Hi. Well, welcome to everybody, and I will tell you there are two spotlights sitting on the back wall, which are going to kind of drive us nuts here a bit, so I can't see too well, so as we get into questions and things like that, we'll make sure everybody gets up to the mic and do things. My name is Jim Atchison. I'm at the Mayo Clinic in Jacksonville, Florida, and presented here at the meetings many years, and over the course of the last at least a year, probably much longer than that, I've kind of noticed that in my clinics, most everybody coming for even acute problems has had one or two or three bursts of steroids, or somebody gave them a shot of steroids, or two or three or four, and then they come for something else, and if we're not careful, we've got some challenges with the amount of steroid use that's going on. So that's what our presentation is going to be about today, and I'm going to lead off just talking about what kind of the purpose of the session is, and then Dr. Standard and Dr. Hunt are going to kind of lead into more of the details, and I'll introduce them real quickly at that time, too, but Dr. Standard's at the University of Pittsburgh, and Dr. Hunt is at Mayo Clinic, Florida, in the Department of Pain Medicine, and they're going to talk a little bit more about relative male equivalents and potency and different things as we use different types of steroids, and then what the recommendations or thoughts are for long-term cumulative use, because there are a lot of risks and side effects that we often, or at least our colleagues, are not considering. So I'd like to preface just a little bit in that I really have the feeling that in PM&R and training programs, we talk about this. We work on how and who's indicated to have these things done. I'm concerned that our other colleagues aren't having that same type of training, and that's part of what I think our mission should be in PM&R is to start educating patients and educating other providers that there are risks and benefits, but the risks are immense, and so if you have indications to use them, fine. If you don't have indications to use them, why are we using a lot of steroids for things that may or may not have best medical evidence literature behind them in order to do that? So I don't usually run through my learning objectives and disclosures and things, but I did want to point out the emphasis. You'll see we're going to talk about the things at the bottom with the relative potency and accumulative use, but the top one to me is something I want you to try and take out of here. You are the spokesperson. You are a person that trained in PM&R and has a good background on who and what to do steroids with for our area, right? I mean, I don't propose to tell a pulmonologist whether they should use steroids or not. I mean, that's not what we're talking about. We're talking about the appropriate or inappropriate use when we're in musculoskeletal and spine problems, and so we usually blow through these also where I have no financial disclosures, and then we say, well, I have no off-label use. Well, as I got to writing that, I was thinking, I don't know that I've ever investigated what are the on-label uses for steroids, right? I mean, they've got to have something, and I'm going to talk about them. Interestingly, it was very difficult to find something that said exactly what are the on-label uses of steroids. Now, you can find a lot about what are they used for, right? I mean, this is the list, amazingly long list, and amazing things, and certainly some people are on steroids forever, you know, after transplant, and they have different medical problems going on, and it does include the inflammatory joint tendon muscle, and then we can have a good long debate on when is it inflamed versus when does it hurt, and that's kind of the point of the whole session, is hurt isn't inflammation, but in many of the other specialties, it's started to become equated with my back hurts, my shoulder hurts, my knee hurts, you must need a burst of steroids, okay? And then when it's time to use them for something what I would consider to be more appropriate, now we have a concern about how much steroid use there has been in that particular person, but certainly many of these we can't argue about. We're not even going to discuss that. The issue is, yes, they're very important in a lot of medical specialties, including our practice in many different ways, but also the point is when we think about our practices, we tend to talk in these sessions about guidelines, and, you know, we're talking about things that occur for musculoskeletal through the American Academy of Family Practice guidelines or the AMSSM guidelines for acute shoulder or knee pain and things like that, so we have had many discussions in the academy meetings and in training programs, I'm sure, about all of these things, including in spine where we have NAS guidelines, we have SIS guidelines for injections, and when are they indicated, and what are we doing, and even though a lot of specialties would argue there's no indication for any of those, we do, but we also would like to follow the best practices. The issue would be for most of these, there are no guidelines in the ED. I see patients from the ED all the time, and yes, their curriculum says they have to train their doctors to be able to manage low back pain and to be able to manage any kind of a musculoskeletal problem, but then I look at their curriculum, right, airway management, acute chest pain, blunt abdominal trauma, well, I'm thinking I probably would focus my teaching on that a little more than what do I do when the person walks in in low back pain, right, but they do go to the ED in low back pain, and interestingly, there are no guidelines from the emergency departments about how to do management of any acute musculoskeletal problems. So it's all word of mouth in that training. That is, I think, a concern that we have to educate the people around us. So out in your areas, I'd like to try to have you start to be the messenger. There are no, none of the guidelines listed above and the ones I can find for acute musculoskeletal injury are there indications for steroids. And so do they change symptoms at times? Probably, and especially in some people, but we all know placebo is 30 to 40% of anything, so I don't know the answer to that totally, but the issue would be if we use them possibly when they aren't absolutely necessary, do we then put the person at risk when they may have some other problem going on? I'm going to hit a couple cases just real quick to give you some thoughts. You all probably have patients where you've seen them, you've thought, hmm, that's kind of unusual, or just running through your patients in your mind, but the first one we're going to talk about is a pretty simple one. And it's not really steroid bad misuse, but it's a person that's had longstanding pain. They went to an orthopedic spine center before coming to us eventually, and they were complaining about having scoliosis as a child, no real complaints, no radicular pattern. They really went in to ask about having scoliosis, you know, at 60 years old, they wanted to have back scoliosis surgery, which I don't think they really understood what that meant. At that office, they had a good exam, and unfortunately on the exam there was a question, maybe brisk reflexes, maybe Hoffman presence, so part of their now differential was going to be cervical stenosis in addition to scoliosis. But as we would see as they kind of move forward, there we go, the scoliosis was not highly prominent, and the orthopedic spine surgeon that was seeing them, talked to them about that, really was concerned whether they might have something else going on, talked to them about they should have imaging. We can debate a lot about the next steps of what they talked about, but then the next thing before they left the office is they got a shot of IM Depo Medrol for axial back pain with scoliosis. All right. How many people think that was probably an indication for scoliosis, or for steroid use? Good. Everybody's asleep, sitting on their hands, I like it. All right. They went back to the same clinic, six months later, same symptoms, they got a partial response to the injection, and I'll tell you why in a minute. They didn't do any of the other stuff the doctor said. They had the same exam, they wanted to have another shot, so he gave it to them. All right. More indication for steroid use? Nope. All right. Came to our clinic eight months later, because they still wanted to have scoliosis surgery, it was very fascinating. So came in, and part of it is we had more records. Well, the bad news part is they have type 2 diabetes. So I'm really wondering what the IM Depo Medrol did to them in that aspect. And they have a history of fibromyalgia. And yes, fibromyalgia often does temporarily respond to steroids, but you can't leave them on steroids forever, correct? So having more history, being able to work through things, we did not find the same physical exam abnormalities. Talked to her about the fact that our surgeons wouldn't consider operating on her unless she really went through an extensive exercise program with her scoliosis, etc., etc. She did have numbness in her hands from the first time, even in that first note. And yes, she had carpal tunnel when we studied her, and so she ended up having the numbness improved with her carpal tunnel surgery. But part of the message that we're talking about today is we do a visit, we don't always get all the information, right? So you're getting ready to do something where you give them more steroid. We don't often know, what did they really get before? So you've got to ask about those things. And then keep in mind, like in this case, she got an IM injection. She got better. There's steroid responders. There's people who respond to steroids all the time. And I see this, and you would recognize it with the idea, like, why do they respond sometimes to a facet injection, but the medial branch block doesn't give them any relief? They're a steroid responder. You could give them steroids in any form, and for a couple days, they'll be better. That's not really the answer to some of these long-term problems. So in this case, I called it a little misuse, right? I mean, it probably didn't cause her any harm, but it certainly wasn't the right indication. Case gets a little bit worse, and then we had a woman who was back in the ED, and she has an unfortunate medical history with history of carcinoma and some previous treatments, including