Development and validation of a nomogram for early prediction of post-stroke shoulder–hand syndrome: a retrospective cohort study

 

What is the EXACT FIX TO PREVENT THIS?

Why don't you know and do the work to get a solution? Predicting failure to recover is positively useless! You're fired!

Laziness? Incompetence? Or just don't care? NO leadership? NO strategy? Not my job? Not my Problem!

Development and validation of a nomogram for early prediction of post-stroke shoulder–hand syndrome: a retrospective cohort study

Xuezheng Li 1

Y

Yu Min 1



Lulu Cheng 1,2

Y

Yunyun Tao 3

M

Meifeng Zheng 4

H

Hua Guo 4



Xuefeng Fu 1

L

Lijun Lu 1

W

H



K

Kaifeng Guo 4*

• 1. Postgraduate Cultivation Base of Guangzhou University of Chinese Medicine, Panyu Central Hospital, Guangzhou, Guangdong, China

• 2. Department of Acupuncture and Moxibustion, Qingdao Central Hospital, University of Health and Rehabilitation Sciences (Qingdao Central Hospital), Qingdao, Shandong, China

Abstract

Background: 

Shoulder-hand syndrome (SHS) is a prevalent complication following strokes. At present, there is no established and dependable method for early prediction of SHS risk. Thus, we undertook this study to create and validate a nomogram for early prediction of SHS following ischemic stroke (IS), with the aim of informing the development of SHS-specific follow-up protocols in clinical practice.

Methods: 

We retrospectively collected data on IS patients admitted to the Affiliated Panyu Central Hospital of Guangzhou Medical University from October 1, 2019 to March 31, 2024. The data was randomly split into a training set and a validation set in a 7:3 ratio, and LASSO regression was used to filter the modeling variables. In addition, the consistency index, area under the receiver operating characteristic curve (AUC), and calibration curve were used to verify the accuracy and discriminant power of the nomogram.

Results: 

A total of 514 patients were enrolled in our study. Significant predictors contained sex, occupation, residence, osteoarthritis, gouty arthritis, myodynamia, heart rate, neutrophils, blood glucose, aspartate aminotransferase, and activated partial thromboplastin time. The AUC for the model constructed on the basis of these predictors was 0.777 (95% CI: 0.727–0.826) in the training set and 0.698 (95% CI: 0.615–0.781) in the validation set.

Conclusion: 

The nomogram constructed on the basis of common clinical features has a high performance in predicting the occurrence of SHS within 6 months after stroke. It can provide a reference for the development of specific prevention programs during clinical practice.

1 Background

Stroke is a serious cerebrovascular disease with high morbidity, disability and mortality (GBD 2016 Stroke Collaborators, 2019). Shoulder-hand syndrome (SHS), a common post-stroke complication (Taylor et al., 2021), is characterized by pain, swelling, and limited mobility of the affected shoulder and hand (Zhang et al., 2021). SHS is highly prevalent within 1–3 months after stroke (Dromerick et al., 2008), with a prevalence of 24–60% (Anwer and Alghadir, 2020). Coincidentally, this is a critical period for functional recovery in stroke patients (Stinear et al., 2020). Therefore, SHS has a significant impact on the daily life and rehabilitation process of patients, often hindering their functional recovery when symptoms are severe.

The pathogenesis of SHS is not fully understood and is generally thought to involve a variety of factors. Brain injury due to stroke causes abnormalities in the nervous system, leading to abnormal perception of pain in the shoulder and hand (Hansson, 2004). Inflammatory response to stroke triggers the release of inflammatory factors, such as IL-6 and TNF-α, which can lead to local tissue inflammation and pain (Heijmans-Antonissen et al., 2006; Huygen et al., 2002). Poor local blood circulation due to stroke causes insufficient nutrients in the tissues, which can result in tissue damage and pain (Iadecola and Anrather, 2011). Loss of motor function after stroke induces stiffness of shoulder and hand joints and muscle atrophy, which causes poor venous and lymphatic return, edema and pain in the upper extremities (Lee et al., 2021). Given the unclear pathogenesis of SHS, it is challenging to develop efficient prevention strategies.

Only one study has specifically constructed a predictive model for SHS, but the number of medical records was very small (Yu et al., 2023). Most studies focus only on risk factors for SHS (Birklein et al., 2018; Ganty and Chawla, 2013). This poses a challenge for the early detection of SHS and the production of specific prevention strategies in clinical practice. Hence, the aim of this study was to develop an accurate and personalized predictive nomogram to help clinicians identify high-risk populations for SHS, implement early intervention, and ultimately improve patient prognosis.

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Acupuncture versus rehabilitation for post-stroke shoulder-hand syndrome: a systematic review and meta-analysis of randomized controlled trials

 

Impossible for acupuncture to have effects except as a placebo. Energy meridians have never been proven to exist.

Acupuncture versus rehabilitation for post-stroke shoulder-hand syndrome: a systematic review and meta-analysis of randomized controlled trials

Jinyuan Shi^1,2†Fuyan Chen^1,2*†‡Yang Liu^1,2†Mingtong Bian^1,2Xiaowei Sun^1,2Ru Rong^1,2Shuo Liu^1,2

• ¹Department of Acupuncture, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
• ²National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China

Background: Shoulder-hand syndrome (SHS) is one of the common sequelae after stroke, which not only hinders the recovery of patients, but also increases the economic burden of the family. In the absence of effective treatment measures, acupuncture treatment has been widely used in China to treat post-stroke shoulder-hand syndrome, but the details are unclear. Therefore, this review aims to evaluate the true efficacy of acupuncture in patients with SHS.

