脑卒中偏瘫肩痛患者的超声图像表现

摘要 目的：通过超声检查以及临床查体,明确脑卒中患者偏瘫肩痛（HSP）的原因,并分析超声表现与肩痛视觉模拟量表（VAS）评分之间的关系。 方法：选取56例首次发生脑卒中偏瘫的患者进行研究,根据VAS评分分为肩痛组及非肩痛组,所有患者均行双侧肩关节超声检查。临床检查包括Brunnstrom分期、Ashworth分级、肩关节半脱位及被动关节活动度（PROM）。 结果：肩痛组患者肩关节半脱位发生率较非肩痛组高（51.4% vs 23.8%）,两组比较差异有显著性意义（P＜0.05）。超声显示,肩痛组患者冈上肌病变（54.3%）和肩峰下—三角肌下滑囊（SA-SD）积液（45.7%）与非肩痛组相比差异有显著性意义（P＜0.05）。相关性分析可见冈上肌病变及肩峰下滑囊积液与偏瘫肩痛之间具有明显的相关性。 结论：肩袖损伤是脑卒中患者偏瘫后肩痛的原因之一,冈上肌损伤及肩峰下滑囊病变同肩痛的程度有关。     

卒中后偏瘫肩痛患者肩周组织超声影像特点

目的:本研究拟通过对脑卒中后偏瘫肩痛患者进行肩关节超声检查,观察卒中后偏瘫患者肩关节及其周围组织的超声影像特点,为偏瘫肩痛患者个体化临床治疗提供客观依据。方法:2016年10月—2017年4月,随机纳入在中山大学附属第三医院康复科住院的31例偏瘫患者进行研究,根据NAS评分将所有患者分为肩痛组和非肩痛组,所有患者双侧肩关节均进行超声检查。体格检查包括肩关节被动关节活动度、Fugl-Meyer上肢功能评定、内收内旋肌群肌张力等。结果:患者肩关节半脱位发生率:肩痛组高于非肩痛组(81.3%vs 40.0%,P=0.018)。肩痛组患者肩胛下肌-喙突滑囊粘连(81.3%)、肩峰下撞击征(75.0%)和肩峰-三角肌下滑囊病变(56.3%)的发生率均显著高于非肩痛组,组间差异有显著性意义(P0.05)。结论:本研究中,卒中后偏瘫肩痛患者的肩关节半脱位、肩胛下肌-喙突滑囊粘连、肩峰下撞击征及肩峰-三角肌下滑囊炎发生率显著高于非肩痛患者。超声影像可明确卒中后偏瘫肩痛患者肩关节及其周围软组织病变,有助于明确导致卒中后肩痛的可能原因,为卒中后肩痛患者的个体化临床治疗提供参考依据。     

脑卒中患者偏瘫肩痛症状的质性研究

目的探索脑卒中患者偏瘫肩痛症状的真实体验、影响因素及症状结局。方法选取2016年3—6月于上海市阳光康复中心住院的16例脑卒中后偏瘫肩痛患者,采用描述性质性研究方法进行半结构式访谈,并以Colaizzi七步分析法分析资料。结果研究提炼出四大主题:患者对于偏瘫肩痛的认识不足、偏瘫肩痛症状体验呈多样性、偏瘫肩痛影响因素复杂、偏瘫肩痛后果严重。结论脑卒中患者对偏瘫肩痛症状认识片面、对症状的关注普遍缺乏,医务人员进行症状管理时应避免偏瘫肩痛诱因和加重因素,及时为患者提供信息支持并积极处理疼痛,提高其对症状的自我管理能力。     

肌内效贴结合肩部强化训练对脑卒中后偏瘫痉挛期患者肩痛的影响

目的:观察肌内效贴结合肩部强化训练对脑卒中后偏瘫痉挛期患者肩痛的影响。方法:70例脑卒中后偏瘫痉挛期肩痛患者随机分为观察组和对照组各35例。对照组给予常规治疗加肩部强化训练,观察组在此基础上辅以肌内效贴治疗。治疗前、治疗4周后分别采用视觉模拟评分法(VAS)评定患侧肩痛,Fugl-Meyer运动评分量表中上肢部分(FMA)评定上肢运动功能和改良Barthel指数(MBI)评定日常生活活动(ADL)能力。结果:治疗4周后,2组患者VAS评分较治疗前显著降低(均P0.01),且观察组更低于对照组(P0.01);2组患者FMA和MBI均显著高于治疗前(均P0.01),且观察组更高于对照组(均P0.05)。结论:肌内效贴结合肩部强化训练能有效减轻脑卒中偏瘫痉挛期患者的肩痛,提高上肢运动功能和ADL能力。     

Post stroke shoulder pain: more common than previously realized.

