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Dla wszystkich: Fizykoterapia w zespole barku porażennego
Wysłano dnia 11-11-2006 o godz. 13:15:28 przez admin |
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Cosi napisał "
Powikłania dotyczące barku są poważnym problemem w wielu schorzeniach, w których występuje porażenie połowicze. Użyłem tu określenia „zespół barku porażennego” dla objęcia szeregu objawów, nie tylko bólowych, dotykających chorych z hemiplegią. Prawidłowa profilaktyka pozwala uniknąć powikłań lub zminimalizować ich skutki, jednak często brak jest odpowiedniej rehabilitacji lub jest ona prowadzona niewłaściwie – w takich przypadkach postępowanie fizjoterapeutyczne umożliwia zmniejszenie dolegliwości bólowych, co pozwala na dalsze przywracanie pacjenta do zdrowia.
Patofizjologia
Porażenie połowicze (hemiplegia) najczęściej towarzyszy udarowi mózgu. Dotyczy ono kończyn po jednej stronie ciała, często również mięśni jednej strony twarzy. Jeżeli porażenie było pochodzenia ośrodkowego (udar mózgu), bardzo często występuje również spastyczność kończyny, zwłaszcza w dystalnym odcinku. Porażone mięśnie nie są w stanie utrzymywać kończyny w położeniu fizjologicznym, wskutek czego obwisa ona, pociągając w dół struktury barku: torebkę stawu ramiennego, więzadła i mięśnie. Przy wykonywaniu przez chorego ruchu występuje cykliczne pociąganie kończyny w dół, wywołujące zmienne naprężenia tkanek barku i powodujące ich uszkodzenie. Współistniejąca spastyczność dodatkowo przyczynia się do zaburzenia prawidłowej mechaniki kończyny, co prowadzi do utrwalenia patologii.
Jeżeli nie jest prowadzona odpowiednia profilaktyka, mająca na celu stabilizację okolicy barkowej i zniesienie spastyczności, występuje szereg powikłań, charakteryzujących się bólem i prowadzących do pogłębiania patologicznych stosunków anatomicznych w obrębie kończyny. Według różnych autorów [1,2] są to:
uszkodzenie pierścienia rotatorówMianem pierścienia lub stożka rotatorów (rotator cuff) określamy grupę mięśni rotujących ramię na zewnątrz. Są to: m. subscapularis, m. infraspinatus, m. supraspinatus i m. teres minor. Spełniają one istotną rolę w stabilizowaniu stawu ramiennego i utrzymywaniu prawidłowej biomechaniki barku. Wskutek mikrourazów, wynikających z „szarpania” mięśni barku przez porażoną kończynę, dochodzi do uszkodzenia stożka rotatorów, co powoduje ból i dalsze pogłębianie zaburzeń anatomicznych i czynnościowych okolicy barkowej.
konflikt okolicy cieśni podbarkowejPomiędzy głową kości ramiennej a wyrostkiem barkowym łopatki, w tak zwanej przestrzeni podbarkowej, biegną ścięgna mięśni rotatorów. W przypadku wystąpienia spastyczności obejmującej pierścień rotatorów dochodzi do uwięźnięcia ścięgien spastycznych mięśni w przestrzeni podbarkowej, a w następstwie do patologicznego tarcia ścięgien o kości z bolesnością i powstaniem odczynu zapalnego.
algodystroficzny zespół „bark – ręka”Uszkodzenie torebki stawu ramiennego na skutek pociągania w dół przez niedowładną kończynę prowadzi do nadmiernego pobudzenia układu współczulnego, co powoduje niedokrwienie i ból okolicy barkowej, wzmagający odpowiedź współczulną kończyny górnej, a w konsekwencji utrwalenie bólu na tle wegetatywnym.
uszkodzenie więzadła kruczo-ramiennegoTak jak w powyższych przypadkach, również więzadło kruczo-ramienne narażone jest na zerwanie gdy staw ramienny nie jest wzmacniany przez aparat mięśniowy i występuje patologiczne pociąganie jego struktur w dół przez porażoną kończynę. Uszkodzenie bogato unerwionego więzadła kruczo-ramiennego objawia się silnym bólem.
podwichnięcie stawu ramiennegoJak już wspomniałem, porażone mięśnie okolicy barkowej nie zapewniają stabilności stawu ramiennego, a dodatkowe obciążenie wywołane obwisaniem kończyny górnej wywołuje patologiczne rozciąganie jego struktur. W fizjologicznych warunkach głowę kości ramiennej chroni przed opuszczeniem panewki nie tylko torebka stawowa, ale również aparat mięśniowo-więzadłowy. Nie stabilizowana kość ramienna pod wpływem obciążenia przesuwa się w dół, co powoduje podwichnięcie stawu ramiennego. Podwichnięcie stawu niekoniecznie musi wywoływać ból, jednak prowadzi ono do innych, wyżej wymienionych powikłań – uszkodzenia pierścienia rotatorów, algodystrofii czy zerwania więzadła kruczo-ramiennego – a więc pośrednio staje się przyczyną wystąpienia bólu.
