manejo intervencionista del hombro doloroso post ictus
TRANSCRIPT
![Page 1: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/1.jpg)
Manejo Intervencionista del Hombro Doloroso
Post-Ictus
Ángel León ValenzuelaUGC Intercentros-Interniveles de
Rehabilitación Cádiz y Puerto Real @Angel_Leon_
![Page 2: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/2.jpg)
RETO
![Page 3: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/3.jpg)
15.000.000
![Page 4: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/4.jpg)
1de cada 6
![Page 5: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/5.jpg)
1ª causa de Discapacidad
![Page 6: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/6.jpg)
1ª causa de Demencia
![Page 7: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/7.jpg)
Mortalidad1ªcausa en ♀2ª causa en ♂
![Page 8: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/8.jpg)
Un nuevo ictus cada 40”
![Page 9: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/9.jpg)
4 de cada 10 Tendrán Hombro Doloroso Hemipléjico
![Page 10: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/10.jpg)
Hombro Doloroso Hemipléjico
Dolor / LimitaciónPeor Recuperación Funcional
Mayor DiscapacidadIngreso prolongado
![Page 11: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/11.jpg)
REHABILITACIÓN INTERVENCIONISTA
Uso de técnicas mínimamente invasivas dentro de un
programa global de tratamiento rehabilitador, con un objetivo
de recuperación funcional
![Page 12: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/12.jpg)
EVALUAR Y DIAGNOSTICAR LOS FACTORES NEUROLÓGICOS
EVALUAR Y DIAGNOSTICAR LOS FACTORES MECÁNICOS
PREVENCIÓN A TRAVÉS DEL POSICIONAMIENTO
REHABILITACIÓN Y CONTROL SINTOMÁTICO
INTERVENCIÓN BASADA EN LA PATOLOGÍA
![Page 13: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/13.jpg)
FACTORES MECÁNICOS
MOTONEURONA SUPERIOR
MOTONEURONA INFERIOR
q Déficit motorq Espasticidadq Dolor centralq Sensibilización central
q Neuropatía periféricaq Plexopatíasq SDRC
q Subluxaciónq Capsulitis Adhesivaq Traumatismosq Patología manguitoq Dolor miofascialq Artropatía gleno-
humeral o acromio-clavicular
FACTORES NEUROLÓGICOS
![Page 14: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/14.jpg)
Strapping and slingsStrapping is used to maintain the shoulder joint in an appropriate anatomic position toprevent or reduce subluxation. Strapping from the onset of stroke until restoration ofmuscle tonemay prevent the incidence, or at least delay the onset, of HSP.51,52 Tapingperpendicular to a muscle inhibits activity, and taping parallel to a muscle promotesactivity.33 The exact mechanism of pain relief remains uncertain. This technique re-quires a trained care provider to apply the dressing, and repeat applications to preventskin irritation. A small study comparing taping versus sham taping in patients withshoulder pain revealed decreased pain-free shoulder abduction, but no significantchange in overall pain or ROM.53 Furthermore, the study was performed without re-gard to specific diagnosis, and was not applied to patients with HSP. There are nohigh-quality studies demonstrating the benefit of taping specifically for HSP.In addition to strapping, shoulder slings have also been used to decrease the stress
on the shoulder joint and prevent subluxation by reducing the gravitational pull on theshoulder joint. However, if the arm is incorrectly positioned, or if use of a sling is notalternated with therapeutic exercise, soft-tissue contractures may occur. Such con-tractures can contribute to the very pain the sling is intended to prevent. Slings are rec-ommended primarily for a flaccid upper extremity, when the patient is upright orwalking, for the purpose of protection.54 Arm troughs and lap trays are recommendedfor use in a wheelchair to support the limb and prevent shoulder subluxation, as well asto prevent traumatic injury. The properly positioned tray and trough can also maintainabduction and limit excessive internal and external rotation.55 Arm slings can support
Box 5Approach to treatment of hemiplegic shoulder pain
Regardless of Cause
! Prevention through positioning
! Bracing, slings, taping
! Physical therapy to optimize range of motion and strength
Neurologic Factors
! Transcutaneous electrical nerve stimulation (TENS)
! Functional electrical stimulation (FES)
! Relaxation/electromyography biofeedback
! Botulinum toxin injection
! Sympathetic blocks
! Pharmacotherapy (eg, antispasticity, neuropathic pain)
Mechanical Factors
! Pharmacotherapy (eg, anti-inflammatory)
! Corticosteroid injection
! Suprascapular nerve block
! Trigger-point injections and dry needling
Complementary and Alternative Medicine
! Acupuncture
! Aromatherapy
! Surgical treatment
Vasudevan & Browne424
![Page 15: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/15.jpg)
23-33% Dolor Central Post-
Ictus, Sensibilización
Central, Negligencia
Bloqueo del ganglio
estrellado
Unidades específicas
Dolor
S. DOLOR REGIONAL COMPLEJO
![Page 16: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/16.jpg)
85% vs 18% Medio y largo plazo
Mayor gravedad
Peor pronóstico funcional
ESPASTICIDAD
![Page 17: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/17.jpg)
Infiltración Toxina BotulínicaIntramuscular
![Page 18: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/18.jpg)
Función
Mejora Dolor y Balance Articular
?
