Shoulder-hand syndrome is also known as reflex sympathetic dystrophy. It is a condition in which the patient suffers from sudden painful swelling of the affected hand and pain in the shoulder joint, with limited hand function. The pain is severe and is complicated by twisting, which is a hindrance to recovery. The syndrome often occurs within 1 to 3 months after stroke, with an incidence of about 12.5% to 70%, and the difference in incidence may be related to different diagnostic criteria.
Diseases causing shoulder-hand syndrome: stroke, heart attack, cervical spondylosis, upper extremity trauma, paraplegia, pulmonary disease, shoulder disease, and those with unknown causes. It can be primary, but can also be precipitated by different factors, such as minor peripheral nerve injury and central nervous system disorders, acute stroke and spinal cord injury, endocrine disorders and myocardial infarction, all of which can cause RSD, which is the main cause of disability and usually affects one limb, but can also affect multiple limbs or any part of the body.
I. Causes
It is currently believed that whatever the etiology, it affects autonomic sympathetic nerves and causes peripheral neurovascular disorders. Other potential factors: the wrist joint is stretched and palmar flexion under compression, overstretching, leakage of fluid into the hand tissue during infusion, and accidental small injuries to the hand are related.
1, abnormal wrist flexion: after CVA, abnormal synergistic movement of the upper limbs and flexion of the wrist and fingers is a typical symptom. Patients are bedridden or wheelchair bound for long periods of time, not noticing 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 syndrome of the affected limb and cannot notice when the hand has been placed at a disadvantage. 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 joint: The therapist may inadvertently cause the patient’s hand to do excessive movement, resulting in damage to the joint and its surrounding structures. For example, encourage the patient to use the extended affected arm to carry weight (the therapist can help the patient to extend the elbow), and then have the patient shift the weight to the affected side as much as possible, which can make the wrist joint more dorsal extension. If the activity is too violent or performed in an uncontrolled manner, the wrist dorsal extension will exceed the normal range.
3. Small accidental injuries to the hand.
It is easy to injure the hand when sensation is absent or neglected; to injure the hand by falling to the hemiplegic side; to be 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 injure the hand. These hand injuries will lead to edema of the hand.
4. Leakage of fluid into the tissue on the back of the hand during infusion.
II. Clinical manifestations
Stage I (early stage).
1. The affected hand suddenly appears swollen Edema is obvious on the back of the hand, including the metacarpophalangeal joints and fingers. The skin wrinkles disappear and the edema is soft and swollen, ending proximally at the wrist joint. 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 hot and humid, and the nails are whiter or less lustrous than on the healthy side.
2, limited joint mobility hand passive posterior rotation is limited, and often feel wrist pain; bowl dorsal extension is limited, when the passive increase in dorsal extension activity and do hand weight-bearing activities can appear pain; metacarpophalangeal joint flexion is obviously limited, can not see the bony bump; finger abduction is seriously obstructed, hands increasingly difficult to fork grip together; proximal interphalangeal joint tonic enlargement, can only slightly flexed, also can not be completely straight, if passive flexion, then If the distal interphalangeal joint is straight, it cannot or can only be slightly flexed, and if it is passively flexed, it becomes painful and limited.
Stage II (late stage): If proper treatment is not given early on, symptoms become more pronounced and pain increases until no pressure on the hand or finger can be tolerated. x-ray examination may show bony changes. In the middle of the dorsal carpal junction area, a distinct hard bulge appears.
Stage III (terminal or posterior stage): The untreated hand becomes fixed with a typical deformity. The edema and pain may disappear completely, but joint mobility is permanently lost.
III. Treatment
The best results are achieved by treating edema, pain and limited motion as soon as they appear. Even after several months, if the above-mentioned 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 the condition of the hand must be treated as an emergency
1.Positioning of the good limb: It is required that flexion of the wrist joint should be avoided in any position, ensuring that the wrist joint is in dorsal extension as much as possible.
(1) Supine position: appropriate abduction and external rotation of the upper limb on the affected side to avoid pressure on the upper limb.
(2) Affected side in the inferior position: make the upper limb of the affected side extend forward, with the palm upward and the wrist joint in mild dorsal extension
(3) healthy side lying position: put a soft pillow in front of the chest, put the upper limb of the affected side on it, pay attention to the padded wrist, keep the wrist joint dorsal extension
(4) Sitting position: Whether sitting in bed or in a wheelchair, always keep the affected upper limb on the table in front of you. A soft pillow can be placed under the arm to prevent wrist flexion, and never let the affected upper limb dangle outside the wheelchair.
Orthopedic splints can also be used for this purpose. The principle of splinting is to support the wrist joint in a moderate dorsal extension position with the distal end not interfering with metacarpophalangeal joint flexion, so that the top of the splint should be proximal to the distal transverse palmar line and properly angled from the first to the fifth metacarpophalangeal joint, with no interference with thumb motion. 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.
2.Application of shoulder sling: A shoulder sling should be applied appropriately in the early stage to prevent dislocation of the shoulder joint and should prevent excessive stretching of the shoulder joint.
3.Exercise therapy: Start active and passive activities as early as possible, which must be very gentle and painless, and then increase the amount of activity when the pain and edema are reduced. 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 loss of forearm rotation, and the therapist should do forearm rotation in the pain-free range as much as possible during therapy. 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 creating hand contractures. In this case, it is better to do less than more of that treatment. Joint mobility is quickly restored after the edema subsides and pain is reduced. Muscle contraction provides a good pumping action to reduce edema. Do not do weight-bearing exercises with the elbow extended 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.
