SHOULDER-HAND SYNDROME: PHYSIOTHERAPY MANAGEMENT

SHOULDER-HAND SYNDROME

INTRODUCTION:

Shoulder hand syndrome

  • A condition characterized by shoulder pain, swelling, stiffness, vasomotor symptoms of arm and hand and skin edema/in duration, seen in patients above age 50 after an acute MI, or less commonly a cerebrovascular accident or head trauma.
  • Shoulder-hand syndrome is attributed to reflex sympathetic stimulation; some patients later develop adhesive capsulitis, sclerodactyly and decreased range of motion with regional demineralization.
  • There is wasting of the muscles and the hand may become hot, sweaty and swollen. Spontaneous recovery is usual but this may take up to two years.
  • Shoulder-hand syndrome (steinbrocker syndrome), also known as reflex sympathetic dystrophy syndrome refers to shoulder pain and shoulder movement disorder associated with ipsilateral hand pain and swelling characteristics, sometimes a group of integrated finger contractures sign.
  • The prevalence of both men and women, women slightly more than men, 90% of patients with age of onset is 50 years of age.
  • The shoulder-hand syndrome generally develops as a  reflex  dystrophy  with  accompanying  causalgia,  characterized by pain in the shoulder.
  • This is also  associated with swelling and pain in the hand, on the  involved  side.  Changes  in  the  shoulder  joint  are  identical  with  those  seen  in  the  frozen  shoulder  syndrome.
  • The shoulder-hand syndrome begins to emerge  as the patient persists in keeping the shoulder and  shoulder girdle immobile.  Disuse of the involved  muscles  brings  on  a  progressively  painful  stiff shoulder.
  • Uniform edematous swelling of the hand  begins to develop and finger joint motion becomes  progressively limited.
  • The mechanism postulated to  be  responsible  is  a  reflex-like  response  to  pain  sensation  by  sympathetic  nerves,  which  communicate with the involved sensory nerve in the internuncial pool in the spinal cord.
  • The sympathetic  nerves  respond  to  the  distally  occurring  pain  by  triggering  a  reflexive  efferent  reactive  vasomotor  action  in  the  involved  region.
  • This  effectively reduces blood circulation to the tissues perceived to  be involved in the pain pattern.
  • The  changes  in  the  hand  brought  on  by  the  shoulder-hand  syndrome  progress  in  three  stages:
  • (1) The patient complains of a burning pain in the  hand which is coincidentally either cold and clammy  or cold, red, moist, stiff and superficially sensitive to  touch or pressure.
  • (2) The hand appears white and  creaseless,  the  skin  thickened,  and  the  hand  is  increasingly cold and stiff.
  • (3) The hand appears pale  and thin, and there is muscular atrophy (guttering)  with  contractures  of  the  joints  (osteoporosis  may  become  evident  with  x-ray).
  • At  the  end  of  this  process the hand and arm is generally useless and  nonfunctional.

ETIOLOGY:

  • Trauma (often minor).
  • Ischemic heart disease and myocardial infarction.
  • Spinal cord disorder.
  • Cerebral lesions.
  • Infections.
  • Surgery.

SIGN AND SYMPTOMS:

  • Due to different causes, clinical manifestations. Secondary to myocardial infarction by more than 2 to 16 weeks after the disease onset, the longest up to 14 months.
  • Slightly more common incidence of left shoulder and hand over the right shoulder and hand or bilateral shoulder and hand onset showed gradually shoulder and hand stiffness, fatigue and discomfort, or hand suddenly pain, stiffness, swelling, or hypersensitivity, sweating and skin color change.
  • The course of the disease can be divided into three stages.
  • Stage 1: Shoulder and hand pain, movement disorders to diffuse swelling appears later, the gradual emergence of stiff, a wider range of shoulder pain, not involving the elbow.
  • This period of sustainable 3 to 6 months.
  • Stage 2: Pain and swelling may gradually reduce and subside gradually increased, but the shoulder joint dysfunction, finger flexion contracture and stiffness, muscle atrophy.
  • X-ray film showed significant osteoporosis, this period will last 3 to 6 months.
  • Stage 3: Palm and subcutaneous tissue contraction, finger tonic deformation activities significant barriers, the shoulder was frozen shoulder fewer residues pain.
  • The duration of symptoms varies, in some cases up to a few years, some stop in the course of development or heal.

CLINICAL FEATURES:

  • Pain:
  • Occurring in one or more extremities is described as severe, constant, burning and/or deep aching pain.
  • All tactile stimulation of the skin (e.g. wearing clothing, a light breeze) may be perceived as painful (allodynia).
  • Paroxysmal dysaesthesias and lancinating pains.
  • Skin changes:
  • Skin may appear shiny (dystrophy-atrophy), dry or scaly.
  • Hair may initially grow coarse and then thin. Nails in the affected extremity may be more brittle, grow faster and then slower.
  • Rashes, Ulcers and Pustules.
  • Abnormal sympathetic (vasomotor changes) activity may be associated with skin that is either warm or cold to touch.
  • Increased sweating (sudomotor changes) or increased chilling of the skin with goose flesh (pilomotor changes).
  • Swelling:
  • Localised, initially pitting and later Brawnyb.Edema may be sharply demarcated along a line on the skin surface.
  • Movement disorder:
  • May develop dystonia.
  • Tremors and involuntary jerking of extremities may be present.
  • Disuse atrophy sets in natural history.
  • Spreading symptoms:
  • A “continuity type” of spread where the symptoms spread upward from the initial site, e.g. from the hand to the shoulder.
  • A “mirror-image type” where the spread was to the opposite limb.
  • An “independent type” where symptoms spread to a separate, distant region of the body. This type of spread may be spontaneous or related to a second trauma.
  • Total body RSD.

