SHS EMG Biofeedback
SHS EMG Biofeedback
SHS EMG Biofeedback
REVIEWED BY
improving upper limb motor
Jacopo Lanzone,
Sant’Isidoro Hospital Ferb Onlus
Trescore Balneario, Italy
function and relieving pain in
Carmen Parra-Farinas,
University of Toronto, Canada patients with the post-stroke
shoulder-hand syndrome: A
*CORRESPONDENCE
LiHua Gu
kmglh169@163.com
SPECIALTY SECTION
This article was submitted to
Bayesian network meta-analysis
Neurorehabilitation,
a section of the journal
Frontiers in Neurology Sisi Feng1 , Mingzhi Tang1 , Gan Huang1 , JuMei Wang1 ,
RECEIVED 28 September 2022 Sijin He2 , Duo Liu2 and LiHua Gu2*
ACCEPTED 13 December 2022
PUBLISHED 10 January 2023 1
Yunnan University of Traditional Chinese Medicine, Kunming, China, 2 Department of Rehabilitation,
CITATION
Kunming Hospital of Traditional Chinese Medicine, The Third Affiliated Hospital of Yunnan University
Feng S, Tang M, Huang G, Wang J, of Chinese Medicine, Kunming, China
He S, Liu D and Gu L (2023) EMG
biofeedback combined with
rehabilitation training may be the best Background: Post-stroke shoulder-hand syndrome (SHS), although not a
physical therapy for improving upper
limb motor function and relieving pain life-threatening condition, may be the most distressing and disabling problem
in patients with the post-stroke for stroke survivors. Thus, it is essential to identify effective treatment
shoulder-hand syndrome: A Bayesian
strategies. Physical therapy is used as a first-line option for treating SHS;
network meta-analysis.
Front. Neurol. 13:1056156. however, it is unclear which treatment option is preferred, which creates
doi: 10.3389/fneur.2022.1056156 confusion in guiding clinical practice. Our study aims to guide clinical
COPYRIGHT treatment by identifying the most effective physical therapy interventions for
© 2023 Feng, Tang, Huang, Wang, He,
improving clinical symptoms in patients with post-stroke SHS using Bayesian
Liu and Gu. This is an open-access
article distributed under the terms of network meta-analysis.
the Creative Commons Attribution
License (CC BY). The use, distribution
Methods: We conducted a systematic and comprehensive search of data from
or reproduction in other forums is randomized controlled trials using physical therapy in patients with SHS from
permitted, provided the original database inception to 1 July 2022. Fugl-Meyer Upper Extremity Motor Function
author(s) and the copyright owner(s)
are credited and that the original Scale (FMA-UE) and pain visual analog score (VAS) were used as primary
publication in this journal is cited, in and secondary outcome indicators. R (version 4.1.3) and STATA (version 16.0)
accordance with accepted academic
practice. No use, distribution or
software were used to analyze the data.
reproduction is permitted which does Results: A total of 45 RCTs with 3,379 subjects were included, and the
not comply with these terms.
intervention efficacy of 7 physical factor therapies (PFT) combined with
rehabilitation training (RT) was explored. Compared with the control group,
all the PFT + RT included were of statistical benefit in improving limb motor
function and pain relief. Also, our study indicated that EMG biofeedback
combined with RT (BFT + RT) [the surface under the cumulative ranking curve
(SUCRA) = 96.8%] might be the best choice for patients with post-stroke SHS.
Conclusion: EMG biofeedback combined with rehabilitation training may be
the best physical therapy for improving upper limb motor function and relieving
KEYWORDS
FIGURE 1
Literature screening process.
Chen and Zheng (43) 27 27 T/C: 63.8 ± 8.4 / BFT + RT CHT + RT 4w FMA-UE
VAS
(Continued)
TABLE 1 (Continued)
C: 63 C: 18/12 VAS
C: 72.42 ± 9.68
Qiao and Ding (39) 51 51 T: 53.45 ± 5.48 T: 22/29 CHT + RT LT + RT 28d FMA-UE
VAS
C: 48 C: 19/12 VAS
(Continued)
TABLE 1 (Continued)
a relatively symmetrical distribution of studies on both sides [MD = 5.91 95%CrI (2.07, 9.76)]; CHT + RT [MD = 4.06
of the inverted funnel. However, some smaller studies are 95%CrI (1.19, 6.93)]; and PT + RT [MD = 3.30 95%CrI
distributed below and outside the inverted funnel, suggesting the (0.13, 6.48)] were all superior to LT + RT. Meanwhile, BFT
possible presence of publication bias (Supplementary Figure 1). + RT [MD = 4.23 95%CrI (0.37, 8.09)] also outperformed ET
An additional Egger’s test was used for secondary verification + RT.
of the presence of publication bias, which showed P = 0.933 We plotted SUCRA lines to rank each intervention
(>0.05), indicating that there is no publication bias in this study category (Figure 3 and Supplementary Figure 5) and compared
(Supplementary Table 2). them with other interventions. BFT+RT (SUCRA = 94.7%)
We constructed a visual network geometry showing all the had the highest probability of improving upper extremity
main evidence of the interventions. Each node represents one motor function in patients with post-stroke SHS, followed
intervention, and its size depends on the number of patients by two equally remarkable interventions CHT+RT (SUCRA
directly studied. As shown in Figure 2, the most common = 76.0%) and PT+RT (SUCRA = 65.6%), and the fourth-
intervention method was ET + RT with nine groups studied (n ranked UWT+RT (SUCRA = 62.3%). In contrast, MT+RT
= 313), followed by PT + RT (n = 259) involving seven groups, (SUCRA = 42.3%), ET+RT (SUCRA = 39.3%), and LT+RT
CHT + RT (n = 292) and UWT + RT (n = 174) involving six (SUCRA = 19.8%) had relatively low probabilities, while
groups, and LT + RT (n = 265) involving five groups. Two other the probability of RT (SUCRA = 0%) was the lowest.
