David T. Yu

Intramuscular electrical stimulation for hemiplegic shoulder pain: a 12-month follow-up of a multiple-center, randomized clinical trial.

Chae J, Yu DT, Walker ME, Kirsteins A, Elovic EP, Flanagan SR, Harvey RL, Zorowitz RD, Frost FS, Grill JH, Fang ZP: Intramuscular electrical stimulation for hemiplegic shoulder pain: A 12-month follow-up of a multiple-center, randomized clinical trial. Am J Phys Med Rehabil 2005;84:832–842. Objective:Assess the effectiveness of intramuscular electrical stimulation in reducing hemiplegic shoulder pain at 12 mos posttreatment. Design:A total of 61 chronic stroke survivors with shoulder pain and subluxation participated in this multiple-center, single-blinded, randomized clinical trial. Treatment subjects received intramuscular electrical stimulation to the supraspinatus, posterior deltoid, middle deltoid, and upper trapezius for 6 hrs/day for 6 wks. Control subjects were treated with a cuff-type sling for 6 wks. Brief Pain Inventory question 12, an 11-point numeric rating scale was administered in a blinded manner at baseline, end of treatment, and at 3, 6, and 12 mos posttreatment. Treatment success was defined as a minimum 2-point reduction in Brief Pain Inventory question 12 at all posttreatment assessments. Secondary measures included pain-related quality of life (Brief Pain Inventory question 23), subluxation, motor impairment, range of motion, spasticity, and activity limitation. Results:The electrical stimulation group exhibited a significantly higher success rate than controls (63% vs. 21%, P = 0.001). Repeated-measure analysis of variance revealed significant treatment effects on posttreatment Brief Pain Inventory question 12 (F = 21.2, P < 0.001) and Brief Pain Inventory question 23 (F = 8.3, P < 0.001). Treatment effects on other secondary measures were not significant. Conclusions:Intramuscular electrical stimulation reduces hemiplegic shoulder pain, and the effect is maintained for ≥12 mos posttreatment.

SKIN COMPLICATIONS IN THE INTENSIVE CARE UNIT

Critically ill patients usually have multiple risk factors for the development of pressure ulcers. Pressure ulcers involve all levels of tissue from bone to skin, and result from excessive pressure and shearing. Control of incontinence, maintenance of adequate oxygen delivery and nutritional support is the key to minimizing the effects of skin breakdown in the intensive care unit. Consistent assessment and surveillance of skin for early signs of pressure ulcer development are essential, as is an interdisciplinary approach with nursing specialists and surgical consultants for pressure ulcers that have developed.

Intramuscular Electrical Stimulation for Shoulder Pain in Hemiplegia: Does Time From Stroke Onset Predict Treatment Success?:

Background. A randomized clinical has shown the effectiveness of intramuscular electrical stimulation for the treatment of poststroke shoulder pain. Objective. Identify predictors of treatment success and assess the impact of the strongest predictor on outcomes. Method. This is a secondary analysis of a multisite randomized clinical trial of intramuscular electrical stimulation for poststroke shoulder pain. The study included 61 chronic stroke survivors with shoulder pain randomized to a 6-week course of intramuscular electrical stimulation (n = 32) versus a hemisling (n = 29). The primary outcome measure was Brief Pain Inventory Question 12. Treatment success was defined as ≥ 2-point reduction in this measure at end of treatment and at 3, 6, and 12 months posttreatment. Forward stepwise regression was used to identify factors predictive of treatment success among participants assigned to the electrical stimulation group. The factor most predictive of treatment success was used as an explanatory variable, and the clinical trials data were reanalyzed. Results. Time from stroke onset was most predictive of treatment success. Subjects were divided according to the median value of stroke onset: early (<77 weeks) versus late (> 77 weeks). Electrical stimulation was effective in reducing poststroke shoulder pain for the early group (94% vs 7%, P < .001) but not for the late group (31% vs 33%). Repeated-measure analysis of variance revealed significant treatment (P < .001), time from stroke onset (P = .032), and treatment by time from stroke onset interaction (P < .001) effects. Conclusions. Stroke survivors who are treated early after stroke onset may experience greater benefit from intramuscular electrical stimulation for poststroke shoulder pain. However, the relative importance of time from stroke onset versus duration of pain is not known.

Percutaneous, intramuscular neuromuscular electrical stimulation for the treatment of shoulder subluxation and pain in chronic hemiplegia: a case report.

Chae J, Yu D, Walker M: Percutaneous, intramuscular neuromuscular electrical stimulation for the treatment of shoulder subluxation and pain in chronic hemiplegia: a case report. Am J Phys Med Rehabil 2001;80:296–301.This case report describes the first survivor with chronic stroke who was treated with percutaneous, intramuscular neuromuscular electrical stimulation (NMES) for shoulder subluxation and pain. The patient developed shoulder subluxation and pain within 2 mo of his stroke. After discharge from acute inpatient rehabilitation, he developed shoulder and hand pain, which was treated with subacromial bursa steroid injection and ibuprofen with eventual resolution. The patient remained clinically stable until approximately 15 mo after his stroke when he developed severe shoulder pain associated with shoulder abduction, external rotation, and downward traction. The patient could not tolerate transcutaneous NMES because of the pain of stimulation. At approximately 17 mo post-stroke, the patient’s posterior deltoid, middle deltoid, and supraspinatus muscles were percutaneously implanted with intramuscular electrodes. After 6 wk of percutaneous, intramuscular NMES treatment, marked improvements in shoulder subluxation and pain, and modest improvements in activities of daily living and motor function were noted. One year after the onset of treatment, the patient remained pain free, but subluxation had recurred. However, the patient was able to volitionally reduce the subluxation by abducting his shoulder. The patient remained pain free for up to 40 mo after the initiation of percutaneous, intramuscular NMES treatment. This case report demonstrates the feasibility of using percutaneous, intramuscular NMES for treating shoulder subluxation and pain in hemiplegia.

