Initial Presentation of Pain in Patients with Fibromyalgia.

BACKGROUND: Fibromyalgia is characterized by diffuse musculoskeletal pain at the time of diagnosis, but many patients report their initial symptoms as being focal or local. OBJECTIVES: To evaluate, prospectively, the initial location of body pain in recently diagnosed patients with fibromyalgia. METHODS: Non-selected patients from the rheumatology clinic who were recently diagnosed with fibromyalgia (≤ 2 years) with symptoms of ≤ 4 years participated in our study. Demographic and clinical parameters were documented, as was the initial location of pain they had experienced. Sub-analysis of data according to gender and ethnicity was conducted using chi-squire test. RESULTS: The study comprised 155 patients. Mean age was 39.8 ± 11.7 years; 85% were female. Mean duration of symptoms was 2.11 years and of diagnosis was 0.78 years. Six patients (3.9%) reported initial symptoms of pain as being diffuse from the start, 10 (6.5%) could not remember the location of their initial symptoms, and 139 (90%) reported initial focal pain. Hands were reported as the initial area of pain for 25.2% of the patients, 19.4% reported the back, and 11% reported both trapezial areas as the initial area of pain. In 90% of the patients (excluding patients with back, abdominal, or chest pain) the initial symptoms were bilateral and symmetrical. No significant difference in initial presentation was found among different gender or ethnic groups. CONCLUSIONS: Pain in fibromyalgia patients usually presents as focal and symmetrical. Bilateral hand pain, followed by back pain, was the most common reported area of initial pain among fibromyalgia patients.

The Effect of Periarticular Injection of Methylprednisolone Acetate in Patients with Primary Osteoarthritis of the Proximal Interphalangeal Joints: A Case Controlled Study.

BACKGROUNDS: Primary osteoarthritis of the proximal interphalangeal joints (PIPJ) is a common entity. It could be associated with local pain that has no effective treatment. Local subcutaneous periarticular injection of methylprednisolone acetate (MPA) was evaluated in a prospective case-control study. METHODS: Patients with painful osteoarthritis of the PIPJ for more than 1 month not responding to nonsteroidal meds were prospectively recruited. Radiographic, demographic, clinical, and lab parameters were documented. Visual analogue scale (VAS) was documented regarding the level of PIPJ pain prior to the injection. Patients had local subcutaneous periarticular injection at the medial and lateral sides of each painful PIPJ of one hand, of 8 mg (0.2 ml) of MPA mixed with 0.1 ml of lidocaine 1% (group 1) at each side. Age- and sex-matched control group were given 0.3 ml of normal saline using the same approach (group 2) at each side. VAS was evaluated 1, 4, and 10 weeks following the injection and compared to baseline levels using Wilcoxon's ranks signed test. RESULTS: Eighteen and sixteen patients were recruited in group 1 and group 2, respectively. There were 11 females in group 1 with mean age of 52.7 ± 9.2 years. Mean VAS in group 1 at baseline was 67 and at weeks 1, 4, and 10 was 23 (p=0.001), 29 (p=0.001), and 55 (p=0.043), respectively. Mean VAS in group 2 at baseline was 65 and at weeks 1, 4, and 10 was 43 (p=0.005), 64 (p=0.534), and 69 (0.698), respectively. CONCLUSIONS: Subcutaneous periarticular injection of MPA + lidocaine at the PIP joints resulted in a small but significant improvement that gradually diminished with time across the week 10, among patients with primary OA of hands.

The impact of intra-articular injection of diprospan at the knee joint on blood glucose levels in diabetic patients.

