MAXWELL CANTOR, SARA CORDELL, SHELLY GRAHAM, CAITLIN LADD, ALI MULCAHY, JULIE POTTER

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Neuromuscular Electrical Stimulation for Shoulder
Subluxation

• MAXWELL CANTOR, SARA CORDELL, SHELLY GRAHAM,
  CAITLIN LADD, ALI MULCAHY, JULIE POTTER
• AKA TEAM AWESOME

2
Background Information

• Shoulder subluxation is a frequent dysfunction
  following stroke
• The recorded incidence of shoulder subluxation is
  varied among sources
• This variation may be accounted for by the
  severity of the stroke and the motor activity
  present in the shoulder girdle post stroke
• Some examples of incidence are 81, 56 and 60
• Electrical stimulation for shoulder subluxation
  is used for patients post-stroke

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Background Information

• Supraspinatus and posterior deltoid muscles have
  been found to be the key shoulder elevators in
  the GH joint
• After stroke, patients experience varying levels
  of paralysis and paresis and have difficulty
  overcoming gravitational pull on the humerus
• Shoulder subluxation is considered a problem
  because it can cause shoulder pain and prevent
  functional recovery of the upper limb
• Preventing shoulder subluxation may increase
  functional ability of patients post-stroke

4
Background Information

• Shoulder subluxation may also be treated post
  stroke by the use of a sling
• Slings can cause contractures and decrease
  function

NMES Video
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Stimulation Parameters

• Electrodes are placed over the muscle bellies of
  the
• supraspinatus
• posterior deltoid 
• Waveform symmetric, biphasic PC
• Moderate pulse duration (150-200 us)
• Frequency 12-25pps (recommend gt30pps)
• Amplitude gradually increase until a F
  isometric contraction
• On/Off 15s on/45s off, 5s ramp
• progress to 30s on/2s off
• 30 minute sessions initially
• progress to 6-8 hours/day
• Continue until realignment persists without
  stimulation
• per Dr. Robinson

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Rationale and Expected Outcomes

• Restore the resting length-tension relationship
  of rotator cuff muscles and deltoid
• Prevents further ligamentous and capsular stretch
  due to gravitational pull
• By keeping the shoulder joint intact, this will
  decrease pain and increase patient function

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Indications

• Patient post stroke who are susceptible
  to/already have shoulder subluxation
• Shoulder muscle paresis or paralysis

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Contraindications

• Unable to give adequate feedback about of level
  of stimulation
• Communication or cognitive deficits
• Peripheral vascular disease or known thrombus
• Area of infection or neoplasm
• Frail skin that may break open easily
• Excessive adipose tissue
• Cautious with patients who are hyper- or
  hypotensive
• It may alter autonomic response

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Efficacy of electrical stimulation in preventing
or reducing subluxation of the shoulder after
stroke A meta-analysis

• 7 studies in Systematic Review
• Inclusion criteria
• randomized/quasi randomized
• surface e-stim
• subjects gt50 years old
• clinical dx stroke
• stimulation frequency gt30Hz or motor response
  obtained
• subluxation, pain and/or function measured
•  Exclusion
• studies including other neurological conditions
• e-stim as part of multiple intervention

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Efficacy of electrical stimulation in preventing
or reducing subluxation of the shoulder after
stroke A meta-analysis

• Intervention
• All studies used e-stim as an adjunct to
  conventional therapy
• Early e-stim
• 4-6wks, 5-7days/wk
• Start e-stim at 1.5-2hr/day, increase to
  4-6hrs/day
• Late e-stim
• 6 wks, 5 days/wk
• Start e-stim at 0.2-1.5hrs/day, increase to
  between 0.5-6hrs/day
• Frequency gt30Hz or tetanic muscle contraction
  obtained
• Increase both duty cycle and duration

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Efficacy of electrical stimulation in preventing
or reducing subluxation of the shoulder after
stroke A meta-analysis

• Results
• Subluxation measurements
• A-P X-ray, measure in millimeters
• 4 trials Compare affected side to unaffected
  side
• 3 trials measure affected side only
• Function
• Strength, EMG activity, performance on functional
  scale
• Pain
• Self-report, request for drugs, pain-free ROM, VAS

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Efficacy of electrical stimulation in preventing
or reducing subluxation of the shoulder after
stroke A meta-analysis

• Results
• Early e-stim w/ conventional therapy
• Prevents 6.5mm of subluxation significant
• Function increase 19 compared to conventional
  therapy alone
• No significant difference compared to
  conventional therapy alone
• Late e-stim w/ conventional therapy
• Reduces subluxation by 1.9mm not significant
• No significant function increase compared to
  conventional therapy alone
• Effective in maintaining pain-free ROM compared
  to conventional therapy alone

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Efficacy of electrical stimulation in preventing
or reducing subluxation of the shoulder after
stroke A meta-analysis

• Conclusion
• Early e-stim w/ conventional therapy 
• Prevents subluxation in acute stroke
• Late e-stim w/ conventional therapy
• Will not significantly reduce a shoulder that is
  already subluxed
• Other considerations
• No long term follow-up of studies mentioned
• Maintenance of results from early e-stim not
  mentioned

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The effectiveness of functional electrical
stimulation for the treatment of shoulder
subluxation and shoulder pain in hemiplegic
patients A randomized controlled trial

• Method?
• 50 hemiplegic patients with shoulder subluxation
  and shoulder pain randomly divided into study
  and control groups
• Study group received FES in addition to
  conventional rehabilitation program
• Control group received conventional
  rehabilitation program only

