목, 어깨통증. 연세의대가정의학교실 이용제 MD, MPH, PhD

Transcription

1 목, 어깨통증 연세의대가정의학교실 이용제 MD, MPH, PhD

2 COI (Conflict of Interest) Declaration 본강좌의내용에대해서 본강의의강사는 직접적또는간접적인 어떠한이해관계도없음을밝힙니다 년대한가정의학회춘계학술대회

3 Core perspectives of optimal health 1. Subclinical inflammation 2. Detoxification 3. Mitochondria - Energy - Oxidative stress 4. ANS, Hormones, and Neurotransmitters 5. Medicinal food and Nutraceuticals 6. Structure Body composition (Bone, fat, muscle) Spine alignment 7. Spirituality

4 What Kind of Doctor is? MD DDS ND DC DO

5 Pain receptors C fiber Metabolism Movement Mechanics Contraction Touch A ß fiber A δ fiber Cool, sharp, and transient pain

6 C-spine - Digital position

7 Shoulder - Overhead activity

8 Prevalence 일생동안적어도한번의심한목통증을경험할가능성 40~70% 20~56 세의남녀 어깨통증의유병률약 15.4%, 29.4%, 목 - 어깨통증으로묶을경우약 27.5%, 32.9%

9 History taking - SCHOLAR S (Site, Severity) CH (Continuity, Characteristics) O (Onset, Overuse) L (Length, Labor) A (Associated symptom, Aggravating factor) R (Radiating pain, Relieving factor)

10 Physical examination 1) Observation (Inspection) 2) Movement assessment 1Active movement testing 2Passive movement testing 3Resisted movement testing 3) Palpation 4) Specific test Spurling test with axial compression, Hoffman test Impingement test (Neer, Hawkins, Yocum) 5) Neurologic examination

11 Major causes of Neck pain 1. Muscles MFP syndrome Torticollis Sprain 2. Spondylosis Disc Facet and uncovertebral joints Soft tissue thickening 3. Referred pain

12 Active movement, C-spine Flexion 45 Extension 55 Lateral flexion 40 Axial rotation 70

13 Neck and shoulder muscles 뒤 앞 옆 Trapezius Splenius capitis/cervicis Semispinalis capitis Levator scapulae Rhomboid Transversospinalis (multifidus, rotator) Scalene Sternoclenoidomastoid (SCM) Deltoid Rotator cuff Supraspinatus, Infraspinatus, Teres minor, Subscapularis 50 (20m)

14 Occipital nuchal line Semispinalis capitis/cervicis Splenius capitis/cervicis T 4

15 Head and Neck muscles

16 IS SS Rm Tm RM TM SS IS TM IS SSc Tm

17 Clinical syndromes Neck pain MFP syndrome Facet syndrome Root compression Motor, Sensory, Reflex Spurling test Axial compression test Shoulder adduction test Raciculopathy Myelopathy Cord compression Hand sensory complaints Hand fine movement Grip and release sign Gait disturbance

18 MFP syndrome MFP syndrome Trigger (tender) point Referred pain Palpation of taut band Local twitch response

19 11 (4m) Horizontal -oblique Coronal Sagittal

20 Normal disc UV joint Degenerated disc Bulging disc HNP Herniated disc Thinning disc Facet -D UVJ-D Disc degeneration with osteophyte formation

21 Spondylosis - Chronic degenerative changes including joints, intervertebral discs, ligaments & connective tissue of cervical vertebrae. Disc pathology Stenosis - Abnormal narrowing of the spinal canal Facet joint syndrome Radiculopathy - Root compression Myelopathy - Cord compression Facet syndrome

22 Herniated disc Bulging Protrusion Extrusion

23 Spinal stenosis Cervical canal diameter: average 17mm Spinal cord diameter: average 10mm Spinal stenosis: Cervical canal diameter <13mm

24 Cervical radiculopathy C-rad is the clinical description of pain and neurological symptoms resulting from any type of condition that irritates a nerve root in the cervical spine 1. Cervical Disc herniation : protruding or bulging discs, or if severe prolapse 2. Cervical Spinal Stenosis : a narrowing of the spinal canal 3. Degenerative Spondylosis : degenerative arthritis and osteophytes

25 Dermatome of Cervical nerve

26 Pain diagram C-rad

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28 Specific test for C-rad Cervical Root compression Spurling test Axial compression T Shoulder adduction T

29 Cervical myelopathy C-myelopathy refers to pathology of the cervical spinal cord Sensory deficits UMN signs (weakness, spasticity, clumsiness, altered tonus) Babinski sign (+) Bowel/bladder symptoms and sexual dysfunction 1. Disc herniation 2. Cervical stenosis with myelopathy 3. Cervical spondylotic myelopathy

30 Specific test for C-myelopathy Grip and release test Hoffman reflex Lhermitte's sign Ankle clonus and Babinski sign

31 Radiologic evaluation of C-spine Plain X-ray - AP Uncovertebral hypertrophy - Lateral PLL alignment, Joint space narrowing, bony spur - Oblique Foramen stenosis - Dynamic view Instability - Open mouth view Cervicogenic headache CT - OPLL MRI non contrast EMG, NCV

