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Three Part Question

IN [adults following CVA] IS [treatment with neuromuscular eletrical stimulation beneficial] AT [reducing shoulder subluxation]

Clinical Scenario

A 34 year old male with a large right MCA infarct presented with left shoulder subluxation causing pain. Information booklets around the use of surface neuromuscular electrical stimulation has mentioned that it can be used to help reduce shoulder subluxation, however very little was known around current research and literature regarding this. Would treatment with surface neuromuscular electrical stimulation reduce shoulder subluxation in his hemiplegic shoulder?

Search Strategy

- Medline, CINAHL, AMED, EMBASE using Ovid interface
- Cochrane library
- Pub Med
- National Clinical Guidelines for stroke
- References
Search terms - [hemiplegi$/CVA/stroke] and [electrical stimulation] and [shoulder subluxation]. Search limited to humans and English language. Search dates from 2000 to current.

Search Outcome

Altogether 26 articles were found of which 2 (1 meta-analysis and 1 RCT) were relevant to the question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ada & Foongchomeheay 2002 Australia	Review of papers on efficacy of surface electrical stimulation on preventing and reducing shoulder subluxation, 2 groups: early and late stroke.	Meta-analysis	Included RCT and quasi-randomised studies	7 individual trials identified (1986 – 2002)
			FES treatment similar	Early: intervention over 4-6wks, 5-7days/wk. Duration increased between 1.5 hrs/day to 4-6 hrs/day
			Early (<2 months post stroke) electrical stimulation plus conventional therapy is superior over early conventional therapy only	Weighted mean differences significant P<0.001, prevents 6.5mm of subluxation
			No evidence that late (>2 months post stroke) electrical stimulation plus conventional therapy superior to conventional therapy only	Weighted mean difference not significant p=0.40, only reduces subluxation by 1.9mm
Koyuncu, Nakipoglu- Yuzer, Dogan & Ozgirgin 2010 Turkey	50 patients with stroke diagnosis & subluxation. FES treatment – 5x(1hr) / day for 4 wks & conventional therapy (25) v conventional therapy only (25)	RCT	↓Subluxation stage in study group (classification developed by Van Langenberghe but no mention in study of what classifications are)	Statistically significant difference p=0.003	Poor written quality of paper Unsure of how randomised patients No mention of what conventional therapy consisted of No follow up
			↓ subluxation in mm in study group	Statistically significant difference p=0.025

Comment(s)

There were very few current relevant RCT’s on the effect of electrical stimulation on hemiplegic shoulder subluxation (3 in the last 10 years) and only one meta-analysis was relevant but this was still 8 years old. Many more recent articles mentioning electrical stimulation and hemiplegic shoulder subluxation are narrative reviews only. Following the review of available literature, it was found that all surface electrodes when treating/preventing shoulder subluxation were applied over the supraspinatus and deltoid area. The intervention was gradually increased to 6 hours per day, 5 days per week for approximately 4-6 weeks in those with early strokes (<2 months). This has implications for clinical use as our patients are more chronic/ long term strokes. However, with an emphasis for stroke patients to be discharged earlier from stroke rehabilitation units, this could be more relevant in the near future. Also there was very little information on the long term effect of electrical stimulation on hemiplegic shoulder subluxation. We must be cautious in interpreting these results in order to change clinical practice as it is obvious that further investigation is required. We can only follow National Stroke Clinical Guidelines which state that “Functional electrical stimulation should not be used on a routine basis” and “Individual patients should be considered for FES as an orthosis in certain circumstances”.

Clinical Bottom Line

In patients with early CVA, surface neuromuscular electrical stimulation may be beneficial at preventing shoulder subluxation. Patients should be assessed on an individual basis.

References

1. Ada L & Foongchomeheay A Efficacy of electrical stimulation in preventing or reducing subluxation of the shoulder after stroke: A meta-analysis Australian Journal of Physiotherapy 2002, 48: 257-267
2. Koyuncu E, Nakipoglu- Yuzer G. F, Dogan A & Ozgirgin N The effectiveness of functional electrical stimulation for the treatment of shoulder subluxation and shoulder pain in hemiplegic patients: A randomised controlled trial Disability and Rehabilitation 2010; 32 (7): 560-566