Electrical stimulation in early stroke rehabilitation of the upper limb with inattention

Transcription

1 Electrical stimulation in early stroke rehabilitation of the upper limb with inattention Merilyn Mackenzie-Knapp! 1La Trobe University Use of electrical stimulation early in stroke rehabilitation may benefit recovery of function. This case report describes the clinical outcomes following electrical stimulation for the supraspinatus of a 25-year-old patient four weeks after a right sided stroke. In this patient, use of electrical stimulation for a total of four hours in 4.5 weeks, appeared to have a number of benefits: subluxation was reduced and patient attention to the arm was increased. There was also a notable improvement in functional use of the arm when task-specific upper limb training was incorporated. Whilst not conclusive, the results of this case study reinforce the value of electrical stimulation in the early management of the upper limb in a stroke patient who clearly demonstrated inattention to his upper limb. The results also highlight the need for well controlled studies to investigate the benefits of electrical stimulation and to establish the optimal timing and parameters for this intervention. Therapists can then more effectively optimise effective upper limb rehabilitation following stroke. [M~ckenzie-Knapp M (1999): CasertJPort: Electrical stimulation in early stroke rehabilitation of the upp,r limb with inattention. Australian Journal of Physiotherapy 45: ] Key words: A~m; Cerebrovascular Disorders; Electric Stimulation Therapy; Hemiplegia Introduction Recovery of the upper limb to functional levels is a critival. Component of rehabilitation after stroke. Recovery rates reported are less than ideal and vary from 5 per cent (Gowland 1982) to 52 per cent (Dean and Mackey 1992). Early discharge reduces the time available for retraining. As therapists, we must focus more than ever on evidence-based practice for effectiveness, efficiency and accountability. Evidence now exists that electrical stimulation early in rehabilitation may be advantageous to the rehabilitation of the upper limb following stroke. Research in neuroplasticity suggests that upper limb retraining may be more beneficial when encouraged early in. rehabilitation. Following brain injury, new central connections are formed by substantial reorganisation (Stephenson 1993). Animal experiments and positron emission tomography of adult subjects with stroke (WeiHer et a11992) indicate that these changes within the nervous system tend to occur early in the recovery stage. However, as little as five minutes of arm therapy per patient day for patients with acute stroke has been reported recently in one hospital (Morgan 1998) which is less than,but not substantially different from, 10 minutes per day of arm retraining in a rehabilitation centre reported six years ago (Goldie et ai1992). "There is increasing interest in the potential for electro stimulation technologies to reduce secondary changes in muscle, prevent stretching of the capsule and to initiate muscle activity sufficiently to maintain gleno~humeral joint alignment" (Carr and Shepherd 1998, pp. 271). Of direct relevance to this is the suggestion by Anderson (1985) that if the capsule is prevented from heing stretched during the flaccid phase of neural recovery after stroke, chronic subluxation and shoulder pain may be avoided and sufficient muscular activity developed to maintain normal alignment of the glenohumeral joint. Malalignment of the gleno-humeral joint because of absence of muscular support has been suggested as a contributing factor in the development of shoulder pain following stroke (Van Ouwellenaller et al 1986). Published studies provide some evidence that electrical stimulation can be effective in reducing subluxation and in encouraging shoulder muscle activity (Baker and Parker 1986, Faghri et al 1994). In a controlled trial of 26 matched patients, Faghri and colleagues applied functional electrical stimulation (FES) over supraspinatus and posterior deltoid muscles using electrostimulation of 35 Hz, 223

2 initially for 1.5 hours daily, progressing to six hours. FES commenced 17 days after stroke and continued for up to six weeks following stroke. However, no details were provided of any functional measurements used to evaluate improvement in ann function, or the physiotherapy treatment given in conjunction with the electrical stimulation. These authors reported reduced subluxation (measured by x-ray), decreased associated pain and possibly facilitated arm muscle recovery. In spite of this success, anecdotally,electrostimulation is little used in the management of the upper limb following stroke, either in acute or rehabilitation practice. This case report describes the initial and final clinical findings following an