Percutaneous intramuscular neuromuscular electric stimulation for the treatment of shoulder subluxation and pain in patients with chronic hemiplegia: A pilot study☆☆☆★
Presented in part at the Rehabilitation Engineering and Assistive Technology Society of North America's annual conference, June 29, 1998, Minneapolis, MN, and at the American Academy of Physical Medicine and Rehabilitation's Annual Assembly, November 6, 1998, Seattle, WA.
Accepted: April 28, 2000;
Abstract
Yu DT, Chae J, Walker ME, Fang Z-P. Percutaneous intramuscular neuromuscular electric stimulation for the treatment of shoulder subluxation and pain in patients with chronic hemiplegia: a pilot study. Arch Phys Med Rehabil 2001;82:20-5. Objective: To investigate the feasibility of percutaneous intramuscular neuromuscular electric stimulation (perc-NMES) for treating shoulder subluxation and pain in patients with chronic hemiplegia. Design: Before-after trial.Setting: University-affiliated tertiary care hospital. Participants: A convenience sample of 8 neurologically stable subjects with chronic hemiplegia and shoulder subluxation. Intervention: Six weeks of perc-NMES to the subluxated shoulder. Main Outcome Measures: Shoulder subluxation (radiograph), shoulder pain (Brief Pain Inventory), motor impairment (Fugl-Meyer score), shoulder pain-free external rotation (handheld goniometer), and disability (FIM™ instrument) were assessed before treatment (T1), after 6 weeks of neuromuscular stimulation (T2), and at 3-month follow-up (T3). A 1-way, repeated-measures analysis of variance using the generalized estimating equation approach was used to evaluate differences from T1 to T2 and from T1 to T3 for all outcome measures. Results: Subluxation (p=.0117), pain (p =.0115), shoulder pain-free external rotation (p <.0001), and disability (p =.0044) improved significantly from T1 to T2. Subluxation (p =.0066), pain (p =.0136), motor impairment (p <.0001), shoulder pain-free external rotation (p =.0234), and disability (p =.0152) improved significantly from T1 to T3. Conclusions: Perc-NMES is feasible for treating shoulder dysfunction in hemiplegia and may reduce shoulder subluxation, reduce pain, improve range of motion, enhance motor recovery, and reduce disability in patients with chronic hemiplegia and shoulder subluxation. Further investigation is warranted. © 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
SHOULDER PAIN is a common complication in hemiplegia, with a prevalence of 34% to 84%.1, 2 In one of the largest reported series of unselected hemiplegic subjects (219) followed longitudinally for an average of 11 months, shoulder pain occurred in 72% of cases.3 Many causes of shoulder pain in hemiplegia have been postulated, including rotator cuff injury,2 tendinitis,3 adhesive capsulitis,4, 5, 6, 7 impingement syndrome,2 reflex sympathetic dystrophy (RSD),3, 8, 9 brachial plexopathy,10 axillary nerve neuropathy,11 spasticity,3, 12 and shoulder subluxation.2, 3, 10, 11, 13 Shoulder subluxation is among the most commonly cited causes of shoulder pain in hemiplegia,2, 3, 10, 11, 13 with a reported incidence of up to 81% in hemiplegic patients.2 Shoulder subluxation occurs most commonly in patients who have flaccid hemiplegia within the first 3 weeks.12
The relation between shoulder subluxation and shoulder pain in patients with hemiplegia remains controversial. However, treatment of shoulder subluxation continues to be the standard of care in many rehabilitation facilities for several reasons. First, shoulder subluxation may be painful. Painful subluxation is difficult to refute when clinical shoulder subluxation is present without evidence of other pathology, pain is present when the upper limb is dependent, and pain abates with manual joint reduction. Second, shoulder subluxation may have a role in the pathogenesis of other painful conditions by stretching local neurovascular and musculoskeletal tissues. Longitudinal studies suggest a correlation between early subluxation and the subsequent development of shoulder pain3, 13 as well as a correlation between subluxation and other types of shoulder pathology implicated in hemiplegic shoulder pain.2, 3, 10, 11 Third, when chronic shoulder pain develops, it is often refractory to available treatment, thus warranting early prevention measures. Fourth, subluxation may inhibit functional recovery by limiting shoulder range of motion (ROM).
