FES FOR THE PAINFUL HEMIPLEGIC SHOULDER

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FES FOR THE PAINFUL HEMIPLEGIC SHOULDER

• Overview
• Summary of research evidence
• Implications for PT practice

Arlene Mendoza, Janet Sanabria, Telan Nelson,
Amanda Lonsdale, Allison Pieracci,
Heather Nordberg
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Learning Objectives

• 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.

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Review of the Hemiplegic Shoulder

• Muscle tone change in the UE from the early to
  late phase of recovery
• Continuum from flacidity-gt hypotonicity-gt normal
  tone-gt hypertonicity-gt 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)

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Incidence of HSP

• In a sample of 10 studies, the incidence of HSP
  varied from 9-73 of hemiplegic stroke patients.
• The onset of HSP ranged from 2 weeks to 6 months
  post-stroke.
• There is no standardized method for
  determining/measuring the epidemiology of HSP.
• The incidence of HSP seems to increase over time
  following stroke.
• Teasell, R. et al. (2008)

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Etiology of HSP

• Multi-factorial
• GH subluxation
• Impingement
• Decreased ROM/Frozen Shoulder
• CRPS (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).

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Prevention and Treatment of HSP

• Acute
• Prevention and Treatment
• Positioning/PROM/Handling/Family education/E-stim
• Chronic
• Treatment
• Positioning
• Injections (steroid, Botox)
• Aromatherapy and acupressure
• Electrical stimulation
• TENS
• FES
• Teasell, R. et al. (2008), Walsh, K. (2001),
  Vaugnat, H. et al. (2003)

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Definition of FES

• FES utilizes electrical currents to activate
  nerves in areas of a patients body affected by
  paralysis, stroke, traumatic brain injuries, and
  other neurological disorders to restore some
  movement function.
• - Cleveland FES Center, OH

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How Does FES Reduce HSP?

• Shoulder subluxation
• and
• ER
• 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)

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How Does FES Reduce HSP?(continued)

• Other proposed mechanisms include
• Stimulation of somatosensory cortex by augmented
  sensory feedback
• Increased proprioceptive stimulation
• Repetitive movements important for motor
  re-learning
• Increased muscle strength
• sNMES of cutaneous sensory nerves may modulate
  pain via gating pathways and central
  neuromodulation.
• Church, C. et al. (2006)

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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)

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Treatment group FES with Conventional
TherapyChantraine, A. et al. (1999)

• Sequence of FES Program
• 1st Sequence
• 90 min, rectangular biphasic, 8 Hz, 350 usec,
  15, 4 channel
• 2nd Sequence
• 30 min, 40 Hz
• 3rd Sequence
• 10 min, 1 Hz

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Reduction in PAIN Treatment group vs.
Control groupChantraine, A. et al. (1999)
  FES Control p value
Time pain reduction pain reduction  
3 mo 70.2 36.2 plt.001
6 mo 77.2 48.6 plt.01
12 mo 80.7 55.2 plt.02
24 mo 80.7 55.2 plt.03
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Improvement in Subluxation GradesTreatment group
vs. Control groupChantraine, A. et al. (1999)

• de Bats Subluxation Scale
• Grade 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 Improvement of subluxation grade  
6 mo 73.7 39.7 plt.001
12 mo 78.9 58.6 plt.05
24 mo 78.9 58.6 plt.05
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Improvement in Recovery of Motor
FunctionTreatment group vs. Control
groupChantraine, A. et al. (1999)
  FES Control p value
Time Recovery of Motor Function Recovery of Motor Function  
6 mo 77.2 46.6 plt.001
12 mo 82.5 60.3 plt.01
24 mo 82.5 60.3 plt.01
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ResultsChantraine, A. et al. (1999)

• 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 mos.
• 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.

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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.

