JBJS:RC-QOL评分可预测慢性肩袖撕裂保守治疗疗效

2015-01-04 黄立 丁香园

肩袖损伤疾病包括从无撕裂到全层撕裂肩袖损伤,是引起肩部疼痛最常见的原因,从诊断到治疗都存在较大争议。肩袖损伤的临床症状与损伤的程度、影像学表现常常无对应关系,给治疗决策带了更大的难度。很多无症状患者发现存在肩袖损伤,现仍无法解释为什么全层撕裂患者一部分出现症状,一部分无症状。 对于肩袖损伤的治疗,Rowe曾这样说“越有经验的医师,越强调保守治疗,慢慢地选择手术治疗”。现在很多医师同意经过

肩袖损伤疾病包括从无撕裂到全层撕裂肩袖损伤,是引起肩部疼痛最常见的原因,从诊断到治疗都存在较大争议。肩袖损伤的临床症状与损伤的程度、影像学表现常常无对应关系,给治疗决策带了更大的难度。很多无症状患者发现存在肩袖损伤,现仍无法解释为什么全层撕裂患者一部分出现症状,一部分无症状。

对于肩袖损伤的治疗,Rowe曾这样说“越有经验的医师,越强调保守治疗,慢慢地选择手术治疗”。现在很多医师同意经过充分保守治疗(至少3月)后才考虑手术治疗肩袖损伤。但何为“充分治疗”,“对于某个患者何种治疗才算充分”仍无标准。同时对于慢性、有症状、全层肩袖撕裂的充分保守治疗有效性仍存在争议,既往文献显示成功率在33%- 92%。

为了解决是否存在患者临床特征预测有症状慢性全层肩袖撕裂保守治疗疗效,及当为期3个月保守治疗有效后是否可以维持2年,为此,加拿大学者Richard S等人进行前瞻性研究,结果发表在近期的JBJS上。

纳入未经过保守治疗的有症状慢性肩袖损伤患者共93例,纳入/排除标准见表一。


表一 纳入/排除标准
1.jpg


所有患者经过五位医师诊治,包括2名运动学医师,2名康复理疗师、1名骨科手术医师。运动学医师与理疗师共同制定康复锻炼计划,包括肩关节运动与力量训练及口服非甾体抗炎药,为期3个月;患者疼痛及运动无改善时不进行力量训练,少数患者超过3个月。

期间研究人员每周与患者接触,评价并督促康复。整个康复计划结束后骨科手术医师诊疗评价每个患者,包括讨论病情,体检肩关节,讨论手术利弊等,最后裁定治疗成功或失败。双盲下治疗前、治疗结束时、治疗结束后2年共三个时段评价患者肩袖损伤生活指数(RC-QOL)。

治疗成功标准:因患者症状改善明显,已无明显症状,患者及手术医师均认为没有必要手术治疗。失败标准:患者因症状无改善选择手术治疗。

结果:1、保守治疗结束时:70例(75%)患者治疗成功。

2、年龄、性别、吸烟史、优势手、症状持续时间、病因(创伤或原发)、关节活动度、外旋强度、撕裂程度、RC-QOL,逻辑回归分析显示只有RC-QOL可预测有症状慢性全层肩袖撕裂保守治疗疗效(如表2)。


表2 年龄/性别等因素与疗效P值
2.jpg

3、保守治疗2年后,共10例患者改变了治疗方案;其中4例最初认定为治疗失败,经进一步康复放弃手术治疗,6例最初认定为成功,大多因再次外伤选择手术治疗。89%患者保守治疗疗效延续至2年后。

4、RC-QOL评分治疗成功组从治疗前49±21,上升至治疗结束(3个月)时82±12;而失败组仅从33±15上升至38±21。2年后未手术治疗的RC-QOL评分80±18。

作者认为,RC-QOL评分可预测有症状慢性全层肩袖撕裂保守治疗疗效;有症状慢性全层肩袖撕裂保守治疗的成功疗效大多可延续2年。

该次研究中保守治疗成功率高,作者认为与研究人员督促作用有关系,使患者能坚持完整的康复理疗。RC-QOL评分是综合自我问卷调查,不仅仅包含了体征,也包括了患者其他各个方面,同时使用方便,基于此次结论其可预防保守治疗疗效,评分高保守治疗可能好,大家不妨在临床试试。


原始出处:

Boorman RS1, More KD1, Hollinshead RM1, Wiley JP2, Brett K2, Mohtadi NG1, Nelson AA1, Lo IK1, Bryant D3.The Rotator Cuff Quality-of-Life Index Predicts the Outcome of Nonoperative Treatment of Patients with a Chronic Rotator Cuff Tear.J Bone Joint Surg Am. 2014 Nov 19;96(22):1883-8. doi: 10.2106/JBJS.M.01457.

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    2015-04-20 lancelotzzl
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    2015-04-12 x35042875

    患OS这个疾病的高风险人群提供干预措施以避免不良预后和机械治疗措施

    0

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    2015-04-12 x35042875

    患OS这个疾病的高风险人群提供干预措施以避免不良预后和机械治疗措施

    0

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    2015-02-19 orthoW

    ?学习了

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    2015-01-06 qingrejiedu

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