PATHOLOGY:

Mechanism of shoulder hand syndrome

  • Sympathetic pain results from tonic activity in myelinated mechanoreceptor afferents. Input causes tonic firing in neurons that are part of a nociceptive pathway.
  • Injury to central or peripheral neural tissue.
  • Elevated levels of soluble tumor necrosis factor receptor 1 (sTNF-R1) and enhanced tumor necrosis factor-alpha activity in patients with polyneuropathy with allodynia.
  • Distal degeneration of small-diameter peripheral axons may be responsible for the pain, vasomotor instability, edema, osteopenia, and skin hypersensitivity of shoulder hand syndrome.
  • Cortical changes, suggesting a possible role in pathophysiology.

DIFFERENTIAL DIAGNOSIS:

  • Unrecognized local pathology (fracture, sprain).
  • Traumatic vasospasm.
  • Cellulitis.
  • Lymphedema.
  • Raynaud’s disease.
  • Thromboangiitis obliterans.
  • Erythromelalgia.
  • DVT.
  • Also, nerve entrapment syndromes, occupational overuse syndromes, and diabetic neuropathy.

MANAGEMENT FOR SHOULDER HAND SYNDROME:

  • No scientifically validated cure exists
  • Therapy is directed at managing the signs and symptoms of the disease
  • A multidisciplinary approach utilizing pharmacotherapy, physical therapy and psychological therapy is most appropriate.

PHYSIOTHERAPY TREATMENTS:

  • Early physical therapy is essential to avoid atrophy and contractures of the affected limb.
  • Physio therapy have been shown to reduce pain and motor impairment, and improve function and coordination ability of the limb.
  • Requires that the patient take an active role in their care.
  • Physical therapy intervention including:
  • TENS.
  • Aquatic therapy.
  • Mirror therapy
  • Desensitization
  • Gradual weight bearing.
  • Stretching.
  • Fine motor control.
  • In acute phase:
  • Immobilization and contralateral therapy should be the treatment. Intensive active therapy in the acute phase can lead to deterioration.
  • In chronic phase:
  • Passive physical therapy including manipulation, manual therapy, massage and mobilizations.
  • Lymphatic drainage can be used to facilitate regression of edema.
  • You can also threat tender points by the following rules: more severe tender points as identified by tenderness to palpation are treated before less severe tender points; more proximal or more medial tender points are addressed before more distally and laterally located points; the area of greatest accumulation of tender points is treated first; when tender points are located in a row, the one in the middle of the row is treated first.
  • Therapeutic exercise including isometric strengthening therapy followed by active isotonic training in combination with sensory desensitization programs.
  • The strengthening training includes exercises for all four extremities and trunk. The exercises can be done with theraband.
  • Desensitization programs contains giving stimuli of different fabrics, different pressure (light or deep), vibration, tapping, heat or cold. The exercises can be stress-loading (f.e. scrubbing, walking, carrying weights), endurance training, written instructions and functional training. It is also useful to give the patient an home exercise program.
  • Mirror therapy or mirror visual feedback:
  • Mirror therapy contains placing both hands into a box with a mirror separating the two compartments and, while moving both hands, watching the reflection of the unaffected hand in the mirror.
  • Reducing pain intensity and improve function in post-stroke shoulder hand syndrome.
  • A significant improvement in pain with mirror therapy.
  • Improve function.
  • Graded motor imagery/learning:
  • Graded motor imagery consists of recognition of hand laterality and imagined hand movement.
  • Relaxation.
  • Cognitive-behavioral therapy:
  • Contains relaxation training, deep breathing exercises, biofeedback.
  • Neuromodulation or invasive stimulation techniques:
  • Neuromodulation contains peripheral nerve stimulation with implanted electrodes, epidural spinal cord stimulation, deep brain stimulation and electrotherapy.
  • Electrotherapy includes transcutaneous electric nerve stimulation TENS, Spinal cord stimulation,non-invasive brain stimulation (repetitive transcranial magnetic stimulation).
  • Other treatments:
  • Whirlpool bath/ contrast baths.
  • Vocational and recreational rehabilitation.
  • Psychological therapies: cognitive-behavioral therapy (CBT), operant conditioning (OC), counselling, pain education and relaxation techniques.
  • Acupuncture, electroacupuncture.
  • Tactile sensory discrimination training.
  • Weight bearing.
  • Ultrasound therapy.
  • Kinesiotaping.
  • Psychological therapy:
  • An integral part of the multidisciplinary treatment approach. Many patients with shoulder hand syndrome have a significant amount of psychological dysfunction, which is a reflection of the disease process itself as opposed to a cause thereof.
  • Pain coping skills.
  • Biofeedback.
  • Relaxation training.
  • Cognitive behavioral therapy.
  • Mirror therapy.
  • Invasive/intervention therapy:
  • Sympathetic nerve blocks.
  • Spinal cord stimulation.
  • Surgical/chemical sympathectomy.
  • Peripheral nerve stimulator.
  • Intrathecal baclofen pump.

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