肩的疼痛2015 ppt課件

1、肩的疼痛Shoulder Pain,ＢＯＢＡＴＨ紀念醫(yī)院　古澤　正道Masamichi FURUSAWABobath Memorial Hospital,腦卒中后遺癥中約有２１～７２％的患者主訴肩痛。Twenty-one % to 72 % of stroke patients complain of shoulder pain.文獻：Van Ouwenaller et al.: Painful shoulder in h

2、emiplegia. Arch 　　　　　　Phys Med Rehabil, 67 : 23-25, 1986. 　　　　　　　　　　　　　　　　　　　Bohannon RW et al.: Shoulder pain in hemiplegia : Statistical 　　　　　relationship with five variables. Arch Phys Med Rehabil, 67 : 　　　　　514-

3、516, 1986. 　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　 Chard MD, Hazleman BL : Shoulder disorders in the elderly. 　　　　　Ann Rheum Dis, 46 : 684-687, 1987. 　　　　　　　　　　　　　　　　　　　　Van Iangenberghe HVK et al.: Shoulder pain in hemiple

4、gia : A book review. Physiother Pract, 4 : 155, 1988.,３種疼痛　(Three kinds of shoulder pain)① 活動時疼痛(Mechanical and local pain while moving and being moved)　　　　　　被動活動和自主活動時的局部疼痛。②安靜時自發(fā)疼痛 (Spontaneous and extensive pain a

5、t rest)　 　夜間睡覺時與長時間輪椅保持坐位時，麻痹的上下肢的存在廣泛的疼痛。肩手綜合征的患者多伴有浮腫?！∵M行運動療法時該癥狀容易消失，故問診是必不可少的。肩的活動時疼痛多先出現(xiàn)。This pain is spontaneous and extensive pain in affected

6、 upper and lower extremities at rest when patients lie on beds and sit on wheelchairs. Most of patients have edema due to shoulder-hand syndrome. As this kind of pain disappears in movement therapy, therapists must ask

7、whether they have such kind of pain or not. This extensive pain tends to be initiated by local shoulder pain. 　　　　　　　　Braus DF et al.: The shoulder-hand syndrome after stroke : A 　　　　　　　 prospective clinical trial. A

8、nn Neurol, 36 : 728-733, 1994.,３種疼痛　(Three kinds of shoulder pain)③ 視丘痛(Thalamic pain)　　　　　　　　　　　　　　　　　　　　　　　　在視床后外側癥候群中，90%的后外側損傷病例可見此種疼痛。Thalamic pain is one of syndrome in the lesion of posterior-lateral part.Ni

9、nety % of patients with the lesion of that part had thalamic pain.(Miyazaki 1997)宮崎東洋：ペインクリニック. 克誠堂、pp40-47?182-193、1997.,花岡一雄?橘直矢：わかりやすい神経系の話. メディカルトリビューン、東京、ｐ５２、１９８５.,posterior,anterior,rightwards (lateral),leftw

10、ards (medial),posterolateral n.,pulvinar thalamus,ventral posterolateral n.,dorsolateral n.,（前外側腹側核）,ventral anterolateral n.,（中間腹側核）　ventrointermedial n.,視 床　Thalamus,dorsomedial n.（視床內側核）,medial corpus geniculatum,

11、lateal corpus geniculatum,(Mori, 1995)森於兎（原著）：解剖學１（改訂１１版）. 大內弘（改訂）、金原出版、p336、1995.,lower fibres of trapezius,upper fibres of trapezius,serratus anterior,levator scapulae,rhomboid minor,rhomboid major,centre of rotati

12、on,centre of rotation,肩胛骨的運動 Scapular Motion,前方,後方,內側,上方,下方,外側,上方,後方,下方,前方,內側,外側,後傾 posterior tilting,,前傾 anterior tilting,上方回旋,upward rotation,,,下方回旋 downward rotation,內旋 int. rot.,,,外旋　 ext. rot.,Bra

13、man JP, Engel SC, LaPrade RF, et al.: In vivo assessment of scapulohumeral rhythm during unconstrained overhead reaching in asymptomatic subjects. J Shoulder Elbow Surg, 18 : 960-967, 2009.,Average humerothoracic plane e

14、levation : 63.3±7.0°forward of coronal plane, and average peak elevation : 132.9±9.9°　　　?、賁capular Rot : Int. Rot. until 125°of arm elevation, then rotated externally with further elevation. 　　

