Glenohumeral subluxation (GHS) is common in patients with stroke and has an effect on the recovery of upper limb motor function [
GHS can be assessed by measuring the distance between the acromion and the humerus. Kumar et al. have confirmed that MSUS measurement of acromion-greater tuberosity (AGT) distance is reliable and effective in assessing GHS in hemiplegic patients [
Among reasons for GHS, the denervation of shoulder muscles caused by brain injury is the main cause and, under the action of gravity, the humeral head downward out of the glenoid fossa [
Functional magnetic stimulation (FMS) has been used to stimulate the muscles and peripheral nerves to promote function recovery. A lot of researches have confirmed the effectiveness of FMS in the aspects of gastric emptying, neurogenic bowel, respiratory muscle conditioning, dysphagia, urinary incontinence, and so on [
The purpose of our study was to, using MSUS, objectively quantify the effect of FMS treatment on GHS in hemiplegic patients with acute stroke. Compared with electrical stimulation, maybe FMS can achieve the same or even better therapeutic effects with lesser side effects.
Patients who were inpatient or outpatient at the Physical Medicine & Rehabilitation Department of the First Affiliated Hospital of Soochow University were screened from August 2016 to May 2017. The inclusion criteria were as follows: (1) stroke onset time of less than one month, (2) less than or equal to grade 3 of the upper limb muscle strength in hemiplegic side, (3) stable vital signs, (4) without aphasia or cognitive dysfunction, and (5) able to sit upright independently (or with one person’s assistance). And exclusion criteria were as follows: (1) history of shoulder dysfunction, (2) combined with myogenic diseases or the peripheral nervous system disease, (3) combined with severe heart, liver, or kidney dysfunction, (4) pacemaker or metal implantation, and (5) combined with severe coagulation dysfunction.
The finger breadth palpation methods were used for GHS diagnosis; that is, AHD is 1/2 fingerbreadth or more. The degree of GHS is defined as follows: 0 degrees = no subluxation, 1 degree = 1/2 fingerbreadth gap, 2 degrees = 1 fingerbreadth gap, 3 degrees = 1 1/2 fingerbreadth gap, 4 degrees = 2 fingerbreadth gap, and 5 degree = 2 1/2 fingerbreadth gap [
The study is a prospective case control study. The recruited patients were assigned to control group and FMS group. Basic information including age, gender, duration of stroke, affected side, and type of stroke were collected from patients and their guardians. The informed consent was signed by patients themselves, and to those who were unable to sign, their guardians were authorized to sign. The study was approved by the Ethics Committee of the First Affiliated Hospital of Soochow University. Screening of eligible patients and collection of basic information were done by one person in the research team.
Both groups received conventional rehabilitation including active and passive motion, weight bearing exercise, grasp, hold and release activities, and ADL activities, 45 minutes a day, consecutive 5 days a week, total for 4 weeks. The conventional rehabilitation of all patients was done by one therapist.
On the basis of conventional rehabilitation, control group received stimulation by electrode stimulation device (BA2008-III, Benao, China). Four electrodes were attached to the places of the supraspinatus and deltoid muscles of the hemiplegic side. And pulse of 200 and micro/s, duty cycle of 1 : 2, wave rise/wave drop of 2 s, and current of 50 mA were applied. The FMS group used magnetic stimulator (MagPro R30, Medtronic A/S, Denmark) connected with a 75 mm figure-of-eight water-cooled coil (MCF-B65) to stimulate the supraspinatus and deltoid muscles of the hemiplegic side. Frequency of 5 Hz with the stimulus intensity at 100% of the resting motion threshold (MT) was applied. Each site of each patient was stimulated for 20 minutes a day in both groups. The treatments were consecutively conducted 5 days a week for a total of 4 weeks. During the treatments, patients were seated upright independently (or with one person’s assistance) in a chair with forearms placing on their laps. Two special therapists were, respectively, trained in one of the treatments, to complete the patients’ treatment programs. In FMS group no patient withdrawn during the treatments, but in control group, there are 4 patients who failed to persist in electrical stimulation due to pain.