interventions [BFT + MT (n = 135) and MT + RT (n = 132)] The existence of inconsistencies between direct and indirect
involved four groups. evidence was assessed by the “nodal split” method. The results
In terms of the outcome of FMA-UE, the efficacy of various (Supplementary Figure 6) showed that there are no significant
physical factor therapies (PFT) combined with rehabilitation inconsistencies in each branch of the entire network (P > 0.05)
training (RT) post-intervention is shown in Figure 3. BFT + [CHT + RT vs. RT (P = 0.566); LT + RT vs. RT (P = 0.123);
RT [MD = 10.21 95%CrI (6.85, 13.58)]; CHT + RT [MD = UWT + RT vs. RT (P = 0.496); ET + RT vs. RT (P = 0.498);
8.36 95%CrI (5.91, 10.82)]; PT + RT [MD = 7.60 95%CrI BFT + RT vs. RT (P = 0.321); LT + RT vs. CHT + RT (P
(5.41, 9.80)]; UWT + RT [MD = 7.41 95%CrI (4.86, 9.96)]; = 0.123); BFT + RT vs. CHT + RT (P = 0.325); and ET +
MT + RT [MD = 6.06 95%CrI (3.09, 9.02)]; ET + RT [MD RT vs. UWT + RT (P = 0.50)]. Thus, we obtained a valid
= 5.98 95%CrI (4.09, 7.88)]; and LT + RT [MD = 4.30 comparison of the above-mentioned different physical therapy
95%CrI (2.00, 6.60)] efficacy were all statistically significant interventions to improve the function of the upper limb of SHS
and significantly superior to the control group. BFT + RT after stroke.
FIGURE 2
The network evidence graph for FMA-UE. RT, rehabilitation training; ET, electrotherapy; LT, light therapy; UWT, ultrasonic wave therapy; CHT,
conduction heat therapy; PT, pressure therapy; MT, magnetic therapy; BFT, biofeedback therapy.
Secondary outcome: VAS [MD = −1.92 95%CrI (−2.53, −1.31)]; CHT + RT [MD =
The I2 values indicated that our preliminary meta- −1.57 95%CrI (−2.12, −1.03)]; ET + RT [MD = −1.33 95%CrI
analysis showed high heterogeneity in VAS scores across all (−1.80, −0.85)]; UWT + RT [MD = −1.28 95%CrI (−1.99,
included studies (I2 = 82.2%, P = 0.000). Comparison-adjusted −0.57)]; and MT + RT [MD = −1.94 95%CrI (−1.94, −0.40)].
funnel plot suggested that the occurrence of publication bias In addition, BFT + RT [MD = −1.49 95%CrI (−2.59, −0.40)];
depends on several scattered points that are asymmetrically PT + RT [MD = −1.31 95%CrI (−2.29, −0.33)]; and CHT +
distributed below and outside the inverted funnel plot RT [MD = −0.96 95%CrI (−1.73, −0.20)] were also significantly
(Supplementary Figure 7). In addition, Egger’s test confirmed superior than LT + RT.
this result (P = 0.011) (Supplementary Table 3). Plotting the SUCRA line to rank each intervention’s
The network diagram is shown in Figure 4, including seven efficacy in pain relief (Figure 5 and Supplementary Figure 8)
interventions and four control groups. ET + RT was the most showed that BFT + RT (SUCRA = 89.9%) obtained the
frequent intervention and investigated in 9 arms (n = 303), best probability compared to the other seven interventions.
followed by the most common intervention of CHT + RT (n However, PT + RT (SUCRA = 84.9%) and CHT + RT
= 352) and PT + RT (n = 244) involving 7 arms; UWT + RT (n (SUCRA = 65.8%) also got a remarkable ranking among
= 144) involving 5 arms; MT + RT (n = 132) involving 4 arms; them, followed by ET + RT (SUCRA = 50.1%); UWT
BFT + RT (n = 105) involving 3 arms; and LT + RT (n = 120) + RT (SUCRA = 48.3%); and MT + RT (SUCRA =
was the least involving only 2 arms. 41.9%). LT + RT (SUCRA = 18.3%) and RT (SUCRA =
The clinical efficacy of VAS pain relief results showed 0.9%) ranked last. The node-splitting model results showed
(Figure 5) that when compared with the control group, except (Supplementary Figure 9) no significant inconsistency between
for LT + RT, the other interventions showed better efficacy: the direct and indirect evidence (P > 0.05), so the current
BFT + RT [MD = −2.10 95%CrI (−3.01, −1.20)]; PT + RT evidence is reliable.
FIGURE 3
Relative effect sizes of FMA-UE efficacy after the intervention according to network meta-analysis. Treatments were ranked in order of their
likelihood of being the best treatment. The numbers in the blue boxes are SUCRA values, representing the rank of the treatments. Meaningful
pairwise comparisons are highlighted in green and bold. RT, rehabilitation training; ET, electrotherapy; LT, light therapy; UWT, ultrasonic wave
therapy; CHT, conduction heat therapy; PT, pressure therapy; MT, magnetic therapy; BFT, biofeedback therapy.
