Electrical Muscle Stimulation Treatments for Cerebral Palsy

Ninety percent of children with cerebral palsy have muscle spasticity as their dominant or exclusive impairment. EMS (electrical muscle stimulation) is the elicitation of muscle contracture through electronic stimulation and is sometimes used to treat children with spastic cerebral palsy. When combined with the right physical therapies, experts have demonstrated that EMS can improve overall motor function, increasing the child’s ability to perform physical tasks such as walking.

There are two ways of approaching EMS. The first is called NMES (neuromuscular electrical stimulation) or FES (functional electrical stimulation). The procedure, done only by a medical professional, involves giving specific muscles or muscle groups short bursts of electrical impulses designed to mimic the normal communication between the brain and the muscular system. Hopefully this can retrain the muscles to respond appropriately to the desires of the brain in a way they frequently don’t in someone suffering from spastic CP.

TES (threshold electrical stimulation) is very different. It involves much lower voltage and can be directed at a specific muscle or muscle group over a long period of time. It can be administered by the patient or a family member and can even take place overnight while the patient sleeps. It does not induce contraction, but instead is used to relieve patients of some of the discomfort and pain that comes with spasticity.

The way that NMES works is that electrodes are placed onto the skin in the vicinity of the muscles that are either in atrophy or have weakened due to spasticity. The electrodes are connected to a small generator. The current is low and rarely causes discomfort to the patient. The intent is to force the muscle to contract in a way that the brain is failing. The response is not dissimilar to having your reflexes induced by tapping on the knee. With TES, the procedure can be administered by a parent at home.

Unfortunately, with spastic cerebral palsy, any improvements brought about by EMS are temporary. The damage to the neuromuscular system is irreversible and the brain really can’t be trained to stimulate the muscles appropriately on its own. In most cases, full-time relief from the impairment of muscle spasticity requires approximately 2 hours of EMS every day of the week. Even then, any prolonged break from treatment will probably result in the abnormal spasticity returning to pre-treatment levels. For many, the benefits, however temporary, are worth a lifetime of daily treatment.

Because of the temporal nature of the benefits, many experts in the cerebral palsy world consider electrical muscle stimulation only as a supplement to standard treatments. Exercise and physical activity are still seen as having more enduring benefits to the ultimate health and well-being of children with cerebral palsy. But the debate is ongoing. Other experts believe that with further advancements, EMS alone may be used to treat and improve, at least, the smaller muscle groups such as in the forearm or wrist. Whether or not EMS can one day stand alone as a treatment for EMS remains to be seen, but it is at least worth consideration as an element of your child’s physical therapy.

Spastic Diplegia in Children With Cerebral Palsy

The form of cerebral palsy known as “spastic diplegia” is one of five categories of spastic CP that help indicate what parts of the body are primarily affected. In the case of diplegia, the lower extremities (legs, hips and pelvis) show spasticity abnormalities while the upper extremities function at a normal or near-normal capacity. Children born with this form of cerebral palsy exhibit near-normal cognitive development and performance, but are frequently delayed in their ability to walk. Once they are able to walk, they commonly have a pronounced scissoring gait, with legs crossing over each other in a stiff, scissor-like pattern.

Even though spastic diplegia is generally considered one of the lesser forms of cerebral palsy, people who suffer from it can expect lifelong difficulty with all voluntary and passive leg movement, as well as pain associated with muscle and joint breakdown that can lead to arthritis and tendinitis. Some forms of spastic diplegia are mild enough to result in barely noticeably abnormalities in balance and gait.

The cause of spastic diplegia, as with many forms of cerebral palsy, is from neonatal asphyxia, a sudden depravation of the oxygenated blood that passes to the fetus through the umbilical cord. This is sometimes combined with a pre-term birth. Spastic diplegia can also be the result of bladder, kidney, urinary tract, STD’s, yeast infections or bacterial vaginosis in the mother during pregnancy. These conditions can lead to infant hypoxia, which inhibits proper development of upper motor neuron function associated with movement.

