The myofascial component of the pain in the painful shoulder of the hemiplegic patient

OBJECTIVES: Poststroke shoulder pain occurs very frequently and compromises function and quality of life. Because treatment depends on a multidisciplinary approach, it is desirable to optimize effectiveness. Myofascial pain syndrome is defined by the presence of trigger points that can also be found in spastic stroke patients. The aim of this study was to evaluate the frequency of myofascial pain in the shoulder girdle muscles in patients with poststroke shoulder pain and to document the clinical and functional results obtained with specific treatment for this condition. METHODS: Spastic stroke hemiplegic patients undergoing rehabilitation at the Rehabilitation Center of the Hospital das Clínicas of the Ribeirão Preto Medical School of the University of São Paulo were evaluated regarding the intensity and characteristics of shoulder pain, previous therapeutic interventions, shoulder goniometry and the presence of trigger points. Patients underwent trigger point blockade by intramuscular infiltration of 1% lidocaine. The evaluation and treatment procedures were repeated in the subsequent 3 weeks as long as the pain intensity was greater than 5 on a visual analog scale (VAS). In the fourth week, the evaluation procedures were repeated. Patients who were in a multiprofessional rehabilitation program were instructed to continue the treatment, and the others received complementary therapeutic advice if necessary to initiate it. The evaluations were performed at 0, 1, and 3 weeks and after 4 months. RESULTS: Twenty-one patients (13 men; age=67.8±10.2 years; right hemiparesis: 11) participated in the study, and there was a reduction in pain assessed by VAS from baseline (7.6±2.7) to the first week (5.8±3.6; p<0.05) through the end of the third week (5.2±3.5; p<0.05), but not at the end of four months (6.6±2.9; p=0.11). Good responders had significantly lower pain levels after the third week and presented with a larger range of motion for passive abduction by the end of 4 months. These results demonstrate that the myofascial component of pain should be considered in poststroke shoulder pain and that its treatment may be a pathway for the rapid and long-lasting relief of symptoms. CONCLUSION: Trigger point blockade with lidocaine can reduce pain perception in spastic hemiplegic shoulder in as much as 50% of stroke survivors for four months.

Coexistence of musculoskeletal disorders in the upper body of labor origin / Coexistencia de trastornos musculoesqueléticos en miembro superior de origen laboral

The coexistence of musculoskeletal disorders is common in work activities around the world, however, information on the subject is insufficient both in Latin America and in Colombia despite its impact at the economic and social level. The objective of this research was to determine the coexistence of musculoskeletal disorders of work origin in the upper body in the working population that attends a Service Provider Institution (IPS). An observational, descriptive, quantitative, and cross-sectional design study was conducted between the first of March in 2017 and the first of March in 2018. Four semiological tests were applied for physiotherapists to seek the coexistence of carpal tunnel syndrome, lateral epicondylitis, rotator cuff syndrome, and cervical myofascial syndrome. Among the results, it was found that 92.6% (n=138) of the patients had two or more pathologies, 59.73% (n=89) had the rotator cuff and the myofascial syndrome, 52.35% (n=78) had epicondylitis and myofascial syndrome, and 37.58% (n=56) had carpal tunnel syndrome and lateral epicondylitis. This study highlights the high coexistence of musculoskeletal disorders in the upper body, especially in the female gender.

La coexistencia de trastornos musculoesqueléticos es común en actividades laborales de todo el mundo, sin embargo la información sobre el tema es insuficiente tanto en América Latina como en Colombia a pesar de su impacto a nivel económico y social; la investigación tuvo como objetivo determinar la coexistencia de trastornos musculoesqueléticos en miembro superior de origen laboral en la población trabajadora que asiste a una Institución Prestadora de Servicios (IPS); Se realizó un estudio de diseño Observacional, descriptivo, cuantitativo y de corte transversal, durante el periodo comprendido entre el primero de marzo de 2017 y el primero de marzo del 2018, se aplicaron cuatro pruebas semiológicas por fisioterapeutas para buscar la coexistencia de Síndrome de túnel del carpo, epicondilitis lateral, síndrome de manguito rotador y síndrome miofascial cervical; entre los resultados se encontró que el 92,6% (n=138) de los pacientes presentaban dos o más patologías, el 59,73% (n=89) síndrome de manguito rotador y síndrome miofascial, el 52,35% (n=78) Epicondilitis y síndrome miofascial y el 37,58% síndrome de túnel del carpo y epicondilitis lateral (n=56). El estudio pone en evidencia la elevada coexistencia de trastornos musculoesqueléticos en miembro superior especialmente en el género femenino.

