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Evidencias en la rehabilitación del hombro doloroso

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Presentación sobre la Evidencia actual en la Rehabilitación del Hombro Doloroso para el curso EVIGRA 2014.

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Evidencias en la rehabilitación del hombro doloroso

  1. 1. Evidencias  en  Rehabilitación  del   Hombro  Doloroso   Ángel León Valenzuela! angel.leon.valenzuela@gmail.com! @Angel_Leon_!            UGC  Intercentros-­‐Interniveles              HHUU  de  Puerto  Real  y  Puerta  del  Mar  (Cádiz)   EVIGRA 2014Granada 19-22 Febrero
  2. 2. Presentar las evidencias de mayor calidad y más actualizadas!
  3. 3. Compartir y difundir!
  4. 4. #Evigra! ! @Angel_Leon_! !
  5. 5. Niveles de evidencia! Nivel  I! Evidencia  obtenida  de  estudios  diagnós4cos,  prospec4vos  o  ECA   de  ALTA  calidad! Nivel  II! Evidencia  obtenida  de  estudios  diagnós4cos,  prospec4vos  o  ECA   de  BAJA  calidad! Nivel  III! Evidencia  obtenida  de  estudios  CASOS-­‐CONTROLES  o   RETROSPECTIVOS! Nivel  IV! Evidencia  obtenida  de  SERIES  DE  CASOS! Nivel  V! Evidencia  obtenida  de  OPINIÓN  DE  EXPERTOS!
  6. 6. Grados de recomendación! A! FUERTE! Una mayoría de estudios nivel I! B! MODERADA! Una mayoría de estudios de nivel II o un único estudio nivel I, apoyan la recomendación ! C! DEBIL! Un solo estudio nivel II o una mayoría de estudios de nivel III y IV apoyan la recomendación ! D! CONFLICTIVA! La recomendación se basa en estos estudios contradictorios ! E! TEÓRICA! Una mayoría de estudios en animales o de cadáveres o estudios de investigación en ciencias básicas apoyan esta conclusión! F! OPINIÓN DE EXPERTOS! Prácticas basadas en la experiencia clínica!
  7. 7. HOMBRO DOLOROSO! •  Cuadro clínico caracterizado por dolor localizado a nivel del hombro, en cualquiera de sus 3 articulaciones (glenohumeral, acromioclavicular y esternoclavicular ) y/o tejidos blandos circundantes ! •  Prevalencia estimada: 16% al 34%!
  8. 8. HOMBRO  DOLOROSO   PATOLOGÍA  EXTRÍNSECA   •  Trastornos cervicales! •  Trastornos nerviosos: radiculopatía, lesión plexo braquial, síndrome de Parsonnage-Turner o neuralgia amiotrófica.! •  Trastornos inflamatorios: polimialgia reumática. ! •  Síndrome de Dolor Regional Complejo! •  Dolor miofascial! •  Lesiones torácicas o costales! •  Dolor referido visceral !
  9. 9. HOMBRO  DOLOROSO   PATOLOGÍA   INTRÍNSECA  
  10. 10. HOMBRO  DOLOROSO   PATOLOGÍA   INTRÍNSECA   ! •  Capsulitis adhesiva! •  Lesiones Manguito! •  Inestabilidad! ! PATOLOGÍA  EXTRÍNSECA   •  Trastornos cervicales! •  Trastornos nerviosos: radiculopatía, lesión plexo braquial, síndrome de Parsonnage-Turner o neuralgia amiotrófica.! •  Trastornos inflamatorios: polimialgia reumática. ! •  Síndrome de Dolor Regional Complejo! •  Dolor miofascial! •  Lesiones torácicas o costales! •  Dolor referido visceral !
  11. 11. CAPSULITIS ADHESIVA!
  12. 12. Health Technology Assessment 2012; Vol. 16: No. 11 ISSN 1366-5278 Health Technology Assessment NIHR HTA programme www.hta.ac.uk March 2012 10.3310/hta16110 Management of frozen shoulder: a systematic review and cost-effectiveness analysis E Maund, D Craig, S Suekarran, AR Neilson, K Wright, S Brealey, L Dennis, L Goodchild, N Hanchard, A Rangan, G Richardson, J Robertson and C McDaid H I A G L E C C C C C A R H Clinical Practice Guidelines MARTIN J. KELLEY, DPT • MICHAEL A. SHAFFER, MSPT • JOHN E. KUHN, MD • LORI A. MICHENER, PT, PhD AMEE L. SEITZ, PT, PhD • TIMOTHY L. UHL, PT, PhD • JOSEPH J. GODGES, DPT, MA • PHILIP W. MCCLURE, PT, PhD Shoulder Pain and Mobility Deficits: Adhesive Capsulitis Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association J Orthop Sports Phys Ther 2013;43(5):A1-A31. doi:10.2519/jospt.2013.0302 REVIEWERS: Roy D. Altman, MD • John DeWitt, DPT • George J. Davies, DPT, MEd, MA Todd Davenport, DPT • Helene Fearon, DPT • Amanda Ferland, DPT • Paula M. Ludewig, PT, PhD • Joy MacDermid, PT, PhD James W. Matheson, DPT • Paul J. Roubal, DPT, PhD • Leslie Torburn, DPT • Kevin Wilk, DPT For author, coordinator, contributor, and reviewer affiliations, see end of text. Copyright ©2013 Orthopaedic Section, American Physical Therapy Association (APTA), Inc, and the Journal of Orthopaedic & Sports Physical Therapy. The Orthopaedic Section, APTA, Inc, and the Journal of Orthopaedic & Sports Physical Therapy consent to the reproduction and distribution of these guidelines for educational purposes. Address correspondence to: Joseph Godges, DPT, ICF Practice Guidelines Coordinator, Orthopaedic Section, APTA, Inc, 2920 East Avenue South, Suite 200, La Crosse, WI 54601. E-mail: icf@orthopt.org RECOMMENDATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A2 INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A3 METHODS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A4 CLINICAL GUIDELINES: Impairment/Function-Based Diagnosis . . . . . . . . . . . . . . . . . . A6 CLINICAL GUIDELINES: Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A14 CLINICAL GUIDELINES: Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A16 SUMMARY OF RECOMMENDATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . A26 AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS. . . . . . A27 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A28
  13. 13. Definición! Restricción funcional del balance articular pasivo y activo del hombro, sin lesiones remarcables en estudios radiográficos, excepto por la posible presencia de osteopenia o tendinosis cálcica.! J Shoulder Elbow Surg. 2011 Mar;20(2):322-5. Frozen shoulder: a consensus definition. Zuckerman JD, Rokito A.!
