Electrical stimulation for preventing and treating post-stroke shoulder pain: a systematic Cochrane review

Comparative study of ultrasonic-guided betamethasone local injection and extracorporeal shock wave therapy in post-stroke hemiplegic shoulder pain: a randomized clinical trial

Objective

This study aimed to compare the efficacy and safety of ultrasound-guided local injection (UGLI) of betamethasone around the shoulder and extracorporeal shock wave therapy (ESWT) in patients with hemiplegic shoulder pain.

Method

Forty-two patients with hemiplegic shoulder pain were randomly divided into the UGLI group (N = 21) and the ESWT group (N = 21). In the UGLI group, betamethasone was injected at the pain point around the shoulder under ultrasonic localization. In the ESWT group, an extracorporeal shock wave was performed at the pain points around the shoulder for 20 min of time, once a week, for 4 consecutive weeks. Both groups received rehabilitation training. The visual analog scale (VAS) evaluation was performed at baseline, 1 h, 1 week, and 1 month after treatment. Furthermore, Neer shoulder joint function scores, upper limb Fugl-Meyer assessment (FMA), modified Barthel index (MBI), Hamilton Depression Scale (HAMD), the MOS-item short-form health survey (SF-36) scores, and serum expression level of cytokine were evaluated at baseline and 1 month after treatment.

Results

After 1-h treatment, the UGLI group showed a greater effect on the degree of pain than the ESWT group (P = 0.017). After 4 consecutive weeks of intervention, the UGLI group showed a significant improvement in the serum level of cytokine expression compared with the ESWT group (P < 0.05). The range of motion (ROM) of the hemiplegic shoulder (P < 0.05) has no difference between the two groups (P > 0.05).

Conclusion

The ultrasonic-guided betamethasone local injection and extracorporeal shock wave both can improve hemiplegic shoulder pain. However, the UGLI can induce a more cytokine expression level.

Does TENS Reduce the Intensity of Acute and Chronic Pain? A Comprehensive Appraisal of the Characteristics and Outcomes of 169 Reviews and 49 Meta-Analyses

Background and Objectives: Uncertainty about the clinical efficacy of transcutaneous electric nerve stimulation (TENS) to alleviate pain spans half a century. There has been no attempt to synthesise the entire body of systematic review evidence. The aim of this comprehensive review was to critically appraise the characteristics and outcomes of systematic reviews evaluating the clinical efficacy of TENS for any type of acute and chronic pain in adults. Materials and Methods: We searched electronic databases for full reports of systematic reviews of studies, overviews of systematic reviews, and hybrid reviews that evaluated the efficacy of TENS for any type of clinical pain in adults. We screened reports against eligibility criteria and extracted data related to the characteristics and outcomes of the review, including effect size estimates. We conducted a descriptive analysis of extracted data. Results: We included 169 reviews consisting of eight overviews, seven hybrid reviews and 154 systematic reviews with 49 meta-analyses. A tally of authors' conclusions found a tendency toward benefits from TENS in 69/169 reviews, no benefits in 13/169 reviews, and inconclusive evidence in 87/169 reviews. Only three meta-analyses pooled sufficient data to have confidence in the effect size estimate (i.e., pooled analysis of >500 events). Lower pain intensity was found during TENS compared with control for chronic musculoskeletal pain and labour pain, and lower analgesic consumption was found post-surgery during TENS. The appraisal revealed repeated shortcomings in RCTs that have hindered confident judgements about efficacy, resulting in stagnation of evidence. Conclusions: Our appraisal reveals examples of meta-analyses with 'sufficient data' demonstrating benefit. There were no examples of meta-analyses with 'sufficient data' demonstrating no benefit. Therefore, we recommend that TENS should be considered as a treatment option. The considerable quantity of reviews with 'insufficient data' and meaningless findings have clouded the issue of efficacy. We offer solutions to these issues going forward.

Investigating the Intervention Parameters of Endogenous Paired Associative Stimulation (ePAS)

Advances in our understanding of neural plasticity have prompted the emergence of neuromodulatory interventions, which modulate corticomotor excitability (CME) and hold potential for accelerating stroke recovery. Endogenous paired associative stimulation (ePAS) involves the repeated pairing of a single pulse of peripheral electrical stimulation (PES) with endogenous movement-related cortical potentials (MRCPs), which are derived from electroencephalography. However, little is known about the optimal parameters for its delivery. A factorial design with repeated measures delivered four different versions of ePAS, in which PES intensities and movement type were manipulated. Linear mixed models were employed to assess interaction effects between PES intensity (suprathreshold (Hi) and motor threshold (Lo)) and movement type (Voluntary and Imagined) on CME. ePAS interventions significantly increased CME compared to control interventions, except in the case of Lo-Voluntary ePAS. There was an overall main effect for the Hi-Voluntary ePAS intervention immediately post-intervention (p = 0.002), with a sub-additive interaction effect at 30 min’ post-intervention (p = 0.042). Hi-Imagined and Lo-Imagined ePAS significantly increased CME for 30 min post-intervention (p = 0.038 and p = 0.043 respectively). The effects of the two PES intensities were not significantly different. CME was significantly greater after performing imagined movements, compared to voluntary movements, with motor threshold PES (Lo) 15 min post-intervention (p = 0.012). This study supports previous research investigating Lo-Imagined ePAS and extends those findings by illustrating that ePAS interventions that deliver suprathreshold intensities during voluntary or imagined movements (Hi-Voluntary and Hi-Imagined) also increase CME. Importantly, our findings indicate that stimulation intensity and movement type interact in ePAS interventions. Factorial designs are an efficient way to explore the effects of manipulating the parameters of neuromodulatory interventions. Further research is required to ensure that these parameters are appropriately refined to maximise intervention efficacy for people with stroke and to support translation into clinical practice.

