A closely monitored 3-phase rehabilitation program isadministered to all patients,

    day2-2,3weeks
    pendulum exercises

    2-3weeks
    passive assisted exercises in the supine position: forward elevation is carried out with the support of the healthy arm, in which gentle traction is applied to the injured shoulder, with the patient trying to reach the edge of the bed behind his or her head from 0- to 180-degree range of motion (Fig. 3B, C).
    External rotation is limited to 45 degrees

    4-6weeks
    Internal rotation and extension are done in the standing position with the aid of a stick (Fig. 3D, E). As
    the progress to union is completed,
    a third phase of active exercises using gradually increased weights (starting from 1 kg) is administered until the 12th postoperative week (Fig. 3F, G).

    12weeks
    If the patient is capable of forward elevation using 2 to 3 kg of weight in the supine position, active dynamic shoulder motion and strengthening exercises are administered in the standing position until the sixth postoperative month.

    6months
    Preservation of shoulder motion and strength is maintained for another 2 to 3 months with stretching and strengthening exercises.




    http://www.orthodoctor.gr/wp-content/uploads/2014/03/Anterior-Traumatic-Shoulder-Dislocation.pdf


    例えば三輪 熱可塑性スプリント に載ってるmallet finger splint は作りやすいけど抜けやすい

    MALLET-SPLINT-WEB2_MED


    ならば、↑の既製品を如何につくるか、成書よりもこの動画が↓ 一番参考になる



    これならスプリントの余りの材料で指を筒状にしてかぶせて、穴を開けるだけ

    自分の指で先に作った方がより時間の節約ができるのであらかじめ作っておくことを勧める
    それから背側にクッションをあてるといい。 リングタイプや↑のタイプ、いずれにしても「DIP関節があたって痛い」という苦情があるので
    クッションはスプリント材の、SAKATA でいえばAA9460LAなど

    スプリントの付け方は以下を参照 要はテーブルにタオルでも敷いてDIP屈曲しないようにスプリントを挿入する 動画みたいに熱で溶かさないのであれば、指先にプッシュ式の石鹸を塗ってからのほうが指先まで挿入できる。

    できれば(痛みが落ち着いていれば)14日以内にリハビリを始める。その方が予後良好

    0日-7日 Active elbow, wrist, and hand exercises should be initiated immediately after injury.
    Shoulder pendulum exercises should be initiated immediately, and attempts at assisted shoulder flexion, abduction, and rotation should begin at 1-week post injury
    Initially, shoulder exercises were performed in the supine position and included forward elevation, external rotation, and internal rotation to the chest.

    maxresdefault


    3週― Isometric deltoid and cuff exercises
    4週― Once clinical fracture union was con- firmed, the sling was discontinued.(6週までに) 骨癒合確認後に、Active range of motion and deltoid and rotator cuff isometric strengthening was added.
    Active exercises were initiated in the supine position and progressed to the seated position. As range of motion improved, active resistance deltoid and rotator cuff exercises were begun.
    6週― progressive strengthening and stretching
    12週―an aggressive stretching and strengthening program was continued until final outcome was achieved


    ↓以下をまとめた

    . Absolute sling immobilization should only be performed over the first 7–10 days post injury
    Distal extremity exercises should be started immediately after the injury, and shoulder range of motion should be initiated within 10 days of the injury if pain allows

    Active elbow, wrist, and hand exercises should be initiated immediately after injury. Shoulder pendulum exercises should be initiated immediately, and attempts at assisted shoulder flexion, abduction, and rotation should begin at 1-week post injury

    Isometric deltoid and cuff exercises should be initiated at 3 weeks, and progressive strengthening and stretching can usually be initiated between 6 and 12 weeks

    . Initially, shoulder exercises were performed in the supine position and included forward elevation, external rotation, and internal rotation to the chest. The sling was continued for 4–6 weeks, and exercises were performed four times daily at home.

    Once clinical fracture union was con- firmed, the sling was discontinued. Active range of motion and deltoid and rotator cuff isometric strengthening was added. Active exercises were initiated in the supine position and progressed to the seated position. As range of motion improved, active resistance deltoid and rotator cuff exercises were begun. Three months after the injury, an aggressive stretching and strengthening program was continued until final outcome was achieved

    Nonoperative Treatment of Proximal Humerus Fractures
    file:///C:/Users/Ishioka1/Downloads/9783319089508-c1%20(3).pdf

    The patients deemed their daily life functions to be normal 8 weeks after the injury.

