Monday, 19 June 2017

OSTENIL® TENDON injections are more effective than corticosteroid injections for the treatment of tendon disorders

Tendon disorders are the most frequent cause of pain in the musculoskeletal system of physically active individuals. There are various conservative treatment methods, but most of them only offer short-term relief. When injecting steroids in the elbow region, the risk of tendon damage also increases.1
A meta-analysis showed that steroid injections are not more effective than placebos.2 Is there also a treatment option that is effective and offers more long-term relief of tendon disorders when taken?

Gorelick et al.3,4 investigated the effectiveness of sodium hyaluronate for the treatment of various tendon disorders. 157 patients diagnosed with tennis elbow were included in the study and divided into three groups. 54 patients received a corticosteroid injection, 49 patients were given an injection with OSTENIL® TENDON (2% sodium hyaluronate) and 54 patients received a combination therapy comprising an initial corticosteroid injection and, 7-10 days later, an OSTENIL® TENDON injection. The efficacy was evaluated using the VAS score and DASH score (Disabilities of Arm, Shoulder and Hand). Follow-up examinations were carried out 6 and 12 months after treatment.

There was a significant reduction in pain after one year compared to the initial value (p<0.0001) for all three forms of treatment. The treatments with OSTENIL® TENDON and the combination therapy were significantly better (p<0.001) than the treatment with corticosteroids after one year. Furthermore, in comparison to the corticosteroid group, there were no side effects (0 vs 10). The level of pain using the VAS scale dropped in the OSTENIL® TENDON group from 10.0 to 0.5, while this only dropped to 5.5 in the corticosteroid group. After one year, combination therapy showed similar effects to the OSTENIL® TENDON treatment, however, there were more side effects attributable to the corticosteroids. The long-term effect of the treatment with OSTENIL® TENDON is also interesting. While pain in the OSTENIL® TENDON group continued to subside over the course of the study, the corticosteroid group experienced an increase in pain again after 6 months.


►Conclusion: An injection with OSTENIL® TENDON is significantly superior to treatment with corticosteroids for the treatment of tennis elbow. The effect of the treatment lasts for a period of at least one year.
A further study investigated the effect of the OSTENIL® TENDON treatment for problems with the Achilles tendon. 56 patients with a newly diagnosed case of Achilles tendinopathy which had not yet been treated were included in the study. 20 patients received an injection with OSTENIL® TENDON, 19 patients were given an injection with corticosteroids and another 17 patients received a combination therapy of rest, splint, physiotherapy and NSARs. The VAS pain scale and the FADI score (Foot and Ankle Disability Index) were used to evaluate efficacy. Follow-up examinations were carried out after 6 weeks and after 3, 6 and 12 months.

All patients suffered from severe pain in the Achilles tendon at the start of the study. The value was 10 cm on the VAS pain scale. All treatment groups exhibited a reduction in pain over the course of the study. However, the sodium hyaluronate group (SH group) was superior to the corticosteroid group at all intervals during the study. Superiority achieved statistical significance after 6 and after 12 months. The carryover effect of the OSTENIL® TENDON treatment could also be seen again here. Even one year after the end of treatment, the pain subsided continuously, while there was an increase in pain again for the steroid group. The effect of corticosteroid treatment corresponded to the effect of conservative treatment in the long term.
Both studies confirm the superiority of the OSTENIL® TENDON treatment compared to the corticosteroid treatment. The effect of the corticosteroid treatment decreases over time, while the effect of OSTENIL® TENDON is still visible even after one year.

►Conclusion: The OSTENIL® TENDON injections are significantly more effective than corticosteroid injections for the treatment of tennis elbow and problems with the Achilles tendon. The effect lasts for a period of at least 12 months.

References:

1 Osborne H (2010): Stop injecting corticosteroid into patients with tennis elbow, they are much more likely to get better by themselves! J Sci Med Sport 13: 380-381.
2 Krogh TP, Bartels EM, Ellingsen T, Stengaard Pedersen K, Buchbinder R, et al. (2013): Comparative effectiveness of injection therapies in lateral epicondylitis: A systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med 41: 1435-1446.
3 Gorelick L, Gorelick AR, Saab A, Ram E, Robinson D (2015): Lateral Epicondylitis Injection Therapy: A Safety and Efficacy Analysis of Hyaluronate versus Corticosteroid Injections. Adv Tech Biol Med 3: 130.
4 Gorelick L et al.; Single Hyaluronate Injection in the Management of Insertional Achilles Tendinopathy in Comparison to Corticosteroid Injections and Non-invasive Conservative Treatments, Sch Bull,: Jul 2015, 16-20.

Tuesday, 18 April 2017

NHS England: Even Longer Delays for Total Joint Replacements! What’s the solution?