Protecting Patient Safety and Preventing Modifiable Complications After Acute Ischemic Stroke

TOPIC

Protecting patient safety and preventing modifiable complications after acute ischemic stroke.

CLINICAL RELEVANCE

Stroke is a leading cause of death and disability in adults. Stroke survivors often experience a variety of deficits related to mobility, nutrition, immunity, mood, and cognition. These post-stroke complications and residual effects can adversely affect safety, placing the patient at risk for further injury. In order to develop a plan of care that protects patient safety, critical care and progressive care nurses must understand the unique needs of this patient population.

PURPOSE

To describe selected ischemic stroke-related physiological changes, how these changes contribute to safety risks, and methods of enhancing patient safety.

CONTENT COVERED

Stroke physiology and stroke-specific interventions that can enable nurses to reduce the risk of falls, dysphagia, malnutrition, dehydration, altered glucose metabolism, device-related infections, aspiration pneumonia, delirium, and depression.

Opposite modulations of corticospinal excitability by intermittent and continuous peripheral electrical stimulation in healthy subjects

Peripheral electrical stimulation (PES) modulates the excitability of the corticospinal tract (CST). This modulation of CST excitability depends on the PES intensity, defined by the amplitude and the width of each pulse, the total pulse number, the stimulation frequency, and the intervention duration. Another key PES parameter is the stimulation pattern; little is known about how PES pattern affects CST excitability, as previous studies did not control other PES parameters. Here, we investigated the effect of the net difference in PES pattern on CST excitability. We use three controlled PESs, intermittent PES (30 Hz) (stimulation trains at 30 Hz with pauses), continuous PES (12 Hz) (constant stimulation at 12 Hz without pauses), and continuous PES (30 Hz) with the same stimulation frequency as the intermittent PES (30 Hz), to compare the effect of the stimulation frequency. The motor evoked potentials (MEPs) and somatosensory evoked potentials (SEPs) of healthy subjects were recorded before and after these three types of PESs in separate sessions. We found that intermittent PES (30 Hz) increased MEP amplitudes, whereas continuous PES (12 and 30 Hz) decreased amplitudes. A significant change in subcortical SEP component occurred during continuous PES (12 and 30 Hz), but not intermittent PES (30 Hz), whereas cortical SEP components showed similar behavior in three types of PESs. We conclude that (1) opposing modulations of CST excitability were induced by the differences in the PES pattern, and (2) these modulations appear to be mediated through different processes in the sensorimotor system. Our findings suggest the possibility that it may be preferable to select the PES pattern in therapeutic interventions based on the putative desired effect and the neural structure being targeted.

A redox-based electrogenetic CRISPR system to connect with and control biological information networks

Electronic information can be transmitted to cells directly from microelectronics via electrode-activated redox mediators. These transmissions are decoded by redox-responsive promoters which enable user-specified control over biological function. Here, we build on this redox communication modality by establishing an electronic eCRISPR conduit of information exchange. This system acts as a biological signal processor, amplifying signal reception and filtering biological noise. We electronically amplify bacterial quorum sensing (QS) signaling by activating LasI, the autoinducer-1 synthase. Similarly, we filter out unintended noise by inhibiting the native SoxRS-mediated oxidative stress response regulon. We then construct an eCRISPR based redox conduit in both E. coli and Salmonella enterica. Finally, we display eCRISPR based information processing that allows transmission of spatiotemporal redox commands which are then decoded by gelatin-encapsulated E. coli. We anticipate that redox communication channels will enable biohybrid microelectronic devices that could transform our abilities to electronically interpret and control biological function.

Treatment of Glenohumeral Subluxation: A Review of the Literature and Considerations for Pediatric Population

OBJECTIVE

The aim of this review was to identify treatment strategies in the research literature to inform all health professionals on best practice strategies when addressing glenohumeral subluxation.

DESIGN

Articles were identified by searching electronic databases. Two reviewers independently appraised the methodological quality of the selected studies. Discrepancies were resolved after corroboration of results.

RESULTS

Research literature pertaining to five major treatment strategies was found (n = 40 peer-reviewed publications), spanning evidence levels I-V. The greatest number of studies concerned neuromuscular electrical stimulation (n = 19), five of which were level I studies, followed by manual preventive strategies, such as slings (n = 20), three of which were level I studies.

CONCLUSIONS

These findings indicate that the most high-quality research supports using neuromuscular electrical stimulation or manual preventive studies, although no studies used direct comparison methods to ascertain relative merits of each type of intervention when compared with others. No evidence suggested that harm was done by using neuromuscular electrical stimulation or manual preventive methods. This literature review suggests that the identified treatment strategies should be considered by clinicians as the treatment of choice for GHS. No literature was identified that reviewed treatment strategies in a pediatric population; however, the authors considerations for treatment in the pediatric population were included.

