Original Article
EFFECTIVENESS OF FUNCTIONAL M USCLE STIM ULATION IN
IM PROVING M OTOR CONTROL AROUND SHOULDER IN PATIENTS
W ITH HEM IPLEGIA
Sirisha Nekkanti
1, Sivakumar.R *
2.
1 Post graduate in Physiot herapy, , Sri Ramachandra Universit y, Porur, Chennai, Tamil Nadu, India. * 2 Addit ional Professor in Physiot herapy, Sri Ramachandra Universit y, Porur, Chennai, Tamil Nadu,
India.
Background: The ef fect of elect r ical st im ulat ion on m ot or out com es around shoulder in acut e hem iplegia is elusive. We t est ed t he eff ect of st im ulat ion of specific m uscles around shoulder on m ot or out com e in shoulder in pat ient w it h hem iplegia.
M ethods: 32 first t im e hem iplegic pat ient of st roke origin w ere random ly allocat ed t o cont rol and experim ent al group. Exper im ent al gr oup received elect rical st im ulat ion apart from exer cises given t o bot h t he groups for 2 w eeks. Delt oid, infraspinat us and upper t rapezius w ere st im ulat ed, along w it h at t em pt t o cont ract t he m uscles. St r oke Rehabilit at ion Assessm ent of M ovem ent (STREAM ) upper com ponent s and m anual m uscle t est ing w ere used for evaluat ion of out com e. Wilcoxon sign rank t est and chi-square t est s w er e used for st at ist ics. Results: Experim ent al group dem onst rated greater recovery com pared t o control group. In bot h groups t rapezius m uscle w ork showed im provem ent in large num ber of pat ient s follow ed by delt oid. STREAM score changes w ere seen a m ore num ber of pat ient s in experim ent al group t han cont rol group.
Conclusion: Elect rical st im ulat ion can be considered as an adjunct t o exercises around shoulder in early st r oke r ehabilit at ion
KEYW ORDS: Elect rical st im ulat ion, Hem iplegia, Rehabilit at ion.
ABSTRACT
INTRODUCTION
Address for correspondence: Sivakum ar. R, Pr incipal and Addit ional Professor, Facult y of Physiot herapy, Sri Ramachandra Universit y, Porur, Chennai 600116, Tamil Nadu, India.
Phone: +919840068412. E-M ail: rsivkumar@gmail.com
DOI: 10.16965/ ijpr.2014.704
Elect rical st imulat ion is one of t he t herapies in neuro rehabilit at ion. Elect rical st imulat ion has been used commonly for reduct ion of spast icit y [1,2], facilit at ing m uscle cont ract ion[3,4,5] in upper limb rehabilitation after stroke. The st imu-lat ion w as generally focused on forearm muscles [1,6,7] and few st udies w ere on st imulat ion of m uscles ar ound t he shoulder [ 8,9] . Ear lier st udies had met hodological differences in t he
paramet ers of st imulat ion; muscles st imulat ed [10] and st rengt h of st imulus - mot or level t o sensory level [11]. As majorit y of t he st udies are done on chronic st roke pat ient s w it h some con-t rol in con-t heir upper excon-t remicon-t y, con-t he resulcon-t s cannocon-t be generalized t o acut e pat ient s w it h absence of cont rol in ext remit ies. Though majorit y of t he studies concluded that elect rical stimulat ion had posit ive effect on mot or out come, Church et .al concluded t hat it can impede t he neural plast ic-it y or result in abnormal neural plast icic-it y [8].
