臨床研究

臨床研究

摘要

輔舟骨綜合症是指輔舟骨和/或脛後肌腱受到刺激和發炎。治療通常包括非甾類抗炎藥,物理治療,訂制鞋墊,鞋的矯正和類固醇注射。當所有保守方法都無法緩解症狀時,患者就需要接受手術治療。

本報告報導一個輔舟骨綜合症的個案。保守治療對該病症無效,但在補充維生素D後症狀有所緩減。處方鞋墊和反复聚焦的衝擊波治療並未能解決一年多的疼痛。鑑於患者40多年來一直堅持素食,我們檢驗了她的維生素D水平。結果顯示她的維生素D有中度缺乏(25-羥基維生素D)。在每天補充2,000 IU維生素D3後,她的VAS疼痛評分在兩週內從4降至0.5。所以,在治理難治的輔舟骨綜合症時,宜考慮患者可能同時患有維生素D缺乏症。

 

 

摘要

脊柱側彎常見於60歲以上的老年人。在不同的彎弧類型中,胸腰段彎弧是最多需要手術治療的,因為它與明顯軀幹移位和殘疾有關。目前的物理治療包括電療,水上運動,核心強化運動和乾針治療等。這些治療的效果強差人意。有症狀的成人脊柱側彎保守治療的長遠成功率很低,因為治療解決了症狀,但不針對成人脊柱側彎所涉及的生物力學。最近的研究顯示,有80%的受試者應用了針對性脊柱側彎的運動治療(PSSE)和支具治療後,脊柱側彎彎弧得到穩定。因此,應該將PSSE和支具治療添加到有症狀成人脊柱側彎的物理治療護理中。對於胸腰段彎弧但存在惡化風險的無症狀患者,應將PSSE視為預防性運動,和將保守治療無效但有明顯脊椎狹窄症的患者轉介往手術治療。

 

 

摘要

很多不同方法已被用於治療貝爾氏麻痺症﹙面癱﹚,包括物理治療,藥物治療和減壓手術。目前標準治療是皮質類固醇與抗病毒劑。這些醫療方法的結果不一,因此需要找出有效的治療方法。。最近的研究顯示,光療,特別是低能紅外線激光治療對面癱的治療效果正面,。在這份報告中,我們回顧了一些關於光療,一種保守和安全的醫療方法臨床應用的文獻,認為低水平激光治療(LLLT)是貝爾麻痺症的重要治療方式,然而,回顧的文獻的偏倚風險相當高,進一步研究可能會改變這種治療方案的效果的估算。總言而之,目前有中等程度的證據支持低能量激光治療貝爾氏麻痺。未來,需要進一步的隨機雙盲對照試驗和高質量的研究,以確定這種治療方案對貝爾麻痺症的益處。

 

 

摘要

直至現在,有很多理論嘗試解釋青少年特發性脊柱側彎(AIS)的病因。維生素D不足或缺乏對脊柱側彎的影響數據有限。之前的研究顯示,青少年的維生素D普遍被發現缺乏和不足,包括AIS患者在內。在香港進行的一系列研究顯示,多達30%患者患有骨質疏鬆。已發現25-羥基維生素D3水平與健康青少年的骨質密度(BMD)呈正相關,與AIS患者的Cobb角呈負相關; 因此,維生素D缺乏被認為在AIS發病機制中扮演一個角色。本研究嘗試檢閱有關AIS病因學的相關文獻,以研究維生素D與各種現有相關理論的關係。我們發現維生素D缺乏症與AIS目前幾種病因學理論有關。我們假設維生素D缺乏和/或不足可通過纖維化,姿勢控制和骨質密度(BMD)的調節影響AIS的發展。在青少年中,維生素K2(一種脂溶性維生素)的缺乏也很普遍; 因此,維生素D缺乏的高患病率可能與減少脂肪攝入量有關。需要進一步的研究來闡明維生素D在AIS的發病機制和臨床處理。

 

 

