Making “Righty” Right Again: - PowerPoint Presentation

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Making “Righty” Right Again:Treatment of Pediatric Hemiparesis

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Megan Blaufuss, OTR/L, MS, CPAM

November 19, 2017

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Background

Pediatric Specialty HospitalProvides comprehensive health care for three populationsPulmonaryFeedingRehabilitationPart of Children’s Health system, which provides full continuum of care

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Objectives

To understand the role of foundational concepts:International Classification of Functioning, Disability and Health (ICF) Model Neuroplasticity Upper Limb Training ProtocolTo understand the efficacy and practical application of specific treatment interventions:Bimanual upper extremity trainingConstraint Induced Movement Therapy (CIMT)Vibration Dynamic orthosesStrapping tapeNeuromuscular electrical stimulation (NMES)

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Foundational Concepts

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International Classification of Functioning, Disability and Health (ICF) Model

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https://

openi.nlm.nih.gov

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Neuroplasticity

Definition: “ability of the nervous system to respond to intrinsic and extrinsic stimuli by reorganizing its structure, function, and connections” (Cramer et al., 2011)Occurs at many levels including:MolecularCellularSystems Behavior Occurs in response to:EnvironmentLearningDiseaseTherapy

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Neuroplasticity in Pediatrics

Injury to developing brain can result in:Changes in synapses and neuronsRestriction of typical development Changes to exposure of activities and experiences during development “Many forms of neuroplasticity are at their maximum during early developmental stages that are exclusive to the developing brain.” (Cramer et al., 2011) Major development occurs in first 2 years of life which could be “critical window” for therapy to be most effective, but this time is often missed (Reid, Rose & Boyd, 2015)

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Principles of Neuroplasticity

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(

Kleim

& Jones, 2008)

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Principles of Neuroplasticity

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(

Kleim

& Jones, 2008)

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Upper Limb Training ProtocolTreatment Progression Hierarchy for Coordinated Movement Practice

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(McCabe et al., 2015)

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Treatment Interventions:Bimanual Upper Extremity Training

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Bimanual Upper Extremity Training - Background

Specific program developed at Columbia University known as hand-arm bimanual intensive therapy (HABIT)Definition: form of functional training utilizing intensive practice (like CIMT) but with focus on bilateral coordination during structured task practice Developed in part due to limitations with CIMT:Invasiveness of restraintAddresses learned non-use but children with hemiplegia have “developmental non-use” Unimanual intervention doesn’t address deficits in bimanual coordination

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(Charles & Gordon, 2006)

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Methodology focuses on:Structured practice with increasing complexityFunctional activities requiring bimanual hand useChild-friendly intervention with emphasis on participant’s goals and parental involvementIncorporates whole-task and part-task practiceWhole-task: activity performed continuously for 15-20 minutesPart-task: symmetrical movements for 30 seconds at a time (typically repeated X 5 trials)Avoids encouraging participants to utilize affected UELack of constraint can make it more challenging for interventionists

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(Charles & Gordon, 2006)

Bimanual Upper Extremity Training - Background

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Bimanual Upper Extremity Training - Background

Inclusion criteria (Gordon et al., 2007):20* wrist and 10* MCP extension from full flexion50% difference between affected and unaffected UE on Jebsen-Taylor Test of Hand functionAbility to lift UE >6 inches from surface of tableScore within 1 SD of mean on Kaufman Brief Intelligence TestFrequency and Intensity:6 hours/day for 10 days with 1 hour home practice ~50% time-on-task

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Brandao et. al, 2013RCT, N = 22Examined HABIT with structured practice group (SPG) vs. unstructured practice group (UPG) – no skill progression in children with hemiplegic CPIntervention consisted of 6 hours/day for 3 weeks (weekdays only) with 1 hour home practice during camp Findings: Participants from both groups demonstrated improvements in dexterity and functional use with no significant differences between groupsIntensive training may not require structured practiceSPG group showed superior improvements in functional goalsBenefit of including goal training

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Bimanual Upper Extremity Training - Background

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Bimanual Upper Extremity Training - Research

Weinstein et. al., 2015Serial test, convenience sample, N = 11Examined neuroplastic changes immediately following and 6 weeks after HABIT in children with hemiplegic CP Intervention consisted of 60 hours of treatment (frequency differed by participant)Findings:Intervention resulted in changes in levels of activation, pattern of lateralization, and white matter integrity (though not in all participants)Intervention also demonstrated a relationship between white matter integrity and manual function which remained significant and actually stronger at follow up