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The effectiveness of functional electrical
stimulation for the treatment of shoulder
subluxation and shoulder pain in hemiplegic
patients A randomized controlled trial

• FES Intervention   
•     Current Biphasic
•     Impulse duration 250us
•     Frequency 36Hz (tetanized muscle
  contraction)
•     Contraction/relaxation ratio 10/12s
  progressing to 30/2s
•     Ramp up/down 1s
•     Duration 60 min
• 4 weeks in length
• Shoulder subluxation levels were evaluated before
  and after treatment (X-ray using classification
  developed by Van Langenberghe et al)

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The effectiveness of functional electrical
stimulation for the treatment of shoulder
subluxation and shoulder pain in hemiplegic
patients A randomized controlled trial

• Results
• Statistically significant difference between the
  pre and post-rehabilitation shoulder subluxation
  values of the study group (plt.001)
• No statistically significant difference between
  pre and post-rehabilitation shoulder subluxation
  values of the control group (pgt.05)
• Comparison of change in subluxation values
  between groups revealed a statistically
  significant difference in favor of the study
  group
• The application of FES treatment to
  supraspinatus and posterior deltoid muscles in
  addition to conventional treatment is more
  effective at treating subluxation in hemiplegic
  patients than conventional treatment itself!

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Outcome Measures

• Subluxation
• Anterior-posterior Radiograph
• Measure from the acromion to the humerus
• Sulcus Sign
• Grades
• lt1cm 1
• 1-2cm 2
• gt2cm 3
• Ultrasonographic Measurements
• Measure from the acromion to the greater
  tuberosity
• Always compare the involved side to the
  uninvolved

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Outcome Measures

•  UE Functional Outcome Measures
• Fugl-Meyer
• Movement Assessment Scale(MAS)
• Item 6 Upper Arm Function
• Bobath Assessment
• Pain
• Visual Analog Scale (VAS)

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What do we recommend?

• Benefit patients for prevention or reduction of
  shoulder subluxation
• More studies need to be performed to
  differentiate time period in which FES is still
  effective
• Parameters from Dr. Robinson and the Systematic
  Review are consistent
• Difference
• Dr. Robinson states to continue until subluxation
  is no longer visible
• Systematic review states 6 week duration

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Percutaneous Intramuscular NMES
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Percutaneous Intramuscular NMES

• Implanted intramuscular stimulation electrodes
  that lead to an external, portable generator
• Implanted near motor points, therefore focally
  stimulates deep muscles
• Avoids cutaneous nociceptors and requires lower
  stimulus intensity...better tolerated by
  patients.
• Easily managed
•  
• Slows/prevents muscle disuse atrophy/subluxation
• Maintains ROM
• Facilitates voluntary motor function
• Increases blood flow, relaxes spastic mm.
• Decreases pain related to subluxation and disuse

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Intervention methods
Asynchronous stimulation of        Supraspinatus
and Middle Deltoid        Trapezius and
Posterior Deltoid             (minimize
repetitive vertical translation of the humeral
head in the glenoid fossa) 6 hrs stim/day for 6
wks (2-3 equal sessions/day) Subjects
seated/standing with UE unsupported during
treatment   Stimulator     On time-20s     Off
time-10s     Ramp-5s     Amplitude-20mA     Adjust
able pulse width     Built-in data logging system
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Outcome measures

• Pain Questionnaire BPI 12
• ADL's/QOL BPI 23
• Degree of subluxation Radiographs
• Painfree PROM Goniometry
• Function Fugl-Meyer Motor Assessment
• Upper limb disability FIM, AMAT

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Study Conclusions
Percutaneous intramuscular NMES is a safe
intervention option to reduce post-stroke
shoulder pain and the degree to which shoulder
pain interferes with daily activities among
chronic stroke survivors with shoulder
subluxation.
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Closing Thoughts

• ???

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References

• Robinson AJ, Snyder-Mackler L. Clinical
  Electrophysiology Electrotherapy and
  Electrophysiologic Testing. 3rd ed. Philadelphia
  Lippincott Williams Wilkins 2008.
•  
• Ada L, Foongchomcheay A. Efficacy of electrical
  stimulation in preventing or reducing subluxation
  of the shoulder after stroke a meta-analysis.
  The Australian Journal Of Physiotherapy.
  200248(4)257-267. 
•  
• Wang RY, Chan RC, Tsai MW. Functional electrical
  stimulation on chronic and acute hemiplegic
  shoulder subluxation. Am J Phys Med Rehabil.
  200079385-390.
•  
• Koyuncu E, Nakipoglu-Yuzer GF, Dogan A, Ozgirgin
  N. The effectiveness of functional electrical
  stimulation for the treatment of shoulder
  subluxation and shoulder pain in hemiplegic
  patients a randomized controlled
  trial. Disability and Rehabilitation. 201032(7)5
  60-566.
•  
• Yu DT, Chae J, Walker M. Intramuscular
  Neuromuscular Electric Stimulation for Poststroke
  Shoulder Pain A Multicenter Randomized Clinical
  Trial. Arch Phys Med Rehab. 200485 695-704. 
•  
• Park G, Kim J, Sohn S, Shin I, Lee M.
  Ultrasonographic measurement of shoulder
  subluxation in patients with post-stroke
  hemiplegia. Journal Of Rehabilitation Medicine
  Official Journal Of The UEMS European Board Of
  Physical And Rehabilitation Medicine serial
  online. September 200739(7)526-530. Available
  from MEDLINE, Ipswich, MA.
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