Absceso subpectoral como diagnóstico diferencial de hombro doloroso: reporte de un caso / Subpectoral abscess as a differential diagnosis of painful shoulder: a case report

Los síndromes dolorosos del hombro son relativamente comunes en la práctica clínica. Habitualmente son causados por un número limitado de patologías. Dentro de los diagnósticos diferenciales, el pinzamiento subacromial, las lesiones aisladas del manguito rotador, capsulitis adhesiva, tendinitis cálcica, patología degenerativa de las articulaciones glenohumeral y acromioclavicular, y la inestabilidad crónica del hombro, son causas comunes. Causas infrecuentes son la rotura del tendón del bíceps, neuralgias, patología infecciosa articular y tumores del hombro. Un absceso subpectoral sin sintomatología infecciosa clara es una causa extremadamente rara de hombro doloroso en el adulto. Presentamos el caso de un paciente de 60 años, que inicia con un cuadro de hombro doloroso cuya causa se identifica como un absceso subpectoral por staphylococcus aureus que se maneja con drenaje quirúrgico y tratamiento antibiótico endovenoso con buenos resultados.

Painful shoulder syndromes are commonly caused by a limited assortment of pathologies. Differential diagnosis include rotator cuff impingement syndrome, rotator cuff tears, adhesive capsulitis, calcific tendonitis, degenerative disease of the joint including acromio-clavicular and gleno-humeral joints and chronic instability. Less common causes are labral tears, biceps tendon rupture, soft tissue infection, neurologic disease, joint infection and shoulder tumors. A subpectoral abscess without infectious clinical features is a very rare cause of shoulder pain in adults. We present the case of a 52 years old male who develops a painful shoulder syndrome caused by a staphylococcus aureus subpectoral abscess, treated by surgical drainage and intravenous antibiotic therapy with good results.

Ejercicios pendulares en el síndrome del hombro doloroso / Pendulum Exercises in Painful Shoulder Syndrome

Se realizó un breve recuento de las estructuras anatómicas que conforman la articulación del hombro, así como, del síndrome del hombro doloroso, su definición y su caracterización clínica epidemiológica. La presente revisión abordó dentro de la kinesioterapia pasiva, los diferentes ejercicios pendulares empleados en el tratamiento fisioterapéutico del síndrome del hombro doloroso. Los objetivos del artículo fueron: la descripción de su técnica de aplicación, la fundamentación de la utilidad de su aplicación, indicaciones y contraindicaciones. Se concluyó que los ejercicios pendulares mantienen su eficacia en el restablecimiento de la movilidad articular en los padecimientos del hombro, sin embargo, existe desconocimiento de sus variedades, así como de su correcta técnica de aplicación.

A brief account of the anatomical structures of the shoulder joint and the painful shoulder syndrome, its definition and clinical epidemiological characterization was performed. This review addressed within the passive physiotherapy, different pendulum exercises used in the physiotherapy treatment of shoulder pain syndrome. The objectives of the paper were: the description of the technical implementation, the basis for the usefulness of its application, indications and contraindications. The authors concluded that pendulum exercises will maintain the effectiveness in restoring joint mobility in shoulder conditions; however, there is lack of its varieties, and its correct application technique.

Avaliação da acupressão auricular na síndrome do ombro doloroso: estudo de caso / Evaluation of ear acupressure on painful shoulder syndrome: case study / Evaluación de la acupresión auricular sobre el síndrome de hombro doloroso: estudio de caso

A Síndrome do Ombro Doloroso (SOD) é definida como dor e limitação funcional decorrente do acometimento de estruturas estáticas e dinâmicas do ombro, como ligamentos, cápsula e músculos. É uma das queixas mais comuns e incapacitantes do sistema musculoesquelético na população em geral com uma prevalência estimada entre 15 a 25%. Este estudo objetivou avaliar os resultados da acupressão auricular quando usada como terapia no tratamento da Dor crônica, secundária à SOD, quanto ao efeito analgésico e terapêutico satisfatório e o tempo estimado de tratamento. Para a obtenção do objetivo foi realizado um Estudo de Caso que teve como intervenção a acupressão auricular com esferas de cristais e como indicador de resultado o questionário Penn Shoulder Score (PSS - Brasil). Os dados foram analisados qualitativa e quantitativamente. Conclui-se que a auriculoterapia é uma importante técnica terapêutica, pois o estudo demonstrou uma melhora na pontuação total do PSS - Brasil em 34,3%.

The Painful Shoulder Syndrome (PSS) is defined as pain and functional limitation resulting from impairment of static and dynamic structures of the shoulder, such as ligaments, capsule and muscles. It is one of the most common and disabling of the musculoskeletal system in the general population with prevalence estimated between 15-25%. This study aimed to evaluate the results of auricular acupressure when used as therapy in the treatment of chronic pain secondary to SOD, and the analgesic effect and therapeutic satisfactory and the estimated time of treatment. To obtain the objective was to perform a case study was to intervene with auricular acupressure beads and crystals as an indicator of the outcome questionnaire Penn Shoulder Score (PSS - Brazil). Data were analyzed qualitatively and quantitatively. We conclude that auriculotherapy is an important therapeutic technique, because the study showed an improvement in the total score of the PSS - Brazil at 34.3%.