FIGURE 4
The network evidence graph for VAS. RT, rehabilitation training; ET, electrotherapy; LT, light therapy; UWT, ultrasonic wave therapy; CHT,
conduction heat therapy; PT, pressure therapy; MT, magnetic therapy; BFT, biofeedback therapy.
active rehabilitation training to achieve the goal of training and patients with SHS can improve patients’ ability to control
treatment (85). According to the results of the meta-analysis and regulate random movements significantly. Meanwhile,
of this study, we found that there are statistical differences it also stimulates their desire to train, which transforms
in the comparison of the efficacy of BFT + RT and electrical passive rehabilitation into active rehabilitation, and improves
stimulation therapy (ET) combined with RT [MD = 4.23 patients’ compliance with training, leading to improved
95%CrI (0.37, 8.09)] in improving limb motor function. The patient outcomes.
results also confirmed the advantages of EMGBF treatment. It In contrast, the potential mechanism of EMG biofeedback
overturns the traditional notion that autonomic nerves cannot in pain relief remains unclear. Related studies found (90) that
be controlled arbitrarily and allows patients to dynamically through the “stimulation-feedback” mode, EMGBF is capable
access electromyographic physiological information at the of converting subtle EMG signals into visual stimuli, thereby
site of information collection, enabling them to learn to motivating patients to engage in active exercises of the core
consciously regulate their psychophysiological activity to muscles of the affected shoulder to stabilize the shoulder
treat somatic disorders (86). It has been demonstrated (87) joint and alleviate pain. The problem is that when hemiplegic
that EMG-BF provides an additional benefit for the recovery shoulder pain is caused by the interaction of multiple etiologies,
of limb function in patients with stroke when combined a single therapy may not be able to achieve the desired
with conventional rehabilitation. Moreover, its efficacy is level of pain relief (91, 92). However, our study draws the
undoubtedly substantial. In addition to promoting the recovery opposite conclusion, which may be related to our combing EMG
of neurological deficits after stroke, it also helps patients biofeedback with rehabilitation training and thus improved
overcome pain-induced resistance to training and motivates efficacy; or it may be associated with the lack of direct evidence
them to participate actively in rehabilitation (88, 89). Related between interventions. Speculation on this contradictory view
studies (43) found that using surface EMG-BF to treat stroke still needs to be validated by more extensive RCTs of the
FIGURE 5
Relative effect sizes of VAS efficacy after the intervention according to network meta-analysis. Treatments were ranked in order of their
likelihood of being the best treatment. The numbers in the blue boxes are SUCRA values, representing the rank of the treatments. Meaningful
pairwise comparisons are highlighted in green and bold. RT, rehabilitation training; ET, electrotherapy; LT, light therapy; UWT, ultrasonic wave
therapy; CHT, conduction heat therapy; PT, pressure therapy; MT, magnetic therapy; BFT, biofeedback therapy.
combined treatment with myoelectric biofeedback on shoulder alleviate pain, and relax tendons have many advantages. It can
pain in the future. dilate the local blood vessels and open pores, which deepens the
Also noteworthy is that CHT + RT and PT + RT drug penetration and gives full play to its effect. Consequently, it
rank relatively high among all interventions and can be improves the time effect of pain symptom relief and facilitated
used adjunctively for post-stroke SHS. CHT mainly consists the metabolism of inflammation and edema. Additionally,
of paraffin wax therapy and moist heat compress therapy. it significantly increased blood flow to the affected limb’s
Wax therapy, as a particular conductive medium, uses this tissues, lowered muscle and ligament tension, and enhanced
principle of warming to conduct heat through the skin to the flexibility of joints and limb movements, thus improving
deep tissues, accelerating tissue repair, promoting cellular therapeutic results (95, 96). They have limitations, however,
metabolism, reducing the tension of tissue fibers, and increasing and should be used with caution in patients who have the
their elasticity. It thereby facilitates muscle strength recovery bleeding tendency in clinical, local sensory abnormality, or wax
and enhances joint mobility. At the same time, the warming allergy (86).
effect can reduce the excitability of the nerve, improve blood Pressure therapy (PT) mainly refers to interstitial pneumatic
circulation, and finally, reduce inflammatory edema, and therapy. With the use of an air pump, the multi-chambered
accelerate the removal of pain-causing mediators. Furthermore, balloon is inflated uniformly and decompressed in an orderly
when the wax is cooled, its fixed condition exerts a local manner, providing centripetal compression from distal to
oppressive impact on the body’s tissues, aiding in the eradication proximal segments of the limb and improving arterial perfusion.
of swelling and having a better effect on the relaxation of the It effectively improves arterial blood circulation in the affected
affected joint ligaments, muscles, and tendons (93). Clinical limb, thereby eliminating edema and improving peripheral
studies have demonstrated that functional training of the vascular function (66, 97). However, given that pneumatic
upper extremity soon following the wax therapy can help therapy inflation and deflation are neither based on blood
patients better participate in the training and complete their flow blockage and recovery pressure nor does it take into
rehabilitation activities better (46, 94). Wet heat compress account the influence of the patient’s upper limb circumference
therapy, also referred to as Chinese herbal medicine moist on the pneumatic therapy pressure, and that patients with
heat compress therapy, is often combined with Chinese herbal stroke frequently have sensory impairment of the affected limb,
medicine. Using the combined effects of herbal efficacy and judging the pneumatic therapy pressure based on the patient’s
physical thermal effect to select herbs that reduce inflammation, subjective sensation alone lacks scientific validity and may cause
adverse effects (98). Consequently, pneumatic therapy has been such as transcutaneous electrical nerve stimulation,
used in relatively few RCTs to treat this disease alone, mainly intermediate frequency electrotherapy, and hyperbaric
as adjunctive therapy after rehabilitation training to provide oxygen or confounding factors such as different frequencies and
muscle relaxation and pain relief. As previously stated, our different intervention durations. Second, the included studies
findings also found that PT + RT is more effective in relieving which were all from China lack ethnic diversity, which may
pain (SUCRA = 84.9%) than improving limb motor function result in the limited generalizability of the findings. Finally,
(SUCRA = 65.6%). significant differences in sample sizes between physical therapy
In addition, studies showed (99, 100) that ultrasonic wave interventions may also have contributed to imprecise analyses.
