体外冲击波治疗髋关节置换后疼痛

背景：髋关节置换后髋部疼痛逐渐成为困扰患者和骨外科医生的棘手问题，如行关节翻修术则将再次给患者造成严重创伤，而体外冲击波治疗肢体疼痛已取得良好的临床疗效。 目的：观察验证体外冲击波对髋关节置换后疼痛的治疗效果。 设计、时间及地点：病例自身对照，双盲评估，于2004-06/2008-02在武汉大学中南医院骨科完成。 对象：选择髋关节置换后疼痛患者51 例（61髋），根据病因分组，骨水泥组骨溶解松动16例（20髋），非骨水泥组骨溶解松动12例（16髋），异位骨化组8例（10髋），急性感染组4例（4髋），慢性感染组5例（5髋），软组织无菌性炎症组4例（4髋），髋臼脱位组2例（2髋）。 方法：患者接受体外冲击波治疗，电压12 kV，3次/s，每次冲击4 000次，能量0.54~1.06 MJ/mm2，1次/周，连续8~12周。 主要观察指标：治疗前后采用目测类比评分法评价疼痛程度，Harris评分评价髋关节功能，X射线观察假体周围骨量变化。 结果：51例患者随访时间18~64个月，平均4.1年，2例死亡。治疗后非骨水泥组、慢性感染组、异位骨化组、软组织无菌性炎症组目测类比评分显著低于治疗前（P < 0.01）。治疗后骨水泥组、非骨水泥组、慢性感染组、异位骨化组及软组织无菌性炎症组Harris评分显著高于治疗前（P < 0.01）。X射线提示假体与骨的界面有新骨形成，假体与髋臼或股骨干之间骨溶解形成的透亮带宽度由治疗前平均3.1 mm减小到治疗后1.2 mm，部分患者出现局部红肿，休息后缓解。 结论：体外冲击波是治疗由于松动、感染、软组织炎症、异位骨化引起的髋关节置换后疼痛的有效方法。     

外伤性膝关节僵硬模型兔中药熏洗治疗后内侧副韧带组织中糖胺聚糖的表达★

背景：中医药治疗膝关节外伤性僵硬取得了较好的疗效，但其机制尚不清楚。 目的：构建膝关节外伤性僵硬模型兔，探讨伤科熏洗汤治疗外伤性膝关节僵硬的可能机制。 方法：向24只兔右膝关节腔内注射自身血液后经管型石膏伸直位固定7周制备兔膝关节外伤性僵硬模型。中药组用伤科熏洗汤局部熏洗膝关节，水熏组用热水熏洗，模型组不做处理。2周后，测定兔血液中丙氨酸氨基转移酶、尿素氮、肌酐及膝内侧副韧带组织中糖胺聚糖水平，同时观察治疗前后兔右膝关节活动度及患侧膝关节的病理改变。 结果与结论：造模7周后，所有动物右膝关节活动度较对侧明显降低(P < 0.01)。伤科熏洗汤治疗2周后，右膝关节活动度无明显增加，关节存在关节囊增厚，新生胶原纤维排列紊乱，滑膜结构消失等病理改变。血液中丙氨酸氨基转移酶、尿素氮、肌酐水平与水熏组、模型组比较差异无显著性意义(P > 0.05)，但膝内侧副韧带组织中糖胺聚糖水平明显增加(P < 0.01)。说明伤科熏洗汤可提高韧带组织中糖胺聚糖水平，对膝关节外伤性僵硬有预防和辅助治疗作用。 关键词：膝关节；外伤性僵硬；伤科熏洗汤；糖胺聚糖；兔     

