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Edema of the paretic hand in elderly post-stroke nursing patients
Abstract
Post-stroke edema of the paretic hand constitutes an additional, functional, and esthetic nuisance for the patient. Although often encountered in daily practice, it is not even mentioned in the stroke chapters of the various textbooks. The phenomenon is far from being elucidated and various aspects are still obscure. In this study we tried to estimate the extent of post-stroke hand edema (PSHE) in a sample of elderly patients. The study group consisted of 188 elderly post-stroke nursing patients with hemi or only hand paresis. Seventy, age matched, non-paretic patients were examined as controls. The basis of comparison was the difference in circumference between the two arms at three sites: mid-finger, hand, and wrist as measured in the control group. Values above two standard deviations (S.D.) of the mean difference in circumference of the controls, at two or three sites, were considered as edema. Edema of the paretic hand was detected in 37% of post-stroke patients. Most (about three-quarters), could be classified as simple PSHE, while the rest may have had reflex sympathetic dystrophy (RSD).
... 1 Patients with hemiplegia may experience several upper extremity troubles (ie, weakness, spasticity, shoulder pain, edema, complex regional pain syndrome [lsqb]CRPS [rsqb], and gleno-humeral subluxation), which require prolonged rehabilitation programs. [2][3][4][5][6] Vasomotor and hemodynamic changes are thought to be involved in the etiopathogenesis of these troubles, via the interruption of central sympathetic-inhibitory pathways, which in turn leads to partial disinhibition of spinal vasomotor neurons and sympathetic hyperfunction. 2 Eventually, the vasoconstrictor tone is expected to increase, resulting in a decrease in cutaneous blood flow. In addition, venous return and lymphatic flow can decrease due to impairment of the upper extremity function with skeletal muscle pumping dysfunction and muscle tone abnormality (hypotonia, spasticity). ...
... [2][3][4][5][6] Vasomotor and hemodynamic changes are thought to be involved in the etiopathogenesis of these troubles, via the interruption of central sympathetic-inhibitory pathways, which in turn leads to partial disinhibition of spinal vasomotor neurons and sympathetic hyperfunction. 2 Eventually, the vasoconstrictor tone is expected to increase, resulting in a decrease in cutaneous blood flow. In addition, venous return and lymphatic flow can decrease due to impairment of the upper extremity function with skeletal muscle pumping dysfunction and muscle tone abnormality (hypotonia, spasticity). ...
... In addition, venous return and lymphatic flow can decrease due to impairment of the upper extremity function with skeletal muscle pumping dysfunction and muscle tone abnormality (hypotonia, spasticity). 2,3,7 During the recovery process after stroke, synergy patterns (abnormal, stereotyped, and primitive movements) are initially present and associated with spasticity and predominance over motor acts. As voluntary movements recover, spasticity and synergies lose their dominancy over voluntary movements. ...
To evaluate blood flow of hand arteries (using Doppler ultrasonography) and sympathetic skin response (SSR) in patients with hemiparesis.
Fifty-six stroke patients (30 M, 26 F) with unilateral hemiparesis (age 53.5 ± 10.8 years, mean disease duration 12.0 ± 19.1 months) were included. The patients' arm and hand motor functions were assessed according to Brunnstrom's stages. SSR was evaluated bilaterally from median nerves at the wrist level. Radial and ulnar artery blood flow was measured at the wrist in the neutral position.
Both radial and ulnar artery volume flow and end diastolic velocity, and radial artery diameter were smaller on the paretic side (all p < 0.0125). Radial artery resistance and pulsatility index were greater on the paretic side (both p < 0.0125). SSR amplitude was lower on the paretic side of patients with right-sided hemiparesis patients (p = 0.009). Hand Brunnstrom's stage was negatively correlated with nonparetic-paretic difference in radial artery volume flow and SSR amplitudes (all p < 0.025).
Hand blood flow was lower on the paretic side and was accompanied by a similar decrease in SSR amplitudes in patients with right-sided hemiparesis. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound, 2014;
... In wrist-hand syndrome following stroke US can define essentially three patterns. The first pattern is a subcutaneous edema with extensive dilatation of lymphatics with moderate effusion in radio-carpal and mid-carpal joint and in both extensor and flexor tendon sheaths, without vascular signals on PDUS, that could represent the entity defined as simple post-stroke hand edema (PHSE), the most frequent edema of hand and wrist observed in hemiplegic patients [9]. The absence of inflammatory hypervascularization is the most prominent aspect of this pattern and this is compatible with the relative absence of pain. ...
... The absence of inflammatory hypervascularization is the most prominent aspect of this pattern and this is compatible with the relative absence of pain. This data supports the role of loss of muscle tone and pump activity and increased venous and lymphatic congestion as etiology of PHSE [9]. ...
... The third pattern is a subcutaneous edema, with moderate effusion in joint spaces and in tendon sheaths, associated to mild synovial inflammatory hypervascularization. This pattern could represent the reflex sympathetic dystrophy (RSD) syndrome of wrist and hand of hemiplegic, where mild inflammation and hypervascularization determine moderate pain and tenderness [9]. ...
The aim of this study was to evaluate the role of bedside ultrasonography (US) in early diagnosis of musculoskeletal complications (MSC) of acquired brain injuries, to describe its incidence and US features in a neurorehabilitation setting.
All 163 patients admitted in tertiary-level neurorehabilitation unit with diagnosis of stroke or severe brain injury (SBI), with symptoms or signs of musculoskeletal pathology, underwent bedside US.
MSC were diagnosed in 51.5%. In 86.9% US clarified diagnosis and/or modified therapeutic approach. Shoulder pain was observed in 27.6%. US showed a shoulder subluxation in 73.3% and a frozen shoulder in 8.8% of painful shoulders. In all the cases rotator cuff abnormalities were noted. Wrist-hand syndrome was observed in 29.4%. US showed mild effusion in wrist joints and tendon sheaths and subcutaneous edema without significant vascularity. Neurogenic heterotopic ossification was observed in 1.8%. US demonstrated the "zone phenomenon" or heterogeneously hypoechoic mass with low resistance vessels within the lesions. Contractures and spasticity were observed in 18.4%. US allowed reliable guidance for Botulinum toxin A injection. Relapsing osteoarthritis and acute arthritis were diagnosed in 15.3% and 7.3% respectively. Patients with MSC had lower Functional Independence Measurement (FIM) and Katz index scores in discharge (p < 0.04 and p < 0.0294 respectively) and more length of hospital stay (p = 0.0024).
Musculoskeletal pathology frequently complicates the course of acquired brain injuries and it delays functional recovery. Bedside US is a cheap and sensitive diagnostic tool and it can aid clinicians to define diagnosis and to choose therapeutic approach.