Stroke is a common disease often requiring rehabilitation, which may be prolonged by shoulder pain. The true incidence of post stroke shoulder pain has not been fully evaluated. In order to establish this, we undertook a prospective study of 123 consecutive patients with a diagnosis of acute stroke during a 6-month period. Patients were assessed by interview, full rheumatological and neurological examination, 14 days post stroke, for a history of shoulder pain according to predetermined criteria. In addition, Barthel Index, HAD score and pain scores were also recorded. Twenty-five percent of patients developed shoulder pain within 2 weeks of their stroke. There was a statistically significant association with ipsilateral sensory impairment (p < 0.005), abnormal rheumatological examination (p < 0.001) and depression score (p < 0.005).We conclude that post stroke shoulder pain is more common than previously realized and in addition to abnormal shoulder joint examination may also be associated with upper limb sensory impairment. Thorough neurological examination is required to detect sensory loss and hence establish patients at risk. This is probably best done by a structured proforma.     

脑卒中早期患者肩部病变损伤及其与肢体功能的相关性研究

目的:通过超声检查的方法对脑卒中早期的肩部病变和损伤进行分析,并研究其与脑卒中患者患侧上肢功能状态之间的相关性.方法:60例脑卒中早期肩痛患者根据患侧上肢Brunnstrom分期不同分为两组,运动功能低下组44例患者,运动功能良好组16例患者,两组患者均进行患肩超声检查和被动关节活动度的测量.结果:脑卒中患者肩部软组织病变和损伤总的发生率为76.7％(n=46),其中肩峰下-三角肌下滑囊积液或炎症的发生率最高,为41.7％(n=25),肱二头肌长头肌腱腱鞘积液或炎症的发生率为30％(n=18),肩袖肌腱炎的发生率为16.7％(n=10),肩袖损伤(部分撕裂或全层撕裂)的发生率为21.7％(n=13).脑卒中患者的肩部病变损伤程度与其患侧上肢运动功能分期之间差异无显著性意义上的相关性(P＞0.05).不同肩部病变程度患者之间的肩关节被动关节活动度差异存在显著性(P＜0.05).结论:脑卒中早期患者的肩部病变损伤发生率很高,其病变程度与患侧上肢的运动功能分期无关,但不同肩部病变对肩关节被动活动度的影响程度不同.早期及时了解脑卒中患者的肩部病变,并给予有效的治疗措施,有利于卒中患者上肢功能的康复.     

偏瘫肩痛患者肩胛肌肉的表面肌电特征研究

目的:应用表面肌电技术探讨偏瘫肩痛患者在上肢特定功能动作中肩胛肌肉的表面肌电特征。方法:选取2019年1月至2019年6月在无锡市同仁康复医院住院的脑卒中后偏瘫肩痛者21例作为偏瘫肩痛试验组(HSP组);年龄、性别以及其他因素与HSP组相匹配的健康志愿者22例为健康对照组。应用表面肌电技术记录HSP组患侧和对照组利手侧上斜方肌(upper trapezius,UT)、中斜方肌(middle trapezius,MT)、下斜方肌(lower trapezius,LT)和前锯肌(serratus anterior,SA)在最大等长收缩(MVIC)以及"够物"动作中的表面肌电信号,原始信号经处理后对比分析肌电特征,包括目标肌肉激活水平(MVIC%)和激活比率(UT/LT、UT/SA、MT/SA)。结果:(1)比较"够物"动作过程中各目标肌肉激活水平:HSP组UT激活水平(MVIC%)大于健康对照组,具有显著差异(P0.01);SA和LT激活水平明显小于对照组(P0.01);两组之间MT的MVIC%值无显著性差异(P0.05)。(2)各目标肌肉的在"够物"过程中UT/LT、UT/SA、MT/SA激活比率情况对比:HSP组的UT/LT、UT/SA、MT/SA的激活比率均高于健康对照组(P0.05)。结论:偏瘫肩痛患者在够物过程中表面肌电存在异常特征性改变。在运动学上,表面肌电用于评估该类患者肩胛骨的运动具有相当可行性,可定量评估其运动功能障碍并为临床康复治疗提供客观指导。     