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Bimanual Upper Extremity Training - Research

Gordon et. al., 2011RCT, N = 42Examined HABIT vs. CIMT in children with hemiplegic CPIntervention consisted of 6 hours/day for 3 weeks (weekdays only) with 1 hour home practice during camp as well as during 6 month follow up periodFindings:Similar improvements in primary measures (AHA and JTTHF)Maintained at 6 month follow upHABIT group made better progress on chosen, practiced goals as well as transfer to unpracticed goalsBut CIMT group with greater gains at 6 month post-test

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Bimanual Upper Extremity Training - Research

Deppe et al., 2013RCT, single blind, N = 47Examined effectiveness of mCIMT vs. intensive bimanual training in patients with hemiplegia (multiple diagnoses)Intervention occurred over 4 weeks and consisted of either:60 hours of mCIMT + 20 hours of bimanual training80 hours of bimanual trainingFindings:Both interventions led to significant improvements in hand function (Melbourne and AHA)mCIMT group had significantly better results on Melbourne than bimanual group (no differences in AHA or PEDI)Increased gains for more severely impaired children, especially with mCIMTOutcome not age-dependent

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Bimanual Upper Extremity Training - Research

Cohen-Holzer et al., 2017Non-randomized clinical trial, N = 17Examined bimanual therapy with one hour of constraint (“hybrid”) to conventional bimanual therapy in children with hemiplegic CPIntervention consisted of 6 hours/day for 3 weeks (weekdays only)Findings:Similar and significant improvements in both groups on AHASignificant improvement in Jebsen Taylor in both groups, but hybrid group made improvements with affected hand and conventional group in unaffected hand

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Bimanual Upper Extremity Training - Research

Dong et al., 2013Systematic review comparing efficacy of CIMT vs. bimanul training in children with hemiplegic CP“neither intervention was superior” – all studies described results that were significant and almost identical Bimanual training may have increased influence on child’s daily routine A combination of the two approaches may lead to greater improvements than either approach alone

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Bimanual Upper Extremity Training - Research

In comparison to CIMT (Gordon, 2011):Bimanual may be better for children with:Mild impairmentsInability to graspPoor tolerance to restraintConstraint may be better for children with:Specific impairments (ex. lack of supination)Less than a 1:1 participant to interventionist ratio“Intensity with sufficient repetitions over many hours of training, more so than ingredients, may well be the key to successful training protocols, especially for older children.”“Usual and customary care schedules are not likely intensive enough”

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Bimanual Upper Extremity Training – Demo

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Treatment Interventions:Constraint Induced Movement Therapy (CIMT)

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CIMT - Background

Involves the use of restraint on unaffected UE to force use of affected UEDeveloped in response to learned nonuse – conditioned suppression of movement (Gillen, 2012)Factors:Neurological suppression of movementNegative reinforcement from attempts to use affected sidePositive reinforcement from one-handed performanceRehab emphasis on compensation

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CIMT - Background

“The first demonstration of an alteration in brain structure due to a therapy-induced improvement in movement after CNS damage.” (Gillen, 2012)Produces cortical reorganizationEmpirical evidence of clinical efficacy Supported by controlled randomized studiesImproves daily, real world useEffects sustained for at least 2 years after interventionConsidered “Gold Standard”Anecdotal evidence of neuroplastic changes “spreading” to other areas such as speech and gait (Pidcock et al., 2009)

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CIMT - Research

Chen et al., 2014Systematic review and meta-analysis, N = 27 studies (children with hemiplegic CP)Findings:At post-test, medium effect for activity level, and small effect for participationAt follow-up, medium effect for participation level and small effect for activity Studies with a dose-equivalent comparison group had a smaller effect size than studies withoutHome-based CIMT therapy had largest effect size, followed by clinic and then camp-based Time of follow-up negatively associated with study effect size

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CIMT - Research

Rocca et al., 2013Non-randomized control trial, N = 14Examined effectiveness of CIMT in children with chronic hemiplegia (congenital or acquired BI), as well as MRI results as predictor of treatment successIntervention consisted of constraint for 3 hours/day, 7 days/wk for 10 weeks (both at home and in clinic)Findings:Significant improvement in scores of QUEST and GMFM at end of treatment and 6 months post-interventionMeasures of lesional damage can predict clinical improvement

