及早被動運動是否能改善旋轉肌袖修補手術後病人肩關節活動功能? Can Early Passive Mobilization Improve Shoulder Function after Rotator Cuff Repair?

1641 5

2019-10-08 已刊登
新刊登 綜 整 意義類型

作  者

張凱晴* 林曼玲 王金蓮 林麗華

實證知識類別

A 類:實證健康照護綜整

PICO

意義/病人的經驗及顧慮

治療/介入措施

運動醫學 Primary Care Sports Medicine

科別

  • 骨骼護理 Orthopaedic Nursing
  • 復健護理 Rehabilitation Nursing

中文關鍵詞

旋轉肌袖撕裂

英文關鍵詞

Rotator cuff repair,Arthroscopic rotator cuff repair,Early passive motion,Early exercise,Range of motion of the shoulder

機構名稱

臺北榮民總醫院

申請單位

護理部

中文摘要

形成臨床提問:
肩關節病變以旋轉肌袖撕裂最常見,症狀有疼痛與手臂上舉困難,保守治療無效時採修補手術,術後何時開始運動,臨床醫師見解不一致,有鼓勵及早運動;也有認為預防再斷裂要晚一點,過與不及都會影響恢復。因臨床病人有截然不同的運動處置,引發臨床問題,以實證為依據探討及早被動運動對肩旋轉肌袖手術後病人的影響。
文獻搜尋的方法與分析:
1.運用實證步驟確立PICO問題:及早被動運動是否能影響肩旋轉肌袖手術病人的肩關節活動功能。 2.搜尋策略:利用Mesh term與Thesaurus設定關鍵字: P (Rotator cuff repair, Arthroscopic rotator cuff repair ), I (Early passive motion, Early exercise),O (Range of motion of the shoulder )。布林邏輯(OR, AND and NOT),條件:2014至2018年、英文,SR、RCT,在PubMed、Medline、CINAHL搜尋;符合文章33篇,刪除重覆或內容不符,最後1篇SR和2篇 meta-analysis納入文獻評讀,並以Oxford center for EBM,2011評析研究證據等級。
文獻的品質評讀:
1.Mazzocca, et al. (2017)::手術後第2、3天進行及早被動運動如以手杖輔助伸展及外旋,於術後第3、6、12週、六個月及一年評估,研究結果(1)肩部活動上舉及外旋:術後第3週實驗組較高(p<.01),(2)疼痛:第12週實驗組較低(p= .04),(3)生活品質:第3、12週和1年實驗組生活品質較好且有顯著差異,重複測量混合效果回歸分析兩組患者復元軌跡檢定(p=.04)有顯著相關性。(LEVEL 2) 2.Chang, et al., (2015):搜尋關節鏡修補術和及早期運動文獻,術後第6及12個月追蹤,研究結果(1)肩部活動前屈及外旋:前屈在第6及12個月及早被動運動組有顯著角度差異。(2)再撕裂率:及早被動運動復發肌腱撕裂率是無及早被動運動1.43倍,具顯著差異。(LEVEL 1) 3. Li, , et al., (2018) :(1)肩部功能:綜合研究結果顯示術後2週內開始及早被動運動,在短、中期追蹤,及早運動組的前屈及外旋角度皆大於延遲運動組.有統計差異。 (2)肌腱癒合率:術前大面積撕裂患者及早被動運動肌腱癒合緩慢,但與延遲被動運動相比無顯著差異(RR 0.90; 95%CI,0.80-1.01; P = .06)。(LEVEL 1)
結論與建議:
綜合三篇研究,及早被動運動能提升生活品質,且不會增加病人疼痛,對肩關節運動功能如上舉及外旋角度在短期內的伸展範圍有些差異,長久來看對肩關節活動無明顯差異,至於及早運動肌腱與再撕裂率,卻有不同研究結果,而不論是早期或晚期接受復健運動,透過修補手術有92%有良好預後。

英文摘要

Ask an answerable question (PICO):
Rotator cuff tear is one of the most common shoulder disease in adults. It often presents with shoulder pain and difficulty in shoulder elevation. Surgical repair often indicated if patients do not respond well to conservative treatment. After surgery, we often suggest patient to rehabilitate as soon as possible to prevent shoulder stiffness and muscle atrophy. However, some surgeons would delay rehabilitation to prevent re-tear of the rotator cuff. Thus, it is common in the clinical setting that patient would question care givers why they should or should not receive rehabilitation after the surgery. Thus, we would like to discuss the influence of early postoperative rehabilitation in patient with rotator cuff tear and answer this clinical question via evidence-based methods.
The Method and Analysis of Literature Review:
1. We would like to use evidence-based methods to set PICO questions to answer whether early postoperative passive range of motion training would influence patients outcomes after rotator cuff repair surgery. 2. Searching strategy: We used Mesh term and Theasurus to set key words: P: Rotator cuff repair, arthroscopic rotator cuff repair I: early passive motion, early exercise O: shoulder range of the motion We used Bollean logic “AND, OR, and NOT” to search English databases from 2014-2018 in PubMed, Medline, CINAHL. Total thiry-three articles were recruited. After exclusion of irrelevant or repeated papers, 2 meta-analysis and 1RCT were finally included. We also used Oxford center for EMB in 2011 to analysis level of evidence.
Critical Appraisal:
1.Mazzocca, et al. (2017): Early passive range of motion with shoulder joint with assisted forward elevation and external rotation were performed and patients were evaluated 3 weeks, 6 weeks, 12 weeks, 6 months and 1 year after surgery. The results showed that patients receiving early rehabilitation has better forward elevation and external rotation 3 weeks after surgery with p< 0.01. Less pain was also noted in patients receiving early rehabilitation 12 weeks after surgery with p= 0.04. Better quality of live was also noted 3 weeks, 12 weeks ad 1 year after surgery if patients received early rehabilitation with p= 0.04. (Level 2) 2. Chang, et al., (2015): The authors analyzed patients subjecting to arthroscopic repair of the rotator cuff tear and compared their outcomes 6 and 12 months after surgery. They found that patients receiving early passive range of motion training had better forward elevation and external rotation of the shoulder joints. Re-tear of the rotator cuff was also found lower in patients subjecting to early rehabilitation with statistical significance. (Level 1) 3. Li, , et al., (2018) : (1) Shoulder function: The results of the comprehensive study showed that the passive movement began early and within 2 weeks after surgery. In the short and medium term, the flexion and external rotation angles of the early exercise group were greater than those of the delayed exercise group. There are statistical differences. (2) Tendon healing rate: Patients with large area tear before surgery had slow healing of tendon after EPM rehabilitation, but there was no significant difference compared with DPM rehabilitation (RR 0.90; 95% CI, 0.80-1.01; P = .06)。(Level 1)
Conclusions and Recommendations:
In conclusion, early postoperative exercise could enhance quality of life without inducing more pain after surgery. Patients receiving early exercise after surgery may have better performances in shoulder forward elevation, abduction in the short term. However, no difference was found in range of motion in the long term. Better outcomes were found in 92% of the patients subjecting to repair of the rotator cuff, despite early or late rehabilitation.