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DOI: 10.16965/ ijpr.2014.704
Received: 16-12-2014 Peer Review : 16-12-2014 Revised: None
In acute st roke pat ient s absence of sense of m uscle cont ract ion m ay ham per t heir mot or learning. The sense of effort produced by t he muscle cont ract ion is an int egral feedback for any movement [12]. Sensat ion from t he muscle cont ract ion w it h joint sense guides t hrough t he movement as well as helps in learning the move-ment . As st roke pat ient s w ill have minimal or absence of m uscle cont ract ion in t he acut e st age, t heir sense of muscle cont ract ion w ill be reduced or absent . This may reduce t heir effort t o cooperat e during a t herapy session t o facili-t afacili-te facili-t he muscle confacili-tracfacili-t ion/ movemenfacili-t. Provid-ing a near normal sensory input for a movement w ill assist in better mot or learning [13]. We felt t hat making t he muscle t o cont ract w it h elect ri-cal st imulat ion along w it h t he pat ient ’s effort w ill provide sense of muscle cont ract ion, t hus improving the of mot or learning. Considering t he deart h st udies on effect of elect rical st imula-t ion on muscles around shoulder and models of neural recovery support ing early proximal recov-ery, w e choose t o st imulate muscles around t he shoulder. We tested effect of elect rical st imula-t ion w iimula-t h porimula-table elecimula-t rical simula-t imulaimula-t or, given imula-t o specific muscles around t he shoulder in improv-ing m ot or cont rol around shoulder in acut e hemiplegic pat ient .
M ETHODS
All pat ient s w it h first t ime hemiplegia due t o non-t raumat ic vascular origin w it hin a w eek of onset , in t he age range of 30 t o 70 years w it h a good comprehension referred for rehabilit at ion w ere scr eened f or inclusion. Pat ient s w it h absence of cont rol in t heir upper ext rem it y measured by STREAM upper limb component (score 0) and manual muscle t est ing (Grade 0) w ere considered for inclusion. Pat ient s w it h previous hist ory of st roke, brain stem infarct s, ort hopedic and neurological condit ions affect -i ng t h e up p er l-i m b r eco v er y, p resence o f sensory deficit s w ere excluded. The nat ure and purpose of st udy w as explained t o pat ient s before recruit ing t hem in t he st udy. Informed consent was taken from every subject . Et hical com mit t ee clearance w as obt ained from t he Inst it ut ional et hics commit t ee.
Thirt y tw o subject s with mean age of 55.87 years (SD 12.6) w ere included in t he st udy. They w ere
randomized into cont rol and experimental group by block randomization. Both the groups received exercises based on mot or relearning program and neruo developm ent al t herapy including facilit at ion of isolat ed muscle cont ract ions and t ask oriented facilit at ion of movements. Isolated muscle cont ract ions of upper fibers of t rapezius (scapular elevat ion in sit t ing), ext ernal rot at ors of glenohumeral joint (external rotat ion in of arm in cont ralat eral sidelying posit ion) and delt oid (shoulder abduct ion t o 90 degrees in supine) w ere facilit at ed w it h t apping on t he muscle belly as a part of t raining. Reaching act ivit ies involv-ing assist ed pickinvolv-ing of a glass from t able, t ouch-ing hand of t he t herapist at different posit ions, t ouching t he pat ient ’s head w ere given as a part of t ask specific t raining.
The experiment al group in addit ion t o common t raining sessions received elect rical st imulat ion t o upper fibers of t rapezius, infraspinat us and delt oid. The stimulat ion w as given w it h port able elect rical st imulat or (Technomed Ltd) delivering int ermit t ent direct current w it h 1 millisecond pulse w idt h and 40 Hz frequency (surged faradic t ype of current ). Three cont ract ions (surges) w ere given per minut e w it h intensity t o produce st rong muscle cont ract ion using t w o carbonized rubber elect rodes and saline as a conduct ing m edium . Pat ient w as asked t o perform t he m ovem ent along w it h t he cur rent . Fift een cont ract ions w ere given t o each muscle in each session, and one session per day w as given. The upper fibers of t rapezius w ere st imulat ed w it h pat ient in sit t ing w it h inst ruct ion t o shrug t he shoulder. Delt oid was st imulated w it h pat ient in supine lying asking for abduct ion of shoulder. Infraspinat us w as st im ulat ed w it h pat ient in cont ra lateral side lying. Pat ient was asked t o ext ernally rot at e t he shoulder t o bring t he hand aw ay from t he bed. Pat ient s w ere inst ruct ed regarding t he movement t o be performed and t o inform difficult y in t olerat ing t he int ensit y of current . At the end of every five contract ions skin w as ch ecked f o r ab no r m al r eact i on s li ke excessive eryt hema. At t he end of t w o w eeks of t raining manual muscle t est ing w as performed for st imulat ed muscles. STREAM w as scored for paret ic upper limb.