A portable diagnostic ultrasound system (M-Turbo, ICTx, SonoSite, America) connected with a 6–13 MHz linear array transducer was used to assess the changes of GHS, AGT, ALT, AHD, SST, and DMT, respectively, in the hemiplegic side and healthy side of shoulder before and after the treatments. At the same time, we used Fugl-Meyer Assessment (FMA) Scale to assess upper limb function of the hemiplegic side in acute poststroke patients.
In the process of measuring these parameters, each patient was placed in a standardized position [
Anatomical structures: AC (acromion); LHTB (long head tendon of biceps); the position and orientation of transducer; and the ultrasound image: GT (greater tuberosity) and AGT (acromion-greater tuberosity).
Anatomical structures; the position and orientation of transducer; and the ultrasound image: LT (lesser tuberosity) and ALT (acromion-lesser tuberosity).
Anatomical structures; the position and orientation of transducer; and the ultrasound image: HH (humerus head) and AHD (acromiohumeral distance).
Anatomical structures: mesoscapula; the position and orientation of transducer; and the ultrasound image: SST (supraspinatus thickness).
Anatomical structures: DT (deltoid tuberosity); the position and orientation of transducer; and the ultrasound image: DMT (deltoid muscle thickness).
Using SPSS19.0 software to do data statistics and analysis, the data were expressed as mean value ± standard deviation.
A total of 34 patients were evaluated and treated, and 4 patients who failed to persist in electrical stimulation due to pain were excluded. Finally, 30 patients (23 men, 7 women) with a mean age of 65 years (range from 38 to 84 years) were eligible for the study. The mean duration after onset was 15 days (range from 7 to 21 days). A summary of the demographic characteristics of the patients is shown in Table
Patients’ demographics.
Type of variable |
Control group | FMS group |
|
---|---|---|---|
Age (years) | 67.20 ± 10.72 | 63.67 ± 15.09 | 0.146 |
Gender | 0.418 | ||
Male | 11.00 | 12.00 | |
Female | 4.00 | 3.00 | |
Duration of stroke (days) | 15.47 ± 2.72 | 13.87 ± 3.36 | 0.359 |
Affected side | 0.224 | ||
Left | 6.00 | 7.00 | |
Right | 9.00 | 8.00 | |
Type of stroke | 1.000 | ||
Hemorrhage | 5.00 | 6.00 | |
Ischemia | 10.00 | 9.00 | |
Degree of GHS | 0.603 | ||
2 degrees | 2.00 | 3.00 | |
3 degrees | 11.00 | 11.00 | |
4 degrees | 2.00 | 1.00 |
Before treatments, there were no differences statistical significance (
Comparison between posttreatment and pretreatment in control group.
Pretreatment | Posttreatment |
|
|
|
---|---|---|---|---|
Difference value of AGT | 15.05 ± 2.41 | 8.70 ± 1.43 | 8.766 | 0.000 |
Difference value of ALT | 12.15 ± 2.55 | 6.22 ± 1.17 | 8.170 | 0.000 |
Difference value of AHD | 3.11 ± 0.37 | 2.20 ± 0.15 | 8.762 | 0.000 |
Difference value of SST | 6.61 ± 0.63 | 3.37 ± 0.64 | 14.010 | 0.000 |
Difference value of DMT | 8.76 ± 0.39 | 5.00 ± 0.58 | 20.986 | 0.000 |
FMA score | 20.00 ± 2.17 | 25.40 ± 2.69 | 6.045 | 0.000 |
Comparison between posttreatment and pretreatment in FMS group.
Pretreatment | Posttreatment |
|
|
|
---|---|---|---|---|
Difference value of AGT | 13.75 ± 3.44 | 5.70 ± 1.15 | 8.595 | 0.000 |
Difference value of ALT | 12.30 ± 2.64 | 3.93 ± 1.03 | 11.435 | 0.000 |
Difference value of AHD | 2.78 ± 0.72 | 0.90 ± 0.49 | 8.375 | 0.000 |
Difference value of SST | 6.54 ± 0.73 | 2.44 ± 0.73 | 15.394 | 0.000 |
Difference value of DMT | 8.45 ± 0.36 | 4.13 ± 0.57 | 24.935 | 0.000 |
FMA score | 22.00 ± 2.54 | 33.47 ± 2.17 | 13.315 | 0.000 |
Comparison between FMS group and control group.
