Background and Purpose Some stroke patients complain of an unpleasant sensation of coldness in the hemiplegic arm. This study aimed to determine the prevalence of this symptom and any associated features.
Methods A questionnaire about symptoms in the arms was sent to patients at least 12 months after stroke. Reflex sympathetic dystrophy (RSD) was diagnosed if four typical symptoms were present in the arm.
Results One hundred patients were recruited and 75 complete replies received. The mean age of the patients was 74 years, and the mean time since the stroke was 19 months. Forty patients (53%) experienced unilateral coldness in the hemiplegic arm. In 14 this sensation was constant, and 10 rated the symptom as troublesome. The symptom developed at a median time of 1 month after stroke, but only 13 patients (32%) sought advice from a doctor. Sensory symptoms and arm and shoulder pain were common, but the only symptoms associated with coldness were numbness (P<.001) and color change (P<.05). Fifteen patients fulfilled the diagnostic criteria for RSD, 13 of whom had coldness only in the hemiplegic arm.
Conclusions A sensation of coldness in the hemiplegic arm is common and distressing. It is associated with numbness and color changes in the arm. Some cases are caused by RSD, but other patients have coldness that may be due to other causes such as a vasomotor abnormality.
A number of unilateral phenomena occur in the hemiplegic arm after a stroke.1 2 3 4 We have noticed that some patients complain of an unpleasant cold sensation in the affected arm. How often the symptom occurs and how significant it is to patients after a stroke are not known. Coldness was rated highly as an important symptom compared with other symptoms caused by stroke in one study, but numbers were small.5 Patients with coldness in the hemiplegic arm have reduced blood flow to the hand and abnormal rewarming after cold stress testing.5 These vasomotor changes may be responsible for the feeling of coldness, but other mechanisms may be important, including sensory or perceptual disturbances caused by the stroke, reflex sympathetic dystrophy (RSD), or simply disuse.
This aims of this study were to determine the prevalence of coldness in the hemiplegic arm and to identify any associated features that might improve our understanding of why some stroke patients develop this symptom.
Subjects and Method
A questionnaire was designed to obtain details about the patients and current symptoms in the arms. A single standard question was to detect the presence of each of the symptoms. Several supplementary questions about the symptoms of coldness and pain were used to obtain more detail. The overall design was short (three legal-sized sheets), simple, and produced in large print. The questionnaire was first used on a trial basis by six inpatients with stroke and was found to be clear and unambiguous. The questionnaire was then sent to stroke patients living at home.
The subjects were consecutive patients with hemiplegia, aged 60 years or older, who had been discharged home from a district general hospital after a new stroke. Stroke was defined according to World Health Organization criteria.6 Patients were recruited from all wards in the hospital and had suffered a stroke that had caused new disability (resulting in a decrease in the modified Barthel Index score compared with the score before admission).
The questionnaire was sent out to patients at least 1 year after the stroke because we had observed that the symptom did not develop immediately after the stroke in many patients. Those patients with language difficulties were assessed by one author (A.F.) with the use of the Frenchay Aphasia Screening Test7 and were not included in the study if they could not complete the test satisfactorily (score <25).
Head CT scans were sought for all patients who replied to the questionnaire. The study was given approval by the local Ethical Committee. The questionnaire covered the following areas: (1) patient details (age, sex, medication) and details of the stroke; (2) coldness in the arms; (3) sensory symptoms (numbness, pins and needles); (4) skin changes (dry or sweaty skin); (5) swelling and color change in the affected arm; (6) shoulder pain; and (7) other arm pain (and its site).
The overall severity of the symptom of coldness was assessed on a visual analog scale from 0 (no problem) to 5 (severe problem).
We were particularly interested in the prevalence of the symptom of coldness and its relation to sensory symptoms and RSD. The diagnosis of RSD was based on criteria outlined by Veldman et al8 and consisted of the presence of the following symptoms in the arm: coldness, swelling, color change, pain in the shoulder, pain in the arm, dry skin, and sweaty skin. RSD was diagnosed as definite if four of the above symptoms were present and possible if only three were present.
When no reply was received, the patient was telephoned and the questionnaire completed verbally. In some cases the patient preferred to send the written questionnaire after the telephone call.
Results were analyzed for the difference between patients with and without coldness with the use of the χ2 test.
