Avaliação do tratamento da dor crônica em ombros de hemiplégicos com bloqueio transforaminal de... por João Eduardo Daud Amadera - Versão HTML

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Abstract

Amadera, JED. Transforaminal Epidural Steroid Injection to Treat Hemiplegic Shoulder Pain:

A Randomized, Double-Blind, Sham-Controlled Trial

"; 2013.

Objective: Because of the lack of effective treatment today for hemiplegic shoulder pain

(HSP) we designed a protocol to evaluate the efficacy of transforaminal epidural

dexamethasone injection (TFESI) in relieving it. Design: A randomized, blind, sham-controlled

trial with assessments before and after TFESI. Setting: Orthopedics and Neurosurgery

department of a tertiary hospital. Participants: Patients (N=38) with HSP refractory to standard

treatments and pain score at rest greater than 4cm on a pain visual analog scale (VAS) of 0 to

10cm. Intervention: TFESI at the C5-6 level. Main Outcome Measure: Variation in VAS score 3

months after interventions. Methods: We performed a randomized, sham-controlled, double

blind clinical trial in which 38 patients were randomized to receive TFESI ("TFESI" group) or

sham ("sham" group). Assessments were performed immediately before, 1 week after and 3

months after by a blinded rater. Results: At baseline, groups did not differ regarding any of the

outcome variables. After 3 months pain intensity was significantly better in the TFESI group as

compared to Sham (p<0.05). For the secondary outcome measures, the functional

independency, the algometry of the trapezius muscle and at the C4 and at the C5 levels and the

algometry of the ligment at the C6-7 and at the C7-T1 levels also improved after the TFESI

treatment (p<0.05). No side effects were found. Conclusions: TFESI is effective for pain relief

and functional independency in patients with HSP. The results of this study suggest that TF has

a superior effect compared with Sham intervention. Larger randomized controlled trials should

be made to confirm efficacy of TFESI in patients with refractory HSP.

Descriptors: Stroke; Pain; Shoulder pain/pathology; Dor de ombro/therapy; Dor de

ombro/physiopathology; Anesthesia, epidural; Dexamethasone; Shoulder pain/pathology;

Shoulder pain/physiopathology; Shoulder pain/etiology; Central nervous system sensitizaiton;

Hemiplegy/physiopathology; Pain treshold/psysiology; Randomized controlled trial; Placebos.

Lista de ilustrações

FIGURA 1-1 – RADIOSCOPIA DA REGIÃO CERVICAL COM A AGULHA ESPINHAL POSICIONADA NO

FORAME DE C5-6 (RAIZ NERVOSA DE C6). ___________________________________________ 12

FIGURA 1-2 - FLUOROSCOPIA CERVICAL MOSTRANDO A AGULHA ESPINHAL NO FORAME DE C6 E A

INJEÇÃO DO CONTRASTE EVIDENCIANDO NERVOGRAMA COM EPIDUROGRAMA. ___________ 13

FIGURA 1-3 – SUBTRAÇÃO DIGITAL DA INJEÇÃO DE CONTRASTE. ______________________________ 14

FIGURA 3-1 - ESCALA VISUAL ANÁLOGA DE DOR ___________________________________________ 22

FIGURA 3-2 – GONIÔMETRO ___________________________________________________________ 25

FIGURA 3-3 - DOMÍNIOS DA MEDIDA DE INDEPENDÊNCIA FUNCIONAL (MIF) ____________________ 27

FIGURA 3-4 – NÍVEIS DE DEPENDÊNCIA FUNCIONAL. CRITÉRIOS PARA A PONTUAÇÃO DA MIF. ______ 28

FIGURA 3-5 – ALGÔMETRO DE PRESSÃO ANALÓGICO _______________________________________ 29

FIGURA 3-6 – ALGOMETRIA DO MÚSCULO TRAPÉZIO _______________________________________ 29

FIGURA 3-7 – ALGOMETRIA DO LIGAMENTO INTERESPINHOSO DE C5-6 ________________________ 30

FIGURA 3-8 – ALGOMETRIA DO DERMÁTOMO DE C7 _______________________________________ 31

FIGURA 3-9 – TESTE DE COORDENAÇÃO E VELOCIDADE DA EFM ______________________________ 33

FIGURA 3-10 – TESTE DE SENSIBILIDADE DA EFM __________________________________________ 34

FIGURA 3-11 – DOR ARTICULAR NA MOVIMENTAÇÃO PASSIVA PELA EFM _______________________ 35

FIGURA 4-1 – ORIGEM DOS SUJEITOS ADMITIDOS NO ESTUDO _______________________________ 39

FIGURA 4-2 – MOTIVOS DE NÃO INCLUSÃO _______________________________________________ 39

FIGURA 4-3 – FLUXO DOS PACIENTES SUJEITOS DA PESQUISA ________________________________ 40

FIGURA 4-4 – EVOLUÇÃO NA ESCALA DE FUGL-MEYER AO LONGO DO TEMPO. ___________________ 46

FIGURA 4-5 - EVOLUÇÃO DA DOR MEDIDA PELA EVA AO LONGO DO TEMPO ____________________ 51

FIGURA 4-6 - EVOLUÇÃO DO DOMÍNIO “DOR” MEDIDO PELO SF-36 AO LONGO DO TEMPO _________ 52

FIGURA 4-7 - EVOLUÇÃO DA DA ESCALA DE FUGL-MEYER AO LONGO DO TEMPO _________________ 52