Unfortunately, the options for preventing and treating shoulder subluxation are limited. Armboards and laptrays have not proven effective and may lead to overcorrection of inferior subluxation, predisposing the affected shoulder to impingement syndromes.14, 15 Use of slings remains controversial because they may cause lateral subluxation, contribute to the deleterious effects of joint immobilization, or promote undesirable synergistic patterns of muscle activation.15 Various slings are available but none consistently provides full joint reduction as an orthotic,15, 16 long-term therapeutic benefit or reduces shoulder pain.
The lack of effective interventions for treating shoulder subluxation has prompted the investigation of neuromuscular electric stimulation (NMES) for treating shoulder subluxation in hemiplegia. Transcutaneous NMES (trans-NMES) (ie, NMES delivered through electrodes placed on the skin surface) reduces shoulder subluxation, may enhance motor recovery, and may reduce shoulder pain in patients with hemiplegia.17, 18, 19, 20 However, trans-NMES may not be clinically practical due to stimulation-induced pain and the need for daily application for up to 6 weeks by a skilled clinician.21, 22 Intramuscular NMES delivered through percutaneously placed electrodes (perc-NMES) is less painful than trans-NMES22 and may be applied by the user or caregiver. This study assessed the clinical feasibility of perc-NMES for treating shoulder subluxation, gathered pilot data on treatment efficacy and identified priorities for further refinement of perc-NMES for treating shoulder dysfunction in patients with hemiplegia.
Methods
Subjects
A convenience sample of 8 subjects with chronic hemiplegia and shoulder subluxation was recruited from the outpatient rehabilitation services of a university-affiliated tertiary care medical center. Subjects were included if they (1) were neurologically stable, (2) had palpable inferior glenohumeral subluxation, and (3) were medically stable. Neurologic stability was defined as hemiplegia longer than 6 months with no documented change in motor impairment, sensory impairment, reflexes, or muscle tone in the 2 months before study enrollment. Candidates were excluded if they had (1) a history of shoulder pathology before hemiplegia onset; (2) existing neurologic deficits at hemiplegia onset; (3) a history of potentially life-threatening cardiac arrhythmia; (4) an implanted cardiac defibrillator or demand-type cardiac pacer; or (5) a prothrombin time international normalized ratio greater than 3.0. The study protocol and consent form were reviewed and approved by our institution's human subjects research committee. All subjects signed the informed consent.
Evaluations
All subjects were tested for glenohumeral subluxation, shoulder pain, shoulder external ROM, motor function, and disability before perc-NMES (T1), 24 hours after completing 6 weeks of perc-NMES (T2), and 3 months after the completion of perc-NMES (T3). Straight anteroposterior (AP) radiographs were used to quantify inferior shoulder (glenohumeral) subluxation. A vertical distance between the most inferolateral point on the clavicular portion of the acromioclavicular joint and the center of the humeral head was measured. These points were marked after superimposing the bony cortices of the affected and unaffected shoulders to enhance the reliability of identifying the bony landmarks. The difference in vertical distance between the affected and normal shoulder of each subject was defined as inferior subluxation. Because the radiograph was used as the reference frame, we seated subjects in a special chair to standardize trunk posture and the distance between the subject and the film cassette. We assessed shoulder pain by means of the Brief Pain Inventory (BPI),23 and report both pain intensity and pain interference scores from that measure. The pain intensity score, which assesses the sensory component of shoulder pain, is a numeric rating scale anchored at both ends. The pain interference score, which assesses the reactive component of shoulder pain, is an average of 7 numeric rating scales that address the effect of pain on activities of daily living. Shoulder pain-free external rotation (SPFER) was measured with the subject in supine position and the shoulder passively positioned in 45° of abduction, 0° of external rotation, and the elbow flexed to 90°. The degree of passive external shoulder rotation when the subject first began to experience shoulder pain was measured with a handheld goniometer. We measured motor impairment by means of the upper extremity portion of the Fugl-Meyer Motor Test (FMT).24, 25, 26 We assessed disability with the self-care portion of the FIM™ instrument27, 28, 29, 30 by interviewing the subject and/or caregiver. To document compliance, subjects were asked to keep a log of stimulation time. An electronic log of total stimulation time, a feature of the stimulator developed during the study, was also available in 3 subjects.