A recent statement issued by NHS England’s Simon Stevens has caused concern that some patients awaiting elective knee and hip replacement operations may have to wait longer than is presently recommended to receive treatment. Current constraints on NHS funding and an increase in demand means budgets are having to be redirected to focus on A&E and cancer care.  The NHS has also stipulated that GPs should considerably reduce the number of people being referred to secondary care Consultants. 

Here are links to articles on this issue:

http://www.bbc.co.uk/news/health-39420662?

https://www.theguardian.com/society/2017/apr/02/labour-challenges-hunt-over-dropping-nhs-waiting-times-target

Are there any therapeutic options open to clinicians which may help alleviate the problems that some patients will face as a result of these changes?


It has been recognised for many years that Viscosupplementation can offer a valuable bridge between conservative care and surgery. Clinical studies have consistently shown intra-articular hyaluronic acid (HA) injections to be safe, efficacious and cost-effective (1-3). 

Before the introduction of the single injection HA OSTENIL® PLUS, OSTENIL® injections were usually administered as a course of up to 5 weekly injections. Mathies et al - in a seminal examination of the relationship between Viscosupplementation and the quality of synovial fluid - showed that Viscosupplementation could delay total knee replacements (TKR) by 4.5 to 6 months, and for some patients up to 12 months. His study also demonstrated that “OSTENIL® was safe and significantly improved symptoms in patients with painful advanced knee OA who were awaiting TKR, and that it improved the quality of life of these patients.” (4) In a larger study which examined the potential of HA for delaying knee arthroplasty, Altman demonstrated that “HA injection in patients with knee OA is associated with a dose-dependent increase in time-to-TKR” (7).

Since the introduction of OSTENIL® PLUS, patients have garnered the same symptom-reducing benefits from a single injection, and for the administering clinician - as well as the patient - the process is a lot more convenient. Significant symptomatic reduction and functional improvement was demonstrated in patients suffering moderate knee OA for up to 6 months following a single injection of OSTENIL® PLUS. (5,6). 




So why aren’t more OA patients in the UK being offered the option to help alleviate symptoms and potentially delay their joint replacement?


One of the major obstacles at present is the “Do not recommend intra-articular HA to treat osteoarthritis” in the current NIHCE guidelines on Knee OA. Although it is important to understand that the NIHCE Guidelines (CG177) DO NOT prohibit clinicians from using OSTENIL. In fact, OSTENIL® PLUS DOES meet the QLY cost to benefit criteria quoted by CG177.

Given the current climate in relation to treating degenerative joint change, clinicians and their patients have a limited number of options left open to them: simple analgesics, NSAIDs, and corticosteroid injections, none of which are entirely benign with prolonged use. Physiotherapy alone is not always an option if the joint has degenerated to such an extent that it makes exercise too painful. All this means that the impact on quality of life due to longer waiting times will be felt even more by an ageing and increasingly overweight population.


If you as an injecting physiotherapist/MSk specialist are receiving an increasing number of referrals of patients suffering symptomatic OA from GPs, have you considered Viscosupplementation as an option?


OSTENIL® injections do not require a Consultant to administer. Instead, local MSk triage services can offer a cost effective solution, providing GPs with an alternative patient treatment pathway, helping avoid unnecessary secondary care referrals - and the associated tariff fee - which would more than cover the cost of an OSTENIL® PLUS injection. As a result, not only would the ever growing demand on secondary care be ameliorated, patient waiting times could be reduced, and clinical outcomes improved. 




If you would like more information or chat to one of our representatives, please contact us on info@trbchemedica.co.uk. You can also visit our website here: ostenil.trbchemedica.co.uk, or call us on 0845 330 7556. 


REFERENCES:

1. Möller I et al. Presented at the 6th World Conference of the Osteoarthritis Research Society International 2001; poster PB22
2. Tsvetkova E et al. Ann Rheum Dis 2010;69(Suppl3):281
3. Funk L et al. Presented at the 9th World Conference of the Osteoarthritis Research Society International 2004; poster P338
4. Mathies B et al. Presented at the 5th Symposium of the International Cartilage Repair Society. May 26–29, 2004; poster 397.
5. Borràs Verdera A et al. Poster presented at the XXV triennial world congress of the International Society of Orthopedic and Traumatology. September 6-9, 2011.
6. K Frobenius “A new high-dose treatment with intra-articular hyaluronic acid facilitates the management of osteoarthritis”. Orthopädische Praxis 46, 5, 2009
7. Altman R, Lim S, Steen RG, Dasa V (2015) “Hyaluronic Acid Injections Are Associated with Delay of Total Knee Replacement Surgery in Patients with Knee Osteoarthritis: Evidence from a Large U.S. Health Claims Database. PLoS ONE 10(12): e0145776. doi:10.1371/journal.pone.0145776

Wednesday, 12 April 2017

Why consider topical Sodium Hyaluronate (HA) in the treatment of tendinopathy?


