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FES FOR THE PAINFUL HEMIPLEGIC SHOULDEROverviewSummary of research evidenceImplications for PT practice
Arlene Mendoza, Janet Sanabria, Telan Nelson,
Amanda Lonsdale, Allison Pieracci, & Heather Nordberg
By the end of the presentation the learner will be able to: Describe the incidence and etiology of hemiplegic shoulder
pain (HSP). Explain the methods for preventing and treating HSP. Define Functional Electrical Stimulation (FES). Explain how FES possibly decreases HSP & increases function. Conclude whether the use of FES post-stroke to treat HSP is
effective and recommended. Explain how time post stroke relates to effectiveness of FES
treatment.
Learning Objectives
Review of the Hemiplegic Shoulder
Muscle tone change in the UE from the early to late phase of recovery:Continuum from flacidity-> hypotonicity->
normal tone-> hypertonicity-> rigidity
Problems that can result from flaccidity:GH subluxation and stretching of the capsule,
ligaments, muscles, and nerves
Problems that can result from hypertonicity:Flexion synergy pattern in which shoulder is
add and IR.Teasell, R. et al. (2008)
Incidence of HSP
o In a sample of 10 studies, the incidence of HSP varied from 9-73% of hemiplegic stroke patients.
o The onset of HSP ranged from 2 weeks to 6 months post-stroke.
o There is no standardized method for determining/measuring the epidemiology of HSP.
o The incidence of HSP seems to increase over time following stroke.
Teasell, R. et al. (2008)
Etiology of HSP
Multi-factorial GH subluxationImpingementDecreased ROM/Frozen ShoulderCRPS (Complex Regional Pain
Syndrome)Spasticity
Ada, L., & Foongchomcheay, A (2002), Chantraine, A. et al. (1999) Teasell, R. et al. (2008), Walsh, K. (2001), Vaugnat, H. et al. (2003).
Prevention and Treatment of HSP
Acute:Prevention and Treatment:
Positioning/PROM/Handling/Family education/E-stim Chronic:
Treatment:Positioning Injections (steroid, Botox)Aromatherapy and acupressureElectrical stimulation
TENSFES
Teasell, R. et al. (2008), Walsh, K. (2001), Vaugnat, H. et al. (2003)
Definition of FES
“FES utilizes electrical currents to activate nerves in areas of a patient’s body affected
by paralysis, stroke, traumatic brain injuries, and other neurological disorders to
restore some movement & function.”- Cleveland FES Center, OH
How Does FES Reduce HSP?
Shoulder subluxation andER
One proposed mechanism of reducing HSP, however it is
uncertain that shoulder subluxation is the cause of HSP.
Chantraine, A. et al. (1999), Ada, L., & Foongchomcheay (2002) , Wang, RY et al. (2000), Price, C & Pandyan, A (2009), Teasell, R. et al. (2008)
How Does FES Reduce HSP?(continued)
Other proposed mechanisms include:Stimulation of somatosensory cortex by augmented sensory feedbackIncreased proprioceptive stimulation
Repetitive movements important for motor re-learning
Increased muscle strengthsNMES of cutaneous sensory nerves may modulate pain via gating pathways and central neuromodulation.
Church, C. et al. (2006)
Shoulder Pain and Dysfunction in Hemiplegia: Effects of Functional Electrical
Stimulation.Chantraine, A. et al. (1999)
Controlled study of 24 months beginning in the first month after onset of stroke.
Included CVA and Brain Injury subjects. 120 patients with a subluxed and painful hemiplegic
shoulder (HSP). Patients were assigned to a control group or
treatment group for a total of 5 weeks Control Group: conventional therapy (60
subjects)Treatment Group: FES and conventional therapy
(60 subjects)
Treatment group: FES with Conventional Therapy
Chantraine, A. et al. (1999)
Sequence of FES Program1st Sequence
90 min, rectangular biphasic, 8 Hz, 350 usec, 1:5, 4 channel
2nd Sequence 30 min, 40 Hz
3rd Sequence10 min, 1 Hz
Reduction in PAIN Treatment group vs. Control group
Chantraine, A. et al. (1999)
FES Control p value
Time % pain reduction
3 mo 70.2 36.2 p<.001
6 mo 77.2 48.6 p<.01
12 mo 80.7 55.2 p<.02
24 mo 80.7 55.2 p<.03
Improvement in Subluxation GradesTreatment group vs. Control group
Chantraine, A. et al. (1999)
de Bats Subluxation ScaleGrade 1: Widening of the GH joint line or outward gliding of humeral head. No rupture of the scapulohumeral girdle. Grade 2: Evidence of the beginning of scapulohumeral girdle rupture. Grade 3: The scapulohumeral girdle rupture is complete. The joint is somewhat impaired.