15、?、赟capulohumeral rhythm, 2.3 : 1 during elevation. 　　　2.7 : 1 during lowering.　　　　　③Maximally tilted 11.8±4.9°anteriorly at 15°of humerothoracic elevation. 　A minimum posterior tilt of 9.8±7.5°at

16、 145°.,①,②,③,7,活動時疼痛( Mechanical and local pain )■初期遲緩期的移乘和臥位翻身時的細微損傷（對于患側上臂的KP應該慎重使用，體干的KP效果較好）In initially flaccid stage, caregivers sometime give microtraumas and excessive stretches of affected shoulders. (I

17、n early stage therapists and caregiver must carefully use proximal and distal KP of affected upper extremities in transfer and turning over. We had better use affected trunks and scapulae.) ■肌張力的不平衡和肌肉（軟組織）粘彈性低下Imba

18、lance of postural muscle tone and decrease of viscoelasticity of muscles and soft tissues① 肩胛骨的不穩(wěn)定 Instability of affected scapula②容易產生短縮的肌肉：胸小肌、胸大肌尤其是鎖骨枝、肱二頭肌、喙肱肌、菱形肌、背闊肌等。與遲緩肌混合在一起。 Shortness : pect minor, pect major

19、 (especially clavicular portion), biceps, coracobrachialis, rhomboids, latissimus dorsi and so on. These exist with hypotonic muscles.①②　　　　恢復肩肱節(jié)律，去除胸大肌的負荷（ de-weight ）　

20、 Recovery of scapulohumeral rhythm & De-weight to P. Major 　Bobath K : Shoulder pain. Phys Ther, 52 : 444-445, 1972.,,,Myers TW : Anatomy Train. Churchill　Livingstone, London, pp18?

21、163, 2006.,Pectoralis minor connects fascially to short head of biceps brachii and coracobrachialis at coracoid process.,9,粘連(Adhesion)■根據偏癱患者肩關節(jié)造影，25%的患者存在粘連變形。特別是肱二頭肌腱鞘達到了58%。 (Fukui 1972) In arthrography, 58% of

22、tendonsheaths of biceps had adhesion.　　　　　　　　福井國彥：片麻痺肩の造影レ線像を中心とする所見及び経過について. リハ醫(yī)學、9 : 183、1972.■偏癱的患側肩多少呈現(xiàn)了粘連性癥狀，48個病例中27個有此癥狀（56.3%）。(Hakuno 1984) Fifty-six % of affected shoulders had adhesion.　　　　　　　　白野明?

23、他：片麻痺肩の関節(jié)造影上の変化について. 総合リハ、12 : 　　　　　　　　　　　　47-52、1984.■偏癱患者關節(jié)造影，根據與半脫位肩關節(jié)的比較，在半脫位上產生關節(jié)的粘連性變化更為常見。而且從肩關節(jié)整體來看粘連的產生也是在半脫位更容易產生。撞擊的可能性極小?！?Hakuno 1986)　In arthrography of 95 shoulder joints, most of adhesion was accompanie

24、d with shoulder joint subuxations.　　　　　　　　　　　　　　　　　　　　　　白野明：片麻痺肩の関節(jié)造影所見. 総合リハ、14 : 203-207、1986.,粘連 (Adhesion)■在實行肩關節(jié)造影的50例病例之中，肩肱關節(jié)處的粘連變化達80%，腱斷裂存在14%。 　　　　　　　　　

25、 (Ono 1994) In arthrography of 50 cases, 80% had adhesion of scapurohumeral joints, and 14% had rupture of tendons.　　　　　　　　小野幸子?他：片麻痺患者の肩痛. リハ醫(yī)學、31 : 928-929、1994.■以發(fā)病未滿1年、主訴肩痛的患者32人進行關節(jié)造影。發(fā)病后2個月以內沒有肩痛癥狀的，50%的病人存

26、在粘連性囊炎(adhesive capsulitis)?！　　?22%的人旋轉肩袖（rotator cuffs ）斷裂，16%存在肩手綜合征、44%存在肩關節(jié)半脫位。粘連性囊炎為肩關節(jié)疼痛的誘因。 　　 Fifty % o

27、f 32 cases who complained of shoulder pain had adhesive capsulitis. Twenty-two % had rupture of rotator cuffs, 16 % had shoulder hand syndrome and subluxations of shoulder joints were found in 44 %. Adhesive capsuli