intervention with the use of electrical stimulation for the upper limb ina patient with a right-sided stroke. Patient profile A 25-year-old right-handed male was in rehabilitation following a right-sided stroke (left hemiplegia) after middle cerebral artery ischaemia. A substantial area of infarction was noted on CT scan. At assessment four weeks following stroke, this patient was non-ambulant' and required occasional assistance from another person when transferring. His upper limb function was minimal (see below). A lap tray was provided for arm support when seated in a wheelchair and a sling offered for his flaccid arm during transfers and early gait training. His management at that time was focused on mobility and transfers. Upper limb assessment: subluxation of the left gleno-humeral joint 3cm 2 no shoulder pain (RASO)3 minimal returning muscle activity (MAS Upper Arm Function, 1)4 full range of shoulder movement cutaneous sensation intact some inaccuracies on proprioception testing of upper limb (3/5)5 inattention and lack of concern for his hemiparetic upper limb Intervention At four weeks following stroke, electrical stimulation was introduced over the supraspinatus region of the shoulder using a Respond Select electrical stimulator (Medtronic Nortech Division, San Diego USA). Self-adhesive carbon electrodes (4.2cm x 4.2cm) with an adhesive patch were applied over the supraspinatus muscle. The patient was seated at a table with the forearm supported. The proximal electrode was placed over the medial one third of the belly of supraspinatus, taking care that the fibres of trapezius were not stimulated by placing the proximal electrode lateral to the trapezius motor point. The distal electrode was applied over the area immediately distal to the acromion over the middle deltoid. The supraspinatus muscle seats the humeral head into the glenoid fossa, slightly abducts the humerus and externally rotates the arm (Faghri etal 1994). The stimulation parameters were a biphasic asymmetrical waveform with a pulse width of 300lls and a frequency of 50 Hz (Electrotherapy Standards 1990). The total "on" time was eight seconds, consisting of a 2sramp up, 5s peak and lsramp down time. The intensity was adjusted to achieve as strong as possible elevation of the humeral head with some shoulder external rotation, without causing discomfort. Electrical stimulation Was applied for 10 to 20 minutes per day, five days per week over a 4.5 week period,a total time of approximately four hours.. The patient's electrical stimulation program was applied concurrently with his continuing gait retraining and an ongoing occupational therapy program aimed at hand retraining. As shoulder muscle activity returned, task-specific training was incorporated to encourage and reinforce stimulationinduced muscle activity. This had previously been 1 FIM 1: patient fully dep~ndent walking: performs less than 25 per cent of task (Functional independence measure Hamilton et al 1987) 2 patient seated. arm unsupported in neutral rotation: tape applied over shoulder; separation between humeral head and acromion palpated and marked: overlying tape later aligned against a ruler to derive subluxation measure. which was measured serially 3 RAS 0 "with patientsupine, affected arm abducted to 30 degrees; shoulder can be passively externally rotated without pain" (Bohannon and LeFort 1986) 4 MMAS 1 "lying, protract shoulder girdle with elevation". Therapist places arm in position and supports elbow in extension (Carr et al 1985) 5 positional mimicry and comparing with intact side (Lincoln et al 1991) 224

3 impossible due to shoulder flaccidity and the patient's inattention to his arm. An initial gross movement of shoulder elevation with external rotation was gradually refined into more functional and taskrelated reach to grasp activities. The patient was instructed to practise bimanual activities in addition to unimanual upper limb activities and the benefits of out-of-therapy practice were explained and encouraged. Outcome Final assessment nine weeks following stroke of the left upper limb revealed: shoulder subluxation was reduced from 3cm to 2cm 6 ; no shoulder pain reported (RASO); active muscle activity in shoulder, elbow and wrist (MMAS Upper Arm Function 4? (MAS Hand Movements 5)8; full range of passive shoulder movement; and reduced inattention: patient spontaneously attempted to use affected upper limb in ADL, including use of plastic cup to drink independently. At this stage of rehabilitation, the patient was walking approximately 50 metres with close supervision and required some assistance (FIM4)9. Gait was slow. Retraining on stairs had been commenced. An assessment three months later, following discharge from rehabilitation, revealed sustained improvement in shoulder and arm function despite discontinuation of electrostimulation eight weeks previously. Use of the arm was incorporated into daily functional tasks although it was apparent that occasional reminders were necessary to include the arm in bimanual skills such as putting shoes on and off. 6as initially tested, patient sitting with arm unsupported: same examiner. 