肩痛を有する脳卒中片麻痺患者における烏口上腕靱帯への局所注射治療の予備的研究

Effects of Local Injection into the Coracohumeral Ligament in Stroke Hemiplegic Patients with Shoulder Pain : A Pilot Study

要旨　目的：脳卒中片麻痺患者に好発する肩痛はquality of lifeを低下させ，リハビリテーション治療の阻害因子となる．脳卒中片麻痺患者の肩痛に対する局所注射治療は数多く報告されているが，烏口上腕靱帯への局所注射治療はこれまで報告されていない．肩痛を訴える脳卒中片麻痺患者に対して，烏口上腕靱帯にステロイド局所注射治療を行い，疼痛，睡眠，可動域の変化を評価した．

方法：当院リハビリテーション科に入院中の脳卒中片麻痺患者で肩痛を有する患者のうち，関節可動域訓練や解剖学的整復，鎮痛薬内服では疼痛コントロールが不十分であった14肩を対象とした．超音波ガイド下に烏口上腕靱帯に対してステロイド局所注射を行った．評価項目は動作時痛，夜間痛，睡眠障害，肩関節可動域（屈曲・外転・下垂位外旋）の変化とした．睡眠障害の評価にはアテネ不眠尺度スコアを用いた．それぞれの項目を注射前，注射2週後，注射4週後に評価した．

結果：注射4週後の動作時痛，注射2週後と4週後の夜間痛とアテネ不眠尺度スコアは有意に改善した．肩関節可動域は注射2週後の屈曲と注射4週後の外旋は有意に改善した．

結論：動作時痛と夜間痛，睡眠障害が有意に軽減したことから，烏口上腕靱帯へのステロイド局所注射は脳卒中片麻痺患者の肩痛を軽減する治療法の1つになり得る．

Abstract　Objective: Shoulder pain, which is common in hemiplegic stroke patients, decreases quality of life and interferes with rehabilitation. Although many local injection therapies have been reported for shoulder pain in hemiplegic stroke patients, that to the coracohumeral ligament has not been reported. In a stroke paraplegic patient with shoulder pain, we evaluated the effect of local steroid injection therapy on pain, sleep and range of movement.

Methods: Among stroke hemiplegia patients with shoulder pain admitted to our rehabilitation department, 14 shoulders with inadequate pain control by joint range of motion training, anatomical restoration, and analgesic medication were included in this study. Local steroid injections were performed on the coracohumeral ligament under ultrasound guidance. The evaluation items were pain during movement, nocturnal pain, sleep disturbance, and changes in shoulder joint range of motion (flexion, abduction, and external rotation in the pronated position). The Athens Insomnia Scale score was used to assess sleep disturbance. Each item was evaluated before injection, 2 weeks after injection, and 4 weeks after injection.

Results: Pain during movement 4 weeks after injection, nocturnal pain and Athens Insomnia Scale score 2 and 4 weeks after injection improved significantly. The range of motion of the shoulder joint was also significantly improved in flexion 2 weeks after injection and in external rotation after 4 weeks of injection.

Conclusion: Local steroid injections into the coracohumeral ligament may be one treatment option to reduce shoulder pain in stroke hemiplegic patients, as it significantly reduced pain during movement and nighttime pain and sleep disturbances.