Intra-articular steroids and splints/rest for children with juvenile idiopathic arthritis and adults with rheumatoid arthritis
Editorial Group: Cochrane Musculoskeletal Group
Published Online: 25 JAN 2006
Assessed as up-to-date: 8 NOV 2005
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Wallen MM, Gillies D. Intra-articular steroids and splints/rest for children with juvenile idiopathic arthritis and adults with rheumatoid arthritis. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD002824. DOI: 10.1002/14651858.CD002824.pub2.
- Publication Status: Edited (no change to conclusions)
- Published Online: 25 JAN 2006
Resting or immobilizing a joint to enhance outcomes following intra-articular (IA) steroid injection is generally advocated. This systematic review aimed to determine the efficacy of IA steroid injections and the influence of post-injection rest.
1. Compare IA steroid injections versus no treatment or placebo.
2. Determine the effects of rest following IA steroid injection in rheumatoid or juvenile idiopathic arthritis.
The Cochrane Central Register of Controlled Trials (CENTRAL- Issue 4, 2003), Cochrane Database of Systematic Reviews (CDSR - Issue 4, 2003), Database of Abstracts of Reviews of Effectiveness (DARE - searched 8.1.04), MEDLINE (1966 to August Week 2 2004), EMBASE (1980 to August Week 2 2004) , CINAHL (1982 to December Week 2 2003), Clinical Trials site of the National Institute of Health, (USA - searched 8.1.04), OTseeker (Occupational Therapy Systematic Evaluation of Evidence - searched 8.1.04) and PEDro (Physiotherapy Evidence Database - searched 8.1.04) were searched. Journals and reference lists were hand searched.
Eligible were randomised controlled trials of IA steroid injections or of rest following IA steroid injections in rheumatoid or juvenile idiopathic arthritis.
Data collection and analysis
Potentially relevant references were evaluated and all data extracted by two independent reviewers.
Five trials (n=346) examining IA steroid injection in the knee joint were included. It was not possible to pool data as outcome measures, timing of follow up and the methods of data reporting differed between trials. There was inconclusive conflicting evidence from two trials that walking time was reduced. There was evidence from one moderate quality trial that pain was reduced at 1-day post-injection (0-100 VAS from 28.33 to 13.46; McGill Pain Scale from 8.89 to 3.96) but not at 1 week or 7-12 weeks post-injection. There is some evidence that IA injections improved knee flexion (by 14 degrees) and reduced knee extension lag (by 20 degrees), knee circumference (median reduction = 0.3 cm) and morning stiffness (reduced from 60 mins to 7.6 mins). One trial (n=91) examined the effects of rest following injection in the knee. The rested group achieved significant improvement in pain, stiffness, knee circumference, and walking time when compared with the non-rested group (no point estimates provided). One trial evaluated rest following injection of the wrist (n=117). Relapse rate was higher in the rested group (rest relapse rate = 24/58, no-rest group = 14/59); but there were no differences between the rested and non-rested groups on pain, joint circumference, wrist function, grip strength or ROM.
There is some evidence to support the use of IA steroid injections and resting a knee following injections but that wrists should not be rested following injections. The included studies involved adult participants so any conclusions can only cautiously applied to children. Further research is required to examine the use and type of rest and the differential responses of different joints following injections.
Plain language summary
Intra-articular steroids and splints/rest for arthritis in children and adults
Do intra-articular steroid injections work for treating rheumatoid arthritis and should people rest after the injections?
Seven moderate quality studies were reviewed and provide the best evidence we have today. The studies tested 346 adults with rheumatoid arthritis. They compared people who had a steroid injection, a fake injection or aspiration/washout of their knees or wrists to each other. Two studies tested whether people should rest their joints after injections.
What is rheumatoid arthritis and how might steroid injections help?
Rheumatoid arthritis is a disease in which the body's immune system attacks its own healthy tissues. The attack happens mostly in the joints of the hands and feet and causes redness, pain, swelling and heat around the joints. Intra-articular steroid injections into a joint can be used to decrease pain and swelling quickly. People may have steroid injections to delay starting steroid pills or arthritis drugs, or when drugs are not controlling pain enough. It is not clear if steroid injections work and if people should rest their joints after injections.
What did the studies show?
One of two studies show that people who had steroid injections had less pain the first day than people who had fake injections.
Pain decreased by about 15 points on a 0-100 scale with a steroid injection and 7 points with a fake injection.
The change in pain, however, was the same after 1 or 7 to 12 weeks with or without steroid injections.
Studies show that people who had steroid injections could bend and straighten their leg better/farther and had less swelling around their knee than people with fake injections. Morning stiffness also did not last as long with steroid injections. But one study shows that people could walk faster with steroid injections while another study shows they could not.