Prolonged Reduction in Shoulder Strength after Transcutaneous Electrical Nerve Stimulation Treatment of Exercise-Induced Acute Muscle Pain

OBJECTIVES

Transcutaneous electrical nerve stimulation (TENS) is commonly used for reducing musculoskeletal pain to improve function. However, peripheral nerve stimulation using TENS can alter muscle motor output. Few studies examine motor outcomes following TENS in a human pain model. Therefore, this study investigated the influence of TENS sensory stimulation primarily on motor output (strength) and secondarily on pain and disability following exercise-induced delayed-onset muscle soreness (DOMS).

METHODS

Thirty-six participants were randomized to a TENS treatment, TENS placebo, or control group after completing a standardized DOMS protocol. Measures included shoulder strength, pain, mechanical pain sensitivity, and disability. TENS treatment and TENS placebo groups received 90 minutes of active or sham treatment 24, 48, and 72 hours post-DOMS. All participants were assessed daily.

RESULTS

A repeated measures analysis of variance and post-hoc analysis indicated that, compared to the control group, strength remained reduced in the TENS treatment group (48 hours post-DOMS, P < 0.05) and TENS placebo group (48 hours post-DOMS, P < 0.05; 72 hours post-DOMS, P < 0.05). A mixed-linear modeling analysis was conducted to examine the strength (motor) change. Randomization group explained 5.6% of between-subject strength variance (P < 0.05). Independent of randomization group, pain explained 8.9% of within-subject strength variance and disability explained 3.3% of between-subject strength variance (both P < 0.05).

DISCUSSION

While active and placebo TENS resulted in prolonged strength inhibition, the results were nonsignificant for pain. Results indicated that higher pain and higher disability were independently related to decreased strength. Regardless of the impact on pain, TENS, or even the perception of TENS, may act as a nocebo for motor output.

Effect of EMG-triggered neuromuscular electrical stimulation with bilateral arm training on hemiplegic shoulder pain and arm function after stroke: a randomized controlled trial

BACKGROUND

Hemiplegic shoulder pain is a frequent complication after stroke, leading to limited use of the affected arm. Neuromuscular electrical stimulation (NMES) and transcutaneous electrical nerve stimulation (TENS) are two widely used interventions to reduce pain, but the comparative efficacy of these two modalities remains uncertain. The purpose of this research was to compare the immediate and retained effects of EMG-triggered NMES and TENS, both in combination with bilateral arm training, on hemiplegic shoulder pain and arm function of stroke patients.

METHODS

A single-blind, randomized controlled trial was conducted at two medical centers. Thirty-eight patients (25 males and 13 females, 60.75 ± 10.84 years old, post stroke duration 32.68 ± 53.07 months) who had experienced a stroke more than 3 months ago at the time of recruitment and hemiplegic shoulder pain were randomized to EMG-triggered NMES or TENS. Both groups received electrical stimulation followed by bilateral arm training 3 times a week for 4 weeks. The primary outcome measures included a vertical Numerical Rating Scale supplemented with a Faces Rating Scale, and the short form of the Brief Pain Inventory. The secondary outcome measures were the upper-limb subscale of the Fugl-Meyer Assessment, and pain-free passive shoulder range of motion. All outcomes were measured pretreatment, post-treatment, and at 1-month after post-treatment. Two-way mixed repeated measures ANOVAs were used to examine treatment effects.

RESULTS

Compared to TENS with bilateral arm training, the EMG-triggered NMES with bilateral arm training was associated with lower pain intensity during active and passive shoulder movement (P =0.007, P =0.008), lower worst pain intensity (P = 0.003), and greater pain-free passive shoulder abduction (P =0.001) and internal rotation (P =0.004) at follow-up. Both groups improved in pain at rest (P =0.02), pain interference with daily activities, the Fugl-Meyer Assessment, and pain-free passive shoulder flexion and external rotation post-treatment (P < 0.001) and maintained the improvement at follow-up (P < 0.001), except for resting pain (P =0.08).

CONCLUSIONS

EMG-triggered NMES with bilateral arm training exhibited greater immediate and retained effects than TENS with bilateral arm training with respect to pain and shoulder impairment for chronic and subacute stroke patients with hemiplegic shoulder pain.

TRIAL REGISTRATION

NCT01913509 .

Ultrasonographic assessment of neuromuscular electrical stimulation efficacy on glenohumeral subluxation in patients with hemiplegia: a randomized-controlled study

Objectives

This study aims to investigate the short-term effects of neuromuscular electrical stimulation (NMES) on glenohumeral subluxation (GHS) in stroke patients.

Patients and methods

This prospective, randomized-controlled study included 24 unilateral hemiplegic patients (10 males, 14 females; mean age 64.1±14.8 years; range 22 to 84 years) with GHS as assessed by ultrasonography between December 2013 and September 2014. The patients were randomly divided into two groups as those in the NMES group (n=12) who were treated with NMES to supraspinatus, upper trapezius, and posterior deltoid muscles combined with conventional physiotherapy and as those in the control group (n=12) who were received conventional physiotherapy alone. Clinical (the Brunnstrom Motor Recovery Stage, Visual Analog Scale [VAS] for Pain and Shoulder Disability Questionnaire [SDQ]) and ultrasonographic (acromion-greater tuberosity distance, thicknesses of supraspinatus, upper trapezius, and posterior deltoid muscles) variables were evaluated before and after treatment in both groups.