radiation to the area, has back pain, feels like it starts in her back, radiates into the sacrum and pelvis, but around to the abdomen also. She couldn't even get on her stomach during the exam. They didn't do a lot of other exam, quite honestly, in the ED that day, other than palpation, which it hurt down in the sacral and gluteal area. So they got a CT of the pelvis, all right, looking for fracture, tumor, et cetera, things like that. Didn't show that. Sent back to the oncologist. Medications included a MedDRAL dose pack, you know, and I didn't see anything in the note that they called the oncologist, and the oncologist said, well, give them a burst of steroids. Now, not when we kind of take it out, but, you know, since I don't know what the oncologists do with that at times, but I would have to still say I didn't see a lot of indication for steroid use. She went back to the oncologist, and here's the fascinating part. This is the most widespread lateral image I could find in the pelvis CT, and L5 is that transitional segment area. That's L4, and when the oncologist did the CT of her abdomen, because she was still having abdominal pain, she had an L4 fracture, and it got missed because the imaging didn't take care of the right area, and we're not here to discuss those kind of things. We're here more to why did she get another burst of steroids when this person has mega, you know, risk factors for having osteoporosis and a fracture, and she had back pain and sacral pain, et cetera, et cetera. So, anyway, she came to see us. That's how we know about the case. With increased pain, by the time she got to us, she'd had a second fracture, actually had L4 and L5 fractures, and we had to work her up and do things and send her to endocrinology to help getting treatment because she was at minus 3.1 to 3.5, et cetera. But she did well. Actually, she went to therapy, was able to get on her stomach at that point, started working on a prone extension program and her weight-bearing exercises for osteoporosis, and she did okay. But the problem would be, okay, how much more steroids should somebody with that type of bone density have? So potential harm there. Might not have been the main reason she had a low bone density, but I'm sure she got plenty of steroids during her chemotherapy and her cancer treatment also. Let's go on to the last one, which is going to show us even a little bit more of a larger problem. So this was a 56-year-old who came to see us with axial neck upper back pain, had pain since 2019, at one point must have had some hand numbness because she told us she'd had carpal tunnel release already, which helped her hand numbness, and she was not doing any type of a therapy exercise program. For her axial, cervical, and thoracic pain, she had received nine epidural steroid injections over the last three years. Improves initially for one to two months, then she would seem to get worse. She came to us from endocrinology, and I'm going to fill you in on some of the details from that. She had been referred to endocrinology because they thought she might have a pituitary adenoma. Because in 2022, she developed widespread fatigue, weight gain, multi-joint arthralgia, lost function. This was an international banker, and she couldn't get out of bed at that time. Of course, the best thing is, let's give her a dose pack, that'll help. She got two more cervical epidural steroid injections because she still had pain, and I don't know how they got her out of bed to go to the injection center. These gave her temporary improvement. She's still thinking, and her doctor was still thinking, this is a good idea. Well, then with all the fatigue, she got a big workup, including brain, et cetera, and a lot of metabolic workup. It was felt that she could have this possible pituitary adenoma, but they were also concerned she had secondary adrenal insufficiency. When she came to see the endocrinologist, what the endocrinologist says is, she has a transient adrenal insufficiency. You can read what I took the quotes right from the endocrinologist's note, extensively from there. This person would be basically adrenal suppressed for a period of time from the exogenous steroids, and then would slowly recover and start to get better, but then wasn't getting fully better, so they ended up getting more steroids again and again, and that's why they were adrenal insufficient. Last comment from the endocrinologist, needs to come off of all the other steroids and go see somebody who could help her manage her pain in a different manner. She came to us, question of surgery for cervical stenosis, she really had some narrowing, but nothing on exam, there were no neuro findings, nothing, it's one of those there. As soon as the radiology report says stenosis, then they get sent in. The point would be, she came to us, she talked about things, we worked on helping her get better. She didn't really want to have surgery, she didn't want to have any injections, she didn't want anything. She loved the idea of what we do in physical medicine, but the bigger point from her standpoint is she said, she took the information from her endocrinologist back to her pain doctor, and she wanted them to be able to understand what was going on. She reported to us, the doctor said, I have never heard of such a thing. So if you're using steroids, I would think this is something you definitely want to be aware of. So our goal today at the end of the session is, hopefully, there will be no physiatrists who walk out today and say, I've never heard of such a thing. And then, back to my main point as we started is, I'd like for you to be the knowledgeable person that's trying to educate your patients and your community about what's going on in the use or potential overuse of steroids. My editorial comment would be, I think the bursts and the use has gone up tremendously since there was very tight restrictions on opioids. And so it's people trying to find something to work that's not being used in the right place, but it's because they lost some of their other tools. And that would be the concern as we move forward, is that we don't keep using it in an inappropriate manner. But we need to talk about that, and we need to educate people. So we're going to move on to the facts. Dr. Standard's going to come up next to speak on his part. Let's see. Click to exit. Make sure we're out. Very good. Thank you very much. Hello. So now I know none of us can say what that pain doctor said, because we just heard it. So we all heard it. How do I start myself here? Slides. Oh, there we go. Okay. So I'm talking about all the sort of, there's a lot of like steroids are evil sort of talk almost here, like what goes wrong here. I don't have any conflicts of interest, none of that sort of stuff. I'm not really advocating a use of anything in particular, but certainly we talk about the use of steroids, which is off label for a huge amount of what we do. We're going to talk a bit about corticosteroids in general, what they do, what their potencies are, talk about systemic and local issues, and maybe a little bit then about like, well, what do you do, right, knowing all this, when you're forewarned, what do you do with all this stuff? So usually we use glucocorticoids, that's what you're using, right? We're not using mineralocorticoids to inject people typically, right? They're used for a huge range of conditions, right? And we can use them orally, IV, intramuscular steroids, intraarticular, periarticular, epidural, other peripheral sites. We use them as a, speaking at writ large in the medical community, all over the place. Glucocorticoids affect the entire endocrine system. They don't just sort of relieve inflammation where you put them. That isn't what happens, right? They clearly interact with the hypothalamic, pituitary, adrenal axis. They affect glucose metabolism, they affect bone metabolism, they affect immune function, they affect adiposity, they affect sex hormones, and numerous other sort of hormonal functions, right? They affect all sorts of things in your body. They clearly decrease ACTH and serum cortisol, which gets us adrenal insufficiency issue. We'll talk a little bit about that. They inhibit the function of TSH, gonadotropins, testosterone, growth hormone, IGF-1, and more, right? They really impact all sorts of hormonal functions in your body, adversely, essentially. When you think about oral versus injected steroids, I hear the, well, we're just injecting them. Both have systemic and local effects, right, depending, and frankly, you inject things, there's no reason to think you stay where you put them, right? We know, there's all sorts of evidence here. So, like, when you do things under fluoro and you're not in a joint or in a fixed space, your contrast site goes everywhere. That's where the steroids go. They go everywhere. We clearly see cortisol suppression. We see systemic side effects. We see complications. We see blood sugar elevations with local injections. This means they go everywhere, right? That's how that happens. They don't stay where you put them. So, there isn't, there's a finite difference here between if you're giving systemic administration, whatever you do. So, if you want a picture of a slide of equivalencies, this is sort of it. So, I took the data equivalencies and I set it for 40 milligrams of triamcinolone as my base because that's sort of probably the most common dose of what I'm familiar with seeing people do. Some people use lower. Some people use higher. But that's the same as 40 milligrams of methamphetanilone. That's about the same as seven and a half of dexamethasone. About six milligrams of betamethasone. I think some people actually tend to use 12 of betamethasone fairly often. So, it may be higher. And to make it orally, that's about the same as 50 of prednisone, right? So, you have in your head one 40 milligram injection is about the same as giving somebody a 50 milligram of prednisone dose systemically is what you're doing. And if you go back to half-life, like these don't last very long, right? Hours, days, it's really all they're sort of in you for. Right? They're not, these are not long-term drugs. Systemically, they do lots of bad things. All those things they influence translate to all sorts of problems. We get reduced bone density. So, you see this even on people in two and a half milligrams orally per day. The most rapid bone loss is in the first six months. You don't have to be on them for five years to get bone density problems. You can have bone density problems in three months. Right? The most rapid