... These studies [2,5] have used more standardised methods to diagnose oedema: a volume difference between both arms greater than 2 standard deviations based on population data provided by Vasiliauskas et al. [6]. Another study found an incidence of 37% if all types of oedema were included or 28% when oedema after suspected complex regional pain syndrome (CRPS) was omitted [7]. ...
... In literature, the incidence of oedema after stroke ranged from 16 to 83% in older studies [3,4]. More recent studies have found incidences ranging from 28 to 37% [2,5,7]. We found rather low incidences of oedema among patients with stroke as incidences varied from 9-13.9% 1 week after inclusion until the third evaluation 3 months later, respectively. ...
... These patients are more likely to have a more severe stroke than the population of stroke patients admitted to an acute neurology ward [2,5]. In the study from Leibovitz et al., elderly patients with stroke residing in a nursing home were assessed and the oedema assessment was performed at median 11 months post stroke [7]. In this study, the latest oedema assessment was performed after 3 months of follow-up. ...
Assessment of the incidence of upper limb oedema in an acute care setting by means of clinical and volumetric evaluation.
Patients with acute hemiparetic stroke were recruited from 2006 until 2009 (n = 125). Baseline measurements consisted of the National Institute of Health Stroke Scale, Fugl-Meyer Assessment Arm Section and demographic characteristics. Oedema assessment was performed at 7 days after inclusion and at 1 month and 3 months follow-up. A standardised water displacement method (objective measurement) was used to define oedema and was compared to data from visual inspection and palpation (subjective measurement).
In literature, the incidence of upper limb oedema ranges from 16-83%, defined by a variety of definitions. Oedema incidence in this study was defined by strict criteria using water displacement and ranged from 9-13.9%, while the incidence of oedema defined by visual inspection and palpation ranged from 6-18.5% during the different stages of follow-up. The agreement (Kappa) between both measurements ranged from 0.23-0.38, which is not more than 'moderate' but comparable to the agreement of 0.34 found in literature.
An objective and subjective assessment of oedema was used; the agreement between both methods was only moderate. The incidence of oedema found in this study is lower than the incidences found in literature.
... The most widely accepted explanation is of increased venous congestion related to prolonged dependency and loss of muscle pumping function in the paretic limb. (Leibovitz et al. 2007). Diagnosis is difficult and depends, in part, on the method of assessment. ...
... )reported a significant correlation between the presence of hand edema and measures of hand function (measured by the Frenchay arm test). Patients without hand edema were more likely to have good hand function. Significant predictor of hand function following stroke included the degree of motor impairment, hypertonia, tactile inattention and edema.Leibovitz et al. (2007)compared the circumference of the hand in three places (mid-finger, hand and wrist) among subjects post stroke (m=188) and non-paretic institutionalized controls (n=70). Hand edema was detected in 37% of post stroke subjects compared with only 2% of control subjects. ...
Key Points Initial degree of motor impairment is the best predictor of motor recovery following a stroke. Functional recovery goals are appropriate for those patients who are expected to achieve a greater amount of motor recovery in the arm and hand. Compensatory treatment goals should be pursued if there is an expected outcome of poor motor recovery. Attempts to regain function in the affected upper extremity should be limited to those individuals already showing signs of some recovery. Neurodevelopment techniques are not superior to other therapeutic approaches in treatment of the hemiparetic upper extremity. It is uncertain whether enhanced therapy results in improved short-term upper extremity functioning. It is uncertain whether repetitive task specific training techniques improve upper extremity function. It is uncertain whether sensorimotor training results in improved upper extremity function. It is uncertain whether mental practice results in improved motor and ADL functioning after stroke. Hand splinting does not improve motor function or reduce contractures in the upper extremity. Constraint-induced movement therapy is a beneficial treatment approach for those stroke patients with some active wrist and hand movement. Sensorimotor training with robotic devices improves functional and motor outcomes of the shoulder and elbow, however, it does not improve functional and motor outcomes of the wrist and hand. There is preliminary evidence that virtual reality therapy may improve motor outcomes post stroke. The Evidence-Based Review of Stroke Rehabilitation (EBRSR) reviews current practices in stroke rehabilitation.
... Although the etiology of poststroke hand edema remains unclear, the most widely accepted hypothesis regarding poststroke upper extremity edema is that the decreased venous return is related to the loss of the muscle-pumping function in the paretic extremity. 5) Thus, the promotion of venous return of the paretic hand would be important for addressing poststroke hand edema. ...
Objective: This study aims to determine the effect of grip exercise by the non-paretic hand on venous return in the paretic arm in stroke in sitting and supine positions.
Methods: The study population included 21 stroke patients (mean age, 59.5 years). The diameter (mm) and time-averaged mean velocity (TAMV) (cm/s) of the axillary vein on the paretic side were measured by ultrasound during three distinct conditions: resting, rhythmic non-resistive grip exercise, and resistive exercise (30% of maximum grip strength) in supine and sitting positions. The venous flow volume (ml/min) was calculated using the obtained data.
Results: In the supine and sitting positions, the venous flow volume during rhythmic non-resistive and resistive exercises was increased in comparison to resting, which resulted in more increased venous flow volume by rhythmic resistive grip exercise than by non-resistive grip exercise (both, p=0.01).
Conclusion: Grip exercise by the non-paretic hand was found to be effective for increasing the venous flow volume in the paretic hand, and resistive grip exercise caused the greatest increase. Our results suggest that rhythmic handgrip exercise may be clinically useful for reducing the incidence of hand edema in stroke patients.
... Hemiplegia is characterized by significant loss of motor function, muscle weakening, and abnormal movements due to muscle tension. Importantly, immobility due to paralysis or pain may lead to edema in hemiplegic patients, with 37% of afflicted individuals developing edema of the hands 2) . ...
[Purpose] The purpose of this study was to investigate the effect of fluidotherapy on hand’s dexterity and activities of daily living for stroke patients with upper limb edema. [Subjects and Methods] The objective of the present study was to treat 30 stroke patients with a three-week course of fluidotherapy to investigate the efficacy of such therapy for reduction of edema. For accurate baseline and post-intervention assessment of edema volume, hand edema was measured in the morning using a forearm volumeter. [Results] Mean edematous volume in the affected side measured 600.53 ± 29.94 ml prior to intervention, significantly decreasing to 533.53 ± 27.85 ml after three weeks of fluidotherapy. To investigate how such reduction may have enhanced the ability to perform activities of daily living, Korean Version of Modified Barthel Index assessment was performed. The results showed 46.10 ± 4.27 points at baseline and significantly improved to a mean score of 49.96 ± 4.34 points at the time of reassessment. Furthermore, Box and Block Test was performed to investigate hand dexterity. Before fluidotherapy, affected patients transferred 21.13 ± 3.63 blocks in one minute, increasing to 23.20 ± 3.42 blocks transferred in one minute following three weeks of treatment. Although the number of blocks transferred did increase slightly, the difference was not statistically significant. [Conclusion] These findings suggest that using fluidotherapy can reduce edema, and such a reduction can have a positive effect on activities of daily living. Based on our current findings, we hypothesize that long-term fluidotherapy treatment may be more effective in reducing edema. © 2017 The Society of Physical Therapy Science. Published by IPEC Inc.