analyses t he STREAM upper lim b score w as cat egorized as less t han 2 and m ore t han 2 (including a score of 2). M CID for STREAM upper limb component is equivalent t o change of 2 point s 14. M anual m uscle t est ing scores are
divided as 0 and 1 or higher score. Chi-square t est or Fisher exact t est (w hen any cou nt recorded less t han 5) w as used for bet w een t he group t est ing.
RESULTS
Table 1 show s t he dem ographic dat a of t he pat ient st udied. The great er per cent age of pat ient s in experiment al group show ed change in t heir mot or cont rol t han in cont rol group. In STREAM scor i n g 85% o f t h e p at ien t s i n experimental group improved t o a score tw o and above, w hereas none show ed such a change in cont r ol gr oup. In exper im ent al gr oup t w o pat ient s scored 5 and one pat ient scored 6 in STREAM upper lim b com ponent s. In cont rol gr oup t hr ee pat ient s scored one and ot her t hirt een had absence of cont rol. STREAM score chan ge w i t h i n exp er i m en t al gr ou p w as st at ist ical ly si gn if i cant (p <0.05) w hi le t he changes in cont rol group did not reach st at ist ical significance.
In exp er i m en t al gr ou p st r en gt h of u pp er t rapezius and deltoid improved in majority of the pat ient s and change w as st at ist ically significant , h o w ev er n u m b er o f pat i en t s w h o h ad improvement in the external rotator strength was minimal, and t he change w as not st at ist ically significant . In cont rol group t hough pat ient s improved in st rengt h of t he muscles evaluat ed, t he change did not reach st at ist ical significance for all t he 3 muscles. In t his group t he upper t r apezius st r engt h change w as obser ved in majorit y of t he pat ient s follow ed by delt oid and external rotat ors (Table 2). In bet ween t he group t est ing, experim ent al group has significant ly gr eat er i m p r o vem ent i n al l t h e v ar i ab les (Table 3).
Table 1: Dem ographic data
Table 2: Frequency table for m uscle pow er at post int er vent ion period
Table 3: Frequency table for bet w een t he group dif ferences
* signif icance at p<0.05
DISCUSSION
We found t hat elect rical st im ulat ion in acute st age of hemiplegia has impact on t he mot or outcome in upper ext remit y. In t he presence of only few st udies t est ing t he effect of elect rical st imulat ion in proximal part of upper ext remit y, t he result of t his st udy reveals t hat elect rical st im ulat ion w ill be an eff ect ive addit ion t o t herapy for improving mot or cont rol. Pat ients in experiment al group show ed im provem ent in m ovement s w hich are not lim it ed t o muscle st imulated in t he st udy. They show ed abilit y t o prot ract scapula, flex elbow, and init iate elbow ext ension. How ever majorit y of t hem improved i n sh o ul d er sh r u ggin g i n si t t i n g. These improvement s can be at t ribut ed t o increase in cerebral blood flow in the sensory –motor cortex revealing an increase in act ivit y in t he area during elect rical st imulat ion [5].
