Turkiye Klinikleri Journal of Health Sciences

.: ORIGINAL RESEARCH
Omuz Ağrısı Olan Spinal Kord Yaralanmalı Hastalarda Fizik Muayene ve Omuz Ultrasonografi Bulguları
Physical Examination and Shoulder Ultrasonography Findings in the Patients with Shoulder Pain After Spinal Cord Injury
Serdar KAYMAZa, Sanem ASLIHAN AYKANb, Tuğba İKİZ KAYMAZa, Sinem UYAR KÖYLÜa
aFiziksel Tıp ve Rehabilitasyon Kliniği, Ankara Fizik Tedavi Eğitim ve Araştırma Hastanesi, Ankara, TÜRKİYE
bFiziksel Tıp ve Rehabilitasyon Kliniği, Sultan Abdülhamid Han Eğitim ve Araştırma Hastanesi, İstanbul, TÜRKİYE
Turkiye Klinikleri J Health Sci. 2019;4(3):288-94
doi: 10.5336/healthsci.2019-64805
Article Language: TR
Full Text
ÖZET
 Amaç: Spinal kord yaralanması (SKY) sonrası parapleji tanısı almış, omuz ağrısı olan ve yardımcı cihaz ya da tekerlekli iskemle (Tİ) kullanan hastalarda, omuz lezyonlarının klinik ve ultrasonografik (US) olarak incelenmesi ve bunların nörolojik seviye, cinsiyet, SKY süresi ile ilişkisinin belirlenmesidir. Gereç ve Yöntemler: Çalışmaya alınan 66 hastanın yaş, cinsiyet, nörolojik seviye, SKY süresi, etiyoloji ve ambulasyon seviyesi belirlendi. Ağrı vizüel analog skalası (VAS) ile değerlendirildi. Nörolojik seviye belirlenirken en son 2011 yılında revize edilen 'American Spinal Injury Association (ASIA)' skalasından yararlanıldı. Omuz muayenesi için 'Omuz Fizik Muayenesi Değerlendirme Ölçeği (PESS)', ultrasonografik değerlendirme için 'Omuz Patolojilerinin Ultrasonografik Sınıflaması (USPRS)' kullanıldı. Bulgular:Hastaların 46 (%69,6)'sı erkek-20 (%30,4)'si kadın olup; yaş ortalamaları 36,00±13,00 yıl idi. Supraspinatus tendon/tüberkülüm majus hassasiyeti, biseps tendon/oluk hassasiyeti, ağrılı ark ile Hawkins-Kennedy dominant ve nondominant omuzda sırayla %60 ve %56 oranında pozitif bulundu. Bilateral supraspinatus tendiniti en sık saptanan ultrasonografi bulgusuydu. Dominant omuzun %4,5'inde supraspinatus tendinopati, %6'sında bisipital tendinopati, non-dominant omuzun %3'ünde supraspinatus tendinopatisi ve %1,5'inde bisipital tendinopatisi saptandı. PESS değeri sağ omuz için 6,24±4,11 sol omuz için ortalama 5,70±4,30 idi. USPRS değerleri ort 11,53±6,07 idi. PESS ile USPRS arasında istatistiksel olarak anlamlı bir ilişki saptandı (p<0,001, r=0,51). Bu skalaların nörolojik seviye, cinsiyet ve SKY süresi ile istatistiksel olarak anlamlı ilişkisi saptanmadı (p>0,05). Ancak, nörolojik seviye ile supraspinatus ve bisipital tendinopati arasında anlamlı ilişki belirlendi (p=0,036). Sonuç: Yardımcı cihaz ya da Tİ kullanan paraplejik hastalarda omuz patolojileri sıktır. Cinsiyet ve SKY süresi omuz patolojisi için risk faktörü değildir. Fakat nörolojik seviye yükseldikçe omuzda tendon patolojisi oluşma ihtimali artmaktadır.

