Electrical stimulation of gluteus maximus in children with cerebral palsy: effects on gait characteristics and muscle strength

Addressing gross motor function by functional repetitive neuromuscular magnetic stimulation targeting to the gluteal muscles in children with bilateral spastic cerebral palsy: benefits of functional repetitive neuromuscular magnetic stimulation targeting the gluteal muscles

Background

Impaired selective motor control, weakness and spasticity represent the key characteristics of motor disability in the context of bilateral spastic cerebral palsy. Independent walking ability is an important goal and training of the gluteal muscles can improve endurance and gait stability. Combining conventional physical excercises with a neuromodulatory, non-invasive technique like repetitive neuromuscular magnetic stimulation probably enhances effects of the treatment. This prospective study aimed to assess the clinical effects of repetitive neuromuscular magnetic stimulation in combination with a personalized functional physical training offered to children and adolescents with bilateral spastic cerebral palsy.

Methods

Eight participants Gross Motor Function Classification System level II and III (10.4 ± 2y5m; 50% Gross Motor Function Classification System level II) received a personalized intervention applying functional repetitive neuromuscular magnetic stimulation (12 sessions within 3 weeks; 12,600 total stimuli during each session). At baseline and follow up the following assessments were performed: 10-m-walking-test, 6-min-walking-test, GMFM-66. Six weeks after the end of treatment the patient-reported outcome measure Gait Outcome Assessment List was completed.

Results

GMFM-66 total score improved by 1.4% (p = 0.002), as did scoring in domain D for standing (1.9%, p = 0.109) and domain E for walking, jumping and running (2.6%, p = 0.021). Gait speed or distance walked during 6 min did not improve from baseline to follow up. Patient-reported outcome showed improvement in 4 patients in altogether 14 ratings. Caregiver-reported outcome reported benefits in 3 participants in altogether 10 ratings.

Conclusion

Repetitive neuromuscular magnetic stimulation promises to be a meaningful, non-invasive treatment approach for children and adolescents with bilateral spastic cerebral palsy that could be offered in a resource-efficient manner to a broad number of patients. To further investigate the promising effects of repetitive neuromuscular magnetic stimulation and its mechanisms of action, larger-scaled, controlled trials are needed as well as comprehensive neurophysiological investigations.

Neuromuscular electrical stimulation to augment lower limb exercise and mobility in individuals with spastic cerebral palsy: A scoping review

Background: Neuromuscular Electrical Stimulation (NMES) is an emerging assistive technology applied through surface or implanted electrodes to augment skeletal muscle contraction. NMES has the potential to improve function while reducing the neuromuscular impairments of spastic cerebral palsy (CP). This scoping review examines the application of NMES to augment lower extremity exercises for individuals with spastic CP and reports the effects of NMES on neuromuscular impairments and function in spastic CP, to provide a foundation of knowledge to guide research and development of more effective treatment.

Methods: A literature review of Scopus, Medline, Embase, and CINAHL databases were searched from 2001 to 2 November 2021 with identified inclusion and exclusion criteria.

Results: Out of 168 publications identified, 33 articles were included. Articles on three NMES applications were identified, including NMES-assisted strengthening, NMES-assisted gait, and NMES for spasticity reduction. NMES-assisted strengthening included the use of therapeutic exercises and cycling. NMES-assisted gait included the use of NMES to improve gait patterns. NMES-spasticity reduction included the use of transcutaneous electrical stimulation or NMES to decrease tone. Thirteen studies investigated NMES-assisted strengthening, eleven investigated therapeutic exercise and demonstrated significant improvements in muscle structure, strength, gross motor skills, walking speed, and functional mobility; three studies investigated NMES-assisted cycling and demonstrated improved gross motor skills and walking distance or speed. Eleven studies investigated NMES-assisted gait and demonstrated improved muscle structure, strength, selective motor control, gross motor skills, and gait mechanics. Seven studies investigated NMES for spasticity reduction, and five of the seven studies demonstrated reduced spasticity.

Conclusion: A growing body of evidence supports the use of NMES-assisted strengthening, NMES-assisted gait, and NMES for spasticity reduction to improve functional mobility for individuals with spastic CP. Evidence for NMES to augment exercise in individuals with spastic CP remains limited. NMES protocols and parameters require further clarity to translate knowledge to clinicians. Future research should be completed to provide richer evidence to transition to more robust clinical practice.

Neuromuscular electrical stimulation to improve gross motor function in children with cerebral palsy: a meta-analysis

OBJECTIVE

To systematically review the effectiveness of neuromuscular electrical stimulation (NMES) as an adjuvant therapy to improve gross motor function in children with spastic cerebral palsy.