  14. 14. Clasificación! A.  PRIMARIO! B.  SECUNDARIO:! A.  Intrínseco: ! –  Ej.: Tendinopatía del manguito, Tendinosis bicipital, Tendinopatía cálcica! B.  Extrínseco:! –  Cx mama, Patología cervical, fractura previa, ACV, etc.! C.  Sistémico:! –  Ej.: DM, hipotiroidismo, etc.!
  15. 15. Factores de riesgo! Richard J Murphy and Andrew J Carr Shoulder pain Clinical Evidence 2010 ! q Sexo  femenino     q Edad  avanzada     q Trauma4smo  de  hombro     q Cirugía   q Diabetes     q Trastornos  cardiorrespiratorios     q Accidente  cerebrovascular     q Enfermedad  del  4roides  
  16. 16. Hª natural! 1.  Congelación (FREEZING)! –  Aumento progresivo del dolor y disminución de la amplitud de movimiento. 6 semanas a 9 meses.! 2.  Congelado (FROZEN)! –  Mejora el dolor, pero la rigidez permanece. 4 a 6 meses.! 3.  Deshielo (THAWING)! –  Mejoría lenta de la movilidad. 6 meses 3 años.!
  17. 17. Diagnóstico!
  18. 18. Exploración física! Diagnóstico fundamentalmente clínico:! – Perdida BA activo y pasivo! – Mayor afectación rotaciones (especialmente RE)! – Patrón capsular a la exploración.! J Shoulder Elbow Surg. 2011 Apr;20(3):502-14. doi: 10.1016/j.jse.2010.08.023. Epub 2010 Dec 16.Current review of adhesive capsulitis.Hsu JE, Anakwenze OA, Warrender WJ, Abboud JA.!
  19. 19. Diagnóstico por imagen! •  No indicado de rutina.! •  Signos RMN y artroRMN:! –  Estrechamiento lig. Coracohumeral (también en ecografía) ! –  Contracción capsular: disminución volumen! –  Estrechamiento a nivel receso axilar.! •  PLoS One. 2011;6(12):e28704. MRI findings for frozen shoulder evaluation: is the thickness of the coracohumeral ligament a valuable diagnostic tool?Li JQ, Tang et al! •  J Shoulder Elbow Surg. 2011 Apr;20(3):502-14. doi: 10.1016/ j.jse.2010.08.023. Epub 2010 Dec 16.Current review of adhesive capsulitis.Hsu JE, Anakwenze OA, Warrender WJ, Abboud JA.!
  20. 20. Tratamiento!
  21. 21. Esteroides orales! Proporcionan beneficios significativos a corto plazo ( < 6 semanas) del dolor, el arco de movilidad del hombro y la función. ! ! •  Maund E, et al . Health Technol Assess. 2012;16(11):1-264 Management of frozen shoulder: a systematic review and cost-effectiveness analysis.! ! II!
  22. 22. Infiltraciones esteroides! •  Beneficios significativos a corto plazo y medio plazo ( < 6 semanas) del dolor, BA, función y discapacidad.! •  No diferencias significativas en la Calidad de Vida.! •  Más efectivo que la FT a corto y largo plazo ! •  Combinada con FT se añade beneficio a los tratamientos individualizados.! •  Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Maund E, et al . Health Technol Assess. 2012;16(11):1-264 ! •  Shoulder pain and mobility deficits: Adhesive Capsulitis. Kelley et al. J Orthop Sport Phys Ther 2013;43(5):A1-A31! A!
  23. 23. Infiltraciones hialurónico! •  3 ECA ! •  Mejora el BA, función y dolor a corto plazo. ! •  Sus resultados son similares a los de la infiltración con corticoides! •  Alto riesgo de sesgo! •  Maund  E,  et  al  .  Health  Technol  Assess.  2012;16(11):1-­‐264  Management  of  frozen  shoulder:  a   systema4c  review  and  cost-­‐effec4veness  analysis.   D!
  24. 24. Acupuntura! •  3 ECA baja calidad (sólo 1 control con placebo)! •  Reducción del dolor Vs placebo (<4 semanas)! •  Importante heterogeneidad! •  Alto riesgo de sesgo! •  Maund E, et al . Health Technol Assess. 2012;16(11):1-264 Management of frozen shoulder: a systematic review and cost- effectiveness analysis.! No pruebas suficientes de eficacia ! III!
  25. 25. Laser! •  Eslamian F, Shakouri SK, Ghojazadeh M, Nobari OE, Eftekharsadat B. Effects of low-level laser therapy in combination with physiotherapy in the management of rotator cuff tendinitis. Lasers Med Sci. 2012 Sep;27(5):951-8. doi:10.1007/10103-011-1001-3.! •  M M Favejee, B M A Huisstede, B W Koes Frozen shoulder: the effectiveness of conservative and surgical interventions—ti–56. doi:10.1136/bjsm.2010.071431! •  Mejoría significativa a corto plazo del dolor y función.! •  No diferencias significativas en el Balance Articular ! ! •  Conflicto de Intereses ?! I!
  26. 26. Fisioterapia! •  12 ECA que comparan distintas técnicas de tratamiento.! •  Importante heterogeneidad! •  Mayor evidencia de la onda corta y de movilizaciones de alto grado (Grados 3-4 de Maitland)! •  Resultados inferiores a corto plazo que la infiltración! •  Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Maund E, et al . Health Technol Assess. 2012;16(11):1-264 ! •  Shoulder pain and mobility deficits: Adhesive Capsulitis. Kelley et al. J Orthop Sport Phys Ther 2013;43(5):A1-A31! C!