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CIMT - Research

DeLuca et al., 2012RCT, multi-site, parallel group, N = 18Examined effects of dosage levels of CIMT for children with hemiplegic CPIntervention consisted of either high dosage (6 hours/day) or moderate dosage (3 hours/day) for 3 weeks (24 hour casting)Findings: Both groups showed significant improvement in 7/8 outcome measures (including at 1 month post-test) with no significant differences between groups

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CIMT – Videos

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Treatment Interventions: Vibration

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Vibration - Background

Involves the use of vibratory stimulus to facilitate AROM of specific musclesTwo Types (Constantino, Galuppo, & Romiti, 2014): Whole-bodyRepeated local vibration of a single muscleFunctions:For vibrated muscle: Activates muscle spindles which activates primary afferent sensory fibers (Ia) thus altering excitability of corticospinal pathway (Tavernese et al., 2013) For antagonist muscle: Reducing muscle activity via reciprocal inhibition and supraspinal inhibition (Liepert & Binder, 2010)

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Vibration - Background

Functions (cont’d): May decrease excitability of alpha motor neurons which reduces spasticity (Bae et al., 2012) and hyperactive reflexes (Cordo et al., 2013)Facilitates cortical activation of primary and secondary somatosensory areas and somatosensory thalamus (Bento et al., 2012) as well as primary motor cortex (Tavernese et al., 2013)Increase in cortical excitability demonstrated via TMSTendon vibration may increase the reflex threshold which decreases co-contraction thus improving cortical control of movement (Conrad, Scheidt & Schmit, 2010) May increase synchronization of motor units when coupled with voluntary contraction (Constantino, Galuppo, & Romiti, 2014)

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Vibration - Research

Noma et al., 2012RCT, N = 36Investigated use of vibration on inhibition of spasticity in adults with stroke Intervention consisted of 5 minutes of resting, stretching (maximal extension of elbow, wrist and finger joints), or vibration (applied to flexors of the arm)Findings:Significant differences in vibration group compared to rest and stretch groups for Ashworth scores and F-wave readings (indicates alpha-motor neuron excitability)

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Vibration - Research

Liepert & Binder, 2010Non-randomized pilot study, N= 10 Examined effectiveness of 5 minutes of vibration to forearm extensor muscles on speed to complete Box and Block Test for adults with chronic stroke (spastic hemiparesis) Findings:20% reduction in time needed to complete test after vibration (statistically significant)Results persisted after 5 minutes of restSubjects reported greater ease in opening hand after vibration

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Vibration - Research

Caliandro et al., 2012Pilot RCT, double blind, parallel-group, N = 49Examined clinical effectiveness of repetitive muscle vibration on motor function of arm one month after treatment in adults with chronic strokeIntervention consisted of 3 sessions X 10 minutes over 3 consecutive days for each muscle (pect minor, biceps and FCU)Findings:No changes in pain report or tone between groupsSignificant improvements in Wolf Motor Function Test scores over time only for vibration group

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Vibration - Research

Tavernese et al., 2013RCT, single-blind, N = 44Examined impact of segmental muscle vibration on biceps and flexor carpi ulnaris on upper limb kinematics in adults with stroke Intervention consisted of 60 minutes of PT, 5X/wk for 2 weeks with experimental group receiving 30 additional minutes of vibration at end of each session Findings:Combined vibration and therapeutic exercise leads to significant decrease in “normalized jerk” – smoothness of movement indicative of motor control Experimental group also demonstrated significantly increased velocity of movementDifferences persisted two weeks after completion of therapy

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Vibration - Research

Constantino, Galuppo, & Romiti, 2014Pilot study, single-blind, N = 23Examined short-term effects of repeated muscle low amplitude, high frequency (300 Hz) vibration on ROM, tone, pain and grip strength in adults with chronic strokeIntervention consisted of use of vibration of wrist and elbow extensors for twelve 30 minute sessions over 4 weeksFindings:Significant increase in grip strength and significant decrease in tone for shoulder, elbow and wristSignificant improvements in Jebsen-Taylor Significant improvements in pain reportsImprovements in scores of QuickDASH and FIM (but not significant)

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Vibration - Research

Casale et al., 2014RCT, double-blind, N = 30Examined physiotherapy with vibration vs. physiotherapy alone in adults with chronic stroke Intervention consisted of 60 minute sessions, 5x/wk for 2 weeks, with experimental group receiving additional 30 minutes of vibration to triceps of spastic arm each treatment day Findings:Vibration provided “better and faster” results on MAS as well as improved motor functions as measured by Armeo robotEffects of vibration on spasticity extends at least 48 hours past application