![Page 19: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/19.jpg)
Pectoral > Subescapular
![Page 20: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/20.jpg)
Redondo >
Dorsal Ancho
![Page 21: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/21.jpg)
50% Medio y largo plazo
Infiltración intraarticular
Bloqueo nervio supraescapular
CAPSULITIS ADHESIVA
![Page 22: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/22.jpg)
53% Tendinopatía PLB y
manguito
Bursitis
Desgarros
Fundamental uso ecografía diagnóstica
Técnicas ecoguiadas
PATOLOGÍA MANGUITO/ARTICULAR
![Page 23: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/23.jpg)
Infiltración corticoesteroides
Intraarticular
![Page 24: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/24.jpg)
Eficaz en la reducción del dolor y el aumento del balance articular en el
HDH tras 2-4 semanas
E. L, B. G, B. E, E.C. C. The effect of local injections in hemiplegic shoulder pain: A prospective, randomized, controlled study. American Journal of Physical Medicine and Rehabilitation; 2009. p. 805–11.
![Page 25: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/25.jpg)
En la capsulitis adhesiva se considera una intervención de primera línea de
tratamiento, dada su eficacia y coste-efectividad, especialmente a corto-medio
plazo.
Maund E, Craig D, Suekarran S, Neilson AR, Wright K, Brealey S, et al. Management of frozen shoulder: A systematic review and cost-effectiveness analysis [Internet]. Health Technology Assessment. 2012. p. 1–264.
![Page 26: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/26.jpg)
Infiltración corticoesteroides Subacromial / ecoguiada
![Page 27: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/27.jpg)
La infiltración subacromial en pacientes con desordenes del manguito asociados al
HDH, mejora el balance articular, disminuye el dolor y la discapacidad y sus efectos se
mantienen hasta 8 semanas
Rah UW, Yoon SH, Moon DJ, Kwack KS, Hong JY, Lim YC, et al. Subacromial corticosteroid injection on poststroke hemiplegic shoulder pain: A randomized, triple-blind, placebo-controlled trial. Arch Phys Med Rehabil. 2012;93(6):949–56.
![Page 28: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/28.jpg)
Bloqueo nervio supraescapular
FarmacológicoRadiofrecuencia
![Page 29: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/29.jpg)
El bloqueo del nervio supraescapular (BNSE) en distintos procesos etiológicos que condicionan hombro doloroso está ampliamente reportado en la literatura.
![Page 30: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/30.jpg)
Eficaz en la reducción del dolor en el HDH al comparar con placebo, sin
alterar resto de parámetros funcionales.
Adey-Wakeling Z, Crotty M, Shanahan EM. Suprascapular nerve block for shoulder pain in the first year after stroke: a randomized controlled trial. Stroke . 2013;44(11):3136–41
![Page 31: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/31.jpg)
FARMACOLÓGICO
Ecoguiado
AL +/- Corticoide
Volúmenes: 5-10ml
RADIOFRECUENCIA
Ecoguiado + NES
Pulsada 40ºC 120 s
Duración: 3-4 meses
![Page 32: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/32.jpg)
DOLOR LOCALIZADO, RIGIDEZ Y “PUNTOS
GATILLO”
Asociación con HDH?
Muy poca evidencia
secundaria
Infiltración miofascial
DOLOR MIOFASCIAL
![Page 33: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/33.jpg)
Infiltración MiofascialPS / Anestésico Local / TBA
![Page 34: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/34.jpg)
DiLorenzo L, Traballesi M, Morelli D, Pompa A, Brunelli S, Buzzi MG, et al. Hemiparetic Shoulder Pain Syndrome Treated with Deep Dry Needling During Early Rehabilitation: A Prospective, Open-Label, Randomized Investigation. J Musculoske Pain. 2004;12(2):25–34.
PUNTO GATILLO
PS
![Page 35: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/35.jpg)
Kamanli A, Kaya A, Ardicoglu O, Ozgocmen S, Zengin FO, Bayik Y. Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome. Rheumatol Int. 2005 Oct;25(8):604–11.
PUNTO GATILLO
PS
AL
TBA
![Page 36: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/36.jpg)
infraespinoso
supraespinoso
![Page 37: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/37.jpg)
Redondo >
Redondo <
![Page 38: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/38.jpg)
trapecio
![Page 39: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/39.jpg)
CONCLUSIONES
Resulta imprescindible el profundizar en el diagnóstico
diferencial y en la identificación de factores etiológicos
implicados para seleccionar las técnicas indicadas
![Page 40: Manejo intervencionista del hombro doloroso post ictus](https://reader031.vdocumento.com/reader031/viewer/2022032014/55cff2d9bb61eb38328b4742/html5/thumbnails/40.jpg)
CONCLUSIONES
Es necesario incluir el uso de técnicas intervencionistas
dentro de los programas individualizados de
Rehabilitación