Shoulder-hand syndrome
Definition
It is the sudden swelling and pain of the affected hand and pain in the shoulder joint with limited function of the hand. Other diseases that cause shoulder-hand syndrome, such as heart attack, cervical spondylosis, upper extremity trauma, paraplegia, pulmonary disease, shoulder joint disease, and those of unknown origin, can be a hindrance to recovery.
Pathogenesis
It is currently believed that whatever the cause, it affects the autonomic sympathetic nerves and causes peripheral neurovascular disorders.
Other potential factors: concomitant degenerative joint degeneration, micro-injuries to the shoulder joint, and disuse atrophy due to prolonged inactivity, resulting in abnormal vascular nerve reflexes.
Scope
It can be primary, but can also be precipitated by different factors, such as minor peripheral nerve injury and central nerve disorders, acute stroke and spinal cord injury, endocrine disorders and myocardial infarction can cause RSD.RSD is the main cause of disability, it usually affects one limb, but can also affect multiple limbs or any part of the body, and only 1 in 5 patients can fully recover their previous activities.
Causes of RSD1
The cause of RSD is still not well understood, but trauma is considered to be the main cause of RSD, accounting for about 30% of cases.
For stroke patients, there may be the following causes2
1.Abnormal flexion of the wrist joint
After CVA, abnormal synergistic movement of the upper extremity and flexion of the wrist and fingers are typical symptoms. Patients who have been bedridden or wheelchair bound for long periods of time do not notice that the arm is placed on the side of the body for long periods of time and the wrist is forced into a flexed position; many patients develop early neglect of the affected limb and fail to notice when the hand is already in a disadvantageous position. Patients with neglect disorder may have actual sensory loss. The forced flexion of the wrist interferes with venous return to the hand. Most of the venous lymphatic return to the hand is on the back of the hand, and in the early stages of RSD, edema in the hand is also predominant on the back of the hand. The obstruction of venous return by wrist flexion appears to be the most common primary factor causing RSD after hemiplegia.
Causes of stroke patients3
2. Excessive strain on the hand joints
The therapist may inadvertently over-activate the patient’s hand, resulting in damage to the joint and surrounding structures. For example, encouraging the patient to use the extended affected arm to carry weight (the therapist may help the patient to extend the elbow) and then having the patient shift the weight to the affected side as much as possible may result in more dorsiflexion of the wrist joint. If the activity is performed too vigorously or in an uncontrolled manner, the wrist dorsiflexion may exceed the normal range.
Cause 4
3.Fluid leakage into the dorsal tissue of the hand during infusion
4, hand small accidental injury when sensory deficit or negligence
It is easy to damage the hand; fall to the hemiplegic side and damage the hand; get burned when inattentively touching a hot plate, cigarette or hot water bottle; the affected hand may be caught in the wheel of a wheelchair and damage the hand. These hand injuries will result in edema of the hand.
Etiology
Cervical sympathetic nerve dysfunction, shoulder hand pump dysfunction theory: the blood return to the shoulder hand depends on the power of the shoulder pump and hand pump, i.e. muscle movement
Clinical manifestations
Stage I (early): sudden swelling of the affected hand: the edema is obvious on the back of the hand, including the metacarpophalangeal joints and fingers, the skin wrinkles disappear, the edema is soft and swollen, ending proximally at the wrist joint, and the tendons of the hand are not visible. The color of the hand changes to pink or lavender, especially when the affected arm is hanging on the side of the body, the hand is warm, sometimes moist, and the nails are whiter or less lustrous than the healthy side.
Clinical manifestations
Restricted joint mobility: passive rotation of the hand is restricted, and wrist pain is often felt; wrist dorsiflexion is restricted, and pain can occur when passively increasing the dorsiflexion mobility and when doing hand weight-bearing activities; metacarpophalangeal joint flexion is significantly restricted, and bony bump is not visible; finger abduction is severely obstructed, and it is increasingly difficult to fork the hands together; proximal interphalangeal joint is tonic and enlarged, and can only be slightly flexed or not completely straightened, and if passively flexed, then pain occurs; distal interphalangeal joint is tense and enlarged, and can only be slightly flexed or not completely straightened. If the distal interphalangeal joint is in an extended position, it cannot or can only be slightly flexed, and if it is passively flexed, it becomes painful and limited.