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Vibration - Research

Paolini et al., 2014RCT, N = 22Examined impact of exercise with vibration (biceps and FCU) vs. exercise alone on reaching motion (EMG and kinematics) in adults with chronic strokeIntervention consisted of 60 minute session, 5x/wk for 2 weeks with experimental group receiving additional 30 minutes of vibration after sessionsFindings:Significantly lower co-contraction for elbow and shoulder muscles for vibration groupSignificantly improved muscle activation of anterior deltoid and biceps in vibration groupObserved changes in EMG of vibration group 4 weeks after conclusion of therapy (vibration leads to changes in neuroplasticity)

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Vibration – Videos

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Treatment Interventions: Dynamic Orthoses

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Dynamic Orthoses - Background

New dynamic orthoses were developed in part as a means to achieve wrist and finger extension necessary to participate in CIMT (Hoffman & Blakey, 2011)Specifically designed for those with moderate to severe paresis Intended to be used in conjunction with repetitive task-specific training Emerging research has demonstrated decrease in spasticity May be a due to the belief that muscle activation while muscle on a stretch can reduce sensitivity of stretch reflexImmediately following muscle contraction at a certain length, stable bonds formed between actin and myosin which “resets” the muscle spindle

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Dynamic Orthoses - Research

Farrell et al., 2007Phase 1 trial, N = 13Examined effectiveness of SaeboFlex on UE ROM, tone, and function in adults with chronic strokeIntervention consisted of training for 6 hours/day for 5 days (primarily consisted of training with device, but also included exercises and NMES)Findings: Significant improvements in all shoulder and elbow AROM, and wrist extension; no improvements in wrist flexion or finger extensionSignificant improvements in Fugl-Meyer and Motor Status Assessment, as well as MAS

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Dynamic Orthoses - Research

Jeon et al., 2012Randomized pre-test/post-test control group design, N = 10Assessed feasibility of intensive training using SaeboFlex for adults with chronic strokeIntervention consisted of 1 hour of training with device, 5X/wk for 4 weeks (both groups wore orthosis during intervention, but experimental group completed exercises with grasp/release while control group did not)Findings:Significant improvement in Fugl-Meyer and Box and Blocks scores for experimental group, only improvement in Fugl-Meyer for control group No significant improvements in Action Research Arm Test in either group (fine motor assessment)

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Dynamic Orthoses - Research

Franck, Timmermans & Seelen, 2013Single case experiment (ABA), N = 8Examined feasibility and efficacy of Saeboflex as adjunct to conventional treatment in adults with moderate – severe impairment as a result of sub-acute stroke (< 3 months)Intervention consisted of 45 minutes/day, 5 days/wk for 6 weeks in addition to typical therapy routineFindings:All patients improved on ARAT and ABILHAND, but after detrending for baseline trends, only significant improvement for ABILHANDPatients rated use of Saeboflex very favorably

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Dynamic Orthoses - Research

Stuck, Marshall & Sivakumar, 2014Clinical case series, N = 7Examined feasibility and efficacy of SaeboFlex in adults with acute stroke (< 84 days post-stroke) with moderate/severe weaknessIntervention consisted of at most 3 sessions lasting 45 minutes each day across 12 weeks both in hospital and at home in addition to conventional therapy (actual average daily training time was 20 minutes/day)Findings:All subjects (with exception of one) achieved significant improvements in ARAT and UL Motricity Index

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Dynamic Orthoses – Videos

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Treatment Interventions: Strapping Tape

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Strapping Tape - Background

Involves use of rigid taping to either provide stability (ex. subluxation) or promote appropriate positioning (ex. wrist and finger extension) to support functionRecommend use of cotton tape as a base layer to protect skin with strapping (aka “rigid” tape) placed on top Different type of tape than kinesiotape

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Strapping Tape - Research

Hayner, 2012Interrupted time series quasi-experimental single-subject ABA design, N = 10Examined effectiveness of California Tri-Pull Taping Method for inferior subluxation in adults with strokeIntervention consisted of 9 tapings across 3 weeks (participants were not receiving any concurrent treatment for UE)Findings:Significant increase in shoulder flexion and abduction both during and 2 weeks after interventionReduction in subluxation only significant from baseline to intervention (not post-intervention)Significantly improved scores in ADL function (Katz Index)No significant changes in pain report at rest

