Y HOC VI^T NAM T H A N G 7/2011 - SO OAC BIET
KET QUA OIEU TRj BAO TON
"CLTNG
K H 6 PVAI" 6 NGUdi
L 6 NTUOI TAI BENH VIEN
T I N HKHANH HOA 2005-2009
Phan Hutu Chinh Dang Thi Thanh Dung, Le Minh Hoan (*)
TOM TAT
Viem cflng khdp vai (viem quanh khdp vai the dong dflng) thfldng gap d ngfldi cao tudi (tren 60 tuoi), diln bien benh keo dai vai thing tdi vai nam khien benh nhan dau ddn va han che van dpng khdp vai nhieu. Dieu trj viem quanh
khdp vai dong cflng thfldng lau dai, can phdi hdp giOci dieu trj npi khoa va vat ly trj lieu. Muc tieu nghien cihi nham danh gia hieu qua phac dd dieu trj bao tdn "cflng khdp vai" 6 benh nhan Idn tuoi tai benh vien Tinh Khanh Hda trong nam 2005-2009. Odi tu'dng: Gom 351 benh nhan dfldc chan doan cflng khdp vai tai phdng kham chuyen khoa Chan thfldng Chinh hlnh. Phu'dng phap nghl§n cii'u: Nghien cflu md ta, can thiep md khdng cd nhdm ddi chfltig. Tat ca benh nhan nghien cflu deu dfldc tien hanh dieu trj: tiem khdp vai bang disprospan ket hdp tap phuc hoi chflc nang khdp vai. Ket qua nghien cufu:
Trifu chflng dau dfldc cai thien ro va ngay sau tuan dau va keo dai trong suot 03 thang qua tat ca cac thong sd danh giai, sfl khac biet cd y nghia vdi p<0,01. Cd 76% sd benh nhan phuc hoi chflc n3ng khdp vai sau 3 thing dieu trj. Ket luan: Tiem disprospan khdp vai ket hdp tap phuc hdi chflc n3ng khdp vai rat cd hieu qua trong dieu trj viem quanh khdp vai the dong cflhg.
TCtkhoa: Viem quanh khdp vai, ddng cflng khdp vai
(*) Khoa ngoai CTCH - Binh viin da khoa Tinh Khdnh Hda
SUMMARY
Peripheral shoulder inflammation (frozen shoulder) is common in the elderly (over 60), changes in disease lasting several months to several years that patients with pain and limited joint movement as much. Treatment of frozen shoulder is often a long-term, collaboration between medical treatment and physiotherapy.
Purpose of the study: to evaluate the effectiveness of consevative treatment "shoulder stiffness" in elderiy patients in hospitals of Khanh Hoa Province in 2005-2009. Objects: Including 351 patients diagnosed with shoulder stiffness in orthopedic clinics. Method: The Observation study, intervention study without control group.
All patient studies were conducted treatment:
inject disprospan into the shoulder joint combined training rehab to the shoulder joint.
Results: the painful were significantly improved after the first week and lasted throughout the 03 months, the difference is significant with p
<0.01. 76% of patients have recovered shoulder joint moverment after 3 months of treatment.
Conclusion: Injection disprospan into shoulder joint combined training and rehabilitation is very effective in the treatment of frozen shoulder.
Keywords: frozen shoulder treatment
HOI THAP K H 6 P HOC VIET NAM: HOI NGHI KHOA HOC TOAN QUOC LAN THLf IX
I. DAT VAN DE
Dau khdp vai rat thudng gap, hau nhu ai ciing gap it nhit mpt lin trong ddi. Cd khoing 7% ngudi trudng thanh (tu 25 - 75 tudi) da tung hi dau khdp vai Thudng gap nhit d lfla tudi 40 - 60 tudi, chilm ti le 0,25% dan sd [1 ]. Viem dinh khdp vai - cflng khdp vai hiem gap hon v i thudng gap d ngudi tren 60 tudi. Khdp vai van dpng vdi bien dp rat rpng nen cau true va sinh co hpc rat phflc tap. Nguyen nhan gay viem dinh khdp vai lien quan din nhilu benh ly kem theo: hpi chung chdp xoay, di dang mdm Cling vai, viem gan co nhi diu, chin thuong;
cd thi gip trong benh viem khdp dang thip, gut...Hon 20% trudng hpp viem dinh khdp vai la man tinh va 65% cd lien quan tdi tdn thuong chdp xoay [ 1 ].