摘要

研究計劃: 這是一份前瞻性研究。

目的: 探討優化施羅特運動會否影響門診成人脊柱側彎患者的胸腰段或腰段的彎弧。

背景:成人脊柱側彎有持續惡化的趨勢、且與腰痛的發病率相關。現時保守治療成效不彰,因為治療並不是針對脊柱側彎。這研究探討優化施羅特運動會否影響門診成人脊柱側彎患者的胸腰段或腰段的彎弧幅度。

研究方法: 大於20o的胸腰段和腰段彎弧的成人脊柱側彎患者參與優化施羅特運動訓練,每周一次,連續4個星期。他們亦需在家中每星期練習3次,持續9個月。基凖量度的數據包括科布氏角、冠狀面偏移、矢狀垂直軸(SVA)、T4-T12脊柱後凸、L1-S1脊柱前凸、骶骨傾斜角、骨盆入射角和骨盆傾斜角。我們使用配對的T測試治療前後的數據以確定施羅特訓練的效果。

結果: 在統計學上,優化施羅特運動顯著減少了科布氏角(p = 0.0032),改善了ATR(p = 0.012),增加了骶骨傾斜角(p = 0.03),減少了骨盆入射角(p = 0.0032)和SVA(p = 0.032)。

結論: 優化施羅特運動能夠改善患有胸腰段或腰段成人脊柱側彎的科布氏角和SVA。

 

 

Abstract

The paper reviews the current imaging methods in the diagnosis and monitoring of patients with adolescent idiopathic scoliosis. Radiography is generally used in the initial diagnosis of the condition. Postero-anterior erect full spine radiograph is generally prescribed, and is supplemented by lateral full spine radiograph when indicated. To reduce the radiation hazard, only the area of interest should be exposed, and follow-up radiographs should be taken with as few projections as possible. When available, EOS® stereoradiography should be used. The radiation of the microdose protocol is 45 times less than that of the conventional radiography. Surface topography offers another approach to monitoring changes of curvatures in AIS patients. Recently, 3D ultrasound has been found to be able to measure the Cobb angle accurately. Yet, it is still in the early developmental stages. The inherent intrinsic and external limitations of the imaging system need to be resolved before it can be widely used clinically. For AIS patients with atypical presentation, computed tomography (CT) and/or magnetic resonance imaging (MRI) may be required to assess for any underlying pathology. As CT is associated with a high radiation dose, it is playing a diminishing role in the management of scoliosis, and is replaced by MRI, which is also used for pre-operative planning of scoliosis.

The different imaging methods have their limitations. The EOS® stereoradiography is expensive and is not commonly available. The surface topography does not enable measurement of Cobb angle, particularly when the patient is in-brace. The 3D ultrasound scanning has inherent intrinsic technical limitation and cannot be used in all subjects. Radiography, however, enables diagnosis and monitoring of the adolescent idiopathic scoliosis (AIS). It is thus the gold standard in the evaluation and management of scoliosis curves.

 

 

Abstract

Introduction:

The review evaluates the up-to-date evidence for the treatment of spinal deformities, including scoliosis and hyperkyphosis in adolescents and adults.

Material and Methods:

The PubMed database was searched for review articles, prospective controlled trials and randomized controlled trials related to the treatment of spinal deformities. Articles on syndromic scoliosis were excluded and so were the articles on hyperkyphosis of the spine with causes other than Scheuermann’s disease and osteoporosis. Articles on conservative and surgical treatments of idiopathic scoliosis, adult scoliosis and hyperkyphosis were also included. For retrospective papers, only studies with a follow up period exceeding 10 years were included.

Results:

The review showed that early-onset idiopathic scoliosis has a worse outcome than late-onset idiopathic scoliosis, which is rather benign. Patients with AIS function well as adults; they have no more health problems when compared to patients without scoliosis, other than a slight increase in back pain and aesthetic concern. Conservative treatment of adolescent idiopathic scoliosis (AIS) using physiotherapeutic scoliosis-specific exercises (PSSE), specifically PSSR and rigid bracing was supported by level I evidence. Yet to date, there is no high quality evidence (RCT`s) demonstrating that surgical treatment is superior to conservative treatment for the management of AIS. For adult scoliosis, there are only a few studies on the effectiveness of PSSEs and a conclusion cannot as yet be drawn.