FES | FMS |
|
|
|
---|---|---|---|---|
Difference value of AGT | 6.35 ± 1.49 | 8.05 ± 2.66 | 2.161 | 0.039 |
Difference value of ALT | 5.93 ± 2.21 | 8.37 ± 1.78 | 3.332 | 0.002 |
Difference value of AHD | 0.91 ± 0.31 | 1.88 ± 0.29 | 8.768 | 0.000 |
Difference value of SST | 3.24 ± 0.44 | 4.09 ± 0.29 | 6.244 | 0.000 |
Difference value of DMT | 3.76 ± 0.60 | 4.32 ± 0.29 | 3.238 | 0.003 |
FMA score | 5.40 ± 1.80 | 11.47 ± 2.72 | 7.194 | 0.000 |
Comparison within control group and FMS group, respectively, and comparison between control group and FMS group. Comparison within groups:
We used the Simplified Fugl-Meyer Motor Function Assessment Scale to assess the hemiplegic upper limb function before and after the treatments, respectively. Before treatments, there was no differences statistical significance (
In our study, the results of MSUS preliminary proved in FMS group, the gap between the ipsilateral side and contralateral side of AGT, ALT, and AHD significantly decreased, and SST and DMT obviously increased. At the same time, FMA substantially improved in the hemiplegic upper limb. These results show that the short time FMS treatment (4 weeks) can obviously improve GHS of the hemiplegic patients with acute stroke and promote the functional recovery of the patients’ paralyzed upper limbs. The changes in several indicators by MSUS measurement, such as AGT, ALT, and AHD, as well as SST and DMT, are consistent with the function of paralyzed upper limb. These coincide with our previous assumptions.
Researches have shown that, in acute poststroke hemiplegic patients, paralysis muscles around the shoulder cannot resist the gravity of upper limb and gradually result in GHS [
Electrical stimulation and magnetic stimulation techniques have been widely used in the field of rehabilitation. Our study results are consistent with previous studies that FES is effective on reducing GHS and promoting the recovery of upper limb function in acute hemiplegic patients [
While repeat transcranial magnetic stimulation (rTMS) is a kind of brain stimulation techniques which has become promising for the recovery of limbs function in hemiplegic patients [
The FMS has been applied in some aspects of rehabilitation and achieved some curative effects [
Our previous studies have shown that MSUS measurement of AGT is reliable and valid in assessing GHS in patients with hemiplegia, which is in agreement with many other researchers [
Muscle thickness affects muscle function and further affects limb function [
In addition, previous studies have shown that the change of muscle thickness could be used as an indicator of muscle atrophy [
Recently, some researchers have studied the synergistic effects of different therapies on limb function recovery after stroke and found that they were more pronounced than single treatment [
Of course, our research also has many limitations. First, the sample size is not large enough. Second, the further follow-up is needed to assess the long-term effect. Third, whether FMS is effective in GHS in patients with chronic hemiplegia is not validated. These questions deserved further exploration and study.
The FMS is effective in the treatment of GHS in patients with early hemiplegia, and compared with the electrical stimulation, it is more effective. The mechanism, effectiveness in chronic hemiplegia, long-term efficacy, and so on of the new way, FMS, need further exploration. Meanwhile, the changes in several indicators by MSUS measurement, such as AGT, ALT, and AHD, as well as SST and DMT, are consistent with the function of paralyzed upper limb. These indicators may be used as an objective basis for monitoring the degree of GHS. Furthermore, the validity and reliability of ALT, SST, and DMT in assessing GHS and upper limb functional require further proof.
The authors declare that there are no conflicts of interest regarding the publication of this article.
This study was supported by Jiangsu Provincial Clinical Medicine Science and Technology Project (BL2012029) and National Natural Science Foundation of China (Grants nos. 81301059 and 81672244). The authors also would like to thank Jingfa Feng, M.D., Nan Su, M.D., Lei Huang, M.D., and Qiang Wang, M.D., for the support of this study.