... 성이 증대되고 있다 [2]. 뇌졸중으로 인한 편마비 환자는 마비측 상지의 근력 약화(muscular weakness), 비정상 적인 근긴장도(myotonus) 등의 운동기능 장애와 더불 어 촉각(tactile sense), 위치 감각(sense of position), 온 도감각(temperature sense), 통각(sense of pain) 등의 감각이 소실되며 [3], 편마비 환자의 37%는 상지 부종으 로 인해 재활의 어려움과 일상생활에 지장을 초래한다 [4]. ...
This study is conducted to provide basic data through the Quantitative Sensory Testing(QST) about edema of the upper extremity with hemiplegia for subacute and chronic patients in management and treatment. For the purposes of the study group I, subacute stroke patients(n
... Poststroke hand oedema occurs in 37% of individuals who experience a chronic stroke and in up to 18.5% of individuals with acute stroke (Gebruers, Truijen, Engelborghs, & De Deyn, 2011;Leibovitz et al., 2007). Although the exact aetiology of poststroke hand oedema is still inconclusive, a few possible causes have been identified, including sympathetic vasomotor dysfunction and dysregulation of the autonomic nervous system caused by stroke (Artzberger & White, 2011;Hesse, Jahnke, Ehret, & Mauritz, 1995), venous congestion due to immobility, and dependent positioning (Artzberger & White, 2011;Geurts, Visschers, van Limbeek, & Ribbers, 2000). ...
Objective/Background: To review the evidence of rehabilitation interventions for the management of poststroke hand oedema.
Methods: We conducted a systematic review of research articles in electronic databases published in English between 1999 and 2015. Two investigators working independently retrieved articles from the Cochrane Central Register of Controlled Trials, SCOPUS, Taylor & Francis Online, Wiley Online Library, CINAHL, Springer (MetaPress), ScienceDirect, PubMed, SAGE Journals Online, EBSCO, and Web of Science. Only controlled trials with outcome measures and interventions for poststroke hand oedema were included. Three investigators critically appraised the selected studies using the Physiotherapy Evidence Database Scale.
Results: Of the 189 articles identified, nine (5 randomized controlled trials, 3 nonrandomized controlled trials, and 1 crossover controlled trial) were selected. These studies are heterogeneous in terms of design and types of intervention for poststroke hand oedema. The interventions reducing hand oedema are Lycra pressure garments with glove splints, bilateral passive motion upper-limb exercises, laser therapy, and acupressure. However, due to these studies' short intervention periods and the fact that hand oedema is not their primary outcome measure, it is not possible to draw a firm conclusion on their clinical significance for managing poststroke hand oedema.
Conclusion: Further study needs to focus solely on interventions for poststroke hand oedema and their long-term effects. No conclusion can be made on the most effective management of poststroke hand oedema until much more evidence is available.
... Articular (peripheral joints) system: Loss of joint range of motion (ROM) is a common impairment of the musculo-skeletal system consequent to immobilization. The restriction of normal range is typically brought about by shortening and adhesion formation in soft tissues surrounding the joint, and in the case of damage to the brain by The ability of FES to excite directly peripheral sensory and motor edema, if present [59]. The FES induced contraction also augments the uncontrolled activation of muscles. ...
... The value of applying electrical stimulation to augment vascular response is realized only when the vascular system is compromised due to damage to the neuromuscular or vascular or both systems. The ability of FES to excite directly peripheral sensory and motor edema, if present [59]. The FES induced contraction also augments the Citation: Alon G (2013) Functional Electrical Stimulation (FES): Transforming Clinical Trials to Neuro-Rehabilitation Clinical Practice-A Forward Perspective. ...
Presenting a forward perspective on the topic of personalized functional electrical stimulation (FES) and discussing its critical role in clinical practice is a challenge, particularly when the goal is to provide biomedical engineers and clinicians with a guide to bridge the gap between laboratory, clinical research, and clinical practice. There are several dimensions to the complexity of the topic. First, is the prevailing and misleading terminology, inadequate evidencebased training of physicians and rehabilitation therapists, and the recognition that until recently most existing FES systems were not designed as wearable systems and are “not patient or therapist friendly”. Most importantly, is the wellestablished phenomenon, that following damage to the musculo-skeletal system or brain, patients’ profile of functional recovery and thus utilization FES as part of the recovery is highly variable, prolonged and largely unpredictable. As a result, legacy research and training methods that depend on interpretation of statistically significant and clinically meaningful findings are inherently limited addressing the needs of most patients. This monograph will focus on: 1) identifying the specific deficits and recovery profiles that each patient presents, 2) providing examples of the diverse modes of actions (mechanisms) that govern wearable FES utilization, 3) the latest developments and shortcoming of wearable FES technologies, and 4) the recognition that FES has limited value if applied in isolation. Finally, an example of personalized training paradigm, centered on individual patient’s needs and measureable progress in functional outcomes will be presented.
... Articular (peripheral joints) system: Loss of joint range of motion (ROM) is a common impairment of the musculo-skeletal system consequent to immobilization. The restriction of normal range is typically brought about by shortening and adhesion formation in soft tissues surrounding the joint, and in the case of damage to the brain by The ability of FES to excite directly peripheral sensory and motor edema, if present [59]. The FES induced contraction also augments the uncontrolled activation of muscles. ...
This nonblinded, block-randomized clinical trial tested the hypothesis that task-oriented functional electrical stimulation (FES) can enhance the recovery of upper-extremity volitional motor control and functional ability in patients with poor prognosis.
Ischemic stroke survivors (FES + exercise group, n = 13, 17.4 +/- 7.6 days after stroke, and exercise-only group n = 13, 23.8 +/- 10.9 days after stroke) trained with task-specific exercises, 30 min, twice each day. The FES group practiced the exercises combined with FES that enabled opening and closing of the paretic hand and continued with FES without exercises for up to 90 mins of additional time twice a day. Both groups trained for 12 wks. Volitional motor control (modified Fugl-Meyer [mF-M]), hand function (Box & Blocks [B&B], and Jebsen-Taylor light object lift [J-T]) were video recorded for both upper extremities at baseline and at 4, 8, and 12 wks.
