UPPER extremity entrapment neuropathies in stroke patients

Abnormal excessive use of non-paretic arm in daily life activities and improper use of the paretic arm in patients with stroke can cause entrapment neuropathies by causing chronic mechanical stress in the upper extremity peripheric nerves. The sensory problems caused by the stroke can be confused with pain and weakness, and this situation makes it difficult to diagnose trap neuropathies. Therefore, the frequency and clinic presentation of entrapment neuropathies in stroke patients are still unknown. The aim of our study; to determine the frequency of upper limb entrapment neuropathy in patients with stroke and to investigate the effect of entrapment neuropathy on the functional levels of patients. The study included 30 hemiplegic patients caused by cerebrovascular event and 30 healthy volunteers who were admitted to the Akdeniz University Medical Faculty Hospital Physical Medicine and Rehabilitation outpatient and inpatient clinic between November 2019 and January 2020. The age, gender, presence of obesity, marital status, educational status, smoking status of the individuals included in the study were questioned. Paretic sides of the stroke group, cerebrovascular event etiologies, cerebrovascular event times, time to rehabilitation, total rehabilitation time and walking device usage were recorded. Functional and motor evaluation of the patients was made with FAS, Barthel scoring and Brunnstrom staging, and muscle tone evaluation with MAS staging. In order to detect the presence of entrapment neuropathy, phalen and tinel test for carpal tunnel syndrome, ulnar nerve compression test and elbow flexion test for ulnar nerve entrapment were performed as physical examination test. Electrophysiological examination was performed to determine whether there was nerve entrapment in the median and ulnar nerves in the patient group and the control group included in the study. While evaluating the data obtained in the study, statistical analyzes were made with SPSS 23.0 package program. P values less than 0.05 were considered statistically significant. In our study, it was seen that patient and control groups had a similar ratio in terms of age, gender, marital status, educational status, and obesity. In our study, as a result of the analysis of the comparison of carpal tunnel syndrome and ulnar nerve entrapment according to the control and patient groups, we didn't found statistically significant difference between the study groups in terms of the incidence of carpal tunnel syndrome. In addition, it was found that the incidence of ulnar nerve entrapment was higher in the patient group compared to the control group. In the patient group, carpal tunnel syndrome was more common in female gender, whereas in the control group ulnar nerve entrapment was more common in male gender. Ulnar nerve entrapment was more common in non-obese subjects in the control group, and this was interpreted as adipose tissue may be a protective factor from ulnar nerve compression. Electrophysiological measurements were compared between study groups. It was determined that the median nerve sensory amplitude values were higher in the control group compared to the patient group. The ulnar nerve sensory distal latency values of the patient group were statistically higher, while the ulnar nerve sensory conduction velocity and motor amplitude values were lower than the control group. When the electrophysiological findings obtained from the paretic and non-paretic extremities in the patient group were compared, it was observed that the median nerve motor conduction velocity on the non-paretic side was higher than the paretic side. The ulnar nerve motor distal latency values on the paretic side were found to be statistically higher than the non-paretic side. There was no statistically significant relationship between carpal tunnel syndrome or ulnar nerve entrapment and positive examination findings in the control and patient groups. No difference was observed between the paretic and non-paretic extremities in terms of carpal tunnel syndrome and ulnar nerve entrapment. According to the presence of carpal tunnel syndrome or ulnar nerve entrapment in the patient group, there was no statistically significant difference in Brunnstrom stages, walking device usage, FAS stage and Barthel score. Rehabilitation period was found to be longer in patients without carpal tunnel syndrome, but this difference was not statistically significant. It was observed that the time to start rehabilitation was longer in patients with carpal tunnel syndrome, but this difference was not statistically significant. Although the time after stroke was longer in patients with ulnar nerve entrapment, this difference was not statistically significant. Changes in median and ulnar nerves can be observed in both paretic and non-paretic extremities of stroke patients. Poor positioning in the paretic extremities, spasticity, use of walking device, decreased motor neuron innervation, or possible atrophy due to non-use are among the possible causes. Further controlled studies involving more patients and control groups are needed to document these peripheral nerve changes and their causes. Key words: stroke, entrapment neuropathy, median nerve, ulnar nerve