肌内效贴对脑卒中患者肩关节半脱位后肩痛的疗效观察

目的:观察肌内效贴对脑卒中患者偏瘫侧肩关节半脱位后肩痛的疗效。方法:56例脑卒中肩关节半脱位后肩痛患者,按照随机数字表法分为治疗组与对照组(各28例),两组患者均实施常规康复治疗及宣教,治疗组在此基础上结合肌内效贴干预。分别于治疗前和治疗6周后通过X线测量法测量肩峰与肱骨头间距(AHI)、肩关节视觉模拟评分(VAS)疼痛、Fugl-Meyer上肢功能评分、肩痛侧腋神经及肌皮神经的运动神经传导测定,对两组治疗结果进行疗效评价。结果:治疗前,两组患者AHI值、VAS评分、Fugl-Meyer上肢功能评分无明显差异(P0.05),且检测所有患者肩痛侧腋神经(刺激部位:Erb点;记录部位:三角肌)及肌皮神经(刺激部位:Erb点;记录部位:肱二头肌)后发现两组中某些患者肌皮神经(30例,53.57%)、腋神经(31例,55.36%)波幅明显低于正常值,而潜伏期轻度延长或正常(提示轴索损伤)。两组治疗6周后,治疗组各项评分改善优于对照组(P0.05)且无不良事件发生。结论:在常规康复治疗的基础上,肌内效贴在脑卒中患者偏瘫侧肩关节半脱位后肩痛早期防治中,具有良好的疗效,其相应机制有待进一步研究。     

Hemiplegic shoulder pain (HSP): Natural history and investigation of associated features

The prevalence of hemiplegic shoulder pain (HSP) and associated factors was studied in patients with a stroke followed for 6 months after discharge from hospital. A questionnaire was used to evaluate shoulder symptoms and an examination of the shoulder and arm was carried out three times over 6 months. A total of 108 patients were studied with a mean age of 71 years. Sixty-nine patients (63.8%) developed HSP at some time during the study period. The number with HSP was 39 at discharge from hospital, 59 at 8 weeks post-discharge and 36 at 6 months. Nine carers reported lifting the patient by pulling on the hemiplegic arm, even though six of them had received advice about correct lifting techniques. Reduced shoulder shrug was associated with HSP at all times and reduced pinch grip was also associated with HSP at discharge from hospital. Patients who required help with transfers were more likely to suffer with HSP. There was no difference in the prevalence of HSP in patients treated at the day hospital compared to those who received domiciliary physiotherapy. It is concluded that HSP is common after a stroke and the prevalence increases in the first weeks after discharge from hospital. Stroke patients and their carers need advice about correct handling of the hemiplegic arm, and more work is required to ensure that correct handling occurs after discharge in patients at high risk of this unpleasant complication.     

类固醇激素肩关节注射对偏瘫肩痛康复效果的Meta分析

目的：评价类固醇激素肩关节注射对偏瘫肩痛（HSP）患者的康复效果，为HSP康复提供循证依据。方法：计算机检索Web of Science、EMBASE、The Cochrane Library、PubMed、中国知网（CNKI）、万方数据库、维普数据库（VIP）中从建库至2020年7月发表的有关类固醇激素与空白/安慰剂肩关节注射疗效比较的随机对照试验（RCT）。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后，采用RevMan 5.3和StataSE 12.0软件进行统计分析。结果：最终纳入9篇文献，其中英语文献5篇，中文文献4篇，共416人。与空白/安慰剂相比，类固醇激素肩关节注射可以显著降低HSP患者的疼痛［SMD＝0.93，95%CI（0.71，1.14），Z＝8.46，P<0.01］，改善日常生活活动能力［SMD＝-0.42，95%CI（-0.65，-0.20），Z＝3.71，P＝0.0002］和上肢运动功能［SMD＝-1.02，95%CI（-1.68，-0.36），Z＝3.02，P＝0.003］，提高肩关节前屈［MD＝-15.41，95%CI（-23.30，-7.52），Z＝3.83，P=0.0001］、外展［MD＝-12.16，95%CI（-15.67，-8.65），Z＝6.79，P<0.01］、外旋［MD＝-8.47，95%CI（-9.94，-7.00），Z＝11.30，P<0.01］和内旋ROM［MD＝-2.95，95%CI（-4.57，-1.32），Z＝3.56，P＝0.0004］。结论：类固醇激素肩关节注射能安全、有效地促进降低HSP患者疼痛，促进上肢功能康复。     