    Physiotherapy after fracture of the proximal end of the humerus. Comparison between two methods.
    https://www.ncbi.nlm.nih.gov/pubmed/6710092

    The review of the literature on proximal humerus rehabilitation suggests that treatment must begin immediately if the harmful effects of immobilization are to be avoided

    In the United Kingdom most patients are immobilized routinely for 3 weeks or longer and are referred for physical therapy.

    Proximal humerus fracture rehabilitation.
    https://www.ncbi.nlm.nih.gov/pubmed/16394751


    One hundred and four patients who had a minimally displaced fracture of the proximal part of the humerus (a so-called one-part fracture) were managed with a standardized therapy regimen and followed for more than one year. The clinical outcome was assessed on the basis of pain, function, and the range of motion of the shoulder. The duration of follow-up averaged forty-one months (range, twelve to 117 months). All fractures united without additional displacement. Eighty patients (77 per cent) had a good or excellent result, fourteen (13 per cent) had a fair result, and ten (10 per cent) had a poor result. Ninety four patients (90 per cent) had either no or mild pain in the shoulder, eight (8 per cent) had moderate pain, and two (2 per cent) had severe pain. Functional recovery averaged 94 per cent; forty-eight patients (46 per cent) had 100 per cent functional recovery. At the time of the most recent follow-up, forward elevation of the injured shoulder averaged 89 per cent; external rotation, 87 per cent; and internal rotation, 88 per cent that of the uninjured shoulder. The percentage of good and excellent results was significantly greater (p < 0.01) and external rotation was significantly better (p < 0.01) at the time of the latest follow-up for the patients who had started supervised physical therapy less than fourteen days after the injury than for the patients who had started such therapy at fourteen days or later.

    Functional outcome after minimally displaced fractures of the proximal part of the humerus.
    https://www.ncbi.nlm.nih.gov/pubmed/9052540


    受傷1週 バストバンド除去   患肢肩関節ができるだけzero positionに近づくように振り子運動をおこなう.自分で3~5分間の下垂位振り子運動を1日30分
    受傷4週 レントゲンで仮骨が見られることを確認し,臥位での他動可動域訓練,自動介助訓練を開姶
    受傷6週 痛み,骨癒合が良好であれば自動可動域訓練と肩関節の筋力トレーニング開始

    (上腕骨近位端骨折に対する保存療法の検討 整形外科と災害外科56 :(3)499-502,2007.)
    *振り子について、肘関節が屈曲位にある場合,骨折部に回旋力が加わる可能性あり

    セッティング 多施設(507施設)。28ヵ国。

    期間 登録期間は2000年12月-2002年4月。追跡期間は18ヵ月。追跡完了は2003年10月。

    対象患者 7599例。40歳以上で過去3ヵ月以内に虚血性脳卒中あるいはTIA発症歴があり,過去3年以内に次のリスク因子を1つ以上有する患者:虚血性脳卒中,MI,狭心症,糖尿病,症候性末梢血管疾患。虚血性脳卒中はTOAST(Trial of Org 10172 in Acute Stroke)分類によるものとした。
    【除外基準】重度の合併症,出血リスクが高い,大手術あるいは血管手術の予定など。

    方法 脳卒中患者のADL自立達成度をmodified Rankin Scale (mRS):下表 を用いて分類 、ADL自立達成の有無、達成時期を18か月間追跡調査 
    (ADL非自立をmRS 3以上 ADL自立をmRS2以下 と定義)
    各Scale症例のADL自立達成時期をコックス比例ハザード比モデルで検証した。

    追跡完了率 追跡完了率は96%

    結果
    mrs


    mRS 3以上の脳卒中1662例; 内訳
    moderate mRS 3 in 931
    severe (mRS 4) in 691
    very severe (mRS 5) in 40 について、

    18ヶ月後、877名の患者(52.8%)がADL自立達成 内訳
    moderate mRS 3 in 589 (63%)  平均3か月で達成
    severe (mRS 4) in 281 (40.6%) 
    very severe (mRS 5) in 7 (17%)  


    末梢動脈疾患(閉塞性動脈硬化症)、DM、脳卒中既往が無ければ有意に回復が見込める


    Rate, degree, and predictors of recovery from disability following ischemic stroke

    Objective: To determine the rate, degree, and predictors of recovery from disabling ischemic stroke.