Results

The SDQ index, acromion-greater tuberosity distance, and supraspinatus muscle thickness were improved in the NMES group, compared to the control group (for all p<0.05). The VAS-pain scores decreased in both groups. There was no statistically significant alterations in the other measurements in both groups (for all p>0.05). The percentage change (%) of the VAS-pain scores was not significantly different between two groups (p=0.03).

Conclusion

Our study results showed that GHS decreased after 20 sessions of NMES treatment. Based on these findings, ultrasonography appears to be a proper imaging tool for the evaluation of GHS in stroke patients.

Effectiveness of neuromuscular electrical stimulation for management of shoulder subluxation post-stroke: a systematic review with meta-analysis

Objectives:

To examine the effectiveness of neuromuscular electrical stimulation (NMES) for the management of shoulder subluxation after stroke including assessment of short (1 hour or less) and long (more than one hour) daily treatment duration.

Data sources:

MEDLINE, CENTRAL, CINAHL, WOS, KoreaMed, RISS and reference lists from inception to January 2017

Review methods:

We considered randomized controlled trials that reported neuromuscular electrical stimulation for the treatment of shoulder subluxation post-stroke. Two reviewers independently selected trials for inclusion, assessed trial quality, and extracted data.

Results:

Eleven studies were included (432 participants); seven studies were good quality, four were fair. There was a significant treatment effect of neuromuscular electrical stimulation for reduction of subluxation for persons with acute and subacute stroke (SMD:–1.11; 95% CI:–1.53, –0.68) with either short (SMD:–0.91; 95% CI:–1.43, –0.40) or long (SMD:–1.49; 95% CI:–2.31, –0.67) daily treatment duration. The effect for patients with chronic stroke was not significant (SMD:–1.25; 95% CI:–2.60, 0.11). There was no significant effect of neuromuscular electrical stimulation on arm function or shoulder pain.

Conclusion:

This meta-analysis suggests a beneficial effect of neuromuscular electrical stimulation, with either short or long daily treatment duration, for reducing shoulder subluxation in persons with acute and subacute stroke. No significant benefits were observed for persons with chronic stroke or for improving arm function or reducing shoulder pain.

Continuous passive motion improves shoulder joint integrity following stroke

Objective: In a pilot study of patients with a first stroke and hemiparesis, we sought to determine whether treatment of the upper limb with continuous passive motion (CPM) that was device delivered would alter impairment, disability or the associated adverse symptoms of shoulder joint instability, pain and tone.

Design: Patients were randomly assigned to receive daily CPM treatments or participate in self-range of motion groups under the supervision of an occupational therapist. All patients received standard daily poststroke therapy for 3.5 h per day. A blinded evaluator at admission and discharge assessed patients using standardized scales of impairment, disability and adverse symptoms.

Setting: Specialized stroke unit of an acute rehabilitation hospital.

Subjects: Two hundred and eighty consecutive patients were screened and 35 of these with a first unilateral stroke, 139-6 days following the acute event, provided informed consent and were randomly assigned to CPM treatment or supervised group self-range exercise.

Main measures: Thirty-two completed the study and were evaluated using standardized measures for motor impairment (Fugl-Meyer, Motor Status Scale and Medical Research Council Motor Power), adverse symptoms (gleno-humeral stability, pain and tone), and disability (Functional Independence Measure).

Results: CPM-treated patients demonstrated positive trends towards improved shoulder joint stability (p =0.06, confidence interval -0.03, 2.3) when compared with patients performing therapist-supervised self-range of motion. There were no significant differences in motor impairment, disability, pain or tone.

Conclusions: Device-delivered continuous passive range of motion may offer an enhanced benefit for some adverse symptom reduction in the hemiplegic arm after stroke over traditional self-range of motion exercise.

Treatment Interventions for the Paretic Upper Limb of Stroke Survivors: A Critical Review

Despite a threefold increase in treatment interventions studies during the past 10 years, “best practice” for the rehabilitation of the paretic upper limb is still unclear. This review aims to lessen uncertainty in the management of the poststroke upper limb. Two separate searches of the scientific literature from 1966-2001 yielded 333 articles. Three referees, using strict inclusion and exclusion criteria, selected 68 relevant references. Cohort studies, randomized control trials, and systematic reviews were critically appraised. Mean randomized control trial quality (n = 33) was 17.1/27 (SD = 5.2, 95% CI = 15.2–19.0, range = 6–26). Mean quality of cohort studies (n = 29) was 11.8/27 (SD = 3.8, 95% CI = 10.4–13.2, range = 4–19). Quantitative syntheses were done using theZ -statistic. This systematic review indicated that sensorimotor training; motor learning training that includes the use of imagery, electrical stimulation alone, or combined with biofeedback; and engaging the client in repetitive, novel tasks can be effective in reducing motor impairment after stroke. Furthermore, careful handling, electrical stimulation, movement with elevation, strapping, and the avoidance of overhead pulleys could effectively reduce or prevent pain in the paretic upper limb. Rehabilitation specialists can use this research synthesis to guide their selection of effective treatment techniques for persons with impairments after stroke.

Percutaneous neuromuscular electrical stimulation (P-NMES) for treating shoulder pain in chronic hemiplegia. Effects on shoulder pain and quality of life

Objective: To evaluate the effect of percutaneous neuromuscular electrical stimulation (P-NMES) of the shoulder muscles on shoulder pain intensity and health-related quality of life in chronic hemiplegia.