One hundred patients were recruited to the study, and 82 replies were received (3 by telephone inquiry). Seven of the returned questionnaires were incomplete and were therefore not included. Of the respondents, 44 were men and 31 were women, with a mean age of 74 years (range, 61 to 88 years). Thirty-five patients had had a left hemiplegia and 40 a right hemiplegia. The mean time since stroke onset was 19 months (range, 12 to 32 months). Head CT scans had been performed in 21 cases: 9 patients had cortical infarcts (8 middle cerebral artery territory, 1 posterior territory), 5 had subcortical infarcts, 4 had multiple infarcts, 2 had hemorrhages, and 1 scan was normal.
Forty-eight patients (64%) had arm coldness. Forty patients (53%) had coldness only in the hemiplegic arm, and 8 had coldness in both arms. Further details were obtained from those patients with unilateral coldness of the hemiplegic arm. In 26 patients the feeling was infrequent, but in 14 the symptom was constantly present. Based on our rating scale from 0 to 5, the mean symptom score was 2.4, with 10 patients rating the symptom as 4 or 5 (Table 1⇓). It can also be seen from Table 1⇓ that 5 patients had constant severe coldness.
Measures taken by patients to alleviate the coldness included local heat (10), rubbing (7), gloves or wrapping in clothes (6), or vigorous movement of the arm (2). However, in 8 patients there was nothing that the patient could do to relieve the symptom. The median time from the stroke to the development of the coldness was 1 month (interquartile range, 0 to 6). No association was found between coldness and the site or type of stroke on CT scan, although the number of scans in patients with unilateral coldness was small (n=9). Of the 40 patients with unilateral coldness, only 13 (32%) had told a physician about the symptom.
Sensory and perceptual symptoms were common in the entire group of 75 respondents (Table 2⇓). Thirty-five patients had numbness, and 28 complained of a symptom of pins and needles in the arm.
Skin changes were less common, with 26 patients noting abnormally dry skin and 10 noting excessive sweating on the hemiplegic side. Only 15 patients had swelling of the hemiplegic arm lasting for a month or more. Intermittent color changes occurred in the hemiplegic arm in 16 cases: 9 patients reported a blue color, 3 patients a change to red, 2 a change to purple, and 2 a change to white.
Pain in the hemiplegic arm was also common, with 43 suffering shoulder pain and 15 having pain elsewhere in the arm. The shoulder pain was only present on movement in 25 patients, constant in 10, at night in 7, and occasional in 1. Pain elsewhere in the arm was felt at the elbow or upper arm in 11 patients, in the hand in 2, at the wrist in 1, and generalized in 1.
We also considered the prevalence of arm symptoms in the subgroup of patients with coldness in the arm. Eight patients had the sensation of coldness in both arms. The significance of the symptom in this group is less clear, and they may have a generalized disorder rather than one related specifically to the hemiplegic arm. We have therefore excluded this group of patients when analyzing the association of symptoms. Patients with unilateral coldness of the hemiplegic arm reported more arm symptoms overall than those without coldness (Table 3⇓). The various arm symptoms were analyzed in the groups with and without coldness to assess possible associations. The symptom of unilateral coldness was associated with numbness (P<.001) and color change (P<.05). Coldness in the hemiplegic arm was not associated with the side of the hemiplegia or any of the other symptoms.
Using our classification, we found that 15 patients (20%) fulfilled the diagnostic criteria for RSD and 14 (19%) had possible RSD. Thirteen patients with RSD and 11 with possible RSD had unilateral coldness of the hemiplegic arm; 16 patients with unilateral coldness in the hemiplegic arm did not have evidence of RSD.
Several unilateral phenomena occur in the hemiplegic arm, including unilateral clubbing,1 sparing of arthritis,2 unilateral eczema,3 and lowered minimal erythema dose for UV light.4 We have noticed that some patients develop an unpleasant feeling of coldness in the hemiplegic arm, which some find difficult to relieve. We have previously shown that vasomotor abnormalities exist in this group of patients with abnormal vasoconstriction occurring in the hemiplegic arm.5
The results of our present survey show that coldness in the hemiplegic arm is common, being present in 48 (64%) of the patients we studied. This sensation of coldness was felt solely in the hemiplegic arm in 40 (53%). Although most of these patients suffered coldness in the arm intermittently, in 14 subjects the symptom was constant.
This problem is unfamiliar to clinicians dealing with stroke patients. Why is this? First, the symptom may develop after a few months when the patient may have been discharged from hospital follow-up. Second, the symptom is variable in its severity, and only 32% of patients with the problem sought advice from a physician.