FES Control p value
Time% Improvement of subluxation grade
6 mo 73.7 39.7 p<.001
12 mo 78.9 58.6 p<.05
24 mo 78.9 58.6 p<.05
Improvement in Recovery of Motor Function
Treatment group vs. Control groupChantraine, A. et al. (1999)
FES Control p value
Time% Recovery of Motor Function
6 mo 77.2 46.6 p<.001
12 mo 82.5 60.3 p<.01
24 mo 82.5 60.3 p<.01
At all measurement stages the FES group had statistically significant improvements in subluxation, pain, and ROM as compared to the control group. Maintained for at least 24 mo’s.
Treatment group: Maximum improvement in pain, subluxation, and motor recovery was observed at 6 months.
Control group: Slow & progressive improvement reaching a max improvement after 1 yr.
Overall: Two thirds of the cases improved in pain, subluxation, and remained constant up to 24 months.
ResultsChantraine, A. et al. (1999)
ConclusionChantraine, A. et al. (1999)
FES appears to decrease pain, subluxation, improve ROM, and increase motor
function and therefore directly influences the degree and rate of recovery.
Intramuscular Electrical Stimulation for Hemiplegic Shoulder Pain
Yu DT, Chae, J. et al (2004)
oSubjects: 61•Treatment Group: 32 (intramuscular NMES)•Control Group: 29 (Cuff-type sling)
oInclusion criteria:•>12 weeks post-stroke•Pain rating >2 on the 11 pt. NRS•1/2 fingerbreadth of inferior glenohumeral subluxation
oTreatment Group:•Intramuscular stimulation 6 hours/day for 6 weeks•20 sec on time/10 sec off time•20 mA and 10 - 200 ㎲•Intramuscular electrodes placed in the supraspinatus, posterior deltoid, middle deltoid, and upper trapezius. •The electrodes were placed in the clinic and left in for the duration of the study.
oControl Group:•Cuff-type hemisling for 6 weeks
Study ParametersYu DT, Chae, J. et al (2004)
oPrimary Outcome Measures:•BPI 12--A pain questionnaire that assesses pain intensity (0-10) scale as well as interference of pain in daily activites.
oSecondary Outcome Measures:•BPI question 23•Subluxation (assessed radiographically)•Pain- free passive ER ROM•Hemiparetic upper limb strength and coordination measured through the Fugl-Meyer motor assessment•Spasticity assessed with Ashworth scale•Upper limb-related activity limitation assessed by FIM instrument and Arm Motor Ability Test
Outcome MeasuresYu DT, Chae, J. et al (2004)
Results: Pain improvement Early group vs. Late group Chae, J. et al (2007)
Percent of treatment successes based on the 2- point success criterion. ES = electrical stimulation. *P = .001. **P < .001.
Percent of treatment successes based on the 30% success criterion. ES = electrical stimulation. *P = .001. **P < .001.
Results: Early Group vs. Late GroupMean change in BPI 12 scores
Chae, J. et al (2007)
ES (n=16) Control (n=14)EOT 5.5 0.93 months 6.5 0.216 months 6.6 1.212 months 6.8 2.4
ES (n=16) Control (n=15)EOT 3.6 0.93 months 2.4 1.16 months 2.3 1.512 months 3.2 2.3
Early group (<77 weeks post stroke)
Late group (>77 weeks post stroke)
Results: Treatment Group vs. Control Group
Chae, J. et al (2007)
At end of treatment (EOT), 84% of the ES group experienced a ≥2 pain scale reduction compared to 31% of the control group.
At 12 months, 78% of the ES group experienced a ≥2 pain scale reduction compared to 52% of the control group.
A significantly higher success rate was seen for the ES group compared to the control group at EOT but not at 3, 6, and 12 months.
There was no significant difference in any of the secondary outcomes measured.
FES can be beneficial for HSP if treated early (<77 weeks), and effects can be seen up to 12 months after treatment.
Late treatment (>77 weeks) showed no significant improvements and any effects are only seen short-term.
The treatment group had a higher success rate at EOT, but there was no significant difference between the treatment group and the control group at all of the follow-up measurements.
ConclusionChae, J. et al (2007)
RCT to Evaluate the Effect of sNMES to the Shoulder After Acute Stroke
Church, C. et al. (2006)176 Stroke patients, within 10 days post stroke
Treatment Group: (90 patients) surface neuromuscular electric stimulation (sNMES) and stroke unit rehab •One electrode over supraspinatus and one over posterior deltoid•30 Hz; 15sec on/ 15sec off (3 sec ramp)•Increase intensity until visible contraction•Treated 1hr, 3x/day for 1 month
Control Group: (86 patients) “sham” sNMES and stroke unit rehab
Outcome MeasuresChurch et al. (2006)
Primary (at 3 months):Action Research Arm Test (ARAT)
Secondary (at 4 weeks and at 3 months):Motricity IndexFrenchay Arm Test0-10 Numerical Pain Rating Scale (UE)5-point adjectival scale (UE pain)Star Cancellation (for cortical function)Participants’ views regarding the sNMESGlobal health status at 3 months (Nottingham
Health Profile and Oxford Handicap Scale)
Results Church et al. (2006)
Results at 4 weeks:oThere were no significant differences in any of the outcome measures between the control group and the treatment group.