Treatment
Percutaneous, intramuscular electrodes were implanted into the posterior deltoid and supraspinatus muscles of the hemiplegic shoulder in all 8 subjects. In 2 subjects with pronounced scapular external rotation and depression, an additional electrode was implanted near the motor point of the upper trapezius to correct the scapular asymmetry. A self-adhesive, carbon-based, surface electrode placed medial to the scapula of the treated shoulder served as a common anode. To minimize bleeding risk in subjects on anticoagulation, precautions were taken to ensure that the prothrombin time was therapeutic. In all subjects, sterile technique was used during the implantation procedure to minimize the risk for infection.
The anticipated electrode exit sites were localized to the superior lateral aspect of the shoulder just medial and posterior to the acromion. The site was cleaned with 10% povidone-iodine using standard sterile technique. In preparation for implanting percutaneous electrodes, the motor points of the posterior deltoid and supraspinatus were localized using monopolar needle stimulation. The paths between the motor points of target muscles and anticipated electrode exit sites were anesthetized with 2% lidocaine. A 19-G hypodermic needle loaded with a percutaneous electrode was tunneled subcutaneously toward the posterior deltoid motor point from the anticipated electrode exit site. At the motor point, pressure was maintained at the needle tip to anchor the barb of the electrode in the belly of the muscle, and the needle was gently withdrawn leaving the electrode in place. The procedure was repeated for the other motor points. The subcutaneous tunneling procedure allows multiple electrodes to exit from the same site, facilitating skin care and connection with the external stimulator. After implantation, a bandage was used to cover the percutaneous electrodes to minimize the risk for accidental displacement. Instructions were given to the subjects and caregivers to notify the investigators if they experienced pain during stimulation, observed reduced muscle contraction during stimulation, or noted evidence of bleeding or infection at anytime.
The percutaneous electrode was of helical configuration wound from Teflon™-insulated, multistranded, type 316L stainless steel wires. Ten millimeters of the insulation was removed at the tip, resulting in a 10-mm2 stimulating surface. The deinsulated tip was angled to form a barb. Balanced biphasic, constant-current pulses were delivered by 1 of 2 stimulators. For the first 2 subjects, a 1.1-kg, laboratory-based stimulator developed at Case Western Reserve University was used. Subsequently, a smaller 50-g stimulatora was developed. The new stimulator was capable of delivering stimulation parameters identical to the larger unit and did not interfere with mobility or daily activities during treatment. The stimulator's current (20mA), frequency (12Hz), and duty cycle (10:10s) were held constant. Stimulus intensity was regulated by adjusting the pulse width, which varied from 10 to 200μs. Stimulus intensity, adjusted to provide optimal joint reduction by palpation without discomfort, remained constant during the 6 weeks of treatment.
Six weeks of stimulation for 6 hours daily was prescribed to all subjects for a total of 252 hours of treatment time. The subjects were allowed to divide treatment time into 2 to 3 daily sessions for convenience in some cases. At the end of the 6-week treatment, all electrodes were removed.
Statistical analysis
A 1-way analysis of variance using the generalized estimating equation approach was used to determine whether differences from T1 to T2 and from T1 to T3 were statistically significant for all outcome measures. For all statistical testing, the α =.05 level was required for significance.
Results
Subject characteristics are summarized in table 1.
| Subject | Sex | Age (yr) | Hemiplegic Side (Left or Right) | Onset to Treatment Time (mo) | Cause |
|---|---|---|---|---|---|
| 1 | M | 59 | Right | 19 | Stroke |
| 2 | M | 74 | Right | 6 | Stroke |
| 3 | F | 65 | Left | 6 | Stroke |
| 4 | M | 61 | Right | 12 | Stroke |
| 5 | M | 47 | Left | 7 | Stroke |
| 6 | M | 48 | Left | 12 | Stroke |
| 7 | M | 39 | Right | 13 | TBI |
| 8 | F | 63 | Right | 31 | Stroke |
Abbreviation: TBI, traumatic brain injury.