Methods: We searched eight databases [PubMed, Embase, Web of Science, Cochrane library, China Biomedical Literature Database (CBM), China Science and Technology Journal (VIP) database, the China National Knowledge Infrastructure (CNKI) database, and Wan fang database] from its inception to March 2025, randomized controlled trials (RCTs) of SHS acupuncture treatment combined with rehabilitation (Rehab). Two investigators independently used pre-designed forms to extract valid data from eligible randomized controlled trials. Meta-analysis was implemented through the Rev. Man software (version 5.4). The strength of the evidence obtained was implemented using the GRADE profiler software. Adverse events (AEs) were collected by reading the full text and used to evaluate the safety of acupuncture treatment.

Results: Forty-seven studies, involving 4,129 participants, met the eligibility criteria, and were included in the review. Overall meta-analysis showed that combined acupuncture rehabilitation significantly improved motor function (upper-limb Fugl-Meyer Assessment (FMA): 41 studies, mean difference (MD) 9.50, 95% confidence interval (CI) [8.47, 10.53]) and pain reduction (visual analog score (VAS): 37 studies, MD: −1.49, 95% CI [−1.66, −1.33]). It also improved activities of daily living (ADL) compared to rehabilitation alone (ADL: 17 studies, MD: 11.94, 95% CI [8.26, 13.63]). There was no significant difference in the occurrence of adverse events (AEs) between acupuncture treatment combined with Rehab and Rehab alone (p > 0.05). The certainty of the evidence was rated low level because of flaws in the study design and considerable heterogeneity among the included studies.

Conclusion: This review found that acupuncture treatment combined with Rehab treatment may have a positive promoting effect on improving motor function, reducing pain, and improving daily living ability in SHS patients. However, due to the existing methodological quality issues, our findings should be treated with caution. Future high-quality studies are urgently needed to validate our findings.

Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD42024536169.

1 Introduction

Stroke is the second largest cause of death worldwide and the first leading cause of acquired long-term disability, leading to an annual global economic burden (1). Post-stroke shoulder hand syndrome (PS-SHS), also known as post-stroke complex regional pain syndrome, is experienced by more than 50% of stroke patients (2), it usually occurs between 2 and 3 months of an acute event and usually presents with pain, hyperalgesia, joint swelling, and limited range of motion (3). Post-stroke shoulder hand syndrome is difficult to treat, and its symptoms may persist for a long time, resulting in limited upper limb function or even irreversible permanent apraxia (4, 5). In addition, SHS may hinder the overall recovery, prolong hospitalization, limit the patients’ activities of daily living (ADL), reduce the quality of life, and bring heavy economic burden on the patients and their families (6). Currently, commonly used treatments for post-stroke SHS include drug therapy, soaking in cold water, physical therapy (PT), occupational therapy (OT), psychotherapy, and sympathetic block (7, 8). Although these conventional treatments were initially found to be effective, their adverse effects cannot be ignored. Low-dose oral steroids are effective in improving the SHS after stroke (9), for example, to avoid adverse effects associated with long-term drug use, steroids are only indicated for short-term treatment and are considered a difficult factor for long-term post-stroke SHS (5), early referral to PT, OT, and psychotherapy may prevent the progression of symptoms (10). However, the disadvantages of these approaches, such as high healthcare costs, increased workforce investment, and increased demands for patient collaboration, have also received attention. In addition, the expertise of rehabilitation therapists varies from different regions, which will affect the treatment effect. The incidence of SHS after stroke remains high and is a challenging problem to be addressed. To date, consistently effective and good patient compliance methods are still lacking (11).

As a basic therapy for the prevention and treatment of traditional Chinese medicine (TCM), acupuncture has been used in clinical practice in China for thousands of years (12). According to the site of application, acupuncture can be divided into abdominal acupuncture (AA) and scalp acupuncture (SA). In addition, according to the surgical method, acupuncture can be divided into manual needle (MA), electro-acupuncture (EA), and warm acupuncture (WA) has been proved to have the advantages of low price, good effect and simple operation (13). Moreover, as a non-pharmacological intervention, acupuncture has better efficacy on chronic diseases difficult to treat with traditional treatment methods, such as low back pain and renal disease (14, 15). As a result of these advantages, acupuncture has received continued interest from the general public and health professionals (16). Furthermore, more medical institutions are using acupuncture clinically and show that acupuncture can be used as a prospective therapeutic measure to improve motor function in patients with SHS (6, 17).

In the last few years, three reviews have been published on acupuncture for SHS. The meta-analysis published in 2018 (18) only evaluated the effect of manual acupuncture on the treatment efficacy in patients with SHS, and manual acupuncture represented only one acupuncture form, and the findings were necessarily limited. The meta-analysis published in 2019 (19) included only 13 studies totaling 1,040 patients, an insufficient sample size, and only evaluated the effect of electroacupuncture effects in SHS patients, and the findings were limited. The meta-analysis, published in 2019 (20), selected FMA, VAS and ADL as outcome measures. The results showed that acupuncture treatment had excellent efficacy in relieving the symptoms of SHS. However, the intervention did not involve warm acupuncture. Therefore, we conducted a systematic review of the latest evidence on acupuncture (including warm acupuncture) as an add-on treatment for the clinical treatment of post-stroke SHS. Furthermore, with the widespread use of acupuncture treatment, more research is published in recent years (17, 21). Therefore, the aim of this review was to explore the effect of acupuncture treatment on the relief of clinical symptoms in patients with SHS and to update previous published reviews.