4. Pain and edema.
(1) Compression-breaking centripetal wrapping
Centripetal finger wrapping has been shown to be a simple, safe and very effective method of treating peripheral edema. The specific method is to wrap the thumb, then the other fingers, from the distal end to the proximal end with a 1 to 2 mm diameter cord, starting with a small loop at the finger clip and then wrapping quickly and forcefully to the proximal end until the root of the finger can no longer be wrapped. 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 how to do this to save treatment time.
(2) 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. Alternating hot and cold water immersions may also be performed.
Soak the affected hand in cold water for 3-5 minutes, then soak in warm water for 3-5 minutes, repeatedly 4-5 times, starting with cold water – end with cold water, to promote the ability of peripheral vasoconstriction, diastolic regulation, can also be added by the therapist manipulation (from the distal end to the proximal end to do squeezing, kneading into), the effect is better.
5.Medication.
Oral medication for pain relief commonly used drugs are: corticosteroids, dimethyl sulfide, Calcitonin (calcitonin), non-steroidal anti-inflammatory drugs, tricyclic antidepressants, etc. Glucocorticoids have anti-inflammatory properties and have a membrane stabilizing effect by inhibiting prostaglandin synthesis, as well as inhibiting the synthesis of inflammatory cellular peptides and blocking the activity of phospholipase A2. Local anesthetic injections interrupt the persistent nerve activity that produces pain, relax muscle spasm, and eliminate the accompanying symptoms of reflex sympathetic dystrophy. The analgesic effect of neurotolepine is achieved by activating the analgesic mechanism-pain downstream system in vivo, which has the effects of analgesia, regulation of vegetative nerves, improvement of microcirculation, regulation of immune function and repair of damage. It has also been reported that neurotropine has better efficacy in the treatment of cerebral edema in stroke patients.
6. Surgical treatment Stellate ganglion block therapy and high thoracic sympathectomy.
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 vertebra and the 1st thoracic vertebra, and innervates the head, neck and upper limbs. 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 laterally together. A 22G 3.5-4 cm long puncture needle (No. 7 needle) is used to enter the needle vertically on the lateral side of the cricoid cartilage, touching the 6th cervical transverse process, retracting the needle by 0.3-0.5 cm, withdrawing no blood, and injecting 0.25% bupivacaine or 1% lidocaine (both containing 10 ml of epinephrine), which can diffuse and block the stellate ganglion. The ipsilateral appearance of Horner’s syndrome and increased finger temperature after drug injection indicated that the block was effective. The sternocleidomastoid muscle was pushed outward with two fingers, and the internal carotid artery and vein were pushed outward together because they were attached to the posterior sheath of the sternocleidomastoid muscle. A 22G 3.5-4 cm long puncture needle (No. 7 needle) is used to enter the needle vertically on the lateral side of the cricoid cartilage, touching the 6th cervical transverse process, retracting the needle by 0.3-0.5 cm, withdrawing no blood, and injecting 0.25% bupivacaine or 1% lidocaine (both containing 10 ml of epinephrine), which can diffuse and block the stellate ganglion. The Horner syndrome and increased finger temperature on the ipsilateral side after the injection indicated that the block was effective, and the Horner’s sign was manifested by pupil narrowing, eyelid drooping, eye sunken, conjunctival congestion, and no sweating on the blocked side.
The drugs used for SB were Connexiton A 40 mg, 2% lidocaine 5 ml, neurotropine 3.6 U, vitamin B12 2000 μg, vitamin B6 200 mg, and saline diluted to 20 ml. suprascapular nerve block, biceps longus interjugal sulcus block and pain point block were used for SB. For suprascapular nerve block, 1 cm above the midpoint of the scapular gonad was used as the entry point, and 0.3 cm of deep stabbing was performed after detecting the scapular notch with the needle tip, and no blood was drawn back before drug injection.
(1) Complications.
(1) Toxic reaction caused by misinjection of drug into blood vessels.
(ii) mistaken injection of drug into the spinal canal, causing a drop in blood pressure and respiratory arrest.
(③) Pneumothorax.
(iv) phrenic nerve palsy.
(6) paralysis of the laryngeal recurrent nerve.
7. 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, cypress, bongfeng, mouton, licorice, raw earth, frankincense, etc.) with drugs such as mucuna pruriens, haitongpi, and forsythia. A decoction of Haidongpi Tang (Haidongpi, Turbinaria, Boswellia, Myrrh, Angelica, Sichuan pepper, Chuanxiong, Safflower, Wei Ling Xian, Licorice, Fang Feng, Angelica) can also be used for external washing. Or use anti-stasis and pain relief ointment (papaya, gardenia, rhubarb, dandelion, ground turtle worm, frankincense, myrrh finely ground, syrup or petroleum jelly to dress) to dress.
Acupuncture and moxibustion treatment Acupuncture points such as shoulder K, shoulder S, arm, Quchi, Waiguan, Yangchi, Zhongzhu, and eight evil points are optional, and needles are used for diarrhea. In case of swelling, the acupuncture points of the well or fingertips can be used to relieve heat and swelling, activate blood circulation and relieve pain. Needle with tonic method, available warm acupuncture moxibustion. At this stage, massage treatment can be given, using techniques such as kneading, holding, and moistening along the meridians, and pointing. Gentle movements are recommended when moving the wrist and hand joints.