7 MMAS4 "sitting, hold extended arm ina forward flexion positi.on for.2 seconds". (Therapist should place arm in position and patient must maintain position with some external rotation). 8 MMA$5 "pick up polystyrene cup from table and put down on table across other side of body". (Do not allow alteration in shape of cup). 9 FlM4minimai assistance required (patient performs more than 75% of the task) Discussion The observations made in this case study support evidence that electrical stimulation may make a positive contribution in the early management of subluxation of the upper limb following stroke. After four weeks ofelecmcal stimulation, in conjunction with task-specific training strategies, significant improvement in overall arm function was evident ina patient whose previously flaccid upper limb had indicated limited potential function. On the basis of observed improvements, the rehabilitation team, the patient and his wife were all more optimistic about the further improved use of his upper limb. Other factors possibly contributing to the outcome must be acknowledged. Recovery of function is maximal early after stroke and it is difficult to detect the benefit of a new treatment intervention (Crow et al 1989), particularly without a control. The course the recovery would have taken without the electrical stimulation intervention reported in this study cannot be known with certainty and an equally or even more favourable outcome may have been achieved by greater concentration on the upper limb by both patient and carers. The 4.5 weeks of treatment prior to the introduction of electrical stimulation had emphasised transfers and gait training, since minimal upper limb progress had occurred. Subluxation was marked; and ongoing inattention by the patient appeared to contribute to the potential for learned non-use of his non-dominant arm. Although there is no agreement on the consequences of inattention for. daily living recovery (pedersen et al 1997) some studies have found the perceptual deficits associated with left hemiplegia indicate adverse function (Lincoln et al 1997) whilst others suggest less spontaneous recovery than for patients with right hemiplegia. Consistent with this, motor rehabilitation in people with left hemiplegia reportedly takes longer and achieving functional outcomes is more difficult (Denes et al 1982). The temporal contiguity of improvement, the improvement in shoulder muscle activity, the reduced subluxation, the continuing absence of pain and the apparent improved awareness of the upper limb in this case suggest electrical stimulation possibly played a role in the outcome. However, this case also raises other questions including the need to establish a range of parameters for using electrical stimulation and to investigate if there is an optimal time for implementing electrical stimulation m the 225

4 Gas(3 Report management of the upper limb after stroke. This patient's electro-stimulation treatment was for approximately 15 minutes a day, substantially less than the 1.5 hours progressing to six hours used by Faghri et al (1994). Prospective controlled studies across the wide spectrum of stroke patients are needed to determine the role of electrical stimulation in initiating early activation of recovering muscle activity and its possible contribution to the reduction of shoulder subluxation and possible delay in onset or prevention of shoulder pain. Studies are also needed to investigate whether electrical stimulation can be successfully combined with voluotaryeffort to strengthen muscle as suggested by Kraft et al (1992) and its possible role in the management of neglect, as suggested by Prada and Tallis (1995). Research indicates that Victorian physiotherapists working in a range of areas use electrical stimulation for muscle re-education (Robertson and Spurritt 1998). However, only a minority oftherapists include electrical stimulation for re-educationand upper limb retraining after stroke. As rehabilitation budgets are limited and rehabilitation bed-days are reducing, it is important to effectively use the time therapists have for rehabilitation following stroke. Changes in clinical practice seem indicated if the neurologically impaired are to gain maximal recovery (Bethune 1994) and these changes should include a greater use of strategies which will optimise outcomes in an environment of reducing lengths of stay. The progress shown by this patient suggests that electrical stimulation may influence motor performance. As a case report it does