Design: Prospective, open label design.

Setting: The outpatient services of a large teaching rehabilitation hospital in the Netherlands.

Subjects: Fifteen stroke survivors with chronic (> six months) hemiplegia and a therapy-resistant painful shoulder with subluxation. All patients suffered from clinically relevant shoulder pain, as assessed by a score of at least 4 out of 10 on a numerical rating scale. Shoulder subluxation was indicated by at least 1/2 fingerbreadth of glenohumeral separation on palpation.

Intervention: Six hours of P-NMES per day for a total of six weeks.

Main outcome measures: Shoulder pain (Brief Pain Inventory), shoulder subluxation (clinical and radiographic), shoulder pain-free external rotation (hand-held goniometer), motor impairment (Fugl-Meyer Motor test) and quality of life (SF-36) were assessed before treatment, after six weeks of intramuscular stimulation, at three months and six months follow-up.

Results: A significant reduction in pain was found on the Brief Pain Inventory. Pain reduction was still present at six months follow-up. All domains, in particular bodily pain, of the SF-36 showed improvement in the short term. After six months of follow-up, bodily pain was still strongly and significantly reduced, whereas social functioning and role physical demonstrated a nonsignificant improvement of more than 10% compared with baseline.

Conclusion: This pilot suggests that P-NMES potentially reduces shoulder pain in chronic hemiplegia. To establish the clinical value of P-NMES in treating hemiplegic shoulder pain a randomized controlled trial is needed.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Pain syndromes in hemiplegic patients and their effects on rehabilitation results

[Purpose] The aim of this study was to determine the frequency, type, and location of pain in hemiplegic patients and the effects on rehabilitation results in our inpatient rehabilitation unit. [Subjects and Methods] Patients rehabilitated between January 2010 and July 2012 were investigated retrospectively. Properties of pain were recorded. Pre- and post-rehabilitation motor evaluation and achievement in daily activities were considered, and differences in scores between groups classified as with and without pain were examined. [Results] The number of patients included in the study was 156. The mean age was 64.28 ± 12.45 years, the mean disease duration was 11.10 months, and the gender distribution was 75 males (48%) and 81 females (52%). Fortysix (29.5%) patients had pain complaints. The nociceptive pain ratio was 86.7%, and the neuropathic pain ratio was 13.3%. Pain was mostly localized at the shoulder joint, with the proportion being 86.9%. In the pain group, statistically significant improvement was found in pain scores after the treatment. There was no significant difference between groups in the pre- and post-rehabilitation Brunnstrom motor evaluation and functional independence measurement scores. [Conclusion] Nociceptive pain is more common than neuropathic pain in patients with hemiplegia, and the shoulder joint is the most frequent location of nociceptive pain.

Effectiveness of functional electrical stimulation in improving clinical outcomes in the upper arm following stroke: a systematic review and meta-analysis

Background. Different therapeutic methods are being used to prevent or decrease long-term impairments of the upper arm in stroke patients. Functional electrical stimulation (FES) is one of these methods, which aims to stimulate the nerves of the weakened muscles so that the resulting muscle contractions resemble those of a functional task. Objectives. The objective of this study was to review the evidence for the effect of FES on (1) shoulder subluxation, (2) pain, and (3) upper arm motor function in stroke patients, when added to conventional therapy. Methods. From the 727 retrieved articles, 10 (9 RCTs, 1 quasi-RCT) were selected for final analysis and were rated based on the PEDro (Physiotherapy Evidence Database) scores and the Sackett's levels of evidence. A meta-analysis was performed for all three considered outcomes. Results. The results of the meta-analyses showed a significant difference in shoulder subluxation in experimental groups compared to control groups, only if FES was applied early after stroke. No effects were found on pain or motor function outcomes. Conclusion. FES can be used to prevent or reduce shoulder subluxation early after stroke. However, it should not be used to reduce pain or improve upper arm motor function after stroke.

Prevalence and determinants of pain in the ipsilateral upper limb of stroke patients

This study investigated the prevalence of pain in the ipsilateral upper-limb in stroke patients. 229 stroke patients (133 men, 96 women; M age = 59.0 yr., SD = 12.4) were assessed with the Pain Behaviors Scales and their motor weakness was measured with the Motricity Index. Results indicated that over 27% of patients experienced pain in at least one joint of the ipsilateral upper limb. Shoulder pain was the most common. Further analysis indicated that the occurrence of pain in the ipsilateral upper limb was higher among women, among patients who used a cane, and among patients with a greater weakness of the affected lower limb.

Upper limb rehabilitation following stroke: current evidence and future perspectives

Stroke is a leading cause of disability worldwide, with its risk increasing with age. Upper limb hemiparesis is common and associated with persistent impairments and associated disabilities. Older stroke populations often suffer multiple comorbidities and restoring independence is complex. Recovery of upper limb function can be crucial for individuals to return to independent living and to participate in community life. This review describes upper limb recovery post-stroke, and some of the new therapeutic approaches available to promote recovery. Technologies (including virtual reality and telehealth) offer the opportunity for more home-based therapies, longer programs and greater access to rehabilitation for older individuals. However, the trials continue to exclude older individuals, so acceptability is poorly understood. Upper limb rehabilitation remains a research frontier, which has been energized by new technologies, but is grounded by the basic need to find ways to allow older individuals to recover independence. This paper aims to review the applicability and generalizability of current research to the older stoke survivor. Future research priorities need to be tailored to consider the older mean age of individuals in stroke rehabilitation.

