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Genicular nerve block in rheumatoid arthritis: a randomized clinical trial

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Abstract

Objective

This study highlights the effect of a genicular nerve block (GNB) on pain, function, and inflammation outcome measures in rheumatoid arthritis (RA) knees.

Methods

A total of sixty-four patients diagnosed with RA using ACR/EULAR 2010 criteria with unilateral persistent knee arthritis were recruited to the study. They were randomly assigned into two groups: group 1 received GNB and group 2 received intra-articular triamcinolone. Both groups were examined by the SOLAR scoring system, visual analog scale (VAS), and Lysholm score at 0, 2, and 12 weeks. A semi-quantitative score was used to assess the tenderness and swelling at the same intervals.

Results

Function and inflammation improved significantly in group 2 at a 2-week interval as compared to group 1, whereas pain improved in both groups with non-significant differences. After 12 weeks, group 1 showed significant improvement as compared with group 2 for the three outcome measures. Neither the disease activity nor the current medication was related to the GNB effect. Disease duration was negatively related to GNB-induced improvement.

Conclusion

GNB is a new promising local therapy for RA to control pain, improve function, and alleviate inflammation of the knee joint. Although it has a relatively short-term effect, yet it has outperformed the steroid effect.

Key Points

• Knee monoarthritis treatment in rheumatoid arthritis is always challenging

• GNB has been approved for the treatment of pain in knee osteoarthritis

• GNB in this study was able to control active knee arthritis and this effect persisted longer thane intra-articular steroid injection

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References

  1. Loppenthin K, Esbensen BA, Ostergaard M, Ibsen R, Kjellberg J, Jennum P (2019) Morbidity and mortality in patients with rheumatoid arthritis compared with an age- and sex-matched control population: a nationwide register study. J Comorbidity 9:2235042X19853484

  2. Einarsson JT, Willim M, Ernestam S, Saxne T, Geborek P, Kapetanovic MC (2018) Prevalence of sustained remission in rheumatoid arthritis: impact of criteria sets and disease duration, a Nationwide Study in Sweden. Rheumatology 58:227–236

    Article  Google Scholar 

  3. Tada M, Inui K, Okano T, Mamoto K, Koike T, Nakamura H (2019) Safety of intra-articular methotrexate injection with and without electroporation for inflammatory small joints in patients with rheumatoid arthritis. Clin Med Insights Arthritis Musculoskelet Disord 12:1179544119886303

    Article  Google Scholar 

  4. Nikas S, Temekonidis T, Zikou A, Argyropoulou M, Efremidis S, Drosos A (2004) Treatment of resistant rheumatoid arthritis by intra-articular infliximab injections: a pilot study. Ann Rheum Dis 63:102–103

    Article  CAS  Google Scholar 

  5. Hollander JL, Brown EM, Jessar RA, Brown CY (1951) Hydrocortisone and cortisone injected into arthritic joints: comparative effects of and use of hydrocortisone as a local antiarthritic agent. J Am Med Assoc 147:1629–1635

    Article  CAS  Google Scholar 

  6. Bentley G, Goodfellow J (1969) Disorganisation of the knees following intra-articular hydrocortisone injections. J Bone Joint Surg British 51:498–502

    Article  CAS  Google Scholar 

  7. Keyszer G, Langer T, Kornhuber M, Taute B, Horneff G (2004) Neurovascular mechanisms as a possible cause of remission of rheumatoid arthritis in hemiparetic limbs. Ann Rheum Dis 63:1349–1351

    Article  CAS  Google Scholar 

  8. Needs C, Webb J, Tyndall A (1985) Paralysis and unilateral arthritis: is the association established? Clin Rheumatol 4:176–180

    Article  CAS  Google Scholar 

  9. Bland JH, Eddy WM, Bywaters E, Rodnan GP (1968) Hemiplegia and rheumatoid hemiarthritis. Arthritis Rheum 11:72–080

    Article  CAS  Google Scholar 

  10. Elsaman A, Sayed A, Radwan A (2020) Hand dominance in early and established rheumatoid arthritis: evaluation by dynamometer, Ritchie index and musculoskeletal ultrasound: a cross sectional study. Reumatismo 72:131–144

    Article  CAS  Google Scholar 

  11. Kim DH, Choi SS, Yoon SH, Lee SH, Seo DK, Lee IG, Choi WJ, Shin JW (2018) Ultrasound-guided genicular nerve block for knee osteoarthritis: a double-blind, randomized controlled trial of local anesthetic alone or in combination with corticosteroid. Pain Physician 21:41–52

    PubMed  Google Scholar 

  12. Collins NJ, Misra D, Felson DT, Crossley KM, Roos EM (2011) Measures of knee function: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL), Lysholm Knee Scoring Scale, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Activity Rating Scale (ARS), and Tegner Activity Score (TAS). Arthritis Care Res 63(Suppl 11):S208–S228