For hyperkyphosis, there is no high-quality evidence for physiotherapy, bracing or surgery for the treatment of adolescents and adults. However, bracing has been found to reduce thoracic hyperkyphosis, ranging from 55 to 80° in adolescents. In patients over the age of 60, bracing improves the balance score, and reduces spinal deformity and pain. Surgery is indicated in adolescents and adults in the presence of progression of kyphosis, refractory pain and loss of balance.

Discussion:

The available evidence reviewed has suggested that different approaches are needed towards the management of different spinal deformities. Specific exercises should be prescribed in children and adolescents with a Cobb angle in excess of 15°. In progressive curves, they should be used in conjunction with bracing. Clarity regarding differences and similarities is given as to what makes PSSE and PSSR specific exercises. As AIS is relatively benign in nature, conservative treatment should be tried when the curve is at a surgical threshold, before surgery is considered. Similarly, bracing and exercises should be prescribed for patients with hyperkyphosis, particularly when the lumbar spine is afflicted. Surgery should be considered only when the symptoms cannot be managed conservatively.

Conclusion:

There is at present high quality evidence in support of the conservative treatment of AIS. The current evidence supports the use of PSSE, especially those using PSSR, together with bracing in the treatment of AIS. In view of the lack of medical consequences in adults with AIS, conservative treatment should be considered for curves exceeding the formerly assumed range of conservative indications.

There is, however a lack of evidence in support of any treatment of choice for hyperkyphosis in adolescents and spinal deformities in adults. Yet, conservative treatment should be considered first. Yet to date, there is no high quality evidence (RCT`s) demonstrating that surgical treatment is superior to conservative treatment for the management of AIS and hyperkyphosis. Additionally, surgery needs to be considered with caution, as it is associated with a number of long-term complications.

 

 

Abstract

Introduction:

Physiotherapeutic Scoliosis-Specific Exercises (PSSE) and bracing have been found to be effective in the stabilization of curves in patients with Adolescent Idiopathic Scoliosis (AIS). Yet, the difference among the many PSSEs and braces has not been studied. The present review attempts to investigate the role of curve correction in the outcome of treatment for PSSEs and braces.

Material and Methods:

A PubMed manual search has been conducted for studies on the role of correction in the effectiveness of PSSE and bracing. For the PSSEs, the key words used were “adolescent idiopathic scoliosis, correction, physiotherapy, physical therapy, exercise, and rehabilitation.” For bracing, the key words used were “adolescent idiopathic scoliosis, correction and brace”. Only papers that were published from 2001-2017 were included and reviewed, as there were very few relevant papers dating earlier than 2001.

Results:

The search found no studies on the role of correction on the effectiveness of different PSSEs. The effectiveness of different PSSEs might or might not be related to the magnitude of curve correction during the exercises. However, many studies showed a relationship between the magnitude of in-brace correction and the outcome of the brace treatment.

Discussion:

The role of correction on the effectiveness of PSSE has not been studied. In-brace correction, however, has been found to be associated with the outcome of brace treatment. An in-brace correction of < 10% was associated with an increased rate of failure of brace treatment, whereas an in-brace correction of >40-50% was associated with an increased rate of brace treatment success (i.e. stabilization or improvement of curves). Thus, in the treatment of AIS, patients should be advised to use highly corrective braces, in conjunction with PSSE since exercises have been found to help stabilize the curves during weaning of the brace. Presently, no specific PSSE can be recommended.

Conclusion:

Braces of high in-brace correction should be used in conjunction with PSSEs in the treatment of AIS. No specific PSSE can be recommended as comparison studies of the effectiveness of different PSSEs are not found at the time of this study.