bone density issues are early. So, it's not just a matter of being on 20 of prednisone for five years. Of long-term users, about half of them get a fracture. Right? Very common. There's clearly evidence suggesting dose-related reduction in bone density with epidurals. Right? Again, it's a systemic administration of steroids. We give people with bone density, we lessen bone density by giving people steroids. Risk fracture actually increases also with inhaled corticosteroids. So, nasal corticosteroids increase risk fracture risk also, again, systemic. Right? You think you're giving them locally, you think you're giving them to a local site, but they are systemic drugs. Other problems we see, osteonecrosis, avascular necrosis. I've seen this a whole number of times myself. I'm sure most of you who've done this for more than a few years have seen this a whole bunch, too. You see it after oral and interarticular corticosteroids. It's not just long-term oral steroids. We clearly see blood glucose elevation in those with diabetes. When you track the studies on this, a single epidural tends to increase it by about 100 to 125. Right? My initial introduction to epidurals when I finished residency and went to fellowship was watching somebody with acute pain on a Friday afternoon at 6 o'clock, which is the worst time to be doing things like this, get an epidural because the referring surgeon called and said, she's in agony, I'm sure this is her disc, just inject her. And I didn't do it. The person I was with injected her, and the next day, she was in DKA in the hospital because she actually had discitis and was diabetic. So it shot things off the chart. So on average, 100, but it can go a lot higher. Reports of peripheral injections sending blood sugars over 350. Seems to maybe be worse in studies on this, some people with a high A1C, poor glucose control, more likely to go off the rails a little bit when you inject them, and they stay elevated for several days when it does go that high. Clearly, we can cause exogenous Cushing syndrome. It's classically associated with ongoing oral steroids. Again, anybody who's been in medicine for more than probably you can't get out of residency without seeing this, I wouldn't think. There are case reports with single or multiple epidurals or interarticular injections causing Cushing syndrome, exogenous Cushing syndrome, systemic administration. Hypertension clearly is an issue. Myopathy, you see type two fiber atrophy. Myopathies with steroids. We definitely get adrenal suppression. So Dr. Friedle, in the LESS study on epidurals for spinal stenosis, they looked at cortisol levels of all the patients in the study and tracked them, right? And about 20% of people who got an epidural steroid injection got, in that study, people either got epidural steroids or epidural lidocaine. So people who got steroids, about 20%, one in five, had more than a 50% reduction in their cortisol level three weeks out still. So they had ongoing adrenal suppression. Compared to about six or 7% in the people who just got the lidocaine. This is particularly prevalent with methylprednisolone and triamcinolone, tended to have this, more so than dexamethasone. You can get infection. So you can get a local infection where you are. You increase your risk of systemic infection with ongoing steroids. And you increase your post-injection surgical risk. This particularly applies, we see this a lot clinically. This comes up in joint replacement, where really you don't want to be injecting somebody very proximate to a joint replacement because you increase their risk. And in general, for a range of surgeries, it about doubles your risk of infection. Lots of other systemic issues. Skin changes, delayed healing, mania and psychosis. I've had patients get abjectly manic after a peripheral injection or an epidural. Gastric ulcers, sleep disturbance. And again, I kind of keep running out of room on my slides. They keep going. We see all this. Locally, what happens when you put them in a local structure, right? We just talked about systemic things. There's evidence of increased apoptosis, or that's sort of programmed cell death of chondrocytes and toxicity from a combination of glucocorticoids and anesthetic when you put them in a joint. And so you probably kill the chondrocytes. You suppress tenosyte activity and collagen production, so you're actually impairing scar formation and healing. And reports of tendon rupture and osteomyelitis. I'll show you a couple pictures of this, but I see this. Plantar fascia rupture is just what happens. Soft tissue atrophy, a separate issue also. So subcutaneous atrophy. Again, I assume people who've done this for a while have seen this too. This occurs with extra articular injections in particular. Studies range 1.5 to 40%, so some, depending what you inject and where, can be quite high. Hypopigmentation without atrophy can also occur. I had a young woman who was probably 25, and somebody put steroids around her Achilles tendon, which I wasn't particularly fond of. But she got subcutaneous atrophy of the skin around her Achilles tendon, and she was very uncomfortable wearing shoes or clothing where people could see her Achilles tendon at 25 years old. Which was actually, that was a major impact on her life and her self-perception and her psyche and her activity. It was remarkably harmful. This is particularly common with less soluble steroids and particularly common when you are superficial with the injection. More shallow injections with less soluble steroids are more likely to do this. All right, if you want a couple studies to talk about all these things, there are a couple studies to talk about all these things. So I just want to show you some pictures of consequence here. So these are things I see. This is a compression fracture in somebody who'd been on steroids. And what you see is she has, it's caused a kyphosis. She's hyperkyphotic in her lower thoracic spine. It's caused a positive sagittal imbalance, which is now permanent, essentially. So she has essentially pain and dysfunction forever, right? This doesn't really kind of get better, better, right? The spine is like this. This woman had two injections in her greater trochanteric area over the course of the summer of 2022. And in September, went to the beach in New Jersey, walked in the sand and completely avulsed her glute med tendon off of her femur. That's what this is a picture of. That's what that is. So it completely avulsed the thing. She saw a surgeon who put it back, who repaired it. But a year later, this is her picture. The muscle is completely atrophied. Right, so that's two trochanteric injections and a walk on the beach. So what happened? This is a picture of subcutaneous atrophy if you haven't seen it. Hypopigmentation, you lose some of the melanin in the skin. It gets hypopigmented and sort of purply pallid is what the skin looks like. This is a patient I saw a number of years ago. This is osteomyelitis after a hamstring tendon injection. Came in to see me with screaming pain after somebody injected his hamstring tendon about three weeks before. And he's got, that picture is the MRI with lots of edema in the bone. That's the ischial tuberosity, that sort of very bright white thing. And this is a CT scan, we'll go back, showing just erosion, like bugs eat things. It's how you find infections, right? Erosions in the bone and sclerosis in the bone. So nasty, and this is like an in the office injection of a hamstring tendon, nothing. He wasn't diabetic, he wasn't anything. Nor was the other, nor was the lady with a torn hamstring. Or a torn sort of glute med, sorry. So what do you do, what do you do with all this, right? You have all the, like, this is our problem. We do these things. Don't talk about data and evidence, but it's tricky, right? We don't have a lot. There are numerous adverse effects with using these drugs. Local injections clearly can cause systemic side effects and can harm local tissues. The benefits of corticosteroids are largely short-term. If you're looking for a long-term document benefit, you're not gonna find any, I don't think. I don't know of any. And efficacy in data is sparse, right? And they're used for all sorts of things. So thinking there's data for all the different things we use them for is not true. So what do you do, how do you think about this? I mean, things like cumulative dose and frequency do matter, right? These things add up, exposures add up. The sequential exposure of focal tissues or systemic things like bone add up over time, right? And how frequency you go matters because you get temporary adrenal suppression in most people to a degree. Ideally, you go with the lowest dose necessary, right? Do you use 80 or 40? Do you use 20 or 40 of triamcinolone? What are you using? You have to think about that a bit. There's some people argue maybe you put a max of like 200 milligram of a triamcinolone equivalent per year, which would be about four, you know, five injections of 40, but that's total. And that's about what, like 250 of prednisone, which is about one prednisone taper for a lot of people. So it's not a lot actually. You really should spread these out because of the adrenal suppression issue. I don't know the actual number. I mean, we don't usually typically just get cortisol levels in people three weeks after their start injection to see if we should give them another one. Maybe we should, but we don't. You have to wonder if other people are injecting them. You live in your own little sphere, your own little world, but what if they have a rheumatologist doing seven injections a year? This is not uncommon, right, at all. And what if somebody else is treating some other part of their body with things? Is somebody giving them oral steroids, right? Have they had anaphylaxis? Have they had an itch? Have they had whatever, been short of breath? Had bronchitis? It all adds up and you have to wonder the proximity of what you're doing to all these other things that are happening to them. And in a given year, given timeframe, how much are they getting? That does sort of matter. You do have to know the relative potencies, right? In general, you have to know the drugs you're using, right? You should go read the package insert and see what they're approved for and what the contraindications are and what you're doing. Be aware of the relative potencies. Be aware of the duration and action solubility because they really are different for different things and different things you might want to inject. And I think maybe if you're really doing this, you