Transcutaneous pulsed radiofrequency treatment for patients with shoulder pain booked for surgery: a double-blind, randomized controlled trial

Shoulder pain is the third most common musculoskeletal problem and accounts for 5% of general practitioner consultations. Although many treatments are described, there is no consensus on optimal treatment and up to 40% of patients still have pain 12 months after initially seeking help for pain. Previously, the effect of transcutaneous pulsed radiofrequency treatment (TCPRFT) was evaluated in a retrospective audit that showed good pain relief for a mean 395 days and justified this randomized sham controlled trial. In this study, 51 patients entered into a randomized double-blinded, placebo controlled study of TCPRFT. Patients were assessed at 4 and 12 weeks by a blinded observer and compared with baseline. We observed sustained reductions in pain at night, pain with activity, and functional improvement at 4 and 12 weeks with active but not sham TCPRFT. The 25 subjects who received active treatment showed statistically significant reductions of 24/100 in pain at night and 20/100 of pain with activity at 4 weeks and 18/100 and 19/100, respectively, at 12 weeks from baseline. Statistically significant lower Brief Pain Inventory pain and function scores (4 and 12 weeks), improved pain self-efficacy (4 weeks), Oxford Shoulder scores (12 weeks), and internal rotation (12 weeks) were seen. Pain at both rest and shoulder elevation were not improved by active treatment. No complications were seen. This study of a simple, low risk, outpatient treatment confirms the findings of our earlier study of TCPRFT for knee pain and shoulder pain audit that transcutaneous pulsed radiofrequency treatment may help some people with painful shoulders.

A randomized controlled trial of surface neuromuscular electrical stimulation applied early after acute stroke: effects on wrist pain, spasticity and contractures

Objectives:

To investigate effects of surface neuromuscular electrical stimulation applied early after stroke to the wrist and finger extensor muscles on upper limb pain, spasticity and contractures in patients with no functional arm movement.

Design:

Secondary analysis from a Phase II, randomized, controlled, single-blind study.

Setting:

An acute hospital stroke unit.

Subjects:

Patients with no useful arm function within six weeks of a first stroke.

Intervention:

Patients were randomized to treatment (30-minute sessions of surface neuromuscular stimulation to wrist and finger extensors and 45 minutes of physiotherapy) or control (45 minutes of physiotherapy) groups. All patients had access to routine care. Treatment was given for six weeks from recruitment.

Results:

Ninety patients (49% male, median age 74 years (range 32–98), median time since stroke onset three weeks (range one to six weeks)) were included. Treatment compliance was variable (mean 28%). The treatment prevented the development of pain (mean difference in rate of change 0.4 units/week, 95% confidence interval (CI) 0.09 to 0.6). Treatment may have prevented a deterioration in contractures (quantified by measuring passive range of movement) in severely disabled patients (mean rate of deterioration −0.5 deg/week; 95% CI −0.9 to −0.06). There were no significant changes in stiffness and spasticity.

Conclusion:

Surface neuromuscular electrical stimulation reduces pain in stroke patients with a non-functional arm. There was some evidence that treatment with electrical stimulation was beneficial in reducing contractures. Treatment had no effect on spasticity.

Current and future interventions for glenohumeral subluxation in hemiplegia secondary to stroke

Poststroke shoulder pain is a common issue and can be caused by glenohumeral subluxation. This entity hinders function and quality of life and is caused by changes in tone and loss of fi ne control of the shoulder joints' supporting structures after a stroke. Current treatments are limited in number and effectiveness and have significant problems and limitations to their use. Furthermore, prior to percutaneous implantable neuromuscular electrical stimulation, there was no evidence for any treatment to provide relief for chronic hemiplegic shoulder pain from glenohumeral subluxation. This clinical review provides a comprehensive review of the anatomy, pathogenesis, clinical features, management, and clinical efficacy of current treatment modalities.

Can surface neuromuscular electrical stimulation of the wrist and hand combined with routine therapy facilitate recovery of arm function in patients with stroke?

OBJECTIVE

To investigate whether treatment with surface neuromuscular electrical stimulation to the wrist extensors improves recovery of arm function in severely disabled patients with stroke.

DESIGN

Single blinded randomized controlled trial.

SETTING

Acute stroke unit and stroke rehabilitation wards of a university hospital.

PARTICIPANTS

Patients with no upper limb function (Action Research Arm Test [ARAT] score 0) (N=90; mean age ± SD, 74±11y; 49% men) were recruited to the study within 6 weeks of stroke. Only 67 participants were alive at the end of the study and data from 66 of these people were analyzed.

INTERVENTIONS

Participants were randomized to surface neuromuscular electrical stimulation using surface electrical stimulators for 30 minutes, twice in a working day for 6 weeks in addition to standardized upper limb therapy or just standardized upper limb therapy.

MAIN OUTCOME MEASURE

The primary outcome measure was the ARAT score. Assessments were made at baseline and at 6, 12, 24, and 36 weeks after recruitment.