therapy (UWT) also has mechanical and thermal physical Compared with the overall sample size (n = 3379), the sample
effects. By directly acting on local subcutaneous tissue, the sizes of BFT + RT (n = 135) and MT + RT (n = 132) are
ultrasound emitted from outside the body is concentrated in relatively small.
the deep surface of the tissue and produces a high-energy
point, which causes the lesion tissue to absorb energy in
a short period of time and rapidly heat up, and produces
Conclusion
physical and chemical effects. Ultimately, it promotes local
Based on the findings of our NMA study, EMG biofeedback
blood circulation, accelerates the absorption of inflammatory
therapy combined with rehabilitation training (BFT + RT) is
factors, reduces the excitability of sensory nerves, and cures pain.
the most effective physiotherapy option for improving upper
However, based on the evidence of this study, UWT did not
extremity motor function and relieving pain in patients with the
present a prominent advantage, especially in terms of pain relief
post-stroke SHS, followed by CHT + RT and PT + RT. However,
(SUCRA = 48.3%). This may be related to the lack of significant
given the macroscopic nature of this study and the lack of direct
differences between various physical therapy interventions and
comparative evidence between multiple countries and centers,
may also be influenced by the number of relevant RCTs available
future studies need to conduct related randomized controlled
for inclusion, resulting in a lack of more direct comparative
trials on more physiotherapy interventions. In addition, it helps
evidence. Similarly, the relatively weak ranking of magnetic
to conduct more relevant and refined meta-analyses successfully.
therapy (MT) with transcranial magnetic stimulation as the
main intervention may be explained by the relative paucity
of studies on the clinical use of magnetic therapy for SHS Data availability statement
compared to others (n = 132). Nevertheless, again, this needs
further confirmation. The original contributions presented in the study are
More noteworthy is that, according to our pooled meta- included in the article/Supplementary material, further inquiries
analysis, no statistical difference was observed in pain relief can be directed to the corresponding author.
between the light therapy combined with rehabilitation training
(LT + RT) group and the control group. Also, based on the
SUCRA values, the top three ranked physiotherapies (BFT Author contributions
+ RT, CHT + RT, PT + RT) are all statistical differences
compared to LT + RT. Generally, this finding is consistent with SF conceived the study and wrote the manuscript. MT, GH,
recent studies (101), indicating that phototherapy has a weak and JW participated in the extraction and analysis of the data.
immediate analgesic effect and that its long-term effectiveness The study was critically supervised, evaluated, and validated by
is mainly determined by its ability to repair tissues. Therefore, it LG, SH, and DL. All of the authors worked on the article and
is commonly used in the adjunctive treatment of pain diseases. agreed with the version that was sent in.
On the contrary, the possible differences in the methodological
design of different current studies result from the continuous
Funding
advancement of medicine and the emergence of new high-
energy lasers and helium-neon lasers. However, due to the
This study was supported by the National Natural Science
setting of inclusion criteria and other technical limitations, we
Foundation of China (grant number. 81860878) and the Yunnan
failed to explore this aspect in depth. This remains to be analyzed
Provincial Education Department Scientific Research Fund
in the future by further collecting more direct evidence.
Project (grant number. 2022Y375).
Limitations Acknowledgments
However, our study has some limitations as well. First, The author would like to thank her friends Yiqin Zhong
our study aims to make comparisons from a macroscopic and Ting Zeng for their help in editing and revising this
perspective, thus ignoring the refined specific interventions manuscript’s images.
The authors declare that the research was conducted in the SUPPLEMENTARY FIGURE 3
absence of any commercial or financial relationships that could Summary chart of quality assessment.
All claims expressed in this article are solely those of the SUPPLEMENTARY FIGURE 6
Node-splitting diagram of FMA-UE.
authors and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the SUPPLEMENTARY FIGURE 7
VAS funnel plot.
reviewers. Any product that may be evaluated in this article, or
claim that may be made by its manufacturer, is not guaranteed SUPPLEMENTARY FIGURE 8
SUPPLEMENTARY FIGURE 9
Node-splitting diagram of VAS.
Supplementary material
SUPPLEMENTARY TABLE 1
The search strategy for PubMed.
The Supplementary Material for this article can be
found online at: https://www.frontiersin.org/articles/10.3389/ SUPPLEMENTARY TABLE 2
References
1. Pertoldi S, Di Benedetto P. Shoulder-hand syndrome after stroke. A complex 12. Zhang XL, Tang CZ, Jia J. Analysis of the current status of Chinese and
regional pain syndrome. Eura Medicophys. (2005) 41:283–92. Western medicine in the treatment of post-stroke shoulder-hand syndrome. Chin
J Rehabil Med. (2015) 30:294–8.
2. Hannan MA, Sabeka MM, Miah MB. Shoulder hand syndrome in hemispheric
stroke. J Neurol Sci. (2013) 333:e167–e167. doi: 10.1016/j.jns.2013.07.693 13. Harden RN, McCabe CS, Goebel A, Massey M, Suvar T, Grieve S, et al.
Complex regional pain syndrome: practical diagnostic and treatment guidelines.