think about different drugs for different locations because you have different consequences. Keep in mind, all drugs are not approved or equivalent risk for every potential use. So this is literally, I found this on, this is a picture of a Kenalog box. Kenalog is Triamcinolone. That's a trade name of one, is a trade name for Triamcinolone. This is the box, right? The box says for intraarticular and intralesional use only, not for IV, IM, intraocular, epidural, or intrathecal use. It says it on the box. So if you use this and it just told you not to use it and you harm someone, I don't know. I don't know how that goes for you, much less the person you harmed. This is Depimedrol, package insert. I see lots of epidurals being done with Depimedrol. I don't do them, but lots of people do. It clearly says in the package insert, contraindicated for intrathecal administration. Why is that a problem if you're doing epidurals? If you're doing epidurals and you do enough of them, you're going to wind up intrathecally sooner or later, right, however good you are. Also says serious neurologic adverse reactions with epidural administration. And it says this, the safety and effectiveness of epidural administration of corticosteroids have not been established and corticosteroids are not approved for this use. It says it in the box. I mean, we use it. Like I see this all the time, but it says it in the box. Right, so, you know, have to think about that a bit. So what do you do, right, knowing all this? I think in some ways we really should be more cautious with specific populations, right? When people have diabetes, you've got to wonder here, right, and do you check their blood sugar and see, do you say at 180 or 200? You just don't do this because knowing they can go up 150, right? How high is too high before you, like if you tell them your blood sugar is what before you call your doctor, endocrinologist to go to the ED? You should probably subtract about 150 from that and that should be your cutoff. People, osteopenia, osteoporosis, you got to watch this. What is a cumulative dose? How much are you giving them? People are already immunosuppressed, right? You got to wonder. Drugs that affect cytochrome P450, there are lots and lots and lots of these because that interacts with the steroid. I think proximity to intense activity, right? You just suppress tenosyte sort of function, right? You suppress chondrocytes and then you're going to have them go like run five miles a day later. I don't know, you got to wonder. You do have to wonder about planned and expected surgeries, right? So I see people who have a bad hip and they say, I want an injection. I go, you got to go talk to the surgeon because I think you need a hip replacement. And I don't know when they're going to do this. So I'm not injecting you because you got to go talk to the surgeon because you shouldn't do this for three months before your surgery. And if you need surgery in a month and a half, you shouldn't get injected right now. Cosmetic concerns. Like, is it worth putting a needle there knowing what can happen? All real things to think about. I think you have to ask yourself and your patients, are any potential short-term benefits really worth the potential long-term harm? Right, like you have to ask yourself that for all this stuff. How many people in the room have been injected? I've never been injected with steroids. I've had lots of them, I'm 58 years old. Lots of things have been hurt, right? I've never had them, right? It's like asking how many spine surgeons have had spine surgery, right? Not a lot, right? I don't think there are really lots of circumstances where this is the case, where this is the imperative, right, once in a while I can see it. I mean, I do it, once in a while I can see it, but I don't think it's that often, and not nearly as often as it's done. I don't, personally. I think you have to think about non-interventional options, which we don't talk as much about all the time, right? Exercise and behavioral interventions are clearly, if not supported, the most supported treatments for a whole host of musculoskeletal conditions. This is what the evidence says we should be doing, right? Frankly, this is us, but this is what we should be doing. Really think about biomechanics, and training, and exercise patterns, and prior injury, and issues distant to the painful site, right, that's this idea of a kinetic chain, and how do people move, and how do they throw a ball, and the person with the elbow pain from throwing a ball probably doesn't have an elbow problem, they probably have a hip, back, or knee problem, right? That's what's causing the problem downstream. This is sort of the victim and culprit approach of sports medicine, for those familiar with that terminology, right? We tend to go treat the victim, right? We look at the rotator cuff, we look at the lateral epicondyle, we look at the ulnar collateral ligament, right? But that's the victim, not the culprit. If we don't fix the culprit, the victim just keeps getting victimized. You know, don't underestimate psychosocial contributors and much of anybody with pain for anything. I hear people talk about athletes are not really that sort of entangled as some people who might come in with chronic low back pain. I don't think that's true, right? There's lots of trauma and stress and anxiety in the life of every athlete, unfortunately. Prior trauma, marginalization are real things. They impact people and their pain. Economics clearly influenced this. Things like food and pharmacy deserts, lack of access to physical activity, all these things get to be barriers to good musculoskeletal health. So how do you sort of overcome them, right? Maybe overcoming them is more important than injecting them. I think in general, what we do, what I try to do is I try to listen. I try to find the barriers and I try to educate people. So many things we treat actually will heal or improve with time and graded use. Things really do get better most of them. Acute injuries tend to get better. If an injury has the ability to heal, I don't know that like a femur fracture can heal itself, probably needs a rod, right? But a lot of injuries can heal themselves. If the tendon is not completely torn, the ligament's not completely torn, it can heal itself and it will probably do a better job on its own given the right sort of environmental stimulus than we will do for it. It heals itself better than we do. And I think you have to talk to people. I have to explain the long-term benefits of working their body. You can talk people off the bridge. I need this to calm down now. Well, do you really, right? Do you really wanna be worse in a year because I do this now, right? You can talk people off the bridge a bit and explain what this takes and it takes time and most people are willing to go there because they really wanna be better. So in conclusion, know the drugs you're using, right? That is the way you have to start. You really should know the drugs, right? That thing Jim said about somebody saying, I never knew this could happen. Didn't know adrenal insufficiency could happen from corticosteroids. He doesn't know the drugs, right? You have to know the drugs you're using because you have to know what they do and don't do. Be aware of systemic and local effects. Think about your population. Think about the patients you're seeing. Be aware of total dose and frequency because it matters. You and the whole ecosystem around you. Think different drugs for different uses. They're different things, right? They have different pharmacokinetics and different properties and probably are better or worse for specific things. And think twice, especially in high-risk populations. And ask yourself this, right? Are they better off without it? Right, that's what I do. I sort of ask myself that question, right? I asked the question of, I started a long time ago trying to frame the question, not sort of, not is this going to help their pain, but is this in the interest of their long-term health, right? If my question is, is this in the best interest of their long-term health, sometimes I get the same answer as this is the best thing for their acute pain. Sometimes I get a very different answer, so I tend to go with the second question. And that's what I got. All right, everybody. Good afternoon. My name is Christy Hunt. I work with Dr. Atchison at the Mayo Clinic in Jacksonville, Florida. I'm kind of a walker and a talker, so we'll see. Can you guys still hear me with this? Great. So, I'm curious. So, my disclosures include research funding for neuromodulation-paid institution, not to myself. We're going to look to summarize, actually, recommendations and guidelines that are going to be coming out. They're not yet published, but we'll be doing some preview work regarding chronic, primarily joint steroid injections. And then we'll also talk a little bit about epidural steroid injections I was also asked to discuss. I'd like to first ask from this group, how many of you are performing injections of steroid peripheral joint or soft tissue targets? Great. And then how many of you are doing, like, axial injections, let's say, facet joint or epidural injections, kind of interventional pain docs? Okay, so a lot of you. So, kind of talking to the home field here. You know, I'm pretty agnostic when it comes to really everything I do in medicine, right? Show me the evidence, right? My mind can be changed, my approach can be altered based on good evidence combined with clinical experience. So, you know, when it comes to, you know, should we, shouldn't we, you know, it's really about kind of risk-benefit versus harm, right? So, you know, also I should mention that actually, in the interest of full disclosure, cortisone was sort of discovered or invented at Mayo Clinic in Rochester. So, part of, you know, so that was quite a long time ago. But it was a combination of a brainchild of a biochemist and a rheumatologist, right? And so this is kind of a great example of people coming from two different aspects of things looking at how can we kind of try to solve some common problems. And indeed, the first indication wasn't for pain. Who knows the first thing we ever injected epidural? Was it steroid? Cocaine. So, hey, could be worse, right? Risk versus harm. And that's actually the first wet tap was also when we started injecting cocaine. So this was actually a combination of almost 30 authors from a different, from the guidelines I'm going to kind of discuss with you that were, that are going to be forthcoming were