    Methods: Patients with ischemic stroke enrolled in the Management of Atherothrombosis With Clopidogrel in High-Risk Patients (MATCH) study underwent long-term prospective assessment of their modified Rankin Scale (mRS) score. Disability (functionally dependent state) was defined as mRS ≥ 3, and recovery (functionally independent state) was defined as mRS < 3. The timing and the independent predictors of recovery were determined using a Cox proportional hazards multiple regression analysis.

    Results: Of 7,599 patients enrolled with ischemic stroke or TIA, 1,662 (21.8%) were disabled (mRS ≥ 3) at baseline (median of 14 [0 to 96] days after stroke onset). Disability was moderate (mRS 3) in 931 (56%) patients, severe (mRS 4) in 691 (42%), and very severe (mRS 5) in 40 (2%). By 18 months, 877 (52.8%, 95% CI 50% to 55%) patients had recovered, 589 (63%, 60% to 66%) with moderate disability, 281 (41%, 37% to 44%) with severe disability, and 7 (17%, 7 to 33%) with very severe disability. Median time to recovery was 3 months for patients with moderate disability and 18 months for severe disability; 82.5% of severely disabled patients remained so at 18 months. Predictors of recovery were moderate disability (mRS 3) at baseline compared with severe (mRS 4: hazard ratio [HR] 2.13, 1.86 to 2.44) or very severe disabling stroke (HR 5.88, 2.86 to 12.5); younger women (aged <65 years, compared with ≥75 years; HR 1.85, 1.47 to 2.33); decreasing time (days) between the qualifying event and the baseline assessment (HR 1.01, 1.01 to 1.02); and the absence of previous ischemic stroke (HR 1.61, 1.35 to 1.92), concurrent peripheral artery disease (HR 1.61, 1.23 to 2.13), or diabetes (HR 1.30, 1.10 to 1.54).

    Conclusions: Half of patients with disabling ischemic stroke recovered within 18 months, and recovery was greatest within 6 months. Significant predictors of recovery included the severity of the index stroke and no history of ischemic stroke, peripheral artery disease, or diabetes.

    55277d8a-1660-41f1-a2e6-69736dcb7170


    1 The fractures of the greater tuberosity of the proximal humerus

    treated nonoperatively

    0-10days immobilization using a Gilchrist bandage until pain relief was achieved, followed by oscillating movements of the arm.
    3–4 weeks active ROM
    6-8 weeks bear weight on their arms

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3247891/

    Nonoperative treatment for a nondisplaced greater tuberosity fracture has been reported to include

    1 week passive range of motion (PROM)
    6 weeks active range of motion (AROM) followed by gradually progressed strengthening once full PROM is reached.

    http://www.jospt.org/doi/pdf/10.2519/jospt.2005.35.8.521


    minimally displaced (<3 mm) fractures of the greater tuberosity
    0-3weeks patients were immobilized in a sling
    3 to 6 weeks pendular and active assisted exercises
    6weeks active exercises

    https://www.ncbi.nlm.nih.gov/pubmed/23639834

    60歳以上・脱臼を合併した症例は特に受傷後2週以内に骨片の転位が進行する可能性があるため早期手
    術を考慮する必要がある.
    「上腕骨大結節骨折における骨片転位の予測因子」


    Neerは10mm未満の転位を,仲川は大結節の前方部であれば5mm,大結節後方部のみの骨片は10mm以内を保存療法の適応と述べた

    治療は3週間体幹固定がおこなわれ,3週経過後より可動域訓練,6週から腱板強化訓練おこなわれた.
    「当科における上腕骨大結節骨折の治療指針」


    2 Shoulder dislocation

    immobilization in 10° of external rotation for three weeks reduces the relative risk of recurrence of a
    first-time traumatic anterior shoulder dislocation when compared with the risk associated with conventional immobilization in internal rotation.
    Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence. A randomized controlled trial. J Bone Joint Surg Am. 2007; 89:2124-2131
    http://medicine.tums.ac.ir:803/Users/ramin_espandar/Journal%20Club%20Articles/=Immobilization%20in%20External%20Rotation%20After%20Shoulder%20Dislocation%20Reduces.pdf