There are probably several causes of coldness in the hemiplegic arm. One possibility is that the coldness is caused by RSD. RSD is a term for a complex disorder that occurs after direct or indirect trauma to a limb. The features of the condition are pain, limited range of movement, edema, and altered skin temperature and color. The symptoms generally occur diffusely in the affected limb and are frequently worse after use.8 RSD is difficult to study because there are no standardized diagnostic criteria and no diagnostic test that is sufficiently sensitive and specific.8 In addition, some of the features of RSD may be altered by the stroke. An example of this is the increase in limb symptoms after use that occurs in RSD. This may be more difficult to ascertain in patients with limited arm function after stroke. Another symptom that may be less specific for RSD after stroke is unexplained diffuse pain. This pain may be due to other causes such as central pain (“thalamic syndrome”) after a stroke.9 Swelling of the hemiplegic arm is common but may be due to the disuse resulting from the stroke or perhaps as a result of axillary vein thrombosis.
With these limitations in mind, we defined probable and possible RSD using a classification similar to that of Veldman et al8 based on common symptoms of the condition. RSD is reported to occur in between 12% and 25% of patients after a stroke.10 11 Vasomotor abnormalities occur in many cases of RSD, but the associated skin temperature changes are variable.12 13 14 In a recent comprehensive survey of patients with RSD, more than 90% of patients described changes in skin temperature of the affected limb, but in only 13% was the limb cooler on objective assessment by the investigators.8 However, this study only included 2 patients with stroke of 829 studied. We found that among the 40 patients with unilateral coldness, 13 had probable RSD and 11 had possible RSD.
RSD is associated with coldness in the hemiplegic arm, but 16 patients in our study had unexplained unilateral coldness with no other features of RSD. We have not addressed the relationship between severity of paralysis and coldness in this study. However, coldness was not associated with more severe paralysis in a previous smaller study.5 The only symptoms that were associated with unilateral coldness were numbness and color change. This lends some support to the view that coldness is related to sensory deficits in some patients, although the mechanism is not clear. However, if this were the only factor involved, one might expect coldness to be more common in patients with a left hemiplegia because these patients are more likely to develop abnormalities of interpreting sensory input. There was no such association between side of the hemiplegia and the feeling of coldness.
Vasomotor instability may cause the color changes noted frequently by the patients with coldness. Our previous work has shown objective changes in skin temperature and blood flow in patients with symptomatic coldness of the hemiplegic arm. Patients with coldness in the hemiplegic arm had reduced blood flow in the hand and abnormal rewarming after cold stress compared with a group without the symptom of coldness.5 This suggests that abnormal vasoconstriction is responsible for the sensation of coldness in this group. After deep inspiration or cough, vasoconstriction occurs in the limbs, which is spinally mediated.15 16 This vasoconstriction is greater in tetraplegic subjects, indicating a descending inhibitory influence on the area of the cord responsible for the response.17 Abnormal persistent vasoconstriction due to a spinal reflex would explain the reduced blood flow to the hemiplegic hand previously reported in patients with coldness.
The best treatment for this distressing coldness is not known, although some patients tried simple local measures such as rubbing, wrapping, or warming the arm. RSD is amenable to simple treatment with analgesics, heat, or cold packs. Exercise for the affected limb may be effective if started early in the course of the disease but in late cases is disappointing.18 Other treatments, including vasodilators19 20 and local blockade of the sympathetic system with guanethidine infusions or sympathectomy,21 have been used with limited success.
If the coldness is caused by a sensory deficit, there is currently no treatment known to produce benefit.
In patients with no features of RSD and abnormal vasoconstriction, some may benefit from vasodilators. There have been no controlled trials of these agents in patients with a cold hemiplegic arm; this is now the subject of our current research.
The symptom of coldness in the hemiplegic arm is common after a stroke. Some patients find it very distressing, although relatively few complain to a physician. The coldness may be produced by a number of conditions, including RSD and vasomotor changes caused by the stroke. The role of sensory deficits is not clear, although a feeling of coldness is associated with numbness in the arm. All clinicians and therapists caring for stroke patients should be aware of the problem. Further work is required to find treatments for the cold hemiplegic arm that are both effective and well tolerated.
This study was funded in part by the Stroke Association (A. Forster). We would like to thank Andrew Vail for statistical advice given in the preparation of this article.
- Received May 9, 1995.
- Revision received June 27, 1995.
- Accepted June 29, 1995.
- Copyright © 1995 by American Heart Association
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