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Intramuscular Electrical Stimulation for
Hemiplegic Shoulder Pain Yu DT, Chae, J. et al
(2004)

• Subjects 61
• Treatment Group 32 (intramuscular NMES)
• Control Group 29 (Cuff-type sling)
• Inclusion criteria
• gt12 weeks post-stroke
• Pain rating gt2 on the 11 pt. NRS
• 1/2 fingerbreadth of inferior glenohumeral
  subluxation

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Study Parameters Yu DT, Chae, J. et al (2004)

• Treatment 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.
• Control Group
• Cuff-type hemisling for 6 weeks

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Outcome Measures Yu DT, Chae, J. et al (2004)

• Primary Outcome Measures
• BPI 12--A pain questionnaire that assesses pain
  intensity (0-10) scale as well as interference of
  pain in daily activites.
• Secondary 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

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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 lt .001.

Percent of treatment successes based on the 30
success criterion. ES electrical stimulation.
P .001. P lt .001.
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Results Early Group vs. Late GroupMean change
in BPI 12 scoresChae, J. et al (2007)
Early group (lt77 weeks post stroke)
ES (n16) Control (n14)
EOT 5.5 0.9
3 months 6.5 0.21
6 months 6.6 1.2
12 months 6.8 2.4
Late group (gt77 weeks post stroke)
ES (n16) Control (n15)
EOT 3.6 0.9
3 months 2.4 1.1
6 months 2.3 1.5
12 months 3.2 2.3
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Results Treatment Group vs. Control GroupChae,
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.

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Conclusion Chae, J. et al (2007)

• FES can be beneficial for HSP if treated early
  (lt77 weeks), and effects can be seen up to 12
  months after treatment.
• Late treatment (gt77 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.

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RCT to Evaluate the Effect of sNMES to the
Shoulder After Acute StrokeChurch, 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

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Outcome MeasuresChurch et al. (2006)

• Primary (at 3 months)
• Action Research Arm Test (ARAT)
• Secondary (at 4 weeks and at 3 months)
• Motricity Index
• Frenchay Arm Test
• 0-10 Numerical Pain Rating Scale (UE)
• 5-point adjectival scale (UE pain)
• Star Cancellation (for cortical function)
• Participants views regarding the sNMES
• Global health status at 3 months (Nottingham
  Health Profile and Oxford Handicap Scale)

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Results Church et al. (2006)

• Results at 4 weeks
• There were no significant differences in any of
  the outcome measures between the control group
  and the treatment group.
• Results at 3 months
• There were no statistically significant
  differences in
• Arm function (ARAT total)
• Upper limb pain
• Star Cancellation
• Global health status

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Is sNMES hazardous for stroke patients with
severe upper limb impairment?Church et al. (2006)
Some upper limb function at baseline ARATgt0 No upper limb function at baseline ARAT0
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
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.
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Many hypotheses why poor outcome with severely
impaired UEChurch 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.

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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.

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The Evidence-Based Review of Stroke
RehabilitationTeasell, 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

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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

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Review Learning Objectives

• 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.

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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. 200584832-842.
• 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
  29953001.

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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 Spinals Action Online Magazine,
  17 Nov. 2008. Web. 24 Apr. 2010.
  lthttp//fescenter.org/index.php?viewarticleid98
  functional-electrical-stimulation-the-future-of-r
  ehabilitationoptioncom_contentItemid15gt
• Teasell, R., Foley, N., Bhogal, S. (2008).
  Version 11 Painful hemiplegic shoulder. Obtained
  from the WWW April 7, 2009 at http//www.ebrsr.co
  m/reviews_details.php?16
• Vaugnat, H. Chantraine, A. (2003). Shoulder
  pain in hemiplegia revisitedContribution of
  functional electrical stimulation and other
  therapies. Journal of Rehabilitative Medicine,
  35 49-56.

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REFERENCES

• 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.
• Walsh, K. (2001). Management of shoulder pain in
  patients with stroke. Postgraduate Medical
  Journal, 77 645-649.
• 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. 200485695-704.