Randomized Controlled Trial to Evaluate the Effect of Surface Neuromuscular Electrical Stimulation to the Shoulder After Acute Stroke

Abstract

Background and Purpose— Surface neuromuscular electrical stimulation (sNMES) after stroke aims to improve upper limb function and reduce shoulder pain, but current evidence of effectiveness is inconclusive. We have undertaken a randomized controlled trial to evaluate sNMES to the shoulder after acute stroke. Methods— One hundred seventy-six patients, within 10 days of stroke onset, were randomized to receive sNMES or placebo in addition to stroke unit care. The primary outcome measure was upper limb function measured by the Action Research Arm Test (ARAT) 3 months after stroke. Secondary outcome measures included other measures of upper limb function, upper limb impairment, pain, disability, and global health status. Outcome assessments were blinded. Results— There was no difference in arm function between groups in terms of the primary outcome measure. The median ARAT at 3 months was 50 in the intervention group and 55.5 in the control group ( P =0.068). Significant differences were seen at 3 months in favor of the control group for other measures of arm function and impairment: grasp and gross movement subsections of the ARAT, Frenchay Arm Test, and the arm subsection of the Motricity Index. Secondary analysis suggested that these differences were most marked in subjects with severe initial upper limb weakness. Conclusions— A 4-week program of sNMES to the shoulder after acute stroke does not improve functional outcome and may worsen arm function in severely impaired stroke patients. “Routine” use of sNMES to the proximal affected upper limb after acute stroke cannot be recommended.

Guidelines for Adult Stroke Rehabilitation and Recovery

“…125 The largest RCT to date testing surface NMES to a hemiplegic shoulder showed no effect on pain prevention in patients with acute stroke; however, pain was not a primary outcome measure in this study. 126 Compliance with the use of surface NMES has been variable in these studies, and surface NMES has been shown to be less well tolerated than intramuscular NMES. [126][127][128] Intramuscular NMES for 6 h/d over 6 weeks with 4 implanted electrodes showed efficacy in 2 open-label trials.…”

“…126 Compliance with the use of surface NMES has been variable in these studies, and surface NMES has been shown to be less well tolerated than intramuscular NMES. [126][127][128] Intramuscular NMES for 6 h/d over 6 weeks with 4 implanted electrodes showed efficacy in 2 open-label trials. 129,130 Pain differences between treatment and control groups remained significant 12 months after treatment, and NMES was more effective in patients with less chronic stroke (defined as <77 months after stroke in this study).…”

Accessing rehabilitation after stroke – a guessing game?

“…There is sufficient evidence that even chronic stroke patients may benefit from an additional package of rehabilitation therapy [39,40] and that natural unassisted recovery may have significant confounding effect when we try to model and predict responsiveness to targeted rehabilitation. In a randomized controlled trial to evaluate the effect of surface neuromuscular electrical stimulation to the shoulder following acute stroke it was clear that the recovery patterns fell into four groups: (a) patients who are recovering up to the 3-month period and then continuing to improve or plateau; (b) patients who recover up to 3 months and then deteriorate; (c) patients who start recovery only after the 3-month period; (d) patients who showed no improvement [41] (see Figure 1).…”

“…The question shifts away from ''does this person The rate of recovery is also variable and there is clear evidence that patients with severe levels of disability also improve. Source of data: Church et al [41] have rehabilitation potential'' to ''what type of rehabilitation is indicated, at what intensity, by whom, where and when''.…”

Functional electrical stimulation in upper extremity recovery of hemiparetic patients after stroke

“…[1][2][3] In 2001, stroke was statistically the leading cause of death in Brazil. 4 A stroke can be caused by hypertension and age, the main risk factors, 5 resulting in paresis or paralysis of the side opposite to the injury, 6,7 and manifested in muscle weakness, spasticity, and atypical motor patterns, disabling its victims or hampering the functionality of the upper limb.…”