海桐皮汤熏洗治疗膝骨性关节炎：与扶他林乳剂的比较

背景：膝骨性关节炎是由于风寒湿邪痹阻关节、经络所致,而海桐皮汤具有使气血通畅,经络舒展,肿胀消退之功效。 目的：观察海桐皮汤熏洗治疗膝骨性关节炎的临床疗效。 方法：将符合纳入标准的110例膝骨性关节炎患者按就诊先后顺序随机分为熏洗组与对照组,其中熏洗组55例,对照组55例。根据设计好的症状体征评分标准,计算治疗前患者的症状体征积分;分别予以海桐皮汤熏洗及扶他林乳剂外用治疗,1个月后比较治疗前后患者的临床症状、体征、疼痛积分的变化及两治疗组在不良反应、失访率和复发率等的差异。 结果与结论：两种药物在改善患者症状体征方面均具有良好疗效,海桐皮汤熏洗疗效[(控显率57.45%,总有效率95.74%)]优于外用扶他林乳剂[(控显率37.0%,总有效率78.3%)]。两组治疗后疼痛积分较治疗前减少(P <0.01或0.05);熏洗组明显优于对照组(P < 0.01)。熏洗组有3例患者出现皮疹、红斑等过敏现象,对照组中2例患者也出现上述过敏现象,均在休息一两天后缓解,两组不良反应差异无显著性意义;熏洗组复发率低于对照组。结果证实,海桐皮汤熏洗对治疗早、中期膝骨性关节炎疗效确切,疗效优于外用扶他林乳剂,且复发率低于对照组。     

单次手法和物理治疗颈型颈椎病：疼痛和关节活动的即刻及短期效果比较

背景：大量研究表明，手法治疗和物理治疗均可显著改善颈型颈椎病患者的疼痛和关节活动度，但两种治疗方式对颈型颈椎病的即刻和短期疗效比较鲜有报道。 目的：比较单次手法治疗和物理治疗对颈型颈椎病患者疼痛和活动的即刻和短期疗效。 方法：颈型颈椎病患者随机分成2组，手法治疗组和物理治疗组，各接受1次治疗。采用疼痛目测类比评分法、压力疼痛阈值和关节活动范围评定患者治疗前、后10 min(即刻疗效)和治疗后第2天(短期疗效)的情况。 结果与结论：手法治疗组患者在单次治疗后的10 min和第2天疼痛目测类比评分较治疗前下降，压力疼痛阈值增加，颈椎各方向关节活动范围均增加(P < 0.05)；物理治疗组患者在单次治疗后的10 min和第2天疼痛目测类比评分较治疗前均下降(P < 0.05)，在治疗后第2天，颈椎左/右侧屈关节活动范围较治疗前增加(P < 0.05)；在治疗后的10 min和第2天，手法治疗组患者的疼痛目测类比评分均低于物理治疗组，压力疼痛阈值均高于物理治疗组，颈椎前屈/后伸，左/右侧屈关节活动范围均大于物理治疗组(P < 0.05)。结果表明单次手法治疗对改善慢性颈痛患者疼痛目测类比评分，压力疼痛阈值和关节活动范围的即刻效果和短期效果均优于物理治疗。 关键词：手法治疗；物理治疗；颈椎病；疼痛；关节活动范围     

中药熏洗配合常规药物治疗腕管综合征的临床分析

目的探讨中药熏洗疗法在腕管综合征患者中的应用。方法根据患者是否愿意加用中药熏洗疗法,将患者分为治疗组(A组)和对照组(B组)。结果治疗组大多数患者能在一个月症状消失,对照组大多数患者的症状消失需两个月。结论中药熏洗能明显的缓解症状,且能明显的缩短常规药物的治疗疗程。     

人工全膝关节置换后持续被动关节运动：48例分析

背景：膝关节置换后的早期康复治疗逐渐引起关注,进行持续被动关节运动的主要目的是恢复膝关节功能,防止关节僵硬,同时促进手术部位血液和关节滑液循环,从而加快组织修复。 目的：评价人工全膝关节置换后持续被动关节运动的疗效。 方法：选择2007-12/2009-10上海瑞金医院集团闵行中心医院骨科和解放军第三○九医院康复医学科进行人工全膝关节置换的48例患者,随机分为治疗组和对照组,24例/组。两组患者在进行全膝关节置换前,给予股四头肌等长收缩等训练,并辅助物理因子治疗。治疗组患者在全膝关节置换后第2天开始进行膝关节持续被动关节运动,1 h/d,每日运动范围以患者略感疼痛为宜,被动运动范围每日增加5°~10°。对照组患者全膝关节置换后抬高患肢30 cm,按骨科常规方法进行临床治疗。采用膝关节外科协会评分系统评价膝关节功能,采用目测类比评分法评定患肢疼痛,通过测量双下肢周径评定患肢肿胀程度,测量膝关节活动度的变化。 结果与结论：全膝关节置换前,两组患者的膝关节功能评分、VAS患肢疼痛评分、双下肢周径、膝关节活动度均基本相似(P > 0.05)。与对照组比较,治疗组在置换后3 d及2周膝关节功能评分显著升高(P < 0.01),置换后3 d VAS患肢疼痛评分及双下肢周径显著降低(P < 0.01),置换后膝关节活动度明显改善,达优率显著升高(P < 0.01)。48例患者均无深静脉血栓形成、感染等并发症发生。结果提示早期持续被动关节运动有助于膝关节置换后疼痛的缓解、肿胀的消除以及膝关节稳定性的增强。     