multidisciplinary, multispecialty, multisociety guidelines, nearly 30 authors. Again, forthcoming, these are not finalized, kind of a preview. I'm going to be kind of sharing the peripheral joint. There's actually joint blocks. There's nerve blocks. It's sort of different things when we have so much time, right? So we're going to focus on cherry-picking a little bit from the joint. And these guidelines will be discussing sort of all these topics, so steroid choice, kind of the interval between injections, imaging modalities, what should we do in large versus small peripheral joints, protocols post-injection, safety monitoring. Again, I'm going to kind of cherry-pick and think the things I think will be most interesting, but there's a lot more that's going to be coming out. And then we're also going to kind of go through what we mean the U.S. Preventive Services Task Force, kind of that format, which is what we followed for this. So these are sort of all the folks. I really enjoyed getting to meet John Fitzgerald. So he's actually a rheumatologist that kind of helped actually change my perspective on some things, and I kind of really enjoyed that relationship. So when we're talking about the U.S. Preventive Services Task Force, grade A or B, these are basically where we mean we probably offer or provide the service. C means, you know, in select circumstances, select patients. A lot of things fall under that grade C. And a lot of what I do, there's not a ton of grade A or B outside of sort of very almost very super common sense things. D is where we kind of recommend against the service, and there's a lot of stuff that falls under I, which is really not enough evidence. We're not too certain. And then, of course, there's level of certainty. So high is when we have multiple, well-designed, high-quality clinical studies that kind of back up and give us a good amount of confidence and certainty in if something should be offered. Moderate is where we have good evidence. We think we can make a good recommendation, but there's a few limitations in the literature. Again, a lot of things fall under this kind of moderate certainty of the evidence category. And then C, kind of low confidence. We've just got to, you know, maybe some case studies, some case series. We don't have a lot of good quality studies to help guide us. So we're going to do a little bit of cherry-picking this afternoon, right? So I'm not cherry-picking in terms of the literature. The Literature Church was comprehensive and really well thought out, but I, again, don't have time to present everything, but here are the things that I think might be most salient and interesting to this audience, and hopefully whet your appetite for looking at the broader set of guidelines when they do come out. There's a lot of references on here, so feel free to kind of focus on those, too. I kind of pointed out, you know, where the main references were that we got these from, but again, can't fit them all on one slide. So in terms of the key takeaways, in terms of choice of steroid, Chris spoke about this a bit. For a peripheral joint, those depo preparations typically favored over the soluble, and low kind of certainty of evidence in that. So, you know, kind of your particulate, more depo preparations may just are thought to last longer than the soluble preparations. A lot of companies are coming out with extended-release steroids, right, because the regular stuff that we use, you know, no one can make a lot of money off of it, so they've got to come out with extended-release steroids, right? Just like extended-release bupivacaine has not actually been shown to be any better in head-to-head studies compared to regular bupivacaine, but they can come out with these new formulations. They have not demonstrated superiority except for potentially patients with diabetes in order to help improve blood glucose control. Again, that's moderate evidence, but we don't have any robust evidence that the longer term lasts a whole bunch longer. And also there's really insufficient evidence to recommend one particular preparation of steroid over another. In terms of safety, we kind of had a long conversation about this. There's actually a study where they took young, healthy male athletes and they measured, you know, kind of how long is steroid thought to really affect their adrenal function. They actually found changes that were persistent up to seven days. So that's usually where that recommendation for an interval between injections, if you have to have an interval between injections, like let's say we take one approach, didn't seem to be helpful, going to try to take another approach, they recommend generally about two weeks or so between injections, probably come from this number. Typically, you know, if you have a diabetic patient who's monitoring their blood sugar, we try to tell them, you know, keep an eye out for the next two to three days, expect it to be elevated. But it can be elevated in patients up to seven days. Holding anticoagulation and peripheral joint injections is not needed, and patients can be within that therapeutic range. There have been patients who have been injected with fairly high INRs, five and above, without adverse effects. But in my clinic, you know, we really try to keep it, if they are on Warfarin, we try to make sure that their INR tries to stay within that therapeutic range of the patient. But patients do not need to hold blood thinners or antiplatelet agents. The risk is not felt to outweigh the benefit in terms of thrombotic events. Generally recommend that patient, that we hold any type of intra-articular steroid injection within one month of an index surgery. But really, most surgeons are going to prefer that you hold it within three months for your hip, knee, shoulder. And again, I think that's pretty common standard practice. In terms of our key takeaways for shoulder, elbow, and some of our small joint injections, lower dose is felt to be equally as effective as higher dose. Now, that's not to say that this applies only to our small joint injections. It may apply to large joint as well. It's just what the studies have shown. So what I will routinely see in my practice is that certain other specialties, orthopedics, might love to give really high doses of these steroids. We had one patient when I practiced in Rochester who went into adrenal failure where people had not finished their procedure documentation in time. And they had received about 360 methylprednisolone equivalents over the course of two or three days and went into adrenal failure. Just because they were going from this practice to that practice to that practice and they weren't minding what one another was doing. So the idea here is that more is not necessarily better. And even though this is kind of focused on large joint injections, you want to think about epidurals as well. Even if you yourself are not practicing spine injections, if you're sending patients for epidural injections, for example, read the procedure documentation if you can. It is not uncommon in practices that I've seen, not in my practice, that patients might get bilateral, two-level, transforaminal epidural steroid injections. Because you're going to bill a lot more for that than you can if you do a single level or a single side. And patients will routinely, I've seen patients get 18 milligrams of betamethasone. I've seen patients, the highest I think I ever saw was 120 milligrams of methylprednisolone equivalents in a single epidural steroid injection. So if patients are receiving these injections, let's say you're going to be doing an injection, sometimes they just ask, well, how many epidurals have you had in the last year? You want to think about, too, how much steroid have they actually received within that. So whether it's a joint, soft tissue, epidural, you want to think about how much have they actually received and if possible, have access to that procedure documentation. You know, this is one, and I actually wrote the elbow section. I was a little bit curious, you know, again, we have to show here's what the literature shows, right? It's not my personal opinion. It's informed by literature search. I don't love the idea personally of steroid for lateral epicondylosis. So we kind of softened it to saying we can consider maybe a single one for emphasis on short-term relief in lateral epicondylosis but can't really recommend multiple and then didn't find any evidence that this could be helpful in medial epicondylosis. Unsurprisingly, the literature supporting some of these small joint injections are most robust in patients with inflammatory arthritis, like rheumatoid arthritis, but not necessarily in osteoarthritis. And again, I'd really encourage you guys to feel free to kind of look at – I know this is really small to see, but we've got all these cell phones. You can take pictures, and you can blow them up. It's amazing what they can do these days. And hopefully – I don't know if you have access to these slides or not, if they're pre-submitted, but feel free to look at those. And then unsurprisingly, try to avoid plantar fascia injections in non-inflammatory heel pain. There might be some support in inflammatory heel pain conditions to consider this. I personally have not seen, you know, kind of astounding results with steroid injections for the plantar fascia, but definitely not indicated or recommended in non-inflammatory heel pain. So when we think about the hip and knee, generally recommended to use caution when we're using high dose and multiple injections. Try to use the lowest effective dose. Increase that time interval. You know, we try to really keep it – you know, I tell patients, let's try to extend this out to three to four months, and really having an end game in mind. Right? This isn't necessarily something we need to do forever. We need to have kind of a plan in place with a – you know, is there a plan for surgery down the road? Is this a patient who absolutely can't have this? And even though this is a conversation about what we do or don't do with steroid, the good news is for a lot of these peripheral approaches, we have a lot of good non-steroidal approaches. Chris did a good job of talking a lot about, you know, kind of rehab approaches and non-interventional approaches. But we are also talking quite a bit at this meeting and other meetings about radiofrequency ablation, you know, percutaneous tenotomy. There's a lot of non – biologics, perhaps. There's a lot of non-steroid options that can be helpful as well. But it's often these large joint injections where