METHODS

MEDLINE, EMBASE, Cochrane CENTRAL, PEDro and Scopus were searched. We included randomized controlled trials examining the effects of NMES combined with other therapies on gross motor function as assessed by the Gross Motor Function Measure (GMFM) and its functional dimensions. Two reviewers independently screened, extracted data, assessed the risk of bias (PEDro) and quality of the evidence (GRADE).

RESULTS

Six randomized controlled trials (pooled n=174) were included in the meta-analysis. NMES combined with other therapies presented medium effect size to improve gross motor function in children with cerebral palsy in comparison with conventional physical therapy or neurodevelopmental therapy. Our sensitivity analysis showed that NMES combined with other therapies was effective to improve GMFM-sitting and standing dimensions but not GMFM-walking dimension.

CONCLUSION

Low-quality evidence suggests that NMES may be used as adjuvant therapy to improve sitting and standing dimensions of GMFM in children with spastic cerebral palsy.

Exercise interventions for cerebral palsy

BACKGROUND

Cerebral palsy (CP) is a neurodevelopmental disorder resulting from an injury to the developing brain. It is the most common form of childhood disability with prevalence rates of between 1.5 and 3.8 per 1000 births reported worldwide. The primary impairments associated with CP include reduced muscle strength and reduced cardiorespiratory fitness, resulting in difficulties performing activities such as dressing, walking and negotiating stairs.Exercise is defined as a planned, structured and repetitive activity that aims to improve fitness, and it is a commonly used intervention for people with CP. Aerobic and resistance training may improve activity (i.e. the ability to execute a task) and participation (i.e. involvement in a life situation) through their impact on the primary impairments of CP. However, to date, there has been no comprehensive review of exercise interventions for people with CP.

OBJECTIVES

To assess the effects of exercise interventions in people with CP, primarily in terms of activity, participation and quality of life. Secondary outcomes assessed body functions and body structures. Comparators of interest were no treatment, usual care or an alternative type of exercise intervention.

SEARCH METHODS

In June 2016 we searched CENTRAL, MEDLINE, Embase, nine other databases and four trials registers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of children, adolescents and adults with CP. We included studies of aerobic exercise, resistance training, and 'mixed training' (a combination of at least two of aerobic exercise, resistance training and anaerobic training).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and potentially relevant full-text reports for eligibility; extracted all relevant data and conducted 'Risk of bias' and GRADE assessments.

MAIN RESULTS

We included 29 trials (926 participants); 27 included children and adolescents up to the age of 19 years, three included adolescents and young adults (10 to 22 years), and one included adults over 20 years. Males constituted 53% of the sample. Five trials were conducted in the USA; four in Australia; two in Egypt, Korea, Saudi Arabia, Taiwan, the Netherlands, and the UK; three in Greece; and one apiece in India, Italy, Norway, and South Africa.Twenty-six trials included people with spastic CP only; three trials included children and adolescents with spastic and other types of CP. Twenty-one trials included people who were able to walk with or without assistive devices, four trials also included people who used wheeled mobility devices in most settings, and one trial included people who used wheeled mobility devices only. Three trials did not report the functional ability of participants. Only two trials reported participants' manual ability. Eight studies compared aerobic exercise to usual care, while 15 compared resistance training and 4 compared mixed training to usual care or no treatment. Two trials compared aerobic exercise to resistance training. We judged all trials to be at high risk of bias overall.We found low-quality evidence that aerobic exercise improves gross motor function in the short term (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.02 to 1.04, N = 65, 3 studies) and intermediate term (mean difference (MD) 12.96%, 95% CI 0.52% to 25.40%, N = 12, 1 study). Aerobic exercise does not improve gait speed in the short term (MD 0.09 m/s, 95% CI -0.11 m/s to 0.28 m/s, N = 82, 4 studies, very low-quality evidence) or intermediate term (MD -0.17 m/s, 95% CI -0.59 m/s to 0.24 m/s, N = 12, 1 study, low-quality evidence). No trial assessed participation or quality of life following aerobic exercise.We found low-quality evidence that resistance training does not improve gross motor function (SMD 0.12, 95% CI -0.19 to 0.43, N = 164, 7 studies), gait speed (MD 0.03 m/s, 95% CI -0.02 m/s to 0.07 m/s, N = 185, 8 studies), participation (SMD 0.34, 95% CI -0.01 to 0.70, N = 127, 2 studies) or parent-reported quality of life (MD 12.70, 95% CI -5.63 to 31.03, n = 12, 1 study) in the short term. There is also low-quality evidence that resistance training does not improve gait speed (MD -0.03 m/s, 95% CI -0.17 m/s to 0.11 m/s, N = 84, 3 studies), gross motor function (SMD 0.13, 95% CI -0.30 to 0.55, N = 85, 3 studies) or participation (MD 0.37, 95% CI -6.61 to 7.35, N = 36, 1 study) in the intermediate term.We found low-quality evidence that mixed training does not improve gross motor function (SMD 0.02, 95% CI -0.29 to 0.33, N = 163, 4 studies) or gait speed (MD 0.10 m/s, -0.07 m/s to 0.27 m/s, N = 58, 1 study) but does improve participation (MD 0.40, 95% CI 0.13 to 0.67, N = 65, 1 study) in the short-term.There is no difference between resistance training and aerobic exercise in terms of the effect on gross motor function in the short term (SMD 0.02, 95% CI -0.50 to 0.55, N = 56, 2 studies, low-quality evidence).Thirteen trials did not report adverse events, seven reported no adverse events, and nine reported non-serious adverse events.