Anahtar Kelimeler: Omuz eklemi; ultrasonografi; spinal kord yaralanması; vizüel analog skala
ABSTRACT
 Objective: Our aim is to evaluate the relationship between neurological level, sex, diagnosis duration and physical and ultrasonographic examination of shoulder in paraplegic spinal cord injury (SCI) patients with shoulder pain using assistive devices or wheelchair. Material and Methods: We included 66 cases in our study. Age, gender, neurological level, duration of SCIambulation level were noted. Pain was evaluated by using visual analog scale (VAS). Neurological level was determined by using 'American Spinal Injury Association (ASIA, 2011)'. The physical and ultrasonographic examination were evaluated with 'Physical Examination of the Shoulder Scale (PESS)' and 'Ultrasound Shoulder Pathology Rating Scale (USPRS)' respectively. Results: Forty-six (69.6%) men and 20 (30.4%) women were included in our study. The mean±standard deviation of age was 36.00±13.00 years. Bilateral supraspinatus tendinitis was the most common ultrasonographic (US) finding. The prevelance of the supraspinatus and bisipital tendinopathy in dominant shoulder were 4.5% and 6%, in non-dominant shoulder were 3% and 1.5% respectively. The mean±standard deviation of PESS was 6.24±4.11 for right and 5.70±4.30 for left shoulder. The mean±standard deviation of USPRS was 11,53±6,07 for shoulders. PESS was positively correlated with USPRS (p<0.001, r=0.51). There was no statistically significant relationship between neurological level, sex, duration of SCI and USPRS or PESS. We found statistically significant relationship between neurological level and supraspinatus-bisipital tendinopathy (p=0.036). Conclusion: Shoulder pathology was seen commonly in paraplegic patients using assistive devices or wheelchairs. Sex and duration of SCI are not risk factor for shoulder pathology. But higher neurological levels increases the risk of tendinopathy in shoulder.

Keywords: Shoulder; ultrasonography; spinal cord injury; visual analog scale
REFERENCES:
  1. Bayley JC, Cochran TP, Sledge CB. The weight-bearing shoulder. The impingement syndrome in paraplegics. J Bone Joint Surg Am. 1987;69(5):676-8. [Crossref]  [PubMed] 
  2. Sie IH, Waters RL, Adkins RH, Gellman H. Upper extremity pain in the post rehabilitation spinal cord injured patient. Arch Phys Med Rehabil. 1992;73(1):44-8.
  3. Curtis KA, Drysdale GA, Lanza RD, Kolber M, Vitolo RS, West R. Shoulder pain in wheelchair users with tetraplegia and paraplegia. Arch Phys Med Rehabil. 1999;80(4): 453-7. [Crossref] 
  4. Wang JC, Chan CR, Tsai YA, Huang WC, Cheng H, Wu HL, et al. The influence of shoulder pain on functional limitation, perceived health, and depressive mood in patients with traumatic paraplegia. J Spinal Cord Med. 2015;38(5):587-92. [Crossref]  [PMC] 
  5. Samuelsson KA, Tropp H, Gerdle B. Shoulder pain and its consequences in paraplegic spinal cord-injured, wheelchair users. Spinal Cord. 2004;42(1):41-6. [Crossref] 
  6. Kivimaki J, Ahoniemi E. Ultrasonographic findings in shoulders of able-bodied, paraplegic and tetraplegic subjects. Spinal Cord. 2008;46(1):50-2. [Crossref] 
  7. Burnham RS, May L, Nelson E, Steadward R, Reid DC. Shoulder pain in wheelchair athletes. The role of muscle imbalance. Am J Sports Med. 1993;21(2):238-42. [Crossref] 
  8. Cooper RA, Boninger ML, Shimada SD, Lawrence BM. Glenohumeral joint kinematics and kinetics for three coordinate system representations during wheelchair propulsion. Am J Phys Med Rehabil. 1999;78(5):435-46. [Crossref] 
  9. Pentland WE, Twomey LT. The weight-bearing upper extremity in women with long term paraplegia. Paraplegia. 1991;29(8):521-30. [Crossref]  [PubMed] 
  10. Lal S. Premature degenerative shoulder changes in spinal cord injury patients. Spinal Cord. 1998;36(3):186-9. [Crossref] 
  11. Boninger ML, Towers JD, Cooper RA, Dicianno BE, Munin MC. Shoulder imaging abnormalities in individuals with paraplegia. J Rehabil Res Dev. 2001;38(4):401-8.