Clinical manifestations
Stage II (late stage): If proper treatment is not given early, the symptoms become more pronounced and the pain increases until no pressure on the hand or finger can be tolerated. In the middle of the dorsal carpal tunnel, there is a hard bump.
Clinical manifestations
Stage III (terminal or sequelae): The untreated hand becomes fixed with a typical deformity, the edema and pain may disappear completely, but the joint mobility is permanently lost.
Treatment of RSD1
Pain relief.
The best results are achieved by treating edema, pain and limited motion as soon as they appear. Even after several months, if these symptoms are still present, treatment is still effective. It is difficult to change the contracture once the hand has returned to its normal size and color. Effective treatment should emphasize patient trust and relaxation and joint mobility exercises. The relationship between impairment, disability and handicap in patients with RSD has been studied and pain is considered the main cause of disability and handicap. The main goal of treatment is to reduce edema as soon as possible, followed by pain and stiffness, and to treat conditions that must be handled as an emergency.
Treatment 2
Positioning
When sitting, the patient’s upper extremity should always be placed on the table in front of him. When moving in a wheelchair, a table should be placed on the wheelchair, making sure that the patient’s hand does not dangle to the side.
Treatment 3
Splinting can be used for this purpose.
The principle of splinting is to support the wrist in a moderate dorsal extension position with the distal end of the splint not interfering with metacarpophalangeal joint flexion, so that the top of the splint is proximal to the distal transverse palmar line and tilted appropriately from the first to the fifth metacarpophalangeal joint with no interference with thumb motion. The splint should be continued until the edema and pain have disappeared and the color of the hand has returned to normal. Self-help activities should be performed while wearing the splint to maintain the mobility of the shoulder.
Treatment 4
Crushing centripetal entrapment
Centripetal finger wrapping has been shown to be a simple, safe and very effective treatment for peripheral edema (Cain and Liebgold 1967). A 1 to 2 mm diameter cord is used to wrap the thumb, then the other fingers, from distal to proximal, starting with a small loop at the finger pinch and then quickly and forcefully wrapping proximally until the root of the finger cannot be wrapped any further. Immediately after wrapping, the therapist quickly pulls the wrapped cord away from the loop at the end of the finger. After wrapping each finger, begin wrapping the hand, again making a loop at the metacarpophalangeal joint, then wrapping from the metacarpophalangeal joint to the proximal end, reaching the base of the thumb, making the thumb tuck in and wrapping the thumb-metacarpophalangeal joint together to the wrist joint. The therapist may wrap the upper extremity from the wrist joint upward. The patient’s family can be taught how to do this to save treatment time.
Treatment 5
Ice therapy
When ice therapy is available, the therapist submerges the patient’s hand in a bucket of ice and water in a ratio of 2:1, so that the hand is easier to submerge and the ice keeps the water cold by melting. The patient’s hands are immersed three times, with a short interval between dips, and the hands are lifted after each dip. The therapist’s hand should be immersed together to determine the tolerance time for the immersion.
Treatment 6
The patient should be allowed to do as much active movement as possible
Even if the hand is completely paralyzed, it should be performed. For example, having the patient lie on his or her back with the upper extremity held up will often stimulate elbow extensor muscle activity. Muscle contraction provides a good pumping effect to reduce edema. Do not do weight-bearing exercises with the elbow extended until the pain and edema have resolved, as these activities may contribute to the development of the syndrome and can cause pain and perpetuate the condition. Any activity or position that can cause pain should be avoided, and the therapist should be aware of the same issues when performing passive joint movements.
