Method: Retrospective chart review was performed in 561 patients. Among 561 stroke patients, 116 subjects were recruited and classified into two groups: patient group, 43 cases with RSD; control group, 73 cases without RSD. Upper extremity function was assessed based on feeding, dressing and personal hygiene scores of the modified Barthel index at the beginning of rehabilitation treatment and at the time of discharge. Causes of stroke and length of stay were recorded. Median nerve-somatosensory evoked

potential studies were performed and assessed.

Results: The incidence of RSD was 7.7% and the time to development of RSD was 62.3±34.1 days after the onset of stroke. There was no significant difference in functional status between two groups at initial and final evaluation. The upper extremity function had improved in both groups although the length of stay was longer in patient group. SSEP abnormalities were more frequent in the patient group.

Conclusion: The presence of well-managed RSD affected neither the functional status nor the functional recovery of upper extremity in stroke patients. (J Korean Acad Rehab Med 2003; 27: 480-484)

Objective: The purpose of this study is to assess the changes of skin temperature quantitatively in the stroke patients with reflex sympathetic dystrophy syndrome (RSDS) using thermography according to their clinical phases as well as changes after treatment.

Method: Patient group was consisted of 17 stroke patients with RSDS. Mean onset time of RSDS after stroke was 10.6 weeks. All patients were assessed by triphasic bone scan and clinically classified by phase I, II, and III. Control group was consisted of 9 stroke patients without RSDS. Temperature difference between affected side and unaffected side in wrist and hand regions were assessed in all subjects using Thermovision 570 (Agema Infrared Systems, USA) when initial clinical diagnosis was made. Seven patients were reassessed after high dose steroid and physical therapy.

Results: In patients with phase I RSDS, affected wrist and hand showed higher temperature distribution than the unaffected side. On the other hand, patients with phase II and III showed lower temperature in the affected side. The mean temperature difference in patients with phase I RSDS was significantly greater than control group. After treatment, skin temperature of affected side was decreased in phase I patients, but increased in phase II patients. Skin temperature difference tended to be normalized after successful treatment.

Conclusion: Using thermography, temperature change of affected hand can be assessed quantitatively in stroke patients with RSDS. The thermography is considered to be a useful tool for evaluation of clinical phases and treatment effect in these patients.

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.

Objective: To evaluate the change of abnormal spontaneous activities according to the clinical and radiologic findings, and to the time course after onset in hemiplegic upper limb.

Method: We scored abnormal spontaneous activities of hemiplegic upper limb muscles (infraspinatus, deltoid, extensor carpi radialis, abductor pollicis brevis, abductor digiti minimi) in 100 hemiplegic patients without peripheral neuropathy. The abnormal spontaneous activities were evaluated according to their radiologic findings and to Brunnstrom stage and the presence of reflex sympathetic dystrophy (RSD), and the time course after the onset (A cross-sectional study). In addition we repeatedly examined 40 hemiplegic patients until 12 weeks after the onset to define the pattern of change (A prospective study).

Results: There was no significant difference in the score of abnormal spontaneous activities according to the radiologic findings. The score of abnormal spontaneous activities decreased while Brunnstrom stage progressed. In both the cross-sectional and prospective studies, we found that the abnormal spontaneous activities decreased according to the time course after the onset in the limb without RSD, but sustained in the limb with RSD.

Conclusion: Abnormal spontaneous activities decreased according to the progression of Brunnstrom stages. The hemiplegic patients with RSD showed more profuse and sustained abnormal spontaneous activities at needle EMG study of hemiplegic upper limb than the patients without RSD.

Objective: We studied the prevalence of abnormal spontaneous activities in hemiplegic upper limbs, its nature and correlation with various clinical features.

Method: Forty-seven patients with hemiplegia from various central nerve system disease within about four months from disease onset were included in the study. The patients who showed obvious clinical evidence of peripheral nerve system disease were excluded. Motor and sensory nerve conduction studies (NCS) of median and ulnar nerves in hemiplegic limbs and motor nerve conduction studies of axillary nerve in both side were done. The cases demonstrating abnormal NCS were excluded in data analysis. Needle electromyography (EMG) was done in proximal muscles (deltoid, supraspinatus, infraspinatus, biceps brachii) and distal muscles (abductor pollicis brevis, abductor digiti quinti and first dorsal interosseous). Muscle strength of shoulder abduction and mass grasp were measured by manual muscle test. Development of shoulder hand syndrome was investigated through clinical examination.

