Physio Network

[Physio Explained] Needles and nuances: breaking down injection therapy with Nick Livadas

Share episode

In this episode we discuss: 

  • History of corticosteroid injections
  • Evidence base behind corticosteroid injections
  • Effectiveness of injection therapy
  • Injection therapy for specific conditions e.g. Frozen shoulder, RC related disorders, carpal tunnel syndrome, tennis elbow
  • Risks and benefits of corticosteroid injections

Want to learn more about Injection Therapy? Nick recently did a brilliant Masterclass with us, called “Injection therapy for Musculoskeletal Disorders” where he goes into further depth on everything you need to know about injection therapy. 

👉🏻 You can watch his class now with our 7-day free trial: https://physio.network/masterclass-livadas

Nick Livadas is an advanced practice physiotherapist and clinical lead for a community musculoskeletal service in the United Kingdom. He combines his clinical caseload with a lecturing position at Teesside University where he leads on an injection therapy masters module. He is currently studying for his PhD and has published academic articles in a variety of musculoskeletal disorders.

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @James_Armstrong_Physio

SPEAKER_02:

We're probably at a state whereby we appreciate that this is a drug that we're injecting. And like any drug, it has a lifespan. So it wears off, just like a paracetamol. But the benefit we get from these corticosteroid drugs typically lasts longer. than your oral medications. And that's the beauty of them. And they've been developed through synthetic processes through the pharmaceutical companies to give them that longer lasting benefit.

SPEAKER_01:

In today's episode, we dive straight into the pros and cons of injection therapy with Nick Lividas. Nick is a tutor on the master's accreditation injection therapy course at Teesside University. He's the former chair of the Association of Physiotherapists in Orthopaedic Medicine and Injection Therapy and has published several papers on injection therapy. And in today's episode, we do dive into the history of corticosteroid injections, evidence-based behind these injections, and we look at the effectiveness of injection therapy and we look at some of the specific conditions that injection therapy might be useful and potentially not so useful for and we also look of course at the risks and benefits to the injections that we offer our patients in the hope that it'll support their recovery. Now if you want to learn more about injection therapy Nick has recently done a brilliant masterclass with us called Injection Therapy for Musculoskeletal Disorders where where he goes into further depth on everything you need to know about injection therapy. You can watch the class with our 7-day free trial, just follow the link in the show notes below. I'm James Armstrong and this is Physio Explained. Nick, it is great to have you on the podcast today. Really looking forward to chatting through the subject matter, especially as you've done a masterclass for us recently, which is going to be a big topic for a masterclass, let alone a 15, 17 minute podcast. So we're going to give it a good go today, Nick, but it's nice to have you on.

SPEAKER_02:

Thanks, James. Pleasure to be on.

SPEAKER_01:

So in today's podcast, we are going to be talking about corticosteroid injections for MSK. And as we said, this is a big, big topic area. We're going to dive straight in in a second, but the Masterclass does cover all of these points in a lot more detail. So it's going to be well worth our listeners checking that out. I think they're going to be wanting to know more after this episode. So Nick, should we start with the success of corticosteroid injections in MSK disorders? How successful are our injections?

SPEAKER_02:

