Effect of EMG-triggered neuromuscular electrical stimulation with bilateral arm training on hemiplegic shoulder pain and arm function after stroke: a randomized controlled trial

Li-Ling Chuang, You-Lin Chen, Chih-Chung Chen, Yen-Chen Li, Alice May-Kuen Wong, An-Lun Hsu, Ya-Ju Chang, Li-Ling Chuang, You-Lin Chen, Chih-Chung Chen, Yen-Chen Li, Alice May-Kuen Wong, An-Lun Hsu, Ya-Ju Chang

Abstract

Background: Hemiplegic shoulder pain is a frequent complication after stroke, leading to limited use of the affected arm. Neuromuscular electrical stimulation (NMES) and transcutaneous electrical nerve stimulation (TENS) are two widely used interventions to reduce pain, but the comparative efficacy of these two modalities remains uncertain. The purpose of this research was to compare the immediate and retained effects of EMG-triggered NMES and TENS, both in combination with bilateral arm training, on hemiplegic shoulder pain and arm function of stroke patients.

Methods: A single-blind, randomized controlled trial was conducted at two medical centers. Thirty-eight patients (25 males and 13 females, 60.75 ± 10.84 years old, post stroke duration 32.68 ± 53.07 months) who had experienced a stroke more than 3 months ago at the time of recruitment and hemiplegic shoulder pain were randomized to EMG-triggered NMES or TENS. Both groups received electrical stimulation followed by bilateral arm training 3 times a week for 4 weeks. The primary outcome measures included a vertical Numerical Rating Scale supplemented with a Faces Rating Scale, and the short form of the Brief Pain Inventory. The secondary outcome measures were the upper-limb subscale of the Fugl-Meyer Assessment, and pain-free passive shoulder range of motion. All outcomes were measured pretreatment, post-treatment, and at 1-month after post-treatment. Two-way mixed repeated measures ANOVAs were used to examine treatment effects.

Results: Compared to TENS with bilateral arm training, the EMG-triggered NMES with bilateral arm training was associated with lower pain intensity during active and passive shoulder movement (P =0.007, P =0.008), lower worst pain intensity (P = 0.003), and greater pain-free passive shoulder abduction (P =0.001) and internal rotation (P =0.004) at follow-up. Both groups improved in pain at rest (P =0.02), pain interference with daily activities, the Fugl-Meyer Assessment, and pain-free passive shoulder flexion and external rotation post-treatment (P < 0.001) and maintained the improvement at follow-up (P < 0.001), except for resting pain (P =0.08).

Conclusions: EMG-triggered NMES with bilateral arm training exhibited greater immediate and retained effects than TENS with bilateral arm training with respect to pain and shoulder impairment for chronic and subacute stroke patients with hemiplegic shoulder pain.

Trial registration: NCT01913509 .

Keywords: Electric stimulation therapy; Shoulder pain; Stroke rehabilitation.

Conflict of interest statement

Ethics approval and consent to participate

The study was approved by the Institutional Review Boards of Chang Gung Medical Foundation (103-7272B) and Mackay Memorial Hospital (15MMHIS063). All participants provided written informed consent and were informed of the study’s purpose, the process, and their right to withdraw from the study at any time.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Flow chart of participants who enrolled in and completed the study. Abbreviations: NMES, neuromuscular electrical stimulation; TENS, transcutaneous electrical nerve stimulation; BAT, bilateral arm training
Fig. 2
Fig. 2
NRS-FRS scores during (a) shoulder active range of motion and (b) shoulder passive range of motion. * P < 0.05 between groups as indicated
Fig. 3
Fig. 3
BPI question 3 scores. *P < 0.05 between groups as indicated

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