    The recognition and treatment of first-time shoulder dislocation in active individuals. JOSPT. 2009;39(2):118-123

    Decisions are made based on the age, activity level of the patient. Generally those that are involved in contact sports and ages 15 to 25 years acute repair may be a viable option based on the high risk of reacurrance, apprehension, impact on sports participation and quality of life, they favour arthroscopic instability repair for athletes in this age group.
    Patients who are age 25-40 have a much lower recurrence rate of dislocation in general and conservative treatment is generally the best RX.

    Older patients over 40, who sustain a Anterior dislocation have lower recurrence rates again but can residual disability from associated soft tissue injuries such as a rotator cuff tear, nerve injury or vascular injury.

    Traditional no-operative treatment has included a period of immobilisation with the arm in internal rotation for 6 weeks, this has not reduced the recurrence rate. Degenerative joint disease was found in both surgical and non-surgical cases.
    A short term clinical study revealed decreased recurrence rates in patients that were immobilised in ER. After 3 weeks of immobilisation they had a recurrence rate of 26% while those who were in IR had a 42% reccurance rate and 46% in patients that were younger than 30 years old.
    Athletes who sustain a first time dislocation at the end of the season or spring practice, one option is early mobilisation, rehabilitation and return to full activity. Another option is to immobilise for 3-4weeks, proceed with rehab, and return the athlete to sport after 6-8 weeks.
    In the young, contact athlete, modern operative stabilisation (open and arthoscopic) which reduces the recurance rate from the 80%-90% range-3-15% range. This is preferred with first time dislocation as the reccurane rate is decreased and it improves a better quality of life.
    The first 2 weeks after the injury occurs is the best time to operate, taking advantage of the good condition of the capsulolabral tissue. Focus of surgery is to repair the capsulolabral avulsion with suture anchors.


    Shoulder Dislocation Original Editor - Haley Stevenson and Sherin Mathew as part of the Temple University EBP Project

    Phase 1 (up to 6 weeks)[1]: Goal is to maintain anterior-inferior stability

    Immobilization
    It has traditionally been thought to be immobilized with internal rotation, but according to Miller, immobilization has been beneficial in external rotation because there is more contact force between the glenoid labrum and the glenoid.[3] Research by Itoi[4] suggests immoboilization at 10 degrees of external rotation has a lower recurrence rate than internal immoboilization at 10 degrees of external rotation has a lower recurrence rate than internal rotation.[4] There is currently no consensus on the duration of immobilization in a sling.[5] But, typical time periods in a sling range for 3-6 weeks if under the age of 40 and 1-2 weeks if older than the age of 40.[4] During the immobilization period, the focus is on AROM of the elbow, wrist and hand and reduction of pain. Isometrics can be incorporated for the rotator cuff and biceps musculature.

    Codman Exercises
    AAROM for external rotation (0-30º) and forward elevation (0-90º)







    Phase 2 (6-12 weeks)[1]: Goal is to restore adequate motion, specifically in external rotation

    AAROM to achieve full range of motion
    When stretching is permitted, passively stretch the posterior joint capsule through the use of joint mobilizations or self-stretching.
    No strengthening or repetitive exercises should start until achievement of full range of motion

    Phase 3 (12-24 weeks)[1]: Successful return to sports or physical activities of daily living

    Begin strengthening exercise
    Strengthening exercises should be impairment-based. Typically begin strengthening exercise in a pain-free motion with exercises for stability. A possible progression could begin by focusing on the rotator cuff musculature and scapular stabilizers, which include trapezius, serratus, levator scapulae, and rhomboids. Then, progress to the larger musculature such as the deltoids, latissimus dorsi, and pectorals.
    Start focusing on functional exercises
    Include proprioceptive training
    Tailor to promote patient's activities and participation in society

    http://www.physio-pedia.com/Shoulder_Dislocation

    このページのトップヘ