Yeah, it's a great question. And it's something that if we reflect on the fact they've been used for 70 years as one of the mainstays of treatment for MSK disorders would probably suggest that they are successful because they have stood the test of time, unlike some other modalities within physiotherapy that have maybe come and gone as the evidence base has maybe challenged their effectiveness. So we're in a position now where we use corticosteroid injections for both soft tissue disorders and but also joint disorders as well. And over the last probably 10 to 20 years, we're seeing more and more research now that has improved in methodological rigour and trustworthiness, that has given us some greater insight into which conditions are maybe more favourable than others. We're probably at a state whereby we appreciate that this is a drug that we're injecting, and like any drug, it has a lifespan. So it wears off, just like a paracetamol. But the benefit we get from these corticosteroid drugs typically lasts longer than your oral medications. And that's the beauty of them. And they've been developed through synthetic processes through the pharmaceutical companies to give them that longer lasting benefit. If we were to look at a ballpark figure in terms of the duration of effect, we're probably around about six weeks to 12 weeks in terms of their effectiveness. It depends if your glass is half full or half empty. For some, that's a long time. But for others, and maybe our patients, that's not a long time at all. Especially maybe if they're living with long-term musculoskeletal pain syndromes. A few weeks' benefit is perhaps not as favourable as they'd hoped or wished for. And I think that's one of the kind of confusions clinicians should navigate in that, yes, they are largely effective. but they are short-term. And I think as clinicians, it's our responsibility to make sure patients are aware that this isn't typically a cure. It is short-term, and like any drug, it will wear off. I guess I'd caveat that in that many patients will have a steroid injection and the clinicians probably listening will also reflect on patients that say, yes, but I had an injection and it resolved my pain. Or I had an injection and it lasted a year. Can I have another one? And we're not truly sure why that is. There's a number of kind of theories in terms of, well, why does the benefit for some people last a lot longer than a few months? And why for some people does it resolve their symptoms? You know, the factors that we may consider there might be regression to the mean, natural history, maybe placebo. Maybe we're kind of breaking an inflammatory cycle that allows them to do other things. And it's the other things that are giving the longer lasting benefit. But on the whole, I think we can look upon corticosteroid injections as an adjunct. And I think that's important for the listeners to appreciate that very rarely are they a standalone treatment. Very rarely are they a first-line treatment, although there might be one or two conditions where we might look to it as a first-line treatment. But they shouldn't really replace other factors that we know to be high-value care, whether that's increasing physical activity levels, working on psychosocial factors that might be contributing, looking at improved sleep hygiene, diet, nutrition, and all those lifestyle changes that As MSK clinicians, we always look to impress upon our patients as important. Naturally, the challenge for clinicians might be the patients that want the quick fix of a corticosteroid injection over some of the other factors that may just be a little bit more tricky to address and work through.

SPEAKER_01:

Perfect. So we can safely say there's some benefit there. Can I put you on the spot, Nick, and say if you were to pick a few disorders that you think the corticosteroid injections are are probably most successful in your opinion or through the evidence. Where would you take us?

SPEAKER_02:

Certainly for trigger finger. So for those patients that have got that kind of locked or catching digit, it is probably a first-line treatment that can be very successful in up to 70% of cases. Symptoms will resolve and never return. Carpal tunnel syndrome is probably another one that we see included within national guidance. across the globe as a first line or second line treatment maybe after splinting. We also see it within national guidance for a number of shoulder disorders. So there's some good evidence to show that if we can kind of maybe offer a corticosteroid in the early stages of frozen shoulder, we may actually prevent that disease process progressing into later stages and get to a quicker recovery. We also see it within shoulder conditions related to rotator cuff related disorders and Occasionally, it's used as a first-line treatment if pain levels are maybe a barrier to engaging in a physical activity exercise approach. But there's naturally some concerns about rotator cuff-related corticosteroid injections because of some of the risks that we may well come on to.

SPEAKER_01:

Absolutely. I think we're definitely going to talk about that in a second as well. And I think a second prong to my question there, are there any disorders where we've seen corticosteroid injections really move away from the use of corticosteroid injections?

SPEAKER_02:

So I think tennis elbow is probably the one that we've seen the biggest shift away from. And that kind of dates back to research from 2006, 2008, where we found actually a worse outcome in people that had the steroid injections than people who did nothing at all. Now, like those groups that had the steroid injection, like most groups, they did really well for a few weeks, but actually they were worse off a year down the line. We say it takes many years for research to come into practice, but we're talking 2006, 2008. And only now are we really seeing that kind of shift away from tennis elbow injections. And that's kind of supported in the literature as well, where the national guidelines are also suggesting that it isn't a kind of treatment. Of course, some of our medical colleagues may still be kind of pursuing with their use to some degree, but even general practitioners in primary care now are slowly kind of catching up with the evidence that for tennis elbow, golfer's elbow, it's probably not what we thought it was. The other one where we've probably seen a slight shift, not to the extent of tennis elbow perhaps, is osteoarthritis of the knee and hip. And that's because some of the kind of perceived risks that we're starting to learn more and more over recent years about the potential harms to joint articular cartilage.