M ot or l ear n in g d ep en ds o n t he f eedb ack received during t he performance of mot or t ask. The individual receives t he feedback of every part of the movement through his propriocept ors in t he joint s and muscles. This t ype of feedback can be t ermed as know ledge of performance or int ernal feedback mechanism. In t his feedback w hen an individual lacks muscle cont ract ion as in case of early part of st roke, t he feedback from t he muscular element w ill be absent . Hence
0 1 2 3 4 5
Deltoid 13 3 0 0 0 0
Infraspinatus 15 1 0 0 0 0
upper trapezius 7 6 3 0 0 0
Deltoid 5 8 3 0 0 0
Infraspinatus 8 5 1 2 0 0
upper trapezius 0 3 9 4 0 0
Experimental group Control group Muscle power
Cont rol group (n=16)
Experim ent al group (n=16)
STREAM UL ≥ 2 0 16*
MMT Deltoid ≥ 1 3 11*
MMT Trapezius ≥ 1 9 16*
MMT Externa rotators ≥ 1 1 8*
Co n t r o l gr o u p (n = 1 6 )
Exp e r im e n t al gr o u p (n = 1 6 )
Age 5 6 .6 +/ -1 1 .1 5 5 .1 +/ -1 4 .4
M ale 1 1 1 2
Fe m ale 5 4
Le ft CV A 8 6
individual cannot feel t he amount of muscle cont ract ion and has t o rely only on t he joint propriocept ors. It is ant icipat ed t hat elect rical st imulat ion given along w it h t he pat ient ’s abilit y t o move, it w ill make t he muscle t o cont ract and provide t he feedback of muscle cont ract ion. This enhanced sensory input , w ould have benefit ed in development of mot or cont rol in experiment al group. M erlet t i et al (1978) st at es t hat force production of muscle improved with the electrical st im ulat ion [3]. We found a im provem ent in cont r act ile abilit y of st im ulat ed m uscles in experimental group. We found st udy by Church et al. (2006) st at ing t hat 4 w eeks st imulat ion t o supr aspinat us and post erior delt oid did not improve mot or out come in severely impaired acute st roke pat ient s after 4-w eek session of t reat ment . It was not clear w het her pat ient ’s att empted movement s along w ith stimulat ion in t his st udy [8].
In cont rol group few pat ient s show ed change in t heir m ot or cont rol. Trapezius act ivit y w as predom inant in t his group. Upper t rapezius act ivit y is a movement generally learnt by t he pat ient s easily as it is a part of flexor synergy of upper limb as well as it is a part of compensatory m ovem ent f or upper lim b elevat ion ar ound shoulder. STREAM score change was observed am o n g t h r ee p at i ent s on l y. Th e m u scl e cont ract ions gained by t hese pat ient s w ere predominantly flicker of contractions, not enough t o perform component s of STREAM upper limb. Chae et al. (2008) st at es t hat met hodological limit at ion found in earlier st udies making int er-pret at ion of t he result s difficult , t hough t hey conclude a positive out come by stimulation. Few st udies w er e not clear r egar din g pat ien t s part icipat ion during st imulat ion, w hich w e feel im port ant for m ot or lear ning [8,15] . Doing muscle w ork along w it h elect rical st imulat ion w ill im prove chances for mot or learning We considered small number of pat ient populat ion st udied and short t herapy durat ion, as limit a-t io ns. Si ze an d si a-t e o f lesi o ns cou ld h av e influenced t he out come, w hich w as not consid-ered in t he st udy.
CONCLUSION
The result s of t his st udy suggest t hat elect rical st imulat ion can be considered as an adjunct t o
exer cises in ear ly par t of r ehabil it at io n in improving t he mot or cont rol after st roke around shoulder.
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Conflicts of interest: None
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How to cite this article
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Sirisha Nekkant i, Sivakumar.R. EFFECTIVENESS OF FUNCTIONAL M USCLE STIM ULATION IN IM PROVING M OTOR CONTROL AROUND SHOULDER IN PATIENTS WITH HEM IPLEGIA. Int J Physiot her Res 2015;3(1):863-867.
DOI: 10.16965/ ijpr.2014.704