patients get the most kind of the highest dose steroid and get a kind of a higher total cumulative dose. There's not necessarily a reason to go above 40 milligrams. There's no evidence that 80 or 60 will do more for you than 40. Certainly, you could consider lower doses. That would be fine. We want to kind of hammer home the point that a higher dose of steroid is not necessarily better. Patients may endorse, I feel better. There's probably that systemic effect they're getting from steroids, right, that kind of some patients don't enjoy that feeling of all this energy and all of that stuff. But we don't have good evidence that anything over 40 of methylpenicillin equivalents is any better. Greater trochanteric pain syndrome, this is probably one of the most common and I think sometimes overused injection approaches, right? Who doesn't love a good troch bursa injection? It's easy to do, lay them on their side, get it done, right? PAs can do it right in the office. So this is a really common thing to get. But, you know, it's really a highly utilized, perhaps overutilized injection. And we're really recommending that, you know, really only considering these if they failed physical therapy or in conjunction with a good physical therapy program. I like the discussion of probably not running on the beach right afterward, right? You want to be really careful when you're doing some of these injections in soft tissue or bursa areas especially to be careful. If I have a patient who's, you know, maybe doing a shoulder bursa injection, something like that, subacromial, subdeltoid bursa, you know, they're going on a flight, right? And I was like, really, you know, you're holding that bag, dragging that bag, throwing it in the, you know, kind of cupboard overhead, things like that. Patients can do poorly with high-impact activities after these types of injections and approaches, and again, especially that troch bursa. So cautioning patients to be careful. So just kind of taking a little bit of a kind of pivoting here a little bit, I would ask to speak a little bit about epidural injections, which I'm happy to speak about. So this is one paper that we put out a couple of years ago. Dr. Friedlee and her group have a couple of nice papers on this. So there are several good papers you can see that talk about epidural injections and safety, but they definitely have systemic effects, and that's an important thing to think about. So we're talking specifically about bone marrow density. This was kind of a narrow question that we had. We found eight studies with over 7,000 patients and a follow-up up to 60 months in some of the studies. Some patients had actually up to 14.7, nearly 15 epidural injections, if you can believe that, and this was on the high end, just a truly staggering amount of methylprednisolone equivalents right there. And overall, the literature suggested with a systematic review approach that there were significant reductions in bone marrow density associated with a cumulative dose more than 200 over one year and more than 400 over three years. So that's where that number kind of comes from is this sort of literature. So this is a number that I try to keep in my mind. It comes to about 180 milligrams of methylprednisolone equivalent. For those of you who don't do spine injections, when you're thinking about when you're reading some of these operative reports, one note on some of the trans-familial epidural steroid injections, it's much more common to use non-particulate steroid like dexamethasone. And for interlaminar approaches, people still might choose to use a kind of a more soluble but still a very small particle beta-methasone injection. If you're seeing your patients routinely getting high doses of methylprednisolone in their trans-familial epidural injections, I kind of look at that a little bit, right, because it means that your interventional pain doctor is not using a particulate steroid injection, which is a higher risk of injury. So there's sort of little trade secrets you can look at to say, you know, what are they thinking about when they're doing injections for my patients? Are they routinely doing higher dose steroid in the epidurals? This can be a shorthand kind of way to look under the hood, if you will, to see how are they going about their decision-making process. And then we don't, as long as we can kind of keep it under about 200 milligrams in post-menopausal women over a year are actually quite higher in 3 grams in men. For me, it's kind of, you know, I'm not kind of going through and saying male versus female. I'm kind of keeping it under that same number. But the literature would suggest that males can kind of tolerate sort of a higher dose. Again, in our practice, we don't necessarily differentiate. But definitely the highest risk is in that post-menopausal Caucasian female population in terms of the highest risk for bone mental density problem. Again, this is just focusing on the epidural injection. So when you add on to that peripheral joints, soft tissue, oral steroid dose packs, all of this stuff really adds up. And then the use of anti-osteoporotic medications probably reduces that risk. But definitely in patients where this is not being monitored, not being controlled, this is more of a problem. So good practice habits when we think about it through the physiatrist lens. So I really would love to emphasize, I think we've all sort of talked about that, understand the dose and the frequency of all of their steroid exposure. You've got to ask them about it. Patients aren't aware of that. You know, I've had, you know, well-meaning, you know, primary care physicians, you know, give their patients an oral steroid dose pack and then send them to me for an epidural steroid injection. It just doesn't make sense, right? So if you can kind of educate practice partners without trying to, you know, hurt anybody's feelings. But it's also a risk versus benefit situation, right? So I was recently treating a colleague who was not in, you know, my same practice area or anything like that, but a physician who was able to self-prescribe himself, you know, long-term steroid to help suppress and treat headache. And then he had an acute radiculopathy. And I knew that if I did a steroid injection with dexamethasone, I might be able to get his pain under better control. Maybe he wouldn't keep popping so much steroid, right? So you have to think about risk versus benefit. Who was the individual patient? How can you reduce that risk exposure to them, right? Not all epidural steroid injections are created equal. So you want to think about just because they had an epidural, what was the dose? What was the approach? And how can you consider, you know, how would that impact either your choice to provide additional epidural steroid injection? Is it indicated? Does it make sense? And then how should that also inform your practice? If you yourself don't do those injections, who are these patients being referred to? And is this still a great person to refer your patients to? We talked a little bit about that. And then if they're getting epidurals for more than a year, closely monitoring that. The new Medicare guidelines, as much as I hate, you know, there's a lot of discussion and controversy about new LCDs and NCDs and how this affects patient care, but at least they're really trying to keep a curb on epidurals, right? So they're really recommending no more than four per year, right? So at least trying to kind of put an end to the practice of that routine series of three, right? Anybody part of the practice where they would get them every two weeks, you know, for a total of three injections and this is the magic trick, right? No evidence behind that, but this is what we need to think about. And then definitely your highest risk population are the postmenopausal females, particularly Caucasian females. And then making sure that these patients are also getting age appropriate bone mineral density, right? This is an important thing we should all be thinking about. I mean, even if you're not the one to do that, making sure that that's being done and understanding if your patient's at higher risk. Even though it is true that targeted injections can have a systemic effect, if you're thinking about the benefit of an oral steroid, like a prednisone tape, or a steroid taper, which is routinely being offered in maybe urgent care, primary care, you know, specialty practices, emergency department, we can probably do a little bit of a better job getting better analgesia and pain relief with a targeted injection over kind of repeated systemic exposure. Remember, this is all about relative risk and harm reduction. The hard thing about guidelines, and the reason why some people are critical of guidelines is they say, gosh, if we put a guideline out there that's too harsh or too rigid, if there's a problem with a patient, if there's a problem in the practice, if there's a problem with safety, it's kind of opening that physician up for liability, right? Because we put guidelines out there that suggested A, B, or C. At the same time, I'd also challenge you to not think so rigidly that you have to follow guidelines perfectly. And if guidelines aren't in place, I can't follow those, right? You know, how many people are prescribing gabapentin for pain or anything, right? How many people are prescribing gabapentin for seizures? No, right? What is it on label for? Seizures, right? And of course, you know, gabapentin is poorly tolerated in many patients. But you and I are making decisions every day where we're trying to optimize or preserve patients' function and improve their quality of life. And I think that physiatrists are uniquely well-positioned to help patients with chronic pain because we don't approach patients with, where's my target for injection, right? We approach patients with, you know, what are you doing now? How does all of the data points, your physical exam, your diagnostics, how does this kind of play, how does this sort of form a summary picture of, you know, what's the diagnosis and what are the functional impairments? And then what's the safest, most effective way to get you from where you are now, poor function and pain, poor quality of life, to having an improved quality of life, right? We're also comfortable with not perfect, right? We're comfortable with taking patients who've had a serious disease, injury, impairment, neurological event, and taking a rehabilitation approach, right? And maybe they're not going to be back to where they were before index event, but maybe they can