 

 

摘要

青少年脊柱側彎配戴支具的成效一直有爭議。有些研究顯示配戴支具和觀察的成效一樣,但亦有些研究顯示配戴支具的成效勝於觀察;它停止彎弧惡化及有效減低彎弧惡化的風險,至做手術的層面。最近,有些研究顯示配戴支具能改善脊柱側彎。但這些研究的質素都被認為很低。在2005年,脊柱側彎研究學會(SRS) 嘗試把支具的標準和測量的結果標準化,方便比較不同的研究。在指引中,≤ 5o的彎弧變化被定義為成功。這顯示了SRS不認為支具能夠矯正或改善彎弧。直到2009年,減少≥ 6o才定義為有改善。這可能反映了在過去一到二十年中支具效果的矯正。

本報告比較過去30年的研究,看看支具的效果是否有改善的趨勢。使用Pubmed及一些關鍵詞(保守治療和青少年特發性脊柱側彎)搜尋由1990-2016年配戴硬支具的相關英文文獻,以探索支具的治療效果是否有改善的趨勢,及支具是否能制止彎弧惡化和矯正彎弧。

自2005年以來的文獻顯示支具能明顯降低做手術的風險。仔細查探後發現手術風險降低與穿戴支具的時間並不相關,而是與支具的類型有關。多年來,波士頓支具的效果並不一致,手術率各不相同,在過去的二三十年中沒有一致的降低做手術趨勢。在2007年的報告顯示,TLSO的手術率高達79%,而在2014年波士頓支具的手術率為28%。然而,使用歐洲支具(Progressive Action Short Brace(PASB),Cheneau衍生支具和Lyon / Sforzesco支具)後的手術率較低,低於8%。同樣,已發現歐洲支具能夠改善患者的側彎風險50%以上。因此,支具不僅會停止側彎惡化。 如果支具結構良好和患者依從性良好,超過50%的患者的側彎是可以改善的,特別是配合脊柱側彎的特定運動。

 

 

摘要

「生長痛」在兒童中非常普遍。雖然局部超負荷、骨骼強度降低、痛楚臨界值降低、維生素D缺乏和足部異常結構,都被認為與「生長痛」有很高的相關性, 但它的病源學還未能得到徹底確定。到目前為止,兒童「生長痛」尚未有共識的標準治療方案。由於臨床上,「生長痛」的症狀會隨著年紀漸漸消失;它亦廣泛地被理解為孩子在成長中,不藥而癒的自然生理現象。故此,很多醫療從業員都傾向不給予針對性治療,甚或不作理會。本文章旨在回顧現時的治療方向及建議。

方法: 在 Pubmed 文獻搜尋器,輸入下述關鍵字:兒童生長痛、治療、矯正梏具、維生素D及兒童生長痛的治療。

結果: 文獻搜尋顯示肌肉伸展運動是第一線治療。雖然硏究總體上未能一致不爭地證實鞋墊的治療效能,但不可否認它能減輕「生長痛」的疼痛及症狀。矯正鞋墊的處方在臨床上是被鼓勵的。又由於大部份有「生長痛」徵兆或症狀的兒童的血清25-羥基維生素D3水平均偏低,因此同時有維生素D缺乏症的兒童應該服用維生素D3 補充劑。

結論: 檢查「生長痛」的兒童時,宜評估血清維生素D水平及足部結構。補充維生素D3和處方矯正鞋墊可以改善「生長痛」相關的徵兆及症狀。

 

 

