|The adjunct effects of electroacupuncture on hemiplegic shoulder
|Hong Kong Polytechnic University -- Dissertations.
Shoulder pain -- Treatment.
|Department of Rehabilitation Sciences
|xii, 93 leaves : ill. ; 30 cm.
|Introduction: Shoulder pain is one of the most common complications observed after stroke (Zorowitz et al, 2005; Lindgren et al, 2007). Gleno-humeral subluxation is one of the causes of the shoulder pain and there was a correlation between early subluxation and shoulder pain (Chae et al, 2001). Good proximal shoulder function is an essential prerequisite for regaining distal hand function but the presence of shoulder pain would deter the recovery of active control over the shoulder and the performance of activities of daily living (Lo et al, 2003; Zorowitz et al, 2005). Therefore, it is essential to have a good assessment tool to document the extent of shoulder subluxation, which can be used as a treatment outcome to evaluate the effectiveness of different clinical interventions for managing the hemiplegic shoulder pain. Ultrasonography is a noninvasive and radiation-free imaging technique that allows real-time dynamic measurement. Previous studies provided evidence that ultrasonography can be used to make diagnosis for a complete rotator cuff tear, and the ultrasonography measure of the acromio-humeral distance (AHD) is both reliable and sensitive to detect the individual variation of the AHD in healthy subjects (Desmeules et al, 2004; Fremont et al, 2000). It may be a good clinical assessment tool for the measurement of hemiplegic shoulder subluxation. As acupuncture has shown to be an effective treatment for various types of shoulder pain in musculoskeletal conditions, it may also be effective in managing shoulder pain among stroke victims, thus promoting motor return and reducing the shoulder subluxation for stroke victims (Green et al, 2005; Guerra de Hoyos et al, 2004; Sun et al, 2001; Wang et al, 1990). Therefore, this thesis consists of two inter-related studies: Study I - Ultrasonographic Measurements of Shoulder Subluxation in Hemiplegic Shoulder Objective: In view of the advantages of ultrasonography and its success in measuring the AHD, the present study aimed to quantify the extent of shoulder subluxation in patients with hemiplegic subluxation in terms of the AHD. We also tried to correlate the AHD with the anthropometric measurement as done by anthropometer. Design: Correlation study Methods: Twenty patients with stroke were recruited. The inclusion criteria were patients suffering from the first stroke within 4 weeks, who have upper limb muscle strength lower than grade 3 based on the manual muscle testing. Exclusion criteria were patients without adequate communication ability to cope with the outcome measures or having contraindication for ultrasonographic measurements. The acromio-humeral distances with the affected shoulder were measured in a dependent and then an impacted position ultrasonographically. The difference between the measurements made in the two positions was defined as the extent of shoulder subluxation. The distance between the acromial process and the lateral epicondyle of the elbow for the affected shoulder in dependent and impacted position by an anthropometer were measured. The above measuring procedures were repeated for the unaffected shoulder also. Result: The difference between the impacted and dependent anthropometric measurement of affected shoulder was positively and highly correlated with the difference between the impacted and dependent AHD measured by ultrasound scanner (r=0.719,p<0.05). For the unaffected shoulder, the difference between the impacted and dependent anthropometric measurement was positively and moderately correlated with the difference between the impacted and dependent AHD measured by ultrasound scanner (r=0.499,p<0.05). Conclusion: The ultrasonograhic measurement of the AHD is highly correlated with the anthropometry measurement of shoulder subluxation. It could potentially be a valid clinical assessment tool for measuring the extent of shoulder subluxation for hemiplegic patients. Study II - The Adjunct Effects of Electroacupuncture on Hemiplegic Shoulder Objective: The present study aimed to examine whether the addition of a 3-week daily electroacupuncture to conventional therapy would enhance treatment effects for hemiplegic's shoulder in terms of reducing pain level and extent of subluxation, and promoting the upper limb motor function. Study Design: A single-blinded, randomized controlled study. Methodology: The inclusion criteria were patients suffering from the first stroke within 4 weeks, who have upper limb muscle strength lower than grade 3 based on the Manual Muscle Test. Exclusion criteria were patients without adequate communication ability to cope with the outcome measures or having contraindications for receiving electroacupuncture. Subjects were randomly allocated to receive either (i.) conventional therapy with electroacupuncture (EA group) or (ii.) conventional therapy alone (control group). Both groups received the respective treatments 5 times a week for 3 weeks. The EA group received additional EA to 6 acupuncture points (G21, SJ 14, LI14, LI 15, EX point Zhongping, GB34) for 30 minutes a day. Evaluation was made at the baseline, end of intervention (3-week) and at the 3-week follow-up by a therapist who was blinded to the group allocation. The outcome measures included Visual Analogue Scale (VAS) for measuring the intensity of pain, pain-free passive range of shoulder external rotation (PER), Fugl-Meyer Upper Extremity Test for measuring upper limb motor function, and anthropometry and ultrasonography for measuring the extent of shoulder subluxation. Data was analyzed by using two way repeated measures analysis of variance. The level of significance was set at 0.05. Results: Sixty patients completed the study. The baseline characteristics and outcome scores were comparable in the two groups. As compared to the baseline, the control group demonstrated a significant increase in VAS over time with a 134.8% increase by the 3-week and 176.2% by the follow-up (all p<0.05). As compared to the baseline, a significant decrease in PER over time was found in the control group with a 29.4% decrease at 3-week, and a 35.4% decrease at the follow-up (all p<0.05). In contrast, no significant change in VAS and PER was found in the EA group over time. Significant differences were found in VAS between two groups at 3-week (p=0.012) and follow-up (p=0.002). At the 3-week and follow-up session, the VAS of the conventional group was significantly higher than did the EA group. The VASs of the conventional group were 135.7% and 160% higher than the EA group at the 3-week and follow-up respectively. Significant differences in PER between two groups were found at 3-week (p=0.001) and follow-up (p<0.001). At 3-week and the follow-up, the PER of the EA group was significantly higher than conventional group. The PERs of the EA group were 36.0% and 48.1% higher than the conventional group at 3-week and follow-up respectively. A significant improvement in Fugl-Meyer (FM) was seen within each group over time. As compared to the baseline, the improvement in the EA group at 3-week (133.9% as compared to the baseline) and follow-up (151.4% as compared to the baseline) were significantly greater than did the control group at 3-week (22.1% as compared to the baseline) and follow-up (32.2% as compared to the baseline) (all p<0.05). Significant differences in FM between two groups were found at 3-week (p=0.001) and follow-up (p<0.001). At 3-week and follow-up, the FM of the EA group was significantly higher than conventional group. The FMs of the EA group were 147.6% and 144.7% higher than did the conventional group at 3-week and the follow-up session respectively. There was a significant increase in shoulder subluxation as measured by anthropometry in the control group over time (p<0.05) while there was no significant change in the EA group (p>0.05). However, there was no significant change of shoulder subluxation as measured by ultrasonography in both groups. Conclusion: The addition of 3-week adjunct electroacupuncture to conventional therapy can retard shoulder pain for patients with hemiplegic's shoulder, and promote greater motor return of the hemiplegic upper limbs than did the conventional therapy alone. The effects could last for at least up to the 6-week follow-up.
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