3. Hartwig M, Gelbrich G, Griewing B. Functional orthosis in shoulder joint
Pain Med. (2022) 23:S1–S53. doi: 10.1093/pm/pnac046
subluxation after ischaemic brain stroke to avoid post-hemiplegic shoulder-
hand syndrome: a randomized clinical trial. Clin Rehabil. (2012) 26:807– 14. Stanton-Hicks MD, Burton AW, Bruehl SP, Carr DB, Harden
16. doi: 10.1177/0269215511432355 RN, Hassenbusch SJ, et al. An updated interdisciplinary clinical
pathway for CRPS: report of an expert panel. Pain Pract. (2002)
4. Borchers AT, Gershwin ME. Complex regional pain syndrome:
2:1–16. doi: 10.1046/j.1533-2500.2002.02009.x
a comprehensive and critical review. Autoimmun Rev. (2014)
13:242–65. doi: 10.1016/j.autrev.2013.10.006 15. Shim H, Rose J, Halle S, Shekane P. Complex regional pain syndrome:
a narrative review for the practising clinician. Br J Anaesth. (2019) 123:e424–
5. Xiaoyin L, Yingyu Z, Yongxin S. Prevention and treatment of the shoulder-
33. doi: 10.1016/j.bja.2019.03.030
hand syndrome after cerebral stroke for patients by arterio-venous hand pump. J
China Med Univ. (2012) 41:270–282. 16. Wang F, Ye JB, Zhao SR, Zheng CM, Huang CY. The efficacy of
comprehensive rehabilitation training combined with intramuscular effect patches
6. Xiangming Y. Research progress on the pathogenesis and comprehensive
on post-stroke shoulder-hand syndrome stage I. Chin J Rehabil. (2017) 32:205–6.
rehabilitation treatment of shoulder-hand syndrome after stroke. Pract Geriatr.
(2015) 29:452–6. 17. Smart KM, Wand BM, O’Connell NE. Physiotherapy for pain and disability
in adults with complex regional pain syndrome (CRPS) types I and II. Cochrane
7. Kondo I, Hosokawa K, Soma M, Iwata M, Maltais D. Protocol to prevent
Database Syst Rev. (2016) 2:CD010853. doi: 10.1002/14651858.CD010853.pub2
shoulder-hand syndrome after stroke. Arch Phys Med Rehabil. (2001) 82:1619–
23. doi: 10.1053/apmr.2001.25975 18. Hutton B, Salanti G, Caldwell DM, Chaimani A, Schmid CH, Cameron
8. Eisenberg E, Geller R, Brill S. Pharmacotherapy options C, et al. The PRISMA extension statement for reporting of systematic reviews
for complex regional pain syndrome. Exp Rev Neurother. (2007) incorporating network meta-analyses of health care interventions: checklist and
7:521–31. doi: 10.1586/14737175.7.5.521 explanations. Ann Intern Med. (2015) 162:777–84. doi: 10.7326/M14-2385
9. Lee SK, Yang DS, Lee JW, Choy WS. Four treatment strategies 19. Chinese Medical Association, Neurology Branch. 2016 Edition of the Chinese
for complex regional pain syndrome type 1. Orthopedics. (2012) 35:e834– Guidelines and Consensus on the Management of Cerebrovascular Disease. Beijing:
42. doi: 10.3928/01477447-20120525-21 People’s Health Publishing House (2016), 106–150.
10. Iolascon G, Moretti A. Pharmacotherapeutic options for 20. Zhu YL, Zhang H, He JJ. Neurological Rehabilitation. Beijing: People’s Army
complex regional pain syndrome. Exp Opin Pharmacother. (2019) Medical Publishing House (2010), 791–792.
20:1377–86. doi: 10.1080/14656566.2019.1612367
21. Savović J, Weeks L, Sterne JA, Turner L, Altman DG, Moher D, et al.
11. Kim YH, Kim SY, Lee YJ, Kim ED. A prospective, randomized cross-over Evaluation of the Cochrane Collaboration’s tool for assessing the risk of bias in
trial of T2 paravertebral block as a sympathetic block in complex regional pain randomized trials: focus groups, online survey, proposed recommendations and
syndrome. Pain Phys. (2019) 22:E417–24. doi: 10.36076/ppj/2019.22.E417 their implementation. Syst Rev. (2014) 3:37. doi: 10.1186/2046-4053-3-37
22. Mengersen K, Stojanovski EJC. Bayesian Methods in Meta-Analysis 1. (2006), 46. Weng DH, Niu DL, Wang JX. The clinical value of rehabilitation training
116–121. doi: 10.1201/b14674-20 combined with novel waxing therapy for post-stroke shoulder-hand syndrome. Lab
Med Clin. (2018) 15:827–30.
23. Seagroatt V, Stratton I. Bias in meta-analysis detected by a simple, graphical
test. Test had 10% false positive rate BMJ. (1998) 316:470–1. 47. Zhang GF, Huang HJ. Functional magnetic stimulation in the rehabilitation
of post-stroke shoulder-hand syndrome. Cardiovasc Dis Elect J Integ Tradit Chin
24. Salanti G. Indirect and mixed-treatment comparison, network, or multiple-
West Med. (2018) 6:80–1.
treatments meta-analysis: many names, many benefits, many concerns for
the next generation evidence synthesis tool. Res Synth Methods. (2012) 3:80– 48. Tan ZY. Clinical efficacy of Chinese herbal hot compresses combined with air
97. doi: 10.1002/jrsm.1037 wave pressure therapy instrument in the treatment of post-stroke shoulder-hand
syndrome. China Med Device Inform. (2018) 24:117–8.
