Ludzkie koronawirusy - autor: Krzysztof Pyrć z Zakładu Mikrobiologii, Wydział Biochemii, Biofizyki i Biotechnologii, Uniwersytet Jagielloński, Kraków

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© Borgis - Postępy Nauk Medycznych 1/2019, s. 31-40 | DOI: 10.25121/PNM2019.32.1.31
Anna Kuryliszyn-Moskal1, Joanna Zablocka2, Andrzej Julian Niewinski1, *Anna Hryniewicz1
Role of physiotherapy in the treatment of shoulder pain in rheumatic diseases – the state of actual knowledge
Rola fizjoterapii w leczeniu zespołu bolesnego barku w chorobach reumatycznych – aktualny stan wiedzy
1Department of Rehabilitation, Faculty of Health Sciences, University of Bialystok, Poland
2Doctoral Studies, Department of Rehabilitation, Faculty of Health Sciences, University of Bialystok, Poland
Streszczenie
W pracy przedstawiono aktualną problematykę dotyczącą zasad leczenia fizjoterapeutycznego zespołów bólowych kompleksu barkowego w przebiegu chorób reumatycznych. Szczegółowo omówiono postępowanie w najczęstszych chorobach reumatycznych, takich jak: RA, OA i SpA. Zwrócono szczególną uwagę na znaczenie postępowania kinezyterapeutycznego, wskazując jednocześnie na rolę leczenia metodami fizykalnymi z zakresu termoterapii, elektrolecznictwa, laseroterapii, zastosowania ultradźwięków i pola magnetycznego. Uzupełniające znaczenie pełni leczenie balneologiczne o działaniu miorelaksującym, przeciwbólowym i przeciwzapalnym.
W podsumowaniu podkreślono, iż celem postępowania rehabilitacyjnego w zespołach bolesnego barku w przebiegu chorób reumatycznych jest nie tylko uzyskanie efektu przeciwbólowego i poprawa stanu funkcjonalnego, lecz przede wszystkim indywidualna i kompleksowa terapia, zmierzająca do osiągnięcia poprawy sprawności chorych, umożliwiającej powrót do codziennej aktywności.
Realizacja skutecznego i kompleksowego programu terapeutycznego wymaga jednoczesnego podjęcia wszechstronnych działań: edukacyjnych, opracowania indywidualnej strategii postępowania fizjoterapeutycznego, psychoterapeutycznego, zastosowania indywidualnie dobranego zaopatrzenia ortopedycznego, a także zaoferowania pomocy socjalnej. W celu realizacji tych zadań niezbędna jest współpraca zespołu specjalistów z wielu dziedzin. Jedynie jak najwcześniejsze wdrożenie interdyscyplinarnego i kompleksowego postępowania stwarza możliwość powrotu chorych do pełnej aktywności rodzinnej, społecznej i zawodowej.
Summary
The study presents the current problems concerning the principles of physiotherapeutic treatment of shoulder pain syndromes in the course of rheumatic diseases. The principles of the treatment in the most common rheumatic diseases such as RA, OA and SpA are discussed. Particular attention has been paid to the importance of kinesitherapeutic treatment, while indicating the role of treatment with physical methods in the field of thermotherapy, electrotherapy, laser therapy, the use of ultrasounds and magnetic field. Balneological treatment with myorelaxing, analgesic and anti-inflammatory effects is of complementary importance.
The summary emphasizes that the goal of rehabilitation in shoulder pain syndromes in the course of rheumatic diseases is not only to achieve analgesic effect and improve the functional status, but, above all, an individual and comprehensive therapy aimed at improving the efficiency of the patients, enabling return to daily activities.
The implementation of an effective and complex therapeutic program requires the simultaneous undertaking of comprehensive activities: educational, developing an individual strategy of physiotherapeutic and psychotherapeutic treatment, the use of individually selected orthopedic supplies, as well as offering social assistance.
In order to perform above procedures, a multidisciplinary team is necessary. Only the most immediate possible implementation of interdisciplinary and complex procedures makes enables patients to return to full family, social and professional activity.