Vide dilu tri, thudng dung phac dd kit hpp nhilu phuang phap, trong dd tiem tai chd vi phyc hdi chflc nang ddng vai trd quan trpng. Dudng nhu nudc ta chua cd nhilu nghien cuu ve dieu tri benh ly nay. Nghien curu nhim myc tieu
1. Dinh gia hieu qua phic dd dilu tri bao tdn "cflng khdp vai" d benh nhan Idn tudi tai b?nh vifn Tinh Khanh Hda trong nam 2005- 2009
2. Khio sat tic dyng khdng mong mudn cua cic phuong phip sfl dyng
I I . DOI THUONG VA PHU'DNG PHAP NGHIEN CUtJ
2.1. Doi tirong nghien cihi
Gdm 351 benh nhan dupe chin doin cflng khdp vai va dilu tai phdng kham chuyen khoa Chin thuang Chinh hinh trong 5 nam (thing I nim 2006 din thing 12 nam 2010) dap ung tieu chuin chpn va loai benh nhan dudi day.
2.1.1. Tieu chuan chon benh nhan nghien ciru
Chan doan cumg khdp vai: theo Iam sing: benh nhin dau va ban che bien dp van ddng cfla khdp vai.
Benh nhan nam > 60 tudi; Benh nhan nu > 55 tudi
Chip nhan tham gia nghien curu vi ididng cd chdng chi dinh tiem ciia glucocorticoid tai chd, khdng di ung vdi cic thinh phin cua thudc sfl dyng la Diprospan (Betamethasone dipropionate vi Betamethasone Na phosphate) va Lidocain 2%.
2.1.2.Tieu chuan loai b^nh nhan khoi nghien ciru
Kem theo gay xuong ddn hay diu tr6n canh tay.
Kem theo cd tdn thuong thin kinh, benh ly re thin kinh do tdn thuang cdt sdng cd, tai bien mach miu nao...
- Cd tien sfl tiem thudc tai vflng vii trudc nghien cflru 03 thing
Khdng tii khim du thdi gian theo ddi 03 thing
2.2. Phvong phap nghien cihi
- Nghien curu tiln cuu, md ta, can thiep md khdng cd nhdm doi chflng
Tat ca benh nhan sau khi dupe chan doan deu duprc dieu tri theo phic do sau day.
+ Benh nhan dugc giai thich rd vl b^nh vi tien trinh dilu tri.
+ Thudc sfl dung: dng Diprospan 01 ml (Betamethasone dipropionate 5 mg.
Betamethasone Na phosphate 2 mg) va them I ml Lidocain 2%.
+ Vi tri tiem: khoang dudi mdm cung vai va 1/3 dudi cfla bao khdp trudc ciia vai.
+ Tdng sd 05 mui. Mui diu va mui thfl hai cich nhau 07 ngay. Mui thfl ba vi thfl tu, vi thfl nim cich nhau 10 ngay.
+ Tap vat ly tri lieu chia lam 3 giai doan:
Y HOC VIET NAM THANG 7/2011 - SO OAC BIET
Tudn I giai doan dau vd viem dinh cdp: tap trong bien dp cho phep, tap khdng dau vdi ta 1 kg d tay tu thi khuyu thing, canh tay tha Idng va bin tay sip, ngfla.
Tudn 2 - giai doan gidm dau: tap thy dpng vi chu ddng khdp vai vdi bien dp ting din do tung benh nhan tu dilu chinh theo mflc dp cd the chap nhan dupe.
- Tic tudn 3 - giai doan phuc hdi: tip thy dpng vi chu ddng khdp vai vdi bien dp tang dan do tung benh nhan tu dilu chinh cd thi.
chip nhan dupe tai khoa VEit ly tri lieu:
Tip van ddng chfl ddng va thy dpng khdp vai.
- Sdng sieu im
I I I . KET QUA NGHIEN CUtJ
3.L Dae diem bfnh nhan nghien ciru Tdng sd benh nhan nghien curu: 351 - Gidi: nam 116, nii 235.
Tudi trung binh: 63,7 ±6,1 tudi. Thip nhat: 55 tu6i; cao nhit: 82 tudi.
Thdi gian mic b?nh trung binh: 4 ± 2,3 (tuk). Ngin nhat 01 tuin; dai nhit: 27 tuin.
Bfnh ly npi khoa kem theo: Dii thio.
+ Dau khi gan bin tay tren vai ben ddi dien: 7%
+ Khd khin khi mac io: 100%.
+ Khdr^ the chai diu binh thudng: 100%.
+ Bien dp dang: 1 0 - 6 0 dp, trung binh 45 dp.
+ Bien dp ra trudc 3 0 - 9 0 dp, trung binh 60 dp.
+ Bien dp ra sau 1 0 - 3 0 dp.
+ Chenh lech dp cao bin tay tren lung tu the cii ao nguc phy nu : 97%.
- Dac diem X quang
+ Hinh anh diu tren xuong canh tay hi keo len cao: 86%.