25. Caldwell DM, Ades AE, Higgins JP. Simultaneous comparison of multiple
treatments: combining direct and indirect evidence. BMJ. (2005) 331:897– 49. Zhou KW, Chen XF, Guo X, Chen B. Efficacy of transcutaneous electrical
900. doi: 10.1136/bmj.331.7521.897 nerve stimulation combined with exercise therapy in the treatment of shoulder-
hand syndrome. Mod Pract Med. (2017) 29:1012–4.
26. Jansen JP, Naci H. Is network meta-analysis as valid as standard pairwise
meta-analysis? It all depends on the distribution of effect modifiers. BMC Med. 50. Li J. Efficacy of intermittent pneumatic compression in the treatment of
(2013) 11:159. doi: 10.1186/1741-7015-11-159 shoulder-hand syndrome in stroke. Chin J Rehabil. (2017) 32:210–1.
27. Mavridis D, Salanti G, A. practical introduction to multivariate meta-analysis. 51. Wu SH, Ye XJ, Gu QY, Chen YS. Clinical effects of pneumatic compression
Stat Methods Med Res. (2013) 22:133–58. doi: 10.1177/0962280211432219 therapy and rehabilitation training in stroke patients with shoulder-hand
syndrome stage I. Heilongjiang Med J. (2017) 41:222–3.
28. Valkenhoef GV, Kuiper J. gemtc: Network Meta-Analysis Using Bayesian
Methods. John Wiley & Sons Ltd (2015). 52. Yang JZ, Zheng FL, Wang ZY Li JW, Xin YC. Analysis of the efficacy
of Chinese medicine iontophoresis combined with comprehensive rehabilitation
29. Brooks S, Gelman A. General methods for monitoring convergence of
training in the treatment of post-stroke shoulder-hand syndrome. Neural Injury
iterative simulations. J Comput Graph Stat. (1998) 7:434–55.
Funct Reconst. (2017) 12:358–65.
30. Page MJ, Shamseer L, Altman DG, Tetzlaff J, Sampson M, Tricco
53. Li JF. Efficacy of Extracorporeal Shock Wave and Ultrasound in the Treatment
AC, et al. Epidemiology and reporting characteristics of systematic
of Shoulder-Hand Syndrome. Jinan: Shandong University (2016).
reviews of biomedical research: a cross-sectional study. PLoS Med. (2016)
13:e1002028. doi: 10.1371/journal.pmed.1002028 54. Xue LF, Jiang JF, Zhang WP, Liang KM. Study of early comprehensive
rehabilitation care for delayed stroke shoulder-hand syndrome. Guangxi Med J.
31. Valkenhoef GV, Dias S, Ades AE, Welton NJ. Automated generation of node-
(2016) 38:1036–8.
splitting models for assessment of inconsistency in network meta-analysis. Res
Synth Methods. (2016) 7:80–93. doi: 10.1002/jrsm.1167 55. Cai HM, Wang W, Ma D, Wang WJ. The efficacy of ultrashort wave in the
stellate ganglion region in patients with shoulder-hand syndrome after cerebral
32. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment
infarction. Chin J Rehabil Med. (2016) 31:688–90.
of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. (2010)
25:603–5. doi: 10.1007/s10654-010-9491-z 56. Lin FY, Chen DS. The efficacy of Chinese herbal fumigation combined with
myoelectric biofeedback therapy in the treatment of post-stroke shoulder-hand
33. Wu DN. The clinical effects of transcranial magnetic electrotherapy on
syndrome. Mod J Integ Tradit Chin West Med. (2016) 25:3377–81.
shoulder hand syndrome after cerebral stroke. Hebei Med J. (2021) 43:1044–1050.
57. Li JF, Zhang Y, Yue SW. Clinical observation of the extracorporeal shock wave
34. Li LX, Zhao S, Zhang HD, Shen J. Efficacy of extracorporeal shock wave
in the treatment of shoulder-hand syndrome. Chin J Rehabil. (2016) 31:255–7.
combined with conventional rehabilitation treatment for post-stroke shoulder-
hand syndrome. Guizhou Med J. (2021) 45:1555–6. 58. Lu HY, Pang QT, Guo GY, Liu P, Song XL. The efficacy of infrared/red light
local irradiation combined with comprehensive rehabilitation in the treatment of
35. Liu Q, Wang ZF. Observation of clinical effect of rTMS on shoulder and hand
shoulder-hand syndrome. Chin J Phys Med Rehabil. (2015) 37:375–7.
syndrome in 50 cases. Anhui Med Pharm J. (2021) 25:124–6.
59. Yuan XM, Chen PN. Study on the use of airwave pressure therapy in
36. Yang LF Li W, Wang SL, Hu Q. Efficacy of neuromuscular electrical
post-stroke shoulder-hand syndrome. J Nurses Train. (2015) 30:1421–3.
stimulation combined with pneumatic compression in the treatment of shoulder-
hand syndrome. Health Wellness Guide. (2021) 2:51–2. 60. Wang X, Zhao LB, Xie DX. The observation of effects to treat stroke and
shoulder-hand syndrome by laser acupuncture irradiation joint acupoint sticking
37. Liu XH, Liu HJ, Guan YM. Effect of low frequency pulse electrical therapy
and rehabilitation training. Laser J. (2014) 35:67–8.
combined with rehabilitation training on patients with shoulder-hand syndrome
after stroke. J Cervicodynia Lumbodynia. (2021) 42:505–7. 61. Shi CX, Xie RJ, Wang XH, Yang YL, Deng Y, Chen L. Researches on
randomized controlled trials of patients with shoulder-hand syndrome after
38. Bao J, Shi P, Song S. Clinical effects of subsuspension exercise therapy
stroke by routine rehabilitation training combined with medium-frequency
combined with shock waves in the treatment of post-stroke shoulder-hand
electrotherapy. Med Res Educ. (2014) 31:41–5.
syndrome. Ningxia Med J. (2021) 43:1015–6.
