粘连性肩关节囊炎的治疗（十）
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。
Recalcitrant Adhesive Capsulitis
A small percentage of patients who have been treated surgically for AC continue to have symptoms. Repeat MUA has been shown to be successful. 46 In a group of 730 patients who underwent MUA for AC, 141 required additional MUA. Improvement was seen after a second MUA, regardless of the outcome of the initial MUA and of the time of recurrence.46 Patients with type 1 diabetes mellitus were at a 38% increased risk of requiring a repeat MUA, compared with the 18% increased risk of the group as a whole (P , 0.0001).
顽固的肩周炎
一小部分接受过AC手术治疗的患者仍然有症状。再次进行麻醉下的松解已被证明是有效的。在一组730名进行过松解的AC患者中，141名患者需要进行二次松解。无论初次松解结果如何，以及松解后多长时间复发，二次松解后症状均会有改善。1型糖尿病患者需要进行二次松解的风险增加了38%，而总体二次松解的风险是18%（P＜0.0001）。
Postoperative Protocol
PT should start as soon as possible in the postoperative setting. An interscalene block or catheter can provide analgesia to allow for immediate post-op ROM. Mariano et al showed that a continuous interscalene block provides greater pain relief, allowing for minimization of opioid use, improvement in sleep quality, and overall increase in patient satisfaction compared with a single application regional block. However, interscalene blocks are not without their own set of risks; cases of reversible radial neurapraxia and phrenic nerve paralysis have been reported.
术后方案
物理治疗应尽早开始。斜角沟阻滞或置管可提供止痛作用，可以使术后的活动度立即达到最佳状态。Mariano等人研究表明，与单次区域阻滞相比，连续斜角沟阻滞的镇痛作用更好，使阿片类药物用量达到最低，改善睡眠质量，并整体提高患者满意度。然而，肌间沟阻滞也有自身的风险;有可逆性桡神经失用症和膈神经麻痹的个案报道。
The PT protocol focuses on achieving (for nonsurgical care) or maintaining (postoperatively) a functional ROM by slow, sustained stretching. PTprescriptionsareshowninFigure 8, A (nonsurgical) and Figure 8, B (surgical). Patients are encouraged to do daily stretching, including wallwalking for forward elevation (Figure 9, A), doorway stretch for external rotation (Figure 9, B), and modified sleeper stretch for internal rotation (Figure 9, C). Patients often find stretching in the shower to be more successful because of the heat.
物理治疗方案侧重于通过缓慢、持续的拉伸来实现或维持(术后)功能性活动范围。理疗方案如图8 A(非手术)和图8 B(手术)所示。我们鼓励患者每天做伸展运动，包括前方爬墙(图9,A)，门边伸展外旋(图9,B)，改良的睡眠位伸展进行内旋(图9,C)。很多患者发现在淋浴时进行伸展运动更容易成功因为环境温度较高。
Postoperatively, a sling is only used for comfort for a few days and must be discontinued by 1 week. Patients are encouraged not to sleep in the sling. Patients are also advised that they may be more comfortable sleeping on an incline for the first week after surgery. Patients are released from follow-up care once they have achieved pain-free ROM that is acceptable to them. At minimum, this includes the ability to perform activities of daily living independently. Patients are advised to return for evaluation if pain during functional ROM returns or they note a recurrence of restricted ROM.
术后，吊带只能使用几天，必须在1周内停止使用。鼓励病人不要在睡眠时使用吊带。我们也建议病人在手术后的第一周睡在有坡度的床上，会更舒服。一旦患者能在无痛的条件下达到最大活动度，就可以停止后续治疗了。至少，患者应恢复独立完成日常生活活动的能力。如果患者达到功能活动度时的疼痛复发或活动度再次受限，建议对患者重新进行评估。