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作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　September 18, 2009 — 根據一篇線上發表於9月15日BMJ期刊的單盲隨機研究結果，受監督的運動對於緩解長期肩膀疼痛的效果優於震波治療。
　　
　　挪威Ullevaal大學醫院的物理治療師Kaia Engebretsen等人寫道，震波治療在肩峰下肩膀疼痛的使用漸漸增加。就我們所知，未曾在臨床試驗比較放射性體外震波治療和運動，特別是肩膀疼痛病患。本研究的目的在於比較放射性體外震波治療和受監督的運動對於肩峰下肩膀疼痛病患的短期效果。
　　
　　在Ullevaal大學醫院復健科與復建醫學門診中，肩峰下肩膀疼痛持續至少3個月的104名病患，被隨機分派接受放射性體外震波治療(每週1次課程、為期4-6週)或受監督的運動(每週2次45分鐘的課程、至多12週)。
　　
　　在研究開始時，兩組的年紀、教育、受影響的慣用手、疼痛期間都相似。主要研究終點為肩膀疼痛與失能指數。
　　
　　研究者發現，在第6、12、18週時，受監督的運動有比較好的治療效果，校正治療效果為 -8.4分(95%信心區間(CI)為 -16.5 至-0.6)。相較於震波治療組，受監督的運動組有顯著較多病患的肩膀疼痛和失能分數改善(64% vs 36%；勝算比(OR)為3.2；95% CI，1.3 - 7.8)。
　　
　　震波治療組的病患有較多人在12至18 週時需要額外的治療(OR，5.5；95% CI，1.3 - 26.4)，且較少人恢復工作。
　　
　　研究作者寫道，對於肩峰下肩膀疼痛，受監督運動的短期改善效果優於放射性體外震波治療。
　　
　　研究限制包括，缺乏安慰劑組、未在肩峰下空間注射局部麻醉劑以改善診斷準確度，對於次級結果變項之差異的偵測能力可能不足。
　　
　　研究作者結論表示，18週之後，在初級結果變項：肩膀疼痛與失能指數、以及1個次級結果變項：工作狀態方面，受監督的運動優於放射性體外震波治療。我們發現，疼痛、功能、動作活動範圍、使用藥物治療等其他次級變項沒有明顯差異。受監督運動組有較多病患改善，或許是因為治療效果。
　　
　　挪威的Health Region East支持本研究。研究作者皆宣告沒有相關財務關係。

Supervised Exercises May Be Better Than Shockwave Treatment for Chronic Shoulder Pain

By Laurie Barclay, MD
Medscape Medical News

September 18, 2009 — Supervised exercises are more effective than shockwave treatment to relieve chronic shoulder pain, according to the results of a single-blind randomized study published online September 15 in BMJ.

"Shockwave treatment is increasingly used for subacromial shoulder pain," write Kaia Engebretsen, a physiotherapist from Ullevaal University Hospital in Oslo, Norway, and colleagues. "To our knowledge, radial extracorporeal shockwave treatment has not been compared with exercises in a clinical trial, [particularly in] patients with shoulder pain. The purpose of this study was to compare the short-term effects of radial extracorporeal shockwave treatment and supervised exercises in patients with subacromial shoulder pain."

At an outpatient clinic of physical medicine and the rehabilitation department at Ullevaal University Hospital, 104 patients with subacromial shoulder pain lasting 3 months or more were randomized to receive radial extracorporeal shockwave treatment (1 session weekly for 4 to 6 weeks) or supervised exercises (two 45-minute sessions weekly for up to 12 weeks).

Age, education, dominant arm affected, and pain duration were similar in both groups at study initiation. The shoulder pain and disability index was the main study end point.

The investigators found a treatment effect favoring supervised exercises at 6, 12, and 18 weeks, with an adjusted treatment effect of ?8.4 points (95% confidence interval [CI], ?16.5 to ?0.6). Compared with the shockwave-treatment group, the group treated with supervised exercises had a significantly higher proportion of patients who improved in terms of shoulder pain and disability scores (64% vs 36%; odds ratio [OR], 3.2; 95% CI, 1.3 to 7.8).

Additional treatment between 12 and 18 weeks was needed in more patients in the shockwave-treatment group than in the exercise group (OR, 5.5; 95% CI, 1.3 to 26.4), and fewer patients returned to work.

"Supervised exercises were more effective than radial extracorporeal shockwave treatment for short-term improvement in patients with subacromial shoulder pain," the study authors write.

Limitations of this study include the lack of a placebo group, the lack of injection of local anesthetics into the subacromial space to improve diagnostic accuracy, and the possibly insufficient power to detect differences in the secondary outcome variables.

"After 18 weeks, supervised exercises were better than radial extracorporeal shockwave treatment in terms of the primary outcome variable — the shoulder pain and disability index — and 1 secondary outcome variable — work status," the study authors conclude. "We found no significant differences for the other secondary outcome variables of pain, function, active range of motion, and use of drug treatment. More patients in the supervised-exercise group improved, probably owing to a treatment effect."

Health Region East, Norway, supported this study. The study authors have disclosed no relevant financial relationships.

BMJ. 2009;339:b3360.