音乐治疗对脑卒中肩痛伴有情绪障碍患者临床疗效的观察

目的:观察音乐治疗对脑卒中后肩痛伴情绪障碍患者的治疗效果,为探究脑卒中后肩痛伴情绪障碍患者的康复干预提供参考。方法:选择肩痛伴情绪障碍的脑卒中患者92例,随机分为常规组和观察组各46例。92例患者均给予常规药物治疗和康复治疗,观察组根据个体化原则联合音乐干预。干预前后对所有患者进行疼痛目测类比法(VAS),上肢Fugl-Meyer运动功能评定量表(FMA),汉密顿焦虑量表(HAMA),汉密顿抑郁量表(HAMD)评定。结果:治疗4周后,2组VAS、HAMA、HAMD评分均较治疗前明显降低(均P 0. 05),观察组更低于常规组(P0. 05); 2组FMA评分均较治疗前明显提高(均P 0. 05),观察组更高于常规组(P 0. 05)。结论:音乐治疗不仅可明显减轻脑卒中后肩痛,还可提高患者的运动功能和改善患者的情绪。     

肩胛上神经阻滞联合肌内效贴对脑卒中后肩痛的疗效分析

目的:初步观察肩胛上神经阻滞结合肌内效贴对脑卒中后肩痛患者上肢功能的疗效。方法:40例脑卒中后肩痛患者随机分为观察组和对照组各20例,对照组给予肩胛上神经阻滞加常规康复治疗,观察组在此基础上辅以肌内效贴治疗。比较2组患者治疗前后的疼痛视觉类比法(VAS)、Fugl-Meyer上肢运动功能评分(FMA-U)、改良Barthel指数(MBI)及肩关节被动活动度(PROM)。结果:治疗4周后,2组VAS评分较治疗前明显降低,上肢FMA-U评分、MBI评分及肩关节PROM明显较治疗前提高(均P0.05),观察组VAS评分、上肢FMA-U评分、MBI评分及肩关节PROM较对照组改善更明显(均P0.05)。结论:肩胛上神经阻滞结合肌内效贴可有效缓解脑卒中后患者肩部疼痛,对提高患者上肢功能及日常生活活动能力有重要的康复意义。     

Reliability and relationship of the fear-avoidance beliefs questionnaire with the shoulder pain and disability index and numeric pain rating scale in patients with shoulder pain

Purpose: The purpose of this study was to determine: 1) the test–retest reliability of Fear-Avoidance Beliefs Questionnaire (FABQ) Work (FABQW) subscale, FABQ Physical Activity (FABQPA) subscale, Shoulder Pain and Disability Index (SPADI) Pain subscale, SPADI Disability subscale, and Numeric Pain Rating scale (NPRS); and 2) the relationship between the FABQPA, FABQW, SPADI pain, SPADI disability, and NPRS after 4 weeks of pragmatically applied physical therapy (PT) in patients with shoulder pain. Design: Prospective, single-group observational design. Methods: Data were collected at initial evaluation, the first follow-up visit prior to the initiation of treatment, and after 4 weeks of treatment. Results: Statistically significant Intraclass Correlation Coefficient (ICC_2,1) values were reported for the FABQPA, FABQW, SPADI Pain, SPADI Disability, and NPRS. A statistically significant moderate relationship between the FABQPA subscale, SPADI subscale, and NPRS could not be established prior to and after 4 weeks of pragmatically applied PT. Statistically significant differences were observed between the initial evaluation and four-week follow-up for the FABQPA, SPADI Pain, SPADI Disability, and NPRS (p < 0.01). Discussion: Since a meaningful relationship between the FABQ, SPADI, and NPRS did not exist, it suggests that the FABQPA may be measuring a metric other than pain. Conclusions: This study suggests that the FABQW may not be sensitive to change over time.     

脑卒中后肩痛患者肩关节的磁共振成像表现初探

目的 利用磁共振成像(MRI)分析脑卒中后恢复期肩痛患者肩关节结构异常改变,探讨脑卒中后肩痛的病因.方法 将符合入选标准的脑卒中患者52例根据患者有无肩痛分为肩痛组(32例)和非肩痛组(20例),2组患者均行常规查体及双侧肩关节MRI检查,并对检查结果行统计学分析.结果 ①2组患者各项临床指标:肩痛组患者肩关节半脱位发生率为53％,与非肩痛组的15％比较,差异有统计学意义(P＜0.05);肩痛组患者肩关节各方向被动活动均受限,其中外展、外旋的被动活动度与非肩痛组比较,差异均有统计学意义(P＜0.05).2组患者Brunnstrom分期评价,肩痛组患侧上肢运动功能不良者27例(84％),非肩痛组为14例(70％),组间差异无统计学意义(P＞0.05);肩痛组痉挛发病率为41％,与非肩痛组的30％比较,差异无统计学意义(P＞0.05).②MRI结果显示:肩痛组患侧肩袖损伤、SA-SD积液、盂肱关节积液和二头肌腱鞘积液的发病率分别为63％、52％、75％和44％,分别与健侧的13％、13％、31％和13％比较,差异均有统计学意义(P＜0.05);非肩痛组患侧盂肱关节积液的发病率为70％,与健侧的17％比较,差异无统计学意义(P＞0.05).肩痛组患侧肩袖损伤、SA-SD积液的发病率与非肩痛组患侧比较,差异亦有统计学意义(P＜0.05).2组患者健侧MRI结果比较,差异均无统计学意义(P＞0.05).结论 肩袖损伤可能是脑卒中后恢复期肩痛的原因之一.     

