Definition
It is the sudden swelling and pain of the affected hand and shoulder joint pain with limited hand function. The pain is complicated by twins, which are a hindrance to recovery, other diseases that cause shoulder-hand syndrome such as heart attack, cervical spondylosis, upper extremity trauma, paraplegia, pulmonary disease, shoulder disease, and those of unknown origin.
Pathogenesis
Regardless of the etiology, it is currently believed that the autonomic sympathetic nerves are affected, causing peripheral neurovascular disorders.
Other potential factors
Associated degenerative joint degeneration, microscopic injury 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 RSD
The cause of RSD is still not well understood, and trauma is considered to be the main cause of RSD, accounting for about 30% of cases.
For stroke patients there may be the following causes.
1. Abnormal flexion of the wrist joint
After CVA, abnormal synkinesis of the upper extremities and flexion of the wrist and fingers is a typical symptom. Patients who are 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 cannot 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. early in RSD, edema of the hand is also predominant on the back of the hand.
The obstruction of venous return by wrist flexion seems to be the most common primary factor causing RSD after hemiplegia.
2. Excessive strain on the hand joints
The therapist may inadvertently over-activate the patient’s hand, resulting in damage to the joint and its surrounding structures. For example, encouraging the patient to use the extended affected arm to carry weight (the therapist can help the patient to extend the elbow) and then having the patient shift the weight to the affected side as much as possible can result in more dorsiflexion of the wrist joint. If the activity is done too vigorously or in an uncontrolled manner, the wrist dorsiflexion will exceed the normal range. Leakage of fluid into the dorsal tissues of the hand during infusion.
Small accidental injuries to the hand can easily occur when sensory loss or negligence occurs; injury to the hand from falling to the hemiplegic side; burns from inattentive contact with a hot plate, cigarette or hot water bottle; injury to the hand when the affected hand may be caught in the wheel of a wheelchair. These hand injuries will result in edema of the hand.
Clinical manifestations
1. Stage I (early).
The affected hand suddenly appears swollen: the edema is evident 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 in 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 on the healthy side.
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 dorsiflexion mobility and when doing hand weight-bearing activities; metacarpophalangeal joint flexion is significantly restricted and no bony bump can be seen; finger abduction is severely obstructed and it is increasingly difficult to fork the hands together; the proximal interphalangeal joint is tonic and enlarged and can only be slightly flexed or completely straightened, and if it is passively flexed, there is If the distal interphalangeal joint is straight, it cannot or can only be slightly flexed, and if it is passively flexed, pain and restriction will occur.
2. Stage II (late stage).
If proper treatment is not given in the early stage, the symptoms will become more pronounced and the pain will increase until no pressure on the hands and fingers can be tolerated. x-ray examination may show changes in bone quality. In the middle of the dorsal carpal junction area, there is an obvious hard bulge.
3. Stage III (terminal or posterior stage).
The untreated hand becomes a fixed typical deformity, edema and pain may disappear completely, but joint mobility is permanently lost.
Treatment of RSD.
1. 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 manifestations are still present, treatment is still effective. Once the actual change has occurred and the size and color of the hand has returned to normal, it will be difficult to change the contracture of the hand. Effective treatment should emphasize patient trust and exercises for relaxation and joint mobility. The relationship between disfigurement, disability and handicap in patients with RSD has been studied and pain is considered to be the most important cause of disability and handicap. The main goal of treatment is to reduce edema as soon as possible, followed by pain and stiffness, and conditions that must be handled as an emergency.
2. Body position
When patients are seated, their upper limbs should always be placed on the table in front of them. When moving in a wheelchair, a table plate should be placed on the wheelchair to ensure that the patient’s hand does not dangle over the side. Splints 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 not interfering with metacarpophalangeal joint flexion, so the top of the splint should be proximal to the distal transverse palm and properly angled from the first to the fifth metacarpophalangeal joint with no interference with thumb movement. The splint should be continued until the edema and pain disappear and the color of the hand returns to normal. Self-help activities should also be performed while wearing the splint to maintain the mobility of the shoulder
3.Pressure-breaking centripetal wrapping
Centripetal finger wrapping has been shown to be a simple, safe and very effective method of treating peripheral edema. This is done by wrapping a 1-2mm diameter cord from the distal to the proximal end of the thumb and then the other fingers, starting with a small loop at the finger clip and then wrapping quickly and forcefully 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, bringing the thumb 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 to operate to save treatment time.
4.Ice therapy
When ice therapy can be used, the therapist immerses the patient’s hand in a bucket mixed with ice and water in a 2:1 ratio of crushed ice to water, so that the hand is easier to immerse and the constant melting of the ice keeps the water temperature cold. The patient’s hand is immersed three times, with a short interval between dips, and the hand is lifted after each dip. The therapist’s hand should be immersed together to determine the tolerance time of the immersion.
5. 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 kept elevated often stimulates elbow extensor muscle activity. Muscle contraction provides a good pumping action to reduce edema. Do not do weight-bearing exercises with elbow extension until the pain and edema have resolved; these activities may contribute to the development of this 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 when performing passive joint exercises.
6. 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; carpal palmar problems are often accompanied by loss of forearm rotation, and the therapist should do 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. Passive activities are often performed too aggressively in the treatment of swollen hands due to the therapist’s fear of producing hand contractures. In this case, it is better to do less than more of that treatment. After the edema subsides and the pain is relieved, joint mobility is quickly restored
7.Oral medication
Pain relief commonly used drugs are: corticosteroids, dimethyl sulfide / calcitonin, non-steroidal anti-inflammatory drugs, tricyclic antidepressants, etc.
8.Stellate ganglion block therapy and high thoracic sympathectomy
Physical therapy hot and cold water bath, whirlpool bath, wax therapy, massage, transcutaneous electrical nerve stimulation, ultrasound, biofeedback, acupuncture, etc. can be used for treatment.
Amputation amputation This treatment is only performed in RSD patients with non-functional limbs, terrible living conditions such as terrible inflammation or unbearable pain.
9. Stellate ganglion block
The stellate ganglion is formed by the fusion of the lower cervical sympathetic ganglion and the 1st thoracic sympathetic ganglion, located anterolaterally between the 7th cervical and lthoracic 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.
Complications.
(1) Toxic reaction caused by misinjection of the drug into the blood vessels.
(2) Misinjection of the drug into the spinal canal, causing a drop in blood pressure and respiratory arrest.
(3) pneumothorax.
(4) phrenic nerve palsy.
(5) paralysis of the recurrent laryngeal nerve.
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 taken orally on the side of limb injury (angelica, red peony, peach kernel, safflower, yellow cypress, windproof, mouton, licorice, raw earth, frankincense, etc.) with drugs such as 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 washing party (broad tendon vine, hooked vine, jin Yin Hua vine, Wang Bu Liuxiang, Liu Fan Nu, Fang Feng, rhubarb, thorny mustard) external washing.