1、肩的疼痛Shoulder Pain,纪念医院古澤正道Masamichi FURUSAWABobath Memorial Hospital,脑卒中后遗症中约有的患者主诉肩痛。Twenty-one % to 72 % of stroke patients complain of shoulder pain.文献：Van Ouwenaller et al.: Painful shoulder in hemiplegia. Arch Phys Med Rehabil, 67 : 23-25, 1986. Bohannon RW et al.: Shoulder pain in hemiplegia :
2、 Statistical relationship with five variables. Arch Phys Med Rehabil, 67 : 514-516, 1986. Chard MD, Hazleman BL : Shoulder disorders in the elderly. Ann Rheum Dis, 46 : 684-687, 1987. Van Iangenberghe HVK et al.: Shoulder pain in hemiplegia : A book review. Physiother Pract, 4 : 155, 1988.,种疼痛(Three
3、 kinds of shoulder pain) 活动时疼痛(Mechanical and local pain while moving and being moved)被动活动和自主活动时的局部疼痛。安静时自发疼痛 (Spontaneous and extensive pain at rest) 夜间睡觉时与长时间轮椅保持坐位时，麻痹的上下肢的存在广泛的疼痛。肩手综合征的患者多伴有浮肿。进行运动疗法时该症状容易消失，故问诊是必不可少的。肩的活动时疼痛多先出现。This pain is spontaneous and extensive pain in affected upper and
4、lower extremities at rest when patients lie on beds and sit on wheelchairs. Most of patients have edema due to shoulder-hand syndrome. As this kind of pain disappears in movement therapy, therapists must ask whether they have such kind of pain or not. This extensive pain tends to be initiated by loc
5、al shoulder pain. Braus DF et al.: The shoulder-hand syndrome after stroke : A prospective clinical trial. Ann Neurol, 36 : 728-733, 1994.,种疼痛(Three kinds of shoulder pain) 视丘痛(Thalamic pain)在视床后外侧症候群中，90%的后外侧损伤病例可见此种疼痛。Thalamic pain is one of syndrome in the lesion of posterior-lateral part.Ninety
6、% of patients with the lesion of that part had thalamic pain.(Miyazaki 1997)宮崎東洋：. 克誠堂、pp40-47182-193、1997.,花岡一雄橘直矢：神経系話. 、東京、.,posterior,anterior,rightwards (lateral),leftwards (medial),posterolateral n.,pulvinar thalamus,ventral posterolateral n.,dorsolateral n.,（前外側腹側核）,ventral anterolateral n.,（
7、中間腹側核）ventrointermedial n.,視 床Thalamus,dorsomedial n.（視床内側核）,medial corpus geniculatum,lateal corpus geniculatum,(Mori, 1995)森於兎（原著）：解剖学（改訂版）. 大内弘（改訂）、金原出版、p336、1995.,lower fibres of trapezius,upper fibres of trapezius,serratus anterior,levator scapulae,rhomboid minor,rhomboid major,centre of rotati
8、on,centre of rotation,肩胛骨的运动 Scapular Motion,前方,後方,内側,上方,下方,外側,上方,後方,下方,前方,内側,外側,後傾 posterior tilting,前傾 anterior tilting,上方回旋,upward rotation,下方回旋 downward rotation,内旋 int. rot.,外旋 ext. rot.,Braman JP, Engel SC, LaPrade RF, et al.: In vivo assessment of scapulohumeral rhythm during unconstrained ov
9、erhead reaching in asymptomatic subjects. J Shoulder Elbow Surg, 18 : 960-967, 2009.,Average humerothoracic plane elevation : 63.37.0forward of coronal plane, and average peak elevation : 132.99.9Scapular Rot : Int. Rot. until 125of arm elevation, then rotated externally with further elevation. Scap
10、ulohumeral rhythm, 2.3 : 1 during elevation. 2.7 : 1 during lowering.Maximally tilted 11.84.9anteriorly at 15of humerothoracic elevation. A minimum posterior tilt of 9.87.5at 145.,7,活动时疼痛( Mechanical and local pain )初期迟缓期的移乘和卧位翻身时的细微损伤（对于患侧上臂的KP应该慎重使用，体干的KP效果较好）In initially flaccid stage, caregivers
