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Management of Tennis Elbow with sodium hyaluronate periarticular injections

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Abstract
Objectives:
To determine the efficacy and safety of peri-articular hyaluronic acid injections in chronic lateral epicondylosis (tennis elbow).
Design:
Prospective randomized clinical trial in primary care sport medicine.
Patients:
Three hundred and thirty one consecutive competitive racquette sport athletes with chronic (>3 months) lateral epicondylosis were administered 2 injections (first injection at baseline) into the subcutaneous tissue and muscle 1 cm. from the lateral epicondyle toward the primary point of pain using a two-dimensional fanning technique. A second injection was administered 1 week later.
Outcomes measures:
Assessments were done at baseline, days 7, 14, 30, 90 and 356. Efficacy measures included patient’s visual analogue scale (VAS) of pain at rest (0-100 mm) and following assessment of grip strength (0-100 mm). Grip strength was determined using a jamar hydraulic hand dynamometer. Other assessments included patients’ global assessment of elbow injury (5 point categorical scale; 1 = no disability, 5 = maximal disability), patients’ assessment of normal function/activity (5 point categorical scale), patients/physician satisfaction assessment (10 point categorical scale), time to return to pain-free and disability-free sport and adverse events as per WHO definition. Differences between groups were determined using an intent-to-treat ANOVA.
Results:
Average age of the study population was 49 years (± 12 years). One hundred and sixty-five patients were randomized to the HA and 166 were randomized to the control groups. The change in VAS pain was -6.7 (± 2.0) for HA vs -1.3 (± 1.5) for control (p < 0.001). The VAS post handgrip was -7.8 (± 1.3) vs +0.3 (± 2.0) (p < 0.001) which corresponded to a significant improvement in grip of 2.6 kg in the HA vs control groups (p < 0.01). Statistically significant improvement in patients’ global assessment of elbow injury (p < 0.02), patients’ assessment of normal function/activity (p < 0.05) and patients/physician satisfaction assessment (p < 0.05) were also observed favoring the HA group. Time to return to pain-free and disability-free sport was 18 (± 11) days in the HA group but was not achieved in the control group. VAS changes were maintained in the HA group at each followup while those in the control significantly declined from baseline. Assessment of patient and physician satisfaction continued to favor the HA group at subsequent followup.
Conclusion:
Peri-articular HA treatment for tennis elbow was significantly better than control in improving pain at rest and after maximal grip testing. Further, HA treatment was highly satisfactory by patients and physicians and resulted in better return to pain free sport compared to control.
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Efficacy of Celecoxib, a COX-2–Specific Inhibitor, and Naproxen in the Management of Acute Ankle Sprain

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Objective: To assess the efficacy and safety of celecoxib and naproxen in the treatment of acute ankle sprain.
Design: Double-blind, parallel-group, randomized trial.
Setting: Multicenter outpatient.
Patients: Adult patients (n = 397) with acute first-degree or second-degree ankle sprain.
Interventions: Patients randomized to celecoxib 200 mg BID (n =198) or naproxen 500 mg BID (n = 198) for 7 days.
Main Outcome Measures: Primary measures of efficacy were Patient’s Assessment of Ankle Pain Visual Analogue Scale (VAS) and Patient’s Global Assessment of Ankle Injury. Secondary efficacy measures included Physician’s Global Assessment of Ankle Injury, Patient’s Return to Normal Function/Activity, and Patients’ and Phy-sicians’ Satisfaction Assessments. Adverse events (AEs) were re-ported by investigators during the study.
Results: For the primary endpoints at day 4, the mean pain VAS scores were 31.9 mm ± 1.96 for celecoxib and 29.0 mm ± 1.91 for naproxen, and the responder rate for Patient’s Global Assessment of Ankle Injury was 71% in the celecoxib group and 72% in the naproxen group, differences that were not statistically significant. In addition, noninferiority analysis demonstrated treatment differences that were within prespecified minimal clinical important differences. Gastrointestinal AEs were the most common AE, accounting for 14% in the celecoxib group and 21% in the naproxen group. The incidence of dyspepsia was 3% for celecoxib compared with 12% for naproxen (P= 0.032).
Conclusions: Celecoxib is as effective as naproxen in treating acute first-degree or second-degree ankle sprains but causes significantly less dyspepsia.
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Hyaluronic Acid for the Treatment of Knee Osteoarthritis

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Long-Term Outcomes from a Naturalistic Primary Care Experience

ABSTRACT

Petrella RJ: Hyaluronic acid for the treatment of knee osteoarthritis: Long-term outcomes from a naturalistic primary care experience. Am J Phys Med Rehabil 2005;84:278–283.

Objective:
Intraarticular hyaluronic acid is indicated for patients with osteoarthritis of the knee. However, clinical experience, especially efficacy and adverse events, with repeated injection series in
the long term are limited.

Design:
Patients were referred to a large primary care center for management of osteoarthritis of the knee. All were naive to intraarticular hyaluronic acid therapy and met our entry criteria, including resting visual analog scale pain of 45 mm, radiographic confirmation of unilateral knee grade 1–3 osteoarthritis, and willingness to receive intraarticular therapy. Patients received a three–intraarticular injection series with Suplasyn (10 mg/ml, 2-ml injection) over 3 wks. Patients were instructed to return for consideration of repeat injection series based on their perception of pain restricting daily activity and a resumption of severity similar to their initial presentation. This prospective naturalistic cohort was followed for 6.7 yrs. Patients completed baseline assessment of rest and walking visual analog scale pain (primary efficacy variable), completed a 5-point categorical global satisfaction score, and recorded adverse events and concomitant therapeutic modality use at each study visit. Patients returned for consideration of a repeat injection series based on their perception of symptom severity and were eligible if their resting visual analog scale pain was 45 mm. The three-injection series and data collection were repeated, and again, patients were given similar instructions regarding consideration of a third injection series.

Results:
Of 897 referral patients, 537 (mean age, 68 ± 8 yrs; mean duration of symptoms, 7.4 ± 4.1 yrs) met our criteria, and only 21 patients did not return for a second injection series. The mean time between first and second series was 27 ± 7 wks. The change in walking visual analog scale pain was significantly improved from baseline after the first series (81.3%, P<0.001) and second series (86.7%, P < 0.0001). Similarly, resting visual analog scale pain was significantly decreased from baseline after the first (P <0.001) and second (P<0.001) series, and patient satisfaction was significantly improved with each injection series (P<0.03 and P<0.01). Very few adverse events were recorded and were limited to local pain and swelling. Use of concomitant therapeutic modalities at presentation for a second injection series included: nonsteroidal anti-inflammatory drugs/cycloox- ygenase-2 medications (37%), acetaminophen (31%), oral nutraceuticals (12%), and physical therapy and bracing (12%).

Conclusions:
Intraarticular hyaluronic acid injections were highly effective in improving resting and walking pain in patients with osteoarthritis of the knee on a first and a second treatment series. Duration of symptom control was about 6 mos, and the therapy was highly satisfactory to patients and was associated with very few local adverse events and limited use of concomitant therapeutic modalities. These data support the potential role of intraarticular hyaluronic acid as an effective long-term therapeutic option for patients with osteoarthritis of the knee.

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