肩胛上神经阻滞与肩峰下注射治疗肩袖撕裂

<正>肩袖撕裂是最常见的肌肉骨骼疾病之一。肩袖撕裂大多数是保守治疗,包括非甾体类抗炎药、物理/作业治疗和肩峰下注射。本研究比较了肩胛上神经阻滞与肩峰下注射治疗急性肩袖撕裂的疗效。受试者为年龄在45岁或以上,均有症状的部分或完全性肩袖撕裂的患者。患者随机接受肩胛上神经阻滞(SSNB)或肩峰下注射(SA)治疗,两种注射治疗均包括9ml 1%罗哌卡因和1ml倍他米松。所有患者在注射后2周、6周和12周均采用改良的Constant-Murley(CM)评分表进行评估,并通过视觉模拟评分(VAS)评估疼痛。数据收集于43名患者,平均年龄为65.2岁。在2周     

非甾体抗炎镇痛药治疗颈肩腰背痛的临床分析

目的：探讨非甾体抗炎镇痛药(NSAIDs)在临床治疗颈肩腰背痛的合理使用方法，为临床非手术治疗颈肩腰背痛提供理论和实践指导。方法：门诊连续观察同期各种颈肩腰腿痛患者应用非甾体抗炎药的临床疗效，分析不同种类非甾体抗炎药在适应症选择、使用时间、疗效及副作用的不同点。结果：非甾体抗炎药在治疗颈肩腰背痛方面疗效可靠，但均存在有胃肠方面的副作用，其程度不同；不同种类的非甾体抗炎药对于不同患者疗效不同，一种类型的非甾体抗炎药疗效不佳时，更换为其它类型的非甾体抗体药可能有效。辅助胃粘膜保护性药物可提高患者对非甾体抗炎药的耐受性。结论：合理使用非甾体抗炎药是临床治疗颈肩腰背痛的有效方法之一。     

康复训练对肩Bankart损伤合并肩袖损伤患者微创术后功能恢复的影响

目的探讨康复训练对肩Bankart损伤合并肩袖损伤患者微创术后功能恢复的影响。方法选择2008年10月至2015年3月在同济大学附属东方医院确诊为肩Bankart损伤合并肩袖损伤患者46例,其中男性26例,女性20例,左肩18例,右肩28例。运动损伤32例,交通伤8例,牵拉伤6例。受伤时间平均6个月(1.8~12个月)。年龄18~45岁,平均(38.6±2.4)岁。术前均行肩关节X线检查和MRI检查,并经关节镜探查明确肩关节Bankart损伤合并肩袖损伤。采用关节镜下肩Bankart损伤合并肩袖损伤修补术42例,关节镜下肩Bankart损伤修补术与小切口辅助下肩袖缝合固定术4例。将术后患者随机分为康复训练组和对照组。其中康复训练组24例,男性16例,女性8例,平均年龄(35.6±2.3)岁;对照组22例,男性12例,女性10例,平均年龄(36.2±2.6)岁。对照组采用短波、脉冲磁疗、低能量半导体激光、冷疗和基础康复训练以及口服非甾体抗炎药。康复训练组在短波、脉冲磁疗及低能量半导体激光、冷疗以及口服非甾体抗炎药基础上,进行内容包括肩关节活动度、肌力、本体感觉、神经肌肉控制、灵活性、协调性和运动能力的训练。分别在术后4周、8周、12周、16周,采用疼痛视觉模拟评分(VAS)、美国肩肘外科医师(ASES)评分、美国加州大学肩评分表(UCLA)对两组患者进行肩关节功能评定。结果康复训练组术后4周肩关节功能评分与对照组相比差异无统计学意义(P>0.05),术后8周康复训练组患者肩关节功能评分较对照组有所提高,但差异无统计学意义(P>0.05)。术后12周、16周康复组肩关节功能评分与对照组相比有较明显提高,差异有统计学意义(P<0.05)。结论研究针对肩Bankart损伤合并肩袖损伤特点,设计一套科学、安全、有效的肩Bankart损伤合并肩袖损伤微创术后康复计划,并依照康复计划对术后患者进行系统的康复训练,可以明显促进肩关节功能的恢复。     