    Article  Google Scholar 

  13. Kon E, Altadonna G, Filardo G, Di Matteo B, Marcacci M (2014) Knee scoring systems European Surgical Orthopaedics and Traumatology The EFORT Textbook: Springer Berlin Heidelberg 3371–88

  14. Liu W-X, Jiang Y, Hu Q-X, You X-B (2018) Improved quality of life and joint functions in patients with knee rheumatoid arthritis who underwent five portal arthroscopic synovectomy. PeerJ 6:e4727

  15. Schäfer VS, Fleck M, Kellner H, Strunk J, Sattler H, Schmidt WA, Ehrenstein B, Backhaus M, Hartung W (2013) Evaluation of the novel ultrasound score for large joints in psoriatic arthritis and ankylosing spondylitis: six month experience in daily clinical practice. BMC Musculoskelet Disord 14:358

    Article  Google Scholar 

  16. Hartung W, Kellner H, Strunk J, Sattler H, Schmidt WA, Ehrenstein B, Fleck M, Backhaus M (2012) Development and evaluation of a novel ultrasound score for large joints in rheumatoid arthritis: one year of experience in daily clinical practice. Arthritis Care Res 64:675–682

    Article  Google Scholar 

  17. Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO 3rd, Birnbaum NS, Burmester GR, Bykerk VP, Cohen MD, Combe B, Costenbader KH, Dougados M, Emery P, Ferraccioli G, Hazes JM, Hobbs K, Huizinga TW, Kavanaugh A, Kay J, Kvien TK, Laing T, Mease P, Menard HA, Moreland LW, Naden RL, Pincus T, Smolen JS, Stanislawska-Biernat E, Symmons D, Tak PP, Upchurch KS, Vencovsky J, Wolfe F, Hawker G (2010) 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis 69:1580–1588

    Article  Google Scholar 

  18. Cader MZ, Filer A, Hazlehurst J, de Pablo P, Buckley CD, Raza K (2011) Performance of the 2010 ACR/EULAR criteria for rheumatoid arthritis: comparison with 1987 ACR criteria in a very early synovitis cohort. Ann Rheum Dis 70:949–955

    Article  Google Scholar 

  19. Shrestha B, Dunn L (2020) The Declaration of Helsinki on medical research involving human subjects: a review of seventh revision. J Nepal Health Res Counc 17:548–552

    Article  Google Scholar 

  20. General Assembly of the World Medical A (2014) World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. J Am College Dentists 81:14

  21. Filippucci E, Farina A, Carotti M, Salaffi F, Grassi W (2004) Grey scale and power Doppler sonographic changes induced by intra-articular steroid injection treatment. Ann Rheum Dis 63:740–743

    Article  CAS  Google Scholar 

  22. Chagas-Neto FA, Taneja AK, Gregio-Junior E, Nogueira-Barbosa MH (2017) In-plane ultrasound-guided knee injection through a lateral suprapatellar approach: a safe technique. Ultrasound Q 33:139–143

    Article  Google Scholar 

  23. Schäfer V, Schmidt W, Backhaus M, Hartung W (2016) Arthritis of the knee joint in rheumatoid arthritis-evaluation of treatment response by ultrasound in daily clinical practice. Open Rheumatol J 10:81

    Article  Google Scholar 

  24. Elsaman AM, Radwan AR, Mohammed WI, Ohrndorf S (2016) Low-dose spironolactone: treatment for osteoarthritis-related knee effusion. A prospective clinical and sonographic-based study. J Rheumatol 43:1114–1120

    Article  CAS  Google Scholar 

  25. Carlsson AM (1983) Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain 16:87–101

    Article  Google Scholar 

  26. Crichton N (2001) Visual analogue scale (VAS). J Clin Nurs 10:706–716

    Google Scholar 

  27. Briggs KK, Lysholm J, Tegner Y, Rodkey WG, Kocher MS, Steadman JR (2009) The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later. Am J Sports Med 37:890–897

    Article  Google Scholar 

  28. Faul F, Erdfelder E, Buchner A, Lang A-G (2009) Statistical power analyses using G* Power 3.1: tests for correlation and regression analyses. Behav Res Methods 41:1149–1160

    Article  Google Scholar 

  29. Cohen J (1988) Statistical Power Analysis for the Behavioral Sciences (2nd edn). Hillsdale: 411 Lawrence Erlbaum Associates, 412

  30. Sarazin J, Schiopu E, Namas R (2017) Case series: monoarticular rheumatoid arthritis. Eur J Rheumatol 4:264–267

    Article  Google Scholar 

  31. Hetland ML, Stengaard-Pedersen K, Junker P, Lottenburger T, Ellingsen T, Andersen LS, Hansen I, Skjødt H, Pedersen JK, Lauridsen UB (2006) Combination treatment with methotrexate, cyclosporine, and intraarticular betamethasone compared with methotrexate and intraarticular betamethasone in early active rheumatoid arthritis: an investigator-initiated, multicenter, randomized, double-blind, parallel-group, placebo-controlled study. Arthritis Rheum 54:1401–1409