Abstract

Long-term follow-up of untreated patients with adolescent idiopathic scoliosis (AIS) indicates that, with the exception of some extremely severe cases, AIS does not have a significant impact on quality of life and does not result in dire consequences. In view of the relatively benign nature of AIS and the long-term complications of surgery, the indications for treatment should be reviewed. Furthermore, recent studies have shown that scoliosis-specific exercises focusing on postural rehabilitation can positively influence the spinal curvatures in growing adolescents. Experiential postural re-education is a conservative, non-invasive approach, and its role in the management of AIS warrants further study. This article reviews current evidence for the inclusion of various forms of postural reeducation in the management of AIS. Recent comprehensive reviews have been researched including a manual and PubMed search for evidence regarding the effectiveness of physical/postural re-education/physiotherapy programs in growing AIS patients. This search revealed that there were few studies on the application of postural re-education in the management of AIS. These studies revealed that postural re-education in the form of exercise rehabilitation programs may have a positive influence on scoliosis; however, the various programs were difficult to compare. More research is necessary. There is at present Level 1 evidence for the effectiveness of Schroth scoliosis exercises in the management of AIS. Whether this evidence can be extrapolated to include other forms of scoliosis- pattern-specific exercises requires further investigation. Because corrective postures theoretically reduce the asymmetric loading of the spinal deformities and reverse the vicious cycle of spinal curvature progression, their integration into AIS programs may be beneficial and should be further examined.

 

 

Abstract

Post-herpetic pain is an extraordinary drug-resistant neuropathic pain, which arises after the skin lesions disappear. The present case is a lady aged 57, who complained of severe herpetic pain on a scale 8 out of VAS 0-10, affecting the right T7 dermatome. She was prescribed acyclovir, nidol, famotidine, neutim and clinovir cream two days after the onset. These whilst reduced the extent of skin eruptions, did not control the neuropathic pain and allodynia. Even touching by clothes provoked severe pain. A week later, she felt “weak” and consulted a Chinese medical practitioner. She was then treated by Chinese medicine and acupuncture. The treatment lasted for one month. It reduced both the pain intensity and frequency. Pain was reduced from nearly 20 hours a day to occasional pain. She was then referred for treatment by monochromatic infra-red energy (MIRE), which has been documented to have similar effects to laser irradiation that is effective in reducing post-herpetic neuralgia. Immediately after the first treatment which lasted for 20 minutes, she felt pain reduction and relaxation of adjoining muscles. After 6 consecutive treatments which spanned over two weeks, she had complete relief and she felt that the circulation in the area returned.

The effects of MIRE are similar to low level laser, which has been found to reduce or control postherpetic pain effectively. It is suggested that MIRE be used in the treatment of post-herpetic neuralgia, given its effectiveness, the ease of use and that it is less dangerous than laser to operate.

 

 

Abstract

Idiopathic scoliosis predominantly afflicts adolescents. Adolescents with mild curvatures do not generally have any symptoms. However spinal fusion is indicated when the deformity exceeds 45°. Treatment is thus necessary to prevent and/or reduce the progression of curvatures to that below which surgery is indicated. Conservative treatment of adolescent idiopathic scoliosis includes observation, scoliosis-specific exercises (SSE) and bracing. There is increasing evidence suggesting that SSE and brace treatment can significantly limit the progression of spinal curvatures. In growing adolescents with curvatures more than 20°, bracing is indicated and should be used in conjunction with SSE. The effectiveness of bracing varies according to the type of brace applied to the patient. In general rigid braces are preferable to soft flexible braces, as the latter falls short of halting curvatures progression. Also, preliminary evidence suggests that asymmetric braces which enable over-correction provide more correction when compared with symmetrical braces. Recently it has also been reported that high quality bracing can also reduce curvatures exceeding 45° in over 70% of growing adolescents. This new knowledge might possibly increase the threshold of surgical indications to beyond 50° or above in the near future.

 

 

Abstract

A new development of correcting exercises has been derived from the original Schroth program in 2010 and the preliminary results have been published that year. Since then the program has been applied in some centers worldwide. As the original Schroth program was the only program so far to improve many signs and symptoms of scoliosis besides the angle of curvature (Cobb angle) it was interesting to look for the preliminary results of the recent development of scoliosis pattern specific corrective exercises derived from the original program, to see if similar effects can be achieved with this less complicated method.

METHODS:

A manual search in Pubmed was conducted, using the key words, Schroth, rehabilitation, and idiopathic scoliosis. Three papers have been found describing the short-term results of this new development today called Schroth Best Practice program (SBP). The papers were reviewed and analyzed with respect to the outcome parameters used.