肩袖修复术后肩峰下类固醇注射

正肩袖修复术后患者经常在出现严重的术后疼痛,控制患者在康复期间持续的疼痛方法的研究较少。本研究旨在确定肩胛下类固醇注射对肩袖修复术后疼痛控制的有效性和安全性。这项回顾性研究纳入了458例接受过关节镜下肩袖修复术且进行最少两年随访的患者。手术后,患者每天一次接受口服非甾体抗炎药,持续两周,并参与标准康复计划。用American Shoulder and Elbow Surgeons(ASES)评分和Constant评分评定肩关节功能。此外,术后采用VAS评分,并对患者满意度进行评价。术后肩关节疼痛     

超声引导下封闭注射治疗肩袖损伤的疗效观察

目的观察超声引导下封闭注射治疗肩袖损伤患者的疗效。方法采用随机数字表法将66例肩袖损伤患者分为观察组及对照组, 每组33例。2组患者均给予常规康复干预, 包括超短波治疗及肩关节功能训练, 观察组患者在此基础上辅以超声引导下封闭注射治疗, 对照组患者则针对肩部压痛点进行徒手封闭注射治疗。于治疗前、治疗2周及4周后分别采用疼痛视觉模拟评分法(VAS)、Constant-Murley肩关节功能评分(CMS)对2组患者肩部疼痛、关节功能恢复情况进行评定, 同时采用通用量角器测量患者肩关节前屈、外展及后伸范围。于治疗4周后对2组患者进行临床疗效评定。结果治疗2周、4周后2组患者疼痛VAS评分、CMS评分及肩关节活动度均较治疗前明显改善(P<0.05), 并且上述时间点观察组患者疼痛VAS评分、CMS评分、肩关节活动度以及治疗4周后总有效率(93.9%)亦显著优于对照组水平(P<0.05)。结论超声引导下封闭注射治疗能在短期内显著缓解肩袖损伤患者关节疼痛, 改善关节功能及生活质量, 其疗效明显优于局部痛点徒手封闭注射治疗。     

超声引导下富血小板血浆注射修复肩袖损伤的疗效观察

目的 探讨超声引导下富血小板血浆注射治疗肩袖损伤的临床疗效。 方法 选取2014年1月至2015年1月期间在我科治疗的60例肩袖损伤患者作为研究对象,采用随机数字表法将其分为观察组及对照组,每组30例患者。观察组给予富血小板血浆注射治疗,对照组给予玻璃酸钠注射治疗。于治疗前、治疗后2周、12周及24周时分别采用上肢Fugl-Meyer量表（FMA）及视觉模拟评分法（VAS）对2组患者上肢功能及疼痛病情进行评定,同时记录治疗过程中2组患者不良反应发生情况,于治疗后24周时采用超声观察肩袖修复情况。 结果 治疗前2组患者上肢FMA评分及疼痛VAS评分组间差异均无统计学意义（P>0.05）;注射治疗后2周、12周及24周时2组患者上肢FMA评分、疼痛VAS评分均较治疗前明显改善 (P<0.05);并且上述时间点观察组患者上肢FMA评分及疼痛VAS评分均显著优于对照组水平 (P<0.05);注射治疗后24周时观察组总有效率为96.6%,注射后未发现明显不良反应;对照组总有效率为63.3%,注射后有2例出现疼痛加重现象,不良反应发生率为6.7%,组间差异均具有统计学意义(P<0.05)。 结论 超声引导下富血小板血浆注射治疗肩袖损伤操作简单且疗效确切,能显著缓解患者肩关节疼痛,加速组织修复并改善关节功能。     

肩袖损伤的诊断治疗（附29例分析）

目的：通过对29例肩袖损伤患者的病例分析,以探讨肩袖损伤的诊断与治疗。方法：对所有患者经物理、影像学检查,并结合肩袖外伤史确诊,然后分别给予非手术治疗和手术治疗,并配以康复治疗。结果：所有病例随访120d～6a,治疗方法不同,疗效不同,总优良率达86%。结论：提高早期的诊断率,可提高肩袖损伤的疗效,不同的损伤,可采取不同的治疗方法。     

