Quantitative sensory study on post-stroke shoulder-hand syndrome*

Xiao-Hong Zi, Yi Yuan* Hai-Qing Xu

Xiao-Hong Zi, Yi Yuan, Hai-Qing Xu, Department of Neurology, Third Xi- angya Hospital, Central South University, Changsha 410013, Hunan Province, China

Xiao-Hong Zi!, Male, Han Nationality, Born in 1962 in Changsha City, Hunan Province, China, Master of Central South University in 1991, Professor. Research direction: cerebrovascular dementia.

Lixiaoz200@ yahoo. com. cn

Telephone: + 86-25-8638601

Received: 2003 -08 -26 Accepted: 2003 -12-10 (04/SZY)

Abstract

BACKGROUND: It is certain that patients with shoulder-hand syndrome (SHS) have a decline in sensation. However, questionnaire or clinical evaluation for sensory disorder is not accurate.

OBJECTIVE： To explore the thermal and vibration sensations of post-stroke patientsby quantitative sensory testing (QST) in an attempt to assess the relationship between small nerve fibre function and SHS.

DESIGN： A case-controlled study.

SETTING AND SUBJECTS: Thirty cases of post-stroke paralysis were selected from outpatients and inpatients in the Third Xiangya Hospital of Central South University from 2000-06 to 2001-04.

METHODS: Limit method was carried out to examine thermal, pain and vibration sensations of affected upper limbs of the matched control patients (control group, n = 15) and the patients with post-stroke shoulder-hand syndrome(SHS group, n = 15). Incidences of shoulder-hand syndrome in two groups were also compared.

MAIN OUTCOME MEASURES: The incidence of sensory disorder, thermal, pain and vibration sensation.

RESULTS: Incidence of sensations dysfunction in SHS group was 67% , significantly higher than that in control group(27% , P < 0. 05). Lowered cold-threshold(26. 73 ± 4. 48 vs 29. 89 ±1.57, P < 0. 05)and elevated warm-threshold(26. 73 ±4. 48 vs 29. 89 ±1.57, P <0.05)were found in both SHS group and control group without significant difference between them. Difference among cold-evoked pain, heat-evoked pain and vibration thresholds was found significantly( P < 0. 01 ⁾ . Differences between cold evoked pain threshold and cold threshold, as well as heat-evoked pain threshold and warm threshold were significant( P < 0. 01).

CONCLUSION: Incidence of disordered sensation function in post-stroke paralyzed patients with SHS increases significantly, which mostly presents by reduced thermal sensation and hyperalgesia. C and A8 nerve fibre dysfunction may play an important role in the pathogenesis.

Zi XH, Yuan Y, Xu HQ. Quantitative sensory study on post-stroke shoulder-hand syndrom.. Zhongguo Unchuang Kangfu 2004; 8(4): 764 —5( China) http: / /www. zglckf. com/2004ml/04 - 04zy. pdf

INTRODUCTION

Shoulder-hand syndrome (SHS), also known as reflex sympathetic dystrophy⑴，is a relatively common finding in post-stroke paralyzed patients with an incidence of 12.5% - 61. 0%. Clinical manifestations include spontaneous pain, pressure pain and hyperalgesia of affected limbs, as well as motor limitation and vasoconstrictive disorder. Increased incidence of SHS in patients with reduced sensation of affected limbs has been reported ⑵，which was believed unrelated to type, region and gender, as proved by questionnaire investigation and clinical examinations!³¹ . Therefore quantitative sensory testing was applied in the study to explore sensation impairments of SHS so that their correlation with small nerve fibre can be determined.

SUBJECTS AND METHODS

Subjects

Fifteen patients with SHS due to stroke and fifteen matched control patients were included from the outpatients and inpatients of the Third Xiangya Hospital from June, 2000 to April, 2001. All subjects were accorded with diagnostic criteria established by the Second National Conference on Cerebravascular Diseases(1986)⑷ and confirmed by CT scanning. Those who suffered from the second stroke and other peripheral nervous dysfunction resulted from diabetes, chronic alcoholism and renal dysfunction were excluded. Patients with shoulder-joint impairment, shoulder injury, neck vertebra dis- easeor armclum wrist tube syndrome and those who were unconscious or severe speechless were also excluded. The mean age of SHS group was(63. 60 ± 6. 17) years old and the course was(39. 80 ±31, 61) days, compared to(61. 60 ± 7. 27) years old and(39. 06 ±34. 80) days in the control group, respectively, which had no significant dif- ference( P >0. 05). Diagnostic criteria accorded with Daviet's⑸. Quantitative sensory testing

