Case Report

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: 223-227.]

Key words: A~m; Cerebrovascular Disorders; Electric Stimulation Therapy; Hemiplegia

Introduction of arm retraining in a rehabilitation centre reported

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
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,

Australian Journal of Physiotherapy 1999 Vol. 45 223

Case Report
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 3cm2
• no shoulder pain (RASO)3
minimal returning muscle activity (MAS Upper
Arm Function, 1)4
full range of shoulder movement
• cutaneous sensation intact
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
224
• 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 ofthe 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 stimulation-
induced muscle activitY. This had previously been
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)
Australian Journal of Physiotherapy 1999 Vol. 45

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 task-
related 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
2cm6;
• 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)
Australian Journal of Physiotherapy 1999 Vol. 45
Case Report
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
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 ofneglect, 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 oftheir
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
226
Victoria 3083. E-mail: merilyum@latrobe.edu.au(for
correspondence).
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