Reply to the letter by Prof. Rothschild. DOI: 10.1007/s10067-019-04560-y
Dear Editor in Chief, We would like to thank Professor Rothschild for his interest in our article and the opportunity to respond to his letter, where he describes Btwo fundamental methodologic flaws^ with regard to our GLUTEAL study, evaluating the role for glucocorticoid injections in the greater trochanteric pain syndrome (GTPS) [1]. His first point relates to betamethasone being water soluble. As described in our publication, the glucocorticoid preparation utilized was Diprophos®, which consists of a mixture of betamethasone disodium phosphate and betamethasone dipropionate. The betamethasone disodium phosphate is indeed water soluble, whereas the betamethasone dipropionate has poor water solubility as it forms local crystal deposits, which explains the prolonged clinical effect of this substance. The second point addresses the number of bursa in the region of the greater trochanter, and Professor Rothschild suggests that there are a total of four. Indeed, we could have been more specific, but generally when one describes the grater trochanteric bursa, it implies the deep subgluteus maximus bursa, which lies beneath the gluteus maximus muscle and iliotibial band, and superficial to the gluteus medius tendon. In the paper by Williams et al. cited in his letter, the authors in fact describe nine different bursae in the region of the greater trochanter that have been potentially implicated in the GTPS, although in most cases either the deep subgluteus maximus bursa or the subgluteus medius bursa is involved [2]. In our experience, the identification of the majority of these bursae with ultrasound is extremely difficult, unless there is a pathological collection of fluid within them. We are not aware of any publication suggesting that the injection of multiple bursae around the greater trochanter has a greater clinical efficacy compared with the injection of a single bursa. In a retrospective review including 65 ultrasound-guided glucocorticoid injections for the GTPS, there was a significantly greater efficacy of injections into the greater trochanteric (deep subgluteus maximus) bursa compared with the subgluteus medius bursa, and that injections into the subgluteus medius bursa were of no clinical benefit [3]. It should be highlighted that imaging evidence of a bursitis is only found in a minority of cases of the GTPS. For example, in the seminal paper by Bird et al., only 8% patients with GTPS demonstrated MRI evidence of bursitis [4]. Other publications have found imaging evidence of bursitis in 15 to 40% of cases of GTPS. Finally, Professor Rothschild states that Ball four bursae are inflamed, or at least sources of clinical symptoms, in almost all individuals^ with GTPS and in the World Journal of Orthopedics, he describes the immediate elimination of pain in 49/50 individuals from his own practice with trochanteric pain in whom four bursae were injected with triamcinolone, with pain relief persisting for greater than 6 months in 47 individuals [5]. It would indeed be very interesting to test this hypothesis in a randomized controlled trial. See related article, https://doi.org/10.1007/s10067-019-04560-y.
Trochanteric area pain, the result of a quartet of bursal inflammation.
Bursitis is quite responsive to therapeutic intervention, once the afflicted area is accurately identified. This is especially notable for some hip complaints. Patients' use of the term "hip" can relate to anything from the low back to groin to lateral thigh pain. Trochanteric area surface localization of "hip" pain may afford an opportunity for immediate cure. Effectiveness of therapeutic intervention is predicated upon injection of not one or two, but all four peri-trochanteric bursa with a depot (minimally water-soluble) corticosteroid. The term trochanteric bursitis suggests that the inflammation is more focal than what is clinically observed. While easier to express, perhaps it is time to refer to inflammation in this area, naming all four affected bursae.
Does a Brief Mindfulness Exercise Improve Outcomes in Upper Extremity Patients? A Randomized Controlled Trial
Background Mindfulness-based interventions are useful in reducing psychologic distress and pain intensity in patients with chronic pain. However, most mindfulness-based interventions are resource-intensive, lengthy, and not feasible for busy orthopaedic surgical practices. Questions/purposes The purpose of this study was to determine if a 60-second personalized mindfulness-based video exercise is (1) associated with improved pain intensity, emotional distress, and state anxiety compared with an attention placebo control (a time-matched educational pamphlet about pain and stress); and (2) feasible and acceptable for patients with upper extremity injury in an orthopaedic practice. Methods This was a single-center, single-blind randomized controlled trial of the mindfulness-based video exercise (60 seconds duration, free online) versus an attention placebo control (an educational pamphlet about pain and stress presented to patients to read over 60 seconds). One hundred forty-nine patients presenting for a new or followup appointment at the office of one of two orthopaedic hand and upper extremity outpatient surgical practices at an urban academic hospital were invited to participate between September 2016 and December 2016. Of 149 patients screened, 125 patients were randomized and completed a demographic questionnaire, the Numeric Rating Scale to assess pain intensity, the State Anxiety subscale of the State Trait Anxiety Inventory to assess state anxiety, and Emotion Thermometers to assess anxiety, anger, and depression before and after the interventions. Postintervention, patients also completed the Client Satisfaction Questionnaire Scale-3 to assess the acceptability. A mean score of 21 or higher is considered acceptable. Feasibility was determined based on number of patients approached who refused participation. The intervention was defined as feasible if refusal rate was lower than 25%. Analysis of covariance was used to test comparative improved pain intensity on the NRS, psychologic distress on the Emotion Thermometers, and state anxiety on the State Anxiety Subscale of the State Trait Anxiety Index after controlling for respective baseline scores. A 1-point minimal clinically important difference (MCID) was used on the NRS for pain intensity. Results Adjusted for the baseline means, compared with patients who received the attention placebo control, patients who participated in the mindfulness-based video exercise demonstrated improved pain intensity (mindfulness-based video exercise: 3.03 ± 0.12; control: 3.49 ± 0.12; mean difference: 0.46 [0.12-0.80]; p = 0.008); state anxiety (mindfulness-based video exercise: 32.35 ± 0.59; control: 35.29 ± 0.59; mean difference: 2.94 [1.29-4.59]; p = 0.001); anxiety symptoms (mindfulness-based video exercise: 1.49 ± 0.19; control: 2.10 ± 0.19; mean difference: 0.61 [0.08-1.14]; p = 0.024); depression (mindfulness-based video exercise: 1.03 ± 0.10; control: 1.47 ± 0.11; mean difference: 0.44 [0.15-0.73]; p = 0.004); and anger (mindfulness-based video exercise: 0.76 ± 0.12; control: 1.36 ± 0.12; mean difference: 0.60 [0.26-0.94]; p = 0.001). However, the observed differences in pain intensity were below 1 point on the NRS, which is the MCID established in patients with chronic pain. No MCID is available for the other measures. The mindfulness-based video exercise was feasible based on a dropout rate of 0%, and acceptability reached the medium range with similar scores in both groups (mindfulness-based video exercise: 20.70 ± 5.48; control: 20.52 ± 6.42). Conclusions A 60-second mindfulness-based video exercise is feasible to implement and acceptable to patients in busy orthopaedic practices. This video exercise is also effective in improving momentary pain, anxiety, depression, and anger in this population, but it is unclear whether these improved pain and distress levels are meaningful to patients who present with low levels of pain and psychologic distress. Future studies should seek to discern whether the improved pain and distress levels we observed are clinically important or whether the intervention delivers larger effects in subgroups of patients experiencing greater pain intensity and if the improved pain and distress levels are durable. Such studies might also assess cost-effectiveness, because this mindfulness-based tool takes little time and few resources to use, and the effects and durability of multiple sessions of a mindfulness-based video exercise. Level of Evidence Level II, therapeutic study.