Management of shoulder and proximal upper limb spasticity using botulinum toxin and concurrent therapy interventions: A preliminary analysis of goals and outcomes

Purpose. To explore the role of Botulinum Toxin type A (BoNT-A) in the management of the spastic hemiplegic shoulder and identify the common achievable goals for treatment.

Method. Set in a regional spasticity management service in the UK, a prospective observational cohort study was undertaken. Patients (n = 16) were receiving BoNT-A (Dysport©) injection and concurrent therapy for spasticity of the shoulder girdle or proximal upper limb following stroke/other acquired brain injury. Mean age 54.5 (SD 15.7) years. Mean time since injury: 15.7 months. Functional goals for intervention were determined through agreement with the patient or their carers using Goal Attainment Scaling (GAS). Evaluation of spasticity (Modified Ashworth Scale), pain (numbered graphic rating scale) and three standard passive function tasks (washing, dressing and positioning) were also undertaken.

Results. Sixteen weeks post-injection, significant improvements were identified in spasticity (Z = ?3.535, p <0.0001), pain (Z = ?1.942, p = 0.052) and passive function (Z = ?3.172, p = 0.002). GAS scores had improved in all but one subject, with goals either achieved or over-achieved.

Conclusions. BoNT-A injection of the proximal upper limb, with combined therapy, produced a reduction in spasticity, improvement in passive function and pain. Management of upper limb spasticity should include evaluation and, if necessary treatment, of the shoulder girdle and proximal musculature.     

The effectiveness of low-level laser therapy on shoulder function in subacromial impingement syndrome

Purpose. To investigate the effectiveness of low-level laser therapy (LLLT) in addition to exercise programme on shoulder function in subacromial impingement syndrome (SAIS).

Method. Sixty-seven patients with SAIS were randomly assigned to either a group that received laser (n = 34) or a group that received placebo Laser (n = 26). Pain, functional assessment, disability and muscle strength of shoulder were assessed before and after a 3-week rehabilitation programme. Besides Laser or placebo Laser, superficial cold and progressive exercise programme were administered to both groups, 5 days a week, for 3 weeks. A progressive exercise programme that was done daily twice under supervision in clinic and at home was given to the patients.

Results. After the treatment, all outcome measurements had shown significant improvement except muscle strength in both the groups. When the parameters of the improvement were compared, there were no significant differences between the two groups after treatment.

Conclusion. We concluded that there is no fundamental difference between LLLT and placebo LLLT when they are supplementing an exercise programme for rehabilitation of patients with shoulder impingement syndrome.     

Assessment of shoulder pain in hemiplegia: Sensitivity of the ShoulderQ

Background.?The ShoulderQ is a structured questionnaire designed to assess timing and severity of hemiplegic shoulder pain (HSP), in order to target pain relief effectively. It includes both verbal and visual graphic rating scale questions, simply presented for patients with language/visuo-spatial deficits following stroke.

Objective.?To assess the sensitivity of the ShoulderQ to clinical improvement in shoulder pain following multi-disciplinary intervention.

Design and setting.?Retrospective analysis of serial questionnaires collected in the course of clinical treatment in an in-patient neurological rehabilitation unit.

Subjects and interventions.?Thirty consecutive adults with cognitive and communicative deficits, presenting with hemiplegic shoulder pain following acquired brain injury. Multi-disciplinary treatment was delivered through an integrated care pathway, and ShoulderQs recorded fortnightly, including at baseline and end of treatment.

Results.?Changes on visual graphic rating scale (VGRS) were associated with verbal reports of improvement (rho 0.665, p < 0.001). Patients were divided retrospectively on the basis of their overall clinical response into responders (n = 18) and non-responders (n = 12). Responders showed significant change in both VGRS and verbal scores, whereas the non-responder group did not. A change in summed VGRS score of ≥3 showed 77% sensitivity and 91.3% specificity for identifying the responders, with a positive predictive value of 93.3%. Summed VGRS scores of ≤2 had a negative predictive value of 73.3%.

Conclusion.?In this preliminary evaluation of clinical data, the ShoulderQ appears to provide a sensitive measure of shoulder pain which is responsive to change in pain experience for those able to complete the questionnaire, despite the difficulties that many of this group of patients may have in reporting their symptoms. Set alongside previously reported test-retest reliability, the results support the utility of the ShoulderQ as a simple and practical tool for evaluation of shoulder pain in patients with severe complex disabilities.     