SPEAKER_00:

Want to take your physio skills to the next level? Look no further than our Masterclass video lectures from world-leading experts. With over 100 hours of video content and a new class added every month, Masterclass is the fastest way to build your clinical skills, provide better patient care and tick off your CPD or CEUs. Click the link in the show notes to try PhysioNetwork's Masterclasses for free today. And

SPEAKER_01:

that segues us really nicely onto... thinking about how safe are corticosteroid injections and what are the risks, Nick?

SPEAKER_02:

As far as physiotherapists that use interventions, corticosteroid probably sits pretty high in the risk ratio. But on the grand scheme of things available compared to surgeries, for example, they are pretty low risk. And the risks that are associated with corticosteroid injections, their incidence rate is pretty low as well. We can probably split those up into local side effects or local risks, and more systemic side effects or kind of systemic risks. The local risks, I guess, would be on the severe scale, maybe sepsis. Because we're injecting a drug that has an immunosuppressive element, we're creating a needle through the skin, there's of course a risk of local infection. Another might be skin changes, skin depigmentation, fat atrophy around the site where you inject. And also there might be a post-injection flare of pain, which is another one. Another local side effect might be a weakening of the tendon tissue. So we know that corticosteroid has a negative effect on collagen, which is the building blocks of our soft tissues. So especially with repeated injections around soft tissues, there's the risk, of course, of rupture or weakening of the tendon tissue. If we're thinking more local side effects from joint injections, we've seen over recent years, research demonstrate that repeated steroid injections And these are studies that look at repeat injections at three-month intervals, which is quite rare. Anyone would do that, I think. But with that kind of an injection approach, we see a thinning of the articular cartilage. So a structural progression of osteoarthritis, which is something that is now starting to inform people, clinicians and patients. On a more systemic level, we've got probably on the severe scale, anaphylaxis. It's a drug they've had in the body. They may not have had it before. and they may have anaphylaxis. There's negative consequences to a buildup of steroid, especially if they have other steroids, medications for other disorders. If we're adding to that steroid load, albeit through a one-off injection, there may be a cumulative effect which can have some more negative effects. Diabetics can have a spike in their blood sugar levels, the immunosuppression that we've mentioned already, that might be a factor for some of our patients that may be already immunocompromised. So maybe some of our elderly patients, some of our patients with comorbidities, those are factors as well that we need to consider. And that was especially true during the COVID pandemic, where many of the corticosteroid injections offered were either not offered at all or certainly reduced in their number.

SPEAKER_01:

I think it's a really interesting point there, Nick, where in physiotherapy we're used to most of our interventions having very low physical risk, if we're honest. So therefore, in relation to that corticosteroid injection, could be seen as quite risky. But then if we look at it in a more medicine-based action, it's probably at one of their lowest risk compared relatively to what else they offer. So when you put it into perspective, I think that's one of the key things, isn't it? And looking at your patient who's sat in front of you.

SPEAKER_02:

Yeah, absolutely.

SPEAKER_01:

Moving forward, obviously, we're going through into the future of physiotherapy and MSK care. What role do you think corticosteroid injections are having now and are going to have going forward?

SPEAKER_02:

