Symptoms and Treatment of Shoulder Hand Syndrome
Shoulder Hand Syndrome (CRPS) is characterized by pain and tenderness of metacarpophalangeal and proximal interphalangeal joints, associated with edema over the dorsum of the fingers, trophic skin changes, hyperaesthesia, and limited range of motion in both the hand and shoulder. 1
Clinical Presentation
Symptoms
- Pain and considerable reduction of movement in the shoulder joint, wrist, and hand 2
- Typically develops 1-6 months after stroke, beginning with shoulder pain and loss of range of motion, then progressing to involve the distal part of the extremity 2
- Edema over the dorsum of the fingers 1
- Trophic skin changes in the affected hand 1
- Hyperaesthesia (increased sensitivity to touch) 1
- Limited range of motion in both proximal (shoulder) and distal (hand) joints 2
Progression
- Develops in three consecutive phases: acute, dystrophic, and atrophic 2
- May present as a complete form affecting both distal and proximal parts of the extremity, or as incomplete forms confined to only one area 2
- Prevalence is estimated at 12.5-27% in stroke patients 2
Diagnostic Approach
- Diagnosis is primarily based on clinical findings 1
- Triple phase bone scan can assist in diagnosis, demonstrating increased periarticular uptake in distal upper extremity joints 1
- X-rays may not show significant changes in early stages 3
Treatment Options
Prevention
- Active, active-assisted, or passive range of motion exercises should be used to prevent CRPS 1
- Protecting the hemiplegic limb from trauma and injuries can reduce the frequency of shoulder-hand syndrome 1
- Avoid overhead pulleys, which encourage uncontrolled abduction and may increase risk of developing hemiplegic shoulder pain 1
Non-pharmacological Management
- Treatment of hemiplegic shoulder pain related to limitations in range of motion includes gentle stretching and mobilization techniques, focusing on increasing external rotation and abduction 1
- Active range of motion should be increased gradually in conjunction with restoring alignment and strengthening weak muscles in the shoulder girdle 1
- Local application of heat before exercise can provide symptomatic relief 4
- Splints and orthoses should be considered for thumb base involvement 4
Pharmacological Management
First-line Treatment
- If there are no contraindications, analgesics such as acetaminophen or ibuprofen can be used for pain relief 1
- Topical NSAIDs should be considered as first pharmacological treatment for mild to moderate pain 4
- Topical capsaicin may be effective for hand involvement 4
Second-line Treatment
- An early course of oral corticosteroids, starting at 30-50 mg daily for 3-5 days, and then tapering doses over 1-2 weeks can be used to reduce swelling and pain 1
- Oral corticosteroids are considered the most effective treatment for SHS based on systematic review 5
- For shoulder pain related to spasticity, injections of botulinum toxin into the subscapularis and pectoralis muscles could be used 1
- Subacromial corticosteroid injections can be used when pain is related to injury or inflammation of the subacromial region 1
- Nasal salmon calcitonin (300 units daily for 4 weeks) has shown satisfactory response in some cases 3
Important Considerations
- Shoulder pain can delay rehabilitation and functional recovery as it may mask improvement of motor function or inhibit rehabilitation 1
- Hemiplegic shoulder pain may contribute to depression, sleeplessness, and reduced quality of life 1
- 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 5
- Some patients with "idiopathic" shoulder pain may have underlying carpal tunnel syndrome and cubital tunnel syndrome, which should be evaluated when conventional treatments fail 6
- Treatment should be multidisciplinary, coordinated, and individualized based on the patient's specific symptoms and phase of the condition 7