The use of electrical stimulation in the treatment of adult traumatic brachial plexus injuries

Purpose

Traditionally the Electrical Stimulation (ES) of muscles was a frequently used adjunct for rehabilitation following nerve injury. More recently its use has been in decline. An international collaborative group of therapists with a special interest in Traumatic Brachial Plexus Injuries (TBPI) was formed in 2017. One of the objectives of the group is to assess and improve the evidence base surrounding the rehabilitation of TBPI. Disparity within the group with regards to the use of ES highlighted the need to explore current practice and the reasons for variability in use.

Approach

An online 'Google forms' survey was developed to gain insight into the use of ES. The form was disseminated via email to "specialist clinicians" in four countries (UK, Sweden, USA and Australia). Participants were identified by members of the collaborative group and were either associates or colleagues.

Outcomes

17 therapists (12 physiotherapists, 5 occupational therapists) consented to participate and completed the online survey. 16/17 were the equivalent of a Band 7 or above and reported at least 3 years specialisation in TBPI (mode 10 years).

Frequency of use ranged from never (5/17), rarely (7/17) to sometimes (5/17). Several reasons were given for non-use (n=5): “Not trained” “Haven't had access to the right equipment” “Understand that there is conflicting evidence regarding when and how” There was consensus with regards to indications for use. Most clinicians reported utilising ES during the early stages of renervation: Medical Research Council (MRC) Grade 1 (10/12) and Grade 2 (11/12). 12/12 reported that they would stimulate the muscle belly with 1 participant reporting that they would be more precise and stimulate over the motor unit. 10/12 reported that they would stimulate the agonist muscle alone. 11/12 reported integration into a home exercise programme (HEP), 10/12 with functional activities and only 1 participant reported that they would use ES in isolation. 7/12 reported that they would use an FES machine and 5/12 a TENS on a stimulation setting. However, there was large variation and inconsistencies with regards to machine settings, duration and frequency of use.

Implications

ES does appear to be a treatment modality that clinicians are using - but not often and with great variability. The reported reasons for non-use include lack of training and perceived limitations within the surrounding literature.

There was agreement within the results with regards to stage of recovery, electrode placement and the incorporation into a HEP and functional activities. Future work may wish to focus on a systematic review of the use of ES in a TBPI cohort in order to analyse the quality of the available evidence and identify treatment parameters.

This study suggests that some specialist therapists consider ES to be a useful adjunct to rehabilitation following TBPI. However, it is not commonly used in practice. The main limitations to use were reported to be a poor quality evidence base and lack of knowledge and training. This has been recognised by the international collaborative group of therapists specialising in TBPI and further work will be directed to address these barriers.

Top three learning points

  1. Wording of surveys/questionnaires requires great thought
  2. Training in electrotherapy differs around the world
  3. Identifying the barriers to treatment is important

Fund acknowledgements

This work was not funded.

Additional notes

This work was presented at Physiotherapy UK 2018.