Results: Mean period from onset of hemiplegia to EMG examination was 45.2⁑23.8 days (8∼108 days). Abnormal spontaneous activities were observed in 78% of patients in one of the muscles examined and were found more frequently in distal muscles than proximal muscles. Frequency of spontaneous activities was not significantly related to the time after onset of disease during the first 4 months. Spontaneous activities were more frequently observed in distal muscles with strength of less than good or fair grade. Patients with spontaneous activities showed tendency to higher incidence of shoulder hand syndrome but there was no statistical significance.

Conclusion: Hemiplegic upper limbs showed frequent abnormal spontaneous activities without definite peripheral nerve involvement. Its unique pattern of distribution should be kept in mind when we meet hemiplegic patients in electromyographic consultation.

Objective: Reflex sympathetic dystrophy (RSD) is a syndrome of post-traumatic neuropathic pain in association with dystrophic changes and signs of sympathetic overactivity. Pain following spinal cord injury occurs frequently, but RSD is not usually considered as one of the common sources of pain. There have only been a few reports of RSD in spinal cord injured patients, although this condition is well-known in the painful upper extremity of hemiplegia due to stroke. The purpose of this study was to investigate the rate of occurrence, characteristic clinical features and more objective evaluation tools for the diagnosis of RSD in cervical cord injured patients.

Method: Thirty-two cervical cord injured patients were evaluated for hand pain, swelling, vasomotor changes and dystrophic skin or nail changes. The patients were evaluated with studies such as three phase bone scintigrathy, digital infrared thermographic imaging (DITI) and plain roentgenograms of the hands.

Results: Eighteen patients (56.3%) were diagnosed as RSD based on the clinical symptoms and findings of three phase bone scintigraphy. Characteristic symptoms were hand pain, edema and dystrophic skin or nail changes, in the order of frequency. In patients with spasticity of the upper extremity, the incidence of RSD was higher than in patients without spasticity.

Conclusion: We should consider RSD as a cause of upper extremity pain in cervical cord injured patients. This will lead to early diagnosis and treatment of the condition and it will be helpful in preventing various complications.

Objective: The purposes of this study were to measure the effect of Stellate ganglion block(SGB) objectively and quantitatively by the use of sympathetic skin response(SSR), and to evaluate the cumulative effects and complications of repetitive SGB and to find out optimal numbers of injection per one cycle in the patients with reflex sympathetic dystrophy(RSD).

Method: Six patients with RSD were evaluated with a SSR test before and after the injection of 1% lidocaine 4 ml by SGB method.

Results: There was a significant prolongation of latencies in SSR of the lesion side of sixty mixed cases by the SGB methods and SSR tests. There were no significant changes in the latency and amplitude of SSR from the lesion side between pre- and post injection states. There was a significant decrease of amplitude in the sound side after the injection. The differences of the amplitudes between pre- and post injections were significantly higher in the lesion side than the sound side. The degree of pain of the patients with RSD was evaluated by visual analogue scale(VAS), which scored on pre and post injection state decreased from 10 to 6.5 by 5 times injections, but did not decrease by more injections.

Conclusion: We concluded that SGB is more effective in the RSD lesion side than the sound side and the SSR is a useful test for evaluating the effect of SGB.

In 12 Reflex Sympathetic Dystrophy(RSD) patients(13 cases) after the acute stroke, Three- phase Bone Scintigraphy(TBS) was performed to evaluate whether the amount of radioisotope reflects the disease activity of RSD. The diagnosis of RSD was based on Kozin's criteria(definite or probable group) and scintigraphic findings(increased radioisotope uptake in all three phases). Initial TBS was performed within 10 days after the onset of clinical symptoms and it was followed up within 5days after the short term steroids therapy. Before and after the steroids therapy, patients were evaluated with respect to pain, swelling and allodynia. Radioisotope uptake of ROI(Regions Of Interest) of all three images was calculated semiquantitatively in initial and follow up scintigraphy.

Pain, swelling and allodynia of the affected hand were improved in all patients after short-term oral corticosteroids therapy. Radioisotope uptake in blood flow image(11 patients, 12 cases) and blood pool image(11 patients, 12 cases) were decreased(p＜0.05), but radioisotope uptake in delayed image was not decreased(p＞0.05).

We concluded that radioisotope uptake in blood flow and blood pool images could reflect disease activity of RSD. It was suggested that decreased capillary vascular permeability by corticosteroids resulted in decreased blood flow and blood pool. The semiquantitative evaluation of TBS may be useful for monitoring the response to therapeutic intervention.

The role of inflammatory mediators in RSD and pharmacologic effect of corticosteroids were also discussed.