11、 sometime give microtraumas and excessive stretches of affected shoulders. (In early stage therapists and caregiver must carefully use proximal and distal KP of affected upper extremities in transfer and turning over. We had better use affected trunks and scapulae.) 肌张力的不平衡和肌肉（软组织）粘弹性低下Imbalance of
12、postural muscle tone and decrease of viscoelasticity of muscles and soft tissues 肩胛骨的不稳定 Instability of affected scapula容易产生短缩的肌肉：胸小肌、胸大肌尤其是锁骨枝、肱二头肌、喙肱肌、菱形肌、背阔肌等。与迟缓肌混合在一起。 Shortness : pect minor, pect major (especially clavicular portion), biceps, coracobrachialis, rhomboids, latissimus dorsi and s
13、o on. These exist with hypotonic muscles.恢复肩肱节律，去除胸大肌的负荷（ de-weight ） Recovery of scapulohumeral rhythm & De-weight to P. Major Bobath K : Shoulder pain. Phys Ther, 52 : 444-445, 1972.,Myers TW : Anatomy Train. ChurchillLivingstone, London, pp18163, 2006.,Pectoralis minor connects fascially to short
14、 head of biceps brachii and coracobrachialis at coracoid process.,9,粘连(Adhesion)根据偏瘫患者肩关节造影，25%的患者存在粘连变形。特别是肱二头肌腱鞘达到了58%。 (Fukui 1972) In arthrography, 58% of tendonsheaths of biceps had adhesion.福井国彦：片麻痺肩造影線像中心所見及経過. 医学、9 : 183、1972.偏瘫的患侧肩多少呈现了粘连性症状，48个病例中27个有此症状（56.3%）。(Hakuno 1984) Fifty-six % of
15、 affected shoulders had adhesion.白野明他：片麻痺肩関節造影上変化. 総合、12 : 47-52、1984.偏瘫患者关节造影，根据与半脱位肩关节的比较，在半脱位上产生关节的粘连性变化更为常见。而且从肩关节整体来看粘连的产生也是在半脱位更容易产生。撞击的可能性极小。(Hakuno 1986)In arthrography of 95 shoulder joints, most of adhesion was accompanied with shoulder joint subuxations.白野明：片麻痺肩関節造影所見. 総合、14 : 203-207、198
16、6.,粘连 (Adhesion)在实行肩关节造影的50例病例之中，肩肱关节处的粘连变化达80%，腱断裂存在14%。 (Ono 1994) In arthrography of 50 cases, 80% had adhesion of scapurohumeral joints, and 14% had rupture of tendons.小野幸子他：片麻痺患者肩痛. 医学、31 : 928-929、1994.以发病未满1年、主诉肩痛的患者32人进行关节造影。发病后2个月以内没有肩痛症状的，50%的病人存在粘连性囊炎(adhesive capsulitis)。 22%的人旋转肩袖（rotat
17、or cuffs ）断裂，16%存在肩手综合征、44%存在肩关节半脱位。粘连性囊炎为肩关节疼痛的诱因。 Fifty % of 32 cases who complained of shoulder pain had adhesive capsulitis. Twenty-two % had rupture of rotator cuffs, 16 % had shoulder hand syndrome and subluxations of shoulder joints were found in 44 %. Adhesive capsulitis is one of causes of
18、shoulder pain.Lo S-F et al.: Arthrographic and clinical findings in patients with hemiplegic shoulder pain. Arch Phys Med Rehabil, 84 : 1786-1791, 2003.,粘连 (adhesion) 由于浮肿导致肱二头肌、肱三头肌长头等起始部位腱鞘和关节囊的短缩和粘连。 Edema makes shortness and adhesion in capsules and tendonsheaths of biceps brachii and triceps br
19、achii etc. Roy CW : Shoulder pain in hemiplegia : A literature review. Clinical Rehabilitation, 2 : 35-44, 1988. 腱炎粘连性囊炎(tendinitis and adhesive capsulitis )肱二头肌长头的疼痛波及肌腹以及肱二头肌间沟的腱炎，在前臂内侧面出现疼痛，肘部形成二头肌腱炎。 Some of he pain in origin of biceps brachii long head comes out in its belly, which is tendiniti
20、s in intertubercular groove. The teniditis in the insertion of biceps brachii indicates pain in upper and volar side. Donatelli RA : 肩. 山本龍二他（監訳）、葵出版、東京、pp83-101、2002. 临床观察(In the clinical observation)在长期卧床的病例中，在胸廓和背部可见短缩与粘弹性低下，上肢上举时肩胛骨和肋骨的分节运动困难。 In the cases who have experienced to lie on beds in
21、long term, shortness and decrease of viscoelasticity of back muscles are observed. These problems made segmental movements of ribcages poor.,Cailliet R : 肩痛（第版）.荻島秀男（訳）、医歯薬出版、pp1451、2004.,肱二头肌长头的冲突Impingement/stretch of the long head of biceps brachii in intertubercular groove Pain,capsule,long head