  27. 27. Ejercicio! •  5 ECA.! •  No definición intensidad, duración, frecuencia etc! •  Sólo uno define ejercicios! •  Instruir a pacientes en ejercicios de estiramiento específicos. La intensidad debe ser determinada según estado inicial del paciente.! B! •  Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Maund E, et al . Health Technol Assess. 2012;16(11):1-264 ! •  Shoulder pain and mobility deficits: Adhesive Capsulitis. Kelley et al. J Orthop Sport Phys Ther 2013;43(5):A1-A31!
  28. 28. Bloqueo del n. supraescapular! •  Beneficios significativos a corto plazo ( 3 meses) del dolor ! •  Los resultados mejoran cuando se aplica con técnica guiada electromiograficamente vs guía anatómica. ! •  Mayor mejoría del dolor y BA que con infiltraciones intrarticulares ! M M Favejee, B M A Huisstede, B W Koes Frozen shoulder: the effectiveness of conservative and surgical interventions—ti–56. doi: 10.1136/bjsm.2010.071431! II!
  29. 29. Bloqueo del n. supraescapular! •  Beneficios significativos a corto plazo ( 3 meses) del dolor ! •  Los resultados mejoran cuando se aplica con técnica guiada electromiograficamente vs guía anatómica. ! •  Mayor mejoría del dolor y BA que con infiltraciones intrarticulares ! M M Favejee, B M A Huisstede, B W Koes Frozen shoulder: the effectiveness of conservative and surgical interventions—ti–56. doi: 10.1136/bjsm.2010.071431! PENDIENTES  ACTUALIZACIÓN  DE   LA  COCHRANE   II!
  30. 30. Radiofrecuencia! •  Series de casos! •  Mejoría del dolor y del BA! •  Resultados se mantienen a medio plazo! Huang CC, Tsao SL, Cheng CY, Hsin MT, Chen CM. Treating frozen shoulder with ultrasound-guided pulsed mode radiofrequency lesioning of the suprascapular nerve: two cases. Pain Med. 2010 Dec;11(12):1837-40. doi:! 10.1111/j.1526-4637.2010.00970.x. Epub 2010 Oct 28. PubMed PMID: 21040432.! IV!
  31. 31. Manipulación bajo anestesia! •  No diferencias entre la manipulación bajo anestesia y tratamientos conservadores (RHB, infiltraciones…)! •  Importantes limitaciones:! –  Ensayos muy heterogéneos. ! –  Recogida de resultados! Health Technol Assess. 2012;16(11):1-264. doi: 10.3310/hta16110.! Management of frozen shoulder: a systematic review and cost-effectiveness analysis.! Maund E, Craig D, Suekarran S, Neilson A, Wright K, Brealey S, Dennis L, Goodchild L, Hanchard N, Rangan A, Richardson G, Robertson J, McDaid C! C!
  32. 32. Hidrodilatación! •  1 ECA y casos controles! •  No diferencia significativa con la manipulación bajo anestesia.! •  No diferencia al comparar con corticoides sólos! •  Maund E, et al . Health Technol Assess. 2012;16(11):1-264 Management of frozen shoulder: a systematic review and cost-effectiveness analysis.! •  Quraishi NA, Johnston P, Bayer J, Crowe M, Chakrabarti AJ. Thawing the frozen shoulder. A randomised trial comparing manipulation under anaesthesia with hydrodilatation. J Bone Joint Surg Br. 2007 Sep;89(9): 1197-200. PubMed PMID:17905957.! •  Tveitå EK, Tariq R, Sesseng S, Juel NG, Bautz-Holter E. Hydrodilatation, corticosteroids and adhesive capsulitis: a randomized controlled trial. BMC Musculoskelet Disord. 2008 Apr 19;9:53. doi: 10.1186/1471-2474-9-53. PubMed PMID:18423042; PubMed Central PMCID: PMC2374785! III!
  33. 33. Distensión artrográfica! Rev. COCHRANE:! –  Existe EVIDENCIA MODERADA de que proporciona beneficios a corto plazo para el dolor, la amplitud de movimiento y la función en la capsulitis adhesiva. ! –  Los resultados mejoran si se realiza fisioterapia posteriormente.! •  Maund E, et al . Health Technol Assess. 2012;16(11):1-264 Management of frozen shoulder: a systematic review and cost- effectiveness analysis.! •  Buchbinder R, Green S, Youd JM, Johnston RV, Cumpston M. Distensión artrográfica para la capsulitis adhesiva En: La Biblioteca Cochrane Plus, 2008 Número 4! Rev.  HTA:   •  No  existe  evidencia   consistente  (Riesgo  de  sesgo   en  la  recogida  de  resultados)   D!
  34. 34. Liberación capsular! •  1 Casos-Control (y 2 series de casos)! •  Poco beneficio de la liberación capsular +/- Manipulación bajo anestesia. ! •  Grant JA, Schroeder N, Miller BS, Carpenter JE. Comparison of manipulation and arthroscopic capsular release for adhesive capsulitis: a systematic review. J Shoulder Elbow Surg. 2013 Aug;22(8):1135-45. doi: 10.1016/j.jse.2013.01.010. Epub 2013 Mar 17! •  Maund E, et al . Health Technol Assess. 2012;16(11):1-264 Management of frozen shoulder: a systematic review and cost-effectiveness analysis.! III!
  35. 35. Movilización bajo anestesia/ Distensión artrográfica / Liberación capsular! Bloqueo n. Supraescapular / Hidrodilatación! Infiltración con esteroides + FT! Laser / Onda corta! Ejercicio terapéutico! Movilizaciones Alto Grado! 1ª Infiltración con esteroides + Programa domiciliario! Propuesta tratamiento!
  36. 36. PATOLOGÍA DEL MANGUITO!
  37. 37. •  Pinzamiento mecánico del tendón del manguito rotador debajo de la parte anteroinferior del acromion, por uno o más de los diferentes componentes del arco acromial: acromion, articulación acromioclavicular, ligamento acromiocoracoideo y apófisis coracoides (Neer 1983)!
