Comparison of Catecholamine Levels in Hemiplegic Patients with and without Reflex Sympathetic Dystrophy

OBJECTIVE: To determine whether the cause of sympathetic dysfunction is due to increased regional sympathetic outflow or receptor supersensitivity to circulating catecholamines in the pathogenesis of reflex sympathetic dystrophy in hemiplegia. METHOD: Ten hemiplegic patients with reflex sympathetic dystrophy were instructed to refrain from smoking or using caffeine and alcohol, and medications that influence catecholamine metabolism were witheld for 24 hours before blood sampling. Patients with cardiovascular disease, diabetes or abnormal liver and renal function tests were excluded from the study. Patients with a history of sympathectomy were also excluded. Ten hemiplegic patients without reflex sympathetic dystrophy served as the control group. Both groups of patients rested in supine position in a quiet room for 30 minutes. A needle with heparin cap was inserted into the dorsal venous arches of the affected hand and patients rested for another 20 minutes, after which blood was drawn through the heparin cap. The blood samples were assayed using high-performance liquid chromatography (HPLC) and norepinephrine and epinephrine were detected electrochemically. 24 hour urine was collected during rest and vanillylmandelic acid (VMA) and metanephrine were also detected using HPLC. RESULTS: The mean plasma norepinephrine levels were 1.05 0.24 ng/ml and 0.47 0.06 ng/ml in RSD affected and unaffected groups respectively, and the plasma norepinephrine level was significantly higher in the patient group with reflex sympathetic dystrophy (p<0.05). The plasma epinephrine and 24-hour urine VMA and metanephrine levels were not significantly different in two groups. CONCLUSION: These results may support a hypothesis of increased regional sympathetic outflow in the pathogenesis of reflex sympathetic dystrophy in hemiplegia.

Effects of Intra-Articular Injection and Subscapularis Motor Point Block on Painful Hemiplegic Shoulder

OBJECTIVE: To evaluate the effects of intra-articular injection of shoulder and subscapularis motor point block on painful hemiplegic shoulder. METHOD: Thirty painful hemiplegic shoulder of recent onset stroke were divided randomly into three groups, i.e. group I: range of motion (ROM) exercise only, group II: intra-articular injection with ROM exercise, group III: subscapularis motor point block with ROM exercise. The intra-articular injection of shoulder was done with 20 ml of normal saline, 5 ml of 1% lidocaine, and 40 mg of triamcinolone. The subscapularis motor point block was done with 5 ml of 5% phenol under electromyographic guide. The ROM in external rotation and simple X-ray of shoulder in full abduction were checked in three groups at pre-treatment and post-treatment 3 week, and the glenohumeral abduction and scapulohumeral rhythm were obtained from the shoulder X-ray. RESULTS: There were significant (p<0.05) improvements of glenohumeral abduction, external rotation, and scapulohumeral rhythm of shoulder in group II and III, but improvement of only glenohumeral abduction was significant in group I. Angular increment of glenohumeral abduction and external rotation was most significant in group III compared with other two groups. CONCLUSION: These results suggest that the intra-articular injection of shoulder and subscapularis motor point block are potentially useful techniques in the prevention and management of the painful hemiplegic shoulder.