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V8n3a08 PDF
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RESUMO SUMMARY
A lesão do manguito rotador é a mais freqüente patologia do The lesion of rotator cuff is the most frequent lesion of the
ombro. Cerca de 180 pacientes foram tratados shoulder. Circa 180 patients were conservatively treated in both
conservadoramente nos dois Serviços nos anos de 1996 e 1997. Clinics during the years of 1976 and 1997. This group of patients
Este grupo recebeu uma ampla gama de tratamentos (apenas received a wide range of treatments (only medication, home
medicação, exercícios caseiros, infiltração, fisioterapia, etc.). exercises, infiltration, physiotherapy, etc). This study evaluated the
Este estudo avaliou os resultados do tratamento conservador results of the conservative treatment in 26 patients with partial and
em 26 pacientes com rupturas parcial e total do manguito rotador. total rupture of the rotator cuff. The protocol consisted of a program
O protocolo consistiu de um programa com 6 meses de duração with duration of 6 months including specific miofascial therapy,
que incluiu terapia miofascial específica, exercícios ativos assisted active exercises and of strengthening of the muscles of
assistidos e de fortalecimento dos músculos do manguito rotador the rotator cuff and axioscapular musculature. The inclusion criteria
e da musculatura axioescapular. Os fatores de inclusão no of the study were: 1) to carry the program with just one reabilitator;
estudo foram: 1) realizar todo o programa com apenas um 2) no previous infiltration; 3) no previous surgery; 4) absence of
reabilitador; 2) não ter recebido infiltração; 3) não ter tido cirurgia diagnosed rheumatopathy. Six months after the end of treatment,
prévia; 4) não ter reumatopatia diagnosticada. Seis meses após eighteen patients (69,22%) presented with satisfactory results,
a alta, dezoito pacientes (69,22%) apresentavam resultado while the other 8 cases (30,78%) were considered not satisfactory
satisfatório, enquanto que os demais 08 casos (30,78%) foram and were referred to surgery.
considerados insatisfatórios e tiveram indicação cirúrgica.
INTRODUÇÃO INTRODUCTION
As lesões degenerativas e traumáticas que afetam o manguito The degenerative and traumatic lesions involving the rotator
rotador (MR) estão entre as mais freqüentes causas de dor no cuff (RC) are among the most frequent causes of shoulder pain,
ombro, merecendo uma atenção cada vez maior no diagnóstico deserving increasing attention in the diagnosis and treatment, and
e tratamento, sendo considerado hoje patologia que exige equipe is considered today as a pathology that should be treated by a
multidisciplinar4, 32. multi-disciplinar team4, 32.
Nesta virada de milênio, a medicina permitiu um significativo Presently, a significant increase in life expectancy was seen
aumento da expectativa média de vida. Além disso, os indivíduos thanks to the progress of the medicine. Besides that persons want
desejam também viver com qualidade de vida, livres de dores to have a better quality of life, free of muscle-skeleton pains, and
do sistema músculo-esquelético, a ponto de permitir a realização able to practice a wide variety of activities related to sport practice
de ampla gama de atividades esportivas e outras. A importância and others. The importance of an articulation of the shoulder with
Vinte e seis pacientes, 09 homens e 17 mulheres com idades Twenty six patients, 9 male and 17 female with age between 34
variando entre 34 e 84 anos (média de 61,6 anos), sendo 12 and 84 years old (average 61,6 years), of which 12 with sedentary
sedentários e 14 considerados ativos, foram incluídos neste life and 14 considered active, were included in this study.
protocolo. As queixas consistiam em dor no ombro, região Complaints were shoulder pain, cervical region, scapular region
cervical, cintura escapular, e terço proximal e lateral do braço. and lateral proximal third of the arm. From these, 8 (30,76%) had
Destes, 08 (30,76%) possuíam ruptura completa do MR e 18 complete rupture of RC and 18 (69,23%) had partial rupture (Table
(69,23%) com ruptura parcial (tabela 1). Ao exame, todos 1). Examination showed that all patients had painful arc and
apresentavam arco doloroso e testes “irritativos”de Neer e positive “irritative” tests of Neer and Hawkins, painful pressure of
Hawkins positivos, dor à palpação em pontos de gatilho nos trigger points of infraspinatus and supraspinatus due to secondary
músculos infraespinhal e supraespinhal devido à disfunção miofascial dysfunction. Additionally there was decrease of passive
miofascial secundária. Além disso, havia diminuição das and active movement amplitude caused by pain 17. The average
amplitudes ativa e passiva de movimento devido à dor 17. O time of the condition was 6 months and all had tried before some
tempo médio de evolução era de 06 meses e todos haviam kind of physiotherapy, without success. The echography or MNR
tentado alguma forma de fisioterapia anteriormente, sem had confirmed the clinical picture of rupture of RC.
sucesso. A ecografia ou a RNM confirmaram o quadro de ruptura Treatment was done with oral NSAIDs, miofascial specific
do MR. therapy (criocinesis, isquemic compression and ultrasound
O tratamento consistiu de anti-inflamatório não-esteróide via applied to the trigger points), continuous ultrasound with frequency
oral, terapia miofascial específica (criocinética, compressão of 1,0 Mhz and dose of 1,5 w/cm 2 for 5 minutes to the subacromial
isquêmica e ultra-som nas miogeloses e nos pontos de gatilho), region 22 ( model AVATAR US 873 - KLD Biossistemas Equip.
