Annals of Rehabilitation Medicine

The Intra-articular Shoulder Injection of Botulinum Toxin A on Stroke Patients with Complex Regional Pain Syndrome.: Kang, Jin Woo , Song, Sun Hong , Koo, Jung Hoi , Kim, Dong Kyu , Joo, Young Jin , Kim, Tae Hoon , Joh, Kwang Duk , Kim, Ui Nyeong; J Korean Acad Rehabil Med 2010;34(6):683-690.

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Objective To evaluate the short-term clinical effects of intra-articular shoulder injection with botulinum toxin type A (BoNT-A) in acute hemiplegic stroke patients with complex regional pain syndrome type I (CRPS I).

Method Fifty patients were assigned at random to receive intra-articular shoulder injection. The treatment groups were divided into two groups: BoNT-A group, 200 IU of BoNT-A and 2 ml of normal saline; triamcinolone acetonide (TA) group, 20 mg of triamcinolone and 2 ml of 2% lidocaine. Uptake ratio of quantitative three phase bone scintigraphy (QTPBS) was calculated by dividing the radioactivity count on the affected side by that on the unaffected side. Shoulder pain was assessed by visual analogue scale (VAS) and neuropathic pain scale (NPS). Range of motion (ROM) of shoulder joint and functional independence measurement (FIM) of upper limb were evaluated. All of them were measured before injection, and 4 weeks after injection.

Results After 4 weeks, the uptake ratio of blood pool phase was significantly decreased in hands of BoNT-A group than TA group. VAS, ROM and upper extremity FIM was similarly improved in both groups. Pain intensity and cold pain of NPS were similarly decreased in both groups. Hot pain and dull pain of NPS decreased more significantly in BoNT-A group than TA group.

Conclusion In the short-term, intra-articular BoNT-A shoulder injection maybe has the therapeutic effect on acute CRPS I related stroke. And the uptake ratio of blood pool phase of the hand of QTPBS may be useful to assess the therapeutic effect of CRPS after acute stroke.

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Clinical Efficacy of Quantitative Bone Scintigraphy in Shoulder Adhesive Capsulitis.: Lee, Yong Taek , Park, Jung Mi , Chung, Seung Hyun; J Korean Acad Rehabil Med 2007;31(6):735-741.

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Objective
To evaluate the clinical efficacy of the quantitative bone scintigraphy in shoulder adhesive capsulitis (AC). Method: Twenty-six AC patients and age-matched 18 healthy controls underwent bone scintigraphy. For the quantitative analysis, region of interest (ROI) was drawn over each gleno-humeral joint area, excluding coracoid process, acromion and acromio-clavicular joint. We obtained the uptake ratios of affected side to unaffected side from anterior and posterior image respectively. Additionally, mean uptake ratios were calculated from both anterior and posterior ROI count. Reference values for each uptake ratio were obtained from 18 healthy controls. Clinical stages of the patients were determined according to the history and physical examination including range of motion under sonographically guided intra-articular anesthesia (Hannafin's stage). Quantitative measurements were analyzed according to Hannafin's stage and clinical findings. Results: Uptake ratios for the patients were significantly higher than the controls (p＜0.05). Sensitivities of the anterior image and mean uptake ratio were 81 % and 62% respectively. All 7 patients with abnormal findings in posterior image were stage II. Ninety-four percent in stage I and II showed abnormal mean uptake ratio. Nocturnal pain was associated with increased uptake ratio, particularly mean uptake ratio (p＜0.05).Conclusion: The findings of quantitative bone scintigraphy correlated with the clinical diagnosis, nocturnal pain and Hannafin's stage. Thus, the quantitative bone scintigraphy may be helpful in the diagnosis of shoulder AC. Additionally, mean uptake ratio and posterior image may contribute to clinical staging of AC (i.e. stage I, II and stage II respectively). (J Korean Acad Rehab Med 2007; 31: 735-741)

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Usefulness of Uptake Ratio of Three Phase Bone Scintigraphy in Complex Regional Pain Syndrome after a Stroke.: Lee, Yu Ryun , Rah, Ueon Woo , Lee, Il Yung , Yim, Shin Young , Yoon, Seok Nam; J Korean Acad Rehabil Med 2007;31(1):41-47.