  12. Boninger ML, Souza AL, Cooper RA, Fitzgerald SG, Koontz AM, Fay BT. Propulsion patterns and pushrim biomechanics in manual wheel chair propulsion. Arch Phys Med Rehabil. 2002;83(5):718-23. [Crossref]  [PubMed] 
  13. Campbell CC, Koris MJ. Etiologies of shoulder pain in cervical spinal cord injury. Clin Orthop Relat Res. 1996;(322):140-5. [Crossref] 
  14. Escobedo EM, Hunter JC, Hollister MC, Patten RM, Goldstein B. MR Imaging of rotator cuff tears in individuals with paraplegia. AJR Am J Roentgenol. 1997;168(4):919-23. [Crossref]  [PubMed] 
  15. Teefey SA, Rubin DA, Middleton WD, Hildebolt CF, Leibold RA, Yamaguchi K. Detection and quantification of rotator cuff tears. Comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic findings in seventy-one consecutive cases. J Bone Joint Surg Am. 2004;86(4):708-16. [Crossref]  [PubMed] 
  16. Martinoli C, Bianchi S, PratoN, Pugliese F, Zamorani MP, Valle M, et al. US of the shoulder: non-rotatuar cuff disorders. Radiographics. 2003;23(2):381-401. [Crossref]  [PubMed] 
  17. Daenen B, Houben G, Bauduin E, Lu KV, Meulemans JL. Ultrasound of the shoulder. JBR-BTR. 2007;90(5):325-37.
  18. Kirshblum SC, Waring W, Biering-Sorensen F, Burns SP, Johansen M, Schmidt-Read M, et al. Reference for the 2011 revision of the International Standards for Neurological Classification of Spinal Cord Injury. J Spinal Cord Med. 2011;34(6):547-54. [Crossref]  [PubMed]  [PMC] 
  19. Brose SW, Boninger ML, Fullerton B, McCann T, Collinger JL, Impink BG, et al. Shoulder ultrasound abnormalities, physical examination findings, and pain in manuel wheelchair users with spinal cord injury. Arch Phys Med Rehabil. 2008;89(11):2086-93. [Crossref]  [PubMed] 
  20. Yamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint SurgAm. 2006;88(8):1699-704. [Crossref]  [PubMed] 
  21. Ferrero G, Mijno E, Actis MV, Zampa A, Ratto N, Arpaia A, et al. Risk factors for shoulder pain in patients with spinal cord injury: a multicenter study. Musculoskelet Surg. 2015;99 Suppl 1:S53-6. [Crossref]  [PubMed] 
  22. Bossuyt FM, Arnet U, Brinkhof MWG, Eriks-Hoogland I, Lay V, Muller R, et al. Shoulder pain in the Swiss spinal cord injury community: prevalence and associated factors. Disabil Rehabil. 2018;40(7):798-805. [Crossref]  [PubMed] 
  23. Veeger HE, van der Woude LH, Rozendal RH. Load on the upper extremity in manual wheelchair propulsion. J Electromyogr Kinesiol. 1991;1(4):270-80. [Crossref] 
  24. Jacobson EC, Lockwood MD, Hoefner VC Jr, Dickey JL, Kuchera WL. Shoulder pain and repetition strain injury to the supraspinatus muscle: etiology and manipulative treatment. J Am Osteopath Assoc. 1989;89(8):1037-40.
  25. Powers CM, Newsam CJ, Gronley JK, Fontaine CA, Perry J. Isometric torque in subjects with spinal cord injury. Arch Phys Med Rehabil. 1994;75(7):761-5.
  26. Giner-Pascual M, Alcanyis-Alberola M, Millan Gonzalez L, Aguilar-Rodriguez M, Querol F. Shoulder pain in cases of spinal injury: influence of the position of thewheel chair seat. Int J Rehabil Res. 2011;34(4):282-9. [Crossref]  [PubMed] 

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