Jamil Natour

Objectives: To evaluate the mean pain level during intra-articular injection (IAI) with corticosteroid and its associated variables. Methods: A cross-sectional study with adult patients with rheumatic diseases, joint swelling and pain > 1 month, receiving a single IAI of triamcinolone hexacetonide (TH). Joints were assessed for pain (VAS 0–10 cm), swelling, demographic data, disease type, fibromyalgia presence, joint size/type, and IAI variables (needle size, TH dose). Pain during IAI (VASIIA) was measured blindly. Joints were divided into High Pain Group (HPG, VASIIA > mean) and Low Pain Group (LPG, VASIIA ≤ mean). Comparisons used three analyses: full sample, excluding fibromyalgia, and a subgroup with VASIIA ≥ 7. Results: 399 joints from 246 patients (mean age 63.6 years, 86.2% women) were studied. Mean VASIIA was 4.8. In Analysis 1, lower pre-IAI VAS scores linked to LPG. Analysis 2 showed that lower pain VAS and rheumatoid arthritis were associated with LPG. Analysis 3 found that LPG was associated with lower pre-IAI pain, rheumatoid arthritis, younger age, and multiple rheumatic diseases. Conclusion: The mean pain during IAI was moderate. Variables associated with lower pain levels included younger age, lower pre-IAI pain, rheumatoid arthritis, and multiple rheumatic conditions. These findings suggest that patient and disease characteristics influence pain perception during joint injections, which could guide personalized pain management strategies in rheumatology.

Objectives: To identify joint recesses with the strongest correlations between ultrasonographic and clinical variables to develop a Brazilian ultrasound-based joint score(USBR Score) for rheumatoid arthritis(RA) patients. Methods: A cross-sectional study was conducted. Small, medium, and large joints recesses [60 (30 bilateral)] were assessed. Sonographic measuremants: Quantitative and semi-quantitative synovitis, power Doppler and bone erosion. Upper limb joint recesses: shoulders, elbows, wrists, metacarpophalangeals[dorsal(d)/palmar(p)], proximal interphalangeals. Lower limb joint recesses: hips, knees, ankles and metatarsophalangeals. Clinical variables: DAS-28, CDAI, SDAI, HAQ, morning stiffness, erythrocyte sedimentation rate, visual analogue scale (0–10 cm) of pain and swelling. Recesses with strongest correlations between ultrasonographic and clinical variables (highest Pearson correlation coefficients; p < 0.05) were selected to the score. Results: Fifty-nine RA patients were evaluated [44 women; 74.6%; mean age 46.50 (9.28 years)]. 3,540 joint recesses and 14,160 ultrasound measurements were analyzed. Ultrasonographic correlations: Quantitative synovitis = 129(R 0.284–0.508); power Doppler = 101(R 0.252–0.569); Semi-quantitative synovitis = 86(R 0.256–0.460); and Bone Erosion = 48(R 0.184–0.381). Recesses with the highest correlations[10(20 per patient)] in descending order: wrists, 5th metacarpophalangeal(d/p), 1st metatarsophalangeal, 1st metacarpophalangeal(d), 4th metacarpophalangeal(d), 2nd metacarpophalangeal(d), 3rd metacarpophalangeal(d/p) and 3rd proximal interphalangeal, ankle and 5th metatarsophalangeal. Quantitative synovitis and power Doppler were selected for inclusion in the score (higher number and stronger statistical correlations), whereas semi-quantitative synovitis and bone erosion were excluded (lower number and weaker statistical correlations). Conclusions: The Ultrasonographic variable included in the Brazilian ultrasound-based score for RA patients is power Doppler due its practicality. The joints indicated to the SCORE US20BR (BR for Brazil) were the following: wrists, 1st − 5th metacarpophalangeals, 3rd proximal interphalangeals, ankles, 1st and 5th metatarsophalangeals. The US20BR Score may optimize the ultrasound assessment of patients with RA.

Objective: To evaluate whether the combination of exercise and intra-articular injection (IAI) effectively improves pain, function, and quality of life in patients with knee osteoarthritis (OA) compared to any control group in the short, medium, and long term through a systematic review. Methods: A comprehensive search strategy was applied in the databases Embase, PubMed, MEDLINE, CENTRAL, CINAHL, and PEDro. Inclusion criteria focused on randomized controlled trials examining the effects of exercise combined with IAI in patients with knee OA, with outcomes assessed at short-, medium-, and long-term follow-ups. The primary outcomes were pain and function. The quality of the evidence was evaluated using the GRADE system. Results: Eleven studies, comprising 802 participants, were included. All studies investigated the combination of IAI and exercise. A statistically significant difference in pain was observed: in the short and medium term, the Botulinum toxin IAI group demonstrated superior pain reduction compared to the Hyaluronic acid IAI group (MD -1.32, 95% CI -2.20 to -0.44 and MD -9.09, 95% CI -13.16 to -5.01, respectively). In the medium term, Saline IAI was more effective than Corticosteroid IAI (MD 1.99, 95% CI 0.49 to 1.90). Regarding function, Saline IAI outperformed IAI with any medication in the short term (MD 0.50, 95% CI 0.20 to 0.79). In terms of quality of life, the Corticosteroid IAI group demonstrated superior physical function and mental health outcomes compared to the Saline IAI group in the medium term (MD -0.43, 95% CI -0.77 to -0.08 and MD -0.38, 95% CI -0.76 to -0.01, respectively). In the long term, physical function improved more with IAI combined with exercise compared to exercise alone. Conclusion: Given the very low quality of the evidence, it is not possible to definitively conclude that the combination of IAI and exercise is more effective than IAI or exercise alone in patients with knee OA. Further high-quality studies are needed to establish more definitive conclusions. Registration: The International Prospective Register of Systematic Reviews (PROSPERO): CRD42021277729. Clinical trial number: Not applicable.