Results at 3 months:oThere were no statistically significant differences in:
• Arm function (ARAT total)• Upper limb pain• Star Cancellation• Global health status
Is sNMES hazardous for stroke patients with severe upper limb impairment?
Church et al. (2006)
There was a statistically significant difference in the grasp and gross subsections of the ARAT and Frenchay Arm Test and the arm portion of the Motricity Index in favor of the control group.
Some upper limb function at baseline ARAT>0
No upper limb function at baseline ARAT=0
Treatment vs. Control
Treatment vs. Control
4 weeks
No Significant Difference No Significant Difference
3 months
No Significant Difference Significant Difference in Favor of Control Group
Many hypotheses why poor outcome with severely impaired UE
Church et al. (2006)
Abnormal afferent stimulation causes maladaptive plasticity.
Early over-use of the affected arm
Unable to report adverse events or wrong delivery
Overstimulation leading to shoulder subluxation
May have promoted learned non-use of this arm.
ConclusionChurch et al. (2006)
For typical stroke patients treated in stroke rehab units:
sNMES does NOT improve upper limb function, nor decrease pain after acute stroke.
Routine use of sNMES CANNOT be recommended as it can pose potential negative consequences in those with initial severe impairment.
Further research is needed to determine if there is a benefit to using sNMES for specific patient populations.
The Evidence-Based Review of Stroke Rehabilitation
Teasell, R. et al., 2008
Canadian Systematic Review
Over 15 Studies included
There is conflicting evidence that FES reduces pain, improves function and reduces subluxation after stroke.
FES may not help with recovery of hemiplegic shoulder.
www.ebrsr.com
Implications for PT
Standardization is needed in reporting HSP
Inconclusive if FES reduces HSP
Inconclusive if FES improves function
FES may be beneficial for treating GH subluxation
Earlier initiation of FES treatment may result in a better outcome
Describe the incidence and etiology of hemiplegic shoulder pain (HSP).
Explain the methods for preventing and treating HSP. Define Functional Electrical Stimulation (FES). Explain how FES possibly decreases HSP & increases
function. Conclude whether the use of FES post-stroke to treat
HSP is effective and recommended. Explain how time post stroke relates to effectiveness of
FES treatment.
Review Learning Objectives
REFERENCES Ada, L., & Foongchomcheay, A. (2002). Efficacy of electrical
stimulation in preventing or reducing subluxation of the shoulder after stroke: A meta-analysis. Australian Journal of Physiotherapy, 48: 257- 267.
Chantraine, A., Baribault, A., Uebelhart, D., & Gremion, G. (1999). Shoulder pain and dysfunction in hemiplegia: Effects of functional electrical stimulation. Archives of Physical Medicine and Rehabilitation, 80: 328-331.
Chae J et al. Intramuscular Electrical Stimulation for Hemiplegic Shoulder Pain: a 12 month follow up of a multiple center, randomized clinical trial. Am J Phys Med Rehabil. 2005;84:832-842.
Church, C., Price, C., Pandyan, AD., Huntley, S., Curless, R., Rodgers, H. (2006). Randomized controlled trial to evaluate the effect of surface neuromuscular electrical stimulation to the shoulder after acute stroke. Stroke, 37: 2995–3001.
REFERENCES Price, CIM., & Pandyan, AD. (2009). Electrical stimulation for
preventing and treating post-stroke shoulder pain. Cochrane Database of Systematic Reviews 2009 (1).
Scott, Tom. "Functional Electrical Stimulation: The Future of Rehabilitation." Cleveland FES Center. United Spinal’s Action Online Magazine, 17 Nov. 2008. Web. 24 Apr. 2010. <http://fescenter.org/index.php?view=article&id=98:functional-electrical-stimulation-the-future-of-rehabilitation&option=com_content&Itemid=15>
Teasell, R., Foley, N., Bhogal, S. (2008). Version 11: Painful hemiplegic shoulder. Obtained from the WWW April 7, 2009 at http://www.ebrsr.com/reviews_details.php?16
Vaugnat, H. & Chantraine, A. (2003). Shoulder pain in hemiplegia revisited:Contribution of functional electrical stimulation and other therapies. Journal of Rehabilitative Medicine, 35: 49-56.
REFERENCESo Wang, RY., Chan, RC., & Tsai, MW. (2000). Functional electrical
stimulation on chronic and acute hemiplegic shoulder subluxation. American Journal of Physical Medicine and Rehabilitation, 79 (4): 385-390.
o Walsh, K. (2001). Management of shoulder pain in patients with stroke. Postgraduate Medical Journal, 77: 645-649.
o Yu DT, Chae J, Walker ME, et al. Intramuscular neuromuscular electrical stimulation for post-stroke shoulder pain: a multi-center randomized clinical trial. Arch Phys Med Rehabil. 2004;85:695-704.
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