這次要來談中風病人上肢常見的水腫，水腫也常會伴隨Reflex Sympathetic Dystrophy(反射性交感神經性失養症)、Shoulder-Hand syndrome(肩手症候群)等疾病。
RSD主要症狀︰腫脹、疼痛、自主神經失調、運動不協調。從外觀上可以觀察到皮膚變薄變亮、指甲變粗變厚以及肌肉萎縮。
Shoulder-Hand syndrome主要症狀︰腫脹、疼痛、溫度會跟其他部位不一樣以及容易造成關節欒縮。
根據統計，中風病人約有33％的比例有上肢水腫(edema)以及腫脹(swelling)的情形發生，如果我們不處理水腫的情形，就很容易變成RSD或是Shoulder-hand syndrome，這對我們之後的復健過程會造成不良的影響。
那會誘發水腫及腫脹的危險因子有那些呢？！像是病人手部呈現hyposensibility(不是很敏感)的狀況、手指頭張力高(hypertonic)、在照顧上欠缺注意以及動作功能不好的病人、嚴重的肩膀痛以及關節contracture(攣縮)這些都是高危險因子。
根據統計，當病人的張力很高，有水腫的情形約佔51.6%；病人的感覺不靈敏，有水腫的情形約佔47.4%；動作缺損的病人，有水腫的情形約佔42.9%。
1.Poor motor function(動作功能不好)︰這是最主要造成水腫的因子。微血管的血壓、組織的滲透壓和血管壁通透性是影響組織液流動的重點因子，半側偏癱的病人因動作功能不好，導致肌肉幫浦的作用變少，使得靜脈回流量以及淋巴液的量減少，這些就堆積在遠端組織，這會使微血管的血壓上升；組織的滲透壓會因血漿蛋白質的濃度變少而下降，濃度變少是因為中風急性期的發炎反應會用掉不少的血漿蛋白質，滲透壓變小，在血管外圍的組織液就不好跑進血管循環系統；除此之外，當我們太隨便處理病人、對於肩膀半脫位做不適當的治療以及做太多去加強關節活動度的活動也都會造成發炎反應，這會降低血管壁的通透性，這樣也會卡一大堆的組織液在血管外面，造成嚴重的水腫及腫脹。
有一些病人手部功能不錯，但還是會有水腫的情形產生，造成水腫的原因可能會是因為儘管手部功能不錯，但比起未受傷前的活動量來講，還是不夠，所以還是會有水腫的情形產生。
2.Hyposensibility和absent carefulness(敏感度太低和缺乏細心照顧)︰這算是比較特別的因子，這發生在像是半側忽略的病人，病人對於患側是沒有什麼感覺，而且也沒有特別去注意到的話，很容易就會水腫以及造成一些肩膀疼痛或是RSD的情形。
3.Hypertonic(張力過高)︰當病人的張力過高，手腕和手指就會flexion(屈曲)，這樣的姿勢也會阻礙到靜脈血流以及淋巴液的回流，進而造成手部嚴重的水腫情形。
那我們要如何減輕水腫的情形呢，現在有很多的治療方式，像是我常用的擺位、簡單的主動動作以及抬高患側加強血液循環、神經肌肉的誘發刺激收縮、吃一些皮質類固醇或是利尿素、Continous Passive Motion、間歇性得壓迫水腫地方或是穿上splint等，這些都是可以用的治療方式，但沒有一種方式是保證特別有用的，所以在治療上還是要多方去嘗試。
在臨床上，水腫處理是迫切的，時間一拖久就會產生RSD、Shoulder-hand syndrome，Joint contracture以及不明的Shoulder pain等，這些都是對於我們的復健療程有極大的影響，也要考慮到病人的藥物內容等情況，說好處理也算不容易根治，說不好處理也算容易減輕症狀。
部份內容參考至
1.Boomkamp-Koppen H GM, Visser-Meily JMA MA. Post M WM, Prevo A JH. Poststroke hand swelling and oedema: prevalence and relationship with impairment and disbility. Clinical Rehabilitation 2005: 19: 552.
2.Iwata M., Kondo I., Sato Y., Satoh K. et al. Prediction od Reflex Sympathetic Dystrophy in Hemiplegia by Evaluation of Hand Edema. Arch Phys Med Rehabil 2002: vol 83.
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