Revised Interpretation of Results

Inter-group comparison between Group 1-Steroid and Group 2- Mustard
Independent T test:
WOMAC SCORING BETWEEN GROUPS

1) Baseline
Group Statistics
Group N Mean Std. Deviation Std. Error

Mean
Steroid 30 83.63 7.000 1.278
womac (%) at base
Mustar
line 30 85.57 5.315 .970
d
Independent Samples Test
Levene's Test for t-test for Equality of Means

Equality of
Variances
F Sig. t df Sig. Mean Std. Error 95%
(2- Differe Difference Confidence
tailed) nce Interval of the
Difference
Lower Uppe
r
Equal -
variances 5.038 .029 1.2 58 .233 -1.933 1.605 -5.146 1.279
womac
assumed 05
(%) at
Equal - 54.
base line
variances not 1.2 09 .234 -1.933 1.605 -5.150 1.284
assumed 05 9
An independent-samples t-test was conducted to compare WOMAC (WESTERN
ONTARIO AND MCMASTER UNIVERSITIES) INDEX in intraarticular steroids and
Mustard fomentation groups at presentations. There was a not a significant difference in the
scores for WOMAC (WESTERN ONTARIO AND MCMASTER UNIVERSITIES) INDEX
at baseline in Intraarticular steroids treatment (M= 83.63, SD=7.000 and Mustard
fomentation (M=85.57, SD=5.315) conditions; t(54.099)= -1.205, p =.233. These results
1
suggest that intraarticular steroids treatment and Mustard fomentation did not differ in
WOMAC (WESTERN ONTARIO AND MCMASTER UNIVERSITIES) INDEX at
presentation.
2) At 15 days follow up
Group Statistics

Mean
Steroid 30 71.83 8.890 1.623
womac (%) at 15
Mustar
days 30 73.07 6.943 1.268
d
Levene's Test t-test for Equality of Means

for Equality of
Variances
(2- Differ Differenc Confidence
tailed ence e Interval of
) the
Difference
Lowe Uppe
r r
Equal -
- 2.88
variances 2.138 .149 .59 58 .552 -1.233 2.059
5.356 9
womac assumed 9
(%) at 15 Equal
- 54.
days variances - 2.89
.59 78 .552 -1.233 2.059
not 5.361 4
9 2
assumed
An independent-samples t-test was conducted to compare WOMAC (WESTERN
ONTARIO AND MCMASTER UNIVERSITIES) INDEX in intraarticular steroids and
Mustard fomentation Groups at 15 days follow up of treatment. There was not a significant
difference in the scores for WOMAC (WESTERN ONTARIO AND MCMASTER
UNIVERSITIES) INDEX in Intraarticular steroids treatment (M= 71.83, SD=8.890 and
2
Mustard fomentation (M=73.07, SD=6.9) conditions; t(58)= .5, p =..552. These results
suggest that intraarticular steroids treatment and Mustard fomentation do not differ in their
effect on WOMAC (WESTERN ONTARIO AND MCMASTER UNIVERSITIES) INDEX
at 15 days of follow up
Group Statistics

Mean
Steroid 30 75.57 7.771 1.419
womac (%) at
Mustar
45days 30 72.97 6.825 1.246
d

for Equality of
Variances
tailed) nce Interval of
the
Difference
Lower Uppe
r
Equal
1.3
variances 2.151 .148 58 .174 2.600 1.888 -1.180 6.380
womac 77
assumed
(%) at
Equal 57.
45days 1.3
variances 05 .174 2.600 1.888 -1.181 6.381
77
not assumed 0
An independent-samples t-test was conducted to compare WOMAC (WESTERN ONTARIO
AND MCMASTER UNIVERSITIES) INDEX in intraarticular steroids and Mustard
fomentation conditions at 45 days follow up of treatment. There was a not a significant
3
UNIVERSITIES) INDEX in Intraarticular steroids treatment (M= 75.57, SD=7.771 and
Mustard fomentation (M=72.97, SD=6.8) conditions; t(58)= 1.3, p =.174. These results
suggest that intraarticular steroids treatment and Mustard fomentation do not differ in their
effect on WOMAC (WESTERN ONTARIO AND MCMASTER UNIVERSITIES) INDEX
at 45 days of follow up.
4) At 3 months follow up
Group Statistics

Mean
Steroid 30 77.60 7.495 1.368
womac (%) at
Mustar
3months 30 72.70 6.644 1.213
d

