Functional Electrical Stimulation

Functional Electrical Stimulation (FES) Koyuncu, E., Nakipoglu-Yuzer, G. F., Dogan, A. & Ozgirgin, N. (2010). The effectiveness of functional electrical stimulation for the treatment of shoulder subluxation and shoulder pain in hemiplegic patients: A randomized controlled trial. Disability and Rehabilitation, 32(7): 560–566.

The study by Koyuncu et al (2010) examined how effective "functional electrical stimulation" (FES) is in addressing pain of the shoulder and subluxation. This study was conducted among patients suffering from hemiplegia. The authors of this study recognized that shoulder subluxation accompanied with pain is usually evident among stroke patients and this hinders rehabilitation efforts. As such, Koyuncu et al (2010) sought to investigate whether stimulating muscles of the upper extremity electrically (FES) could lead to benefits among patients with shoulder subluxation and pain. This paper examines the methods, data analysis, results, discussion and conclusions reached in the study conducted by Koyuncu and colleagues. It was identified that FES (used in combination with conventional interventions) is an effective intervention in relieving shoulder pain and subluxation among hemiplegic patients.

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Koyuncu et al (2010) conducted an experimental study with a sample of 50 participants. In this randomized controlled trial, the sample was selected from among 530 hemiplegic patients. The selected sample had to be positive for the study variables i.e. shoulder pain and shoulder subluxation. The random assignment of the sample into either control or treatment group was helpful in reducing sampling bias and ensuring that every respondent was given an opportunity to participate in the study. Exclusion from the study was based on several things, including presence of shoulder subluxation and pain and whether this pain and subluxation was related to stroke among other exclusion measures. The ethicality of this study was met in that the researchers sought written and informed consent from participants in addition to approval by the "Ankara Physical Medicine and Rehabilitation Education and Research Hospital Training Planning Committee" (Koyuncu et al, 2010, p.

561).

It was appropriate for Koyuncu and colleagues to have inclusion/exclusion criteria as this helps in obtaining a sample that has the information that is best fitting for the study.

Since this study was quantitative, the authors positioned themselves to obtain a lot of information using a small sample. This also reduced the cost of the study without compromising the quality of the study. This is an advantage with quantitative studies.

At the beginning of the study, participants were evaluated on their VAS while the shoulder was at rest, in "passive range of motion (PROM), and AROM." This tested for shoulder flexion and abduction movements. This was done to assess extent of shoulder pain prior to, and after the study. To determine shoulder subluxation, the researchers performed Xrays on the anteroposterior position before and after the rehabilitation. The X-rays were performed 24 hours post FES on both shoulders for each participant. In addition to ensuring patient safety due to X-ray, Koyuncu et al (2010) also effectively avoided effects of confounding factors by taking the X-rays while patients sat straight and arms were not

supported. Uniformity and standardization of data was upheld by having one investigator conduct all measurements. To help in determining any differences in effects of intervention on the study groups, the authors performed FES to the study group in addition to the conventional rehabilitation measures applied to all participants. At a frequency of 36 MHZ, FES was conducted for 20 sessions throughout the study with each session lasting for one hour, five times a day.

Using SPSS, the authors were able to analyse data for normality among other important statistical measures. Descriptive statistics are particularly useful in portraying the characteristics of the sample. In this case, Koyuncu et al (2010) used descriptive statistics to determine demographic characteristics such as mean age of participants among other variables. These formed a good basis for comparison with previous studies on the same subject while at the same time comparing subjects in the two study groups in this study.

Inferential statistics such as Student's t-test, Mann-Whitney U test and Wilcoxon Signed rank came in handy in drawing inferences on existence of statistically significant differences between the two study groups. Chi-square test was useful in making comparison of test variables between the groups. Statistical significance was taken at a p-value of <.05.

The decision of the authors to use non-parametric tests such as Mann-Whitney U test is an indication that the data was not normally distributed. It was therefore very commendable for the authors to choose the non-parametric tests.

The results of the study showed disproportionality in composition of males versus females. Females were significantly more than males in either group. The researchers however were able to cite that even in previous studies (and in general) female hemiplegic patients are usually more than male patients. In most patients, the cause of stroke was indicated as thromboemboli with only a few cases of stroke being related to haemorrhage.

The demographics of the participants were shown to be of no statistically significant

difference. However, statistically significant differences were identified in shoulder subluxation (prior and after rehabilitation) for the study group. PROM VAS values were statistically significant for control group. All other measurement variables were found to have no statistically significant differences before and after rehabilitation. It was clear that FES led to a greater decrease in subluxation levels in the study group as compared to the control group.

It is pertinent to point out that the authors concluded that their findings generally agreed with the findings of other authors on the same topic. Such correlations were particularly found when examining effectiveness of FES in relieve of shoulder pain. There was also agreement with other studies in regard to mean age of patients and composition of males versus female patients. As earlier mentioned, women were more likely to have hemiplegia than men while the mean age for hemiplegic patients was found to range between 61 and 63 in most studies.

This article was relevant to my current study since it focuses on use and effectiveness of electric stimulation of an upper extremity. In a clinical setting, physicians can harness the findings of this study to effectively address shoulder subluxation and pain in stroke patients.

In addition, the findings that AROM VAS and PROM VAS do not differ in effectiveness among patients receiving FES and conventional treatment versus those receiving conventional treatment only would be useful in deciding the most appropriate rehabilitation measure to take. It is obviously clear that augmenting conventional treatment with FES would achieve better results. The use of FES alone is however not investigated in this study, thus physicians should still consider the combined therapy until such a time when effectiveness of FES alone is determined. This therefore creates room for further research.

Considering that this study was not cultural inclusive, it may be inaccurate to generalize the findings. While the authors were able to demonstrate the effectiveness of FES

in treatment of shoulder subluxation and shoulder pain, they were not able to substantiate, candidly, the sole contribution of FES given that other conventional treatments were applied.

In other words, the effect size of FES and that of conventional treatments was not differentiated. It would therefore be appropriate to conduct studies which quantify the effect size of FES. This would help in making conclusions on whether to use more of FES and less of conventional treatments or otherwise in rehabilitation of hemiplegia with shoulder subluxation and pain. Regardless of these few deficiencies, it is no doubt that the study by Koyancu and colleagues gives medical practitioners an extra bullet in the treatment of shoulder subluxation and shoulder pain; this bullet is FES.

Reference Koyuncu, E., Nakipoglu-Yuzer, G. F., Dogan, A. & Ozgirgin, N. (2010). The effectiveness of functional electrical stimulation for the treatment of shoulder subluxation and shoulder pain in hemiplegic patients: A randomized controlled trial. Disability and Rehabilitation, 32(7): 560–566.