62. Guo J, Ruan H. Clinical observation of comprehensive rehabilitation
39. Qiao XX, Ding X. Effect of modified external application of traditional
treatment for patients with shoulder-hand syndrome after stroke. Chin J Trauma
Chinese medicine liquid in patients with stage I post-stroke shoulder-hand
Disabil Med. (2013) 21:291–2.
syndrome. Guangxi Med J. (2020) 42:1463–6.
63. Wang Y, Li BL, Wang AL. He-ne laser is modulated medium frequency
40. Ren K, Wei JM, Cheng H, Han L. Clinical study on heat ironing of chinese
electric therapy combined with rehabilitation nursing intervention curative effect
herbal wax combined with routine rehabilitation for shoulder-hand syndrome after
observation of shoulder hand syndrome after stroke. Laser J. (2013) 34:84–5.
stroke. New Chin Med. (2020) 52:62–5.
64. She LY, Wang P. The effect of ultrashort wave therapy and movement
41. Zhang JP Li L, Xu QQ Li F, Wang N. Clinical study of sling exercise
rehabilitation training on hemiplegic stroke patients with stage I shoulder-hand
training combined with shock wave therapy in treatment of I stage shoulder-hand
syndrome. China Med Herald. (2013) 10:45–50.
syndrome after stroke. Shandong J Tradit Chin Med. (2019) 38:652–6.
65. Hu KH Li YA, Xiong GH, Cheng K, Qin L, Jiang W, et al. Clinical study
42. Li H, Lai DD. Phase I clinical efficacy of ultrashort wave combined with
of intermittentpressure therapy combined with immersion of hot and cold water
exercise therapy for hemiplegic patients with shoulder-hand syndrome. Shenzhen J
alternately on stroke patients with shoulder-hand syndrome. Chin J Rehabil.
Integ Tradit Chin West Med. (2019) 29:144–5.
(2013) 28:106–8.
43. Chen JM, Zheng SY. Clinical study on blood-activating and collaterals-
66. Zhao YY, Ma YW. Analysis of the efficacy of pulsed laser combined with
dredging traditional Chinese medicine fumigation combined with surface
intermittent pneumatic compression in the treatment of post-stroke shoulder-
electromyography biofeedback for post-stroke shoulder syndrome. Chin Arch
hand syndrome. Chin J Misdiagn. (2012) 12:1820–1.
Tradit Chin Med. (2019) 37:2605–8.
44. Zhang C, Liu GY, Xiao SR Yi Z, Wang CL. Observation on effect of TCM 67. Zhang XL, Guan QB, Gu XD, Wang DP, Hu YM. Effect of transcutaneous
directinal medication combined with ultrasound on stage I of shoulder-hand electrical nerve stimulation on sympathetic skin responses in patients with post-
syndrome after stroke. China Med Pharm. (2019) 9:51–3. stroke shoulder-hand syndrome. Chin J Phys Med Rehabil. (2012) 12:920–3.
45. Gong Y, Guo CF, Zhang JY, Wang H. The efficacy of Chinese herbal collapse 68. Liu GH, Cui GL, Zhu RX. Air pressure wave treatment for shoulder-
combined with infrared irradiation on post-stroke shoulder-hand syndrome. hand syndrome after stroke treatment efficacy analysis. Guide China Med. (2012)
Heilongjiang J Tradit Chin Med. (2019) 48:4–6. 10:11–3.
69. Guo YH, Chen HX, Yang ZJ Li M. The efficacy of alternating hot and cold 85. Li JH, Wang J. Clinical Application of Surface Electromyography Diagnostic
herbal bath therapy combined with rehabilitation training in the treatment of Techniques. Zhejiang: Zhejiang University Press (2015).
post-stroke shoulder-hand syndrome. Chin J Phys Med Rehabil. (2011) 04:303–4.
86. Yan TB. Physiotherapy. Beijing: People’s Health Publishing House (2016).
70. Zhang M, Huang Y. Clinical analysis of infrared acupoint irradiation in
87. Woodford H, Price C, EMG. biofeedback for the recovery
the treatment of post-stroke shoulder-hand syndrome. Chin J Pract Nerv Dis.
of motor function after stroke. Cochrane Database Syst Rev. (2007)
(2011) 14:60–1.
2007:CD004585. doi: 10.1002/14651858.CD004585.pub2
71. Liu DH, Dong JG. Efficacy of ultrashort wave therapy combined with
88. Tan WB. Design of a surface EMG-based myoelectric biofeedback
rehabilitation training in the treatment of post-stroke shoulder-hand syndrome.
training and therapy system. South China Univ Technol. (2019) 18:8578–
Chin J Med. (2011) 46:58–9.
86. doi: 10.1109/JSEN.2018.2865623
72. Su Q, Chen QF. Efficacy of intermittent pneumatic compression in
89. Guo JM. Clinical study on the effect of high frequency repetitive transcranial
the treatment of post-stroke shoulder-hand syndrome. J Qiqihar Med Univ.
magnetic stimulation combined with myoelectric biofeedback therapy on the
(2010) 31:2539–40.
rehabilitation of upper limb motor function in stroke patients with hemiplegia.