腰椎间盘突出症患者血清白细胞介素1β及白细胞介素6和肿瘤坏死因子α变化与渗湿通络法治疗的影响：随机对照☆

目的：观察腰椎间盘突出症患者血清细胞因子应用渗湿通络法治疗后的变化。 方法：①对象：选择2005-02/12中国中医科学院望京医院收治的寒湿痹阻型腰椎间盘突出症患者43例，随机分成试验组22例和对照组21例，患者对治疗知情同意。另选择志愿参加试验的健康成年人30人为正常组。②干预：试验组患者给予渗湿通络法则下的薏苡仁汤加减（薏苡仁、杜仲、川断、木防己、威灵仙、鸡血藤、独活、牛膝、白芍等）口服，1剂/d，早晚分服，连服4周。对照组患者给予腰痛宁胶囊口服，4粒/次，1次/d，连服4周。③评估：于治疗前和4周治疗后分别应用放免法测定患者血清白细胞介素1β、白细胞介素6、肿瘤坏死因子α水平；采用目测类比评分法测定患者疼痛；根据日本整形外科学会（JOA）腰痛疾患疗效评定标准判定临床疗效。 结果：①43例患者血清白细胞介素１β、白细胞介素6、肿瘤坏死因子α较健康人有异常升高（P < 0.01）；治疗后试验组患者血清白细胞介素1β、肿瘤坏死因子α含量下降（P < 0.05、P < 0.01），对照组患者血清肿瘤坏死因子α含量下降（P < 0.05）。②试验组、对照组治疗前后症状体征积分、疼痛评分均有明显改善（P < 0.01），试验组治疗前后症状体征积分、疼痛评分差值均优于对照组（P < 0.05）。 结论：应用渗湿通络法治疗后患者血清中异常升高的白细胞介素1β、白细胞介素6、肿瘤坏死因子α水平降低，疼痛症状改善明显。     

股神经阻滞在全膝人工关节表面置换围手术期多模式镇痛中的应用

背景：股神经阻滞作为一种新兴疼痛控制方式在人工膝关节置换后的应用尚未见广泛开展。 目的：观察股神经阻滞在人工膝关节表面置换围手术期镇痛中的临床疗效。 方法：将接受单侧人工膝关节表面置换的77例患者随机分为治疗组(32例)和对照组(35例),两组患者均采用多模式镇痛方式,即置换前3 d口服塞来昔布+术中术区局部“鸡尾酒疗法”注射+自控静脉镇痛泵;另外,治疗组患者置换后则于患侧行股神经阻滞。 结果与结论：人工膝关节表面置换后48 h内,治疗组吗啡使用量及相关不良反应明显低于对照组(P < 0.05);置换后1周内,治疗组患者疼痛目测类比评分与关节活动度改善情况明显优于对照组(P < 0.05);两组患者置换后3个月HSS评分比较,差别无显著性意义(P > 0.05)。结果显示膝关节表面置换后应用股神经阻滞技术可有效缓解置换后疼痛并促进关节功能早期恢复,同时可降低吗啡用量,从而有效减少相关不良反应的发生。因此,该方法是一种安全有效、镇痛效果满意的镇痛方法。     