OBJECTIVE: To evaluate the effect of intra-articular (IA) corticosteroid injection (IACI) of betamethasone dipropionate/betamethasone sodium phosphate (Diprospan) on blood glucose levels in diabetic patients METHODS: Patients with type 2 diabetes and symptomatic osteoarthritis of the knee (OAK) in whom medical therapy failed were administered 1 mL Diprospan IACI (5 mg of betamethasone dipropionate +2 mg of betamethasone sodium phosphate). Patients were asked to monitor blood glucose levels before and 2 h after meals for 1 week before and 12 days after the injection was administered. A control group was administered an IA injection of hyaluronic acid. RESULTS: Twelve patients from the Diprospan group and six from the control group were recruited for the study. Patients in the Diprospan group had significantly increased blood glucose levels with median initial and peak levels of 187.5 mg% and 310 mg%, respectively, at a median of 4 and 11.5 h following IACI, respectively. The last peak level was seen after a median of 45 h following IACI. There was no significant increase in blood glucose levels in the control group. CONCLUSION: Diprospan IACI is associated with significantly increased blood glucose levels in all diabetic patients with OAK.

The Impact of Intra-articular Depot Betamethasone Injection on Insulin Resistance Among Diabetic Patients With Osteoarthritis of the Knee: A Case-Control Study.

OBJECTIVE: The aim of this study was to evaluate the impact of intra-articular corticosteroid injection (IACI) of depot betamethasone at the knee joint on insulin resistance (IR). METHODS: Patients with type 2 diabetes, non-insulin treated, with painful osteoarthritis of the knee were requested to participate in our study. After consent, demographic, clinical, and laboratory parameters were documented in addition to fasting blood glucose (FBG) and fasting blood insulin levels just prior to IACI of 1 mL of depot betamethasone. Fasting blood glucose and fasting blood insulin levels were repeated the next day following the IACI and 8 days later. Age- and sex-matched group of patients with type 2 diabetes from the same clinic were recruited as a control group (case-control study). Insulin resistance was calculated using Homeostasis Model Assessment-Insulin Resistance. Mann-Whitney U test, χ test, and Wilcoxon signed rank tests were used for statistical analysis. RESULTS: Eleven patients were recruited in the patients' group and 10 patients in the control group. Median FBG in the patients' group at baseline was 148 ± 51 mg/dL, and median IR was 5.12 ± 2.46. One day following the IACI, median FBG level was 247 ± 104 mg/dL (P = 0.004, compared with baseline), with median IR of 20.8 ± 7.01 (P = 0.0039). The median ratios of blood glucose and IR 1 day following the IACI compared with baseline were 1.7 and 4.1, respectively. Eight days following the IACI, mean FBG and IR levels were not significantly different from baseline. CONCLUSIONS: Intra-articular corticosteroid injection of betamethasone at the knee joint among patients with diabetes was associated with a significant increase in IR levels compared with baseline levels, 1 day following the injection. The mean percentage of increase in IR was higher than that for FBG levels.

The effect of local injection of methylprednisolone acetate on the hypothalamic-pituitary-adrenal axis among patients with greater trochanteric pain syndrome.

Greater trochanteric pain syndrome (GTPS) is a common clinical entity for which the most effective treatment is local corticosteroid injection (LCI). There are no studies on the effect of LCI among patients with GTPS on the hypothalamic-pituitary-adrenal axis. The present study recruited nonselected patients diagnosed with GTPS. After consenting, participants received low dose (1 µg) of adrenocorticotropin hormone (ACTH) stimulation test at 09:00. Immediately following the test, participants received a LCI of 80 mg of methylprednisolone acetate at the greater trochanteric region. The ACTH stimulation test was repeated 1, 2, 4, and 6 weeks following the LCI. Cortisol samples were obtained at just prior to (basal) and 30 min (post-stimulation) following every ACTH stimulation test. Serum cortisol levels of <500 µmol/l obtained 30 min following the ACTH stimulation test were considered evidence of secondary adrenal insufficiency. The study enrolled 22 patients, 21 of whom completed participation. There were 19 female participants (~90%), and mean age of all the participants was 55.2 ± 8.6 years. Four participants showed evidence of secondary adrenal insufficiency, which was observed only at weeks 1 and 2 following the LCI. Mean serum cortisol level among these four participants 30 min following the ACTH stimulation test was 354 µmol/l, with a range of 268-430 µmol/l. LCI of 80 mg of methylprednisolone acetate in the greater trochanteric area among patients with GTPS was associated with transient secondary adrenal insufficiency in ~20% of the patients, mainly 1 week following the injection.