Treatment 7
Passive motion
Careful passive movements of the shoulder joint can prevent shoulder pain; passive movements of the hand and fingers should also be very gentle so as not to cause pain; carpometacarpal problems are often accompanied by a loss of forearm rotation, and the therapist should try to perform forearm rotation in the pain-free range as much as possible during treatment. All of these exercises can be performed with the patient in the supine position with the upper extremity elevated to facilitate venous return. Because therapists are concerned about developing hand contractures, they tend to be too aggressive with passive activities when treating hand swelling. In this case, it is better to do less than more. After the edema subsides and the pain is relieved, joint mobility is quickly restored.
Treatment 8
Oral medications are commonly used for pain relief: corticosteroids, dimethyl sulfide, Calcitonin (calcitonin), non-steroidal anti-inflammatory drugs, tricyclic antidepressants, etc.
Treatment 9
Stellate ganglion block therapy and high thoracic sympathectomy physical therapy hot and cold water baths, whirlpool baths, waxing, massage, transcutaneous electrical nerve stimulation (TENS), ultrasound, biofeedback, and acupuncture can be used for treatment. amputation amputation this treatment is only performed in patients with RSD who have non-functional limbs, terrible living conditions such as terrible inflammation or intolerable pain.
Stellate ganglion block
The stellate ganglion consists of a fusion of the lower cervical sympathetic ganglion and the 1st thoracic sympathetic ganglion, located anterolaterally between the 7th cervical and 1st thoracic vertebrae, and innervates the head, neck and upper extremities. During the block, the patient lies flat on his back with a thin pillow under the shoulder and is placed in an extremely posterior cervical position. The transverse process of the 6th cervical vertebra is palpated in the plane of the cricoid cartilage.
The operator pushes the sternocleidomastoid muscle laterally with two fingers, as the internal carotid artery and vein are attached to the posterior sheath of the sternocleidomastoid muscle, so they are also pushed together laterally. A 22G3.5–100px long puncture needle (No. 7 needle) is used to enter vertically in the lateral aspect of the cricoid cartilage, touch the 6th cervical transverse process, 0.3–12.5px, draw back no blood, and inject 0.25% bupivacaine or 1% lidocaine (both containing 10ml of epinephrine (see below), which can block the stellate ganglion by diffusion. The ipsilateral presence of Horner’s syndrome and increased finger temperature after drug injection indicated that the block was effective.
The sternocleidomastoid muscle was pushed laterally with two fingers, and the internal carotid artery and vein were also pushed laterally because they were attached to the posterior sheath of the sternocleidomastoid muscle. A 22G3.5–100px long puncture needle (No. 7 needle) is used to enter vertically in the lateral aspect of the cricoid cartilage, touching the transverse process of the 6th cervical vertebra, 0.3–12.5px, and then injecting 0.25% bupivacaine or 1% lidocaine (both containing 10ml of epinephrine (see below), which can block the stellate ganglion by diffusion. The presence of Horner’s syndrome and increased finger temperature after ipsilateral injection indicates that the block is effective.
Complications.
①Toxic reaction caused by accidental injection of the drug into the blood vessel;
②Injecting the drug into the spinal canal by mistake, causing a drop in blood pressure and respiratory arrest;
③Pneumothorax;
④Phrenic nerve palsy;
⑥Returning laryngeal nerve palsy.
In the treatment group, SGB+SB was used. 5 ml of lidocaine and 3.6 U of neurotropine diluted to 10 ml with saline were used for SGB. The anterior approach was adopted and the drug was administered via cervical 6. Patients showed Horner’s sign within 0.5 to 3.0 min as the mark of success.
Stellate ganglion block and periacetabular block
The Horner’s sign was manifested by pupil narrowing, eyelid drooping, eyeball inversion, conjunctival congestion, and no sweating on the blocked side. SB was performed with suprascapular nerve block, biceps longus interjugal sulcus block and pain point block. The suprascapular nerve block was performed at 1 cm above the midpoint of the scapular gland, and the needle tip was used to detect the scapular notch and then stabbed deeply for 0.3 cm, and the drug was injected after no blood was drawn back.