  38. 38. Diagnóstico!
  39. 39. Exploración física! SYSTEMATIC REVIEW Diagnostic Accuracy of Clinical Tests for Subacromial Impingement Syndrome: A Systematic Review and Meta-Analysis Marwan Alqunaee, RCSI, Rose Galvin, BSc (Physio), PhD, Tom Fahey, MD, FRCGP ABSTRACT. Alqunaee M, Galvin R, Fahey T. Diagnostic accuracy of clinical tests for subacromial impingement syn- drome: a systematic review and meta-analysis. Arch Phys Med Rehabil 2012;93:229-36. Objective: To examine the accuracy of clinical tests for diagnosing subacromial impingement syndrome (SIS). Data Sources: A systematic literature search was conducted in January 2011 to identify all studies that examined the diag- nostic accuracy of clinical tests for SIS. The following search engines were used: Cochrane Library, EMBASE, Science Di- rect, and PubMed. Study Selection: Two reviewers screened all articles. We included prospective or retrospective cohort studies that exam- ined individuals with a painful shoulder, reported any clinical test for SIS, and used arthroscopy or open surgery as the reference standard. The search strategy yielded 1338 articles of which 1307 publications were excluded based on title/abstract. Sixteen of the remaining 31 articles were included. The PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines were followed to conduct this review. Data Extraction: The number of true positives, false posi- tives, true negatives, and false negatives for each clinical test were extracted from relevant studies, and a 2ϫ2 table was constructed. Studies were combined using a bivariate random- effects model. Heterogeneity was assessed using the variance of logit-transformed sensitivity and specificity. Data Synthesis: Ten studies with 1684 patients are included in the meta-analysis. The Hawkins-Kennedy test, Neer’s sign, and empty can test are shown to be more useful for ruling out rather than ruling in SIS, with greater pooled sensitivity esti- mates (range, .69–.78) than specificity (range, .57–.62). A negative Neer’s sign reduces the probability of SIS from 45% to 14%. The drop arm test and lift-off test have higher pooled specificities (range, .92–.97) than sensitivities (range, .21–.42), indicating that they are more useful for ruling in SIS if the test is positive. Conclusions: This systematic review quantifies the diagnostic accuracy of 5 clinical tests for SIS, in particular the lift-off test. Accurate diagnosis of SIS in clinical practice may serve to improve appropriate treatment and management of individuals with shoulder complaints. Key Words: Meta-analysis; Rehabilitation; Sensitivity and specificity; Subacromial impingement syndrome. © 2012 by the American Congress of Rehabilitation Medicine SHOULDER PAIN IS the third most common musculosk- eletal consultation in primary care, and second most com- mon cause of referrals to orthopedic and sports medicine clin- ics. 1,2 The differential diagnosis of conditions that cause shoulder pain is a challenging and complex area of musculo- skeletal practice. Subacromial impingement syndrome (SIS) is the most frequent cause of shoulder pain. SIS is a clinical syndrome that indicates pain and pathology relating to the subacromial bursa and rotator cuff tendons within the subacro- mial space. The 3 stages of SIS are subacromial bursitis, partial-thickness and full-thickness rotator cuff tears.3 The cause of SIS is considered to be multifactorial, with both extrinsic and intrinsic factors involved in its pathogenesis. 4 The primary factors relating to the intrinsic theory are muscle overload and weakness, shoulder overuse and repetitive tissue microtrauma, and degeneration of the rotator cuff. The key elements of the extrinsic hypothesis are shape of the acromion, glenohumeral instability, altered scapulothoracic rhythm, os acromiale, and degeneration of the acromioclavicular joint.5,6 Clinicians have traditionally relied on a clinical examination comprising a subjective history and physical examination, fol- lowed by various clinical tests to diagnose SIS. Numerous clinical tests have been described to evaluate the presence of impingement syndrome and to determine the integrity of the individual components of the rotator cuff.7 These tests can be broadly classified as impingement or pain provocation tests and rotator cuff strength tests. Impingement tests are designed to reproduce symptoms or pain by compressing the greater tuber- osity against the acromion.8,9 Rotator cuff strength tests assess the integrity of the individual rotator cuff tendons and their respective musculotendinous units. Table 1 contains the com- From the HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland. Supported by the Health Research Board (HRB) of Ireland through the HRB Centre for Primary Care Research (grant no. HRC/2007/1). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organi- zation with which the authors are associated. Reprint requests to Rose Galvin, BSc (Physio), PhD, HRB Centre for Primary Care Research, Dept of General Practice, Royal College of Surgeons in Ireland, 123 St. Stephens Green, Dublin 2, Republic of Ireland, e-mail: rosegalvin@rcsi.ie. 0003-9993/12/9302-00341$36.00/0 doi:10.1016/j.apmr.2011.08.035 List of Abbreviations CI confidence interval LR likelihood ratio PRISMA preferred reporting items for systematic reviews and meta-analyses QUADAS quality assessment of diagnostic accuracy studies ROC receiver operating characteristic SIS subacromial impingement syndrome 229 Arch Phys Med Rehabil Vol 93, February 2012 Database of Abstracts of Reviews of Effects (DARE) Produced by the Centre for Reviews and Dissemination Copyright © 2014 University of York Page: 1 / 3 Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, Wright AA. Database of Abstracts of Reviews of Effects (DARE). 25 Abril 2013! Diagnostic accuracy of clinical tests for! subacromial impingement syndrome: a systematic review and meta-analysis. Alqunaee M, Galvin R, Fahey T. Arch! Phys Med Rehabil. 2012 Feb;93(2):229-36. ! Physical tests for shoulder! impingements and local lesions of bursa, tendon or labrum that may accompany! impingement. Hanchard NC, et al. Cochrane Database Syst Rev. 2013 Apr 30;4:CD007427. ! Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement(Review) Hanchard NCA, Lenza M, Handoll HHG, Takwoingi Y This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2013, Issue 4 http://www.thecochranelibrary.com Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
  40. 40. Alto Valor Predictivo Negativo! S. Subacromial! Alta Sensibilidad! Hawkins-Kennedy ! Signo del Neer ! Empty-Can (Jobe)!
