Enhancement of muscle activity by electrical stimulation in cerebral palsy: a case-control study

Neuromuscular Electrical Stimulation of Upper Limbs in Patients With Cerebral Palsy: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

The aim of the study is to assess the effects of neuromuscular electrical stimulation on the upper limbs of patients with cerebral palsy.

DESIGN

We searched PubMed, Cochrane, Embase, and Scopus databases for randomized controlled trials examining the effects of neuromuscular electrical stimulation on the upper limbs of children with cerebral palsy.

RESULTS

Eight randomized controlled trials ( N = 294) were included in the meta-analysis. Compared with traditional physical therapy, sensorimotor training and task-oriented training, constraint-induced movement therapy, dynamic bracing, and conventional robot-assisted therapy, neuromuscular electrical stimulation in combination with these therapies resulted in significantly greater functional scale scores (standardized mean difference = 0.80; 95% confidence interval = 0.54 to 1.06), muscle strength of upper limbs (standardized mean difference = 0.57; 95% confidence interval = 0.25 to 0.88), and spasticity of upper limbs (relative risk = 2.53; 95% confidence interval = 1.46 to 4.39; standardized mean difference = -0.18; 95% confidence interval = -0.29 to -0.06) but did not improve the wrist range of motion (standardized mean difference = 0.43; 95% confidence interval = -0.04 to 0.91). In addition, the effect of neuromuscular electrical stimulation on functional scale scores remained after 3-mo follow-up (standardized mean difference = 0.68; 95% confidence interval = 0.16 to 1.2).

CONCLUSIONS

Neuromuscular electrical stimulation effectively improved hand function, muscle strength, and spasticity in patients with cerebral palsy.

The effect of combined transcranial pulsed current stimulation and transcutaneous electrical nerve stimulation on lower limb spasticity in children with spastic cerebral palsy: a randomized and controlled clinical study

BACKGROUND

In the current study, we applied a combination of non-invasive neuromodulation modalities concurrently with multiple stimulating electrodes. Specifically, we used transcranial pulsed current stimulation (tPCS) and transcutaneous electrical nerve stimulation (TENS) as a novel strategy for improving lower limb spasticity in children with spastic cerebral palsy (SCP) categorized on levels III-V of the Gross Motor Function Classification System (GMFCS) with minimal side effects.

METHODS

Sixty-three SCP children aged 2-12 years, who were classified on levels III-V of the GMFCS were randomly assigned to one of two groups, resulting in 32 children in the experimental group and 31 children in the control group. The experimental group underwent a combination therapy of tPCS (400 Hz, 1 mA cerebello-cerebral stimulation) and TENS (400 Hz, max 10 mA) for 30 min, followed by 30 min of physiotherapy five times per week for 12 weeks. The control group underwent physiotherapy only 30 mins per day five times per week for 12 weeks. In total, all groups underwent 60 treatment sessions. The primary outcome measures were the Modified Ashworth Scale (MAS) and Modified Tardieu Scale (MTS). Evaluations were performed 3 days before and after treatment.

RESULTS

We found a significant improvement in MAS and MTS scores of the lower limbs in the experimental group compared to the control group in the hip adductors (Left: p = 0.002; Right: p = 0.002), hamstrings (Left: p = 0.001; Right: p < 0.001, and gastrocnemius (Left: p = 0.001; Right: p = 0.000). Moreover, MTS scores of R1, R2 and R2-R1 in left and right hip adduction, knee joint, and ankle joint all showed significant improvements (p ≤ 0.05). Analysis of MAS and MTS scores compared to baseline scores showed significant improvements in the experimental group but declines in the control group.

CONCLUSION

These results are among the first to demonstrate that a combination of tPCS and TENS can significantly improve lower limb spasticity in SCP children classified on GMFCS levels III-V with minimal side effects, presenting a novel strategy for addressing spasticity challenges in children with severe SCP.