I think we will still see a situation where corticosteroid injections will be used for a plethora of different MSK disorders. I've been injecting for 17 years now, and certainly my own practice and my colleagues, we've all reflected on that. We see steroid injections used less now than we did 15 plus years ago. So there has been a natural shift in a reduction of corticosteroid use. Where the kind of the gold standard is from a research perspective is to try and work out which subgroups of patients with a specific disorder may do better than others. You know, which patients that have an arthritic knee are going to do better with a steroid injection and which are not? Which patients with our rotator cuff disorders are going to do better than others? And we're not there yet. So if we do come to a place where we're better able to subgroup patients, this may be based on research, I think that will put us in a in a better position going forward to make sure our use of steroids is judicious and appropriate for our patient cohort. Another kind of factor to consider now is we live in a personalised care world. So now more than ever, a patient is part of that shared decision-making process. And many, many patients come to that clinical consult quite often with a preference already that they'd like to try a steroid injection. That may be appropriate. It may not be appropriate. It's upon us as clinicians then to have that decision-making conversation with a patient, whether your listeners are injectors or not, if they engage with the masterclass, listen back through this, hopefully they'll have that appreciation of the benefits versus the risks to have that better shared decision-making conversation with patients. From a personal perspective, when we do have that shared decision-making conversation and the patients actually appreciate the risks that they'd maybe not appreciated before, they suddenly kind of have that moment of dawning and think, actually, maybe that's not for me. What other option did you say was available? And then they may move away to the other more conservative kind of measures as well. I guess another factor of the future is the unknown in terms of what other injectable options may surface as appropriate. You know, we've got lots of trials around platelet-rich plasma. We struggle at the moment with the methodological quality of those trials to kind of draw any firm conclusions, and they haven't really made it into guidelines as a recommended treatment. There might be some tentative recommendations for their use, but it may be that we see a greater supporting evidence for platelet-rich plasma. We're seeing other biologicals increasingly being used within research as well. We don't have the body of research for that to impact on practice in mainstream care just yet, but that might be a factor as well. And there'll be many cases for years to come where patients just struggle to engage with rehab. because their pain levels are so high. Oral medication might not take the edge off it to allow them to engage. And for many, it can be seen as a window of opportunity and that they fully accept it's not going to be a repeated treatment. They're fully on board with the fact it might wear off after a few weeks, but it might just give them that window to engage in the rehab, increase the physical activity levels. Part of that might be losing some weight. And for many patients, that might be something that they really value. The last consideration for the future is probably those patients that maybe have tried the conservative measures, given it a really good go, but they haven't found the benefit. They're aware of the surgical options, but perhaps they're medically unsuitable for surgery. Maybe they've been denied surgery on their past medical history. It might be unsafe to consider surgical intervention. And for some patients who have several months of benefit from a one-off steroid injection, even a year's benefit, that one-off injection every nine months a year might allow them to stay independent, might allow them to sleep, might allow them to get to the shops or do those activities that are important to them in life. And to kind of withhold that would probably be unethical if they've tried all other interventions and not suitable for surgery, and they've got this treatment that they reflect on offers a really sustained benefit. The reason why it's sustained, we don't know, but for some it does. So in that cohort of patients as well, we've also got a small subgroup of which corticosteroid injections can offer real value in helping them kind of live their lives as independently as possible.

SPEAKER_01:

Brilliant, Nick. It's a massive area, isn't it? Actually, I think it's a really interesting area for physiotherapists and MSK clinicians out there. And certainly, I think this is highlighted already, that actually having a really good understanding as a clinician of about injections enables you to have that conversation with patients. And as you rightly said earlier, the shared decision-making. And if we don't have the knowledge of the risks, the benefits, and the kind of realistic outcomes that corticosteroid injections may or may not have, then how on earth can we have that conversation with patients? So I think it's really, you've highlighted a need for whether you inject or not. Certainly if you inject, but if you don't, you still need to have that good understanding to have those beneficial conversations. Am I right in that?

SPEAKER_02:

Absolutely. I think the masterclasses, it's pitched at both non-injectors and injectors. So there is something there for both groups that will enable them to have better conversations with patients, clinically reason through the options available and come to a point of personalised care, which will be different for every person in front of us.

SPEAKER_01:

Absolutely, absolutely. Nick, thank you so much for your time. It's been really, really useful and a good insight into the use of injections. So for those of you watching or listening even, sorry, who would like to learn more about corticosteroid injections, their use, the benefits, the risks and everything in between, do head in to the links below to click on and get involved in that masterclass. It's going to be well worthwhile, I'm sure, Nick. So thank you very much again for your time.

SPEAKER_02:

Thanks, James. No problem.

SPEAKER_01:

Great. Have a good evening Nick. Cheers.