  41. 41. Alto Valor Predictivo Positivo! Alta Especificidad! Drop Arm! Lift off Test!
  42. 42. Desgarro de subescapular ! – Internal rotation lag sign: sensibilidad muy alta 97 %! – Lift-Off Test: alta especificidad!
  43. 43. Patología del Infraespinoso: ! – Patte: tenía una especificidad muy alta 95 %, pero también de alta sensibilidad 94%! – Rot externa contra resistencia: una especificidad del 99% y la sensibilidad de 96% !
  44. 44. Patología del Supraespinoso: ! –  No había ninguna prueba individual con propiedades tan altas! –  Empty Can Test (Jobe) puede ser útil para descartar la lesión con sensibilidad de 94%!
  45. 45. Diagnóstico por Imagen! SENSIBILIDAD! ESPECIFICIDAD! RMN! ECO! A-RM! RMN! ECO! A-RM! ROTURAS COMPLETAS! 0,94! 0,92! 0,94! 0,93! 0,93! 0,92! Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NCA, Faloppa F. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD009020. DOI: 10.1002/14651858.CD009020.pub2.! •  No  hubo  diferencia  estadís4camente  significa4va  en  el   rendimiento  de  diagnós4co  para  la  detección  de  desgarros  de   espesor  completo  al  comparar  la  RM,  ecograaa  y  artroRM.    
  46. 46. SENSIBILIDAD! ESPECIFICIDAD! RMN! ECO! A-RM! RMN! ECO! A-RM! ROTURAS PARCIALES! 0,74! 0,52! *! 0,93! 0,93! *! Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NCA, Faloppa F. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD009020. DOI: 10.1002/14651858.CD009020.pub2.! •  El  rendimiento  diagnós4co  de  la  resonancia  magné4ca  y  de  la   ecograaa  puede  ser  similar,  pero  disminuye  su  sensibilidad   para  la  detección  de  desgarros  de  espesor  parcial.   *  No  posible  metaanálisis   Diagnóstico por Imagen!
  47. 47. Ramon P. Ottenheijm, Mariëtte J. Jansen, J. Bart Staal, Ann van den Bruel, René E. Weijers, Rob A. de Bie, Geert-Jan Dinant, Accuracy of Diagnostic Ultrasound in Patients With Suspected Subacromial Disorders: A Systematic Review and Meta-Analysis . Arch Phys Med Rehabil Vol 91, October 2010! SENSIBILIDAD! ESPECIFICIDAD! BURSITIS SUBACROMIAL! 0,79-0,81! 0.94 - 0 .98! TENDINOPATÍAS! 0,67-0,93! 0.88 - 1.00! T. CALCIFICANTE! 1! 0.85 - 0.98! Diagnóstico por Imagen!
  48. 48. Tratamiento!
  49. 49. REVIEW ARTICLE (META-ANALYSIS) Subacromial Impingement Syndrome: Effectiveness of Pharmaceutical InterventionseNonsteroidal Anti-Inflammatory Drugs, Corticosteroid, or Other Injections: A Systematic Review Renske van der Sande, MD,a Willem D. Rinkel, MSc,b Lukas Gebremariam, MD,a Elaine M. Hay, FRCP, MD,c Bart W. Koes, PhD,a Bionka M. Huisstede, PhDa,b From the Departments of a General Practice and b Rehabilitation Medicine, Erasmus MC e University Medical Center, Rotterdam, The Netherlands; and c the Arthritis Research Campaign National Primary Care Centre, Keele University, Keele, United Kingdom. Abstract Objective: To present an evidence-based overview of the effectiveness of pharmaceutical interventions, including nonsteroidal anti-inflammatory drugs, corticosteroid injections, and other injections, used to treat the subacromial impingement syndrome (SIS). An overview can help physicians select the most appropriate pharmaceutical intervention, and it can identify gaps in scientific knowledge. Data Sources: The Cochrane Library, PubMed, Embase, PEDro, and CINAHL databases. Study Selection: Two reviewers independently selected relevant reviews and randomized clinical trials. Data Extraction: Two reviewers independently extracted the data and assessed the methodologic quality. Data Synthesis: A best evidence synthesis was used to summarize the results. Three reviews and 5 randomized clinical trials were included. Although we found limited evidence for effectiveness in favor of 2 sessions with corticosteroid injections versus 1 session, for the effectiveness of corticosteroid injections versus placebo, nonsteroidal anti-inflammatory drugs, or acupuncture, only conflicting and no evidence for effectiveness was found. Moderate evidence was found in favor of immediate release oral ibuprofen compared with sustained-released ibuprofen in the short- term. Also, moderate evidence for effectiveness was found in favor of glyceryltrinitrate patches versus placebo patches in the short-term and mid term. Furthermore, injections with disodium ethylene diamine tetraacetic acid plus ultrasound with ethylene diamine tetraacetic acid gel were more effective (moderate evidence) than was placebo treatment in the short- and long-term. Conclusions: This article presents an overview of the effectiveness of pharmaceutical interventions for SIS. Some treatments seem to be promising (moderate evidence) to treat SIS, but more research is needed before firm conclusions can be drawn. Archives of Physical Medicine and Rehabilitation 2013;94:961-76 ª 2013 by the American Congress of Rehabilitation Medicine Musculoskeletal disorders of the shoulder, including tendinitis and bursitis, are difficult to differentiate in clinical practice. In the Complaints of the Arm, Neck, and/or Shoulder (CANS) model, the term subacromial impingement syndrome (SIS) is used for the rotator cuff syndrome, tendonosis of the Musculus infraspinatus, Musculus supraspinatus, and Musculus subscapularis, and bursitis in the shoulder area.1 More than 50% of the patients suffering from chronic CANS reported complaints of the shoulder.2 The relation between shoulder complaints and work-related factors, such as repetitive work, working with the hand above the shoulder, and high psychosocial job demands, has been found positive by several authors.3 In general practice, SIS is the most frequently reported diag- nosis of the shoulder, with a cumulative incidence of 5 per 1000 patients per year.4 Patients with SIS are characterized by pain localized in the shoulder that is exacerbated when performing overhead activities.5 The first step in treatment for SIS by a general practitioner often includes an analgesic.6 Also, corti- costeroid injections are an often-used intervention in primary care.7 New treatment modalities such as tenoxicam injections8 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. 0003-9993/13/$36 - see front matter ª 2013 by the American Congress of Rehabilitation Medicine http://dx.doi.org/10.1016/j.apmr.2012.11.041 Archives of Physical Medicine and Rehabilitation journal homepage: www.archives-pmr.org Archives of Physical Medicine and Rehabilitation 2013;94:961-76 Subacromial Impingement Syndrome: Effectiveness of Pharmaceutical Interventions–Nonsteroidal Anti- Inflammatory Drugs, Corticosteroid, or Other Injections: A Systematic Review! Renske van der Sande, et al. Archives of physical medicine and rehabilitation 1 May 2013!