液电式体外冲击波治疗创伤性距骨缺血性坏死

背景：创伤性距骨坏死至今为止尚无理想的治疗方法,体外冲击波是目前一种微创、简单、疗效显著的骨肌系统疾病治疗新方法,其是否能够治疗距骨坏死尚无相关研究。 目的：应用液电式体外冲击波治疗创伤性距骨缺血性坏死并分析其治疗效果,探索创伤性距骨坏死新的治疗方法。 方法：纳入2004-09/2009-06武装警察部队医学院附属医院收治的创伤性距骨缺血性坏死患者34例,均为单侧发病,按随机数字表达分为体外冲击波疗法组和对照组,每组17例。采用体表痛点定位结合X射线定位,工作电压8~10 kV,能流密度0.12~0.16 mJ/mm2,冲击频率40~50次/min,冲击次数800~1 000次。1次/周,共治疗3~5次。治疗前后采用目测类比评分评估疼痛情况;参照美国足踝关节外科协会踝关节功能评分进行功能评价;治疗后18个月时复查踝关节MRI,比较治疗前后坏死面积的变化。 结果与结论：两组病例治疗后18个月,体外冲击波疗法组的疼痛、踝关节功能、踝关节MRI坏死面积的改善情况均优于对照组(P < 0.01)。对照组有1例因创伤性关节炎剧烈疼痛致踝关节活动受限,于治疗后第15周行踝关节融合术。提示液电式体外冲击波治疗创伤性距骨缺血性坏死是一种值得提倡的非侵入性、方法简单、疗效显著、并发症少的微创治疗方法。     

糖尿病性骨质疏松患者血清自由基代谢与糖骨康的影响*

目的：糖尿病患者常伴有体内过氧化脂质水平的明显升高,而自由基增多可加重糖尿病并发症的发生和发展。糖骨康为治疗糖尿病骨质疏松症的临床验方，观察糖骨康对糖尿病骨质疏松患者骨密度、空腹血糖、糖化血红蛋白和血清超氧化物歧化酶、丙二醛含量的影响。 方法：①对象及分组：选择2003-03/2006-03在邯郸市第一医院老年病科和涉县中医院骨科收治的糖尿病骨质疏松患者139例。随机分为治疗组74例（年龄60~82岁），对照组65例（年龄60~85岁）。另设健康体检人员为正常组40名。上述人员对所用的治疗及检测指标均知情同意。③用药：治疗组服用中药糖骨康汤剂（由熟地黄、山萸肉、山药、锁阳、龟板、丹参、川芎组成，采用自动煎药机水煎包装）；对照组服用盖天力片(江苏启东盖天力制药厂生产)，两组同时口服西药常规降糖药，30 d为1疗程。④评估：治疗前后检测两组患者空腹血糖、糖化血红蛋白变化；比较正常组与两组患者治疗前骨密度、超氧化物歧化酶活性、丙二醛含量的差异。 结果：①两组患者空腹血糖以及糖化血红蛋白的比较：与治疗前比较，两组治疗后空腹血糖以及糖化血红蛋白均明显下降（P < 0.05或P < 0.01），但两组治疗后比较差异无统计学意义（P > 0.05）。②两组患者骨密度的比较：与治疗前比较，两组治疗后骨密度均明显上升（P < 0.05或P < 0.01），治疗组在升高骨密度方面优于对照组（P < 0.05）。③两组患者超氧化物歧化酶活性、丙二醛含量的比较：治疗后两组血清超氧化物歧化酶活性显著上升（P < 0.05或P < 0.01），丙二醛含量显著下降（P < 0.05或P < 0.01），治疗组在升高超氧化物歧化酶活性和降低丙二醛含量方面优于对照组（P < 0.05）。④正常组与治疗组、对照组患者骨密度、超氧化物歧化酶活性、丙二醛含量的比较：与正常组比较，治疗组、对照组患者骨密度和血清超氧化物歧化酶活性显著降低，丙二醛含量显著升高（P < 0.01）。 结论：糖骨康具有调节糖尿病骨质疏松患者自由基代谢，降低血糖，抑制骨质疏松的作用。     

Pain intensity measurements in patients with acute pain receiving afferent stimulation.

Six different pain rating scales, including a "pain relief scale", were compared in 80 patients suffering acute orofacial pain. Pain intensity measurements were made before and after a 30 min period of afferent stimulation (TENS/vibration and placebo). A good correlation was found between pain scores derived from the pain relief scale, visual analogue-, numerical- and graphic rating scales. The verbal rating scale did not perform well. The pain relief scale and the numerical rating scale are interesting alternatives to the established visual analogue scale.     