RESULTS

There were statistically significant improvements in measures of wrist extensor (mean difference 0.5; 95% confidence interval [CI], 0.0-1.0) and grip strength (mean difference 0.9; 95% CI, 0.1-1.7) over the treatment period. Arm function (ARAT score) was not significantly different between the groups over the treatment period at 6 weeks (mean difference 1.9; 95% CI, -2.9 to 6.8) or over the study period at 36 weeks (mean difference 6.4; 95% CI, -1.8 to 14.7), and the rate of recovery was not significantly different (mean difference 0.7; 95% CI, -0.2 to 1.6).

CONCLUSIONS

In patients with severe stroke, with no functional arm movement, electrical stimulation of wrist extensors improves muscle strength for wrist extension and grip, and larger studies are required to study its influence on arm function.

Transcutaneous electrical nerve stimulation for the management of painful conditions: focus on neuropathic pain

The management of neuropathic pain is challenging, with medication being the first-line treatment. Transcutaneous electrical nerve stimulation (TENS) is an inexpensive, noninvasive, self-administered technique that is used as an adjunct to medication. Clinical experience suggests that TENS is beneficial providing it is administered at a sufficiently strong intensity, close to the site of pain. At present, there are too few randomized controlled trials on TENS for neuropathic pain to judge effectiveness. The findings of systematic reviews of TENS for other pain syndromes are inconclusive because trials have a low fidelity associated with inadequate TENS technique and infrequent treatments of insufficient duration. The use of electrode arrays to spatially target stimulation more precisely may improve the efficacy of TENS in the future.

Shoulder tenotomies to improve passive motion and relieve pain in patients with spastic hemiplegia after upper motor neuron injury

HYPOTHESIS

Shoulder adduction and internal rotation contractures commonly develop in patients with spastic hemiplegia after upper motor neuron (UMN) injury. Contractures are often painful, macerate skin, and impair axillary hygiene. We hypothesize that shoulder tenotomies are an effective means of pain relief and passive motion restoration in patients without active upper extremity motor function.

MATERIALS AND METHODS

A consecutive series of 36 adults (10 men, 26 women) with spastic hemiplegia from UMN injury, shoulder adduction, and internal rotation contractures, and no active movement, who underwent shoulder tenotomies of the pectoralis major, latissimus dorsi, teres major, and subscapularis were evaluated. Patients were an average age of 52.2 years. Pain, passive motion, and satisfaction were considered preoperatively and postoperatively.

RESULTS

Average follow-up was 14.3 months. Preoperatively, all patients had limited passive motion that interfered with passive functions. Nineteen patients had pain. After surgery, passive extension, flexion, abduction, and external rotation improved from 50%, 27%, 27%, and 1% to 85%, 70%, 66%, and 56%, respectively, compared with the normal contralateral side (P < .001). All patients with preoperative pain had improved pain relief at follow-up, with 18 (95%) being pain-free. Thirty-five (97%) were satisfied with the outcome of surgery, and all patients reported improved axillary hygiene and skin care. Age, gender, etiology, and chronicity of UMN injury were not associated with improvement in motion.

DISCUSSION

We observed improvements in passive ROM and high patient satisfaction with surgery at early follow-up. Patients who had pain with passive motion preoperatively had significant improvements in pain after shoulder tenotomy.

CONCLUSION

Shoulder tenotomy to relieve spastic contractures resulting from UMN injury can be an effective means of pain relief and improved passive range of motion in patients without active motor function.

[Painful hemiplegic shoulder in stroke patients: causes and management]

INTRODUCTION

The hemiplegic shoulder pain is common after a stroke. Its appearance brings pain and limits daily living activities as well as participation in specific Neuro-rehabilitation programs. All this leads to a worse functional outcome. Good management of patients can reduce both the frequency and intensity of shoulder pain, improving functional outcome.

DEVELOPMENT

We conducted a literature search of various databases between 1980 and 2008. The articles were evaluated using the PEDro scoring system. Five evidence levels were established for the conclusions.

CONCLUSIONS

Shoulder subluxation, occurs at an early stage after stroke and is associated with subluxation of the shoulder joint and spasticity (mainly subscapularis and pectoralis). Slings prevent subluxation of the shoulder. It is preferable to move within a lower range of motion and without aggression to prevent the occurrence of shoulder pain. The injection of corticosteroids does not improve pain and range of motion in hemiplegic patients, while botulinum toxin combined with physical therapy appears to reduce hemiplegic shoulder pain.

Transcutaneous Electrical Nerve Stimulation (TENS) A Possible Aid for Pain Relief in Developing Countries?

Transcutaneous electrical nerve stimulation (TENS) refers to the delivery of electrical currents through the skin to activate peripheral nerves. The technique is widely used in developed countries to relieve a wide range of acute and chronic pain conditions, including pain resulting from cancer and its treatment. There are many systematic reviews on TENS although evidence is often inconclusive because of shortcomings in randomised control trials methodology. In this overview the basic science behind TENS will be discussed, the evidence of its effectiveness in specific clinical conditions analysed and a case for its use in pain management in developing countries will be made.

Transcutaneous electrical nerve stimulation (TENS) for cancer bone pain

In the cancer population, painful bony metastases are common, difficult to treat and significantly reduce quality of life. Common treatments include opioid analgesics, bisphosphonates, and radiotherapy; yet these have significant side effects and are not universally effective. Transcutaneous electrical nerve stimulation (TENS) is inexpensive, relatively free from side effects, and widely available. We present a case study of successful TENS therapy in a patient with cancer bone pain and discuss the rationale for using TENS in this setting.