  50. 50. AINES! Múl4ples  ECA:       •  Diclofenaco   •  Flurbiprofeno   •  Naproxeno   •  Celecoxib   •  Ibuprofeno   •  Ibupfofeno  liberación   sostenida     Subacromial Impingement Syndrome: Effectiveness of Pharmaceutical Interventions–Nonsteroidal Anti- Inflammatory Drugs, Corticosteroid, or Other Injections: A Systematic Review! Renske van der Sande, et al. Archives of physical medicine and rehabilitation 1 May 2013! Celecoxib único que compara con placebo! II!
  51. 51. AINES! Múl4ples  ECA:       •  Diclofenaco   •  Flurbiprofeno   •  Naproxeno   •  Celecoxib   •  Ibuprofeno   •  Ibupfofeno  liberación   sostenida     Subacromial Impingement Syndrome: Effectiveness of Pharmaceutical Interventions–Nonsteroidal Anti- Inflammatory Drugs, Corticosteroid, or Other Injections: A Systematic Review! Renske van der Sande, et al. Archives of physical medicine and rehabilitation 1 May 2013! Celecoxib único que compara con placebo! PENDIENTES  ACTUALIZACIÓN  DE   LA  COCHRANE   II!
  52. 52. Otros fármacos orales! •  No disponemos de ensayos clínicos aleatorizados sobre AINEs tópicos, Paracetamol y Opioides! •  Guías Práctica clínica: Recomendado el control del dolor con analgésicos.! III!
  53. 53. Parches de nitroglicerina! Estudio basado en 1 ECA! •  Parche NTG + RHB! •  Placebo + RHB! •  Hay débil evidencia de la efectividad de los parches de nitroglicerina Vs placebo a corto (12 semanas) y medio plazo (24 semanas)! •  Subacromial Impingement Syndrome: Effectiveness of Pharmaceutical Interventions–Nonsteroidal Anti-Inflammatory Drugs, Corticosteroid, or Other Injections: A Systematic Review Renske van der Sande, et al. Archives of physical medicine and rehabilitation 1 May 2013 (volume 94 issue 5 Pages 961-976 DOI: 10.1016/j.apmr.2012.11.041)! III!
  54. 54. Infiltraciones esteroides 
 Patología del manguito! •  5 ECAS ! •  Mejoría significativa del dolor Vs placebo! •  No diferencias al comparar con TENS u Onda corta! •  Rabini A, et al Effects of local microwave diathermy on shoulder pain and function in patients with rotator cuff tendinopathy in comparison to subacromial corticosteroid injections: a single-blind randomized trial. J Orthop Sports Phys Ther. 2012 Apr;42(4):363-70. doi: 10.2519/jospt.2012.378722281781. Epub 2012 Jan 25. ! •  Subacromial Impingement Syndrome: Effectiveness of Pharmaceutical Interventions–Nonsteroidal Anti- Inflammatory Drugs, Corticosteroid, or Other Injections: A Systematic Review. Renske van der Sande, et al. Archives of physical medicine and rehabilitation 1 May 2013. ! II!
  55. 55. Infiltraciones esteroides 
 S. Subacromial! •  7 ECAS (4 alta calidad) = empate a 2.! •  Evidencia conflictiva sobre la efectividad de las inyecciones con corticoides Vs placebo a corto (4 semanas) y medio plazo (12 semanas)! Subacromial Impingement Syndrome: Effectiveness of Pharmaceutical Interventions–Nonsteroidal Anti- Inflammatory Drugs, Corticosteroid, or Other Injections: A Systematic Review! Renske van der Sande, et al. Archives of physical medicine and rehabilitation 1 May 2013! D!
  56. 56. Infiltraciones AINES 
 S. Subacromial! •  3 ECAS.! •  No diferencias significativas en la infiltración con corticoide Vs AINE. ! •  No diferencias entre infiltración combinada corticoide + AINE! ! Subacromial Impingement Syndrome: Effectiveness of Pharmaceutical Interventions–Nonsteroidal Anti- Inflammatory Drugs, Corticosteroid, or Other Injections: A Systematic Review! Renske van der Sande, et al. Archives of physical medicine and rehabilitation 1 May 2013! II!
  57. 57. ¿Infiltraciones ecoguiadas?! Bloom JE, Rischin A, Johnston RV, Buchbinder R. Image-guided versus blind glucocorticoid injection for shoulder pain. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD009147. DOI: 10.1002/14651858.CD009147.pub2.! II! •  Pruebas de calidad moderada indican que no hay ninguna diferencia en el dolor o la función ! •  Pruebas de calidad moderada sugiere que hay probablemente ninguna diferencia en la incidencia de eventos adversos!