Equality of
Variances
Difference
Lower Uppe
r
Equal
2.6
variances 1.961 .167 58 .010 4.900 1.829 1.239 8.561
womac 79
assumed
(%) at
Equal 57.
3months 2.6
variances not 17 .010 4.900 1.829 1.238 8.562
79
assumed 8
Independent-samples t-test was conducted to compare WOMAC (WESTERN ONTARIO
4
fomentation Groups at 3 months of follow up of treatment. There was a significant difference
in the scores for WOMAC (WESTERN ONTARIO AND MCMASTER UNIVERSITIES)
INDEX at 3 months of follow up in Intraarticular steroids treatment (M=77.60, SD=7.495
and Mustard fomentation (M=72.70, SD=6.64) conditions; t(58)= 2.67, p =.01. These results
suggest that intraarticular steroids treatment and Mustard fomentation differ in their effect
on WOMAC (WESTERN ONTARIO AND MCMASTER UNIVERSITIES) INDEX at 3
months of follow up. Mustard Fomentation found to be significantly reducing WOMAC
Index than Intraarticular steroids treatment.
Group Statistics

Mean
Steroid 30 81.73 7.497 1.369
womac (%) at
Mustar
6months 30 71.33 7.545 1.377
d

Equality of
Variances
Difference
Lower Uppe
r
Equal
5.3 14.28
variances .077 .782 58 .000 10.400 1.942 6.513
womac 56 7
assumed
(%) at
Equal 57.
6months 5.3 14.28
variances not 99 .000 10.400 1.942 6.513
56 7
assumed 8
5
Independent-samples t-test was conducted to compare WOMAC (WESTERN ONTARIO
fomentation Groups at 6 months of follow up of treatment. There was a significant
UNIVERSITIES) INDEX at 6 months of follow up in Intraarticular corticosteroids treatment
(M=81.73, SD=7.497 and Mustard fomentation (M= 71.33 , SD= 7.54 ) conditions; t(58)=
5.356, p =.000. These results suggest that intraarticular corticosteroids treatment and Mustard
fomentation differ in their effect on WOMAC (WESTERN ONTARIO AND MCMASTER
UNIVERSITIES) INDEX at 6 months of follow up. Mustard Fomentation significantly
reduced WOMAC Index than Intraarticular steroids treatment.
VAS SCORING BETWEEN GROUPS
1) Baseline
Group Statistics
group N Mean Std. Deviation Std. Error

Mean
Steroid 30 6.97 1.033 .189
vas(mm) at base
Mustar
line 30 7.20 .887 .162
d

for Equality of
Variances
(2- Differe Differenc Confidence
tailed) nce e Interval of
the
Difference
Lowe Uppe
r r
6
Equal -
variances .117 .734 .93 58 .352 -.233 .249 -.731 .264
vas(mm)
assumed 9
at base
Equal - 56.
line
variances .93 69 .352 -.233 .249 -.731 .265
not assumed 9 2
An independent-samples t-test was conducted to compare VAS score in intraarticular steroids
and Mustard fomentation groups at baseline presentations. There was not a significant
difference in VAS score at baseline in Intraarticular steroids Group (M= 6.97, SD=1.03 and
Mustard fomentation group (M=7.2, SD=.887) conditions; t (58) = -.939, p =.352. These
results suggest that intraarticular steroids and Mustard fomentation groups did not differ in
VAS score at presentation
Group Statistics

Mean
Steroid 30 5.83 1.262 .230
vas(mm) at 15 days Mustar
30 6.27 1.285 .235
d

Equality of
Variances
Difference
Lower Uppe
r
Equal -
vas(mm)
variances .115 .736 1.3 58 .193 -.433 .329 -1.091 .225
at 15 days
assumed 18
7
Equal - 57.
variances not 1.3 98 .193 -.433 .329 -1.091 .225
assumed 18 1
An independent-samples t-test was conducted to compare VAS score in intraarticular
steroids and Mustard fomentation Groups at 15 days follow up of treatment. There was not a
significant difference in VAS score in Intraarticular steroids (M=5.83, SD=1.262 and
Mustard fomentation Groups (M=6.27, SD=1.285) conditions; t (58) = 1.3, p =.193. These
results suggest that intraarticular steroids and Mustard fomentation groups do not differ in
their effect on VAS score at 15 days of follow up
Group Statistics