Mean mF-M score of the FES group (24 +/- 13.7) was significantly better (P = 0.05) at 12 wks compared with the control group that scored 14.2 +/- 10.6 points. The B&B mean score did not reach statistical significance (P = 0.058) in favor of the FES group (10.5 +/- 2.4 blocks) over the control group (2.5 +/- 4.9 blocks). The J-T task time did not differ between groups. Eight (FES) compared with three (control) patients regained the ability to transfer five or more blocks (P = 0.051), and six (FES) compared with two (control) completed the J-T task in 30 sec or less after 12 wks of training (P = 0.09).
FES + exercise as used in this preliminary study is likely to minimize motor loss, but it may not significantly enhance the ability to use the upper extremity after ischemic stroke. Anecdotally, more patients may regain some functional ability after training with FES compared with training without FES. Patients with severe motor loss may require prolonged task-specific FES training.
... The evaluation of hand edema was performed according to Leibovitz et al. 31 We used a tape measure to record circumference at the proximal phalange of the index finger, the mid-metacarpal line, and the wrist proximal to the carpometacarpal joint crease. The measurements were performed on both hands. ...
To quantify the preventive effect of a neutral functional realignment orthosis on pain, mobility, and edema of the hand in subacute hemiparetic poststroke patients with severe motor deficits.
Randomized trial.
Rehabilitation center.
Poststroke patients (N=30) with subacute hemiparesis and severe deficits of the upper limb were enrolled. Fifteen patients were randomized to a standard rehabilitation program without orthosis and 15 patients received an experimental orthosis in addition to their standard rehabilitation program.
The orthosis group wore the neutral functional realignment orthosis for at least 6 hours daily.
Hand pain at rest (visual analog scale), wrist range of motion (Fugl-Meyer Assessment subscale), and edema of hand and wrist (circumferences). Outcome measures were assessed at time of randomization and after 13 weeks between groups.
At baseline, 2 patients in each group complained about a painful hand. After 13 weeks, 8 subjects in the control group and 1 subject in the orthosis group complained of hand pain (P=.004). Mobility and edema evolved similarly in both groups.
Neutral functional realignment orthoses have a preventive effect on poststroke hand pain, but not on mobility and edema in the subacute phase of recovery.
Objective
The development and validation of a nomogram for the individualized prediction of hemiplegic shoulder pain (HSP) during the inpatient rehabilitation of stroke patients.
Design
Retrospective cohort study.
Setting
The rehabilitation department at a tertiary hospital.
Participants
A total of 376 stroke patients admitted to inpatient rehabilitation between January 2018-April 2021 were included in this study.
Interventions
Not applicable.
Main Outcome Measure
The outcome measure was shoulder pain on the patients’ hemiplegic side occurring at rest or with movement during hospitalization.
Results
Among the 376 stroke patients, 113 (30.05%) developed HSP. Five independent predictors were included in the nomogram: subluxation, the Brunnstrom stage, hand edema, spasticity, and sensory disturbance. The nomogram was a good predictor, with a C-index of 0.85 (95% confidence interval, 0.81–0.89) and corrected C-index of 0.84. The Homer–Lemeshow test (χ² = 13.854, P = 0.086) and calibration plot suggested good calibration ability of the nomogram. The optimal cut-off value for the predicted probability of HSP was 0.30 (sensitivity, 0.73; specificity, 0.83). Moreover, the decision curve analysis revealed that the nomogram would add net clinical benefits if the threshold possibility of HSP risk was between 5% -88%.
Conclusions
Our nomogram could accurately predict HSP, which may help clinicians accurately quantify the HSP risk in individuals and implement early interventions.
Oedeemvorming bij CVA-patiënten is een reëel probleem, vooral in de bovenste extremiteit. Het oedeem ontstaat in de eerste weken na het CVA. Dit is tijdens de intensieve fase van de revalidatie. Het oedeem geeft extra beperkingen waardoor de CVA-patiënt het revalidatieproces als minder succesvol ervaart. Het oedeem wordt nog altijd onderschat en er is geen eenduidige definitie om oedeem te diagnosticeren. In dit hoofdstuk worden in het kort de ontstaansmechanismen en de incidentie van oedeem bij CVA-patiënten besproken. De huidige diagnostische methoden worden behandeld en een nieuwe gestandaardiseerde meetmethode gebaseerd op waterverplaatsing wordt voorgesteld. Hieraan zijn predictieformules gekoppeld die gebruikt kunnen worden als nieuw diagnosecriterium voor oedeem. Tot slot worden de actuele behandelingen beschreven.
Methods : The subjects in this study were 8 patiens with post-stroke hand edema. The patients were treated with acupuncture on A-Shi point in hand. We treated them once a day, 7 days. The effectiveness was assessed by hand volumeter and mesuring tape. And Wilcoxon signed rank test was performed to evaluate the effect. Results : A significant change was observed after 7 times acupuncture treatment. Both volume and circumference of hand were decreased after treatment. Conclusions : This study suggests that A-Shi point acupuncture is effective for reducing poststroke hand edema, although further study would be necessary.
Stroke is a leading cause of disability worldwide, with its risk increasing with age. Upper limb hemiparesis is common and associated with persistent impairments and associated disabilities. Older stroke populations often suffer multiple comorbidities and restoring independence is complex. Recovery of upper limb function can be crucial for individuals to return to independent living and to participate in community life. This review describes upper limb recovery post-stroke, and some of the new therapeutic approaches available to promote recovery. Technologies (including virtual reality and telehealth) offer the opportunity for more home-based therapies, longer programs and greater access to rehabilitation for older individuals. However, the trials continue to exclude older individuals, so acceptability is poorly understood. Upper limb rehabilitation remains a research frontier, which has been energized by new technologies, but is grounded by the basic need to find ways to allow older individuals to recover independence. This paper aims to review the applicability and generalizability of current research to the older stoke survivor. Future research priorities need to be tailored to consider the older mean age of individuals in stroke rehabilitation.
Purpose: The purpose of this study was to evaluate the effects of the meridian massage on the hand edema, activities of daily living (ADL), and depression in hemiplegic stroke patients. Methods: The research was a quasi-experimental design using a non-equivalent control group pre-post test. The subjects were 40 stroke patients who admitted to rehabilitation department in a hospital. The data was collected from January to March, 2009 used the millimeter measurement for checking hand edema and the structured questionnaires. The meridian massage on affected hand was carried out for 10 minutes per day during 2 weeks to the experimental group. Descriptive statistics,-test, Fisher's exact test, and t-test with SPSS/WIN 12.0 program were used to analyze the data. Results: After the intervention, there were statistically significant differences in the changes of hand edema, ADL, and depression in the experimental group compared with the control group. Conclusion: The meridian massage was effective in improving hand edema, the level of ADL, and depression for the hemiplegic stroke patients. Therefore the meridian massage can be utilized as an effective adjuvant therapy for stroke patients suffering from hand edema in clinical practice.