Firstly, the difference between HA and other glycosaminoglycans is that it is non-sulfated, forms in the plasma membrane instead of the Golgi apparatus, and can be very large, with its molecular weight often reaching the millions1. HA is considered to be a key molecule in the tissue regeneration process. It has been shown to modulate via specific HA receptors, inflammation, cellular migration, and angiogenesis, which are the main phases of wound healing7.

In relation to tendinopathies, hyaluronic acid modulates a variety of cellular functions: anti-inflammatory activity, enhanced cellular proliferation and collagen deposition. Studies have shown a link between the inhibition of fibroblast proliferation, with a reduction in the formation of adhesions at the tendon healing site; by limiting the proliferation of fibroblasts, HA may reduce the risk of adhesions.2

It has sometimes been assumed, in relation to tendinopathic change, that because there is an excess of GAGs detectable within the local bio-chemical environment, there is an excess of hyaluronan, which is not necessarily the case. For example, the activity of hyaluronidase (enzymes that catalyse the degradation of hyaluronan) has been shown to increase during the healing of equine superficial digital flexor tendon injuries6.

Multiple studies analysing tendon healing have confirmed that HA reduces the formation of scars and granulation tissue, and also prevents adhesions2. Importantly, HA forms part of the extracellular matrix as a major component of ground substance, giving structure for other GAGs and proteoglycans3. In tendon healing, the GAGs provide a temporary structure in the early stages of the wound4. So without the presence of HA, there is evidence to suggest that other GAGs are of limited use. Also, high levels of HA are thought to be instrumental in scar-less healing by facilitating the movement and proliferation of fibroblasts, and by regulating the production and type of collagen5.

HA also plays an important role as a hydrating agent, being able to absorb 3,000 times its own weight in water4. HA appears to inhibit the expression of key intermediaries for the inflammatory signalling pathways (NF-kB), by reducing the expression of pro inflammatory factors, exogenous HA may reduce the fragmentation of endogenous HA and further stimulate synthesis of endogenous HA.7,8.



References

1.       Fraser JR, Laurent TC, Laurent UB (1997). "Hyaluronan: its nature, distribution, functions and turnover" (PDF). J. Intern. Med. 242 (1): 27–33. doi:10.1046/j.1365-2796.1997.00170.x. PMID 9260563.
2.       Michele Abate, Cosima Schiavone, and Vincenzo Salini, “The Use of Hyaluronic Acid after Tendon Surgery and in Tendinopathies,” BioMed Research International, vol. 2014, Article ID 783632, 6 pages, 2014. doi:10.1155/2014/783632.
3.       Bertolami, C.N. (1984)Glycosaminoglycan interactions in early wound repair. In: Hunt, T.K., Heppenstall, R.B., Pines., Rovee, D. (eds). Soft and Hard Tissue Repair: Biological and clinical aspects. Eastbourne: Praeger Scientific.
4.       Snyder, R.J. (1999)Wound management: a global perspective. Ostomy/Wound Management 45: 9, 26-30.
5.       Desai, H. (1997)Ageing and wounds, part 2: healing in old age. Journal of Wound Care 6: 5, 237-239.
6.       J. W. Foland, G. W. Trotter, B. E. Powers, R. H. Wrighley, and F. W. Smith, “Effect of sodium hyaluronate in collagenase-induced superficial digital flexor tendinitis in horses,” American Journal of Veterinary Research, vol. 53, no. 12, pp. 2371–2376, 1992.
7.       Litwiniuk M., Krejner A., Grzela T. (2016). Hyaluronic acid in inflammation and tissue regeneration. Wounds 28, 78–88.
8.       Litwiniuk, Malgorzata, Alicja Krejner, and Tomasz Grzela. "Hyaluronic Acid In Inflammation And Tissue Regeneration". Wounds 28.3 (2016): n. pag. Print.

Monday, 20 March 2017

Tear supplements


Currently, tear supplements are available as solutions, ointments and gels. They can be used as often as necessary to keep the corneal surface and conjunctiva wet. Preferably, the topical application of a well-formulated tear supplement and lubricating agent should provide relief for both aqueous- and mucin-deficient dry eye. Moreover, functions associated with the lipid layer of the precorneal tear film should not be altered by the tear supplement.

There are several objectives that tear supplements aim to fulfil in the treatment of dry eye.

Objectives of tear supplements




Ideally, tear supplements should fulfil the physico-chemical role of a normal tear film. In addition, they should not disturb corneal metabolism nor be toxic to the eye, even with frequent use. It should also have a refractive index similar to that of the cornea to see correctly. This involves consideration of certain characteristics in the formulation if tear supplements are to resemble physiological tears. These include electrolyte concentration, viscosity, mucomimetic properties, pH, osmolarity and the absence of preservatives. 

Your can read more about this subject here: http://vismed.trbchemedica.co.uk/business-professionals/vismed-eye-drops/the-ideal-tear-supplement