Outcome data are tabulated in raw form in table 2.
| Radiographic Vertical Subluxation (mm) | Shoulder Pain-Free External Rotation(deg/90) | FMT Upper Extremity Subscale (score/66) | BPI Pain Intensity (score/10) | BPI Pain Interference (score/10) | FIM Self-Care Subscale (score/42) | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Subject | T1 | T2 | T3 | T1 | T2 | T3 | T1 | T2 | T3 | T1 | T2 | T3 | T1 | T2 | T3 | T1 | T2 | T3 |
| 1 | 19 | 5 | 2 | 0 | 35 | 20 | 13 | 14 | 19 | 7 | 4 | 0 | 1.3 | 0.3 | 0 | 36 | 36 | 42 |
| 2 | 7 | 2 | 7 | 15 | 25 | 40 | 4 | 4 | 13 | 2 | 0 | 5 | 1 | 0 | 1.7 | 22 | 33 | 39 |
| 3 | 7 | 11 | 11 | 0 | 40 | 15 | 4 | 4 | 4 | 10 | 0 | 2 | 6.7 | 0 | 1 | 13 | 19 | 20 |
| 4 | 4 | 0 | −4 | 40 | 45 | 40 | 5 | 7 | 12 | 0 | 0 | 0 | 0 | 0 | 0 | 28 | 29 | 37 |
| 5 | 24 | 20 | 10 | 22 | 38 | 25 | 5 | 5 | 18 | 6 | 7 | 3 | 3.4 | 2 | 0 | 25 | 28 | 29 |
| 6 | 5 | −4 | −3 | 34 | 47 | 20 | 14 | 15 | 21 | 5 | 0 | 2 | 2.4 | 0 | 2 | 25 | 24 | 18 |
| 7 | 16 | 4 | N/T | 27 | 40 | 35 | 43 | 52 | 48 | 5 | 4 | 3 | 0.9 | 0.3 | 1.4 | 38 | 42 | 42 |
| 8 | 0 | 2 | 0 | 10 | 25 | 40 | 4 | 4 | 4 | 3 | 0 | 0 | 0.1 | 0 | 0 | 26 | 31 | 29 |
| Mean | 10.3 | 5.0 | 3.3 | 18.5 | 36.9 | 29.4 | ||||||||||||
| Median | 5 | 6 | 15.5 | 5 | 0 | 2 | 1.15 | 0 | 0.5 | 25.5 | 30 | 33 | ||||||
| AC | −5.3 | −7.2 | 18.4 | 10.9 | 1.63 | 5.88 | −2.88 | −2.88 | −1.65 | −1.21 | 3.63 | 5.38 | ||||||
| Upper CI | −1.1 | −12.4 | 26.3 | 20.3 | 3.61 | 8.70 | −0.64 | −0.59 | −0.24 | 0.23 | 6.12 | 9.72 | ||||||
| Lower CI | −9.3 | −2.0 | 10.4 | 1.5 | 0.36 | 3.05 | −5.11 | −5.16 | −3.06 | −2.66 | 1.13 | 1.03 | ||||||
| p* | .0117 | .0066 | <.0001 | .0234 | .1092 | <.0001 | .0115 | .0136 | .0220 | .1005 | .0044 | .0152 | ||||||
| *p listed under T2 and T3 apply to the differences between the outcome measured at that testing period and the outcome measured at T1. | ||||||||||||||||||
Abbreviations: N/T, no test; T1, pretreatment test period; T2, posttreatment follow-up test period; T3, 3-month follow-up test period; AC, adjusted change; CI, confidence interval.
In all 8 subjects, full joint reduction by palpation was achieved during stimulation of all implanted muscles. However, in at least 1 motor point of 3 subjects, stimulation at the highest intensity (ie, 200μs) resulted in discomfort that was thought to be from volume-conducted stimulation of cutaneous or periosteal nociceptors or impingement of the humerus on the acromion. In all cases, pain during stimulation was eliminated by relocating the electrodes or reducing the stimulus intensity. Local skin redness noted by 1 subject during the 6-week treatment phase resolved with topically applied bacitracin ointment. The electrode was left in place and used for stimulation. Five electrodes in 2 subjects fractured during removal, leaving a fragment of the distal stimulating tip in the muscle. We found no medical complications from these retained fragments at 34- and 40-month follow-up of the 2 subjects. Stimulation of the supraspinatus muscle was inconsistent and provided incomplete or undetectable joint reduction in all subjects. Stimulation of the posterior deltoid resulted in complete joint reduction in all subjects.
The total stimulation time prescribed for all subjects was 252 hours (6h/d for 6wk). The median reported compliance for total stimulation time was 100%, with a range of 81% to 110%. In 3 subjects, an electronic log of total stimulation time was available and showed 34%, 53%, and 101% compliance with the prescribed regimen.