ultra-som contínuo com freqüência de 1,0 Mhz e dosagem de Elet. Ltda.), exercises for stretching in external rotation in shoulder
1,5 w/cm 2 por 05 minutos à região subacromial 22 ( modelo plan and horizontal abduction at 30 degrees of flexion, strengthning
AVATAR US 873 - KLD Biossistemas Equip. Elet. Ltda.), exercises with isometrics (Fig. 1), elastic bands (Fig. 2) and weights
exercícios de alongamentos em rotação externa em plano de (Fig. 3) for shoulder external and internal rotators, muscles of the
escápula e em adução horizontal a 30 graus de flexão, exercícios scapular waist (trapesius and anterior serratile) and deltoid (final
de fortalecimento com isométricos (fig. 1), bandas elásticas (fig. phase) according to the protocol from Picture 17, 16. No patient
2) e pesos (fig. 3) para rotadores externos e internos do ombro, received infiltration with corticoid or other therapy. The estimated
músculos da cintura escapular (trapézio e serrátil anterior) e time of treatment was 6 months, with a follow up evaluation 6
deltóide (etapa final) de acordo com protocolo constante no months after the end of treatment 2.
quadro 1 7, 16. Nenhum paciente recebeu infiltração com
corticóide ou outra terapêutica. O tempo estimado de tratamento
foi de 06 meses, com avaliação 06 meses após a alta2.
Quadro 1 Picture 1
Programa de fisioterapia Program of physiotherapy
Fig. 2 - B Fig. 2 - C
Fig. 3 - C
CONCLUSÕES CONCLUSIONS
1. Um programa de reabilitação com exercícios supervisionados 1. A rehabilitation program with supervised exercises is efficient
é eficaz e pode ser considerado como a primeira opção em and can be considered as the first option in patients with rupture
casos de pacientes com rupturas do MR.; of RC:
2. O fator ocupação em pacientes com atividade profissional 2. The occupational factor in patients with professional activity
pode ser indicativo de mau prognóstico com tratamento can indicate bad prognosis with the conservative treatment;
conservador;
3. Surgery can be indicated in patients with strong pain and that
3. A cirurgia pode ser indicada para os casos de dor intensa e
do not respond to the treatment program in 3 to 6 months.
que não responde ao programa de tratamento entre 03 a 06
meses.
Com base no teste de Mann-Whitney 9, os dados foram Using Mann-Whitney test 9, data was analysed according to
analisados de acordo com os seguintes critérios funcionais: the following functional criteria:
1. Elevação ativa igual ou superior a 135 o ; 1. Active elevation iqual or superior to 135 o ;
2. Levar a mão à protuberância occipital externa; 2. Raise the hand to the external occipital protuberance;
3. Levar a mão à coluna tóracolombar. 3. Move the hand till the thoracolumbar spine.
Considerando os movimentos descritos acima, os pacientes Considering the above movements, patients were classified
foram classificados de acordo com o escore abaixo: using the scores below:
• Excelente (E) - Todos os movimentos sem dor; • Exccelent (E) – All movements without pain;
• Bom (B) - Sem dor espontânea e com 02 movimentos normais; • Good (G) – Without spontaneous pain and with 2 normal
• Regular (R) - Sem dor espontânea e com dor em 02 ou mais movements;
movim. • Regular (R) - Without spontaneous pain and with pain in 2 or
• Mau (M) - Com dor espontânea e aos movimentos. more movements;
• Bad (B) – With spontaneous pain and pain to movements.
Os resultados deste estudo podem ser visualizados nos
quadros 1e 2. The results of this study can be seen in Picture 1 and 2.
Empregamos também a escala de classificação para ombro A scale for classification of shoulder was also used - UCLA
- UCLA modificada, assim como o critério de pontuação (quadros modified, as well as the criteria for scoring (Picture 3 and 4,
3 e 4, respectivamente) 6. A pontuação da casuística deste estudo respectively) 6. The scoring of this study casuistic is shown in
está expressa na tabela 1. Table 1.
Quadro 2 Picture 2
Percentuais dos resultados Percent of Results
Dor
Função
Grau 5 — Normal 5
Grau 4 — Bom 4
Grau 3 — Moderado 3
Grau 2 — Ruim 2
Grau 1 - Contração muscular 1
Grau 0 — Nenhuma 0
Satisfação do paciente
Satisfeito ou melhor 5
Insatisfeito ou pior 0
Quadro 4
Critérios de pontuação para análise dos resultados
Resultado Pontuação
Excelente 34 a 35
Satisfatório
Bom 28 a 33
Moderado 21 a 27
Insatisfatório
Ruim 20 ou menos
Pain
Function
Grade 5 — Normal 5
Grade 4 — Good 4
Grade 3 — Moderate 3
Grade 2 — Bad 2
Grade 1 — Muscular contraction 1
Grade 0 — None 0
Patient satisfaction
Satisfied or better 5
Not satisfied or worse 0
Picture 4
Criteria of scoring for results analysis
Result Score
Exccelent 34 a 35
Satisfactory
Good 28 a 33
Moderate 21 to 27
Not satisfactory
Bad 20 or less
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