Neuromuscular electrical stimulation for motor restoration in hemiplegia

Clinical applications of neuromuscular electrical stimulation (NMES) in stroke rehabilitation provide both therapeutic and functional benefits. Therapeutic applications include upper and lower limb motor relearning and reduction of poststroke shoulder pain. There is growing evidence that NMES, especially those approaches that incorporate task-specific strategies, is effective in facilitating upper and lower limb motor relearning. There is also strong evidence that NMES reduces poststroke shoulder subluxation and pain. Functional applications include upper and lower limb neuroprostheses. Lower limb neuroprostheses in the form of peroneal nerve stimulators is effective in enhancing the gait speed of stroke survivors with foot-drop. The development of hand neuroprostheses is in its infancy and must await additional fundamental and technical advances before reaching clinical viability. The limitations of available systems and future developments are discussed.

Guidelines for management of ischaemic stroke and transient ischaemic attack 2008

This article represents the update of the European Stroke Initiative Recommendations for Stroke Management. These guidelines cover both ischaemic stroke and transient ischaemic attacks, which are now considered to be a single entity. The article covers referral and emergency management, Stroke Unit service, diagnostics, primary and secondary prevention, general stroke treatment, specific treatment including acute management, management of complications, and rehabilitation.

Neuromodulation of effects of upper limb motor function and shoulder range of motion by functional electric stimulation (FES)

Upper extremity motor impairment is a major contributing factor to functional disability of stroke patients. Functional electric stimulation (FES) is one of the therapeutic regimens for the management of upper extremity dysfunction after stroke. This review shows that therapeutic FES intervention on supraspinatus and posterior deltoid muscles for 6 weeks is effective to speed up upper limb motor recovery in hemiplegia of short-duration after stroke or less severely affected symptoms. The positive effect of FES could be attributable to neural mechanisms including: an enhanced information flow from the joint and muscle afferents, a better visual perception of the movement produced, and a stronger muscle contraction due to direct stimulation of the motor neuron. However, FES was demonstrated as not being effective in reducing the shoulder range of motion of external rotation in patients with either short- or long-duration hemiplegia. In order to offer better management in maintaining or improving limited shoulder range of motion, other types of electrical stimulation should be considered.

Efficacy of electrical nerve stimulation for chronic musculoskeletal pain: a meta-analysis of randomized controlled trials

Previous studies and meta-analyses of the efficacy of electrical nerve stimulation (ENS) for the treatment of chronic pain of multiple etiologies have produced mixed results. The objective of the present study was to determine whether ENS is an effective treatment for chronic musculoskeletal pain by using statistical techniques that permit accumulation of a sample size with adequate power. Randomized, controlled trials published between January 1976 and November 2006 were obtained from the National Libraries of Medicine, EMBASE, and the Cochrane Library. Prospective, placebo-controlled studies using any modality of ENS to treat chronic musculoskeletal pain in any anatomical location were included. The main outcome measure was pain at rest. The use of statistical methods to enhance data extraction and a random-effects meta-analysis to accommodate heterogeneity of ENS therapies permitted an adequate number of well designed trials of ENS to be included in the meta-analysis. A total of 38 studies in 29 papers, which included 335 placebo, 474 ENS, and 418 cross-over (both placebo and at least one ENS treatment) patients, met the selection criteria. The overall results showed a significant decrease in pain with ENS therapy using a random-effects model (p<0.0005). These results indicate that ENS is an effective treatment modality for chronic musculoskeletal pain and that previous, equivocal results may have been due to underpowered studies.

Intramuscular Electrical Stimulation for Shoulder Pain in Hemiplegia: Does Time From Stroke Onset Predict Treatment Success?

Background. A randomized clinical has shown the effectiveness of intramuscular electrical stimulation for the treatment of poststroke shoulder pain. Objective. Identify predictors of treatment success and assess the impact of the strongest predictor on outcomes. Method. This is a secondary analysis of a multisite randomized clinical trial of intramuscular electrical stimulation for poststroke shoulder pain. The study included 61 chronic stroke survivors with shoulder pain randomized to a 6-week course of intramuscular electrical stimulation (n = 32) versus a hemisling (n = 29). The primary outcome measure was Brief Pain Inventory Question 12. Treatment success was defined as ≥ 2-point reduction in this measure at end of treatment and at 3, 6, and 12 months posttreatment. Forward stepwise regression was used to identify factors predictive of treatment success among participants assigned to the electrical stimulation group. The factor most predictive of treatment success was used as an explanatory variable, and the clinical trials data were reanalyzed. Results. Time from stroke onset was most predictive of treatment success. Subjects were divided according to the median value of stroke onset: early (<77 weeks) versus late (> 77 weeks). Electrical stimulation was effective in reducing poststroke shoulder pain for the early group (94% vs 7%, P < .001) but not for the late group (31% vs 33%). Repeated-measure analysis of variance revealed significant treatment ( P < .001), time from stroke onset ( P = .032), and treatment by time from stroke onset interaction ( P < .001) effects. Conclusions. Stroke survivors who are treated early after stroke onset may experience greater benefit from intramuscular electrical stimulation for poststroke shoulder pain. However, the relative importance of time from stroke onset versus duration of pain is not known.