28、tis is one of causes of shoulder pain.　　　　　　　　Lo S-F et al.: Arthrographic and clinical findings in patients with 　　　　　　　　　　　　　hemiplegic shoulder pain. Arch Phys Med Rehabil, 84 : 1786-1791, 　　　　　　　　　　　　2003.,粘連 (adh

29、esion) ■由于浮腫導致肱二頭肌、肱三頭肌長頭等起始部位腱鞘和關節(jié)囊的短縮和粘連。 Edema makes shortness and adhesion in capsules and tendonsheaths of biceps brachii and

30、 triceps brachii etc. Roy CW : Shoulder pain in hemiplegia : A literature review. Clinical Rehabilitation, 2 : 35-44, 1988.

31、 ■腱炎?粘連性囊炎　(tendinitis and adhesive capsulitis )　　　　　　　　　　　　　　　　　　　　　　　　　　　　肱二頭肌長頭的疼痛波及肌腹以及肱二頭肌間溝的腱炎，在前臂內側面出現(xiàn)疼痛，肘部形成二頭肌腱炎。 　 Some of he pain in origin of biceps brachii long head comes out in its belly, whi

32、ch is tendinitis in intertubercular groove. The teniditis in the insertion of biceps brachii indicates pain in upper and volar side. Donatelli RA : 肩のリハ

33、ビリテーション. 山本龍二?他（監(jiān)訳）、　　　　　　メディカル葵出版、東京、pp83-101、2002. ■臨床觀察　(In the clinical observation)　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　在長期臥床的病例中，在胸廓和背部可見短縮與粘彈性低下，上肢上舉時肩胛骨和肋骨的分節(jié)運動困難。 　

34、 In the cases who have experienced to lie on beds in long term, shortness and decrease of viscoelasticity of back muscles are observed. These problems made

35、segmental movements of ribcages poor.,Cailliet R : 肩の痛み（第３版）.荻島秀男（訳）、醫(yī)歯薬出版、pp14?51、2004.,肱二頭肌長頭的沖突Impingement/stretch of the long head of biceps brachii in intertubercular groove ? Pain,capsule,long head of biceps,s

36、ynovial membrane,long head of biceps,synovial fluid,synovial membrane,,transverse ligament,,biceps,,Scapulohumeral Synovial Bursa and Joint Capsule,coracoacrominal lig.,Mechanism of Biceps (long head),伸展二頭肌長頭在結節(jié)間溝? 疼痛,Im

37、pingement 撞擊　　　　　　　　　　　　　　　　　 (impingement syndrome, chronic subacrominal impingement syndrome)肩峰、喙肩韌帶、喙突、肩鎖關節(jié)會與腱板和肩峰下滑液囊發(fā)生撞擊，發(fā)生慢性的持續(xù)的疼痛時，稱為impingement綜合癥。 Impingement is the phenomenon that the acromion, coracoacromi

38、nal lig., coracoid process and acromioclavicular joint collide to rotator cuffs and subacrominal bursa. When collisions are repeated and pain occurs, it is called impingement syndrome.(Tamai 2002) 玉井和哉：インピンジメント癥候群

39、. 「肩の痛み」 寺山和雄?片岡治（監(jiān)修）、南江堂、pp85-98、2002.,■撞擊與夾痛　impingement & pinching　　　　　　　　　　　　上肢水平外展運動中產生的疼痛，推測為肩峰下滑液囊　　　　　　　　　　　　和肱三頭肌長頭的夾痛。 The pain while moving an arm horizontally is guessed to be caused by pinching a

40、capsule and a long head of triceps brachii.■根據運動方向產生的疼痛 Different local pain in different directions of the movement 前方上舉時的疼痛 (What is the local p

41、ain while elevating a arm ?) ：　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　水平外展時的疼痛 (What is the local pain while abducting horizontally ?) ：　　　　　　　　　　　　　　　　　　　　　　　水平內收時的疼痛 (What is the local pain while adducting horizontally?) ：　　

42、　　　　　　　　　　　　　　　　　　　　　　上肢放下時的疼痛 (What is the local pain while descending arm ?) ：,,(Mori 1995)

43、 森於兎（原著）：解剖學１（改訂１１版）. 大內弘（改訂）、金原出版、pp128?341、1995.,結節(jié)間溝Intertubercular groove,,肱二頭肌長頭long head tendon of biceps brachii,,(Mori 1995)　　　　　　　　　　　　　　　森於兎（原著）：解剖學１（改訂１１版）. 大內弘（改訂）、金原出版、p207、199