Pain management using Han’s acupoint nerve stimulator combined with patient-controlled analgesia following neurosurgery A randomized case control study

BACKGROUND: Han’s acupoint nerve stimulator (HANS) has been frequently used to relieve pain by promoting the central nerve system’s release of endogenous opioid peptides through electric stimulation to the body surface. OBJECTIVE: To investigate the pain-relieving effects of HANS, combined with patient-controlled analge-sia, following neurosurgery, and to observe adverse reactions and effects. DESIGN, TIME AND SETTING: A randomized control observation was performed at the Department of Neurology in the First Affiliated Hospital of Gannan Medical College (Ganzhou, Jiangxi Province, China) from January 2005 to February 2006. PARTICIPANTS: Forty patients, who were selected for craniotomy and required pain relief following sur-gery at the Department of Neurology in the First Affiliated Hospital of Gannan Medical College (China), were included in this study. METHODS: Forty patients underwent neurosurgery and were randomly divided into two groups: pa-tient-controlled analgesia plus HANS (+HANS, n = 20) and patient-controlled analgesia (-HANS, n = 20). Both groups were well matched in baseline data. Automatic syringe infusion pump ZZB-150 was the product of Nantong Aipeng Medical Instruments Co., Ltd. (China). Patient-controlled analgesia consisted of 100 mL 0.02% lappaconitine/0.02% metoclopramide. LH-402 HANS instrument was produced in Beijing (China), with a serial number of 402183. The HANS instrumentation was used to stimulate the Hegu-Laogong acu-point on one side and Jiaogan, Shenmen penetrating Shen, Waifei, Naogan penetrating Pizhixia ear acupoints on the affected side for one hour, with 2-hour intervals. The disperse-dense wave was alternating, with a 2/100 Hz frequency of electrical stimulation. MAIN OUTCOME MEASURE: The scores of visual analogue scale and incidence of adverse reaction were observed in two groups following surgery. RESULTS: Compared with the -HANS group, the visual analogue scale scores were remarkably lower in the +HANS group six hours after surgery (P < 0.01), and the incidence rate of adverse reactions, such as nausea and vomiting, was also decreased (P < 0.05). CONCLUSION: The application of HANS to induce body surface stimulation can enhance the effect of pain relief and reduce adverse reactions when used in combination with patient-controlled analgesia follow-ing neurosurgery. The effect of combined therapy is superior to patient-controlled analgesia alone. Key Words: neurosurgery; Han’s acupoint nerve stimulator; pain management; lappaconitine     

Patient preferences for capillary vs. venous INR determination in an anticoagulation clinic: a randomized controlled trial

BACKGROUND: Patients who are receiving warfarin therapy require frequent blood testing to monitor the intensity of anticoagulation. Although previous studies suggest that capillary blood monitoring of the international normalize ratio (INR) is rapid and reliable, patient preferences for the method of blood drawing have not been investigated. METHODS: We performed a randomized controlled trial of patients attending an anticoagulation clinic in which patients were randomly allocated to undergo capillary or venous INR monitoring. Patient satisfaction with the outpatient visit, pain associated with blood drawing, and time spent in the clinic were assessed for each patient. RESULTS: Sixty patients were studied. Using a 10-point visual analogue scale to quantify patient satisfaction (0-very satisfied; 10-very dissatisfied), patients expressed a strong preference for capillary INR monitoring over venous INR monitoring (1.64 vs. 4.45; P < 0.001). Using a 10-point visual analogue scale to quantify pain with blood sampling (0-no pain; 10-very painful), patients who underwent capillary INR testing had less pain than venous INR testing (0.83 vs. 2.23; P < or = 0.004). Patients spent, on average, 33 fewer minutes in the clinic with capillary INR testing than venous INR testing (P < 0.001). DISCUSSION: Our findings support the routine use of capillary blood testing, using a portable monitor, for the management of patients in outpatient anticoagulation clinics.     

Osteonecrosis: an overuse injury of the shoulder in paraplegia: case report

The shoulder of the wheelchair dependent paraplegic is subject to overuse injury with subsequent pain. The major overuse syndromes observed include soft tissue injuries and secondary degenerative arthritis. This report presents a case in which bilateral osteonecrosis of the humeral heads was found to be the source of pain in the shoulders of an active paraplegic without any evidence of disease or medical treatment associated with the development of osteonecrosis. Osteonecrosis should be entertained in the differential diagnosis of overuse injuries of the shoulder in paraplegia.     