Purpose:
As there is no evidence for a specific treatment for post-stroke-induced hand oedema, rehabilitation centre Blixembosch formalized a best practice protocol. We investigated whether the Blixembosch hand oedema protocol is usable in daily practice and leads to lower incidence (prevention) and shorter duration (treatment) compared with care as usual.
Methods:
In a non-randomised comparative trial, we investigated 206 post-stroke patients admitted to two Dutch rehabilitation centres. Hand volumes were measured at least bi-weekly using a volumeter. Treatment was started according the protocol (Blixembosch) or following care as usual (Leijpark). Usability was assessed with a survey among professionals.
Results:
In the Blixembosch group, 16% developed oedema after admission, compared with 21% in the control group (p = 0.019). Average duration of oedema (both developed before and after admission) was 6.5 weeks in the Blixembosch group compared with 3.1 weeks in the control group (p = 0.000). Professionals were positive about the protocol.
Conclusion:
The study showed that the protocol is usable in daily practice and has a small beneficial effect on hand oedema incidence rates compared with care as usual. The negative effect on duration of hand oedema could also be caused by the difference in prognosis between the two groups.
At the present time, there is only one standard test that evaluates the performance of transcutaneous electrical nerve stimulator (TENS) devices. The rationale for this test is not well documented and its scope and limitations are unclear. The thrust of this paper is to discuss the selected factors that are likely to affect the performance standard. These include stimulus waveform, constant current versus constant current voltage output and electrode size. Each of these parameters have been shown to influence the stimulation output and the conductive characteristics of human tissue. Stimulating with different waveforms significantly affects peak current, peak voltage and total pulse charge, but insignificantly affects the phase charge. Using a different electrode size alter all stimulus output values during excitation of peripheral nerves, indicating tile need to specify electrode size for simulated tissue loads. Data show that a single load is not adequate to simulate the conductive medium of human tissue. Instead a family of loads is considered and their validation for testing conditions is discussed
Objective:
The purpose of the study was to evaluate the effi cacy of Kinesio Tape (Kinesio USA, Albequerque, NM) for reducing hand edema in individuals with hemiplegia post stroke.
Methods:
Seventeen individuals who experienced acute stroke were screened for visual signs of edema and were randomly assigned to experimental and control groups. The experimental group received Kinesio Tape that was applied to hand and forearm for 6 days in combination with standard therapy; the control group received standard therapy. Blinded raters assessed edema reduction via circumferential measurements.
Results:
Application of Kinesio Tape did not result in statistically signifi cant reduction in edema. Large and medium effect sizes were seen for edema reduction at the metacarpophalangeal and wrist joints, respectively, with Kinesio Tape.
Conclusion:
Further research is warranted to investigate the utility of Kinesio Tape in edema reduction.
To investigate the disuse hypothesis as an explanation for upper limb oedema in patients with stroke.
Longitudinal observational study.
Patients with acute hemiparetic stroke were recruited from 2006 to 2009 (n=139).
Patients wore 2 uni-axial accelerometers, 1 on each wrist, for 2 periods of 48 h with a 1-week interval. Activity performed by the patients with acute stroke was measured by determining total activity, measured as a total sum of raw counts, and calculating the ratio variable. The National Institute of Health Stroke Scale (NIHSS), Fügl-Meyer Assessment and modified Rankin Scale were used. During a 3-month follow-up, patients underwent 3 assessments of upper limb oedema.
The incidence of upper limb oedema range for the objective evaluation was 7.7-14.7%, while the incidence for the subjective evaluation ranged from 11.5% to 18.1%. No significant differences were found between patients with and without oedema concerning the activity variables; therefore no prognostic value could be determined.
No difference in upper limb activity was found between patients with and without oedema after stroke. It is doubtful that loss of activity of the paretic limb is solely responsible for the development of upper limb oedema after stroke.
Examination procedures preferred by physical therapists have not been documented either specifically or comprehensively. The purpose of this study was to determine which tests and measures are used most frequently by specialists in the examination of adults with stroke.
Physical therapy specialists were identified as having geriatric or neurologic certification through the American Board of Physical Therapy Specialties. A request to participate in a Web-based survey was sent to 471 individuals in the American Physical Therapy Association's Directory of Certified Specialists.
A comprehensive list of tests and measures was first derived from the Interactive Guide to Physical Therapist Practice. The list was finalized based on several exclusion criteria and the results of a pilot study. Subjects rated the frequency of use of 294 tests and measures with patients post-stroke on a Likert scale.
The survey response rate was 31.7% (n = 128). The 50 most frequently used tests and measures were identified.
The results of this study do not identify the tests and measures that clinicians should use, only those that the specialists use. Nevertheless, clinicians may want to consider tests and measurements frequently used by specialists when examining adults with stroke.
Vasomotor changes occur in the arm after hemiplegic stroke. Previous studies have provided conflicting results, with most showing an increase in skin temperature of the hemiplegic arm. However, a number of patients complain of distressing coldness of the hemiplegic arm.
Eleven patients with symptomatic coldness and 10 patients with hemiplegia but no coldness were recruited. The severity of the symptom of coldness was compared by questionnaire with other common symptoms after stroke. A thermographic camera was used to record the finger skin temperature response to cold stress. Blood flow to both hands was also measured simultaneously by means of two plethysmographs. In all patients there were no symptoms in the unaffected arm, and this was used as a control.
The symptom of coldness rated highly compared with other symptoms. In the symptomatic group the finger temperature on the hemiplegic side was lower at rest (median difference at rest, 0.65 degrees C; P < .0001) and at all times after cold stress. In the asymptomatic group the fingers on the hemiplegic side were colder at rest and after initial cooling (median temperature difference, 0.2 degrees C) but at no other time. Hand blood flow on the hemiplegic side was also decreased in the symptomatic group by 35%. This was not seen in the asymptomatic group.
Coldness of the hand may be a severe and distressing symptom in some patients after hemiplegia. Symptomatic patients have lower finger skin temperatures at rest and after standard cold stress. These symptomatic patients also had reduced blood flow to the hemiplegic hand.