Objective: To evaluate the effectiveness of intra-articular injections (IAIs) with triamcinolone hexacetonide (TH) combined with a progressive resistance exercise program (PREP) in improving pain, function, muscle strength, and quality of life in elderly patients with knee osteoarthritis (OA). Methods: Fifty-nine elderly individuals with knee OA were randomized into three groups: IAI with TH (IAI-TH) + PREP, IAI with saline solution (IAI-SS) + PREP, and IAI with placebo + PREP. The IAIs were administered once, one week before starting PREP, which was performed twice weekly for 12 weeks. Outcomes assessed at baseline and at 2, 6, and 12 weeks post-IAI included pain (Numerical Pain Scale - NPS), swelling, function (Western Ontario and McMaster Universities Osteoarthritis Index - WOMAC), quality of life (Short Form-36 - SF-36), performance tests (Six-Minute Walk Test − 6MWT, Timed Up and Go Test - TUGT, Short Physical Performance Battery - SPPB), and muscle strength (one-repetition maximum test − 1RM). Due to the COVID-19 pandemic, only 15 participants per group completed the study protocol. Results: All groups showed significant intragroup improvements over time in pain, function, muscle strength, and quality of life. However, no statistically significant differences were found between the groups for any of the assessed outcomes. The bodily pain domain of the SF-36 and analgesic consumption were the only measures showing differences over time. Conclusion: The combination of IAI-TH and a 12-week PREP (twice weekly) was not superior to IAI-SS or placebo combined with the same PREP in improving pain, function, or quality of life in elderly patients with knee OA. These findings highlight the role of exercise as a key therapeutic strategy, regardless of prior IAI. Future studies with larger sample sizes and long-term follow-ups are needed to better assess the role of intra-articular corticosteroid injections in OA rehabilitation. Clinical trial number: ensaiosclinicos.gov.br (RBR-556md5g). Registered 27 October 2022.

Background/objective: Fibromyalgia is a non-inflammatory syndrome characterized by generalized muscle pain, with other symptoms. Numerous forms of physical training for this population have been studied through high-quality randomized clinical trials involving strength, flexibility, aerobic conditioning and multicomponent exercise interventions. This research evaluated the effectiveness of a functional exercise program at reducing pain, improving functional capacity, increasing muscle strength as well as improving flexibility, balance and quality of life in individuals with fibromyalgia. Methods: Eighty-two women with fibromyalgia were randomized into two groups. The functional exercise group performed functional exercises in 45-minute sessions twice per week for 14 weeks. The stretching exercise group performed flexibility exercises with the same duration and frequency. Outcome measures were: visual analog scale for widespread pain; Fibromyalgia Impact Questionnaire for health-related quality of life; Timed Up and Go test for functional performance; one-repetition maximum for muscle strength, Sit and Reach test on Wells bench for flexibility; Berg Balance Scale for balance; SF-36 for general quality of life. Results: After the intervention, the functional exercise group had a statistically significant reduction in pain (interaction p = 0.002), and improvement in health-related quality of life measured by the Fibromyalgia Impact Questionnaire (interaction p < 0.001) and in general health state domain of SF-36 (interaction p = 0.043) compared to the stretching exercise group. No significant differences between groups were found regarding improvements in functional capacity, muscle strength, flexibility or balance. Conclusion: Functional exercise training was effective at reducing pain and improving quality of life in patients with fibromyalgia compared to stretching exercises. Trial registration: ClinicalTrials.gov Identifier: NCT03682588 First prospectively registered in March 2018.

Objective: This study aims to evaluate the effect of functional versus resistance exercise training on the functional capacity and quality of life of psoriatic arthritis patients. Methods: Forty-one psoriatic arthritis patients (18 to 65 years old) were randomized into two groups: functional training group and resistance exercise group. The functional training group underwent functional exercises with elastic band and the functional training group underwent machine resistance exercise twice a week for 12 weeks. Outcome measures were: The Bath Ankylosing Spondylitis Functional Index (BASFI) and Health Assessment Questionnaire for the Spondyloarthropathies (HAQ-S) for functional capacity and functional status, one-repetition maximum test for muscle strength, the Short Form 36 health survey questionnaire (SF-36) for quality of life, and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Disease Activity Score 28 (DAS-28) for disease activity. Analyzes were performed by a blinded evaluator at baseline (T0), six (T6) and twelve (T12) weeks after the beginning of the exercise. Results: At baseline, the groups were homogeneous in the clinical and demographic characteristics. There was a statistical intra-group improvement for both groups in the BASFI, BASDAI, HAQ-s, and DAS-28. In the quality-of-life assessment, both groups showed statistical intra-group improvements for all domains except the “emotional aspect” domain in the resistance exercise group. In the muscle strength, there was a statistical improvement for all exercises in both groups, except for the “alternate biceps (bilateral)” exercise. Conclusion: Functional training and resistance exercise are similarly effective in improving functional capacity, functional status, disease activity, general quality of life, and muscle strength in patients with psoriatic arthritis. Trial registration: ClinicalTrials.gov: NCT04304326. Registered 11 March 2020, https://clinicaltrials.gov/ct2/show/NCT04304326?term=NCT04304326&draw=2&rank=1.