+Hinh anh cald hda gan CO tren gai: 3,2%
- Ddnh gid kit qud
+ Mflc dp dau: benh nhin tu dinh gii theo VAS (visual analogue scale) tfl 0-10 diem
+ Mflc dp ban chi van ddng cua b?nh:
thiy thudc danh gia theo VAS, tfl 0-10 dilm + Thdi dilm dinh gii kit qui: Trude nghien cflu (TO), sau moi mui tiem (Tl, T2, T3, T4, T5) va lin cuoi la T12 (sau 12 tuin)
Ngoai ra, cic benh nhin tu dinh gii mflc dp cii thien dau vi phyc hdi chflc theo ti dudng: 11%; benh ly tim mach: 57%; benh 1? phin trim cfla mflc dp ban diu (sau 12 git: 3,3%, viem khdp dang thip RF (+): tuin)
3,1%.
Tiln sfl dilu tri: da dilu tri thudc qua dudng udng: 61%; da tip vat ly tri lieu:
8,2%; da keo nin khdp vai va dflng thudc nam: 6,7%.
- D&c diim lam sdng
+ Dau: dau ca ngay va ting nhieu ve d6m: 100%.
+ Dau khi nim nghieng vl ben vai tdn thuong: 98%.
+ Dau khi xoay ngoai d tu the cinh tay d?ng 0 do, k h u ^ tay 90 dp va cing tay ip nguc: 96%.
- Nhan xet tdc dung khdng mong muon + Cic phan flng tai chd khi tiem va cic tic dyng chim.
Phin flng dau ting sau tiem, phin flng tran dich khdp, nhiem khuin vi tri tiem...
+ Trieu chung toan than: thay ddi mach, huylt ip, dau dau, chdng mat, budn ndn, ndn, min ngfla, sdc...Cac trieu chflng khac (nlu cd).
+ Mflc dp tai biln (nlu cd): Tilp tyc tham gia nghien cflu hoic cin ngflng nghien cflu.
HQI THAP K H 6 P H O C VIET NAM: HOI NGHj KHOA HOC T O A N QUOC LAN THlf IX
3.2. Ket qua nghien cihi 3.2.1. Quy trinh diiu tn
Sd lupng mui tiem trung binh da thuc hien: 3 (it nhat 01 mui, nhilu nhit: 05 mui.
Vi cd nhimg benh nhan sau 1 hoac 2 lin tiem benh nhin da dau va ddng y tap vat ly tri lieu,
3.2.2. Ket qud diiu tri
Thdi gian tap vat ly tri lieu: 4 ± 1,5 (1 den 12 tuan): mpt sd benh nhin sau 1 hoac 2 lan tiem da dau nhieu va tu tip vit ly tri lieu theo hudng dan vi phyc hdi chflc ning khdp vai tdt.
Ket qua
IMflc dp dau (VAS) IMflc dp han che van dpng (VAS)
Giam dau*
Phuc hoi cd nang *
Tru'dc nghien
cu'u TO 7,7±0,63
5,7±0,9
0%
0%
T l 1 tuan
3,2±1,17 6,89±1,1
7 1 % 0%
T2 2 tuan
2,9±1,34 7,5±1,3
79%
13%
T3 3 tuan
2,6±1,21 11,3±1,7
85%
4 1 %
T4 4 tuan
1,1±0,17 11,9±1,7
93%
47%
T5 6 tuan
0,9±0,11 12,6±1,9
100%
62%
T6 12 tuan
0,7±0,13 14,5±2,1
100%
76%
Ghi chfl: Danh gii mflc dp giam dau v i Phyc hdi chflc nang theo dinh gia cua bpnh nhin Nhdn xet: Hi?u qua dieu tri dupe cai thien rd vi ngay sau tuin diu ve trieu chflng dau qua tit ca cic thdng so dinh gia vdi p<0,01. Cd 76% sd benh nhan phyc hdi chflc ning khdp vai sau 3 thing dieu tri
3.3.3. Cdc tdc dung khong mong muon Dau thupng vi trong qua trinh dilu tri:
13%, song khdng cd biln chung chay mau da day (dua tren cac trieu chung lim sang).
Tang huylt ap: 4,5%, dupe kilm soat tdt vdi cic thudc ha ap thdng thudng.
Shock vdi thudc tiem: 0%.
- B^nh ly tun mach ning hay dot quy: 0%.
Viem dau tai cho tiem: 0%
IV. BAN LUAN:
Theo Kevin and Lee Kenedy [1] thi cic rdi loan niy thudng hi chin doin sai khiln cho mit chflc ning khdp vai trim trpng. Cic tri?u chung thudng gap cung nhu trong nghien curu cfla chung tdi: dau, khd khin khi mic do chi tren, bien dp cao cua ban tay tu
the cai ao nguc, giim xoay ngoai vi mpt chin doan chinh xie thudng rat khd khin.