Studies on the aetiology and treatment of post-stroke hand oedema and shoulder-hand syndrome (SHS) published from January 1973 until August 1998 were identified. Eleven studies were included with at least some control for confounding. These were evaluated on 11 methodological criteria and by standardized effect sizes. There were five aetiological studies: four cohort studies and one study consisting of two case series using a within-subjects design. The matters investigated included lymph scintigraphy in hand oedema, bone scintigraphy, putative risk factors and the existence of autonomic dysregulation and peripheral nerve lesions in SHS. There were six therapeutic studies: one randomized controlled trial, one non-randomized controlled trial, one cohort study and three case series, of which two studies used a within-subjects design. These studies investigated continuous passive motion and neuromuscular stimulation in hand oedema as well as oral corticosteroids, intramuscular calcitonin and trauma prevention in SHS. A great diversity of pathophysiological and therapeutic insight was found. Based on systematic analysis of the literature, the following conclusions seem justified: (i) the shoulder is involved in only half of the cases with painful swelling of wrist and hand, suggesting a "wrist-hand syndrome" between simple hand oedema and SHS; (ii) hand oedema is not lymphoedema; (iii) SHS usually coincides with increased arterial blood flow; (iv) trauma causes aseptic joint inflammations in SHS; (v) no specific treatment has yet proven its advantage over other physical methods for reducing hand oedema; and (vi) oral corticosteroids are the most effective treatment for SHS.
Complex regional pain syndrome type I (CRPS I, formerly known as reflex sympathetic dystrophy) is a painful neuropathic disorder that develops after trauma affecting the limbs without overt nerve injury. Clinical features are spontaneous pain, hyperalgesia, impairment of motor function, swelling, changes in sweating, and vascular abnormalities. In this study, the pathophysiological mechanisms of vascular abnormalities were investigated. Furthermore, the incidence, sensitivity and specificity of side differences in skin temperature were defined in order to distinguish patients with definite CRPS I from patients with extremity pain of other origin. In 25 CRPS I patients and two control groups (20 healthy subjects and 15 patients with other types of extremity pain), cutaneous sympathetic vasoconstrictor activity was altered tonically by the use of controlled thermoregulation. Whole-body temperature changes were induced with a thermal suit in which cold or hot water circulated. The vascular reflex response (skin blood flow, laser Doppler flowmetry, skin temperature, infrared thermometry) was analysed to quantify sympathetic outflow. Measurements were performed during a complete thermoregulatory cycle, i.e. during the entire spectrum of sympathetic vasoconstrictor activity from high (whole-body cooling) to low sympathetic activity (whole-body warming). Venous noradrenalin levels were determined bilaterally in five CRPS patients. (i) Three distinct vascular regulation patterns were identified related to the duration of the disorder. In the "warm" (acute) type of regulation, the affected limb was warmer and perfusion values were higher than in the contralateral limb during the entire spectrum of sympathetic activity. In the "intermediate" type of regulation the limb was either warmer or colder. In the "cold" (chronic) type of regulation, skin temperature and perfusion values were lower on the affected side during the entire spectrum of sympathetic vasoconstrictor activity. (ii) Noradrenalin levels were lower on the affected side, even in chronic patients with considerable cutaneous vasoconstriction. (iii) Temperature and blood flow differences between the two sides were dynamic and most prominent at a high to medium level of vasoconstrictor activity. (iv) In both control groups, there were only minor side differences in flow and temperature. In conclusion, it is suggested that, in CRPS I, unilateral inhibition of sympathetic vasoconstrictor neurones leads to a warmer affected limb in the acute stage. Secondary changes in neurovascular transmission may lead to vasoconstriction and cold skin in chronic CRPS I, whereas sympathetic activity is still depressed. Vascular abnormalities are dynamic. The maximal skin temperature difference that occurs during the thermoregulatory cycle distinguishes CRPS I from other extremity pain syndromes with high sensitivity and specificity.
The prevention of venous thromboembolism in medical patients remains questioned. All consecutive outpatients admitted in our medical unit were considered for inclusion in this study which aimed to estimate the prevalence of asymptomatic venous thrombosis on admission and the incidence during hospital stay. Exclusion criteria were: age <18 years, suspicion of venous thromboembolism, stay <4 days, ongoing anticoagulant therapy. Venous compression ultrasonography of the lower limbs was performed within 48 h. 234 patients were included. The prevalence of asymptomatic deep vein thrombosis on admission and the incidence during hospital follow-up were respectively 5.5% (95% confidence interval, 3.1 to 9.5%) and 2.6 per 1,000 person-days (95% confidence interval, 0.0 to 5.2). The prevalence and the incidence reached respectively 17.8% (95% confidence interval, 8.5 to 32.6%) and 6.0 per 1,000 person-days (95% confidence interval, 0.0 to 12.7) among patients over 80 years. A high prevalence of asymptomatic deep vein thrombosis on admission was suggested particularly among elderly medical patients.
The prevention of venous thromboembolism in medical patients remains questioned. All consecutive outpatients admitted in our medical unit were considered for inclusion in this study which aimed to estimate the prevalence of asymptomatic venous thrombosis on admission and the incidence during hospital stay. Exclusion criteria were: age <18 years, suspicion of venous thromboembolism, stay <4 days, ongoing anticoagulant therapy. Venous compression ultrasonography of the lower limbs was performed within 48 h. 234 patients were included. The prevalence of asymptomatic deep vein thrombosis on admission and the incidence during hospital follow-up were respectively 5.5% (95% confidence interval, 3.1 to 9.5%) and 2.6 per 1000 person-days (95% confidence interval, 0.0 to 5.2). The prevalence and the incidence reached respectively 17.8% (95% confidence interval, 8.5 to 32.6%) and 6.0 per 1000 person-days (95% confidence interval, 0.0 to 12.7) among patients over 80 years. A high prevalence of asymptomatic deep vein thrombosis on admission was suggested particularly among elderly medical patients.
Background: In paralysed limbs quite often edemas are seen, which might pose problems during rehabilitation. The origin of these edemas is not fully understood. Methods: 48 patients with hemiplegia and edema of the paralysed arm were studied; in 40 patients lymphoscintigraphic studies (static and dynamic lymphography) were performed. Results: In 80% of these cases lymphatic flow in the paralysed arm was increased compared to the healthy arm. If there was marked edema in the paralysed arm, the increase of lymph flow was considerable (p < 0,01). Conclusions: Edemas in hemiplegic extremities are not due to lymphedema, as in lymphedema the lymph flow usually is very slow. They most likely are caused by disorders of filtration and reabsorbtion, due to a dysfunction of the autonomic nervous system.