have an improved function and quality of life. So this is what we're trying to do every day. So it's about managing risk. I don't think it's about demonizing a particular drug or steroid or approach. It's about taking the knowledge of everything that we have and trying to make the best decision in a shared decision-making process with the patient, right? Whether that's drug, whether that's physical therapy, whether that's injection, whether that's surgery, trying to understand the patient, where they are, and what's the safest, most effective way to get them to where they need to go. So we will have forthcoming multidisciplinary, multispecialty guidelines coming out, hopefully within the next three to six months that address nerve block, joint, also have information on epidural injection there, as well as trigger point injections, soft tissue. Again, everybody in this room knows this. Try to use the lowest effective dose of steroid. There's not necessarily reason to put steroid into your trigger point injections, not necessarily reason to put steroid into your sympathetic blocks, right? So, and you want to think about what are your steroid sparing alternatives? Can we use techniques like radiofrequency ablation? Can we use techniques like tenotomy? And that's, again, only if procedures are indicated, right? Are we continuing to go back to physical therapy? Are we reinforcing that message of home exercise program and kind of helping to motivate patients in that way? Can we employ an anti-inflammatory diet, right? I gave a talk last week. There's a ton of information about anti-inflammatory diet, about addressing metabolic syndrome, and how can we address the whole patient and actually use the fact that they are in chronic pain and that there might be lifestyle choices that help to reduce that chronic pain. So rather than steroid to help reduce inflammation, what can we do in terms of their lifestyle, their nutrition, their activity to help reduce systemic inflammation burden? Sometimes patients have never actually heard this message and you're actually uniquely qualified to be able to say, hey, you're having chronic pain. Let's have a conversation about how there's some other things in the lifestyle that we can do to help reduce, you know, the inflammatory burden and improve your pain. Definitely leverage the maximal interval between injections. So again, we try to say, you know, three to four months between most types of injections. And again, if like, let's say there's unique circumstances where you're having an epidural and they have an acute radiculopathy and you're sort of trying to work with a surgeon and you're sort of trying to make the best decision, try to wait at least two weeks between epidurals if you're needing to take a different approach. It's pretty rare in my practice for what I do with patients that I would ever do with injections that close together, but there might be unique circumstances when we're trying to sort of help get a patient towards surgery, we need to take a different approach. And then again, this is a good thumbnail approach is try to consider maintaining that epidural steroid exposure to less than 200 milligrams over a one year period. And if we're doing epidurals beyond that period of time, sort of questioning, is this the right thing to do? Do we need to have them go see a surgeon? Again, there can be certain circumstances where that might be appropriate, but let's just scrutinize those choices when we can. So I think now we'll do the panel approach, is that right? Thank you. Anybody with questions, if you would, please come up to the microphone and ask them directly, and then I'm going to watch the – there's online stuff going on here, so we're watching that for a second, too, so please go ahead. Male Speaker I was wondering if there have been any – looking into recommendations or guidelines for substituting steroid with, like, Ketorolac, using, like, NSAIDs. There have been a couple of recent studies showing equivalent outcomes for knee joint and subacromial bursa comparing steroid and that NSAID. Female Speaker I think that it's also hard to know, like, are these things clearly safer compared to steroid, right? So it might be reasonable to consider, but it's also reasonable to ask, you know, are you getting substantially more bang for your buck? I don't think we know that for sure. Male Speaker So, I mean, there's – I don't know about you. I watched our numbers. I didn't see a lot of A's and B's saying you should inject people, right? So you're comparing it to something. If you compare, like, long-term studies on lateral alpha-gonolitis, people are worse at a year. So saying you're better than worse means maybe you're doing nothing. I don't know. So, like, there isn't good data on them in the first place. And so compared to study, then you got to wonder, is that drug – what happens to that drug intra-articulately, right? What does it do inside the joint? I don't know if we know what an NSAID does intra-articulately, because I doubt any have FDA indications for doing that, but I've never seen a study on sort of the effects of cartilage of intra-articular – and the issue of, you know, off-label use – I mean, we do it all the time. We do it for all sorts of things, right? And medicine in general does this, because that's sort of what we have. We use the tools available to us. But when you start doing things that are really sort of, you know, against what it actually says – this is contraindicated for it on the bottle. That's a bit different, right? And when you start doing things where you really don't have a literature base to stand on and things go bad, I wonder if you have much leg to stand on personally, right? And then you have, you know, not just sort of the legal ramifications, you have the sort of, like, go to bed at night ramifications of, did I have to do that? So I think you have to wonder that a bit. Female Speaker Yeah, I agree. And I think that on-label is one question, and it's an important one, and, you know, indications for use and all that, but it's also standard of care, right? So I think that those are sort of two different things that can be the same, but definitely if you're operating outside of standard of care, that's, you know, a concern. Not saying that you can't or should never do it, but definitely a reason to be thoughtful. Female Speaker Just to that tort all point, we've actually been discussing that in my department recently, and the question there is, yeah, how does it get out of the joint? Does it, what does it do in the joint? But also, you know, is that, would that limit your utility for folks who are on blood thinners? Because now you're putting an NSAID that is presumably going to become systemic, like we said about the steroids. So that's one of the concerns that had been raised in my department. But my question is, I am in an orthopedics department, and I do, I mean, it's collegial, they appreciate what PMNR has to offer, but they do use 80 milligrams for each of their knee injections, you know, of catalog, and they'll do, you know, two knees, two shoulders, and so that person's getting 160 at a time. And so, I mean, I've made the conscious effort myself to use 40. Look, I might try 20 now, you know. But so how do you, I mean, my surgeons are backed up for their joint replacements. They're like four to six months out for some of their surgeries. And so they're saying, well, let's give this patient that injection. We just got to get them through. We just got to get them, you know, give them that extra three months until they can get to their surgery. Or alternatively, I'm not doing a surgery until they fail that steroid injection. What, I mean, how do you, how do you speak to the surgeons or even the patients who like insist no, they need, they have to have this injection? How do you, how do you say no when you don't believe that it's probably necessary or worth the risk? So, I mean, I go back to the question I asked. What's in the best interest of their long-term health, right? And so somebody's got, you know, advanced OA and AVN and collapsed their femoral head. They shouldn't really be waiting three months for hip surgery, right? And you shouldn't be injecting either. They should be getting a hip replacement. And so you have that like how bad is bad thing in there somewhere. You have what are your other options here to get them through it? What you really want with that patient, if they're already on the ramp for hip replacement, you want them to come out well, is what you want them to do. So you have this conversation about what's our best way to get you to come out well. I know you hate swimming pools, but maybe you should go to a pool. Maybe you got to get on a bike. Maybe you got to go to PT because we want you to come out well. And you don't want to do things to them that are going to make them come out unwell. And if you have, for example, you know, if you go back to a 70-year-old female with osteopenia and a bad hip and you put in 200 milligrams of Depo three months before you go replace her hip, maybe it's not a good idea for the hip replacement, right, because you're dropping her bone density. So I mean, I look at it in that context, and I do the right thing for the person in front of me. I don't work for people who do that. So I don't run into that direct conflict of interest at times. But I think you have to do the right thing for the person in front of you. And I think I have these conversations about what, like, this is our goal. You know, it's June. You're looking at a hip replacement. I want you in your garden next summer, right? So I want to make sure your hip replacement goes as well as it can possibly go. That's our plan right now, because we know you're going to have to have it. So what do I have to do to get there? And maybe we're going to work on your diet. Maybe we're going to work on your sleep. We want you to go in. You know, we want you to go in as well as you can go so you come out as well as you can come out. But I just sort of shift the whole conversation. If in that it turns out that, like, yeah, it's worth putting steroids in because it's four months before their hip or whatever, it's worth doing it, but then you go as low as you can go. But I have that conversation to sort of reframe it so it's not about, like, make me better now. Yeah. It's probably two different questions. One is the payer question of the failed conservative therapy before they proceed to surgery and if that conservative therapy includes intra-articular injection. Again, if they're getting a single