Su phyc hdi van ddng cfla cic benh nhin trong nhdm nghien cun chflng tdi nhanh hon, theo tic gia Buchbinder va cpng su [dan theo 1]. Tic gia nay nhan thay van dpng khdp vai dupe cai thi^n sau 6 tuin dung corticoid theo dudng udng. Chflng tdi n h ^ thiy Corticosteroid tiem vao trong khdp ddng vai trd chu dao trong phyc hdi cfla bpnh nhin.
Mpt sd tic gia nghien cfln phuong phap nin boat dpng khdp vai dudi giy me di nhin xet phuong phap giup tang bien dp khdp vai, tuy nhien cd the giy giy xuong canh tay hoac viem, phu ne tai khdp vai. Gin day chi dinh ndi soi giai phdng khdp vai dupe chi dinh ngiy cang rpng rii [2], nhung chua pho
Y HOC VIET NAM T H A N G 7/2011 - SO OAC BIET
bien d nudc ta. Do viy, sfl dung kit hpp tiem Diprospan tai cho kit hop phyc hdi chflc ning la phic do dan gian, dd img dung tai cic CO sd dieu tri.
Theo Kevin and Lee Kenedy [1], cflng vai la tinh trang dau khdp vai thudng gap trong ddi sdng hang ngay, su phuc hdi keo dii vi van cd mdt ti le kha cao benh nhin khdng hdi phyc diy dfl chflc ning nhu trudc, ciing nhu tinh hinh quin ly benh nhin trong cpng ddng cfla mang ludi y te cdn chua diy du. Kit qui nghien cuu chflng tdi cho thiy cdn 24% benh nhin chua phyc hdi hoin toin sau 3 thing dieu tri.. Tuy nhien, phic do td ra an toin, chflng tdi chi gap 13% sd benh nhin dau thupng vi, khdng gap bien chflng chiy miu dudng tieu hda. Cd 4,5% sd benh nhin ting huyet ip mflc dp vua phii dupe kilm soil tdt vdi cic thuoc ha ip thdng thudng.
Khdng gip cic tai biln khic (sdc, nhiem khudn, dau tang sau tiem)
Nghien curu trong nim 2005-2009 vl hi?u qua va tinh an toan cfla phic dd dilu tri bao tdn "cflng khdp vai" d benh nhin ldn tudi t^i b?nh vi?n Tinh Khanh Hda, sfl dyng kit hpp tiem Diprospan t?i cho kit hpp phyc hIi chflc ning trong 03 thing cho thiy phuong phip tiem Diprospan tai cho ket hpp phyc hdi chflc ning la phic do dat hipu qua cao, an toin. Phic do thuc hien don giin, de flng dyng tai cic co sd dilu tri tai nudc ta.
Tuy nhien cin khuyin cio khi tiem phai dim bao vd trung tuyet ddi vi chi dupe thuc hien bdi bic sy chuyen khoa duoc dao tao ky ning tiem khdp.
V. KET LUAN
Qua nghien curu 351 benh nhin "cflng khdp vai" tfl 55 tudi trd len tudi tai benh vien Tinh Khinh Hda trong nim 2005-2009 sfl dyng ket hpp tiem Diprospan tai chd ket hpp phyc hdi chflc ning, chflng tdi thu dupe ket qui nhu sau
/. Hieu qud cda phdc do
1.1. Trieu chung dau duoc cai thien rd va ngay sau tuin diu vi keo dii trong sudt 03 thing qua tat ci cic thdng sd dinh giii, su khic biet cd y nghia vdi p<0,01.
1.2. Cd 76% sd benh nhin phyc hdi chflc nang khdp vai sau 3 thing dieu tri
1. vi tdc dung khong mong muon cua cdc phirffng phdp sit dung
Dau thupng vi : 13%; khdng gip biln chflng chiy mau dudng tieu hda.
Tang huylt ip: 4,5%, duprc kilm soat tdt vdi cic thudc ha ip thdng thudng.
Khdng gip cic tai biln khic (soc, nhiem khuan, dau ting sau tiem...)
TAI LIEU THAM KHAO
1. Kevin Pile and Lee Kenedy, Problem solving in rheumatology. Clinical pusblishing, 2008, section 1, Painful shoulder, rotation cuff and shoulder frozen, page 11.
2. Stephen J McPhee and Maxin A.
Paradakis, Curent medical diagnosismand treatment, 2011, Chapter 20, Musculoskeletal and Immuologic disorder.