TRIAL REGISTRATION

ChiCTR.org, ChiCTR1800020283, Registration: 22 December 2018 (URL: http://www.chictr.org.cn/showproj.aspx?proj=33953 ).

Neuro-mechanical aspects of playing-related mobility disorders in orchestra violinists and upper strings players: a review

Orchestra musicians are at high risk of neuro-mechanical disorders due to the intense stresses their body withstand, leading to pain and injury. This review presents a comprehensive account of the works on the circumstances and types of playing related mobility disorders of upper strings players, as well as on the relevant neuro-mechanical factors and perspectives to those disorders. The following aspects are considered: asymmetry and imbalance in the musculo-skeletal system, muscle-bone-joint interactions, repetitive overloading and fatigue. An additional factor relates to neuro-muscular redundancy in the motor system, whereby more muscles and tendons than strictly necessary are engaged in performing a motor task, thus making the system indeterminate, with no unique solution. This same task can be performed with different muscle combinations. It is thus of interest to verify whether playing disorders may be alleviated by considering alternative techniques of performance.

Synergistic Improvement in Children with Cerebral Palsy Who Underwent Double-Course Human Wharton's Jelly Stem Cell Transplantation

Background

Our previous studies confirmed that human Wharton's Jelly stem cell (hWJSC) transplantation improved motor function in children with spastic cerebral palsy (CP). This study investigated the dose-effect relationship between the transplanted cell dosage and efficacy in CP children.

Methods

CP children who received one- or two-course (four or eight times lumbar puncture, 4 or 8 × 10⁷ hWJSCs) cell therapy were recruited into this study. Assessments of motor function were performed according to scales for gross motor function measurement (GMFM) and fine motor function measurement (FMFM). The measurement data obtained in the two different groups were analyzed by t-test. Univariate repeated measures analysis of variance was used to compare the data obtained at baseline and 6 or 12 months posttransplantation and met the conditions for Mauchly's sphericity test.

Results

The results for fifty-seven pediatric CP patients (including 35 male and 22 female patients) who completed follow-up showed that gross and fine motor functions improved after cell therapy. Interestingly, the GMFM and FMFM scores in patients who received one course of transplantation were significantly increased at 6 months after treatment. Moreover, another course of transplantation further improved gross and fine motor function in children. The scores for GMFM and FMFM were significantly higher at 6 months posttransplantation than at baseline and showed a linear upward trend. There was no gender difference in GMFM. Interestingly, there was a significant difference between male and female patients in the B and C dimensions of FMFM. These results reveal a gender-related susceptibility to stem cell therapy, especially for movement capability of the upper extremity joint and grasping ability. Similarly, in the group aged ≤3 years old, the improvement observed in dimension A (lying and rolling) of GMFM was nearly exponential and showed a quadratic trend. The results for FMFM were similar to those for GMFM. Moreover, the improvement in motor function was not age dependent.

Conclusions

In this study, our data collectively reveal that CP children display sex- or age-dependent responses to hWJSC therapy; these results shed light on the clinical utility of this approach in specific populations.

Does therapeutic electrical stimulation improve function in children with disabilities? A comprehensive literature review

The use of therapeutic electrical stimulation for medical purposes is not new; it has been described in medical textbooks since the 18th century, but its use has been limited due to concerns for tolerance and lack of research showing efficacy. The purpose of this review is to discuss the potential clinical applicability, while clarifying the differences in electrical stimulation (ES) treatments and the theory behind potential benefits to remediate functional impairments in youth.The literature review was performed as follows: A total of 37 articles were reviewed and the evidence for use in pediatric diagnoses is reported.The synthesis of the literature suggests that improvements in various impairments may be possible with the integration of ES. Most studies were completed on children with cerebral palsy (CP). Electrical stimulation may improve muscle mass and strength, spasticity, passive range of motion (PROM), upper extremity function, walking speed, and positioning of the foot and ankle kinematics during walking. Sitting posture and static/dynamic sitting balance may be improved with ES to trunk musculature. Bone mineral density may be positively affected with the use of Functional Electrical Stimulation (FES) ergometry. ES may also be useful in the management of urinary tract dysfunction and chronic constipation. Among all reviewed studies, reports of direct adverse reactions to electrical stimulation were rare.In conclusion, NMES and FES appear to be safe and well tolerated in children with various disabilities. It is suggested that physiatrists and other healthcare providers better understand the indications and parameters in order to utilize these tools effectively in the pediatric population. MeSH terms: Electrical stimulation; child; review.

