electrical stimulation of the upper limb · •upper limb passive all differ in aims but follow a...
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Electrical stimulation of the upper limb
Paul Taylor
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Three upper limb Pathways
• Shoulder subluxation
• Upper Limb Active Function
• Upper limb Passive
All differ in aims but follow a similar 6 month protocol and include a 1 month treatment withdrawal to assess if treatment continuation is indicated.
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Shoulder Subluxation
• Initial assessment
• Set up
• 2 week follow up
• 6 week follow up
• 10 week follow up
• 18 week follow up (withdraw ES)
• 22 week reassessment
Indication•Pain
Outcome measures•Pain VAS•ARMA•Subluxation distance•GAS
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Passive pathway
• Initial assessment
• Set up
• 2 week follow up
• Stretching/mobilisation & splinting
• 6 week follow up
• 10 week follow up
• 18 week follow up (withdraw ES)
• 22 week reassessment
Indications
• No active movement
• Pain
• Spasticity
• Difficulty in managing hygiene, dressing etc
Outcome measures
• Pain VAS
• ARMA
• GAS
ES a passive activity aiming to strengthen muscle, reduce spasticity, increase ROM and desensitise pain
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Active pathway
• Initial assessment• Set up• 2 week follow up• Stretching/mobilisation &
splinting• 6 week follow up• 10 week follow up• 18 week follow up
(withdraw ES)• 22 week reassessment
Indications• Some active movement• Pain• Spasticity• Difficulty in managing
hygiene, dressing etcOutcome measures• Pain VAS• ARMA• Box & Block, ARAT, Jebson
etc.• GAS
Important to encourage active participation with ES to practice functional movements or tasks
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ES Tips
• Use bigger electrodes on bigger muscles
• Strongest effect under the black electrode
• Blue Pals can be more comfortable
• Covidien blue electrodes are two stiff to follow contours of the skin
• Asking for too much is bad for adherence
• Always provide printed photos and place a copy in the notes
• If you can’t find the electrode position do movement on you self and palpate the muscle movement
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Shoulder subluxation- overlapping channel
• 2 channel stimulation –mode 8 (40Hz) or 9 (20Hz)
• Supraspinatus & posterior Deltoid alternating with anterior & middle Deltoid or Supraspinatus & middle Deltoid alternating with anterior & posterior Deltoid
• Active on posterior deltoid to encourage external rotation
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Microstim modes 8 (40Hz) or 9 (20Hz)• Humorous lifted into the glenohumeral socket by the first channel and
maintained in position by the second
• Start with 2 x 15 min and build up over 4-6 weeks to 2x 1h
• Some patients choose to use longer periods
• 40Hz may be more comfortable, 20Hz may give less fatigue
• Initial training at 40Hz will give smother contraction later with 40Hz
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Hand opening
IndicationsFinger thumb and wrist spasticityReduced ROMReduced strength or volitional movement
PlacementActive placed over common extensors / posterior interosseousnerve
Indifferent over motor-point of extensor pollicis longus, abductor pollicis longus and extensor indices
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Hand opening
Rule of Three Fingers
Indifferent 3 fingers from the wrist
Active 3 fingers above indifferent and offset half an electrode width to the ulna side
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Hand opening
Fine tuning
Swap the polarity to determine the relative proportion of thumb/index finger extension and wrist/finger extension.
Move active to determine the relitive amount of ulna and radial deviation and finger and wrist extension
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Ulnar nerve stimulation
IndicationsReduce flexor spasticityStrengthen Intrinsics & thumb adductionReshape “flat” hand
PlacementRemember, little, ring and part of middle are ulna nerve and index is median nerve so place indifferent over index (median nerve) side to achieve a balanced effect across the fingers
Alternate with long finger extensors (mode 6) for an effective reduction in stifness / spasticity of the hand.
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Median Nerve – Intrinsic muscles
IndicationTo strengthen intrinsics and thumb abductionReduce flexor spasticityReshape flat handEncourage a tripodGrip
PlacementPlace indifferent Ulna side (little finger) of lumbricalsto achieve a balanced movement of the fingers and active over the centre of the wrist
Alternate with Forearm Extensors (hand opening mode 6)
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Alternative position if more thumb abduction required or if median nerve stim
is uncomfortable
IndicationTo strengthen intrinsics and thumb abductionReduce flexor spasticityReshape flat handEncourage a tripodGrip
PlacementPlace indifferent Ulna side (little finger) of lumbricalsto achieve a balanced movement of the fingers and active over the thenareminence
Alternate with Forearm Extensors (hand opening mode 6)
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Rohomboids and lower Trapezius
Indications•Winged scapular•Shoulder girdle instability
Placement•Medial and lower boarder of the scapula•Choose active and indifferent by trial and error
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Shoulder flexion/abduction and reaching
Shoulder flexion/abduction Elbow extension
weak triceps, high biceps tone can be uncomfortable - watch overflow to radial nerve
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Reciprocal stimulation - alternating channels (mode 6)
Elbow extension Elbow flexion, forearm supination
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Combining elbow flexion with shoulder flexion or extension
Elbow & shoulder flexion Elbow flexion, shoulder extension
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General reaching
• One channel over anterior deltoid and triceps
• One channel over forearm extensors
• Mode 7 symmultaneous
Consider gravity assisted positions to start with