TSA2001-Type quantitative nerve sensory analysis instrument was purchased from Medoc. Com, Israel. Method of limits was used for all the sensation examinations. Thenar eminence and affected thumb were subjected to thermal and vibration sensation examinations. A contact thermode with beginning temperature of 32 \ was used to apply a constant 1 \ / s increase (warm and heat-evoked pain ) or decreasing ( cold and cold-evoked pain ) thermal stimulus until the patient pressed the response button to show that a temperature change felt by the patient. Thus we got a thermal threshold, and then repeated it for the next stimulus for totally 4 times to get the mean values. Vibration stimulus kept at a constant 0.1 -12 pm/s increase and repeated for totally 5 times. Variance of data higher than 1 was considered that the operator' s subjec- tivel factors were involved in the examination and re-operation was required. Sensory reduction was confirmed by one of following criteria: cold threshold ! 28 \ ; warm threshold " 36 \ ; cold-evoked pain threshold ! 5 heat-evoked pain threshold " 51 \; vibration threshold "5 pm/s( accorded with normal range provided by Medoc Com. ) .

Statistical analysis

SPSS 10. 0 software was adopted. Quantitative data were expressed as Mean ± SD. Student' s t test was used for comparing the means of paired groups; Counting data was expressed by frequency and ratio and Chi-square test was used to compare the difference. P < 0. 05 means significant difference.

RESULTS

Incidence of sensory disorder

Ten patients in SHS group( # = 10) suffered from sensation disorder with an incidence of 67%, compared to 27% in control group( # =4). The difference was significant^ P < 0. 05

Quantitative sensory testing

Significantly lowered cold threshold and elevated warm threshold were found in SHS group, significantly different from those of control group(26. 73 ±4. 48 vs 29. 89 土 1.57, P <0. 05; 36. 83 ± 1. 90 仍 35. 40 ± 0. 89, P < 0. 05, respectively⁾. Cold-evoked pain, heat-evoked pain and vibration threshold between groups had no significant difference. But difference between cold-evoked pain threshold and cold threshold, as well as heat-evoked pain and heat threshold were significantly reduced in SHS group compared to those of control group(4.97 ±2. 17 and 8.83 ±4.51, P < 0.01"#

5. 37 ± 2. 20 and 8. 14±2. 48, $ = —2.99" = —3.23, P <0.01， as shown in Table 1.

DISCUSSION

Pathogenesis of post-stroke SHS still remained unknown. Since it is predominated by spastic flexor of affected upper limbs, bladebone sinkage, backward contraction and shoulder inward circle, trauma and shoulder joint half-dislacation was liable to occur because the shoulder bone will slide away when making outward movements ； In addition, since surrounding tissues are rich in nerves, which consist of autonerves and sensation nerve fibres, tiny bleeding and nervous inflammatory reaction can be induced by repeated traumas, which is resulted in dilated capillary, increased permeability and activated C nociceptor and AS mechanic stimulus receptor ⑹ .Therefore it may be correlated with peripheral nerve impairmentsSensation impairments in patients with SHS lead to deficient protection of affected limbs, resulting in the occurrence of the above conditions. In our study, significantly increased incidence of sensation obstacle was found in patients with SHS(67.7% )， higher than 41.7% reported by Chalsen， which might be due to higher sensitivity of QST, subclinical case enrollment and proportionally small sample.

