terça-feira, 5 de maio de 2009

ARTIGO DO MÊS - (17/2009)

Cuff tear arthropathy: Current trends in diagnosis and surgical management
Feeley, BT; Gallo, R.A.; Craig, E.V.
J Shoulder Elbow Surg (2009) 18, 484-494


Massive tears of the rotator cuff resulting in arthritis of the glenohumeral joint remain a difficult challenge. Although cuff tear arthropathy (CTA) has been recognized for more than 150 years, a treatment strategy with uniformly satisfactory outcomes remains elusive, partly due to the difficulty in defining CTA in the literature. Most studies combine true CTA, rheumatoid arthritis, and massive rotator cuff tears under the CTA diagnosis.

Determining outcomes from these studies is difficult.

Hemiarthroplasty and total shoulder arthroplasty have led to pain relief, but the high rate of glenoid component loosening after total shoulder arthroplasty is a concern, and active range of motion remains limited after hemiarthroplasty.
There is increasing interest in the use of a constrained or reverese total shoulder arthroplasty to treat this complex process, with promising early results. This review article studies current trends in the diagnosis and management of arthritis due to massive cuff tears and CTA.
Keywords: Rotator cuff; tendon tears; arthropathy; cuff-tear arthropathy; hemiarthroplasty; total shoulder arthroplasty; reverse total shoulder arthroplasty

in Nonsurgical Management (no mesmo artigo)
Despite the presence of a large rotator cuff tear, many patients can function quitewell with minimal pain by using the deltoid and scapular stabilizing muscles (...) Physical therapy also can be quite beneficial: Exercises that focus on strengthening the deltoid musculature and scapula can allow select patients to function quite well.

A review of the literature, however, has not definitively shown that physical therapy results in improved functional outcomes of full thickness and massive rotator cuffs. Ainsworth et al (2007) systematically reviewed exercise therapy for nonoperative management of full thickness tears of the rotator cuff. They concluded that although no randomized controlled trials met the inclusion criteria, there was some evidence that exercise can improve the functional outcome of shoulders with full thickness rotator cuff tears. Both studies suggest that a trial of physical therapy is warranted in CTA and may provide at least short-term benefits. However, patients must be counseled that physical therapy will not heal the rotator cuff and, therefore, the disease process will likely progress regardless of the clinical improvement.

Comentário: independentemente da opção terapêutica seguida (tratamento conservador ou cirúrgico) é necessário reeducar a função através dos padrões normais de movimento num contexto de alterações estruturais que são irreversiveis em elementos fundamentais na estabilidade do ombro. MESMO NO CASO DE CIRURGIA DE SUBSTITUIÇÃO por artroplastia, os príncipios para a normalização da função e dos padrões neuromotores mantém-se.
Raul Oliveira, Fisioterapeuta

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