Introduction
Pain syndrome of the shoulder and cervical spine is the second most frequent complaint of the musculoskeletal system, following back pain in the lumbosacral segment. The term “shoulder” is a colloquial term for pectoral girdle, which includes bones (collarbone, scapula, humerus), their connections to the axial skeleton, as well as the connection of the shoulder and chest wall and joints: shoulder, acromioclavicular and sternoclavicular. Ligaments and muscles, forming, along with the ligatures, myofascial meridians, are also important elements, acting as the transmission of tensions caused by muscles (1).
Pain may be the result of structural or functional damage. Structural changes usually appear as a result of an injury or inflammatory process, while functional damage consists of disorders of the nervous system, muscle synergy and shoulder arthroplasty. Both, internal and external factors affect the above dysfunctions. Internal factors include: impaired vascularization, inflammatory and degenerative changes in the course of rheumatic diseases, high intramuscular pressure. The external factors are mechanical loads (1-3). Risk factors for shoulder pain syndrome include: excessive physical effort during work, older age, smoking, long-term immobilization of the limb, muscle weakness of the upper limb, postural defects, abdominal obesity, diabetes, and low physical activity (4). Often, one patient reveal several causes of pain (3, 4).
The fact that the upper limb is an open biokinematic chain means that even a small degree of dysfunctions in the shoulder area cause significant pain (5).
The most common symptom that hinders daily functioning of the patient is the pain that occurs soon after the limb activity begins. Occasionally, it is accompanied by swelling that indicates the development of inflammation in the tissues (5).
In the acute phase, lasting approximately six weeks, pain and increased muscle tension lead to a reduction in mobility in the joint. In the chronic phase, pain is reduced, while muscle tone, causing the appearance of contracture – increases, leading to further limitation of motion (5). Shoulder pain may also radiate to nearby structures. As a result of the progressive functional destabilization process, the pectoral girdle elevation is observed, slightly above the level of a healthy shoulder. Change in skin temperature around the affected shoulder joint and increased sensitivity to touch as well as crepitations in the joint are further symptoms of joint dysfunction (6).
Shoulder pain is a common complaint in the course of rheumatic diseases such as: rheumatoid arthritis (RA), ankylosing spondylitis (SpA) or osteoarthritis (OA). Although the mechanism of pain formation is better understood, a considerable variety of the clinical picture requires individual programming of the rehabilitation procedure, depending on the degree of damage and the nature of dysfunction. The issue of current knowledge about physiotherapy in patients with shoulder pain syndrome in the course of rheumatic diseases is the subject of further considerations.
General principles of physiotherapeutic treatment in shoulder pain syndromes in the course of rheumatic diseases
Physiotherapeutic treatment should be preceded by a detailed clinical examination, necessary to identify damage of particular structures of the shoulder complex, assess the degree of damage and the nature of dysfunction.
Diagnostic procedure consists of three elements: case history, physical examination and additional tests. The subjective examination includes a detailed interview concerning not only the nature, severity and location of pain, but also the circumstances in which pain appeared, the current treatment and the patient expectations towards the rehabilitation process. Objective examination includes observation of the shoulder area, posture, palpation, assessment of muscle strength, joint stability and measurement of limb length and circumferences. The next step is to conduct functional tests, active and passive, to assess the mobility of the shoulder joint and the location of dysfunction. Additional tests, such as radiological investigation, computer tomography, magnetic resonance imaging, ultrasound, computer arthrography or electromyographic examinations are performed to determine the cause of dysfunction and detailed assessment of pathological changes.
The choice of method depends on the degree of damage and the type of dysfunction. In the acute phase, conservative treatment is recommended, combining pharmacotherapy (analgesics, non-steroidal anti-inflammatory drugs, muscle relaxants, glucocorticosteroids – locally) with rehabilitation. Initially, in the period of significant pain intensity, in addition to pharmacological treatment, it is recommended to reduce the load and immobilize the joint in abduction using a properly selected orthotic stabilizing of the shoulder joint (stabilization by orthotic devices).
In further stages, in order to achieve the desired range of movement and its maintenance, as well as reduce pain, individual kinesitherapy and physical procedures are applied. Maintained limitation of mobility is an indication to use manual therapy techniques under anesthesia, increasing the range of motion in the joint. Occasionally, surgical treatment is necessary (7).