not meet the strict criteria for evidence-based practice. The measured changes in ann function reported here will hopefully encourage controlled studies to more closely evaluate the early introduction of electrical stimulation in the management of individuals with stroke, especially those who initially display inattention, shoulder subluxation and non-use of their affected upper limb. Acknowledgements Thanks are extended to 3rd year physiotherapy students Anna Patterson and Tim Penno, to the staff at the Caulfield General Medical Centre and to Associate Professor Val Robertson for her assistance withprepariog the manuscript. Auth()r Merilyn Mackenzie-Knapp, School of Physiotherapy, La Trobe University, Bundoora Victoria merilyum@latrobe.edu.au(for correspondence). References Anderson L (1985): Shoulder pain in hemiplegia. Am(3rican Journal of Occupational Therapy 39: Baker L and Parker K (1986): Neuromuscular electrical stimulation around the shoulder. Physical Therapy 66: Bethune 0 (1994): Another look at neurological rehabilitation. Australian Journal of PhYSiotherapy 40): Bohannon R and LeFort A (1986): Hemiplegic shoulder pain measured with the Ritchie Articular Index. Internal Journal of Rehabilitation Research 9: Carr J, Shepherd R, Nordholme L and Lynne D (1985): A motor assessment scale. Physical Therapy 65: Carr J and Shepherd R (1998): Neurological Rehabilitation: Optimizing Motor Performance. OXford: Butterworth Heinemann, pp. 147,271. Grow J, Lincoln N, Nouri F and De Weerdt W (1989): The effectiveness of EMGbiofeedbackin the treatment of arm function after stroke. International Disability Studies 11 (4): Dean C and Mackey F (1992): Motor assessment scale l;cores as a means of rehabilitation following stroke. Australian Journal of Physioth(3rapy 38: Denes G, Semenza C, Stoppa E and Lis A (1982): Unilateral spatial neglect and recovery from hemiplegia. A follow-up study. Brain 105: Electrotherapeutic Terminology in Physical Therapy. Report by the Electrotherapy Standards Committee by the Section on Clinical Electrophysiology of the American Physical Therapy Association (1990): American PhYSical therapy Association, Alexandria, Virginia.. Faghri P, Rogers M, Glaser R, Bors J, Ho C and Akuthota P (1994): The effects of functional electrical stimulation on shoulder subluxation, arm function recovery and shoulder pain in hemiplegic stroke patients. Archives of Physical Medicine and Rehabilitation 75: Goldie P, Matyas T and Kinsella G (1992): Movement rehabilitation following stroke. Research Report to the Department of Health, Housing and Community Services, Melbourne, Victoria. Gowland C (1982): Recovery of function following stroke: profile and predictors. Physiotherapy Canada 34: Hall J, Dudgeon B and Guthrie M (1995): Validity of clinical measures of shoulder subluxation in adults with poststroke hemiplegia. American Journal of Occupational Therapy 49 (6): Hamilton B, Granger C, Sherwin F, Zielezny M and Tashman J (1987): A uniform national data system for medical rehabilitation. In Fuhrer M (Ed.): Rehabilitation Outcomes-analysis and Measurement. Baltimore: Paul Brooks Publishing Company, pp

5 Heilman K and Valeilstein E (1985): Clinical Neuropsychology (2nd ed.) New York: Oxford University Press. Kraft G, Fitts S and Hammond M (1992): Techniques to improve function of the arm and hand in chronic hemiplegia. Archives of Physical Medicine and Rehabilitation 75: Lincoln N, Crow J, Jackson J, Waters G, Adams Sand Hodgson P (1991): The unreliability of sensory assessments. Clinical Rehabilitation 5: Lincoln, N, Drummond A, Berman P (1997): Perceptual impairment and its impact on rehabilitation outcome. Disability and Rehabilitation 19 (6): Morgan P: Lecture Report: The potential for upper limb recovery following neurological damage. (1998): Newsletter of the Victorian Neurology Special Interest Group. July. Pedersen P Henrik M Jorgensen S, Nakayama H, Raaschou H and Olsen T (1997): Hemineglect in acute stroke-incidence and prognostic implications. The Copenhagen Stroke Study. American Joumal of Physical Medicine and Rehabilitation 76 (2): Prada G and TaUisR (1995): Treatment of the neglect syndrome in stroke patients using a contigency stimulator Clinical Rehabilitation 9: Robertson V and Spurritt D (1998): Electrophysical agents: Implications of their availability and use in undergraduate clinical placements. Physiotherapy 84 (7): Stephenson R (1993): A review of neuroplasticity: Some implications for physiotherapy in the treatment of lesions of the brain. Physiotherapy 79 (10): Van Ouwenaller C, Laplace P and Chantraine A (1986):.Painful shoulder in hemiplegia. Archives of Physical Medicine and Rehabilitation 46: Weiller C, Chollet F and FristonK {1992}: Functional reorganization of the brain in recovery from striatocapsular infarction in man. Annals of Neurology 31: