Update on prevalence of pain in patients with cancer: Systematic review and meta-analysis. J Pain Symptom Manage 2016;51:1070-90.
Huang IC, Hudson MM, Robison LL, Krull KR. Differential impact of symptom prevalence and chronic conditions on quality of life in cancer survivors and non-cancer individuals: A population study. Cancer Epidemiol Biomarkers Prev 2017;26:1124-32.
Favejee MM, Huisstede BM, Koes BW. Frozen shoulder: The effectiveness of conservative and surgical interventions–systematic review. Br J Sports Med 2011;45:49-56.
Steuri R, Sattelmayer M, Elsig S, Kolly C, Tal A, Taeymans J, et al
. Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: A systematic review and meta-analysis of RCTs. Br J Sports Med 2017;51:1340-7.
McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, et al
. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage 2014;22:363-88.
von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al
. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. Ann Intern Med 2007;147:573-7.
Jüni P, Hari R, Rutjes AW, Fischer R, Silletta MG, Reichenbach S, et al
. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev. 2015;22:CD005328.
McCabe PS, Maricar N, Parkes MJ, Felson DT, O'Neill TW. The efficacy of intra-articular steroids in hip osteoarthritis: A systematic review. Osteoarthritis Cartilage 2016;24:1509-17.
Aly AR, Rajasekaran S, Ashworth N. Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: A systematic review and meta-analysis. Br J Sports Med 2015;49:1042-9.
Connell CM, Raby S, Beh I, Flint TR, Williams EH, Fearon DT, et al
. Cancer immunotherapy trial registrations increase exponentially but chronic immunosuppressive glucocorticoid therapy may compromise outcomes. Ann Oncol 2017;28:1678-9.
Kaye AD, Manchikanti L, Novitch MB, Mungrue IN, Anwar M, Jones MR, et al
. Responsible, safe, and effective use of antithrombotics and anticoagulants in patients undergoing interventional techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician 2019;22:S75-128.
Asdourian MS, Swaroop MN, Sayegh HE, Brunelle CL, Mina AI, Zheng H, et al
. Association between precautionary behaviors and breast cancer-related lymphedema in patients undergoing bilateral surgery. J Clin Oncol 2017;35:3934-41.
Ferguson CM, Swaroop MN, Horick N, Skolny MN, Miller CL, Jammallo LS, et al
. Impact of ipsilateral blood draws, injections, blood pressure measurements, and air travel on the risk of lymphedema for patients treated for breast cancer. J Clin Oncol 2016;34:691-8.
[Table 1], [Table 2], [Table 3], [Table 4]