AUTHORS' CONCLUSIONS

The quality of evidence for all conclusions is low to very low. As included trials have small sample sizes, heterogeneity may be underestimated, resulting in considerable uncertainty relating to effect estimates. For children with CP, there is evidence that aerobic exercise may result in a small improvement in gross motor function, though it does not improve gait speed. There is evidence that resistance training does not improve gait speed, gross motor function, participation or quality of life among children with CP.Based on the evidence available, exercise appears to be safe for people with CP; only 55% of trials, however, reported adverse events or stated that they monitored adverse events. There is a need for large, high-quality, well-reported RCTs that assess the effectiveness of exercise in terms of activity and participation, before drawing any firm conclusions on the effectiveness of exercise for people with CP. Research is also required to determine if current exercise guidelines for the general population are effective and feasible for people with CP.

Effectiveness of Rehabilitation Interventions to Improve Gait Speed in Children With Cerebral Palsy: Systematic Review and Meta-analysis

BACKGROUND

Children with cerebral palsy (CP) have decreased gait speeds, which can negatively affect their community participation and quality of life. However, evidence for effective rehabilitation interventions to improve gait speed remains unclear.

PURPOSE

The purpose of this study was to determine the effectiveness of interventions for improving gait speed in ambulatory children with CP.

DATA SOURCES

MEDLINE/PubMed, CINAHL, ERIC, and PEDro were searched from inception through April 2014.

STUDY SELECTION

The selected studies were randomized controlled trials or had experimental designs with a comparison group, included a physical therapy or rehabilitation intervention for children with CP, and reported gait speed as an outcome measure.

DATA EXTRACTION

Methodological quality was assessed by PEDro scores. Means, standard deviations, and change scores for gait speed were extracted. General study information and dosing parameters (frequency, duration, intensity, and volume) of the intervention were recorded.

DATA SYNTHESIS

Twenty-four studies were included. Three categories of interventions were identified: gait training (n=8), resistance training (n=9), and miscellaneous (n=7). Meta-analysis showed that gait training was effective in increasing gait speed, with a standardized effect size of 0.92 (95% confidence interval=0.19, 1.66; P=.01), whereas resistance training was shown to have a negligible effect (effect size=0.06; 95% confidence interval=-0.12, 0.25; P=.51). Effect sizes from negative to large were reported for studies in the miscellaneous category.

LIMITATIONS

Gait speed was the only outcome measure analyzed.

CONCLUSIONS

Gait training was the most effective intervention in improving gait speed for ambulatory children with CP. Strength training, even if properly dosed, was not shown to be effective in improving gait speed. Velocity training, electromyographic biofeedback training, and whole-body vibration were effective in improving gait speed in individual studies and warrant further investigation.

Neuromuscular electrical stimulation versus volitional isometric strength training in children with spastic diplegic cerebral palsy: a preliminary study

BACKGROUND

To date, no reports have investigated neuromuscular electrical stimulation (NMES) to increase muscle force production of children with cerebral palsy (CP) using high-force contractions and low repetitions.

OBJECTIVE

The aims of this study were to determine if isometric NMES or volitional training in children with CP could increase muscle strength and walking speed and to examine the mechanisms that may contribute to increased force production.

METHODS

Eleven children with spastic diplegia were assigned to an NMES training group or to a volitional training group. Participants in the NMES group had electrodes implanted percutaneously to activate the quadriceps femoris and triceps surae muscles. The volitional group trained with maximal effort contractions. Both groups performed a 12-week isometric strength-training program. Maximum voluntary isometric contraction (MVIC) force, voluntary muscle activation, quadriceps and triceps surae cross-sectional area (CSA), and walking speed were measured pre- and post-strength training.

RESULTS

The NMES-trained group had greater increases in normalized force production for both the quadriceps femoris and triceps surae. Similarly, only the NMES group showed an increase in walking speed after training. Changes in voluntary muscle activation explained approximately 67% and 37% of the changes seen in the MVIC of the NMES and volitional groups, respectively. Quadriceps femoris maximum CSA increased significantly for the NMES group only.

CONCLUSIONS

This study was the first to quantitatively show strength gains with the use of NMES in children with CP. These results support the need for future experimental studies that will examine the clinical effectiveness of NMES strength training.