Discussion
Future work is needed in 4 major areas. First, a better understanding of the natural history of shoulder pathology in patients with hemiplegia is needed to guide the application of this intervention. Second, further refinements of the intervention are needed to optimize treatment efficacy and the potential for clinical transfer. Third, the validity and reliability of critical outcome measures must be established. Finally, efficacy must be determined in larger scale, randomized, controlled trials with adequate follow-up periods.
To further our understanding of the factors that lead to the development of shoulder pain, the dynamic nature of many conditions seen in hemiplegia must be considered. The long-term effects of conditions that may exist transiently should be studied in a longitudinal manner. The lack of a statistically significant correlation between shoulder subluxation and pain in several cross-sectional analyses has been cited as evidence that subluxation does not cause pain.6, 7, 31 However, cross-sectional data are insufficient to substantiate this conclusion because subluxation may cause pain directly or indirectly. Subluxation develops early12 and may resolve spontaneously,32 whereas pain may develop after hospital discharge.33 Therefore, subluxation may not be present when pain develops, but may nevertheless have a role in the pathogenesis of other painful conditions. Longitudinal data are limited but have documented a correlation between subluxation and pain.3, 13 Furthermore, correlations between subluxation and RSD,3 neuropathy,11 and rotator cuff tear2have been documented.
Often, the optimal use of medical technology does not have a clearly identifiable end point, and NMES for treating shoulder subluxation is no exception. However, several aspects of NMES for shoulder dysfunction in hemiplegia may warrant additional investigation before treatment efficacy is studied further. The first is muscle selection for stimulation. The muscles selected for trans-NMES in other published studies were based on data reported by Basmajian and Bazant.34 In that study, electromyographic activity in the shoulder muscles of healthy adults was observed during rest and inferiorly directed traction on the upper limb. The supraspinatus was found to be uniformly active and the posterior deltoid less active under these conditions.34 These results may not be relevant for treating shoulder subluxation because of differences in physiologic characteristics between hemiplegic and neurologically intact subjects, the lack of correlation between electromyographic activity and muscle force, and the difference in loading patterns between the intact and chronically unstable shoulder. Stimulation of the supraspinatus muscle results in inconsistent joint reduction in the subluxated hemiplegic shoulder and provides less joint reduction than other shoulder muscles.35 Stimulation of muscles with strong medially directed forces—other rotator cuff muscles, muscles with superiorly directed force vectors such as the coracobrachialis and muscles that stabilize the scapula—may significantly enhance the efficacy of this intervention. Based on preliminary data from our laboratory, it is probable that stimulating several muscles may better reduce subluxation during stimulation than stimulating the supraspinatus alone. The optimal number of muscles to stimulate is not known. Stimulating more muscles may potentially improve treatment efficacy or reduce the total stimulation time needed.
Optimizing the muscle selected for stimulation requires a precise and accurate assessment of glenohumeral alignment. For precision, bony landmarks on the humerus and scapula must be identified reliably. Because both anterior and inferior subluxation are common in chronic shoulder instability,36 accurate assessment of abnormal joint translation should account for at least 2 and probably 3 dimensions. Use of the unaffected shoulder as a reference can augment accuracy by normalizing for anatomic variation among individuals. Our data suggest that palpation of the subacromial space does not account for glenohumeral translation in the AP dimension. Radiographic techniques that quantify shoulder subluxation in multiple dimensions have been reported.37, 38 In the method described by Boyd et al,37 subjects are seated in a pivoting chair to standardize position and to ensure that the radiographs are taken with reference to the plane of the scapula. Because special equipment is required, widespread use of this technique may not be feasible. Furthermore, the technique does not take into account variability in glenoid orientation relative to the body of the scapula. We believe that the most sensitive and reliable measure of abnormal glenohumeral translation should take several factors into account. First, the position of the trunk and upper limb should be standardized. Second, a comparison to the unaffected shoulder should be made to minimize the effect of normal variability in glenohumeral translation among individuals. Third, all measures should be referenced to the glenoid fossa rather than to the edge of the radiograph, the trunk, or the body of the scapula. Fourth, joint translation should be quantified in 3 dimensions. The reliability and validity of a new measure that considers these 4 factors is under investigation in our laboratory.