It should be emphasized that the aim of rehabilitation treatment of patients with shoulder pain syndrome in the course of rheumatic diseases is not only to achieve analgesic, anti-inflammatory and functional improvement, but, above all, versatile effect, aiming at achieving general fitness, enabling return to previous life activity (7).
Physiotherapy of shoulder pain in the course of rheumatoid arthritis
Rheumatoid arthritis is a chronic, inflammatory autoimmune disease characterized by a broad spectrum of clinical manifestations. Inflammation includes all joint structures, leading to their irreversible damage. As a consequence, there is a limitation of motion, contractures, subluxation, deformations and muscle atrophies (8).
The development of the inflammatory process in the course of RA leads to the rotator cuff tear, whose tendons intertwine with the fibers of the joint capsule. Limitations in the mobility of shoulder and acromioclavicular joints lead to disturbance of the motor pattern. The situation is aggravated by muscular dystrophies caused by immobility (escape from pain) and inflammatory reaction. Calcium deposits appear on the supraspinatus muscle, leading to its disruption in the late period of the disease, which may result in an axillary dislocation of the head of humerus.
What is more, disturbed balance of the supraspinous muscle and the long head of biceps muscle with deltoid muscle may lead to the subacromial impingement syndrome (3). Inflammation also includes structures of adjacent muscles and tendons (e.g. tendon of the biceps muscle), a rotator cuff and bursae (especially subacromial bursa). Pain in the shoulder area may also be the result of changes in the cervical spine (3).
Rehabilitation of a rheumatoid patient with shoulder pain syndrome requires comprehensive management. The early implementation of treatment is of particular importance, in the reversible phase of the development of the inflammatory process, when distortions in the musculoskeletal system are not yet fixed. The essence of the procedure is to break the vicious circle of pain, which determines the simultaneous analgesic, relaxing and relieving effects. In addition to pain management, an important goal of physiotherapeutic activities is to increase muscle strength and the range of motion in the joints and restore proper movement patterns (7).
The analgesic effect of cryotherapy has been demonstrated, especially during the period of intensified inflammatory changes in joints of the shoulder complex (9). In studies conducted by Piechura et al., an air stream at a temperature of -65°C to -75°C has been used, resulting in a reduction of pain and increase of muscle strength (10).
A valuable complement to therapy is a procedure in a cryochamber, which beneficial effects on the body is not only systemic, but also due to the lowering of the pain threshold, after a few minutes in the cryochamber a decrease in muscle tone and the severity of pain is observed (11). This allows to improve the range of movement, which is used during kinesitherapy.
The results of recent reports also indicate the analgesic and anti-inflammatory effects of laser biostimulation. Reduction of morning stiffness in patients with RA by 95% and reduction in pain by 70% has been demonstrated (12). It is also recommended local laser therapy (with synovium regeneration effect) on the periarticular area, ultrasounds and iontophoresis (with hydrocortisone, non-steroidal analgesics, lignocaine) (11).
In the field of electrotherapy, it is recommended to use transcutaneous electrical nerve stimulation (TENS) with a strong analgesic effect, lasting up to several hours after the procedure (1).
Recent observations indicate the beneficial effects of Extracorporeal Shock Wave Therapy (EWST), which not only has analgesic effects, but also improves microcirculation and stimulates the repair (regeneration) processes of tissues. It is recommended to perform the procedure several times (3-5 times) with weekly breaks (13, 14). Very good treatment results are also noted during the use of magnetotherapy, which improves microcirculation and improves nutritional processes in the diseased area (15).
In the remission period, infrared radiation and compresses are also used before the exercises, however, deeply overheating treatments, such as mud compresses, should be avoided.

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otrzymano: 2019-01-09
zaakceptowano do druku: 2019-01-30

Adres do korespondencji:
*Anna Hryniewicz
Klinika Rehabilitacji Uniwersytet Medyczny w Białymstoku
ul. M. Skłodowskiej-Curie 24a, 15-276 Białystok
tel.: +48 (85) 746-86-06
anna.hryniewicz@umb.edu.pl

Postępy Nauk Medycznych 1/2019
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