  58. 58. Plasma rico en plaquetas! No evidencia del beneficio del PRP en patología del manguito.! II! Arthroscopy. 2012 Nov;28(11):1718-27. doi: 10.1016/j.arthro. 2012.03.007. Epub 2012 Jun 12.! The role of platelet-rich plasma in arthroscopic rotator cuff repair: a systematic review with quantitative synthesis.! Chahal J, Van Thiel GS, Mall N, Heard W, Bach BR, Cole BJ, Nicholson GP, Verma NN, Whelan DB, Romeo AA.! Cochrane Database Syst Rev. 2013 Dec 23;12:CD010071. doi: 10.1002/14651858.CD010071.pub2.! Platelet-rich therapies for musculoskeletal soft tissue injuries.! Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC.!
  59. 59. Laser! •  Yavuz F, Duman I, Taskaynatan MA, Tan AK. Low-level laser therapy versus ultrasound therapy in the treatment of subacromial impingement syndrome: A Rndomized clinical trial. J Back Musculoskelet Rehabil. 2013 Dec 17. [Epub ahead of print] PubMed PMID: 24346151! •  Eslamian F, Shakouri SK, Ghojazadeh M, Nobari OE, Eftekharsadat B. Effects of low-level laser therapy in combination with physiotherapy in the management of rotator cuff tendinitis. Lasers Med Sci. 2012 Sep;27(5):951-8. doi: 10.1007/10103-011-1001-3! •  Tendinopatía del manguito: Mejora el dolor a corto plazo Vs placebo y Ultrasonido.! •  S. Subacromial: evidencia conflictiva! II!
  60. 60. Magnetoterapia! •  Tendinopatía cálcica y SIS a corto y medio plazo! •  Significificación clínica débil! •  1ECA No efecto en otros procesos! Pulsed electromagnetic field and exercises in patients with shoulder impingement syndrome: a randomized, double-blind, placebo-controlled clinical trial. Galace de Freitas D, Marcondes FB, Monteiro RL, Rosa SG, Maria de Moraes Barros Fucs P, Fukuda TY. Arch Phys Med Rehabil. 2014 Feb;95(2):345-52.! II!
  61. 61. Ultrasonidos! • Evidencia conflictiva de los US Vs placebo a corto plazo. ! • No evidencia a medio plazo.! Subacromial impingement syndrome—effectiveness of physiotherapy and manual therapy. Lukas Gebremariam, et al. Br J Sports Med 2013;0:1–8. doi: 10.1136/bjsports-2012-091802 ! ! D!
  62. 62. Iontoforesis ac. acético! Evidencia moderada de NO eficacia en la reabsorción de calcio.! II! Ciccone CD. Does acetic acid iontophoresis accelerate the resorption of calcium deposits in calcific tendinitis of the shoulder? Phys Ther. 2003 Jan;83(1):68-74. PubMed PMID: 12495407.!
  63. 63. Ondas de choque! •  Tendinopatía calcificante: Son mas efectivas que placebo para mejorar el dolor, la calcificación y la función. ! •  Tendinopatía no calcificante: no son eficaces ! Clinical improvement and resorption of calcifications in calcific tendinitis of the shoulder after shock wave therapy at 6 months' follow-up: a systematic review and meta-analysis.! Ioppolo F, Tattoli M, Di Sante L, Venditto T, Tognolo L, Delicata M, Rizzo RS, Di Tanna G, Santilli V.! Arch Phys Med Rehabil. 2013 Sep;94(9):1699-706. doi: 10.1016/j.apmr.2013.01.030. Epub 2013 Mar 13.! ! I!
  64. 64. Kinesio tape! Actualmente no existe evidencia para apoyar el uso de kionesio tape en la práctica clínica.! Physiother Theory Pract. 2013 May;29(4):259-70. doi: 10.3109/09593985.2012.731675. Epub 2012 Oct 22.! The clinical effects of Kinesio® Tex taping: A systematic review.! Morris D, Jones D, Ryan H, Ryan CG.! II!
  65. 65. Ejercicio! •  Hasta 19 ECA analizados! •  Es necesario estandarizar y describir los protocolos de tratamiento.! •  Son necesarios estudios de mayor calidad metodológica.! II! The effectiveness of physiotherapy exercises in subacromial impingement syndrome: a systematic review and meta-analysis.! Hanratty CE, et al. Database of Abstracts of Reviews of Effects (DARE) Septiembre 2013! !
  66. 66. Ejercicio! •  Reduce el dolor! •  Aumenta la Fuerza.! •  Mejora la Función (autopercibida)! •  Mejora la Calidad de Vida ! •  Los ejercicios domiciliarios son tan efectivos como los supervisados por fisioterapeutas ! II! The effectiveness of physiotherapy exercises in subacromial impingement syndrome: a systematic review and meta-analysis.! Hanratty CE, et al. Database of Abstracts of Reviews of Effects (DARE) Septiembre 2013! !
  67. 67. Radiofrecuencia! •  4 ECA ! •  Mejoría significativa del dolor! •  Resultados se mantienen a medio plazo! II!
  68. 68. Cirugía! No diferencias en los resultados en el dolor y la función del hombro entre la actitud conservadora y quirúrgica! Clin J Sport Med. 2013 Sep;23(5):406-7. doi: 10.1097/01.jsm.0000433152.74183.53.! Is there evidence in favor of surgical interventions for the subacromial impingement syndrome?! Tashjian RZ.! I!
  69. 69. Cirugía! •  No diferencias entre Cirugia abierta, artroscópica o “mini- open”! •  No diferencias entre fijación “single-row” o “double-row”.! Clin J Sport Med. 2013 Sep;23(5):406-7. doi: 10.1097/01.jsm.0000433152.74183.53.! Is there evidence in favor of surgical interventions for the subacromial impingement syndrome?! Tashjian RZ.! II! Seida J, et al. Comparative Effectiveness of Nonoperative and Operative Treatment for Rotator Cuff Tears. Comparative Effectiveness Review No. 22. (Prepared by the University of Alberta Evidence-based Practice Center) AHRQ 2010.!