22、 of biceps,synovial membrane,long head of biceps,synovial fluid,synovial membrane,transverse ligament,biceps,Scapulohumeral Synovial Bursa and Joint Capsule,coracoacrominal lig.,Mechanism of Biceps (long head),伸展二头肌长头在结节间沟 疼痛,Impingement 撞击 (impingement syndrome, chronic subacrominal impingement syn
23、drome)肩峰、喙肩韧带、喙突、肩锁关节会与腱板和肩峰下滑液囊发生撞击，发生慢性的持续的疼痛时，称为impingement综合症。 Impingement is the phenomenon that the acromion, coracoacrominal lig., coracoid process and acromioclavicular joint collide to rotator cuffs and subacrominal bursa. When collisions are repeated and pain occurs, it is called impingeme
24、nt syndrome.(Tamai 2002) 玉井和哉：症候群. 肩痛 寺山和雄片岡治（監修）、南江堂、pp85-98、2002.,撞击与夹痛impingement & pinching上肢水平外展运动中产生的疼痛，推测为肩峰下滑液囊和肱三头肌长头的夹痛。 The pain while moving an arm horizontally is guessed to be caused by pinching a capsule and a long head of triceps brachii.根据运动方向产生的疼痛 Different local pain in different
25、directions of the movement 前方上举时的疼痛 (What is the local pain while elevating a arm ?) ：水平外展时的疼痛 (What is the local pain while abducting horizontally ?) ：水平内收时的疼痛 (What is the local pain while adducting horizontally?) ：上肢放下时的疼痛 (What is the local pain while descending arm ?) ：,(Mori 1995) 森於兎（原著）：解剖学（
26、改訂版）. 大内弘（改訂）、金原出版、pp128341、1995.,结节间沟Intertubercular groove,肱二头肌长头long head tendon of biceps brachii,(Mori 1995)森於兎（原著）：解剖学（改訂版）. 大内弘（改訂）、金原出版、p207、1995.,结节间滑液鞘Intertubercular synovial membrane,(Yazaki 2008)矢崎潔：再人間上肢運動考（）.、31(1) : 54-61、2008.,肘关节屈伸运动时（）的肱三头肌和胸大肌的关系Relationship between biceps and pe
27、ctoralis major when an elbow extends and flexes. （）肱二头肌起作用时长头腱产生压力的方向 The direction of power on the long head of biceps brachii （）伸展时，生理上作为协同肌的胸大肌对肱骨的牵引方向 The direction of contraction on the pectoralis major when elevating an humerus、（）肱二头肌和胸大肌的位置关系elationship on alignments between long head of bice
28、ps and p. major长头肌腱处直接加压，结节间沟和周边疼痛Pressure is given to a long head of biceps in intertubercular groove, and pain tends to occur.,flexion,extension,岁男性、脑出血（右侧偏瘫）、发病后月、右肩痛 Age : 49 Y, Male, Dx.: Cerebral Hemorrhage (Right Hemi and Rt. Shoulder Pain), 2 Months after a Stroke,翻身时麻痹侧右上肢落在身后，牵张痛会在肱二头肌长头起始
29、部出现。When he turns over from supine to left side-lying while sleeping on a bed, he often leaves his right arm and then has right shoulder pain.,为了预防对于肱二头肌长头起始部位过度的伸张和撞击，调整肩肱节律。 In order to prevent stretch and impingement, scapulohumeral rhythm is corrected with placing.,在患者翻身时,PT要诱导从右侧上肢开始的翻身动作。保持肩胛带
30、的前伸。A therapist guides the right scapula and arm move upward when turning over. The patients awareness is important.,Self control to prevent shoulder pain患者自己控制，左手把持麻痹侧上肢，在不引起疼痛下翻身。,(Mori 1995) 森於兎（原著）：解剖学（改訂版）. 大内弘（改訂）、金原出版、pp337344、1995.,水平外展时肱骨三头肌长头和关节囊的夹痛 Pinching ad pain of a long head of trice
31、ps brachii and a joint capsule abducting horizontally.,Long head of triceps,Teres major,Teres minor,Long head of triceps,Teres major,(Tamai 2002) 玉井和哉：症候群. 肩痛 寺山和雄片岡治（監修）、pp85-95、2002. Neer CS: Cuff tears, biceps lesions, and impingement. Shoulder Reconstruction. (Ed.) Neer CS, WB Saunders, Philadel