Inter-nodal sulcus block: The inter-nodal sulcus between the greater and lesser tuberosities of the humerus is touched at the top of the shoulder, avoiding the cephalic vein, and the needle is inserted into the long head tendon of the biceps muscle and injected into the greater and lesser tuberosity crest and rostral process. The painful point block was selected from the supraspinatus fossa, infraspinatus fossa, subacromial, and internal superior scapular angle. Inject 3-5 ml of medication into the most sore and painful area, and then inject no more than 5 points at a time. In the control group, acupuncture massage was performed on the affected side and shoulder, and 12d was used for 1 course of treatment. 1 to 2 courses of treatment were given.
For the treatment of shoulder subluxation, the lower part of the affected shoulder was padded in the lying position, and the upper limb on the affected side was padded in the sitting position or suspended in front of the chest with a triangular scarf, and the shoulder joint was passively exercised. Relieve spasm and dilate blood vessels to stop the vicious circle of vasomotor disorders
The suprascapular nerve innervates the sensation of the main part of the shoulder, so after blocking it, the pain of the shoulder can be reduced. The long head of the biceps muscle starts at the upper edge of the articular glenoid, surrounds the head of the humerus and exits the joint capsule at the level of the anatomical neck of the humerus, and goes down through the interjugular sulcus. The greater and lesser tuberosities of the humerus are the stops of the rotator cuff muscles (supraspinatus, infraspinatus, teres minor and subscapularis), the rostral process is the starting point of the rostro-humeral muscle and the short head of the biceps, and the supraspinatus fossa, infraspinatus fossa, subscapularis and internal suprascapularis are the starting points of the muscles that fix the shoulder joint. The pain points mostly occur in these places, and blocking them can significantly reduce the pain.
Glucocorticoids have anti-inflammatory properties and membrane stabilizing effects by inhibiting prostaglandin synthesis, as well as inhibiting the synthesis of inflammatory cellular peptides and blocking phospholipase A2 activity. Local anesthetic injection interrupts the persistent nerve activity that produces pain, relaxes muscle spasm, and eliminates the accompanying reflex sympathetic dystrophy.
The analgesic effect of neurotolepin is achieved by activating the analgesic mechanism-pain downstream system in the body. The analgesic effect is achieved by activating the analgesic mechanism-pain downstream system in the body. It has also been reported that neurotropine has good efficacy in the treatment of cerebral edema in stroke patients.
Current status of TCM treatment
In the early stage, it is advisable to invigorate blood and clear heat, relieve water and relieve pain, and can be treated orally with one side of limb injury (angelica, red peony, peach kernel, safflower, yellow cypress, windproof, mouton, licorice, raw earth, frankincense, etc.) plus mucuna pruriens, haitongpi, and forsythia. A decoction of Haitongpi Tang (Haitongpi, Turbinaria, Boswellia, Myrrh, Angelica, Sichuan pepper, Chuanxiong, Safflower, Wailingia, Licorice, Fenghuang, Angelica) can also be used for external washing. Or use anti-stasis and pain relief ointment (papaya, gardenia, rhubarb, dandelion, ground beetle, frankincense, myrrh finely ground together, syrup sugar or petroleum jelly dressing) to dress.
Acupuncture treatment
Acupuncture can be chosen from shoulder K, shoulder S, arm, Quchi, Waiguan, Yangchi, Zhongzhu, eight evil points, etc. Needles with diarrhea method. In case of swelling, trigeminal needles can be used to puncture the well points or fingertip bleeding to relieve heat and swelling, activate blood circulation and relieve pain.
Middle and late stage and sequelae treatment
Shu tendons and blood circulation, can be taken orally Shu tendon soup (Angelica sinensis, Chen Pi, Qiang Wu, bone fragmentation tonic, stretching tendon grass, Wu Jia Pi, Sang Sang Sang, papaya), can also use the above made of pills and bulk for long-term use. Or use orthopaedic external cleansing formula (Kuanzhuiteng, Hooked vine, Jinyinhua vine, Wang Buliuxing, Liu Fanu, Fangfeng, Dahuang, Jingcai) for external cleansing.
Acupuncture
Acupuncture with tonic method, available warm acupuncture moxibustion. Massage treatment can be given during this period, using techniques such as kneading, holding, and moistening along the meridians, and pointing. The movement of the wrist and hand joints should be gentle.