Dr. William John Little’s first recorded encounter with cerebral palsy during the 1860’s is reported to have been among children displaying signs of spastic diplegia. For this reason, spastic diplegia is sometimes referred to as “Little’s Disease.” Diagnosis of spastic diplegia usually can’t be made until a child is several months or even several years old, but a child can be labeled “high risk” if they experienced birth trauma before, during or shortly after delivery. This includes prematurity of more than 3 weeks. If a child does not meet standard developmental milestones regarding movement of the legs (usually around 18 months), a preliminary diagnosis of spastic diplegia may be made. Around this time, a parent may observe a child’s legs as unusually stiff or floppy (which will gradually lead to stiffness). The cause of this is the failure of the motor neurons to properly develop muscle tone. Normal muscles function in pairs-one contracting while the companion muscle relaxes. When this function is compromised, both muscles contract simultaneously. Hypertonia is the result of too much muscle tone. Hypotonia is too little muscle tone.

Some of the indicators of spastic diplegia include:

1) Children often prefer sitting in a “W” position. Physical therapists will encourage sitting cross-legged or chair sitting.

2) Children may fail in early attempts to crawl, or begin crawling by pulling themselves forward with the use of their forearms, letting their legs drag behind.

3) Children who have failed to pull themselves to a standing position by age 2 and a half may require devices, such as braces, to assist with standing. Standing puts important stress on leg bones and joints, thus promoting healthy growth.

4) Toe walking or feet-rolling–can be improved with low profile/low impact leg braces.

5) Spastic diplegia can lead to gradual hip dislocation, a condition that promotes arthritis and pain. For this reason, regular hip x-rays and exams are needed to monitor the disease.

Physical therapy, including massage therapy, is the most important treatment for any form of spasticity, aimed at training and strengthening muscles to promote healthy bone growth, balance and motor functions. There are medication that can be taken to relax tight muscles and minimize spasms. Injecting Botox into overly tight muscles has proven to provide at least temporary relief. In more extreme cases, surgery can be performed to lengthen muscles. Other treatments include electrical muscle stimulation, hyperbaric oxygen therapy and hippotherapy.

If pain and spasticity are severe enough to inhibit walking, orthopedic surgery can become an option. First, it must be determined which of the 30 major muscles are causing the problem. Gait analysis, a computerized diagnostic technique, is used as a guide in making

Before surgery occurs, doctors must determine which among the 30 major muscles involved in walking are causing the problem. Doctors today use a computerized diagnostic technique known as gait analysis to guide them in making surgical decisions. Gait analysis uses:

1) cameras that record how an individual walks

2) force plates that detect how the feet land

3) a test called electromyography that records muscle activity

4) a computer program that gathers and analyzes the data.

Using this information, doctors can precisely locate which muscles would benefit from surgery and how much improvement in gait can be expected. The timing of such surgeries is based on the child with cerebral palsy’ s motor development and age. Surgery to correct spasticity in upper leg muscles is likely to occur between ages 2 and 4, while surgery to correct spasticity in the lower muscles (hamstring, Achilles tendon) would likely occur around age 7 to 8. Orthopedic surgery had evolved into a relatively simple procedure, often being done on an outpatient basis.

In cases of extreme spasticity and associated pain, SDR (selective dorsal rhizotomy) surgery may be required. SDR surgery involves severing specific nerves at the base of the spinal column to release stress on the targeted muscles.

The Benefits of Hippotherapy in Children With Cerebral Palsy.

Pioneered by German, Swiss and Austrian therapists during the 1960’s, then standardized in the United States and Canada during the 1980’s, the treatment strategy of hippotherapy (“hippo” is the Greek word for “horse” ) has evolved into a highly valued form of physical, occupational and speech therapy for children with cerebral palsy. In numerous cases it has resulted in dramatic improvements to both motor skills and emotional well-being.

Hippotherapy programs have been developed for children of all degrees of motion and ability. While some facilities have been created specifically for hippotherapy, most programs take place on full range horse farms led by a team of therapists, including a physical therapist, a horse handler and sometimes a speech/language therapist. Physical therapists can receive board certification from the American Hippotherapy Association. They are there to guide and monitor the child for issues of balance and control. The horse handler is there to ensure safety and provide basic riding instruction to both child and parent.