A neuroprosthesis for high tetraplegia

Abstract Background: This case report describes a neuroprosthesis that restored shoulder and elbow function in a 23-year-old man with chronic C3 complete tetraplegia. Before implementation of the neuroprosthesis, electrodiagnostic testing revealed denervation from CS to T1, with the greatest degree of denervation in the C8 and T1 myotomes. Thirteen percutaneous intramuscular electrodes were implanted into muscles acting on the shoulder and elbow of one upper limb. Before functional testing, the subject underwent a conditioning regimen to maximize the strength and endurance of the implanted muscles. Results: After completion of the 8-week exercise regimen, stimulated active range of motion against gravity included 60° of shoulder abduction, 45° of shoulder flexion, 10° of shoulder external rotation with the shoulder passively abducted to 90°, and 110° of elbow flexion. Stimulated elbow extension lacked 20° of full extension with gravity eliminated. After system setup, the subject was able to pick up mashed potatoes on a plate with a utensil and bring them to his mouth using the neuroprosthesis and a balanced forearm orthosis. A switch mounted on the headrest of the subjects wheelchair and a position sensor mounted on the co tralateral shoulder allowed the subject to control movement of his upper limb.

Electrical Stimulation for Treating Chronic Poststroke Shoulder Pain Using a Fully Implanted Microstimulator with Internal Battery

Yu DT, Friedman AS, Rosenfeld EL: Electrical stimulation for treating chronic poststroke shoulder pain using a fully implanted microstimulator with internal battery. This case report describes the first stroke survivor with chronic poststroke shoulder pain treated with electrical stimulation delivered via a fully implanted microstimulator containing a rechargeable internal battery. In light of existing efficacy data for similar types of treatment, the investigational system described in this report was developed to address the limitations of previously evaluated electrical stimulation devices. A 58-yr-old male stroke survivor with chronic hemiparesis and chronic shoulder pain received up to 6 hrs of stimulation daily over 12 wks. The microstimulator was implanted percutaneously near the axillary nerve at the quadrilateral space, under local anesthesia during an outpatient procedure. The implantation procedure was well tolerated. There were no adverse events related to the implantation procedure or treatment (implanted peripheral nerve stimulation). Outcomes were obtained before treatment, after 12 wks of treatment, and at 3-mo follow-up. Question no. 12 of the Brief Pain Inventory was used as the primary outcome measure to evaluate response to treatment. Shoulder pain decreased from 8/10 before treatment to 4/10 after treatment and decreased further to 3/10 at 3-mo follow-up. Passive range of motion and motor function also improved after treatment. Sensation, shoulder subluxation, activities, and quality-of-life did not change. The feasibility, safety, and efficacy of implanted peripheral nerve stimulation to treat poststroke shoulder pain should be evaluated further in clinical trials already underway.

Feasibility of restoring shoulder and elbow function in high tetraplegia by functional neuromuscular stimulation

Individuals with high tetraplegia (functional levels of C1-C4) resulting from spinal cord injury typically retain voluntary control only over shoulder shrug and head-neck motions, and are thus highly disabled. Restoration of even rudimentary movements would significantly increase the independence and quality of living for these individuals. We have therefore begun an effort to use functional neuromuscular stimulation (FNS) and/or reconstructive surgeries in these individuals to restore shoulder and elbow function. One individual with complete C3 tetraplegia has had percutaneous stimulating electrodes implanted into the biceps, triceps, anterior deltoid, posterior deltoid, pectoralis major, latissimus dorsi, and infraspinatus muscles. The shoulder forces and moments produced by stimulated contractions of individual muscles and by various combinations of muscles varied with arm position as expected. FNS produced a maximum shoulder flexion moment of 12.9 Nm, a maximum adduction moment of 5.9 Nm, and a maximum abduction moment of 7.5 Nm. Although voluntary actions produced very little shoulder abduction moment when used alone, stimulated contractions of the deltoid and infraspinatus muscles used together with voluntary shoulder girdle motions more than doubled the maximum moment produced by FNS alone.

Thigh Hematoma in the Active and Aging Person with Spinal Cord Injury

AbstractAn active lifestyle in the aging person with spinal cord injury (SCI) increases the potential for injuries to the musculoskeletal system. We report three unusual cases of thigh hematoma with no apparent history of trauma in aging patients with long-standing SCI. These patients were all employed and had active lifestyles. They ranged in age from 43 to 60 years, with lesions from T8 to T11 and had been paraplegic for 12-30 years. They presented with thigh swelling without any obvious cause. Diagnostic work-up did not reveal etiology. However, a functional history, re-creation of their activities and seating assessment identified the most likely causes of the thigh hematomas. Treatment of thigh hematoma is discussed. Physicians treating patients with long-standing SCI should pay special attention to changes in function and lifestyle and their potential effects on the musculoskeletal system. (J Spinal Cord Med 1997; 20:70-73)