Trajectories of pain in adolescents: a prospective cohort study

Identification of different patterns of change in pain over time - trajectories - has the potential to provide new information on the course of pain. Describing trajectories among adolescents would improve understanding of how pain conditions can develop. This prospective cohort study identified distinct trajectories of pain among adolescents (11-14 years) in the general population (n = 1336). Latent class growth analysis was carried out on the self-reported frequency of back pain, headache, stomach pain and facial pain, which was collected every 3 months for 3 years. Forty four percent of adolescents had a ‘painful’ trajectory for at least one pain site, and 12% reported persistent pain at one or more pain site. Headache was the most common; 25% of subjects were in a ‘painful’ trajectory and 5% reported persistent pain. Back pain and stomach pain were also common, with 22% and 21% of subjects in painful trajectories, respectively. Facial pain was the least common, with only 10% in a painful trajectory, and 1% reporting persistent pain. Trajectory characteristics were similar at baseline across pain sites, with the more painful trajectories having significantly higher levels of depression and somatization, lower life satisfaction and more females. Trajectories did not differ significantly at baseline in physical activity levels or BMI. Agreement of trajectory membership among pain sites was moderate. In summary, reporting a painful trajectory was common among adolescents, but persistent pain was reported by a small minority, and was usually experienced at a single pain site.     

超声引导下复方倍他米松和盐酸利多卡因注射对脑卒中后肩关节疼痛的改善作用

目的  分析超声引导下复方倍他米松和盐酸利多卡因注射对脑卒中后肩关节疼痛的改善作用。方法  选取2020年1月~ 2021年6月于本院治疗的60例脑卒中后肩关节疼痛患者为研究对象,按照随机数字表法将患者分为治疗组和对照组,30例/ 组。对照组在常规康复治疗基础上进行徒手定位药物注射治疗;治疗组在常规康复治疗基础上进行超声引导下复方倍他米松和盐酸利多卡因注射。观察比较两组患者治疗前后疼痛程度、肩关节活动度、上肢功能运动情况和不良反应发生情况。结果  治疗2周、4周后,治疗组患者视觉模拟评分低于对照组患者（P < 0.05）,肩关节前屈、外展、外旋活动度大于对照组患者（P < 0.05）,Fugl-Meyer运动功能量表上肢部分评分高于对照组患者（P < 0.05）;两组患者不良反应总发生率差异无统计学意义（P>0.05）。结论  相较于徒手定位药物注射治疗,超声引导下复方倍他米松和盐酸利多卡因注射对脑卒中后肩关节疼痛患者疼痛改善效果更为明显,可有效改善肩关节活动度和上肢运动功能。     

针灸治疗脑卒中后偏瘫颈肩痛的临床效果

目的 探讨针灸治疗脑卒中后偏瘫颈肩痛的临床效果。方法 选取2018年5月至2020年5月本院200例脑卒中后偏瘫颈肩痛患者作为研究对象,按照随机数字表法将其分为对照组和观察组,各100例。对照组给予常规西药治疗,观察组在对照组基础上给予针灸治疗。比较两组患者的神经功能、疼痛程度、肢体功能、临床疗效。结果 治疗前,两组的NFDS、VAS评分比较,差异无统计学意义（P>0.05）;治疗后,两组的NFDS、VAS评分均较治疗前降低,且观察组低于对照组,差异具有统计学意义（P<0.05）。治疗前,两组的上肢功能、下肢功能评分比较,差异无统计学意义（P>0.05）;治疗后,两组的上肢功能、下肢功能评分均较治疗前升高,且观察组高于对照组,差异具有统计学意义（P<0.05）。观察组的治疗总有效率为94.00%,高于对照组的81.00%,差异具有统计学意义（P<0.05）。结论 针灸治疗脑卒中后偏瘫颈肩痛的效果显著,可改善患者的神经功能及肢体功能,缓解疼痛程度,值得临床推广应用。