    Article  CAS  Google Scholar 

  32. Aletaha D, Maa JF, Chen S, Park SH, Nicholls D, Florentinus S, Furtner D, Smolen JS (2019) Effect of disease duration and prior disease-modifying antirheumatic drug use on treatment outcomes in patients with rheumatoid arthritis. Ann Rheum Dis 78:1609–1615

    Article  CAS  Google Scholar 

  33. Ferdinand Iannaccone D, Samuel Dixon R, Andrew KM (2017) A review of long-term pain relief after genicular nerve radiofrequency ablation in chronic knee osteoarthritis. Pain Physician 20:E437–E444

    Article  Google Scholar 

  34. Elsaman A, Hamed A, Radwan A (2021) Ultrasound-guided epidural block in axial spondyloarthritis patients with limited spine mobility: a randomized controlled trial. Korean J Pain 34:114

    Article  CAS  Google Scholar 

  35. Elsaman AM, Hamed A, Radwan AR (2021) Therapeutic potential of digital nerve block in rheumatoid arthritis patients: a clinical and sonographic prospective study. Clin J Pain

  36. Stewart GJ, Knight LC, Arbogast BW, Stern HS (1980) Inhibition of leukocyte locomotion by tocainide, a primary amine analog of lidocaine: at study with 111indium-labeled leukocytes and scanning electron microscopy. Lab Invest 42:302–309

    CAS  PubMed  Google Scholar 

  37. Cassuto J, Sinclair R, Bonderovic M (2006) Anti-inflammatory properties of local anesthetics and their present and potential clinical implications. Acta Anaesthesiol Scand 50:265–282

    Article  CAS  Google Scholar 

  38. Hogan QH, Stadnicka A, Bosnjak ZJ, Kampine JP (1998) Effects of lidocaine and bupivacaine on isolated rabbit mesenteric capacitance veins. Reg Anesth Pain Med 23:409–417

    CAS  PubMed  Google Scholar 

  39. Reyes-García MG, García-Tamayo F (2009) A neurotransmitter system that regulates macrophage pro-inflammatory functions. J Neuroimmunol 216:20–31

    Article  Google Scholar 

  40. Eriksson AS, Sinclair R, Cassuto J, Thomsen P (1992) Influence of lidocaine on leukocyte function in the surgical wound. Anesthesiology 77:74–78

    Article  CAS  Google Scholar 

  41. Bjorck S, Dahlstrom A, Ahlman H (1989) Topical treatment of ulcerative proctitis with lidocaine. Scand J Gastroenterol 24:1061–1072

    Article  CAS  Google Scholar 

  42. Terslev L, Torp-Pedersen S, Qvistgaard E, Danneskiold-Samsoe B, Bliddal H (2003) Estimation of inflammation by Doppler ultrasound: quantitative changes after intra-articular treatment in rheumatoid arthritis. Ann Rheum Dis 62:1049–1053

    Article  CAS  Google Scholar 

  43. Mortada MA, Abdelwhab SM, Elgawish MH (2018) Intra-articular methotrexate versus corticosteroid injections in medium-sized joints of rheumatoid arthritis patients—an intervention study. Clin Rheumatol 37:331–337

    Article  Google Scholar 

  44. Bliddal H, Terslev L, Qvistgaard E, Konig M, Holm C, Rogind H, Boesen M, Danneskiold-Samsøe B, Torp-Pedersen S (2006) A randomized, controlled study of a single intra-articular injection of etanercept or glucocorticosteroids in patients with rheumatoid arthritis. Scand J Rheumatol 35:341–345

    Article  CAS  Google Scholar 

  45. Singh JA, Mahowald ML (2009) Intra-articular botulinum toxin A as an adjunctive therapy for refractory joint pain in patients with rheumatoid arthritis receiving biologics: a report of two cases. Joint Bone Spine 76:190–194

    Article  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Rheumatology and Rehabilitation, Sohag University Hospital, Sohag, Egypt

    A. M. Elsaman

  2. Department of Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Suez Canal University, Ismailia, Egypt

    A. Maaty

  3. Department of Rheumatology and Rehabilitation, Minia University Hospital, Minia, Egypt

    A. Hamed

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  1. A. M. Elsaman
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  2. A. Maaty
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  3. A. Hamed
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Contributions

The 1st author designed the study and it was approved and revised by the 2nd and 3rd authors. The 1st and 2nd authors performed US examination and GNB, while the 3rd author did the clinical evaluation and guaranteed blinding of clinical data.

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Correspondence to A. M. Elsaman.

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Elsaman, A.M., Maaty, A. & Hamed, A. Genicular nerve block in rheumatoid arthritis: a randomized clinical trial. Clin Rheumatol 40, 4501–4509 (2021). https://doi.org/10.1007/s10067-021-05821-5

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  • DOI: https://doi.org/10.1007/s10067-021-05821-5

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