Pre-injection of hyaluronic acid does not affect the systemic effects of intra-articular depot betamethasone injection at the knee joint.

Intra-articular injection (IAI) of both hyaluronic acid (HA) and depot-steroid preparations had the advantage of quick and prolonged favorable effects on pain relief among patients with symptomatic osteoarthritis of the knee (OAK). The effect of IAI of HA on the systemic effects of the intra-articular steroids had not been investigated. Non-selected patients attending the rheumatology clinic with symptomatic OAK who failed NSAIDS and physical therapy were offered an IAI of HA at the knee joint followed 20 min later by an IAI of 1 ml of Celestone Chronodose at the same joint (group 1). Morning serum levels of cortisol were obtained just prior to the IAI and 1, 2 and 8 days later. Demographic, clinical, and laboratory parameters were obtained also from all the patients. Age- and sex-matched group of patients from the same clinic were recruited as a control group (group 2). Mean baseline serum cortisol levels in group 1 was 381 ± 154 mmol/l vs. 376 ± 119 in group 2 (p = 0.954). Morning serum cortisol levels at day 1 and day 2 were 24 ± 6 and 22 ± 6 mmol/l, respectively, in group 1 patients vs. 27 ± 5.8 (p = 0.214) and 25 ± 5.6 mmol/l (p = 0.200), respectively, in group 2. These levels were significantly lower than baseline levels in each group. Morning serum cortisol levels at day 8 in group 1 and group 2 were 349 ± 128 and 314 ± 99 mmol/l, respectively (p = 0.419). Pre-injection of HA at the knee joint did not affect the systemic effect on the hypothalamic-pituitary-adrenal axis of IAI of Celestone Chronodose.

The impact of intra-articular methylprednisolone acetate injection on fructosamine levels in diabetic patients with osteoarthritis of the knee, a case-control study.

Fructosamine is a glycated protein that reflects blood glucose control over the last 2-3 weeks. There are no studies that address the impact of intra-articular injection (IAI) of methylprednisolone acetate (MPA) on fructosamine levels among patients with type-2 diabetes and osteoarthritis of the knee (OAK). Non-selected patients attending the rheumatology or orthopedic clinic with type-2 diabetes and painful OAK, who failed non-steroidal anti-inflammatory drugs (NSAIDS) and physical therapy, were asked to participate in our study. After consent blood tests were drown for fructosamine, hemoglobin A1c (HbA1c) level, complete blood count, lipid profile, serum albumin, serum protein, c-reactive protein, and erythrocyte sedimentation rate. Demographic and different clinical parameters were also documented. Immediately after that, patients had IAI of 80 mg of MPA at the knee joint (group 1). Two to three weeks later, the same blood tests were repeated (except for HbA1c). Age- and sex-matched group of patients with type-2 diabetes and painful OAK attending the same clinics, but who were managed by NSAIDS were asked to participate as a control group (group 2) and had the same evaluation at enrollment and 2-3 weeks later, after consent. Eighteen patients from either group completed the study. Mean fructosamine level in group 1 patients was 263.7 ± 31.8 mg% prior to the IAI vs. 274.6 ± 39.3 mg% (p = 0.035), 2-3 weeks later, while mean fructosamine level in the control group (group 2) at enrollments was 274.2 ± 31.2 mg% vs. 269 ± 30.2 mg%, p = 0.509, 2-3 weeks later. There was no significant change in any other parameter tested at enrollment in either group, compared to those obtained 2-3 weeks afterwards. Body mass index was on the edge of significance as a predictor for a significant change in fructosamine level in group 1 patients. IAI of 80 mg of MPA in patients with type-2 diabetes and OAK had resulted in a significant, though mild increase in fructosamine levels 2-3 weeks later.