Toradol SolutionAdvantages and possible risks associated with steroid injection compared with nonsteroidal anti-inflammatory drugs NSAIDs for shoulder pain are not fully understood. To compare the efficiency and safety of steroid injection versus NSAIDs for non steroidal anti inflammatory injections with shoulder pain. Study eligibility criteria, participants, and interventions: Study appraisal and synthesis methods: Eight RCTs involving participants were included in the meta-analysis.
Non-steroidal anti-inflammatory analgesic injections. - PubMed - NCBI
Advantages and possible risks associated with steroid injection compared with nonsteroidal anti-inflammatory drugs NSAIDs for shoulder pain are not fully understood.
To compare the efficiency and safety of steroid injection versus NSAIDs for patients with shoulder pain. Study eligibility criteria, participants, and interventions: Study appraisal and synthesis methods: Eight RCTs involving participants were included in the meta-analysis. Not all diseases that can lead to shoulder pain were included, detailed intervention protocols were inconsistent across studies, and some estimated data were input into comparison while some data were lost, which could exert an influence on pooled results.
Steroid injection, compared with oral NSAIDs, provides slightly more improvement in shoulder function without superiority in pain relief or risk of complications at 4 to 6 weeks. Treatment decision should be made based on diseases. NSAIDs injection might be a treatment method for shoulder pain.
Manyconditions, such as adhesive capsulitis, tendinitis, and shoulderimpingement syndrome SIS , can result in shoulder pain. Based on these recognitions, many nonoperative modalities, including steroid injection, nonsteroidal anti-inflammatory drugs NSAIDs , and shockwave, are introduced into practice and have accumulated considerable experience.
However, side effects, such as pain, vasovagal reaction, serum glucose level changes, and facial flush reaction, might prevent patients from this treatment. Previously, 2 meta-analyses have summarized the evidence on this topic. The conclusion, however, is controversial. Therefore, based on newly published articles, 15 , 16 an update review is needed. Reference lists of previous systematic reviews with regard to physiotherapy in adhesive capsulitis and the included studies were also reviewed.
Detailed searching strategy for Pubmed is in Appendix. No language filter was performed. Secondary outcomes were pain relief and complication rate. Range of motion was not selected as one of the outcome of interest because different diseases had different characteristic limitation of range of motion. Comparisons were performed at 4 to 6 weeks after intervention as this period was also the commonly applied course of oral NSAIDs.
The first 2 authors independently reviewed all titles included after primary literature research. Inconsistencies were resolved by discussion and consensus. The first 2 reviewers independently extracted the outcomes of interest and complication rate from the included studies. Besides, the author and published year, disease, number of patients included, interventions details, and summary of findings were extracted. Any disagreement would be resolved by discussion and consensus.
Review Manager, Version 5. A random-effects model was used for comparisons because disease categories, disease duration, detailed intervention protocols, and other confounding factors were inconsistent among studies. However, heterogeneity was also assessed by Q statistic and I 2 statistic. The latter describes the percentage of total variation across studies due to heterogeneity rather than chance.
An effect size of 0. When standard deviation SD was known for baseline and endpoint instead of change, a correlation of 0. In the absence of data from authors, mean SD calculated from available studies was put to use. Publication bias was not detected due to limited number of studies included. Specifically, tendinitis would be regarded as SIS. One study would be omitted in each turn to figure out the origin of heterogeneity. The first 2 reviewers independently used the Cochrane risk of bias tool to evaluate the risk of bias of each included trial.
Any inconformity will be resolved by discussion. The overall quality of evidence for each of the outcomes was rated by applying the Grading of Recommendations Assessment, Development, and Evaluation approach. Publication bias was not able to assess and therefore was rate as none. After removing duplicates, studies were identified by primary search. After reading titles and abstracts, were excluded and 9 were left. Full text of the 9 articles were reviewed for further evaluation.
A total of patients were included in the current analysis, of which received steroid injection. All steroid injections were performed only once.
Anesthetics was not reported to be combined with steroid injection in 2 studies 27 , 29 and not combined with NSAIDs injection in 1 study. Among the included studies, 2 were adhesive capsulitis, 15 , 29 1 was nonspecific painful shoulder, 28 2 were tendinitis, 11 , 27 and 3 were SIS. No study employed intention-to-treat method and only 3 studies had sample size calculation prior to interventions. Four studies with 3 diseases reported data in terms of functional improvement.