A modified visual analogue scale for the assessment of chronic pain

The present common evaluation of pain is scored through the use of visual analogue scale (VAS) to assess the intensity of pain and, sometimes, an additional table in which the frequency of pain attacks during the day is reported. We propose a modified 2D-VAS to assess both the intensity and the frequency (expressed by the percentage of the time in which pain is experienced during the day). Thus with only one scale and graphic representation, we can have a clear picture of the patient’s condition before and during any treatment to relieve his pain.     

Prevalence and intensity of pain after stroke: a population based study focusing on patients' perspectives

OBJECTIVE: To determine prevalence and intensity of pain after stroke, focusing on patients' perspectives. METHODS: During a one year period, 416 first-ever stroke patients were included in the population based Lund Stroke Register. After 4 and 16 months (median), 297 patients (98% of survivors) were followed up. Worst pain intensity during the previous 48 hours was assessed on a visual analogue scale (VAS), range 0 to 100: a score of 0 to 30 was defined as no or mild pain; 40 to 100 as moderate to severe pain. NIH stroke scale (NIHSS) score and HbA1c were assessed at baseline. At 16 months, screening for depression was done using the geriatric depression scale (GDS-20), and cognition with the mini-mental state examination (MMSE). Predictors of pain were determined by multivariate analyses. RESULTS: Moderate to severe pain was reported by 96 patients (32%) after four months (VAS median=60). Predictors of pain were younger age (p=0.01), female sex (p=0.006), higher NIHSS score (p<0.001), and raised HbA1c (p=0.001) at stroke onset. At 16 months, only 62 patients (21%) had moderate to severe pain, but pain intensity was more severe (median VAS score=70; p<0.016). Higher pain intensity correlated with female sex, worse GDS-20 score, better MMSE score, and raised HbA1c. Pain was persistent in 47%, disturbed sleep in 58%, and required rest for relief in 40% of patients. CONCLUSIONS: Although prevalence of pain after stroke decreased with time, after 16 months 21% had moderate to severe pain. Late pain after stroke was on average more severe, and profoundly affected the patients' wellbeing.     

Diurnal variation and individual differences in the perception of intractable pain.

41 patients with intractable pain rated its intensity on a visual analogue scale at two hourly intervals, from 08.00 to 22.00, for seven successive days. These pain ratings were found to exhibit a marked diurnal variation. Differences in this diurnal variation were associated with the personality and sex of the patient, and with whether or not the patient typically went out to work during the day. For the majority of the patients the variations in reported pain intensity were unrelated to those in oral temperature and alertness ratings. The implications of these results for the effective relief of pain are discussed.     

Brief Report: Judging Pain Intensity in Children with Autism Undergoing Venepuncture: The Influence of Facial Activity

The biasing effect of pain sensitivity information and the impact of facial activity on observers' judgements of pain intensity of children with autism were examined. Observers received information that pain experience in children with autism is either the same as, more intense than, or less intense than children without autism. After viewing six video clips of children with autism undergoing venepuncture, observers estimated pain intensity using a visual analogue scale. Facial activity as coded by Chambers et al. (Child Facial Action Coding System Revised Manual, 1996) had a significant impact on observers' estimates of pain intensity; pain sensitivity information did not. These results have important implications for the assessment and management of pain in children with autism.     

Ilizarov贯穿固定钢针和环形外固定系统治疗下肢骨折的临床应用

背景：Ilizarov贯穿固定钢针和环形外固定系统可用于肢体延长、畸形矫正和治疗难治性骨与软组织问题等骨科领域。 目的：综述Ilizarov贯穿固定钢针和环形外固定系统在下肢骨折治疗中的应用进展。 方法：由第一作者检索1997/2011 PubMed数据库及万方数据库有关Ilizarov贯穿固定钢针和环形外固定系统治疗下肢骨折方面的文献。 结果与结论：Ilizarov贯穿固定钢针和环形外固定系统是治疗各种下肢骨折的有效方法,因其生物学固定、副损伤小,可降低软组织并发症,早期活动,早期负重,骨折愈合快,无需二次手术取内固定物等明显优势而越来越受到广大骨科医生的欢迎。