玻璃酸钠联合痛点神经阻滞治疗冻结肩的临床疗效分析

目的:观察肩关节腔内注射玻璃酸钠及肩周痛点、肩胛上神经阻滞治疗冻结肩的临床效果.方法将冻结肩患者随机分为3组,每组20例.A组(肩周痛点及肩胛上神经阻滞组),B组(肩关节腔注射玻璃酸钠组),C组(联合治疗组);每周1次,5次为一个疗程;治疗期间行肩关节功能锻炼.观察治疗前后各组的治疗效果.结果:3组患者较治疗前皆取得了满意的效果;C组的治疗效果尤为明显,与A组、B组比较,差异具有显著性(P＜0.05).结论:联合方法治疗冻结肩效果好于单独使用肩周痛点及肩胛上神经阻滞和肩关节腔注射玻璃酸钠法.     

术前不牵引用组合性手术治疗年长儿先天性髋关节脱位

[目的]探讨术前不牵引用组合性手术治疗年长儿先天性髋关节脱位(CDH)的治疗效果.[方法]选择28例CDH,男9例,女19例,双髋脱位4例,共32个髋关节.年龄7～13岁,平均9.8岁.术前股骨头上移1.2～5.0cm,平均3.1cm,髋臼指数38～62°,平均46°.应用组合性手术方法,术中先松解股内收肌,再取Smith-Peterson切口,充分剥离松解髂骨内外板肌肉,"Z"形延长腰大肌,其中股骨必须短缩、旋转截骨,先用组合式外固定器固定截骨断端,盐水冲洗髋臼,将股骨头复位,这样可以方便测量、矫正和调整股骨上段的角度,保留前倾角20°,颈干角130°左右,股骨截骨端再上钢板固定,但外固定仍保留.髋臼顶强力造盖,关节囊"7"形切开和正确关闭,术后患肢持续牵引4～6周,早期活动髋关节.[结果]术后随访2～6a5个月,平均3.8a,优14髋,良9髋,可7髋,差2髋,优良率71.9%.[结论]术前不牵引手术治疗年长儿CDH,正确选择手术指证,应用组合性手术,术后持续牵引下早期活动髋关节,可获得较好效果.年长儿CDH复位手术后,亦为中年后需施行全髋关节置换者创造近似正常的解剖条件.     

冻结肩一次治愈——发现新体征及其对诊断与治疗的意义

用手法松解治疗冻结肩152例。发现新体征:1.腋前襞挛缩与上臂夹角变锐;2.腋后襞挛缩,背阔肌变短;3.肩关节外展肩峰与肱骨大结节间皮肤凹窝消失;4.胸椎侧弯;5.患侧手无名指掌指关节屈肌腱鞘结节样增厚,压痛明显。探讨了其对诊断及治疗的意义。     

Dislocations of the sternoclavicular joint

Dislocations of the sternoclavicular joint are uncommon, with the posterior variety having a potential for considerable morbidity. Radiologic management and diagnosis can be difficult. In this review article, the joint antomy and mechanisms of dislocation are discussed and the incidence and clinical manifestations described. Six case reports are presented to illustrate causative mechanisms, diagnoses, and radiologic appearances. Computed tomography is the best method of demonstrating the sternoclavicular joint, but a number of specialized plain film projections are also described and illustrated; these should be more widely known. Treatment of the joint dislocations is briefly discussed.     

Intertrochanteric valgus lengthening osteotomy in adults with coxa vara

Surgical Principles Intertrochanteric open wedge valgus osteotomy with lateral femoral displacement to gain limb length. Internal fixation with a 95° condylar plate. Revised Version from: Operat. Orthop. Traumatol. 2 (1990), 193–202 (German Edition).     

Pseudarthrosis of the acromion - a differential diagnosis in anterolateral shoulder pain

A case of longstanding posttraumatic anterolateral shoulder pain in a 25-year-old woman is presented. It was primarily unsuccessfully handled as impingement syndrome but turned out to be caused by pseudarthrosis of the acromion. The abnormality was not apparent on plain X-ray film. The suspicion was raised after scintigraphy, which showed increased density in the acromion. The diagnosis was made by computerized tomography and confirmed and treated successfully surgically.     

回旋扣压法治疗肩关节脱位

目的:探讨肩关节脱位的简易复位方法。方法:对1990～2002年门诊治疗的27例肩关节脱位行回旋扣压法复位进行回顾性分析。结果:27例新鲜或习惯性肩关节脱位经回旋扣压法复位,非麻醉下复位成功19例,首次复位失败经臂丛麻醉后复位成功6例。结论:应用回旋扣压法对肩关节脱位进行复位方法简单,可单人非麻醉下进行,动作温柔,能减少患者的紧张情绪,特别适用于新鲜或习惯性肩关节脱位。操作中不使用暴力,有四两拨千斤之功效。