The driving principle behind hippotherapy is that the horse is influencing the client, rather than the client endeavoring to control the horse. (There are no age limits to hippotherapy, but for purpose of this article we are talking specifically about children with CP.) The child is positioned on the horse by a physical therapist and horse handler. By responding to the horse’s natural (yet carefully monitored) movements, the child involuntarily activates neglected muscle groups to sit up straighter, maintain better balance and motor plan new movements. That’s the mechanics of it. But as most anyone involved with hippotherapy will assure you, there’s also the less tangible, but equally therapeutic bond that develops between child and horse.

In the process of riding, the child will naturally match the rhythms established by the horse’s movement. The horse’s pelvic movements actually mirror that of the human pelvis. The walking horse literally moves the body of the child in a more natural walking pattern than they are probably used to. Consistent riding often leads to improved muscle tone, motor function and overall sense of balance.

With the help of a speech therapist, the simple verbal commands given by the horse handler to control the horse are progressively given over to the child. Many speech therapists rate this particular discipline as one of the most successful they’ve encountered. The process and results of this process can be very empowering for the child, improving their overall level of self-esteem and sense of well-being.

Hippotherapy is not appropriate treatment for every single child with cerebral palsy, but it might be something to consider and discuss with your child’s physical therapist and pediatrician. Unfortunately at this time, very few health insurance plans cover this type of therapy.

As with all physical endeavors, there are some risks when working with large animals. To ensure safety, your child must be able to digest and follow simple rules of instructions from the horse handler. Make sure that you’re working with the right people and see that your child is properly outfitted, including a well-fitting helmet and body padding.

Hippotherapy is a fascinating process, one that has yielded tremendous results. Is it right for you and your child? The potential benefits make it at least worth an investigation.

Assistive Communication Devices and Applications for Children With Cerebral Palsy

Cerebral palsy can result in some or many of a wide array of impairments or developmental delays, some minor, others major. For many children with CP, the ability to communicate effectively can be a real challenge. This may be the result of cognitive impairments, where they struggle with vocabulary and idea processing, or it may be more about the motor skills that govern the mouth, lips and tongue. CP related hearing impairments can also have a profound effect on a child’s ability to communicate. Learning complex language and speech skills is uniquely human. So is the ability to invent and utilize adaptive devices to aid those who struggle with this process.

Children develop and use language at roughly their own pace, but a child who fails to meet certain developmental milestones for communication should be tested for speech and hearing issues. Babies should react to sound from birth and even look towards the source of a sound by 6 months. If a child isn’t hearing sound well enough to react to it, they will have a difficult time learning to speak. Hearing screenings are available to infants of any age.

In our highly technical world, many new techniques and devices have been developed aimed at assisting young people with hearing and speech impairments in their efforts to communicate. AAC (Augmented and Alternative Communication) strategies and devices exist in many formats from high-tech to low-tech. With the proliferation of highly sophisticated assistive devices comes the fear that children will lose their motivation to attempt speech.

Before choosing which specific method of intervention or technology will be of greatest benefit to your child with cerebral palsy, seek the nearest rehabilitation or teaching hospital that offers evaluation and assistance in choosing AAC systems. Many of them offer assistive technology clinics where teams of AAC specialists along with speech pathologists, occupational and physical therapists can work directly with AAC technology vendors to design a service plan customized for your child. Having all these professionals under one roof streamlines the process by facilitating effective communications between professionals you might otherwise have to visit individually in multiple cities. The result is an AAC system customized specifically to your child’s abilities and needs and the training that both you and your child will need.

Science has made mind-boggling advances over the past decade and there’s no end in sight. Laboratories have developed brain/computer interface systems that provide communication and control capabilities to individuals with severe motor disabilities.

VOCAs (voice output communication aids), such as those used by famous physicist Dr. Stephen Hawking, allow individuals with severe speech impairments to communicate verbally by using voice synthesizers filtered through computers, including laptops and hand-held devices.

It’s an undeniable fact that people with severe speech and motor impairments are having their lives changed for the better as a result of these amazing advancements in the field of assistive technology and augmentative communications. Some of the more impressive AAC devices and assistiveware applications on the market today include: Proloque, Proloque2Go, KeyStrokes, TouchChat, TouchStrokes, SwitchXS, LayoutKitchen, Minspeak, VisioVoice, GhostReader, Digit-Eyes, Pictello. Go to each products website to learn more about what systems the work on and other details.