32 C2 C3 Uncovertebral joint hypertrophy C4 C5 C6 C7

33 Posterior tubercle of C1 C2 Spinous process of C2 C3 C4 C5 C6 Laminae of C4 Inferior articulating facet of C5 Facet joint (C5-6) Superior articulating facet of C6 C7

34 C2 Foraminal stenosis C3 C4 C5 C6 C7

35 D SP C2 SP C3

36 Lateral mass C1

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40 Major causes of Shoulder pain 1. AC joint disease 2. Impingement syndrome 3. GH joint disease 4. Referred pain

41 More details I. Acromioclavicular joint disease II. Impingement syndrome, RCS Subacromial bursitis Supraspinatus tendinitis Supraspinatus tear (partial, full-thickness) III. Glenohumeral joint disease Frozen shoulder (Adhesive capsulitis) Glenoid Labrum tear SLAP tear (superior labral tear from anterior to posterior) Bankart tear

42 Anterior Posterior Bony structure of shoulder

43 Deltoid, Biceps

44 Subscapularis

45 Supra-Infraspinatus, Teres minor

46 Coracoacromial arch, SASD bursa 4. SA bursa 4 5. SD bursa **Coracoacromial arch** 1. Acromion 2. CA ligament 3. Coracoid process

47 Active movement, Shoulder Forward flexion 180 Abduction 180 External Rotation 45 Extension 40 Adduction Internal rotation 55

48 Resisted movement, Shoulder Empty can test - Supraspinatus Lift off test - Subscapularis Ext rotation & Int rotation - Infraspinatus,Subscapularis Speed test - biceps

49 Impingement test, Shoulder Neer test Hwakins test Yocum test

50 Impingement syndrome Coracoacromial arch

51 Glenoid labrum tear SLAP tear Bankart tear An injury from overhead and throwing athletes An injury of the anterior (inferior) glenoid labrum due to anterior shoulder dislocation

52 Radiologic evaluation of Shoulder Plain X-ray Shoulder AP, Axial, Outlet view Ultrasonography 1 Biceps long head, GT & LT 2 Subscapularis 3 Supraspinatus (Crass position) 4 Infraspinatus, Tm MRI non contrast MR arthrography MR arthrography is more sensitive and specific than either MRI or ultrasonography for diagnosing both full-thickness and partial-thickness tears in a metaanalysis of studies on MRI.

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54 Shoulder MRI, Coronal view, T2-WI "Bankart lesions -anterior-inferior labrum. Injuries to this part of Supraspinatus

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57 Biceps tendon-transverse scan

58 Biceps tendon-longitudinal scan

59 Subscapularis-longitudinal scan

60 Subscapularis-transverse scan

61 Crass position for supraspinatus scaning Extension + Adduction + Internal rotation Supraspinatus

62 Infraspinatus & teres minor Tm GT Tm IS

63 RCT, total tear - Bunch sign (+) RCT, partial tear - Bunch sign (-) Calcific tendinitis, Supraspinatus US guided SASD injection

64 Live demonstration, Shoulder

65 What kind of techniques Action mechanism IMNS TPI Nerve block IA injection Prolotherapy Chiropractic Central (para-vertebral) muscle and nerve stimulation Peripheral (local) muscle relaxation by mechanical and chemical destruction Incomplete blunting of nerve plexus Intra and peri-articular anti-inflammation Correction for inflammatory response of ligament Correction for malalignment

66 How can I find active TrP? Flat palpation Pincer palpation (SCM, Latissimus dorsi)

67 TPI Preparations 기본준비사항 Anaphylaxis kit 소독제, 반창고, 장갑 Corticosteroids Triamcinolone 5-40 mg Local anesthesia 2% Lidocaine 0.5-1% Lidocaine Syringe & Needle IMS 5cc, 10cc 25 Gy (2.5, 6 cm) Plunger Needle (3,4,5 cm) Prolotherapy 50% DW, 20% DW % DW Lubricant Hyaluronic acid

68 Prolotherapy Preparations

69 IMS and Radiculopathic Model

70 Cross section of C5 level 3-5 cm

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72 Patient s position, C-spine

73 Patient s position T-spine

74 Stretching and strengthening Isometric neck - extension Isometric neck - side bend Head tilt - neck curl Head tilt - neck side bend Neck extension on hands and knee Scapular squeeze

75 Frozen shoulder Wand exercise - FL, EX, ER, IR, AB, AD Each exercise should be done PAIN- FREE, and for 3 sets of 20 repetitions Scapular ROM Pectoralis Biceps

76 1. Supraspinatus exercise 2. Shoulder flexion 3. Shoulder extension 4. Horizontal Abduction 5. Horizontal Adduction 6. Internal rotation

77 7. External rotation 8. Scapular Elevation Shrugs 9. Scapular protraction 10. Scapular retraction 11. Scapular Retraction and External Rotation 12. Scapular Retraction and Elevation

78 Treatment of Shoulder pain AC joint disease Impingement syndrome GH joint disease AC joint Injection Rehabilitation SASD injection Prolotherapy Acromioplasty GH joint injection SLAP Repair

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