Comparing stimulation-induced pain during percutaneous (intramuscular) and transcutaneous neuromuscular electric stimulation for treating shoulder subluxation in hemiplegia

OBJECTIVE

To determine whether percutaneous (intramuscular) neuromuscular electric stimulation (perc-NMES) is less painful than transcutaneous neuromuscular electric stimulation (trans-NMES) for treating shoulder subluxation in hemiplegia.

DESIGN

Double-blind, crossover trial.

SETTING

University-affiliated tertiary care hospital.

PARTICIPANTS

A convenience sample of 10 hemiplegic subjects with at least 1 fingerbreadth of glenohumeral subluxation.

INTERVENTIONS

All subjects received 3 randomly ordered pairs of perc-NMES and trans-NMES to the supraspinatus and posterior deltoid muscles of the subluxated shoulder. Both types of stimulation were optimized to provide full joint reduction with minimal discomfort.

MAIN OUTCOME MEASURES

Pain was assessed after each stimulation with a 10-cm visual analog scale (VAS) and the McGill Pain Questionnaire, using the Pain Rating Index (PRI) scoring method. Subjects were asked which type of stimulation they would prefer for 6 weeks of treatment. Wilcoxon's signed-rank test was used to compare median differences in VAS and PRI between perc-NMES and trans-NMES.

RESULTS

Median VAS scores for perc-NMES and trans-NMES were 1 and 5.7, respectively (p = .007). Median PRI scores for perc-NMES and trans-NMES were 7 and 19.5, respectively (p = .018). Nine of the 10 subjects preferred perc-NMES to trans-NMES for treatment.

CONCLUSION

Data suggest that perc-NMES is less painful than trans-NMES in the treatment of shoulder subluxation in hemiplegia.

A comparison between control methods for implanted FES hand-grasp systems

Implanted neuroprostheses employing functional electrical stimulation (FES) provide grasp and release to individuals with tetraplegia. This paper describes and compares three methods of controlling the stimulated hand movement: shoulder position, wrist position and myoelectric activity from the wrist extensors. Three experienced neuroprosthesis users were evaluated with each of the control methods by performing a grasp release test (GRT). A significant improvement was found between each functional electrical stimulation (FES) method and tenodesis without FES. No significant difference in overall performance was found between the three FES methods of control. Each method of control demonstrated advantages and disadvantages which depend upon characteristics of the individual patient. Factors which must be considered are injury level, voluntary wrist strength, proximal upper limb strength, the level of cognition of the patient, hand-grasp characteristics, cosmeses, importance of using both arms, and personal preference. Due to the unique characteristics of each controller type, it is advantageous to have each type available for the FES patients to adapt the system to the needs and desires of the individual patient.

An implanted upper-extremity neuroprosthesis. Follow-up of five patients

An implanted neuroprosthesis supplying functional neuromuscular stimulation was used to provide grasp and release to tetraplegic individuals. This article describes the results, at a minimum of three years, for the first five patients to have operative implantation of an eight-channel stimulator-receiver. All of the patients had a clinically complete spinal cord injury with motor function remaining at the level of the fifth or sixth cervical nerve root. In addition to implantation of the stimulator system, each patient had augmentative operations on the hand to improve function. The procedures included tendon transfers, side-to-side tendon anastomoses, arthrodesis of the interphalangeal joint of the thumb, and rotational osteotomy of the radius. The neuroprosthesis provides two grasp patterns controlled by voluntary motion of the shoulder or wrist. Functional evaluations included measurement of pinch force, a grasp-release test, evaluation of the level of functional independence, and usage surveys. Pinch force ranged from eight to twenty-five newtons. All five patients demonstrated functional grasp patterns, had increased independence, and were able to use the neuroprosthesis at home on a regular basis. The implanted stimulator has proved to be safe and reliable, with seven years as the longest time in situ at the time of writing.

Plasma levels, half-life values, and correlation with physiologic assays for growth and immunity

Plasma prednisolone levels have been measured hourly in children receiving a single dose of oral prednisone. Peak prednisolone levels occurred one to two hours after ingestion; half-life studies gave a mean value of 132 minutes in most children. Some children had marked variability in absorption and metabolism of prednisone. Somatomedin activity and cell-mediated immunity were inhibited by plasma prednisolone values which were achieved by single doses of prednisone of 0.5 mg/kg or higher. Monitoring prednisolone levels may be of value in identifying those children who accumulate excessively high levels on moderate dosage regimens.