Mean
Steroid 30 5.43 .898 .164
vas(mm) at 45days Mustar
30 5.33 1.028 .188
d

for Equality of
Variances
(2- Differe Differenc Confidence
tailed) nce e Interval of
the
Difference
Lower Uppe
r
Equal
vas(mm) .40
variances 1.061 .307 58 .690 .100 .249 -.399 .599
at 45days 1
assumed
8
Equal 56.
.40
variances 96 .690 .100 .249 -.399 .599
1
not assumed 0
An independent-samples t-test was conducted to compare VAS score in intraarticular steroids
and Mustard fomentation conditions at 45 days follow up of treatment. There was no
significant difference in the scores for VAS score in Intraarticular steroids (M=5.43, SD=.89
and Mustard fomentation (M=5.33, SD=1.02) conditions; t (58) = 0.4, p =.690. These results
suggest that intraarticular steroids treatment and Mustard fomentation application do not
differ in their effect on VAS score at 45 days of follow up.
Group Statistics

Mean
Steroid 30 5.37 1.273 .232
vas(mm) at 3months Mustar
30 4.73 1.230 .225
d

Equality of
Variances
Difference
Lower Upper
Equal
1.9
variances .012 .914 58 .055 .633 .323 -.013 1.280
60
vas(mm) at assumed
3months Equal
1.9 57.
variances not .055 .633 .323 -.013 1.280
60 933
assumed
9
Independent-samples t-test was conducted to compare VAS score in
intraarticular steroids and Mustard fomentation Groups at 3 months of follow up of
treatment. There was a significant difference in the scores for VAS score at 3
months of follow up in Intraarticular steroids treatment (M=5.37, SD=1.27 and
Mustard fomentation (M=4.73, SD=1.23) conditions; t (58)= 1.96, p =.05. These
results suggest that intraarticular steroids treatment and Mustard fomentation differ
in their effect on VAS score at 3 months of follow up. Mustard Fomentation found
to be significantly reducing VAS score than intraarticular steroids treatment
Group Statistics

Mean
Steroid 30 5.77 1.455 .266
vas(mm) at 6months Mustar
30 4.17 1.020 .186
d

Equality of
Variances
Difference
Lower Uppe
r
Equal
4.9
variances 6.668 .012 58 .000 1.600 .324 .951 2.249
vas(mm) 33
assumed
at
Equal 51.
6months 4.9
variances not 96 .000 1.600 .324 .949 2.251
33
assumed 3
10
Independent-samples t-test was conducted to compare VAS score in intraarticular steroids
and Mustard fomentation Groups at 6 months of follow up of treatment. There was a
significant difference in VAS score at 6 months of follow up in Intraarticular corticosteroids
treatment (M=5.77, SD1.455=and Mustard fomentation (M=4.17, SD=1.020) conditions;
t(58)= 4.933, p =.000. These results suggest that intraarticular steroids treatment and Mustard
fomentation differ in their effect on VAS score at 6 months of follow up. Mustard
Fomentation significantly reduced VAS score than that in intraarticular steroids treatment.
PAIRED T TEST INTRA GROUP COMPARISON

1) Group 1 (Intraarticular steroid Group)
WOMAC
1) At 15 Days
Paired Samples Statistics
Mean N Std Deviation Std. Error Mean
WOMAC
83.6333 30 6.99992 1.27800
BASE LINE
WOMAC 15
71.8333 30 8.89046 1.62317
DAYS
Paired Samples Test

Paired Differences t df Sig. (2-
Mean Std. Std. Error 95% Confidence tailed)
Deviation Mean Interval of the
Difference
Lower Upper
WOMAC BASE
Pair 11.800
LINE - WOMAC 8.60393 1.57086 8.58724 15.01276 7.512 29 .000
1 00
15 DAYS
11
A paired-samples t-test was conducted to compare WOMAC Scores at baseline and 15
days of follow up of intraarticular steroids. There was a significant difference in the scores
for WOMAC at baseline (M=83.63, SD=6.99) and WOMAC at 15 days follow up (M=71.83,
SD=8.89) conditions; t (29) =-7.52, p = 0.001. These results suggest that WOMAC reduced
significantly after 15 days of treatment with intra articular steroids.
2) At 45 days
Paired Samples Statistic
WOMAC BASE
83.6333 30 6.99992 1.27800
LINE
WOMAC 45
75.5667 30 7.77123 1.41883
DAYS
Paired Samples Test

Difference
Lower Upper
WOMAC BASE
Pair 8.0666
LINE - WOMAC 7.40891 1.35268 5.30013 10.83320 5.963 29 .000
2 7
45 DAYS
days of follow up of treatment with intraarticular steroids. There was a significant difference
in the scores for WOMAC at baseline (M=83.63, SD=6.99) and WOMAC at 45 days follow
up (M=75.56, SD=7.77) conditions; t (29) =-5.96, p = 0.001. These results suggest that
WOMAC reduced after 45 days of treatment but it is more compared to 15 days follow up
suggesting that effect of intra articular steroids is waning off.
3) At 3 months
12
WOMAC BASE
83.6333 30 6.99992 1.27800
LINE
WOMAC 3
77.6000 30 7.49529 1.36845
MONTHS
Paired Samples Test

Difference
Lower Upper
WOMAC BASE
Pair 6.0333
LINE - WOMAC 6.60973 1.20677 3.56522 8.50145 5.000 29 .000
3 3
3 MONTHS
Paired-samples t-test was conducted to compare WOMAC Scores at baseline and 3
months of follow up of treatment with intraarticular steroids. There was a significant
difference in the scores for WOMAC at baseline (M=83.63, SD=6.99) and WOMAC at 3
months follow up (M=77.60, SD=7.49) conditions; t (29) =-5.00, p = 0.001. These results
suggest that WOMAC reduced after 3 months of treatment but it is more compared to 15 days
and 45 days follow up suggesting that effect of intra articular steroids is further waning off.
4) At 6 months
WOMAC BASE
83.6333 30 6.99992 1.27800
LINE
WOMAC 6
81.7333 30 7.49682 1.36873
MONTHS
13
Paired Samples Test
Difference
Lower Upper
WOMAC BASE
Pair LINE - 1.900
4.25360 .77660 .31168 3.48832 2.447 29 .021
4 WOMAC 6 00
MONTHS
months of follow up of treatment with intraarticular steroids. There was a significant
difference in the scores for WOMAC at baseline (M=83.63, SD=6.99) and WOMAC at 6
months of follow up (M=81.73, SD=7.49) conditions; t (29) =-2.44, p = 0.021. These results
suggest that WOMAC reduced after 6 months of treatment but it is more compared to 15
days, 45 days and 3 months of follow up period suggesting that effect of intra articular
steroids is weaning off to the extent of being equal to baseline scores..
2) VAS
1) At 15 days

Mean N Std. Deviation Std. Error Mean
VAS BASE
6.9667 30 1.03335 .18866
LINE
VAS 15 DAYS 5.8333 30 1.26173 .23036
Paired Samples Test

Difference
Lower Upper
VAS BASE LINE - VAS 1.1333
.81931 .14958 .82740 1.43927 7.577 29 .000
15 DAYS 3
14
A paired-samples t-test was conducted to compare VAS Scores at baseline and 15 days of
follow up of intraarticular steroids. There was a significant difference in the scores for VAS
at baseline (M=6.96, SD=1.03) and VAS at 15 days follow up (M=5.83, SD=1.26)
conditions; t (29) =-7.57, p = 0.001. These results suggest that VAS reduced significantly
after 15 days of treatment with intra articular steroids.
2) At 45 days

VAS BASE
6.9667 30 1.03335 .18866
LINE
VAS 45 DAYS 5.4333 30 .89763 .16388
Paired Samples Test

Difference
Lower Upper
VAS BASE LINE - VAS 1.5333
.81931 .14958 1.22740 1.83927 10.251 29 .000
45 DAYS 3
at baseline (M=6.96, SD=1.03) and VAS at 15 days follow up (M=5.43, SD=.897)
after 15 days of treatment with intra articular steroids and further reduced compared to 15
days follow up.
15
3) At 3 Months

VAS BASE
6.9667 30 1.03335 .18866
LINE
VAS 3
5.3667 30 1.27261 .23235
MONTHS
Paired Samples Test

Difference
Lower Upper
VAS BASE LINE - 1.600
1.24845 .22793 1.13382 2.06618 7.020 29 .000
VAS 3 MONTHS 00
A paired-samples t-test was conducted to compare VAS Scores at baseline and 3 months
of follow up of intraarticular steroids. There was a significant difference in the scores for
VAS at baseline (M=6.96, SD=1.03) and VAS at 3 months follow up (M=5.36, SD=1.27)
conditions; t (29) =-7.02, p = 0.001. These results suggest that not only VAS reduced
significantly after 3 months of treatment with intra articular steroids but also reduced further
compared to 45 days follow up.
4) At 6 Months

VAS BASE
6.9667 30 1.03335 .18866
LINE
VAS 6
5.7667 30 1.45468 .26559
MONTHS
Paired Samples Test
16
Mean Std. Std. Error 95% Confidence Interval tailed)
Deviation Mean of the Difference
Lower Upper
VAS BASE LINE - VAS 6 1.2000
1.42393 .25997 .66829 1.73171 4.616 29 .000
MONTHS 0
Paired-samples t-test was conducted to compare VAS Scores at baseline and 6 months of
at baseline (M=6.96, SD=1.03) and VAS at 6 months follow up (M=5.76, SD=1.45)
conditions; t (29) =-4.61, p = 0.001. These results suggest that VAS with intra articular
steroids treatment reduced marginally after 6 months of treatment compared to baseline but
also increased further compared to 45 days follow up suggesting waning of effect of steroids
on patients symptoms.
Group 2 Mustard Fomentation
WOMAC
1) At 15 days

WOMAC
85.5667 30 5.31545 .97046
BASE LINE
Pair 1
WOMAC 15
73.0667 30 6.94279 1.26757
DAYS
Paired Samples Test

Lower Upper
WOMAC BASE LINE - 12.5000
3.95448 .72199 11.02337 13.97663 17.313 29 .000
WOMAC 15 DAYS 0
17
days of follow up of mustard fomentation. There was a significant difference in the scores for
WOMAC at baseline (M=85.56, SD=5.31) and WOMAC at 15 days follow up (M=73.06,
significantly after 15 days of treatment with mustard fomentation.
2) At 45 days

WOMAC
85.5667 30 5.31545 .97046
BASE LINE
WOMAC 45
72.9667 30 6.82532 1.24613
DAYS

Difference
Lower Upper
WOMAC BASE LINE - 12.600
3.91813 .71535 11.13695 14.06305 17.614 29 .000
WOMAC 45 DAYS 00
WOMAC at baseline (M=85.56, SD=5.31) and WOMAC at 45 days follow up (M=72.96,
significantly after 15 days of treatment with mustard fomentation.
3) At 3 Months

WOMAC
85.5667 30 5.31545 .97046
BASE LINE
Pair 3
WOMAC 3
72.7000 30 6.64442 1.21310
MONTHS
18
Difference
Lower Upper
WOMAC BASE LINE - 12.866 23.03
3.05956 .55860 11.72421 14.00913 29 .000
WOMAC 3 MONTHS 67 4
months of follow up of mustard fomentation. There was a significant difference in the scores
for WOMAC at baseline (M=85.56, SD=5.31) and WOMAC at 3 months follow up (M=72.7,
significantly after 3 months of treatment with mustard fomentation compared to baseline and
at 45 days of follow up indicating sustained progressive relief of symptoms.
4) At 6 Months

WOMAC
85.5667 30 5.31545 .97046
BASE LINE
Pair 4
WOMAC 6
71.3333 30 7.54450 1.37743
MONTHS

Difference
Lower Upper
Pair 4
14.233 18.78
WOMAC BASE LINE - 4.14964 .75762 12.68383 15.78284 29 .000
33 7
WOMAC 6 MONTHS
19
for WOMAC at baseline (M=85.56, SD=5.31) and WOMAC at 6 months follow up (M=72.3,
significantly after 6 months of treatment with mustard fomentation compared to baseline, 45
days and 3 months of follow up indicating sustained progressive relief of symptoms.
VAS
1) At 15 days

VAS BASE
7.2000 30 .88668 .16189
LINE
VAS 15 DAYS 6.2667 30 1.28475 .23456
Paired Samples Test

Difference
Lower Upper
Pair VAS BASE LINE

.93333 .82768 .15111 .62427 1.24239 6.176 29 .000
1 - VAS 15 DAYS
follow up of mustard fomentation. There was a significant difference in the scores for VAS at
baseline (M=7.2, SD=0.88) and VAS at 15 days follow up (M=6.26, SD=1.28) conditions; t
(29) =-6.1, p = 0.001. These results suggest that VAS reduced significantly after 15 days of
treatment with mustard fomentation
2) At 45 days

VAS BASE
7.2000 30 .88668 .16189
LINE
VAS 45 DAYS 5.3333 30 1.02833 .18775
20
Paired Samples Test

Lower Upper
Pair VAS BASE LINE - 1.8666
.77608 .14169 1.57687 2.15646 13.174 29 .000
2 VAS 45 DAYS 7
A paired-samples t-test was conducted to compare VAS Scores at baseline and 45
VAS at baseline (M=7.2, SD=0.88) and VAS at 45 days follow up (M=5.33, SD=1.02)
after 45 days of treatment with mustard fomentation
3) At 3 Months

VAS BASE
7.2000 30 .88668 .16189
LINE
VAS 3
4.7333 30 1.22990 .22455
MONTHS
Paired Samples Test

Difference
Lower Upper
VAS BASE
Pair 2.466 13.88
LINE - VAS 3 .97320 .17768 2.10327 2.83007 29 .000
3 67 2
MONTHS
A paired-samples t-test was conducted to compare VAS Scores at baseline and 3
for VAS at baseline (M=7.2, SD=0.88) and VAS at 3 months follow up (M=4.73, SD=1.22)
21
after 3 months of treatment with mustard fomentation compared not only to baseline but also
when compared to 45 days indicating sustained progressive benefit in patients symptoms.
4) At 6 Months

VAS BASE
7.2000 30 .88668 .16189
LINE
VAS 6
4.1667 30 1.01992 .18621
MONTHS
Paired Samples Test

Lower Upper
Pair VAS BASE LINE - 3.0333

1.06620 .19466 2.63521 3.43146 15.583 29 .000
4 VAS 6 MONTHS 3
Paired-samples t-test was conducted to compare VAS Scores at baseline and 6 months
of follow up of mustard fomentation. There was a significant difference in the scores for VAS
at baseline (M=7.2, SD=0.88) and VAS at 6 months follow up (M=4.73, SD=1.22)
after 6 months of treatment with mustard fomentation compared not only to baseline and 45
days follow up but also when compared to 3 months follow up indicating progressive long
lasting benefit in patients symptoms
Complications:
In Group 1 (Intra articular steroid group) 4 patients (13.3%) cases had few complications.
Case no 5 and 23 had infection following steroid injection which required further active
22
interventions like antibiotics and dressings. Eventually infection settled within 6 weeks but
patients were left with more pain due to septic destruction of cartilage. Case no 18 had
vasovagal syncope following injection had to be managed by fluids and limb elevation. Case
25 had subcutaneous lipoatrophy by the end of 6 months follow up which was asymptomatic
but cosmetically disagreeable forming another source of patients discomfort. There were no
complications reported in Group 2(Mustard group).
DISCUSSION:
This is a prospective study of 60 patients randomly allocated to two groups.
Osteoarthritis is not just mechanical problem but it is mediated through various inflammatory
mediators too. Both steroids and mustard target this part of pathology and provide relief to
majority of patients. We chose to include Kellegren Lawrence stages 1, 2 and 3 as most
epidemiological studies have defined osteoarthritis in this scale (Osteoarthritis. Paul Creamer
Marc Hochberg;The Lancet Vol 350, Aug 1997:503-508) and as the next stage is not
amenable for conservative treatment. In the present study steroids show progressive
improvement in patients clinical condition in the initial period but after 3 months the effects
starts falling and by 6 months the WOMAC score falls almost equal the baseline score ,
emphasizing that the good effect of steroids lasts not very long and this correlates well with
the study conducted by Neil Bodick et al.,( An Intra-Articular, Extended-Release
Formulation of Triamcinolone Acetonide Prolongs and Amplifies Analgesic Effect in patients
with Osteoarthritis of the Knee
A Randomized Clinical Trial Neil Bodick, MD, PhD, Joelle Lufkin, Christina Willwerth, Anjali Kumar,
PhD, James Bolognese, PhD,
Chris Schoonmaker, PhD, Rahul Ballal, PhD, David Hunter, MD, and Michael Clay, J Bone Joint Surg Am.
2015;97:877-88)( C. T. Hepper, J. J. Halvorson, S. T. Duncan, A. J. M. Gregory,W. R. Dunn, and K. P. Spindler, The
efficacy and duration ofintra-articular corticosteroid injection for knee osteoarthritis:
a systematic review of level I studies, Journal of the American Academy of Orthopaedic Surgeons, vol. 17, no. 10, pp. 638
23
646,
2009.)( P. A. Dieppe, B. Sathapatayavongs, H. E. Jones, P. A. Bacon,and E. F. Ring, Intra-articular steroids in
osteoarthritis,Rheumatology and Rehabilitation, vol. 19, no. 4, pp. 212217,
1980.) The likely site of action of intra-articular corticosteroids in the osteoarthritic joint is the
inflamed synovium. Synovitis has been demonstrated with both histology and imaging
technologies and is recognized as an important element in the pathophysiology of the
disease. The symptom free interval provided by steroids can be regarded as due to
suppression of this ongoing synovitis and hence may not last long.( Scanzello CR, Goldring SR. The
role of synovitis in osteoarthritis pathogenesis. Bone. 2012 Aug;51(2):249-57.)( Benito MJ, Veale DJ, FitzGerald O,
van den Berg WB,
Bresnihan B. Synovial tissue inflammation in early and late osteoarthritis. Ann Rheum Dis 2005; 64: 1263-126
)( Krasnokutsky S, Belitskaya-Lvy I, Bencardino J, Samuels J,

Attur M, Regatte R, Rosenthal P, Greenberg J, Schweitzer M, Abramson SB, Rybak L. Quantitative magnetic resonance
imaging evidence of synovial proliferation is associated
with radiographic severity of knee osteoarthritis. Arthritis Rheum 2011; 63: 2983-2991 )
Steroids are associated with complications like superficial infection and subcutaneous
atrophy in four patients in this study. The clinical outcome in this group was compounded by
additional disease burden due to complications and treatment measures on these patients.
Even though sterile precautions were taken while steroid injection, patients local skin
condition, systemic immunosuppression due to diabetes and other diseases may have
contributed to microbial invasion. Naresh Kumar Raymond J Newman attributed the
subcutaneous lipoatrophy to failure of drug delivery deep into the joint or seepage of drug
into subcutaneous planes The instances of dizziness, syncope, haemorrhage, and local
discomfort are probably not dissimilar from other injections performed in the surgery;
24
.( Complications of intra- and peri-articular steroid injections Naresh Kumar
Raymond J Newman, British Journal of General Practice, June 1999:465-466).
Mustard fomentation (Mustard Benefits & Information.
Herbwisdom;2016:http://www.herbwisdom.com/herb-mustard.html) has consistently
progressive improvement in patients clinical condition from baseline to 6 months follow up.
The WOMAC and VAS scores in the present study are statistically significant both within the
group and when compared to steroid group. Though literature on mustard fomentation is
scanty to compare this study, we observe the nociceptive and counter irritant properties of
mustard in any form are effective enough to relieve the main symptom of osteoarthritis i.e.,
pain.( Acupuncture -A Problem for the Anesthetist ? .Sampson Lipton FFA RCS Proc. roy.
Soc. Med. Volume 67 August 1974:731-732)
Consistent increase in the patients functional profile with mustard fomentation can
also be attributed to ability of patient and feasibility of frequent application of mustard
fomentation on a regular basis. The absence of any complications in this group is further
encouraging in this direction.
Limitations of Study:
1) Small sample size to the magnitude of prevalence of disease
2) Both WOMAC and VAS are subjective and depend on patients understanding and
reliability about symptoms.
25
Conclusion:
Intra articular steroids and mustard fomentation are effective means of treating cases
of osteoarthritis but considering the cost effectiveness, complications, ease of administration,
patient compliance and moreover longer lasting pain relief, we conclude that Mustard
fomentation should be preferred as a primary mode of treating osteoarthritis of knee and
steroids be kept only as an adjunctive measure.
Summary:
This was a prospective study of evaluating effectiveness of intra articular steroids and
mustard fomentation on osteoarthritis of knee and comparing them with each other. 60
patients were enrolled and randomly allocated to two groups. Each group received the
respective treatment modalities as per standards laid down. Steroid group had initial good
relief and failed to sustain the same for 6 months and associated with few complications but
mustard group achieved the good relief of symptoms which lasted even after 6 months.
Considering the long lasting good relief and no complications study concluded mustard
fomentation to be superior to steroids even though both of them cannot alter the disease
course as it is a progressive degenerative inflammatory disease.
26
Abstract:
Objectives: To study effects of intra articular steroids and mustard fomentation on
osteoarthritis of knee and compare their effectiveness.
Materials and Methods: One knee of 60 patients, both males and females was
included in the study. 30 Patients were randomly included in each of two groups. i.e., steroid
group and mustard group. Patients were followed up at 15 days, 45 days , 3 months and 6
months. They were assessed at each follow up with WOMAC and VAS scoring and SPSS
version 20 for windows software was used for analysing the results.
Results: Group I showed progressive decrease in the WOMAC and VAS scores at 15
days, 45 days. But WOMAC started increasing to baseline levels at 3 months and 6 months
follow up. Few compliations reported. Group II showed consistent decrease in these scores in
all the follow up periods and there was long lasting relief. No complications reported.
Conclusion: In terms of significant sustained and long lasting relief in group II and
lack of complications we conclude that Mustard fomentation is the preferred method of
choice over steroids for Osteoarthritis of knee.
27

Revised Interpretation of Results

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Inter-group comparison between Group 1-Steroid and Group 2- Mustard

WOMAC SCORING BETWEEN GROUPS

Group N Mean Std. Deviation Std. Error

Independent Samples Test

Levene's Test for t-test for Equality of Means

ONTARIO AND MCMASTER UNIVERSITIES) INDEX in intraarticular steroids and

scores for WOMAC (WESTERN ONTARIO AND MCMASTER UNIVERSITIES) INDEX

at baseline in Intraarticular steroids treatment (M= 83.63, SD=7.000 and Mustard

fomentation (M=85.57, SD=5.315) conditions; t(54.099)= -1.205, p =.233. These results

WOMAC (WESTERN ONTARIO AND MCMASTER UNIVERSITIES) INDEX at

Group N Mean Std. Deviation Std. Error

Independent Samples Test

Levene's Test t-test for Equality of Means

ONTARIO AND MCMASTER UNIVERSITIES) INDEX in intraarticular steroids and

difference in the scores for WOMAC (WESTERN ONTARIO AND MCMASTER

UNIVERSITIES) INDEX in Intraarticular steroids treatment (M= 71.83, SD=8.890 and

effect on WOMAC (WESTERN ONTARIO AND MCMASTER UNIVERSITIES) INDEX

Group N Mean Std. Deviation Std. Error

Independent Samples Test

Levene's Test t-test for Equality of Means

An independent-samples t-test was conducted to compare WOMAC (WESTERN ONTARIO

AND MCMASTER UNIVERSITIES) INDEX in intraarticular steroids and Mustard

fomentation conditions at 45 days follow up of treatment. There was a not a significant

UNIVERSITIES) INDEX in Intraarticular steroids treatment (M= 75.57, SD=7.771 and

effect on WOMAC (WESTERN ONTARIO AND MCMASTER UNIVERSITIES) INDEX

at 45 days of follow up.

Group N Mean Std. Deviation Std. Error

Independent Samples Test

Levene's Test for t-test for Equality of Means

Independent-samples t-test was conducted to compare WOMAC (WESTERN ONTARIO

AND MCMASTER UNIVERSITIES) INDEX in intraarticular steroids and Mustard

in the scores for WOMAC (WESTERN ONTARIO AND MCMASTER UNIVERSITIES)

INDEX at 3 months of follow up in Intraarticular steroids treatment (M=77.60, SD=7.495

on WOMAC (WESTERN ONTARIO AND MCMASTER UNIVERSITIES) INDEX at 3

months of follow up. Mustard Fomentation found to be significantly reducing WOMAC

Index than Intraarticular steroids treatment.

Group N Mean Std. Deviation Std. Error

Independent Samples Test

Levene's Test for t-test for Equality of Means

AND MCMASTER UNIVERSITIES) INDEX in intraarticular steroids and Mustard

fomentation Groups at 6 months of follow up of treatment. There was a significant

difference in the scores for WOMAC (WESTERN ONTARIO AND MCMASTER

UNIVERSITIES) INDEX at 6 months of follow up in Intraarticular corticosteroids treatment

fomentation differ in their effect on WOMAC (WESTERN ONTARIO AND MCMASTER

UNIVERSITIES) INDEX at 6 months of follow up. Mustard Fomentation significantly

reduced WOMAC Index than Intraarticular steroids treatment.

VAS SCORING BETWEEN GROUPS

group N Mean Std. Deviation Std. Error

Independent Samples Test

Levene's Test t-test for Equality of Means

VAS score at presentation

group N Mean Std. Deviation Std. Error

Independent Samples Test

Levene's Test for t-test for Equality of Means

An independent-samples t-test was conducted to compare VAS score in intraarticular

significant difference in VAS score in Intraarticular steroids (M=5.83, SD=1.262 and

their effect on VAS score at 15 days of follow up

group N Mean Std. Deviation Std. Error

Independent Samples Test

Levene's Test t-test for Equality of Means

An independent-samples t-test was conducted to compare VAS score in intraarticular steroids

and Mustard fomentation conditions at 45 days follow up of treatment. There was no

differ in their effect on VAS score at 45 days of follow up.

group N Mean Std. Deviation Std. Error