44、5.,結節(jié)間滑液鞘Intertubercular synovial membrane,,(Yazaki 2008)　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　矢崎潔：再び人間の上肢の運動を考える（１）.　ボバースジャーナル、31(1) : 54-61、2008.,肘關節(jié)屈伸運動時（Ｃ）的肱三頭肌和胸大肌的關系　Relationship between biceps and pectoralis maj

45、or when an elbow extends and flexes. （Ａ）肱二頭肌起作用時長頭腱產生壓力的方向 The direction of power on the long head of biceps brachii　　　　　　　　　 （Ｂ）伸展時，生理上作為協(xié)同肌的胸大肌對肱骨的牽引方向　　 The direction of contr

46、action on the pectoralis major when elevating an humerus　　　　　　　　　　　　　　　　　　、、（Ｄ?Ｅ）肱二頭肌和胸大肌的位置關系　elationship on alignments between long head of biceps and p. major長頭肌腱處直接加壓，結節(jié)間溝和周邊疼痛　Pressure is given to a long head of b

47、iceps in intertubercular groove, and pain tends to occur.,,flexion,extension,４９歲男性、腦出血（右側偏癱）、發(fā)病后２月、右肩痛 Age : 49 Y, Male, Dx.: Cerebral Hemorrhage (Right Hemi and Rt. Shoulder Pain), 2 Months after a Stroke,翻身時麻痹側右上肢

48、落在身后，牽張痛會在肱二頭肌長頭起始部出現(xiàn)。When he turns over from supine to left side-lying while sleeping on a bed, he often leaves his right arm and then has right shoulder pain.,,,為了預防對于肱二頭肌長頭起始部位過度的伸張和撞擊，調整肩肱節(jié)律。 In order to preve

49、nt stretch and impingement, scapulohumeral rhythm is corrected with placing.,,,,,在患者翻身時,PT要誘導從右側上肢開始的翻身動作。保持肩胛帶的前伸。A therapist guides the right scapula and arm move upward when turning over. The patient’s awareness

50、 is important.,,Self control to prevent shoulder pain患者自己控制，左手把持麻痹側上肢，在不引起疼痛下翻身。,,,(Mori 1995) 森於兎（

51、原著）：解剖學１（改訂１１版）. 大內弘（改訂）、金原出版、pp337?344、1995.,水平外展時肱骨三頭肌長頭和關節(jié)囊的夾痛　 Pinching ad pain of a long head of triceps brachii and a joint capsule abducting horizontally.,,,Long head of triceps,Teres major,Teres minor,Long head

52、of triceps,Teres major,(Tamai 2002) 玉井和哉：インピンジメント癥候群. 「肩の痛み」 寺山和雄?片岡治（監(jiān)修）、pp85-95、2002. 　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　Neer CS: Cuff tears, biceps lesions, and impingement. Shoulder Reconstruction. (Ed.) N

53、eer CS, WB Saunders, Philadelphia, pp41-142, 1990. (右図),Impingement 撞擊綜合癥Impingement Syndrome,岡上肌出口狹小化　　　Narrow supraspinatus outlet,,Cailliet R : 肩の痛み（第３版）.荻島秀男（訳）、醫(yī)歯薬出版、pp27-28?66-68、2004.,在損傷部位的壓痛,Rupture of Supraspin

54、atus　　　　　　岡上肌的斷裂,Pressure pain in the lesion,肩懸吊肩(Shoulder Sling),,左側偏癱Lt. Hemi.,活動時疼痛的對策 (The approach to local pain while moving) ■平衡肌張力和恢復肌肉粘彈性 Postural control, modulation of postural muscle tone, restoration

55、 of vscoelsticity.■恢復肩肱節(jié)律　Recovery of scapulohumeral rhythm?肩胛骨的定勢Scapula setting?肩胛帶的穩(wěn)定性與運動性　Selective stability and movement of scapula ■對于短縮，在KP控制的部位導入關節(jié)松動術　

56、 Mobilizing to shortness of muscles and soft tissues,肩胛骨的定勢　　Scapula setting腦梗塞（右側偏癱）　68歲　男性Dx. Cerebral Infarction (Rt. Hemiplegia) Age : 68Y,,,,,,Scapula setting,,,,偏癱側肩胛提肌起始部的疼痛Pain in the origin of aff