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Strapping Tape - Research

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Strapping Tape - Research

Link to YouTube videohttps://drive.google.com/file/d/0B6M0b3zrX4wscWRWajNvSFMyRXM/view?usp=sharingLink to handouthttps://drive.google.com/file/d/0B6M0b3zrX4wscWRWajNvSFMyRXM/view?usp=sharing

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Strapping Tape – Videos

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Treatment Interventions: Neuromuscular Electrical Stimulation

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NMES - Types

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NMES - Types

Neuromuscular electrical stimulation (NMES) “use of pulsed alternating electrical current to stimulate a motor response by depolarizing intact peripheral nerves” Functional electrical stimulation (FES)Subcategory of NMES which utilizes NMES during a functional activityTranscutaneous electrical nerve stimulation (TENS)Technically encompasses all forms of electrical stimulation, but typically involves reduction of pain Electrical Stimulation for Tissue and Wound Repair (ESTR) Involves output of greater than 150 volts

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(

Bracciano

, 2008)

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NMES - Functions

Improves muscle strengthEnhances range of motionInhibits muscle spasticity or spasmsImproves enduranceRe-educates musclesControls edemaReplaces orthoses

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(PAMPCA, LLC)

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NMES - Contraindications

Lower back or uterus during 1st trimesterMetastasisOsteomyelitisThrombosisPatients on diureticsOver craniofacial or cervical region if history of seizure or CVA

Near phrenic nerve or bladder stimulators Over carotid sinusNear diathermy devicesOver or near metal pins, plates or hardwarePatients with infection or active hemorrhageCardiac pacemakers

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(PAMPCA, LLC)

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NMES - Precautions

FractureDecreased sensationDecreased cognitive abilityPregnancySensitive skin

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(PAMPCA, LLC)

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NMES - Age Requirements

The literature does not specifically state at what age it is safe to use“In this clinic, children under 16 months of age are not treated with NMES” Believe other methods are sufficient to help with motor learning (Carmick, 1997)No article reviewed included lower age limit, youngest participants were two days old; suggested younger children may have better tolerance because of absence of anxiety (Bosques et al., 2016)

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NMES - Pathophysiology

NMES targets large, fast twitch muscles first, where as volitional contractions target small, slow twitch muscles first Contractions via NMES are more fatiguing than volitional contractions (Cameron, 2009)

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Fiber Type

Fatigability

Atrophy Tendency

Motor Control

Large, fast twitch

Quick to fatigue

First to atrophy

Gross

movement

Small, slow twitch

Slow to fatigue

Last to atrophy

Fine

movement

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NMES - Pathophysiology

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AFFERENT

EFFERENT

NMES is a “two way street” – efferent (motor nerve) and afferent (GTOs and muscle spindles

)

“Feedback loop may be as important as the actual muscle activation.”

(

Sheffler

&

Chae

, 2007

)

“Often unclear how much of the effectiveness…is due to central versus peripheral mechanisms”

(Merrill, 2009)

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NMES - Research

Hsu et. al, 2010RCT, single-blind, N = 66Compared High NMES (60 min/day), Low NMES (30 min/day), and control in adults with acute strokeFindings:Both NMES groups showed statistically significant improvements on Fugl-Meyer and ARA vs. control, with no significant differences between the two groups“A minimum of 10 hours of NMES in combination with regular rehabilitation may improve recovery of arm function in stroke patients during the acute stage.”

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NMES - Research

Lin & Yan, 2011RCT, single-blind, N = 46 Examined standard treatment vs. standard treatment + NMES in adults with acute strokeNMES group received 30 min/day, 5 days/wk for 3 weeks Findings:Improvements in both groups after 3 weeks on Fugl-Meyer and MAS which persisted for 1, 3, and 6 months after treatmentThe average scores in NMES group statistically better than control group.