People had less pain, stiffness, swelling, and could walk faster if they rested their knees after steroid injections to their knees. But after steroid injections to their wrists, people felt the same whether they rested their wrists or not - but more had a relapse when they rested.
How safe are steroid injections?
No side effects due to injections were reported.
What is the bottom line?
The level of quality of the evidence is 'silver'. Intra-articular steroid injections can improve pain, movement, stiffness and swelling and are safe in adults with rheumatoid arthritis. There is no evidence to say whether this is true for children.
Knees should be rested after a steroid injection, but wrists should not.
1. 比較關節內注射類固醇與未注射或安慰劑。2. 關節內注射類固醇後休息來治療幼年型類風濕性關節炎及成人類風濕性關節炎的效果。
搜尋Cochrane Central Register of Controlled Trials (CENTRALIssue 4, 2003), Cochrane Database of Systematic Reviews (CDS Issue 4, 2003), Database of Abstracts of Reviews of Effectiveness (DARE earched 8.1.04), MEDLINE (1966 to August Week 2 2004), EMBASE (1980 to August Week 2 2004), CINAHL (1982 to December Week 2 2003), Clinical Trials site of the National Institute of Health, (USA searched 8.1.04), OTseeker (Occupational Therapy Systematic Evaluation of Evidence searched 8.1.04) and PEDro (Physiotherapy Evidence Database searched 8.1.04)。並手動搜尋參考文獻之文章。
5個研究包含346例膝關節內注射類固醇病患於分析中。因結果測量、追蹤時間、數據方式報告不同因此無法將資料混合分析。兩篇報告行走時間縮短，但結論並不一致。一篇中等品質研究指出注射一天後疼痛減少(0 – 100 VAS 由28.33到13.46 cGill Pain Scale 由8.89到3.96)，但一週及7到12週後並無差異。關節內注射類固醇改善膝彎曲角度﹝14度﹞及減少膝部伸展延遲﹝20度﹞，膝圍 (減少中位數0.3公分)及晨僵 (由 60分到7.6分)。1個研究包含91例檢驗注射後休息，休息組比未休息組在減少疼痛、僵硬、膝圍及行走時間有顯著改善﹝未給點估計﹞。一篇研究注射腕關節(n = 117)後休息，復發率在休息組較高(休息組復發率 = 24/58,未休息組復發率 = 14/59)，但在疼痛、關節大小，僵硬、手腕功能、握力或運動範圍兩組無顯著差異。
此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。
關節內注射類固醇是對於治療類風濕性關節炎有效?而注射後是否需要稍微休息? 本研究回顧了7個品質中等的研究，並提出了迄今最佳的證據。 研究共測試了346名成人類風濕性關節炎病患，比較關節內各注射類固醇者、假注射、抽吸/沖洗膝蓋者；2個研究檢驗是否關節內注射後需要休息。類風濕性關節炎是什麼?關節內注射類固醇有何幫助? 類風濕性關節炎是一種免疫系統攻擊建康組織的疾病；它通常攻擊手腳關節，造成關節周圍泛紅、疼痛、腫脹、以及發熱。關節內注射類固醇可以快速減少疼痛及腫脹。病患可以使用類固醇注射來延遲服用類固醇藥丸或關節炎藥物，或是在藥物無法控制時使用類固醇注射。注射類固醇效果與注射後是否需要休息並不清楚。 研究呈現出什麼? 其中一項研究表明，比起假注射的人, 有作類固醇注射的人可以減輕第一天的疼痛。疼痛減少再有注射類固醇組約 15分(在0 – 100分的量表中)，假注射是7分。然而在疼痛的轉變，不論有無使用類固醇注射, 在1天後或7至12週都是一樣的。研究表明，比起假注射的人, 類固醇注射的人可以彎曲得更好，也比較少膝蓋腫脹。只要有類固醇注射, 晨僵也沒有持續。但有研究表明， 使用類固醇注射的人可以步行更快，但另一項研究卻認為不行。如果他們做完膝蓋類固醇注射後多休息, 人們可以較不會疼痛，僵硬，腫脹，並能走得更快。 但在他們的手腕注射類固醇，人們覺得休息與否是沒有差別, 但在休息組有更多人復發。類固醇注射是如何安全的？目前沒有因為注射類固醇產生的副作用被報告。什麼是底線？證據的品質程度是‘銀’級。關節內注射類固醇可以改善疼痛, 活動, 僵硬,和腫脹 並且是安全的應用在成人類風濕性關節炎. 但目前沒有證據說明在兒童也是同樣狀況。膝關節注射類固醇後需要休息，而腕關節則不需要。