El síndrome de hombro doloroso (SHD) se define como dolor y limitación funcional que resulta del deterioro de las estructuras estáticas y dinámicas de los hombros, como ligamentos, cápsula y los músculos. Es uno de los más comunes y incapacitantes del sistema músculo-esquelético en la población general con una prevalencia estimada entre el 15-25%. Este estudio tuvo como objetivo evaluar los resultados de la digito presión auricular cuando se usa como terapia en el tratamiento del dolor crónico secundario a la SHD, y el efecto analgésico y terapéutico satisfactorio y el tiempo estimado de tratamiento. Para lograr el objetivo ha sido realizar un estudio de caso Estudo de Caso en que se tuve como intervención la acupressão auricular con esferas de cristales y como indicador de resultado el cuestionario Penn Shoulder Score (PSS - Brasil). Los datos se analizaron cualitativa y cuantitativamente. Llegó-se a la conclusión de que la auriculoterapia es una técnica terapéutica importante, porque el estudio demostró una mejoría en la puntuación total de la PSS - Brasil en el 34,3%.

Anatomical and clinical study of the subscapular nerves

Introduction: Painful shoulder on hemiplegic patients has been associated to subscapular muscle spasticity.An alternative for treatment is based on subscapular nerve block using phenol. However, there is lack ofinformation on anatomical references for subscapular nerves blockage technique. The aim of this study wasto determine mean values and confidence intervals for maximum penetration points in order to facilitateblockage during anesthetic procedure of subscapular nerves. Material and methods: Using 30 dissected adultcadaver limbs, the medial edge of scapula and a horizontal plan to the lower edge of the bone spine wereidentified. The maximal and minimal angles of the penetration points of the subscapular nerve both above andbelow the horizontal plan were measured, as well as the minimal and maximal distances from the medial edgeof scapula. Superior and inferior bisector angles and the mean horizontal distance (in mm) were calculatedfor descriptive analysis. Kolmogorov-Smirnov normality test indicated the normal distribution of the data(p > 0.05). Results: Mean superior angle was 6.63° (confidence interval 4.52-8.75), mean inferior angle was11.30° (confidence interval 8.73-13.86) and mean horizontal distance was 72.53 mm (confidence interval69.25-75.80). Conclusions: According to this data, for maximum points blocking after solution injection, theneedle should be introduced horizontally at the scapula spine level under its medial edge to a mean depth of72.53 mm. Then, the needle must be driven upwards in a 6.63° angle and later, driven downwards to form a11.30° angle with the horizontal plan. Those mean values represent 95% of the distribution.

La ultrasonografía en el estudio de síndrome de hombro doloroso / Musculoskeletal ultrasound in the evaluation of the painful shoulder

El síndrome de hombro doloroso es una causa frecuente de consulta en la práctica clínica diaria. Su origen puede ser traumático, inflamatorio, degenerativo, infeccioso o tumoral. El abordaje diagnóstico implica un amplio conocimiento de la anatomía regional y la aplicación de maniobras clínicas y técnicas de imagen que conduzcan a un diagnóstico certero para la aplicación de un tratamiento óptimo en cada paciente. En los años recientes, el ultrasonido musculoesquelético ha demostrado ser una herramienta complementaria de altísima utilidad en el examen complementario de los pacientes con hombro doloroso, especialmente en el contexto de la práctica reumatológica. Revisaremos los principales hallazgos patológicos evaluados por esta técnica.

Painful shoulder syndrome is a frequent cause of daily clinical consultation. Its origin can be traumatic, inflammatory, degenerative, infectious or tumor like. The boarding diagnosis implies an ample knowledge of the regional anatomy and the application of clinical and technical maneuvers of image that leads to an accurate diagnosis for the application of an optimal treatment in each patient. In the recent years, the musculoskeletal ultrasound has demonstrated to be a complementary tool of highest utility in the complementary examination of the patients with painful shoulder, especially in the context of the rheumatological practice. We will review the main pathological findings evaluated by this technique.

Ultrasonography-guided Subacromial Bursal Injection of Corticosteroid: A Comparative Study of Two Dose Regimens

OBJECTIVE: To investigate the treatment efficacy between low and high dose of triamcinolone acetonide in the treatment of ultrasonographic-guided subacromial bursa injection. METHOD: Forty two patients with periarticular shoulder disorders were randomly assigned to receive injection with 10 mg (group 1, 20 patients) or 40 mg (group 2, 22 patients) triamcinolone acetonide. After a single injection, participants were followed up for 6 weeks. Treatment efficacy was measured upon pre-treatment and post-treatment on week 1, 3, 6, using visual analog scale for average pain intensity during 24 hours (24 h VAS), Shoulder Function Assessment scale (SFA), Shoulder Disability Questionnaire (SDQ), and active range of motion (AROM). Participants and the assessor were blinded for group assignment. RESULTS: Six weeks after injection, the 24 h VAS, the SFA, the SDQ, and the AROM (internal rotation, external rotation, and abduction) showed a significantly greater improvement in group 2 than group 1 (p <0.05). CONCLUSION: This study showed that in the treatment of periarticular shoulder disorders greater pain relief and functional improvement were obtained with a dose of 40 mg triamcinolone acetonide than with a dose of 10 mg.