Children with cerebral palsy: a systematic review and meta-analysis on gait and electrical stimulation

Objective: To conduct a systematic review and meta-analysis using the International Classification of Functioning to determine the summary effect of electrical stimulation on impairment and activity limitations relevant to gait problems of children with cerebral palsy.

Methods: We identified 40 cerebral palsy and electrical stimulation studies, and 17 gait studies qualified for inclusion. Applying enablement classification methods to walking abnormalities created two subgroups: impairment (N = 14) and activity limitations (N = 15). Overall, 238 participants experienced electrical stimulation treatments and 224 served as a no stimulation control group. Calculations followed conventional data extraction and meta-analysis techniques: (a) individual standardized mean differences, (b) summary effect size, (c) I 2heterogeneity test, (d) fail-safe N analysis and (e) moderator variable analyses.

Results: Common outcome measures associated with impairment (n = 3) and activity limitations (n = 6) were submitted to separate random effects models meta-analyses, and revealed significant cumulative effect sizes: (a) impairment = 0.616 (SE = 0.10) and (b) activity limitations = 0.635 (SE = 0.14). I 2indicated low and medium amounts of dispersion, whereas fail-safe analyses revealed high N-values for both disablement categories. Moderator variable analyses further confirmed the positive treatment effects from both functional and neuromuscular stimulation.

Conclusions: The present systematic review and meta-analyses determined medium effect sizes for electrical stimulation on walking impairment and activity limitations of children with cerebral palsy.

Review of electrical stimulation in cerebral palsy and recommendations for future directions

Electrical stimulation (ES) for treatment of neuromuscular disorders is introduced. Various forms of ES are defined. Characteristics of cerebral palsy (CP) and treatment options are given. The clinical objectives of ES for CP treatment are stated. A review of the literature for treatment in CP is given. Several common themes within the literature and limitations in prior studies are explored. The majority of studies have used surface stimulation, which has several inherent limitations. To address these limitations, implanted devices may be used. Implanted device systems include percutaneous stimulation systems, and fully implantable leaded systems. While both of these technologies have advantages over surface stimulation, they also have their own limitations. To further address the limitations of percutaneous and fully implantable leaded systems, the Alfred Mann Foundation has developed a completely implantable, telemetered device known as the Radio Frequency Microstimulator (RFM). Results from a study using the RFM for arm rehabilitation in poststroke patients are given. A list of desirable design features for an ES system for CP is given. The next generation microstimulator device under development at the Alfred Mann Foundation is presented. This device may well serve the needs for ES in CP.

Effects of electrical stimulation, exercise training and motor skills training on strength of children with meningomyelocele: a systematic review

This systematic review provides a critical synthesis of research regarding the effects of electrical stimulation, exercise training, and motor skills training on muscle strength in children with meningomyelocele. Nine databases were searched using terms related to meningomyelocele and physical therapy interventions. Of 298 potentially relevant citations, six met the inclusion criteria. Each was rated using the systematic review guidelines of the American Academy for Cerebral Palsy and Developmental Medicine. Two studies examined changes in quadriceps muscle torque following electrical stimulation, three investigated upper extremity exercise training, and one evaluated quadriceps strength after motor skills training. Although the limited evidence suggests improvements in strength when using these interventions, much of the evidence is of low methodological quality and all studies were published more than 10 years ago. Further research is needed regarding various strength-training interventions for children with meningomyelocele and the relationship between increased strength and improved activity and participation.