intra-articular corticosteroid injection, the long-term harm of that is probably not substantial, right? Again, there are plenty of patients getting these 160 milligrams of steroid and they're not being harmed, right? So we have some good standout cases of terrible things that have happened, but that doesn't happen to every patient, right? So it's an informed consent conversation. And then if you're working with your practice partners who, again, are trying to do the very best thing for the patient, maybe you can say, like, yeah, let's stick to 40 milligrams for our injection and not 80, right? Maybe if we're looking at routine six-month ramp, maybe we're looking at, like, is radiofrequency ablation an option, you know? And then can you leverage any analgesia that they do receive with, you know, whatever procedure you are choosing to employ, if that's appropriate? Can they engage in prehab, right, and trying to sell patients on that idea can be really helpful to, indeed, optimize their long-term outcomes after surgery. I had a guy who had AVN and couldn't even walk, but he was, he'd had an acute coronary event, absolutely could not come off of blood thinners for six months. So we did radiofrequency ablation in that patient, you know, in discussion with surgery, had that whole conversation. I mean, this is a good example of, you know, trying to work together to do the best thing for the patient in his specific circumstance. Just to help them reduce suffering, you know, until surgery. Let me interject a couple from the online. You mentioned maybe limiting high-impact activities after some of the injections. How long do you usually keep them from doing higher-impact activities? I think it's a somewhat data-free zone in terms of that. I personally tell people five or seven days. I don't know if that's the right answer. I just don't like them going in, certainly when they're, like, they have the anesthetic and I don't like them doing much of anything because they're kind of numb. And then, you know, yeah, I give them sort of, personally, five or seven days. I don't know what you give your patients when you put a steroid around something that is, like, in a joint or around a tendon. Yeah, we routinely do two weeks, and I feel strongest about it with tendon, you know, because of the, because of, you know, that's what's been shown to have the highest risk of there being some sort of tendon complication. I think with joints, I generally tell them about, you know, I say it takes up to two weeks to take full effect, right? So I might maybe say kind of, you know, take it easy for a few days until you see how this impacts you. But I feel strongest about that waiting for the tendinopathy. And then, Dr. Hunt, from the guidelines or the information that you were looking at about from, it asked about doing multiple joint injections, like we talk about maybe not doing an epidural within at least two weeks and hopefully longer. Is there a thought in there on a recommendation regarding, let's say you had a knee injection done, how long should you wait to do a shoulder injection, any sequence, interval of waiting between different peripheral joint injections? Yeah, with lack of clear recommendations on those exact scenarios, our general recommendation would be try to wait two weeks between steroid injections if you can, if the injection is involving steroid. If you absolutely have to kind of stack them together, it's sort of like waiting at least three days or something to wait for that kind of that acute, you know, quarter, you know, that acute, you know, adrenal impact to calm down. But it's generally, if you can, try to wait two weeks between injections, even though, again, plenty of patients are getting both shoulders, both knees, both hips, getting it all done within a week, you know, and they're not being harmed by that. But if you can increase that interval out, that is generally felt to be best. I mean, they're not being harmed, but you don't know when they're going to be, is the problem, right? You can say there are lots of people aren't being harmed, but there are lots of people not being harmed by crossing a street in the dark and dark clothing with no lights, right? Like most people get hit by a car, but so I mean, yeah, I don't totally agree with that. I mean, you got to watch what you're doing. I think the longer is better, right? If you look at these studies on adrenal suppression, most people are better within a couple of weeks, but all are not. Some people have very sustained adrenal suppression in small numbers of people. So you really have to like, it's an individualized thing a bit. Like what is your patient like? What is their age like? How many other steroids have they had? All these things sort of add up, right? And what is your total dose for the year? And like how, like this whole idea of knowing what everybody else is doing, what's happening and looking in the whole context really does sort of matter because you're trying to help. And it's probably a good point. I mean, the person who shows up in your office and needs to have a shoulder and a knee done and has never had anything done before, that would probably even seem a little unusual. They probably have had some of them done before. So then that factors back into the decision too. And yeah, I just want to say, I'm not in any way suggesting that just because it happens to people, it doesn't mean that feel free to go nuts. No, no. I wasn't thinking you said that. You just have to acknowledge that to people like, well, gosh, but we do this all the time. Sort of like you don't know. It's like a Russian roulette. You don't know when it's going to land on somebody that's going to have a problem. Well, I'm sure it's, you know, I imagine it's handled on a case by case basis and with a number of factors playing into it. I'm just curious if any of you in your own practice have formed your own kind of modified acceptable either total steroid dose or single injection steroid dose for certain high dose or certain high risk, excuse me, populations like a poorly controlled diabetic or a postmenopausal osteopenic or parotic patient. If you've found yourself, you know, forming more kind of black and white guidelines in those situations. I don't know. I don't have like, I mean, I actually try to minimize them as much as possible. It gets very individualized, right? Because you really do wind up with some, if you took everybody all comers, you wind up with some pretty weird extreme circumstances sometimes where your back's against the wall a little bit in terms of what you're going to do here. Like your ablation of like a collapsed AVN hip that just had an MI and got like, this does not happen all the time. So once in a while you got to go. So having really rigid things is hard. I think you individualize it and you weigh the risk of every individual thing you're doing. Right? And then if the, why am I doing this? What am I going to get for this? What are they going to get for this versus in the context of this, I see increased risk for harm. Maybe I shouldn't do this. Right. And, and you know, what I said about like talking people off the bridge here all the time, like, well, people want something done. Like this is what people give me is the defense of like, I do things because people want things done. Most people really don't want stuff done to them. They want to feel better and they may think the only way to feel better is to have something done to them. Therefore they want something done. I don't think anybody in this room, if you all tell me you want needles stuck in you later today, raise your hand. If you want spine surgery tomorrow, raise your hand. Like I don't think my patients don't want spine surgery. A lot of convincing, I need it, but they don't really want it. If I can explain the consequence and the structure, like Jim said, this guy came in saying, fix my scoliosis. He had like a 20 degree curve. Like you should like never, right, like, no, do you know we're going to do a 14 level surgery on you. It's going to take like 8 to 12 hours. You have 100% complication rate and if you're over 70, you probably got about a 5% mortality rate and you'll never be able to touch your toes or see your feet again. You want to do that? Right? Like, no, like, so you can explain the circumstance and I think it's good to have guidelines. It's good to think about structures. It's good to add up things and say no more than 200, but weird things happen and we all wind up in this position of like what's my best answer here and that's what you think through. That's how I do it. I'm going to circle back for a second too there, just with the idea that we get put into the tough situations, okay, making a tough call. The worst part is when we looked at those equivalents up there for prednisone when they get a dose back, right, which is 60, 50, 40 down, so it's 200 and some milligrams and they got it for no reason. They've already had their 200 milligrams. Now what do you do? So our message more is, okay, there's times and there's things and yes, we do them. If we make a good educated decision, that's fine, but the nonspecific use otherwise puts those decisions in jeopardy and so we need to be very vocal as a specialty on not having nonspecific use done when there's no indication in the areas we know about. Once again, I'm not proposing we go out and challenge oncology or pulmonology or anybody else, but the issues are if you had your Dimedrol dose pack and usually that's two or three in the course of time, now you come in and you're trying to make that decision you're trying to make, it's more risky and it's more difficult to make the right decision for the right person at the right time would be the way I would think about it. So let's eliminate more of the nonspecific and we're not following guidelines just rote and routinely. I mean, we do plenty of off-label use of everything, but with some literature support, I would say most of the time and there is not any guideline or literature support for that nonspecific use is the major point and I apologize. I think if you have more questions, if you would want to come up, we're just about out of time. So hopefully you got something good out of the session and please be a vocal member of the PM&R community out in your area. Thank you.

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education

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appropriate indications

guidelines

injections

peripheral joints

alternatives

individualized care

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