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To evaluate usefulness of uptake ratio of three phase bone scintigraphy in assessing the complex regional pain syndrome (CRPS) type I in stroke patients Method: Forty three stroke patients were diagnosed as CRPS type I based on their symptoms and confirmed by three phase bone scintigraphy. Uptake ratio was calculated by dividing the radioactivity count on the affected side by that on the unaffected side in each phase. Mean uptake ratio was compared among the groups classified by the clinical diagnosis and by the response to treatment. In addition, uptake ratio was compared before and after treatment. Results: Mean uptake ratio of the wrist in blood pool phase was significantly higher than other parts of the body (p＜0.05). However, there was no significant difference among the groups classified by the clinical diagnosis nor by the response to treatment. The changes of uptake ratio were variable after treatment, but only the uptake ratio of the wrist in blood flow phase showed correlation with the degree of swelling. Conclusion: Uptake ratio of three phase bone scintigraphy was not correlated with clinical findings. (J Korean Acad Rehab Med 2007; 31: 41-47)

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The Comparative Analysis between Digital Infrared Thermography Imaging and Three-phase Bone Scintigraphy in the Post-hemiplegic Complex Regional Pain Syndrome.: Lee, Chang Ho , Hyun, Jung Keun , Lee, Seong Jae , Jeon, Jae Yong; J Korean Acad Rehabil Med 2006;30(2):122-127.

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To evaluate the benefit of digital infrared thermography imaging (DITI) and three-phase bone scintigraphy (TPBS) for detecting the post-hemiplegic complex regional pain syndrome (CRPS). Method: DITI and TPBS were done in 26 patients with post-hemiplegic CRPS clinically and 14 hemiplegic patients without CRPS as controls. Positive findings were interpreted when the affected hands were 1.0^oC higher than those of unaffected hands in DITI system and pathological uptake in the regions of interest (hands without fingers-carpal bones, metacarpal bones and metacarpopharyngeal joints) in de-layed phase of the TPBS. Results: The sensitivities of DITI and TPBS to detect CRPS were the same to each other as 46.2%, and specificities were 85.7% and 100% respectively. Nineteen of 26 patients (sensitivity=73.1%) were interpreted as abnormal when at least one test showed a positive finding. As a result, an increased diagnostic strength was achieved.Conclusion: These findings suggest that the combination of TPBS and DITI can improve the diagnostic strength of post- hemiplegic CRPS. (J Korean Acad Rehab Med 2006; 30: 122-127)

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Quantitative Measurement of Three Phase Bone Scintigraphy in Stroke Patients with Complex Regional Pain Syndrome.: Hong, Joon Beom , Han, Tai Ryoon , Kim, Dai Youl , Kim, Il Soo , Lee, Jong Jin , Chung, June Key; J Korean Acad Rehabil Med 2005;29(4):337-342.

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To evaluate usefulness of quantitative measurement of three phase bone scintigraphy in assessing the complex regional pain syndrome (CRPS) after stroke using reference value in healthy adults. Method: Twenty nine stroke patients with CRPS and 15 stroke patients without CRPS underwent three phase bone scintigraphy (TPBS). Uptake ratio was calculated by isotope count of affected side divided in isotope count of unaffected side in each phase. Reference value was obtained in 13 healthy adults. The sensitivity and specificity of quantitative measurement of TPBS was assessed. Results: In the all phases of hand, uptake ratios of the CRPS group were significantly higher than non-CRPS group(p＜0.05). There was no significant difference in the delayed phase of shoulder between the CRPS group and the non- CRPS group. In the delayed phase of hand, sensitivity and specificity of quantitative measurement of TPBS were 82.8% and 86.7%, whereas those of qualitative interpretation by nuclear physician were 65.5% and 66.7%, respectively. Conclusion: Quantitative measurement of TPBS was more sensitive and more specific than qualitative interpretation by nuclear physician in assessing the CRPS after stroke. Quantitative measurement of TPBS may be helpful in detecting CRPS after stroke. (J Korean Acad Rehab Med 2005; 29: 337-342)

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Reflex Sympathetic Dystrophy in Cervical Cord Injured Patients.: Kim, Seong Woo , Park, Chang Il , Park, Eun Sook , Kim, You Chul , Shin, Ji Cheol , Kim, Seong Won , Cho, Sung Rae; J Korean Acad Rehabil Med 1999;23(1):24-30.

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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.

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Therapeutic Effect of Oral Corticosteroids in Post-Stroke Reflex Sympathetic Dystrophy: Semiquantitative evaluation of three-phase bone scintigraphy.: Sung, Duk Hyun , Lee, Kang Woo , Kim, Byung Tae , Kwon, Jeong Yi , Kim, Jong Moon; J Korean Acad Rehabil Med 1997;21(5):851-859.

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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.