32、phia, pp41-142, 1990. (右図),Impingement 撞击综合症Impingement Syndrome,冈上肌出口狭小化Narrow supraspinatus outlet,Cailliet R : 肩痛（第版）.荻島秀男（訳）、医歯薬出版、pp27-2866-68、2004.,在损伤部位的压痛,Rupture of Supraspinatus冈上肌的断裂,Pressure pain in the lesion,肩悬吊肩(Shoulder Sling),左侧偏瘫Lt. Hemi.,活动时疼痛的对策 (The approach to local pain while
33、moving) 平衡肌张力和恢复肌肉粘弹性 Postural control, modulation of postural muscle tone, restoration of vscoelsticity.恢复肩肱节律Recovery of scapulohumeral rhythm肩胛骨的定势Scapula setting肩胛带的稳定性与运动性Selective stability and movement of scapula 对于短缩，在KP控制的部位导入关节松动术 Mobilizing to shortness of muscles and soft tissues,肩胛骨的定势S
34、capula setting脑梗塞（右侧偏瘫）68岁男性Dx. Cerebral Infarction (Rt. Hemiplegia) Age : 68Y,Scapula setting,偏瘫侧肩胛提肌起始部的疼痛Pain in the origin of affected levator scapulae 姿势性疲劳 Postural fatigueCailliet R : 肩痛（第版）.荻島秀男（訳）、医歯薬出版、pp275-285、2004.,短缩Shortness,疼痛Pain,左侧骨盆后撤 Lt. pelvis retraction,Caillet R :頚腕痛（第版）. 荻島秀男
35、（訳）、医歯薬出版、p226、2004.,Increase of kyphosis,Downward rotation,Levator scapulae,Locked long muscles : Strained,Locked short muscles : Bunched（一塊）,不活动的长肌：紧张（）,Myers TW : Anatomy Train. ChurchillLivingstone, London, p18, 2006.,Increase of thixotropy (触变性的改变）,28,肩手综合症始于疼痛的肩和上肢Shoulder-hand syndrome is occ
36、urred by local pain in affected shoulders and upper extremities.Donatelli RA : 肩. 山本龍二他（監訳）、葵出版、東京、pp83-101、2002.,Braus DF et al.: The shoulder-hand syndrome after stroke : A prospective clinical trial. Ann Neurol, 36 : 728-733, 1994.,肩手综合症由局部损伤引起。Shoulder-hand syndrome is initiated by peripheral le
37、sions (local pain).,大范围的麻痹侧上下肢的安静时自发痛Spontaneous and extensive pain at rest首先出现麻痹侧运动时的局部疼痛。 推测疼痛是由于炎症时产生的缓激肽、复合胺、组胺、钾离子等的神经激肽广泛存在于浮肿部位。缓激肽等物质促进组织产生、游离前列腺素类物质。 The local shoulder pain while being moved occurs before this kind of pain. It is guessed that the neurokinin like bradykinin, serotonin, hist
38、amine, Ach and potassium is accumulated a lot in edema and then production of prostaglandin is increased and causes spontaneous and extensive pain of affected upper extremities at rest. Awad EA : Interstitial myofibrositis : hypothesis of the mechanism, Arch Phys Med, 54 : 449-453, 1973. (Kumazawa 1
39、990) 熊澤孝朗：痛覚. 脳科学 中村嘉男酒田英夫（編）、朝倉書店、pp187-200、1990.交感神经产生了诱发疼痛的物质-神经激肽（ neurokinin ）。由于不存在皮肤血管扩张，疼痛的阈值降低。 Sympathetic nerves produce which makes pain. It dilates skin vessels and lowers the threshold of pain. Wattay EG : Reflex sympathetic dystrophy syndrome. Clinical Management, 9 (1) : 28-29, 1989.
40、,肩手综合症Shoulder Hand Syndrome麻痹侧上肢的肌肉活动低下 肌肉血流减少 Decrease of muscle activities of an affectted upper extremity Decrease of blood flow in muscles 皮肤骨组织的血流增加Increase of blood flow in skins and bones reversely局部的代谢障碍微循环恶化、神经激肽产生 伤害感受器的向心性冲动增加Poor local metabolism Inflammation of soft tissues and a lot o
41、f production of neurokininIncrease of afferent impulses from nociceptors内环境稳定，有促使皮肤骨组织增加的血流正常化的作用Reactions to normalize the increase of blood flow of skins and bones by homeostasis但是交感神经活动亢奋。 细小动脉收缩交感神经和躯体感觉神经产生去甲肾上腺素的化学信号，增加向心性冲动，在脊髓水平，反射性的交感神经兴奋。 Activities of sympathetic nerves becomes higher. Capillaries contract. In sympathetic nerves and sensory nerves, chemical transmission of noradrenalin happens, and then afferent impulses increase. In spinal cord, sympathetic nerves reflexively excite. (Ishibashi 2002) 石橋徹：反射性交感神経性. 肩痛 寺山和雄片岡治（監修）、pp183-197、2002.,
