Presentation of the Shoulder and Hand Due to Hemiplegia
11.7 Edema of the Hand
Hemiparetic shoulder pain may be associated with edema of the hand. An untreated edematous hand can lead to irreversible contractures of the hand and fingers that interfere with potential functional use of the hand in the future. This condition is also referred to as the shoulder hand syndrome or complex regional pain syndrome (CRPS), sympathetic reflex dystrophy, causalgia or sudeatrophy. The reported inci- dence of Shoulder hand syndrome after stroke varies, with an estimated prevalence between 2 and 49% (Chae, 2010). The symptoms of the edema to the hand are divided into three stages:
– First stage
– There is sudden swelling of the whole hand and fingers, leading to movement restriction at the joints of the hand and the wrist. The edema is mainly visible on the back of the hand and usually ends just above the wrist joint. Wrinkles of the skin disappear and the tendons of the hand are no longer visible. The swelling feels soft and the color of the hand changes; usually a pink or purple tint will appear. The hand feels warm and sometimes moist. The nails look whiter and
11 Presentation of the Shoulder and Hand Due to Hemiplegia
110
less translucent than those of the non-affected hand. There is also noticeable pain that exacerbates throughout exercise and practice.
– Second stage
– When the hand is not treated properly, the pain becomes so severe that the patient no longer tolerates the caregiver exercising minimal pressure on their hand or fingers. Hard knots may appear on the back of the hand and typically osteopo- rotic changes may be visible upon X-ray examination.
– Third stage
– When a hand is not treated, the edema will disappear, as will the pain. In this stage mobility has been lost and there is atrophy in hand. This results in serious deformation of the hand and fingers, which can no longer be effectively used by the patient.
11.7.1 Causes
The sudden onset of symptoms, in patients who did not previously suffer from pain or restriction of movement, seems to indicate that there is a specific cause of the edema and that inactivity and the “hanging” of the arm subsequently maintain these symptoms. Several studies indicate the role of reduced shoulder stability as a cause of CRPS development.
Different causes can contribute to the emergence of the edema:
– Palmar flexion:
– Palmar flexion is the prolonged flexion in the wrist, with the palm to the forearm.
The patient is often resting in the bed or sitting in their wheelchair for a long time, in which the wrist is often unnoticeably positioned in palmar flexion. Due to this state of the wrist, the venous drainage of the hand is blocked.
– Dorsal flexion:
– Dorsal flexion is the overstretching of the wrist, with the hand bending to the forearm. This can occur during ADL practice or during therapy session, where the patient rests on their hemiplegic arm on the couch or the bed, thereby pushing the movement toward dorsal flexion.
– Light injury
– In case of reduced sensation or inattention of the affected side, the patient may suffer light injury. For example, the hand may get caught in the wheelchair wheel without the patient being aware of it. This can also lead to edema of the hand.
11.7.2 Prevention and Treatment of the Edema
In order to prevent edema of the hand, the patient, caregiver and multidisciplinary team must pay attention to the following issues:
– Good positioning of the arm in bed and in the (wheel) chair;
– Avoid excessive bending or stretching of the wrist;
L. A. Vroon van der Blom and T. M. Silveira
111
– Prevention of trauma at the hand/arm;
– A wheelchair worktop and/or a preventive splint can be considered when the patient is unable to take good care of his hand.
When there is an edema, it is important that treatment commences at the first stage of the condition. The primary treatment goals are: reduction of the edema, pain relief, retention of mobility and functional recovery.
References
Chae J. Post stroke complex regional pain syndrome. Top Stroke Rehabil. 2010;17(3):151–62.
Dutch Heart Foundation, Committee Stroke-Rehabilitation. Rehabilitation after stroke guidelines and recommendations for healthcare providers. The Hague: Dutch Heart Foundation; 2001. In Dutch.
Harrison R, Field TS. Post stroke pain: identification, assessment, and therapy. Cerebrovasc Dis.
2015;39(3–4):190–201.
Hatem SM, Saussez G, della Faille M, Prist V, Zhang X, Dispa D, Bleyenheuft Y. Rehabilitation of motor function after stroke: a multiple systematic review focused on techniques to stimulate upper extremity recovery. Front Hum Neurosci. 2016;10:442.
Intercollegiate Stroke Working Party. National clinical guidelines for stroke: prepared by the Intercollegiate Stroke Working Party. 5th edn; 2016.
Lindgren I, Gard G, Brogårdh C. Shoulder pain after stroke—experiences, consequences in daily life and effects of interventions: a qualitative study. Disabil Rehabil. 2017;40:1–7.
Lohman AHM. Shape and movement, manual of human movement apparatus. 11th ed. Houten:
Bohn Stafleu van Loghum; 2008. In Dutch.
11 Presentation of the Shoulder and Hand Due to Hemiplegia
113
© Springer International Publishing AG, part of Springer Nature 2018 B. Buijck, G. Ribbers (eds.), The Challenges of Nursing Stroke Management in Rehabilitation Centres, https://doi.org/10.1007/978-3-319-76391-0_12 E. T. M. Sarr-Jansman
TallKing Results B.V, Ugchelen, The Netherlands e-mail: [email protected]
D. J. Rowberry, R.N. (*)
College of Human and Health Science, Swansea University, Swansea, UK e-mail: [email protected]