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NMES - Research

Hara et. al., 2013 Pilot study, N = 16Examined effects EMG-FES on brain cortical perfusion in adults with chronic strokeIntervention consisted of EMG-FES 1-2x/week for 40 minutes over 5 monthsFindings: Prior to treatment, most subjects showed dominant perfusion in contralesional somatosensory cortexResults show that treatment resulted in dominant perfusion in ipsilesional somatosensory cortex, which resulted in functional improvement in hemiparetic UE

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NMES - Research

McCabe et al., 2015RCT, single-blind, N=39Compared motor earning (ML) training vs. ML + FES vs. ML + robotics in adults with chronic strokeML focused on reducing compensatory movement, massed practice, attention to task and training specificity Treatment occurred for 5 hours/day, 5 days/week for 12 weeks utilizing 1:3 group paradigm (FES and robotics for 1.5 hours/day)Findings:All three groups demonstrated significant improvement in functional measures after treatment, with no differences between groups“Emerging empirical evidence is supporting long-held clinical observation; that is, for recovery of persistent discoordination after stroke, many hours of specifically formulated practice are required.”

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NMES - Research

Howlett, et al., 2015 Systematic review with meta-analysis (included only moderate- to high-quality randomized controlled trials with adults with stroke), N=485 (18 trials, including both upper and lower extremity)Findings:FES improved activity compared with training alone with moderate effect sizeUnable to draw conclusions regarding whether FES improves participation or if benefits are long-lasting

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NMES - Research

Ramos & Zell, 2000 (Miami Children’s Hospital Brachial Plexus Program)ArticleFindings:“Although there have been anecdotal reports as to the efficacy of its use, professional literature and data regarding NMES is still lacking for the treatment of brachial plexus and other major nerve injury.”“In our experience, virtually every child with a peripheral nerve injury benefits at some point during rehabilitation from NMES. The benefits are most obvious when combined with a properly designed program of active and passive range of motion strengthening exercises and functional activities.”

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NMES - Research

Okafor et al., 2008RCT, N = 16Examined conventional therapy (exercises, tactile stimulation, soft tissue manipulation and splinting) vs. NMES in infants with brachial plexus injuryTreatment consisted of 45 mins/day, 3x/wk for 6 weeksFindings:NMES group had statistically significant differences in all outcome measures (shoulder abduction, elbow flexion, wrist extension and arm circumference)

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CIMT - Research

Xu et al., 2012RCT, single-blind, N = 68Examined effectiveness of three treatment groups in children with hemiplegic CP:CIMT (3 hours/day, 5 days/wk for 2 weeks + 1 hour at home which extended to 2 hours for 6 months after intervention)CIMT plus NMES (20 minutes/day, 5 days/wk for 2 weeks on wrist and finger extensors)Traditional OT (same frequency as CIMT – involved NDT, motor learning, stretching, strength, coordination, etc.)Findings:CIMT plus NMES group showed greater rate of improvement in UE test scores at each follow upCIMT plus NMES showed greater rate of improvement in Peabody visual-motor integration subtestAll three groups showed improvements at 6 months on social life ability scale with no significant differences between groups, but trend favored CIMT plus NMES group

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CIMT - Research

Xu et al., 2015RCT, single-blind, N = 23Examined effectiveness of three treatment groups in children with hemiplegic CP:CIMT (3 hours/day, 5 days/wk for 2 weeks)CIMT plus NMES (20 minutes/day, 5 days/wk for 2 weeks on wrist and finger extensors)Traditional OT (3 hours/day, 5 days/wk for 2 weeks)All involved addition of 1 hour/day of home practice which extended to 2 hours/day for 6 months post-interventionFindings: All three groups demonstrated significant improvement in EMG readings of wrist extensors and co-contraction ratio, with greatest rate of improvement in NMES group EMG findings positively correlated to scores of UE functional test and grip strength

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NMES - Research

Gudlavalleti et. al., 2015 Non-randomized clinical trial, N = 126Examined effectiveness of CIMT vs. NMES in adults with stroke Intervention 8 weeks long and consisted of: CIMT - restraint for 4-6 hours/day while performing ADLs, grasp/release, etc NMES – two 30 minute sessions/day on wrist and finger extensors (prepped with PROM and stretching)Findings:Both groups showed significant improvements in all four outcome measures at 2 and 4 month follow up (no significant difference between groups)

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NMES - Research

Bosques, et al., 2016 Systematic review of use of NMES in children with disabilities, N = 37 articlesFindings:Articles indicate NMES can increase muscle strength in hemiparetic UE in children with CP (“clinical significance is unknown”)Articles indicate combined use of BTX and NMES potentially improves function and motor control, compared to BTX aloneArticles indicate that children with hemi CP, TBI or stroke with decreased UE function may benefit from NMES for 20 mins/day, 5 days/week for 2-6 weeks

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NMES - Research

Bosques, et al., 2016 Findings: No adverse reactions were reported in most of the students, and one study reported that patients receiving NMES had improved tolerance of stretching and therapies (for skin irritation recommended hypoallergenic electrodes)“ES should be incorporated into therapies to maximize functional progress in order to assist cortical-reorganization, train for appropriate motor patterns, and to maximize neurodevelopmental skills for upper and lower extremity function and gait in children.”