RESULTS:

Outcome parameters were Angle of Trunk Rotation (ATR), Vital Capacity (VC), surface topography, electromyography, stabilometry and Cobb angle before and after a course of treatment. There was a significant improvement of all parameters after the application of this new program in all the three papers in the short- to mid-term.

CONCLUSIONS:

Scoliosis corrective exercises are supported by two randomized controlled trials (RCT) and should regularly be applied in mild scoliosis at risk for progression. Unspecific exercises such as Yoga, Dobomed cannot be regarded as effective as exercises using a well defined scoliosis pattern specific corrective routine.

 

 

Abstract

Idiopathic scoliosis afflicts 2-3% of the population. For mild curvatures, observation is the treatment of choice. Though this passive "wait and see" approach has been used for many years, the practice is inconsistent among different countries. In Anglo-Saxon countries where scoliosis specific exercises are not practised, observation is indicated for curvatures below 25° in growing children and adolescents. In countries, such as France, Germany, Italy and Poland where scoliosis specific corrective exercises are employed, only patients with no signs of maturity and with curvatures below 15° are treated by observation. Patients with curvatures between 15 - 25° are treated by scoliosis specific exercises. In view of the unpredictability of the progression of scoliosis curvatures in immature patients and the lack of knowledge of long term biomechanical repercussions of mild idiopathic scoliosis on lumbar spine and lower extremities, it is proposed that active intervention through scoliosis specific exercises rather than passive observation be employed in the treatment of mild adolescent idiopathic scoliosis.

 

 

Abstract

Spinal bracing is indicated in moderate to severe curves during growth. Brace effectiveness in halting progression of adolescent idiopathic scolisosis has been shown in a Cochrane review and in a randomized controlled trial (RCT). The outcome of brace treatment is dependent on the extent of in-brace correction and compliance. We have reviewed the literature on bracing to determine the types of brace that offer the best in-brace correction.

MATERIALS AND METHODS:

The literature has been searched for papers on bracing with documented in-brace corrections and long-term results.

RESULTS:

The in-brace percentage of correction of asymmetric braces is generally higher than that of the symmetric braces. According to the literature found in our search, long-term corrections are possible when starting treatment early, at an immature stage and with asymmetric braces of recent standards.

CONCLUSIONS:

Bracing today is supported by high quality evidence (Level I). Asymmetric braces have led to better corrections than that described for symmetric braces . An improvement of the average corrective effect has been described due to the latest CAD / CAM development. Long-term corrections are possible when starting brace treatment early, at an immature stage and with asymmetric braces of recent standards.

 

 

Abstract

Objective

The purpose of the study is to describe the use of monochromatic infrared energy (MIRE) therapy in the management of 2 patients with Bell's palsy.

Clinical features

Two patients presented to a chiropractic clinic with Bell's palsy that was diagnosed by a medical physician. Both patients were treated using MIRE. The acute patient was a 32-year-old male. He presented with left facial palsy 1 day before the consultation. He was unable to puff the left cheek and close the left eyelid. He had difficulty raising the left eyebrow. The chronic case was a 46-year-old lady. Prior to the first consultation, she was treated with corticosteroid and electro-acupuncture for one and a half years, with incomplete recovery. When first seen, the left corner of mouth drooped and she had difficulty raising her left eyebrow.

Intervention and outcome

Monochromatic infrared energy therapy, emitting 890 nm infrared light, was placed on the post-auricular area, pre-auricular area, the temple and mandibular area of the affected side. Each treatment lasted 30 minutes. Photographs were taken every week to document changes. The acute case received 19 treatments in 6 weeks. He reported an improvement of 95%. The chronic case received a total of 45 treatments in 9 months. She rated an improvement of 50%. At the conclusion of treatment, she was able to close her left eyelid and puff her left cheek but still could not raise her left eyebrow.

Conclusion

These 2 patients seemed to respond to a different degree to the MIRE therapy. As 71% of patients with Bell's palsy recover uneventfully without any treatment, the present study describes the course of care but cannot confirm the effectiveness of MIRE therapy in the management of Bell's palsy.