For a long time, judgment of sensation dysfunction had depended on clinical examinations and even the patients' subjective description, which was difficult to quantify and lacked of repeatability, specificity and efficiency in trials. According to nervebiology, cold were proved to be conducted by small marrow nerve fibres (AS), heat by marrowless C nerve fibres, while cold-evoked pain by combination of AS and C nerve fibres ； heat-evoked pain mostly conducted by C nerve fibers with some by AS fibers; and vibration by big marrow A" fibers!¹¹¹ . By testing the thresholds of these sensations, mall nerve fiber functions can be judged. QST currently is the only preferable measurement for judgment. Tahmoush et a/^[12] reported significantly lowered cold-evoked pain and heat-evoked pain threshold in patients with SHS without cold， heat and thermal threshold changes. QST in this study also proved normal vibration threshold in SHS group, indicating no A" impairment, while declined cold threshold accompanied with increased heat threshold might due to different enrolling standards, because higher incidence of sensation dysfunction occurred in stroke patients than in the common people. This study also found that, though cold-evoked pain and heat-evoked pain thresholds were normal in SHS group, difference between cold and cold-evoked pain threshold, as well as heat and heat evoked pain thresholds reduced significantly than those in control group, suggesting that small thermal changes induced hyperglysia might support the hypothesis that C and AS nerve fibres play an important role in SHS.

To conclude, incidence of sensation disorder in post-stroke paralyzed patients with SHS increases significantly, mainly presented by thermal sensation reduction and hyperglysia, amongst which C and AS nerve fibres may play an important role in SHS pathogenesis. Because of the limitation of sample size and detection location, nowadays it is difficult to completely determine the functions of different nerve fibres in post-stroke SHS pathogenesis.

REFERENCES

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脑卒中肩手综合征患者感觉障碍的定量分析!

资晓宏，袁 毅,徐海清(中南大学湘雅三医院神经内科,湖南省长沙市 410013)

资晓宏★，男，1962年生，湖南省长沙市人，汉族，1991年中南大学湘雅 医学院硕士毕业，教授，主任，主要从事脑血管疾病的研究。

摘要

背景:脑卒中偏瘫后肩手综合征(shoulder-hand syndrome, SHS)患者感觉 减退已被证实，而感觉障碍的评估多用问卷式调査或仅为粗略临床检 査来完成，难以精确评估。

目的：运用定量感觉检查技术(quantitative sensory testing, QST)检査脑卒 中后肩手综合征观察组和脑卒中对照组各15例患者的温度觉及振动 觉，并进行定量分析，以了解小纤维神经功能状态及其与肩手综合征的 关系。

设计:病例对照研究(case-control study) □

地点和对象：研究地点为中南大学湘雅三医院，对象涉及2000-06/ 2001-04湘雅三医院门诊及住院脑卒中后瘫痪病例。

方法：用界限法分别检查观察组与对照组偏瘫侧上肢大鱼际掌侧温度 觉阈值与拇指掌侧振动觉阈值。检査温度觉时，使用一个小的与检测区 皮肤接触的热电极探头，探头温度以1 D/s速度递增(热觉、热痛觉) 或递减(冷觉、冷痛觉)，直至受检者产生感觉的那一刻由受检者本人按 下按钮停止刺激。得到一个温度觉阈值，探头温度恢复到预置温度准备 下一次刺激。重复4次得到平均温度觉阈值-在检测振动觉时,振动器 的刺激强度以0. 1-12 pm/s的速度递增，重复检测6次。

主要观察指标:感觉障碍发生率,温度觉、痛觉及振动觉的数据。

结果：SHS组中感觉障碍发生率为67%较对照组27%显著增高(P I 0. 05)。SHS组与对照组定量感觉比较，主要表现为冷觉阈值降低(分别 为 26.73 ±4.48, 29.89±1.57, P <0. 05)，热觉阈值增高(分别为 36.83 土1.90, 35.40 土0.89, P <0.05，冷痛觉阈值、热痛觉阈值与振 动觉阈值之间的差异无显著性意义。冷痛觉阈值与冷觉阈值的差值(P

< 0. 01)及热痛觉阈值与热觉阈值之间差值(P < 0. 01)差异有显著性 意义。

结论:脑卒中偏瘫后SHS患者感觉障碍发生率显著增高□主要形式为温 度觉减退和痛觉过敏°C类和A8类神经纤维功能障碍可能在SHS发病 中起重要作用。

主题词:脑血管意外;反射性交感神经营养障碍;偏瘫

中图分类号:R743文献标识码:A 文章编号:1671 — 5926(2004)04 — 0764 - 02 资晓宏，袁毅，徐海清.脑卒中肩手综合征患者感觉障碍的定量分析IJ1.中国临 床康复,2004,8(4) ：764-5

http: / /www. zglckf. com /2004ml /04 — 04zy. pdf

(Edited by Gu LJ/Sun SG/Wang L)