57、ected levator scapulae ＊姿勢性疲勞 Postural fatigueCailliet R : 肩の痛み（第３版）.　荻島秀男（訳）、醫(yī)歯薬出版、pp275-285、2004.,,,短縮　Shortness,疼痛　Pain,左側骨盆后撤　　　　　 Lt. pelvis retraction,,Caillet R :　頚と腕の痛み（第３版）. 荻島秀男（訳）、醫(yī)歯薬出版、p226、2004.,Incr

58、ease of kyphosis,Downward rotation,Levator scapulae,Locked long muscles : Strained,Locked short muscles : Bunched（一塊）,不活動的長?。壕o張（＋）,Myers TW : Anatomy Train. Churchill　Livingstone, London, p18, 2006.,Increase of thixot

59、ropy (觸變性的改變）,28,肩手綜合癥始于疼痛的肩和上肢　　　　Shoulder-hand syndrome is occurred by local pain in affected shoulders and upper extremities.Donatelli RA : 肩のリハビリテーション. 山本龍二?他（監(jiān)　訳）、メディカル葵出版、東京、pp83-101、2002.,,Braus DF et al.: Th

60、e shoulder-hand syndrome after stroke : A prospective 　　　　　clinical trial. Ann Neurol, 36 : 728-733, 1994.,肩手綜合癥由局部損傷引起。Shoulder-hand syndrome is initiated by peripheral lesions (local pain).,大范圍的麻痹側上下肢的安靜時自發(fā)痛Spontaneou

61、s and extensive pain at rest　　　　　　　　　　　　■首先出現(xiàn)麻痹側運動時的局部疼痛。 　推測疼痛是由于炎癥時產生的緩激肽、復合胺、組胺、鉀離子等的神經激肽廣泛存在于浮腫部位。緩激肽等物質促進組織產生、游離前列腺素類物質。 The local shoulder pain w

62、hile being moved occurs before this kind of pain. It is guessed that the neurokinin like bradykinin, serotonin, histamine, Ach and potassium is accumulated a lot in edema and then production of prostaglandin is increa

63、sed and causes spontaneous and extensive pain of affected upper extremities at rest. 　　Awad EA : Interstitial myofibrositis : hypothesis of the mechanism, 　　　　　　　　　　Arch Phys Med, 54 : 449-453, 1973. 　　　　　　　　　　　　　　　

64、　　　　　　　　　　　　　(Kumazawa 1990) 熊澤孝朗：痛覚. 「脳の科學１」 中村嘉男?酒田英　　　　夫（編）、朝倉書店、pp187-200、1990.■交感神經產生了誘發(fā)疼痛的物質-神經激肽（ neurokinin ）。由于不存在皮膚血管擴張，疼痛的閾值降低。 Sympathetic nerves produce which makes pain. It dilates skin vessels and

65、lowers the threshold of pain.　　　　　　　　　 Wattay EG : Reflex sympathetic dystrophy syndrome. Clinical 　　　　　　　　　　　　　 　Management, 9 (1) : 28-29, 1989.,肩手綜合癥　Shoulder Hand Syndrome?麻痹側上肢的肌肉活動低下　　　 肌肉血流減少

66、 Decrease of muscle activities of an affectted upper extremity Decrease of blood flow in muscles ?皮膚骨組織的血流增加　Increase of blood flow in skins and bones revers

67、ely?局部的代謝障礙　　　　微循環(huán)惡化、神經激肽產生 傷害感受器的向心性沖動增加　　Poor local metabolism Inflammation of soft tissues and a lot of production of neurokinin　　　　　Increase of afferent impulses from nociceptors?內環(huán)境穩(wěn)定，有促使皮膚骨組織增

68、加的血流正?；淖饔谩　　　　eactions to normalize the increase of blood flow of skins and bones by homeostasis?但是交感神經活動亢奮。 ?、偌毿用}收縮　②交感神經和軀體感覺神經產生去甲腎上腺素的化學信號，增加向心性沖動，在脊髓水平，反射性的交感神經興奮。 Activitie

69、s of sympathetic nerves becomes higher. ①Capillaries contract. ②In sympathetic nerves and sensory nerves, chemical transmission of noradrenalin happens, and then afferent impulses increase. In spinal cord, sympathetic

70、 nerves reflexively excite. (Ishibashi 2002) 石橋徹：反射性交感神経性ジストロフィー. 「肩の痛み」 　寺山和雄?片岡治（監(jiān)修）、pp1