Management of Shoulder Hand Syndrome in Elderly People

Introduction

Complex regional pain syndrome (CRPS) is chronic pain following a stroke, surgery, or an injury and usually affects the arms or the legs. It is also called reflex sympathetic dystrophy or Sudeck’s atrophy. Complex regional pain syndrome is of two types; Type I CRPS occurs after an illness or nerve injury, but it does not involve direct damage to the nerve in the affected area: Type II CRPS occurs following a distinct nerve injury. It usually develops as an exaggerated inflammatory response to a trauma or nerve damage, but the exact cause is unknown.

What Is a Shoulder-hand Syndrome?

A painful condition that leads to disabilities of the upper extremities is called shoulder-hand syndrome. It greatly impacts patients, their families, and the healthcare systems worldwide. It generally occurs between 2 to 36 weeks following a stroke and is seen in patients above 60 years, most commonly in males than females. Shoulder hand syndrome is often managed by non-pharmaceutical therapy, but the effectiveness of the treatment is unclear.

What Are the Signs and Symptoms of Shoulder-hand Syndrome?

Signs and symptoms associated with shoulder hand syndrome include:

• Sudden onset of pain in the shoulder, hand, elbow, and wrist.

• Swelling of the affected shoulder.

• Stiffness and discomfort in the affected shoulder and hand.

• Difficulty in the movement of fingers.

• Muscle atrophy (thinning of the muscles).

• Tingling, burning sensation, or numbness.

• Changes in the color of the skin, hair, and nail growth.

What Are the Associated Factors of Shoulder-hand Syndrome?

Some of the complications of shoulder hand syndrome include:

• Myocardial infarction (lack of blood flow to the heart muscles).

• Cervical spondylosis (degeneration of the cervical joint).

• Changes in blood circulation.

• Trauma.

• Hemiplegia (paralysis of either the left or right side of the body).

How Can Shoulder-hand Syndrome Be Managed in Elderly People?

The management of shoulder hand syndrome is quite challenging, especially in elderly people; it is usually treated by a multidisciplinary approach, including medications and physical therapy. The most commonly preferred mode of management is the non-pharmacological approach, but the effectiveness of the same is debated. The other modalities of treatment include traditional and pharmacotherapy. The ultimate aim in management is the gradual, steady, and fully functional restoration of the affected parts.

Some of the treatment modalities include:

• Physical Therapy: Occupational therapy or physical therapy uses a program of graded motor imagery (GMI) or therapy using mirror visual feedback (MVF). GMI and MVF therapies are based on increasing the attention towards the affected limb by performing exercises or modifying daily activities, which reduces pain, and the fear of movement and improves the range of motion.

• Mirror Therapy: It uses a mirror or a mirror box for the therapy and is conducted by asking the patient to sit before a mirror and move the healthy limb so that the brain perceives it as the limb affected by the syndrome. It helps to improve the sensory-motor function and reduces the pain and edema in the upper limb of the patients affected by a stroke.

• Splinting: The next objective is to reduce edema, normalize the sensations, facilitate normal positioning and increase the limb function to bring about independence in the working of the individual. Functional splinting can be resorted in those severe cases to improve blood circulation to the affected areas. Specialized garments or techniques of manually mobilizing the edema can help reduce it. Desensitizing techniques, either superficial or over the surface, are employed to normalize the area with increased sensitivity. The active movements can be initiated in the affected part, followed by weight loading, starting with smaller objects and gradually increasing the load.

• Pharmacotherapy: Before starting pharmacotherapy, it is essential to explain to the patient that no therapy has been proven to be completely beneficial in either curing or reducing the underlying symptoms. It is important to diagnose cases early, within 6 to 18 months of onset, as they respond better to nerve blocks or drugs acting as a bridge therapy followed by a natural healing process. The medicines that can be used include nonsteroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen, Naproxen, etc., and corticosteroids such as Prednisolone may be administered orally or injected locally into the shoulder. It is essential to practice monotherapy to avoid the adverse effects arising out of using multiple medicines.

The other medicines include tricyclic antidepressants, which are extremely beneficial in treating neuralgia and associated comorbidities like depression, anxiety, and insomnia. It has been noticed that starting the steroid treatment as early as possible is beneficial through immunomodulation (alteration in immunity). Drugs such as Bisphosphonates, Alendronate, and Calcitonin help bone-modulating metabolism and prevent bone loss in the affected area. Anticonvulsants, especially those blocking the entry of sodium and calcium into the neurons, have been beneficial by reducing the action potential. Carbamazepine, Oxcarbazepine, Gabapentin, Phenytoin and Lamotrigine can be used. Opioids such as Morphine, Tramadol, and Tapentadol and inhibitors of monoamines like Serotonin and Noradrenaline have also been found to be beneficial to some patients. Ketamine, Amantadine, and Dextromethorphan act by blocking the NMDA receptors and have also been recommended in some cases, and reasonable benefit has been established.

• Orthoses: Special devices such as braces or splints immobilize the affected area, help prevent shoulder subluxation in post-stroke patients, and decrease the risk of the shoulder-hand syndrome.

• Acupuncture: It is usually combined with a rehabilitation program and involves the insertion of long and thin needles, which help stimulate the nerves and muscles, thereby increasing the blood flow. Acupuncture reduces pain and improves limb function and performance of daily activities compared to the rehabilitation program alone.

• TENS Therapy: Transcutaneous electric nerve stimulation involves the application of electrical impulses to the nerve endings, which helps in reducing the pain in the affected hand and shoulder and improves mobility.

• Lasers: Laser treatment is also effective in reducing the pain and swelling of the affected limbs, promoting patient independence, and improving the range of motion.

Conclusion

A painful condition leading to disabilities of the upper extremities is called shoulder-hand syndrome; it usually occurs following a stroke, surgery, or injury to the nerve. It is usually associated with a sudden onset of pain in the shoulder, hand, elbow, and wrist, swelling, and stiffness of the shoulder, leading to a decreased range of motion. It is usually managed by medications and physiotherapy followed by rehabilitation techniques to restore the function of the limbs gradually and helps promote independence among patients.