Vasomotor changes in extremities paralyzed by cerebral lesions have long been recognized. There has, however, been considerable question as to the correct interpretation of the manifestations which have been observed. A review of the extensive literature dealing with the recorded cases will be presented later. In the case reported here, the vasomotor changes, observed from the onset of the paralysis, were far more marked and definite than those usually reported. Because of the unequivocal character of these changes their relation to the known physiologic activity of the central and peripheral portions of the sympathetic nervous system seems clear. The case is presented in order to facilitate the correlation of the physiology of the human nervous system with recent developments in the study of the cortical representation of this system in infra-human primates (Fulton, Kennard and Watts) and to stimulate additional observations of vasomotor changes early in cases of paralysis of
Eighty-five consecutive post-CVA hemiplegic patients were assessed prospectively for radionuclide and clinical features of reflex sympathetic dystrophy (RSD). Scintigraphy, a safe and relatively noninvasive procedure, has proved to be more sensitive than clinical evaluation for early diagnosis of RSD. RSD was found to be mor prevalent in the post-CVA hemiplegic patient than previously reported. Twenty-one patients (25%) exhibited radionuclide evidence of RSD based on delayed scan criteria of increased uptake in the hemiplegic wrist, metacarpal-phalangeal (MCP) and interphalangeal (IP) joints. Two patients of soft tissue blood flow were observed. Eighty scan-positive RSD patients presented a low flow pattern identical to the non-RSD hemiplegic patients while the remaining thirteen exhibited a high flow pattern. Neither demographic characteristics co-morbid conditions, etiology of CVA, nor site of lesion had any bearing on RSD development. There was no clinical or radionuclide evidence of bilateral involvement commonly described in other heterogeneous RSD populations. Clinical diagnosis was difficult, as various features of the syndrome were often present for other reasons and the presentation was frequently incomplete. MCP tenderness to compression proved to be the most valuable clinical signs of RSD, with a predictive value, sensitivity, and specificity rates of 100%, 85.7%, and 100% respectively.
mechanisms of vascular abnormalities were investigated. perfusion values were lower on the affected side during Furthermore, the incidence, sensitivity and specificity of the entire spectrum of sympathetic vasoconstrictor side differences in skin temperature were defined in order activity. (ii) Noradrenalin levels were lower on the affected to distinguish patients with definite CRPS I from patients side, even in chronic patients with considerable cutaneous with extremity pain of other origin. In 25 CRPS I patients vasoconstriction. (iii) Temperature and blood flow and two control groups (20 healthy subjects and 15 differences between the two sides were dynamic and most patients with other types of extremity pain), cutaneous prominent at a high to medium level of vasoconstrictor sympathetic vasoconstrictor activity was altered tonically activity. (iv) In both control groups, there were only minor by the use of controlled thermoregulation. Whole-body side differences in flow and temperature. In conclusion, temperature changes were induced with a thermal suit in it is suggested that, in CRPS I, unilateral inhibition of which cold or hot water circulated. The vascular reflex sympathetic vasoconstrictor neurones leads to a warmer response (skin blood flow, laser Doppler flowmetry, skin affected limb in the acute stage. Secondary changes in temperature, infrared thermometry) was analysed to neurovascular transmission may lead to vasoconstriction quantify sympathetic outflow. Measurements were and cold skin in chronic CRPS I, whereas sympathetic performed during a complete thermoregulatory cycle, i.e. activity is still depressed. Vascular abnormalities are during the entire spectrum of sympathetic vasoconstrictor dynamic. The maximal skin temperature difference that activity from high (whole-body cooling) to low sympathetic occurs during the thermoregulatory cycle distinguishes activity (whole-body warming). Venous noradrenalin CRPS I from other extremity pain syndromes with high sensitivity and specificity. levels were determined bilaterally in five CRPS patients.
Chapter 185. Human Papillomavirus Infections.
1. A group of eight male patients with moderate hemiparesis was studied at rest and during 40 min of exercise on four occasions. Both two-leg and one-leg exercise were performed and each leg was studied separately. Arterial concentrations and leg exchange of carbohydrate substrates and free fatty acids were examined. In addition, the concentrations of intramuscular metabolites for each leg were measured at rest and immediately after exercise.
2. In two-leg exercise, oxygen uptake for the paretic leg was significantly lower than for the non-paretic leg at rest (55%) as well as during exercise (40%). Glucose uptake by the paretic leg was smaller (25–50%) and there was no measurable net leg exchange for lactate. Recordings of pedal pressure indicated that the paretic leg did considerably less work than the non-paretic leg throughout the exercise period. The rate of uptake of oleic acid was lower for the paretic leg (50%) in the resting state but similar for the two legs during exercise. The recovery of 14CO2 from [14C]oleic acid during exercise was significantly reduced for the paretic leg.
3. During one-leg exercise, oxygen and glucose uptakes by the working leg were similar for the paretic and non-paretic leg but lactate release was significantly greater for the paretic leg during exercise (30–45%).
4. The concentrations of ATP and creatine phosphate in the basal state were similar for the two legs. ATP and creatine phosphate fell significantly in the two legs during both the two-leg and the one-leg exercise period. The most marked decrease in ATP was noted for the paretic leg during one-leg exercise. The pattern of glycogen depletion during one-leg exercise for the paretic leg indicated primarily activation of the type II fibres. In contrast, the depletion pattern for the non-paretic leg suggested mainly recruitment of type I fibres.
5. The results indicate that, during exercise, paretic muscle shows a reduced blood flow, an augmented lactate production and a diminished capacity to oxidize free fatty acids. These metabolic derangements may be referrable to an augmented number and increased activation of type II muscle fibres as well as to alterations in the structure of muscle mitochondria. In addition, the present study indicates that one-leg exercise should be preferred to two-leg exercise when studying leg muscle circulation and metabolism in hemiparetic patients.
The purpose of the study is to investigate the relationship between the hemodynamic change and the production of edema in the hemiplegic leg. This study was designed to compare the hemodynamics in the involved edematous leg with that in the unaffected non-edematous leg in hemiplegic patient using straingauge plethysmography and photo-plethysmography. Examinations were undertaken in 20 patients with hemiplegia. Arterial Inflow Ratio [healthy side; hemiplegic side (100/ml ml/min)]: 19.2 +/- 16.2; 27.6 +/- 23.4. Venous Distensitivity: 1.5 +/- 0.8; 1.9 +/- 1.0. Maximum Venous Outflow: 90.8 +/- 43.1; 120.0 +/- 52.9. Tissue Flow Ratio: 1.1 +/- 0.5; 1.6 +/- 0.6. The values for hemiplegic side were significantly higher than those for healthy side in all patients. It was confirmed by using photo-plethysmography that none of the patients had arterial obliterative disease. It was suggested that one of the causes of the production of edema in a hemiplegic limb was due to the dilated capillary vessels and congested lower extremity.