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NMES - Parameters

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https://

quizlet.com

/56970630/therapeutic-modalities-e-

stim

-flash-cards/

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NMES - Parameters

AmplitudeDistance of rise above or below baseline of each pulseLevel of intensityTypically measured in milliamperesFor NMES, must be high enough to elicit motor response (PAMPCA, LLC)

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https://

www.medco-athletics.com

/

lectureseries

/

electro.html

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NMES - Parameters

For children with orthopedic issues…If goal is strengthening, use highest intensity tolerableIf goal is muscle re-education, use mild tonic contraction to cue appropriate movement (PAMPCA, LLC)

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NMES - Parameters

Pulse DurationLength of time required to complete the wave shapeTypically between 200-300 microsecondsCyclingApplies when using two channelsAlternate – channels fire opposite one anotherSynchronous – channels fire at same time (PAMPCA, LLC)

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NMES - Parameters

Ramp Time Lead time before wave reaches its peakMay need to increase ramp time with spastic musclesUsually between 1.0-2.0 seconds (PAMPCA, LLC)Rate Number of pulse cycles being deliveredGenerally expressed in pulses per second (pps)Usually between 20-50, most common for UE is 35 (Bracciano, 2008)

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NMES - Parameters

Duty Cycle Also known as on/off ratioAmount of time stimulation is being delivered compared to amount of time stimulation is offOften expressed as a ratio (1:1, 1:2, etc)As condition improves, can increase duty cycle (Bracciano, 2008)

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NMES - Patient Comfort

Studies examining whether differences in currents, waveforms and devices affect patient comfort have been inconclusiveEncourage relaxation of antagonists When voluntary contraction is coupled with stimulated contraction, appears to lead to better tolerance (PAMPCA, LLC)

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NMES - Accomodation and Polarity

AccomodationAutomatic rise in threshold of excitation that occurs in tissuesMay need to increase intensity of stimulation after 5-10 minutes (PAMPCA, LLC)Polarity Not applicable when using symmetrical waveformWith asymmetrical waveform, want to use negative (stimulating) electrode over motor unit Motor unit is the motor neuron along with motor fibers it innervates (PAMPCA, LLC)

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NMES - Electrodes

Must have adequate contact with skinDensity of current is inversely related to size of electrode (small electrodes allow for stronger physiological response, but also have greater perception of stimulation)Use of larger electrode on positive lead may increase patient comfort Make sure skin is cleanThe greater the distance between electrodes, the deeper the currentShould be placed no closer together than one half the diameter of the electrode (PAMPCA, LLC)

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NMES - Electrodes

Greater effectiveness when electrodes placed parallel to muscle fibersAvoid removing by pulling on the wires, and if trimming electrode, do not cut through wireApply few drops of tap water to tacky side when beginning to dry outThrow away once no longer adhesive (PAMPCA, LLC)Can use ultrasound gel to improve conductivity or to assist when finding motor unit

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NMES - Documentation

Treatment goalElectrode placementTreatment timeOn/Off timeRamp timeIntensity

Subjective patient commentsObjective observations related to movementPatient response to treatment (Bracciano, 2008)

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NMES - Units

Saebo AvivaStimCost: $195 (or $58 over 4 months)Pros:Has a triggerDoes not lose intensity when pausedCons:Must use preset programsDoes not allow for asymmetrical programsCannot use with small (1.375” electrodes)

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NMES - Units

ProM-720 TENS & Electro Muscle Stimulation Combination UnitCost: $46.95Pros:Has preset or customizable programs (including asymmetrical)Reasonably pricedCan use all sizes of electrodesCons:Can be difficult to configure

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NMES - Units

Empi

UnitsCost: varies (~$350.00)Pros:Has preset or customizable programs (including asymmetrical)Fairly easy to program Can use all sizes of electrodesCons:No longer commercially available by companyDoes not have a trigger

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NMES – Videos

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Final questions?Time to play!megan.blaufuss@childrens.com

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