Profilaktyka
Aby nie dopuścić do wystąpienia powikłań, odpowiednie postępowanie profilaktyczne należy rozpocząć natychmiast po wystąpieniu porażenia, w przypadku udaru mózgu jeszcze na „ostrym” oddziale neurologicznym lub udarowym. Obejmuje ono przede wszystkim prawidłowe ułożenie chorego, a także zabezpieczanie niedowładnej kończyny przy wykonywaniu czynności higienicznych przy chorym. Jak najszybciej należy rozpocząć też ćwiczenia bierne, pamiętając o patologicznej wiotkości, występującej w pierwszym okresie po incydencie.
W drugiej fazie, „kompensacyjno-regeneracyjnej” [1], najważniejsza jest kinezyterapia, umożliwiająca przywrócenie pacjentowi prawidłowych wzorców ruchowych, a także odpowiednie zaopatrzenie ortotyczne, obejmujące przede wszystkim różnego rodzaju temblaki, zapobiegające podwichnięciu w stawie ramiennym.
Fizykoterapia w profilaktyce zespołu barku porażennego ma dwa cele. Po pierwsze – wzmocnienie mięśni okolicy barkowej, tak aby mogły one stabilizować staw ramienny i okoliczne struktury. Ten cel realizuje elektrostymulacja funkcjonalna (FES), wykonywana za pomocą osobistych stymulatorów. Terapia trwa 6 tygodni, przy czym czas zabiegu jest zwiększany stopniowo od 1,5 godziny do 6 godzin dziennie. Stymulacja prowadzona jest prądem o przebiegu prostokątnym, częstotliwości od 35-50 Hz i natężeniu umożliwiającym uniesienie kości ramiennej połączone z odwiedzeniem i wyprostem. Efekty sześciotygodniowego usprawniania utrzymują się po kilku miesiącach, a częściowo nawet po dwóch latach [2].
Inne źródła donoszą o skuteczności stosowania stymulacji TENS za pomocą prądów o częstotliwości 3-60 Hz [3].
Drugim zadaniem fizykoterapii jest zniesienie spastyczności. Wykorzystujemy do tego celu tonolizę oraz miejscową krioterapię, przy czym według niektórych autorów [4] krioterapia jest skuteczniejsza w obniżaniu spastyczności, natomiast tonoliza pozwala na lepszą poprawę sprawności ręki. Dobre skutki przynosi tonoliza wykonywana dwuelektrodowo, po stronie antagonistów przykurczonych mięśni, za pomocą prądów interferencyjnych. Najlepsze efekty daje oczywiście połączenie krioterapii z tonolizą stosowane wraz z kinezyterapią.
Leczenie
Jeżeli brak jest odpowiedniej profilaktyki lub jest ona prowadzona nieprawidłowo, dochodzi do wystąpienia powikłań, których głównym odczuwanym przez chorego objawem jest ból. Z pomocą przychodzą tu metody fizjoterapeutyczne: kinezyterapia, masaż oraz fizykoterapia.
Do metod fizykalnych stosowanych w usuwaniu bolesności barku zaliczamy elektrostymulację (TENS), najlepiej w połączeniu z sonoterapią, oraz krioterapię miejscową. Skuteczny jest tu TENS symetryczny, aplikowany elektrodami płaskimi umieszczonymi po obu stronach barku (m. pectoralis maior i m. infraspinatus). Połączenie przezskórnej elektrostymulacji z sonoterapią pozwala na skuteczne znajdowanie punktów spustowych (trigger points), odpowiedzialnych za odczyn bólowy [5], przy czym głowicę ultradźwiękową (katodę) umieszczamy w miejscu punktu spustowego, a anodę po przeciwnej stronie barku.
Spośród stosowanych metod proponuje się również akupunkturę [6], a także laseroterapię, aplikowaną na trigger points (dawka 5-15 J/cm2, 10-15 zabiegów) [7]. Wymieniana jest również magnetoterapia barku polem 10 mT o częstotliwości 40 Hz [8]. Należy jednak podkreślić, że skuteczność tych metod nie została udokumentowana, a złotym standardem w fizykalnej terapii bólu barku porażennego pozostaje elektroterapia, elektrosonoterapia oraz krioterapia.