  70. 70. Descompresión subacromial! Programa Individual! Ejercicio! Terapia manual! Programa Grupal! Ejercicio terapéutico! AINES +/- ANALGÉSICOS! + Programa domiciliario! Intervencionismo! Radiofrecuencia! Artroscopia! Tto individual! Ondas de choque! Magnetoterapia ?! Infiltración + Ejercicio Terapéutico! AINES +/ LASER! + Programa domiciliario! Propuesta tratamiento! S. Subacromial puro! Tendinopatía (incluida cálcica)!
  71. 71. INESTABILIDAD!
  72. 72. La luxación de hombro representa casi el 50% de todas las luxaciones articulares. ! ! Son anteriores en 90-98% de los casos! •  Inestabilidad de hombro. Scott Welsh et al. Actualización Medscape Septiembre 2012! •  Consensus statement on shoulder instability. Arthroscopy. 2010 Feb;26(2):249-55. Bak K, Wiesler ER, Poehling GG; ISAKOS Upper Extremity Committee.!
  73. 73. Diagnóstico!
  74. 74. Exploración física! Database of Abstracts of Reviews of Effects (DARE) Produced by the Centre for Reviews and Dissemination Copyright © 2014 University of York Page: 1 / 3 Which  physical  examina4on  tests  provide  clinicians   with  the  most  value  when  examining  the  shoulder?   Update  of  a  systema4c  review  with  meta-­‐analysis  of   individual  tests.  Hegedus  EJ,  Goode  AP,  Cook  CE,   Michener  L,  Myer  CA,  Myer  DM,  Wright  AA.   Database  of  Abstracts  of  Reviews  of  Effects  (DARE).   25  Abril  2013   Physical tests for shoulder! impingements and local lesions of bursa, tendon or labrum that may accompany! impingement. Hanchard NC, et al. Cochrane Database Syst Rev. 2013 Apr 30;4:CD007427. ! Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement(Review) Hanchard NCA, Lenza M, Handoll HHG, Takwoingi Y This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2013, Issue 4 http://www.thecochranelibrary.com Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
  75. 75. Lesiones del Labrum (sup): Test de compresión pasiva con una sensibilidad del 89%, especificidad 85%!
  76. 76. Inestabilidad anterior: Test de aprehesión con una sensibilidad del 65%, especificidad 95%!
  77. 77. Inestabilidad anterior: Test de la sorpresa con una sensibilidad del 81%, especificidad 86%!
  78. 78. Diagnóstico por Imagen! Diagnostic Value of US, MR y MR artrography in shoulder inestability. Roman Pavic et al. Injury Int J. Care (2013) S26-S32! La RM es la prueba de elección inicial, con una especificidad del 82% y sensibilidad del 94%! ! La artro-RM es el gold standard para la evaluación previa a la cirugía.!
  79. 79. Diagnóstico por Imagen! La RM es más precisa para lesiones de Hill- Sachs o Bankart! ! La artro-RM es superior en lesiones ligamentosas complejas y del labrum! Diagnostic Value of US, MR y MR artrography in shoulder inestability. Roman Pavic et al. Injury Int J. Care (2013) S26-S32!
  80. 80. Tipo de Inmovilización! No diferencias entre la inmovilización en rotación externa Vs rotación interna! Immobilization in internal or external rotation does not change recurrence rates after traumatic anterior shoulder Dislocation. Patrick Vavken, et al. J Shoulder Elbow Surg (2014) 23, 13-19! mulative RR for recurrent dislocations after immobilization in internal rotation (IR) and external rotation (ER) for patients r younger. The pooled estimates are very similar to those for all ages, mostly because a large majority of patients with tions are adolescents and young adults. P. Vavken et al. final analysis of recurrent dislocation. However, we did find high values for post hoc power analysis. Conclusion The currently available best evidence does not support a relative effectiveness of immobilization in external rotation compared with internal rotation in reducing recurrent shoulder dislocations in patients with traumatic anterior shoulder dislocations. However, after we reviewed the current clinical data and the ava science, it is our opinion that a yet-to-be- subgroup of patients could benefit from such Future investigations are needed to test this Disclaimer The authors, their immediate families, and a foundations with which they are affiliate Figure 4 Cumulative RR for recurrent dislocations after immobilization in internal rotation (IR) and external rotation (E aged older than 30 years. Figure 3 Cumulative RR for recurrent dislocations after immobilization in internal rotation (IR) and external rotation (E aged 30 years or younger. The pooled estimates are very similar to those for all ages, mostly because a large majority o shoulder dislocations are adolescents and young adults. II!Tratamiento conservador!
  81. 81. Tiempo de Inmovilización! Edad < 13 años es un factor predictivo de recurrencia! ! No hay beneficios en inmovilizar > 1 semana en pacientes jóvenes! ! Immobilization in internal or external rotation does not change recurrence rates after traumatic anterior shoulder Dislocation. Patrick Vavken, et al. J Shoulder Elbow Surg (2014) 23, 13-19! II!
  82. 82. Programa de Rehabilitación! Consensus statement on shoulder instability. Arthroscopy. 2010 Feb;26(2):249-55. ! Bak K, Wiesler ER, Poehling GG; ISAKOS Upper Extremity Committee.! •  Diseño individualizado! •  Programa de ejercicios! •  Recuperación del rango de movimiento! •  Ejercicios dinámicos! •  Propioceptivos! •  Estabilización escapular! III!
  83. 83. Ejercicios Isocinéticos! Los programas Isocinéticos son eficaces en la evaluación y rehabilitación de la inestabilidad de hombro microtraumatica! Isokinetic intervention in microtraumatic shoulder instability: an update. Gremeaux V, Croisier JL, Forthomme B. J Sports Med Phys Fitness. 2012 Aug;52(4):413-23. Review. PubMed PMID: 22828467.! II!
  84. 84. Cirugia! Chahal J, Marks PH, Macdonald PB, Shah PS, Theodoropoulos J, Ravi B, Whelan DB. Anatomic Bankart repair! compared with nonoperative treatment and/or arthroscopic lavage for first-time traumatic shoulder dislocation.! Arthroscopy 2012; 28(4): 565-575! II! La reparación artroscópica reduce la inestabilidad recurrente y mejora la calidad de vida en adultos jóvenes tras la primera luxación.!

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