Muscle conditioning, an issue with a potentially large impact on the efficacy of NMES for treating shoulder subluxation, has not received adequate attention. The large number of variables that could be studied complicate research in this area. Reduced shoulder subluxation has been accomplished by gradually increasing stimulation to avoid fatigue17, 18 or by applying maximal stimulation throughout the course of treatment.39 The latter method is less time consuming and potentially less costly. The adverse affect of stimulated-muscle fatigue on muscle conditioning, on persistent reduction of subluxation, and on pain have not been documented. In the typical pattern for trans-NMES, the clinician ramps up the stimulus, holds it constant, ramps down the stimulus, and allows a brief “off” period to allow the muscle to rest. This cycle results in a brief concentric muscle contraction, a longer isometric contraction, and a brief eccentric contraction. The best mode of NMES “exercise” to promote strength, endurance, and passive muscle properties has not been studied.
It is also unclear whether the beneficial effects of stimulated muscle contraction may be enhanced by contraction against resistance. Shoulder subluxation was reduced when NMES was applied in the dependent upper limb, resulting in stimulated contraction against the weight of the limb39 as well as in the supported upper limb.17, 18 Methods to optimize the effects of muscle contraction against resistance while minimizing the potential for further injury to soft tissues in the unsupported upper limb are currently under investigation in our laboratory. The number of variables that can be studied to optimize muscle conditioning during NMES may prohibit optimization of all variables. However, the selection of optimal target muscles for stimulation, the effect on treatment efficacy of stimulated-muscle fatigue, muscle activation against resistance, and avoidance of further soft tissue injury may warrant more immediate investigation.
The dose-response relationship between total treatment time and reduction of subluxation and pain has not been studied. However, in randomized controlled trials of subjects with acute hemiplegia, a total treatment time of 84 hours did not result in statistically significant reduction of subluxation or pain,40 whereas a total treatment time of approximately 252 hours did,18 suggesting that a relationship exists between total treatment time and subluxation and between total treatment time and pain. A difference in stimulation parameters, the degrees of joint reduction during stimulation, and subject compliance are among many variables that may confound these findings. Future dose-response studies should standardize the stimulation administered and assess compliance using devices that electronically log treatment time. In the majority of studies of trans- or perc-NMES, stimulation was administered for 6 hours daily for 6 weeks and resulted in persistent reduction of subluxation at follow-up ranging from 6 weeks to 6 months.17, 18, 20, 38, 39 However, in each study, a trend was found toward increasing subluxation at the follow-up assessment. These data suggest that in some hemiplegic individuals, maintenance treatment or use of NMES as an orthotic may be required to achieve persistent reduction of subluxation. In our study, subjects with chronic hemiplegia tended to maintain glenohumeral alignment after treatment was discontinued if motor recovery occurred after treatment. In cases in which longer treatment with NMES is needed, current delivered by means of implanted electrodes without percutaneous leads may be more practical than trans- or perc-NMES. The percutaneous electrodes used in the present pilot study have an 88% probability of survival at 6 months, which declines to 48% at 5 years.41 A primary advantage of subcutaneous electrodes is their potential for long-term use. Implanted components can be injected into muscle or surgically placed. Chronic treatment may be needed in a subset of hemiplegic individuals with shoulder subluxation.
The present pilot data show that intramuscular perc-NMES is feasible for treating shoulder dysfunction in persons with hemiplegia and suggest that this intervention may reduce shoulder pain, improve ROM, enhance motor function, and reduce disability. However, conclusions regarding the efficacy of this application cannot be made from the present results because of the study's small sample size, lack of a rigorous control group, short length of follow-up, and use of outcome measures that have not been validated in the study population. Further studies that address these issues are needed before this potential treatment modality is put into clinical use. Further development of the intervention is also needed. Several basic components, including target muscles for stimulation, muscle conditioning, dose-response relationships, and identification of the optimal target populations, have yet to be optimized. The potential for treating shoulder dysfunction in hemiplegia with perc-NMES is promising and becomes even more so when the potential for further refinement of this application is considered.
Conclusions
Percutaneous, intramuscular NMES for treating shoulder dysfunction in hemiplegia is feasible and it may reduce shoulder subluxation, reduce shoulder pain, improve ROM, enhance motor recovery, and reduce disability in persons with chronic hemiplegia and shoulder subluxation. Further studies are warranted.
Acknowledgements
The authors thank Linda Quinn for her statistical assistance and Dr. Hunter Peckham for his generous academic mentorship. A portion of this work was completed in partial fulfillment of Maria E. Walker's thesis requirement for a Master's of Science, Case Western Reserve University, May 1998.
Supplier
a. NeuroControl Corp, 8333 Rockside Rd, Valley View, OH 44125.
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