FINAL POST!

In summary, NMES can be seen as a viable treatment tool in the rehabilitation of the upper limb post stroke. The main functional advantage offered by NMES is its ability to correctly position the humeral head in the glenoid fossa. This reduces sublaxation of the GHJ, which is a common complication of stroke. NMES fulfils this purpose by using a standard frequency of 50Hz, which is an optimal pulse frequency for muscle strengthening. This is in comparison to the wide frequency variations (1-200Hz) implemented by standard TENS machines. However, NMES treatment parameters are not specific to individual body parts.

Whilst the majority of literature is supportive of the use of NMES in rehabilitation programs post stroke, many studies also identify the fact that whilst NMES can help increase function and reduce sublaxation, it is not always effective in relieving upper limb pain. Furthermore, some evidence suggests that NMES may only be effective when the patient is receiving regular treatments.

A significant contraindication for use, which is specific to post stroke patients, is diminished or altered sensation.  Such sensory deficits can affect their ability to recognize the response of their body to the treatment. However, the cost effective nature of this treatment, coupled with the increasing demand placed on the health care system as a result of an ageing population, ensures it’s place as a crucial treatment modality for rehabilitation of the upper limb post stroke.

As this is our last post on this topic, we would like to thank all of you who have followed our progress and hopefully learnt from the information obtained. We look forward to learning more about the future direction and changes of NMES and its use in rehabilitation of the upper limb post stroke in the coming years.

This is Hayley and Meg, signing out.
:-)

   

Contraindications for the use of NMES post stroke.

In previous posts, we mentioned that we thought NMES was quite a viable method and potentially an important part in the rehabilitation of the upper limb post stroke. However, the more we thought about using NMES in this manner, the more we started thinking about safety with electrical equipment, such as NMES machines. Surely there must be some contraindications, precautions or safety procedures to follow when using these treatment methods?

Drussendorfer (2009) identifies a number of contraindications relating to the use of NMES in physiotherapy. These include:

• Stimulation through or across the chest, or over the carotid sinuses
•  Cardiac pacemakers or implanted stimulators
• Uncontrolled hypertension/hypotension
•  Peripheral vascular disease
• Pregnancy
• Acute inflammation
• Seizure history            
•  Confused patients or immature patients
• Obesity            
•  Osteoporosis

This was all well and good, however we decided to press on with our research in an attempt to find out whether there were any specific contraindications relating to the use of NMES on the upper limb post stroke,

The information we found was somewhat limited. However, the following conditions may be seen as factors which could, potentially, limit the use of NMES in post stroke clients. It should be noted, however, that this obviously depends on the magnitude of the stroke itself, the type of stroke suffered and the areas of the body affected as a result.

•         Diminished mental capacity: Porth & Matfin (2009), state that stroke can cause cognitive and behavioural deficits. Drussendorff (2009), identifies such deficits as possible contraindications in the use of NMES, especially when this diminished mental capacity decreases the ability of the individual to make informed decisions or understand the intended procedure.
• 
  
•          Sensory Deficits: Additionally, Porth & Matfin (2009) identify sensory deficits as extremely common amongst individuals post stroke. Drussendorfer (2009), identifies this decrease in sensation as a possible contraindication to the use of NMES. This is due to the fact that such individuals may be unable to recognize changes in the response of their body to the treatment, which can potentially lead to injuries such as skin burns.

Whilst we are now aware of the contraindications that may prevent individuals from using NMES in their rehabilitation programs post stroke, we also feel pretty happy with the fact that, in the majority of cases, it is both a safe and accessible treatment technique for such individuals. In our next and final post, we will endeavour to provide you with a summary of the most important findings of our topic.

Until then,
Hayley and Meg.
:-)

References

Drussendorfer, R. (2009). Stroke: Activities of Daily Living. Reviewed on the 30^th March (2011) at http://www.ebscohost.com/uploads/discovery/pdfs/topicFile-152.

Porth, C.M. & Matfin, G. (2009). Pathophysiology: Concepts of Altered Health States (8^th Ed.). Lippincott Williams & Wilkins: Philadelphia, PA.

NMES - exploring alternative viewpoints.

Well, what can we say? We did warn you in the previous post that this entry may not be too rosy, and it seems we have not failed to deliver. Over the past week we were saddened to find out that, unbelievably, not everyone is as supportive of the role of NMES in the rehabilitation of the upper limb post stroke as we detailed in our last post. We knew such universal praise was too good to be true!


Whilst the majority of the evidence we have discovered has been supportive of the role of NMES; Church, Price, Pandyan, Curless, Huntley & Rodgers (2006) not only failed to support the use of NMES, but went as far to say that they believed it can have negative consequences in relation to the recovery of the upper limb post stroke. They believe NMES may actually impede recovery by producing abnormal afferent stimulation proximally, which can later interfere with the recovery of distal tissues through maladaptive plasticity (Church et al, 2006). Once we managed to digest this rather intense lump of information, we realized that this was not good news. How many other professionals would dispute the use of NMES in such situations? We were determined to find out.

Figure 1.1. There is conflicting evidence for the role of NMES in increasing upper limb function post stroke.

In the days that followed we continued our search for information but were unable to find much other evidence that supported the statements presented by Church et al (2006). However, according to Maffiuletti (2010), there is often considerable variation between the conclusions drawn from various different studies. Basically, this infers that NMES current parameters are often poorly reported, and therefore may affect the outcome of such studies. In the same way, the methods used by researchers to evaluate NMES retraining effectiveness are usually quite heterogeneous, thereby rendering it difficult to compare the outcomes of the different NMES studies (Vanderthommen et al, 2007) to guage the overall effectiveness of this technique.


Confusion and sadness has now given way to clarity and a new optimism for the potential healing capacity of NMES. Comparison of our research over past posts identifies the fact that the majority of the literature supports the use of NMES in the recovery of the upper limb post stroke. Personally, we support this point of view, and believe in the abilities of NMES to aid recovery in such situations. What do you think?


Additionally, it was also indicated in our last blog that we would be discussing the future direction of NMES and its role in rehabilitation of the upper limb post stroke. Although difficult to find information relating to this specifically, we were able to determine that the future for this method is bright. With an ageing population who now enjoy increases in cardiovascular survival and many of whom also engage in other risk factors such as inactivity and smoking, it is predicted by many that the incidence of stroke will increase over the coming years (Niessen, Barendregt, Bonneux & Koudstaal, 1993). We believe that the use of NMES will therefore become more crucial and accepted as the demand for rehabilitation post-stroke increases, especially due to the cost-effective nature of NMES and the demand placed on the health care system from increased disease states in an ageing population (Yu, Chae, Walker, Kirsteins,, Elovic, Flanagan, Harvey, Zorowitz, Frost, Grill, Feldstein & Fang, 2004). Yu et al (2004) also believe in the future capabilities of NMES, especially due to recent technological advances which have increased the practicaliy and availability of clinical implementation. However they also state that, due to the somewhat poor quality of the research available, further studies are needed to expand upon proposed clinical applications and define more optimally advanced prescriptive parameters.


In our next and what will be our final post, we will endeavour to discuss relevant contraindications and safety procedures in regards to NMES and its use on individuals post-stroke.

Until then,
Hayley and Meg

References

Church, C., Price, C.  Pandyan, A.D., 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: Journal of the American Heart Association, 37, 2995-3001.


Maffiuletti., N.A. (2010). Physiological and methodological considerations for the use of neuromuscular electrical stimulation. European Journal Applied Physiology (110) 223–234.


Niessen, L. W., Barendregt, J. J., Bonneux, L. & Koudstaal, P. J. (1993). Stroke Trends in an Ageing Population. Stroke, 24, 931-939.


Vanderthommen. M. & Duchateau. J. (2007). Electrical stimulation as a modality to improve performance of the neuromuscular system. Exercise Sport Science Review (35)180–185.


Yu, D.T., Chae, J., Walker, M. E., Kirsteins, A., Elovic, E. P., Harvey, R. L., Zorowitz, R. D., Frost, F. S., Grill, J. H., Feldstein, M. & Fang, Z. (2004). Intramuscular Neuromuscular electrical stimulation for post stroke shoulder pain: A multicentre randomized clinical trial. Archives of Physical Medicine and Rehabilitation, 85 (5), 695-704. 


Images
http://linncitychiro.com/wp-content/uploads/2009/04/estim.jpg

NMES and Supportive Evidence

We’ve got NMES on our minds! Well, it’s hard not to now that we have gained such an extensive understanding of the appropriate NMES parameters needed to ensure optimal recovery of the upper limb post stroke. It now seems appropriate to review the literature further, the majority of which can be seen as supportive towards this particular electrotherapeutic device.

As we have been reviewing the relevant available literature in regards to NMES and its involvement with upper limb recovery post stroke, we have discovered that the majority of the studies we have analysed are supportive of the effective role NMES has on this condition. The literature supports the idea of electrical stimulation of the upper limb post stroke and its ability to reduce existing subluxation of the shoulder joint, decrease upper limb pain and facilitate recovery of upper limb function (Linn, Malcolm & Lees 1999). Thus, it has become apparent to us that NMES can be thought of as a ‘supportive backbone’ for stroke recovery.

Additionally, a randomized controlled study conducted by Linn et al (1999) was used to determine the efficacy of electrical stimulation in preventing shoulder subluxation in patients post stroke. Patients involved in the study were assessed within 48 hours of their stroke and those in the treatment group were immediately put on a regime of electrical stimulation for 4 weeks. All patients were assessed at 4 weeks and 12 weeks after stroke with assessments being made of shoulder subluxation, pain and motor control of the upper limb. Results indicated that the treatment group had significantly less subluxation and pain after the treatment period of four weeks, however at the end of the follow-up period (12 weeks) there were no significant difference between the 2 groups. Therefore, from analysing this study, it became apparent to us that NMES can prevent shoulder sublaxation and upper limb pain post stroke. However, the effects may be withdrawn when the patient stops receiving the treatment. We therefore began to wonder, is NMES only effective when the patient is receiving regular treatment?

Figure 5.1. Examples of the facilitation of muscle contractions in hemiparetic hands

Kimberly & Carey (2002) discuss the use of NMES in promoting recovery of the upper limb post stroke and make the brief statement that NMES can be seen as being beneficial in reducing shoulder subluxation but inconsistent in reducing shoulder pain. Basically what Kimberly & Carey (2002) are saying is that, whilst NMES has been found to have a positive effect on reducing sublaxation of the shoulder post stroke, it may not have this same positive result on reducing shoulder pain.

The study conducted by Vuagnat & Chantraine (2003) only had positive outcomes from NMES treatment. According to Vuagnat et al (2003) when NMES was applied early after the onset of the stroke in patients with shoulder pain and subluxation, only positive, beneficial effects on subluxation, pain and mobility of the upper limb were evident.

Furthermore, Yu, Chae, Walker, Kirsteins, Elovic, Flanagna, Harvey, Zorowitz, Frost, Grill, Felstein & Fang (2004) also support the effective use of NMES on upper limb post stroke recovery. In a single-blinded, randomized clinical trial where the subjects received NMES to the supraspinatus, posterior deltoid, middle deltoid and trapezius for 6 weeks, NMES reduced post stroke shoulder pain among those with shoulder subluxation. The effect was also maintained for at least 6 months post treatment, this highlighting the potential long term benefits NMES can have on the patients condition. This result differs from that previously discussed in the study by Linn et al (1999), as they suggest the benefits of NMES are only effective when the patient is receiving regular treatment.

Stroke Survivor's Hand Video Clip- this particular movie effectively illustrates NMES evoking electrical muscle contractions on the patient’s hemiparetic hand. This short clip is particularly confronting as the impairments which prevail post stroke are extremely apparent.

http://www.youtube.com/watch?v=VoAuB27RjDQ&feature=related

Hand Stimulation Video Clip- Although the following movie does not portray the same personal and emotional response as the first, it demonstrates electrical stimulation of just the forearm, hand and fingers. Examples of short pulses of electrical current which stimulate the muscles in the hand and fingers are demonstrated followed by sustained, long contractions which effectively stretch the hand and fingers. Both forms of electrical stimulation are effective in increasing function and muscular strength of the hand and fingers post stroke.

http://www.youtube.com/watch?v=kkT-SYFpw7M

We could continue analysing studies which support the literature on the effective and positive outcomes achieved through NMES in the recovery of upper limb function post stroke. However, we feel we have made our point crystal clear. The majority of relevant literature is supportive in the role of NMES treatment post stroke!

Our next blog may not be as rosy as we will look into the literature which believes NMES may actually impede recovery of upper limb recovery post stroke. We will also discuss the quality of literature and what the future holds for NMES.

However until then, keep smiling!

Hayley and Meg

REFERENCES;
Linn, S. L., Malcolm. H. & Lees, K.R. (1999) Prevention of Shoulder Subluxation After Stroke With Electrical Stimulation. American Heart Association, Inc. (30) 963-968.

Kimberly, T.T. & Carey, J.R. (2002) Neuromuscular electrical stimulation in stroke rehabilitation. University of Minnesota, USA.

Vuagnat. H. & Chantraine. A. (2003) Shoulder pain in hemiplegia revisited: contribution of functional electrical stimulation and other therapies. Journal of Rehabilitation Medicine 35(2):49-54.

Yu. D., T., Chae. J., Walker. M.E., Kirsteins. A., Elovic. E.P,, Flanagan. S.R., Harvey. R.L., Zorowitz. R.D., Frost. F.S., Grill. J.H., Feldstein. M. & Fang. Z.P. (2004) Intramuscular Neuromuscular Electric Stimulation for Post Stroke Shoulder Pain. Arch Phys Medicine Rehabilitation (85) 695-704.

Images;
http://www.mechanical-writings.com/post-stroke-rehabilitation/