The level of evidence was low. Subgroup analysis found that NSAIDs, compared with steroid injection, had similar results for SIS but was inferior to steroid injection for nonspecific shoulder pain and adhesive capsulitis.
Five studies with 3 diseases had results in view of pain relief. Four studies reported complications. Two gastrointestinal reaction, 1 headache, and 2 dyspepsia were identified. Data at 6 weeks after interventions were not available, and authors could not be connected in 1 article. Only 1 complication, a temporary fainting episode, was found in steroid injection group. This is a further meta-analysis about the effect of steroid injection versus NSAIDs for shoulder pain.
The present study of 8 RCTs showed that compared with oral NSAIDs, steroid injection could provide significantly more functional improvement for painful shoulder, albeit with similar effect on pain relief. Complication was observed without superiority in favor of either treatment, indicating equal safety for both interventions. When steroid injection was compared to injectable NSAIDs, the conflicting results indicated the remarkable differences in study design and intervention protocols.
Two former meta-analyses were conducted on this topic. Arroll and Goodyear-Smith 13 compared steroid injection versus oral NSAIDs in terms of remission rate, a predefined method to reflect the number of patients who had evident response to treatment, and did not find any superiority in favor of either intervention.
In addition to remission rate, another meta-analysis chose pain relief and active abduction as secondary outcomes and found that steroid injection was superior to NSAIDs with significantly higher remission rate with similar effect on pain relief and active abduction. In our study, instead of remission rate, we employed the mean and SD of functional improvement as the primary outcome, since remission rate, as a dichotomous value, could not show the improvement of glenohumeral function, which was a continuous progress, and was defined inconsistently across studies.
Adhesive capsulitis causes loss of passive external rotation, while SIS leads to abduction defect. Instead, we employed the complication rate as another secondary outcome, in an attempt to figure out the safety of both treatments. According to the pooled results, both treatments had similar complication rate, and complications were mainly temporary and not serious. Besides, injectable and oral NSAIDs were compared to steroid injection separately, providing more detailed evidence for clinical practice.
The heterogeneity was remarkably significant in functional improvement. This was mainly caused by inconsistent intervention protocols and different diseases, the latter of which was analyzed by subgroup analysis. The heterogeneity was caused by the study conducted by White et al. Different dosages were used for shoulder pain.
An accurate diagnosis is of vital importance to guide clinical practice. Concern must be taken in relate to oral NSAIDs, which carries significant dose-related risks of cardiovascular, renal, hematological, and other systemic adverse events especially for the elderly, who are more likely to suffer shoulder pain.
In order to reduce these risks, high risk patients should be notified, and protective drugs concomitant with less damaging NSAIDs should be prescribed at the lowest effective therapeutic dose for the shortest possible duration. According to the available evidence, different NSAIDs injection doses and frequencies were used and contradictory results were observed.
There are several limitations in the current meta-analysis. First, not all diseases that can lead to shoulder pain were included, thus decreasing the reliability. Besides, although oral and injectable NSAIDs were compared to steroid injection separately, detailed intervention protocols were inconsistent across studies, undermining the current outcomes.
Finally, some estimated data were input into comparison and some data were lost, which could exert an influence on pooled results. Based on current evidence for shoulder pain, steroid injection, compared with oral NSAIDs, provides slightly more improvement in shoulder function without superiority in pain relief or risk of complications at 4 to 6 weeks.
The funder, Jiwu Chen, was responsible for this article. The authors have no conflicts of interest to disclose. National Center for Biotechnology Information , U. Journal List Medicine Baltimore v. Published online Dec This is an open access article distributed under the Creative Commons Attribution License 4. This article has been cited by other articles in PMC. Abstract Advantages and possible risks associated with steroid injection compared with nonsteroidal anti-inflammatory drugs NSAIDs for shoulder pain are not fully understood.
Study Selection The first 2 authors independently reviewed all titles included after primary literature research. Data Collection and Management The first 2 reviewers independently extracted the outcomes of interest and complication rate from the included studies. Data Analysis Review Manager, Version 5. Assessments of Quality of Evidence The first 2 reviewers independently used the Cochrane risk of bias tool to evaluate the risk of bias of each included trial.
Open in a separate window. Functional Improvement Four studies with 3 diseases reported data in terms of functional improvement. Pain Relief Five studies with 3 diseases had results in view of pain relief. Complication Rate Four studies reported complications. Supplementary Material Supplemental Digital Content: Click here to view.