粘连性肩关节囊炎的治疗（五）

 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。

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Corticosteroid Injections

Intra-articular corticosteroid injections decreasepain in early stages of AC. In a double-blind, placebo-controlled randomizedstudy of ultrasonography-guided intra-articular and rotator interval corticosteroidinjections in 122 patients with AC, a notable decrease in shoulder pain at 6 weekswas observed. These results were maintained at 12 weeks but were no longer notableat 26 weeks. No difference existed between the group who receivedintra-articular corticosteroid injection and the group who received a combinedintra-articular and rotator interval injection. In a meta-analysis, nine randomizedcontrolled trials for 453 patients were analyzed. From 6 to up to 26 weekspostintervention, no superiority was noted in favor of either steroid injectionor PT for functional improvement. However, steroid injection did provide moreimprovement in passive external rotation by 26 weeks. Last, in a study of 106 patients,four injections with cortico-steroid with or without distension given during 8weeks were better than PT alone. However, in the long term no difference wasshown, suggesting that natural healing takes place regardless of intervention.

皮质类固醇注射

关节内注射皮质类固醇可减轻AC早期疼痛。在一项双盲、安慰剂对照随机研究中，作者在超声引导下给122例AC患者关节内和肩袖间隙内注射皮质类固醇，术后6周随访时，肩痛显著减轻。术后12周时疼痛评分仍有显著差异，但在术后26周时差异不再显著。关节内注射皮质类固醇组与关节内及肩袖间隙联合注射组之间无差异。在另一项荟萃分析中，对包含共453例患者的9个随机对照试验进行了分析。观察期从干预后6周到最长26周，作者发现，类固醇注射或理疗对功能改善疗效相当。然而，类固醇注射确实能在26周内改善被动外旋功能。最后，在一项对106名患者的研究中，在8周内给予4次皮质类固醇注射（伴有或不伴有关节囊松解）比单独理疗效果更好。然而，从长期来看，两种治疗没有显示出任何差异，这表明即使不给予任何干预，肩周炎均有自然愈合的趋势。

Despite these findings, intra-articular steroidinjections do seem to have a role in patients with AC. In a retrospectivelongitudinal study of 339 patients with AC, all patients who were unresponsive toat least 1 month of conservative treatment underwent ultrasonography-guidedcorticosteroid injection, and all outcomes, at both 1 month and 12 months, werebetter when the amount of time in pain before injection was shorter. Therefore,this group concluded that early injection improves outcomes of AC at bothshort- and long-term follow-ups.They feel that if pain persists despite conservativemanagement, injection in the early time frame helps shorten the natural historyof AC.

尽管有这些发现，关节内类固醇注射似乎确实对AC有效。一项对339例AC患者的回顾性纵向研究，本研究纳入的所有患者均至少接受了1个月以上的保守治疗且无效。本研究中，给予超声引导的皮质类固醇注射，在术后1个月和12个月随访时发现，注射前累积疼痛时间越短的患者，注射治疗效果越好。因此，该组得出结论，不论是短期和长期随访，早期类固醇注射治疗均可以改善AC。他们认为，在保守治疗效果不佳的情况下，早期注射有助于缩短AC的自然病程。

A notable amount of research also existedinto the best technique for injection of the glenohumeral joint and whetherultrasonography guidance has a role to play. In a randomized controlled studyof ultrasonography-guided injections versus blind intra-articular injections,improvements in pain, ROM, and functional scores were observed in theultrasonography-guided group at 1 and 4 weeks, but these findings were notstatistically significant. In a prospective ran- domized study of 42 patients,designed to determine the ideal position for glenohumeral injection, no differencewas found in the joint space window available for injection with the patient inthree different positions (palm on thigh, hand on opposite shoulder, andhanging arm position), but injections given in all three positions yieldedstatistically significant improvement in pain and ROM.

对于盂肱关节注射的最佳技术以及超声引导是否起作用也有大量的研究。在一项随机对照研究中，超声引导注射与盲法关节内注射相比，超声引导组在1周和4周时疼痛、活动度和功能评分均有改善，但这些差异无统计学意义。一项针对42名患者的前瞻性随机研究旨在确定关节盂肱部注射的理想位置，在患者处于三种不同位置（手掌放在大腿上、手放在对侧肩上和吊臂位置）时，可供注射的关节间隙窗口没有发现差异，但三种体位的注射都能显著改善疼痛和关节活动度。

Extracorporeal Shock Wave Therapy

In a prospective randomized controlledstudy of 40 patients treated with ECSWT versus oral steroids, Chen et al showednotable improvement in Constant Shoulder Score and ROM by the fourth week and statisticallysignificant improvement in ADL function by the sixth week in patients treatedwith ECSWT. In a systematic review of 19 trials (1,249 participants), the useof ECSWT in general did not generate any additional adverse events comparedwith that in the control groups in all studies. Importantly, ECSWT has beenshown to improve functional outcomes in patients with diabetes and maytherefore be a desirable alternative to corticosteroids for this patientpopulation who are not ideal candidates for corticosteroid injections becauseof the effect on their blood glucose control.

体外冲击波疗法

在一项前瞻性随机对照研究中，Chen等人发现，40名接受冲击波治疗的患者与口服类固醇治疗的患者相比，接受冲击波治疗的患者第4周的恒定肩关节评分和活动度显著改善，第6周时日常生活功能显著改善。在对19项试验（1249名参与者）的系统回顾中，与所有研究中的对照组相比，冲击波的使用总体上没有产生任何额外的不良事件。重要的是，冲击波治疗已被证明能改善伴有糖尿病患者的功能转归，因此对于那些因血糖控制效果不佳而不能理想地接受皮质类固醇注射的患者群体来说，冲击波治疗可能是皮质类固醇的理想替代治疗方法。