What is the role of neuromuscular electrical stimulation (NMES) in the treatment of hemiplegic shoulder pain?

Updated: Feb 08, 2019
  • Author: Robert Gould, DO; Chief Editor: Stephen Kishner, MD, MHA  more...
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Answer

Answer

The aim of NMES is to reduce subluxation of the hemiplegic shoulder without the use of splints, since no sling design definitively prevents or treats shoulder subluxation. [57] NMES may even elicit strong sedative effects on pain by acting on sensory nerves. Faghri and coauthors propose that it also could be used prophylactically as a temporary means of splinting the shoulder until recovery of motor function is sufficient to support the glenohumeral joint. [12] Numerous other studies have suggested that it also improves spasticity and enhances muscle strength of the hemiparetic limb.

Chantraine and colleagues found that patients with hemiplegia and subluxation who received 5 weeks of NMES had significantly more improvement in pain relief, reduced subluxation, quicker motor recovery, and possibly facilitated recovery of shoulder function. These results were maintained for up to 2 years. [57] However, it was recommended that patients continue exercising to maintain control of their pain.

In patients with chronic hemiplegic stroke and TBI, Yu and coauthors used percutaneous NMES (perc-NMES) in the posterior deltoid and supraspinatus muscles 6 hours a day for 6 weeks. [22] This resulted in reduced subluxation and improvements in pain and disability. These results were maintained during 3 months of follow-up.

A subsequent study by Yu and coworkers showed that perc-NMES is less painful than transcutaneous NMES, has a much easier application, and has potential for long-term use. This study also found a reduction of shoulder subluxation, with possible enhancement of recovery and improvement in shoulder pain. [23]

Chae and coauthors reported that intramuscular electric stimulation to the supraspinatus, posterior and middle deltoid, and upper trapezius for 6 hours a day for 6 weeks helped control shoulder pain in chronic stroke survivors. [9] Compared with the wearing of a cuff-style sling over a similar 6-week time frame, electric stimulation produced better pain control (63% vs 21%), and the effect was maintained through 12 months posttreatment.

At this point, the optimal muscles and number to stimulate has not been established. Yu and coauthors believe that using muscles with strong superior and medially directed forces, as well as those stabilizing the scapula, may significantly enhance the efficacy of this intervention. [22, 23]

Even after 6 months poststroke, forced active repetitive movements of the paretic limb through the use of NMES appears to enhance motor and functional recovery. This has been clinically proven to occur as a result of neuroplasticity, in which active repetitive training of the hemiparetic limb causes functional reorganization in the adjacent intact cortex, subsequently allowing for maximum motor recovery.

Chae and colleagues treated the extensor digitorum communis (EDC) and extensor carpi radialis (ECR) by combining neuromuscular stimulation with active repetitive wrist and finger extension exercises for 1 hour per day for a total of 15 sessions, which produced significantly enhanced motor recovery that was maintained for up to 12 weeks. [8] However, no significant functional effect was proven.

A study by Wilson et al reported that in patients with hemiplegic shoulder pain, pain and pain interference were reduced and pain-free external range of motion (ROM) was improved, with insertion of a fully implantable peripheral nerve stimulator. The five patients who received the device, which included a pulse generator, as well as an electrode to stimulate the affected shoulder’s axillary nerve, experienced pain relief of 50% or more at 6- and 12-month follow-up. In four of the participants, pain remained at least halved at 24 months. [58]


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