冷效应加压输出护理在肩袖损伤肩关节镜检查患者中的应用效果

目的探讨冷效应加压输出护理在肩袖损伤肩关节镜检查患者中的应用效果。方法选择2018年1月至2019年10月收治于我院并接受肩关节镜检查的肩袖损伤患者90例为研究对象,将收住单号病室的肩袖损伤患者45例设为对照组,收住双号病室的肩袖损伤患者45例设为试验组,对照组接受常规护理,试验组在对照组基础上加用冷效应加压输出护理。比较两组患者检查前及检查后12,24,48 h的疼痛评分和肿胀评分。结果试验组检查后12,24,48 h疼痛评分和肿胀评分均低于对照组(P 0.05)。结论采用冷效应加压输出护理对肩袖损伤肩关节镜检查患者施加干预,可获得良好的术后疼痛、肿胀缓解控制效果。     

耳穴压籽在肩袖损伤围手术期镇痛效果观察

目的:探讨耳穴压籽在肩袖损伤围手术期疼痛护理中的镇痛效果观察。方法:选择接受肩关节镜手术治疗的肩袖损伤患者40例,采用随机数字表法分为观察组和对照组,每组20例,所有患者手术治疗所选用的麻醉方式均为全身麻醉。对照组进行围手术期常规护理;观察组在常规护理的基础上,于患者手术前及术后用生王不留行籽按压心、神门、交感、皮质下、肩5个耳穴,分别记录患者术后6h、12h、24h、48h的疼痛数值评分,以及患者对镇痛满意度。结果:观察组术后6h、12h、24h、48h的NRS评分(3.45±0.78)(3.97±0.65)(2.83±0.56)(2.35±0.57)明显低于对照组(3.78±0.63)(4.59±0.83)(3.78±0.41)(3.51±0.69),2组比较差异有统计学意义;观察组患者满意度95%,明显高于对照组60%,2组比较差异有统计学意义。结论:肩袖损伤围手术期耳穴压籽,可减轻肩袖损伤术后疼痛,提高患者镇痛满意度和功能锻练依从性,积极配合治疗与护理。     

肩关节镜下肩袖修复术治疗肩袖损伤的临床效果

目的探讨肩关节镜下肩袖修复术治疗肩袖损伤的临床效果。方法将我院2018年2月至2019年2月收治的52例肩袖损伤患者随机分为对照组(26例,开放式肩袖修复术)和观察组(26例,全肩关节镜下肩袖修复术)。比较两组的治疗效果。结果治疗后,两组的肩关节前屈、内旋、外旋活动度及Constant-Muley肩关节评分均增加,数字评估量表(NRS)评分均降低,且观察组显著优于对照组(P<0.05);观察组的治疗优良率显著高于对照组(P<0.05)。结论肩关节镜下肩袖修复术治疗肩袖损伤的临床效果显著,能够有效减轻患者疼痛,加快患者术后肩关节功能的恢复,值得临床推广应用。     

PEER umbrella systematic review of systematic reviews: Management of osteoarthritis in primary care

ObjectiveTo determine how many patients with chronic osteoarthritis pain respond to various non-surgical treatments.Data sourcesPubMed and the Cochrane Library.Study selection Published systematic reviews of randomized controlled trials (RCTs) that included meta-analysis of responder outcomes for at least 1 of the following interventions were included: acetaminophen, oral nonsteroidal anti-inflammatory drugs (NSAIDs), topical NSAIDs, serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, cannabinoids, counseling, exercise, platelet-rich plasma, viscosupplementation, glucosamine, chondroitin, intra-articular corticosteroids, rubefacients, or opioids.Synthesis In total, 235 systematic reviews were included. Owing to limited reporting of responder meta-analyses, a post hoc decision was made to evaluate individual RCTs with responder analysis within the included systematic reviews. New meta-analyses were performed where possible. A total of 155 RCTs were included. Interventions that led to more patients attaining meaningful pain relief compared with control included exercise (risk ratio [RR] of 2.36; 95% CI 1.79 to 3.12), intra-articular corticosteroids (RR = 1.74; 95% CI 1.15 to 2.62), SNRIs (RR = 1.53; 95% CI 1.25 to 1.87), oral NSAIDs (RR = 1.44; 95% CI 1.36 to 1.52), glucosamine (RR = 1.33; 95% CI 1.02 to 1.74), topical NSAIDs (RR = 1.27; 95% CI 1.16 to 1.38), chondroitin (RR = 1.26; 95% CI 1.13 to 1.41), viscosupplementation (RR = 1.22; 95% CI 1.12 to 1.33), and opioids (RR = 1.16; 95% CI 1.02 to 1.32). Preplanned subgroup analysis demonstrated no effect with glucosamine, chondroitin, or viscosupplementation in studies that were only publicly funded. When trials longer than 4 weeks were analyzed, the benefits of opioids were not statistically significant.ConclusionInterventions that provide meaningful relief for chronic osteoarthritis pain might include exercise, intra-articular corticosteroids, SNRIs, oral and topical NSAIDs, glucosamine, chondroitin, viscosupplementation, and opioids. However, funding of studies and length of treatment are important considerations in interpreting these data.     

EXERCISE REHABILITATION IN THE NON-OPERATIVE MANAGEMENT OF ROTATOR CUFF TEARS: A REVIEW OF THE LITERATURE

The incidence of rotator cuff tears increases with age, with full-thickness rotator cuff tears present in approximately 25% of individuals in their sixties, and more than 50% of those in their eighties. While surgery is considered an effective treatment, recurrent tears at the insertion site are common, especially with degenerative tears, which are frequent in the older population. More recently, there has been increasing interest in exercise rehabilitation and physical therapy as a means to manage partial and full thickness tears of the rotator cuff by addressing weakness and functional deficits. Recent studies have suggested that patients opting for physical therapy have demonstrated high satisfaction, an improvement in function, and success in avoiding surgery. When considering the increasing rate of shoulder surgery and the associated economic and social burden rotator cuff surgery places on both the patient and the health care system, non-surgical management such as physical therapy and exercise may, in selected cases, be a treatment alternative to surgical repair. The purpose of this clinical commentary is to provide an overview of rotator cuff pathology and pathogenesis, and to present an evidence-based case for the role of conservative rehabilitation in the management of rotator cuff injuries.

Level of Evidence

Level 5     

Rotator cuff tears: is non-surgical management effective?

Background: Rotator cuff-related shoulder pain is a common musculoskeletal complaint with an increasing number of people with shoulder pain undergoing surgical repair each year. The relationship between rotator cuff tendon tears and shoulder pain remains equivocal due to the high prevalence of tears in people without symptoms, which suggests that a proportion of people will undergo surgery on tissues not related to their symptoms. As a result there have been suggestions to initially manage atraumatic tears non-surgically.

Objectives: The objective of this narrative review was to present current evidence regarding the assessment and management of full-thickness rotator cuff tears.

Major findings: To date, three randomised controlled trials have compared surgical with non-surgical management of rotator cuff tears. Outcomes show a small but non-significant effect in favour of surgery. Only one study has looked at long-term outcomes of greater than one year. Overall 129 subjects have completed a course of non-surgical management and therefore low participant numbers may not be sufficient to draw firm conclusions.

Conclusions: Current evidence currently supports the consideration of a non-surgical approach in the management of people with shoulder symptoms and identified rotator cuff tears, for a period of time.     

Risk factors for rotator cuff disease: A systematic review and meta-analysis of diabetes,hypertension, and hyperlipidemia

BackgroundRotator cuff disease is a common cause of shoulder pain. Comorbidities such as diabetes, hypertension, and hyperlipidemia may be associated with rotator cuff disease, likely because of mechanisms related to vascular insufficiency.ObjectivesWe performed a systematic review of the association of diabetes, hypertension, and hyperlipidemia with the diagnosis of rotator cuff disease.MethodsFollowing systematic queries of PubMed, Embase, Cochrane, CINAHL, and Science Direct, articles meeting eligibility criteria and reporting on the association of one or more risk factors (diabetes, hypertension, and hyperlipidemia) and rotator cuff disease were considered. Meta-analysis was performed to quantitatively summarize the associations between each risk factor and rotator cuff disease. We assessed study quality with the Newcastle-Ottawa Scale (NOS) and performed a qualitative assessment of risk of bias.ResultsAfter a full-text review of 212 articles, 12 articles assessing diabetes, 5 assessing hypertension and 8 assessing hyperlipidemia were eligible. The odds of having rotator cuff disease was increased with diabetes (odds ratio [OR] 1.49, 95% confidence interval [CI] 1.43–1.55), hypertension (OR 1.40, 95% CI 1.19–1.65) and hyperlipidemia/dyslipidemia (OR 1.48, 95% CI 1.42–1.55). Diabetes was also specifically associated with rotator cuff tears (OR 1.28, 95% CI 1.07–1.52). Synthesizing assessment for risk of bias suggested that current epidemiologic evidence for an association was plausible for diabetes and hyperlipidemia but not hypertension.ConclusionsDiabetes, hypertension, and hyperlipidemia were associated with rotator cuff disease in our meta-analysis. However, the possibility of bias exists for all 3 co-morbidities evaluated and is likely highest for hypertension. High-quality studies with the ability to incorporate time since first diagnosis of co-morbidity are scarce and much needed.     

Diagnostic accuracy of clinical examination features for identifying large rotator cuff tears in primary health care

Objectives:

Rotator cuff tears are a common and disabling complaint. The early diagnosis of medium and large size rotator cuff tears can enhance the prognosis of the patient. The aim of this study was to identify clinical features with the strongest ability to accurately predict the presence of a medium, large or multitendon (MLM) rotator cuff tear in a primary care cohort.

Methods:

Participants were consecutively recruited from primary health care practices (n = 203). All participants underwent a standardized history and physical examination, followed by a standardized X-ray series and diagnostic ultrasound scan. Clinical features associated with the presence of a MLM rotator cuff tear were identified (P<0.200), a logistic multiple regression model was derived for identifying a MLM rotator cuff tear and thereafter diagnostic accuracy was calculated.

Results:

A MLM rotator cuff tear was identified in 24 participants (11.8%). Constant pain and a painful arc in abduction were the strongest predictors of a MLM tear (adjusted odds ratio 3.04 and 13.97 respectively). Combinations of ten history and physical examination variables demonstrated highest levels of sensitivity when five or fewer were positive [100%, 95% confidence interval (CI): 0.86–1.00; negative likelihood ratio: 0.00, 95% CI: 0.00–0.28], and highest specificity when eight or more were positive (0.91, 95% CI: 0.86–0.95; positive likelihood ratio 4.66, 95% CI: 2.34–8.74).

Discussion:

Combinations of patient history and physical examination findings were able to accurately detect the presence of a MLM rotator cuff tear. These findings may aid the primary care clinician in more efficient and accurate identification of rotator cuff tears that may require further investigation or orthopedic consultation.     

A Multi-Structural Approach to Treatment of a Patient With Sub-Acromial Impingement: A Case Report

Abstract

Sub-acromial impingement is a condition commonly seen by physical therapists, however little evidence is available regarding the efficacy of this treatment. This case report describes the use of manual therapy and exercise, using a multi-structural approach to manage this condition. The subject was a 48-year-old retired physiotherapist complaining of recurrent shoulder pain during daily activities, although her daily function was not limited. Passive joint mobilization techniques of the cervical spine, costovertebral joints, and the glenohumeral joint as well as soft tissue mobilization techniques of the rotator cuff muscles were used. Exercises were prescribed to “set” the scapula in an optimal position and to facilitate and strengthen the rotator cuff muscles. After two treatments, the patient consulted an orthopaedic surgeon due to imminent decrease in funding for her treatment and a cortisone injection was administered. This decreased her pain immediately by 90%. However, two months later she attended three further physical therapy treatments because of recurrence of the pain. Six months after these treatments she was still pain-free. This case illustrates that physical therapy can be effective in the treatment of sub-acromial impingement, using a multi-structural approach to treatment.     

Rotator cuff tendonitis in lymphedema: a retrospective case series

OBJECTIVES: To report rotator cuff tendonitis as a complication of lymphedema and to discuss the possible etiology and treatment options. DESIGN: Retrospective review of 8 cases. SETTING: University hospital outpatient clinic. PARTICIPANTS: A total of 8 breast cancer patients with a history of lymphedema and ipsilateral shoulder pain. INTERVENTION: Patients with lymphedema and ipsilateral shoulder pain were diagnosed with rotator cuff tendonitis if all of the following 3 tests were positive: supraspinatus test, Neers impingement test, and Hawkins impingement test. Patients diagnosed with rotator cuff tendonitis were prescribed a nonsteroidal anti-inflammatory drug (NSAID) and physical therapy (PT). MAIN OUTCOME MEASURES: Improvement in symptoms of shoulder pain at a 4- to 6-week follow-up, as measured by visual analog scale (VAS). RESULTS: Seven of 8 patients reported a subjective decrease in their symptoms of shoulder pain at a 4- to 6-week follow-up. The average improvement in shoulder pain as measured by VAS was a 4.5-point decrease from the original pain score given. One of 8 patients had a full-thickness supraspinatus tendon tear and required additional decongestive therapy and PT to obtain relief of symptoms. CONCLUSIONS: Rotator cuff tendonitis is a complication of lymphedema caused by internal derangement of tendon fibers, which may be subject to impingement, functional overload, and intrinsic tendinopathy. Conservative treatment with NSAIDs and PT is a safe and effective treatment.     

Comparison of acromiohumeral distance in symptomatic and asymptomatic patient shoulders and those of healthy controls

BackgroundThe reduction of the subacromial space has traditionally been linked to rotator cuff pathology. The contribution of this narrowing, both in the development and maintenance of rotator cuff tendinopathy, is still under debate. The objective of the present study was compare the acromiohumeral distance at 0 and 60 degrees of active shoulder abduction in scapular plane, static position, in both symptomatic and contralateral shoulders, between participants with unilateral rotator cuff related shoulder pain, and in asymptomatic participants.MethodThis was a cross-sectional observational study. Seventy-six participants with chronic shoulder pain were assessed. Forty participants without shoulder pain were also recruited to compare the acromiohumeral distance with symptomatic participants. The acromiohumeral distance was measured at 0 and 60 degrees of active shoulder abduction in all the groups by ultrasound imaging. Mean differences between symptomatic versus contralateral shoulders, and versus healthy controls, were calculated.FindingsThere were no statistical significant differences (p > .05) in the acromiohumeral distance at 0 degrees of shoulder elevation between the groups. However, significant differences were found at 60° between symptomatic and contralateral shoulder groups (0,51 mm; 95% CI: −0.90 to −0.12).InterpretationsDifferences in shoulder pain perception at 0° are not attributable to acromiohumeral distance differences. However, treatments focused on increasing AHD at 60° could be prescribed, as a significantly reduced AHD was found in symptomatic shoulders when compared with contralateral shoulders. Further research is needed to determine, not only static differences in AHD, but also dynamic differences.     

Magnetic resonance imaging of rotator cuff disease and external impingement

Magnetic resonance (MR) imaging plays a major role in helping to identify rotator cuff disease and in demonstrating the pathology associated with external impingement. Many surgeons rely on MR imaging to assist in decision making and presurgical planning for patients with rotator cuff pain. This article reviews the etiology of external impingement and rotator cuff tears, and describes the MR imaging appearance of the normal and the pathologic rotator cuffs. It focuses on the supraspinatus tendon because this is the tendon involved in 95% of rotator cuff tears.     

Does spinal manipulative therapy help people with chronic low back pain?

A systematic review of randomised clinical trials was conducted to assess the effect of spinal manipulative therapy on clinically relevant outcomes in patients with chronic low back pain. Databases searched included EMBASE, CINAHL, MEDLINE and PEDro. Methodological assessment of the trials was performed using the PEDro scale. Where there was sufficient homogeneity, a meta-analysis was conducted. Nine trials of mostly moderate quality were included in the review. Two trials were pooled comparing spinal manipulative therapy and placebo treatment, and two other trials were pooled comparing spinal manipulative therapy and non-steroidal anti-inflammatory drugs (NSAIDs). Spinal manipulative therapy reduced pain by 7mm on a 100mm visual analogue scale (95% CI 1 to 14) at one month follow-up when compared with placebo treatment, and by 14mm (95% CI -11 to 40) when compared with NSAIDs. Spinal manipulative therapy reduced disability by 6 points (95% CI 1 to 12) on a 100-point disability questionnaire when compared with NSAIDs. It is concluded that spinal manipulation does not produce clinically worthwhile decreases in pain compared with sham treatment, and does not produce clinically worthwhile reductions in disability compared with NSAIDs for patients with chronic low back pain. It is not clear whether spinal manipulation is more effective than NSAIDs in reducing pain of patients with chronic low back pain.