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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.