73. Bi LY, Tang ZY, Qian XH, Ye XL. Clinical observation of microwave Southern Med Univ. (2019) 20:3754.
irradiation combined with kinesiotherapy for shoulder-hand syndrome. J Pract
90. Wang CE. Effect of combination of acupuncture, massage and
Med. (2008) 3:355–7.
electromyographic biofeedback therapy on symptom and shoulder joint function
74. Liu M, Huang ZM, Jiang HX. The effect of hyperbaric oxygenation in in patients with hemiplegic shoulder pain. Mod J Integ Tradit Chin West Med.
combination with rehabilitation training in patients with shoulder-hand syndrome (2021) 30:2777–81.
after stroke. Chin J Rehabil Med. (2008) 2:123–5.
91. de Oliveira AKA, da Costa KSA, de Lucena GL, de Oliveira Sousa C,
75. Lumley T. Network meta-analysis for indirect treatment comparisons. Stat Filho JFM, Brasileiro JS. Comparing exercises with and without electromyographic
Med. (2002) 21:2313–24. doi: 10.1002/sim.1201 biofeedback in subacromial pain syndrome: a randomized controlled trial. Clin
Biomech. (2022) 93:105596. doi: 10.1016/j.clinbiomech.2022.105596
76. Zhang YQ, Ma YH. Progress in the study of scapular dyskinesia in patients
with post-stroke shoulder pain. Chin J Rehabil Med. (2020) 35:498–501. 92. Kamonseki DH, Calixtre LB, Barreto RPG, Camargo PR. Effects
of electromyographic biofeedback interventions for shoulder pain and
77. Green S, Buchbinder R, Hetrick S. Physiotherapy
function: systematic review and meta-analysis. Clin Rehabil. (2021)
interventions for shoulder pain. Cochrane Database Syst Rev. (2003)
35:952–63. doi: 10.1177/0269215521990950
2003:CD004258. doi: 10.1002/14651858.CD004016
93. Lv FY Li J, Wang LJ. The clinical application of pan-analysis wax therapy. J
78. Anandkumar S, Manivasagam M. Multimodal physical therapy management
Precis Med. (2006) 6:564.
of a 48-year-old female with post-stroke complex regional pain syndrome.
Physiother Theory Pract. (2014) 30:38–48. doi: 10.3109/09593985.2013.814186 94. Sun GT, Jiang XX, Wu CJ, Dong SX, Huang ZY. Wax therapy for post-stroke
shoulder pain. Heilongjiang Med Pharmacy. (2017) 40:52–5.
79. Zhang MM, Hao N, Li YL, Guo YN, Xiao WX, Ge JL. Clinical effect of
wet compress with Sanggui Shuangzhi Fang combined with wax therapy in the 95. Wang Y. Clinical study on the prevention of local pain caused by peripheral
treatment of post-stroke shoulder-hand syndrome. Jilin J Chin Med. (2022) 42:566– intravenous infusion of 10% potassium chloride solution with Chinese herbal moist
9. heat compresses. Shanghai Univ Tradit Chin Med. (2019) 95:100646.
80. Zhao XK, Zhou JJ, Zhang QQ. Efficacy of high-energy laser in the treatment of 96. Guo JH, Chen LN Li H. Recent research on chinese herbal fumigation
early stroke patients with shoulder-hand syndrome. Acta Med Sin. (2021) 34:132–6. therapy. Lishizhen Med Mater Med Res. (2000) 10:948–9.
81. Tian Y, Geng D, Chen GM Li HB. Clinical effect of high frequency repetitive 97. MacLellan Donald G, Fletcher John P. Mechanical compression in
transcranial magnetic stimulation on shoulder-hand syndrome after stroke. J the prophylaxis of venous thromboembolism. ANZ J Surg. (2007) 77:418–
Neurosci Mental Health. (2021) 21:494–8. 23. doi: 10.1111/j.1445-2197.2007.04085.x
82. Yan XY Yu XQ, Yuan MH, Ding H, Zou WB, Wang L, et al. Efficacy 98. Zhang DD, Cao F, Zhan Q. Effect of modified air pressure therapy on upper
observation of occupational therapy combined with ultrasound in the treatment extremity motor function in patients with stage I shoulder-hands syndrome after
of shoulder and hand syndrome. Pract Clin J Integ Tradit Chin Western Med. stroke. J Neurol Neurorehabil. (2018) 14:161–6.
(2022) 22:109–12.
99. Liu JY, Qiu L, Zheng X, Zhang M, Zhang J. Clinical application of ultrasound
83. Kraft E, Storz C, Ranker A. Physikalische Therapie in der Behandlung in the treatment of painful diseases. Chin J Rehabil. (2013) 28:468–70.
des komplexen regionalen Schmerzsyndroms [Physical therapy in 100. Ainsworth R, Dziedzic K, Hiller L, Daniels J, Bruton A, Broadfield J,
the treatment of complex regional pain syndrome]. Schmerz. (2021) et al. prospective double blind placebo-controlled randomized trial of ultrasound
35:363–72. doi: 10.1007/s00482-021-00577-y in the physiotherapy treatment of shoulder pain. Rheumatology. (2007) 46:815–
20. doi: 10.1093/rheumatology/kel423
84. Gaume A, Vialatte A, Mora-Sánchez A, Ramdani C, Vialatte FB,
A. psychoengineering paradigm for the neurocognitive mechanisms 101. Liu Y, Fang M, Chen LP, Shen W. Advances in the therapeutic mechanisms
of biofeedback and neurofeedback. Neurosci Biobehav Rev. (2016) and clinical applications of high energy laser therapy in pain disorders. Chin J Pain
68:891–910. doi: 10.1016/j.neubiorev.2016.06.012 Med. (2020) 26:894–7.