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Therapeutic pulsed ultrasound with or without intra-articular methotrexate in the management of rheumatoid arthritis

Abstract

Objectives

The aim of the study was to evaluate the role of combined therapeutic pulsed ultrasound with intra-articular methotrexate as against pulsed ultrasound treatment program alone in the management of chronic synovitis in rheumatoid arthritis patients.

Patients and methods

A total of 38 patients were enrolled in the study. All patients were above 18 years of age with inadequate clinical response in the form of persistent monoarthritis. Of them, 24 completed the study. Patients were divided into two equal treatment groups: The first group (12 patients) received three consecutive intra-articular methotrexate injections and daily therapeutic pulsed ultrasound sessions, whereas the second group (12 patients) received daily therapeutic low-intensity pulsed ultrasound sessions. All patients were subjected to clinical, laboratory, and ultrasound evaluation before and after treatment.

Results

Patients were subjected to an ultrasound evaluation before and after treatment to detect synovial thickness, hot spots, erosions and effusion, with highly statistically significant difference observed in the number of swollen joints, tender joint count, visual analogue scale scores and synovial thickness at the wrist (P<0.01) in the group of patients who received ultrasound and methotrexate. In addition, there was a statistically significant difference with respect to hot spots, number of erosions and joint space narrowing (P<0.05).

Conclusion

The combination of pulsed ultrasound therapy with repeated intra-articular methotrexate can give us better results in the form of decreased effusion, tenderness, inflammation and synovial membrane thickness, all of which translate into significant recovery of function and reduction in pain in rheumatoid patients with resistant monoarthritis or oligoarthritis, with the least number of side effects and without the need of adding another disease-modifying agent and/or resorting to surgical synovectomy.

References

  1. Smolen JS, Aletaha D. What should be our treatment goal in rheumatoid arthritis today? Clin Exp Rheumatol 2006; 24 (Suppl 43): S7–S13.

  2. Jorge LL, Gerard C, Revel M. Evidences of memory dysfunction and maladaptive coping in chronic low back pain and rheumatoid arthritis patients: challenges for rehabilitation. Eur J Phys Rehabil Med 2009; 45:469–477.

    PubMed  Google Scholar 

  3. Creamer P, Keen M, Zananiri F, Waterton JC, Maciewicz RA, Oliver C, et al. Quantitative magnetic resonance imaging of the knee: a method of measuring response to intra-articular treatments. Ann Rheum Dis 1997; 56:378–381.

    CAS  Article  Google Scholar 

  4. Dixon ASJ, Cosh JA, Kersley GD. Local corticosteroid therapy for painful rheumatic states. A comparison of triamcinolone hexacetonide (Lederspan) and prednisolone acetate (Precortisyl). Clin Trials J 1972; 9:14–18.

    Google Scholar 

  5. Bain LS, Balch HW, Wetherly JM, Yeadon A. Intraarticular triamcinolone hexacetonide: double-blind comparison with methylprednisolone. Br J Clin Pract 1972; 26:559–561.

    CAS  PubMed  Google Scholar 

  6. Oka M, Menkes C, Ruotsi A. Nonsurgical synovectomy. Scand J Rheumatol Suppl 1975; 12:132–133.

    CAS  PubMed  Google Scholar 

  7. Hall GH, Head AC. Intra articular methotrexate. Lancet 1975; 2:409.

    CAS  Article  Google Scholar 

  8. Tiliakos NA, Lawrence T, Wilson C. Intra-articular methotrexate in RA. Arthritis Rheum 1982; 25:554.

    Article  Google Scholar 

  9. Durk H, Kotter I, Saal JG. Intra-articular methotrexate in corticosteroid resistant monoarthritis. Arthritis Rheum 1994; 37 (Suppl): 554.

  10. Nakaya H, Shimizu T, Isobe Kl, Tensho K, Okabe T, Nakamura Y, et al. Microbubble-enhanced ultrasound exposure promotes uptake of methotrexate into synovial cells and enhanced antiinflammatory effects in the knees of rabbits with antigen-induced arthritis. Arthritis Rheum 2005; 52:2559–2566.

    CAS  Article  Google Scholar 

  11. Tachibana K, Uchida T, Ogawa K, Yamashita N, Tamura K. Induction of cell-membrane porosity by ultrasound. Lancet 1999; 353:1409.

    CAS  Article  Google Scholar 

  12. Kim HJ, Greenleaf JF, Kinnick RR, Bronk JT, Bolander ME. Ultrasound-mediated transfection of mammalian cells. Hum Gene Ther 1996; 7:1339–1346.

    CAS  Article  Google Scholar 

  13. Katano M, Naruse K, Uchida K, Mikuni Takagaki Y, Takaso M, Itoman M, et al. Low intensity pulsed ultrasound accelerates delayed healing process by reducing the time required for the completion of endochondral ossification in the aged mouse femur fracture model. Exp Anim 2011; 60:385–395.

    CAS  Article  Google Scholar 

  14. Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988; 31:315–324.

    CAS  Article  Google Scholar 

  15. Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst Rev 2005; 2:CD005328.

    Google Scholar 

  16. Prevoo ML, Van’T Hof MA, Kuper HH, Van Leeuwen MA, Van De Putte LB, Van Riel PL. Modified disease activity scores that include twenty-eight-joint counts: development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum 1995; 38:44–48.

    CAS  Article  Google Scholar 

  17. Mahoney CM, Morgan MR. Therapeutic approaches to the treatment of tissue: therapeutic ultrasound bypasses canonical syndecan-4 signaling to activate Rac1. J Biol Chem 2009; 284:8898–8909.

    CAS  Article  Google Scholar 

  18. Hetland ML, Stengaard Pedersen K, Junker P, Lottenburger T, Ellingsen T, Andersen LS, et al. 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 2006; 54:1401–1409.

    CAS  Article  Google Scholar 

  19. Blyth T, Stirling A, Coote J, Land D, Hunter JA. Injection of the rheumatoid knee: does intra-articular methotrexate or rifampicin add to the benefits of triamcinolone hexacetonide? Br J Rheumatol 1998; 37:770–772.

    CAS  Article  Google Scholar 

  20. Hasso N, Maddison PJ, Breslin A. Intra-articular methotrexate in knee synovitis. Rheumatology 2004; 43:779–782.

    CAS  Article  Google Scholar 

  21. Williams AS, Camilleri JP, Goodfellow RM, Williams BD. A single intraarticular injection of liposomally conjugated methotrexate suppresses joint inflammation in rat antigen-induced arthritis. Br J Rheumatol 1996; 35:719–724.

    CAS  Article  Google Scholar 

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Correspondence to Alaa A. Labeeb PhD.

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Labeeb, A.A., Casale, R., Soliman, S.G. et al. Therapeutic pulsed ultrasound with or without intra-articular methotrexate in the management of rheumatoid arthritis. Egypt Rheumatol Rehabil 40, 198–202 (2013). https://doi.org/10.4103/1110-161X.123807

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  • DOI: https://doi.org/10.4103/1110-161X.123807

Keywords

  • intra-articular
  • methotrexate
  • pulsed ultrasound