It is commonly observed in patients with established hemiplegia following cerebrovascular accidents (CVA), that the skin temperature (Ts) of the leg and foot is notably cooler on the affected side of the body; the relationship to cutaneous blood flow, however, has not previously been investigated. In the present study, observations of foot and calf blood flow via venous occlusion plethysmography in water were made in six patients with hemiplegia of 5-13 months duration, both at observed Ts and at standard temperature (ST). Similar measurements were obtained on six age-matched control subjects. The patients' mean Ts values for the foot and calf were significantly lower on the affected side, while those for the nonaffected side were not significantly different from control group values. At non-equivalent water temperatures (Tw) blood flows in the patients' affected feet were lower than those on the nonaffected side, but at the ST they were similar. Further, under these conditions, the flows in both feet were lower than in control subjects. Flows in the patients' affected calves were not significantly reduced at non-equivalent TW; at the ST they did not differ significantly from those of the controls. These observations suggest that, in patients who have suffered a stroke, the reduction of TS of the affected limb is associated with reduced limb blood flow, which cannot be attributed to changes in limb tissue composition. Since the reduced limb blood flow on the affected side is more marked in the foot, it is likely to be due to reduction of blood flow in the skin. In addition, the reduction of flow in the foot of the nonaffected leg suggests a more generalized change of skin circulation in these patients.
Some stroke patients complain of an unpleasant sensation of coldness in the hemiplegic arm. This study aimed to determine the prevalence of this symptom and any associated features.
A questionnaire about symptoms in the arms was sent to patients at least 12 months after stroke. Reflex sympathetic dystrophy (RSD) was diagnosed if four typical symptoms were present in the arm.
One hundred patients were recruited and 75 complete replies received. The mean age of the patients was 74 years, and the mean time since the stroke was 19 months. Forty patients (53%) experienced unilateral coldness in the hemiplegic arm. In 14 this sensation was constant, and 10 rated the symptom as troublesome. The symptom developed at a median time of 1 month after stroke, but only 13 patients (32%) sought advice from a doctor. Sensory symptoms and arm and shoulder pain were common, but the only symptoms associated with coldness were numbness (P < .001) and color change (P < .05). Fifteen patients fulfilled the diagnostic criteria for RSD, 13 of whom had coldness only in the hemiplegic arm.
A sensation of coldness in the hemiplegic arm is common and distressing. It is associated with numbness and color changes in the arm. Some cases are caused by RSD, but other patients have coldness that may be due to other causes such as a vasomotor abnormality.
Symptoms interpreted as unilateral disturbances of autonomic function, such as coldness, dryness, sweating, and trophic changes, are well known but incompletely understood clinical problems after stroke. The present study provides data related to the incidence and mechanisms behind such symptoms.
Temperature perception thresholds, skin temperatures, evaporation rates, and skin blood flow responses were measured bilaterally in 37 stroke patients aged 58 +/- 13 years (mean +/- SD) and in a control group of 15 patients aged 64 +/- 15 years with a single transient ischemic attack.
Of the 37 stroke patients, 43% reported a sensation of coldness in the contralesional side of the body. Basal skin blood flow and temperature were relatively lower in the contralesional side. There was an excess of evaporation in the contralesional side after brain stem lesions and in the ipsilesional side after hemispheric lesions. Vasomotor reflex asymmetries occurred in 34% of the patients and were due to weak vasodilator or vasoconstrictor reflexes in the ipsilesional side. These abnormalities correlated significantly to sensations of unilateral coldness, hypalgesia, and thermohypesthesia in the contralesional side and anatomically to lesions in spinothalamo-cortical pathways.
Focal central nervous system lesions due to stroke may result in symptoms and measurable evidence of unilateral disturbance of skin sympathetic function. Vasomotor asymmetries are probably due to lesions of vasomotor pathways descending uncrossed. Subjective coldness may be due to disturbed central processing.
Disturbances of the autonomic nervous system are common in patients with various cerebrovascular diseases. They are attributed to damage of the central autonomic network, particularly in the frontoparietal cortical areas and in the brain stem, or to a disruption of the autonomic pathways descending from the hypothalamus via the mesencephalon, pons, and medulla to the spinal cord. The most common clinical problems include abnormalities in heart rate and blood pressure regulation, reflecting cardiovascular autonomic dysfunction, and asymmetric sweating with cold hemiplegic limbs, reflecting changes in the sudomotor and vasomotor regulatory systems. Bladder and bowel dysfunction and impotence are also frequent complaints after stroke, but the present knowledge concerning their prevalence and clinical significance is still limited. Cardiovascular autonomic dysfunction, which is mainly related to increased sympathetic activity, is most evident in the acute phase of stroke, whereas other autonomic disorders, such as abnormal sweating, are long-standing or even irreversible. In addition to the well-established sympathetic hyperfunction, abnormalities of the parasympathetic nervous system may also contribute to the autonomic imbalance after stroke. Reliable recognition of autonomic dysfunction using quantitative analysis methods is important, because these disturbances are not only subjectively disabling and uncomfortable, but they may also be prognostically unfavorable. Moreover, quantitative measurements also form the ground for successive treatment of various stroke-related autonomic disorders.
To determine the predictive value of measurements of hand edema for the development of reflex sympathetic dystrophy (RSD).
Cohort study.
Departments of rehabilitation medicine in 3 general hospitals and 1 rehabilitation hospital in Japan.
Thirty-four stroke patients.
Not applicable.
Measurement of the circumference of the middle finger was used to evaluate hand edema. The degree of hand edema was expressed by the ratio of circumference of the middle finger (RCMF) in the affected side to that in the uninvolved extremity.
Eight of 34 patients developed clinical RSD from 2 to 4 months after stroke. Hand edema showed a significant relationship to the development of RSD (ie, the patients who had an RCMF of above 1.06 at 4 weeks poststroke had significantly higher incidence of RSD than those with a lower RCMF; P=.0127).
It is possible to predict the development of RSD in hemiplegia by measuring hand edema 4 weeks poststroke.
Vascular responses to warming were studied in hemiplegic patients and after sympathectomy, using venous occlusion plethysmography of foot and leg. Comparisons were made with corresponding age groups. The pattern of response was essentially unchanged in hemiplegic patients, but was altered substantially where sympathetic pathways had been interrupted.
The circulation and unilateral edema in cerebral hemiplegia
- Weiss
Weiss, S., Ellis, L.B., 1930. The circulation and unilateral edema in cerebral hemiplegia. J. Clin. Invest. 9, 17–18.
Impedance pletismography in relation to the unilateral amputee
- Thompson
Thompson, R.G., 1965. Impedance pletismography in relation to the unilateral amputee. Bull. Prostate Res. 10, 82–90.
Hemiedema in cases of hemiplegia
- Luhan
Luhan, J.A., 1936. Hemiedema in cases of hemiplegia. Arch. Neurol. Psychiatr. 36, 42–57.
Szintigraphische Untersuchungen des Lymphtransportes in gelahmten oberen Extremitaten
- Werner
The cold hemiplegic arm
- Wanklyn