Paweł Piątkowski
Literatura:
1. Cieśla W., Pilawski A.: Zespół bolesnego barku hemiplegika. Rehabilitacja w Praktyce 2/2006, s.16-18
2. Paci M., Nannetti L., Rinaldi L.A.: Podwichnięcie stawu ramiennego w porażeniu połowiczym – przegląd literatury. Rehabilitacja Medyczna 2006, t. 10, nr 1, s. 55-64
3. Kwolek A. et al.: Wykorzystanie przezskórnej elektrostymulacji prądami o częstotliwości od 3 do 60 Hz w rehabilitacji pacjentów z niedowładem połowiczym po udarze mózgu. XII Sympozjum Polskiego Towarzystwa Rehabilitacji, Kraków 2006
4. Pasternak-Mlądzka I., Dobaczewska R., Otreba D.: Dobór metod fizjoterapeutycznych i ich skuteczność w uzyskaniu poprawy funkcji ręki spastycznej u pacjentów po udarze mózgu. XII Sympozjum Polskiego Towarzystwa Rehabilitacji, Kraków 2006
5. Grymel-Kulesza E. et al.: Wpływ kompleksowej terapii na jakość życia pacjentów w leczeniu uszkodzeń pierścienia rotatorów. XII Sympozjum Polskiego Towarzystwa Rehabilitacji, Kraków 2006
6. Chen L.: A new thinking of acupuncture and moxibustion treatment of shoulder pain after hemiplegia. Zhongguo Zhen Jiu. 2006 Sep;26(9):669-71
7. Sieroń A., Pasek J., Mucha R.: Lasery w medycynie i rehabilitacji. Rehabilitacja w Praktyce 2/2006, s.26-30
8. Sieroń A., Mucha R., Pasek J.: Magnetoterapia. Rehabilitacja w Praktyce 3/2006, s.29-32
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Re: Fizykoterapia w zespole barku pora?ennego (Wynik: 1)
przez Tomasz_Borowski dnia 11-11-2006 o godz. 20:42:13
(Informacje o użytkowniku | Wyślij wiadomość) http://www.fizjopedia.pl | | Godnym pochwa?y jest fakt, ?e w czasach mody na nowinki terapeutyczne, kto? przypomina o istnieniu „starej”, poczciwej fizykoterapii. Dlatego z najszczersz? ciekawo?ci? przeczyta?em ten artyku?. Przyznam delikatnie, ?e mam nieco mieszane odczucia.
Po pierwsze, szkoda, ?e a? 60% obj?to?ci tekstu zajmuje opis (a w?a?ciwie przepisanie z podr?cznika) powszechnie znanych jednostek klinicznych. To zupe?nie zb?dne cho?by z tego powodu, ?e opisie leczenia fizykalnego autor i tak nie ró?nicuje leczenia poszczególnych jednostek, ale wrzuca je do jednego worka z etykietk? z przedziwn? nazw? „zespó? barku pora?ennego”.
Po drugie, z sobie tylko znanych powodów do profilaktyki zalicza leczenie spastyczno?ci. Zatrzymuj?c si? na punkcie zatytu?owanym (roboczo, jak mniemam) „Profilaktyka” zaniepokoi?y mnie dwie rzeczy:
- ufno??, ze elektrostymulacja FES „wzmacnia” i „stabilizuje” staw ramienny, a efekty tej?e terapii utrzymuj? si? „cz??ciowo nawet po dwóch latach” (nie za bardzo rozumiem, co owe „cz??ciowe utrzymywanie efektów si? terapii” ma oznacza?);
- oraz brak rozró?nienia rzeczywistej roli fizykoterapii w leczeniu spastyczno?ci. Zdanie bowiem, i? „najlepsze efekty daje oczywi?cie po??czenie krioterapii z tonoliz? stosowane wraz z kinezyterapi?” nie pozwala wysnu? jednoznacznych wniosków, co do rzeczywistych proporcji terapeutycznego oddzia?ywania kinezyterapii i fizykoterapii.
Po trzecie, w punkcie „Leczenie” ju? pierwsze zdanie potrafi zaskoczy? przedziwnym rozumieniem autora, czym s? powik?ania. Wed?ug autora, powik?ania s? efektem braku profilaktyki. Mo?e si? czepiam, ale nie lubi? kolokwialnych skrótów my?lowych w tekstach aspiruj?cych do naukowych.
O samym leczeniu niewiele napisano. Wymieniono tylko z nazwy kilka zabiegów, podaj?c standardowo stosowane miejsca aplikacji i parametry zabiegowe.
Na zako?czenie mam te? jeszcze jedno „ale”. Ja wiem, ?e jest „mile widziana” jak najd?u?sza lista wykorzystanych pozycji bibliograficznych. Zabieg ten ma to podnie?? rang? danego tekstu w oczach czytelników. Rozumiem to doskonale w przypadku, gdy ma pokrycie w rzeczywisto?ci.
Prosz? jednak Autora, by zechcia? mi wskaza? wykorzystanie pracy pt. „A new thinking of acupuncture and moxibustion treatment of shoulder pain after hemiplegia. Zhongguo Zhen Jiu. 2006 Sep;26(9):669-7” w napisaniu swego artyku?u.
Tomasz Borowski |
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