粘连性肩关节囊炎的治疗（四）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

本次文献选自Redler LH, Dennis ER. Treatment of Adhesive Capsulitis of the Shoulder. J Am Acad Orthop Surg. 2019;27(12):e544-e554. 本次学习由阎芳副研究员主讲。

Also, several studies have looked at the incidence of AC after rotator cuff repair (RCR). A meta-analysis of seven studies on stiffness after arthroscopic RCR found resistant stiffness or stiffness requiring capsular release in 3.3% of patients. Another study by Huberty et al on 489 patients who underwent RCR found symptomatic postoperative stiffness in 4.9% of patients. Further analysis revealed that it was most common in workers compensation patients (8.6%), patients younger than 50 years (8.6%), those with coexisting calcific tendinitis (16.7%), those with partial articular-sided tendon avulsions (13.5%), and those with concomitant labral tears (11.0%). In a study of 345 patients, Namdari and Green found that 47 patients with preoperative stiffness had persistent stiffness after RCR, of which only 3 required capsular release.

另外，一些研究也关注了肩袖修复术（RCR）后AC的发生率。对关节镜下RCR术后关节僵硬的7项研究进行荟萃分析，发现3.3%的患者有抵抗性僵硬或僵硬，并需要关节囊松解。Huberty等人对489名接受RCR的患者进行的另一项研究发现，有4.9%的患者出现术后僵硬症状。进一步分析发现，出现术后僵硬最常见的是工伤补偿患者（8.6%）、50岁以下患者（8.6%）、合并钙化性肌腱炎患者（16.7%）、部分关节侧肌腱撕脱伤患者（13.5%）和合并盂唇撕裂患者（11.0%）。在一项对345名患者的研究中，Namdari和Green发现47名术前关节囊僵硬的患者在RCR后仍有持续僵硬，但其中只有3名患者需要关节囊松解。

Patients with upper extremity trauma can also have resultant stiffness or posttraumatic stiffness (PTS) which has been theorized to progress along a similar pathway to AC. In a study of 73 patients undergoing open reduction internal fixation (ORIF) for proximal humerus fractures, Clavert et al found that PTS developed in 4.1% of patients. In a study by Lancaster et al on 64 patients with PTS after upper limb trauma, manipulation under anesthesia (MUA) was a successful intervention for improving ROM and Oxford Shoulder Scores. The improvement in ROM after MUA was similar to that observed in patients who underwent MUA for idiopathic AC.

上肢创伤患者也可能出现相应的僵硬或创伤后僵硬（PTS），理论上这种僵硬的发展与AC相似。Clavert等人对73名接受肱骨近端骨折切开复位内固定（ORIF）的患者进行了研究，发现4.1%的患者出现了PTS。Lancaster等人对64例上肢创伤后PTS患者进行的一项研究表明，麻醉下手法松解（MUA）是改善活动度和Oxford肩关节评分的一种成功的干预措施。MUA治疗后活动度的改善与原发性AC患者MUA治疗后的改善相似。

AC has been documented in 10% of patients after breast cancer surgery. The incidence was higher in the patients aged 50 to 59 years and in those who underwent mastectomy (with or without reconstruction) compared with those who underwent lumpectomy.

Again using the Longitudinal Health Insurance Database 2005 in Taiwan, patients who underwent surgery for a cervical herniated disk disease had a markedly higher risk (1.66) of developing shoulder capsulitis in 6-month follow-up compared with patients who received conservative therapy only.

Last, though not surgical, worth mentioning is a case study of 3 cases of acute onset of AC after pneumococcal and influenza vaccines.

乳腺癌手术后10%的患者会发生AC。年龄在50-59岁之间且接受乳房切除术（有或没有重建）的患者肩周炎的发病率高于仅接受肿块切除术的患者。

根据台湾2005年纵向健康保险资料库的数据，与仅接受保守治疗的患者相比，因颈椎间盘突出症接受手术的患者在术后6个月的随访中发生肩关节囊炎的风险明显更高（1.66）。

最后，虽然不是外科手术，但值得一提的是一项个案报道发表了3个肺炎球菌和流感疫苗接种后急性发作AC 的病例。

Treatment Options

Nonsurgical Management

Many options are available for improving the pain, ROM, and functional scores in patients with newly diagnosed AC or in those who wish to avoid surgery. Treatment should be geared toward the phase of AC (Figure 3). Oral anti-inflammatories, either nonsteroidal (NSAIDs) or a short tapered course of corticosteroids (particularly helpful in patients with very severe pain), can be helpful in reducing patients’ symptoms, enough to make physical therapy (PT) tolerable. This point needs to be stressed–medications will not relieve their pain completely but are instead being used so they can effectively participate in PT. Narcotics do not have a role in the nonsurgical management of AC. In addition to the mainstays of nonsurgical management with PT, oral anti-inflammatories, and cortisone injections, other modalities include extracorporeal shock wave therapy (ECSWT), calcitonin pharmacotherapy, ultrasonography-guided hydrodissection, and hyaluronic acid (HA) injections. A recent systematic review graded various nonsurgical interventions based on study scientific rigor and level of evidence.23  Therapeutic exercises and mobilization were strongly recommended for reducing pain and improving ROM and function in patients with stage 2 and 3 AC. Corticosteroid injections were most effective in early AC. Acupuncture with therapeutic exercises was moderately recommended for pain relief, improving ROM and function. Continuous passive motion was recommended for short-term pain relief but not for improving ROM or function. Ultrasonography for pain relief or for improving ROM or function was not recommended.

治疗方法的选择

非手术疗法

对于新诊断的AC患者或希望避免手术的患者，有许多方法可以用来改善疼痛、活动度和功能评分。治疗应针对AC不同阶段来进行（图3）。口服消炎药，无论是非甾体类药物（NSAIDs）还是短疗程的皮质类固醇（尤其对非常剧烈疼痛的患者有帮助），都有助于减轻患者的症状，足以使患者可以耐受理疗。有一点需要强调——药物不会完全缓解他们的疼痛，而是在药物帮助下，患者可以更有效地进行理疗。麻醉药品不用于AC的非手术治疗。除了理疗、口服消炎药和激素注射等非手术治疗的主要方法外，其他方法包括体外冲击波治疗（ECSWT）、降钙素药物治疗、超声引导下的水分离术以及透明质酸（HA）注射。最近的一项系统综述根据研究的科学严谨性和证据水平对各种非手术干预进行了分级。对于2期和3期AC患者，强烈建议进行治疗性运动和活动，以减轻疼痛，改善活动度和功能。早期AC患者注射皮质类固醇最有效，中度建议进行针灸和治疗性运动，以缓解疼痛，改善活动度和功能。持续被动运动被推荐用于短期疼痛缓解，但不推荐用于改善活动度或功能。不建议使用超声缓解疼痛或改善活动度或功能。