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

Journal of NeuroEngineering and Rehabilitation, Dec 2017

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. 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. 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). 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. NCT01913509 .

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

Chuang et al. Journal of NeuroEngineering and Rehabilitation Effect of EMG-triggered neuromuscular electrical stimulation with bilateral arm training on hemiplegic shoulder pain and arm function after stroke: a randomized controlled trial Li-Ling Chuang 1 3 4 You-Lin Chen 1 Chih-Chung Chen 1 3 4 Yen-Chen Li 7 Alice May-Kuen Wong 1 3 An-Lun Hsu 0 2 -Ju Ch 0 Equal contributors 1 Department of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University , Taoyuan , Taiwan 2 Department of Physical Therapy, Mackay Memorial Hospital , Taipei , Taiwan 3 Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou Medical Center , Taoyuan , Taiwan 4 Healthy Aging Research Center, Chang Gung University , Taoyuan , Taiwan 5 No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan 33302 , Taiwan 6 Neuroscience Research Center, Chang Gung Memorial Hospital, Linkou Medical Center , Taoyuan , Taiwan 7 Physical therapy, Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital , Taoyuan , Taiwan 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, posttreatment, 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). (Continued on next page) - (Continued from previous page) 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. Background Introduction Hemiplegic shoulder pain is a common complication following stroke that restricts shoulder mobility and may interfere with rehabilitation [ 1 ]. Initial post-stroke weakness and spasticity lead to shoulder instability and immobility, which can cause pain directly or place the capsule at risk for trauma, subsequently leading to pain [ 2 ]. The etiology of hemiplegic shoulder pain is multifactorial, including shoulder subluxation, spasticity in the pectoralis major and subscapularis, adhesive capsulitis, bursitis, tendonitis, and shoulder-hand syndrome [ 3 ]. Accordingly, a wide variety of current treatment regimens have been used, such as shoulder positioning, slings and support aids, strapping and taping, surgical interventions, triamcinolone acetonide injections, electrical stimulation, and so on [ 3, 4 ]. The most promising interventions for hemiplegic shoulder pain are surface or percutaneous neuromuscular electrical stimulation (NMES) and intraarticular corticosteroid injections [ 3, 4 ]. Although corticosteroid injections may give satisfactory results, potential side effects include postinjection flare and tendon rupture [5]. Percutaneous NMES requires invasive procedures to implant electrodes and poses the risk of electrode-related infections, which makes clinical implementation difficult [ 6, 7 ]. Given the potential adve (...truncated)


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Li-Ling Chuang, You-Lin Chen, Chih-Chung Chen, Yen-Chen Li, Alice May-Kuen Wong, An-Lun Hsu, Ya-Ju Chang. Effect of EMG-triggered neuromuscular electrical stimulation with bilateral arm training on hemiplegic shoulder pain and arm function after stroke: a randomized controlled trial, Journal of NeuroEngineering and Rehabilitation, pp. 122,