Вы находитесь на странице: 1из 11

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1

Name of the Candidate and Address

Name of the Institution

Course of Study and Subject

Date of Admission to the Course

SHWETA MADAKE
MangalwarPeth;
Nandniker Galli ; Miraj- 416410
Maharashtra.
Goutham College Of Physiotherapy.
Master of PhysiotherapyPediatric Physiotherapy
27/6/2011

Title of the Topic EFFECTIVENESS OF NEUROMUSCULAR ELECTRICAL STIMULATION OVER


FUNCTIONAL PROGRESSIVE RESISTANCE EXERCISE IN IMPROVING MOBILITY

IN SPASTIC DIPLEGIC CHILDREN.


Brief Resume of the Intended Work :
6.1 Need of the study :
The cerebral palsy is a permanent but not unchanging neurodevelopmental disorder
caused by a non progressive defect or lesion in single or multiple locations in the immature brain.
The defect or lesion occur in utero or during or shortly after birth and produces motor impairment
and possible sensory deficits that are usually evident in early infancy.; 1
Cerebral palsy is a condition with multiple causes leading to damage to the central
nervous system. Also certain prenatal, perinatal and postnatal factors have been associated with
Cerebral palsy.2 Asphyxiating birth complications, disorder of coagulation, intrauterine exposure
to infection or inflammation are associated with increased risk of Cerebral palsy .3
Insufficient cerebral perfusion, cytokine mediated damage, triggered by maternal infection,
neonatal infection and neonatal oxygen induced or ventilator induced lung injury are also some of
the causes.4
Cerebral palsy has been classified in a number of ways. A classification based on the area
of the body exhibiting motor impairment yields the designations of monoplegia(one limb),
diplegia (lower limb), hemiplegia ( upper and lower limbs on one side of body) and quadriplegia (

all four limbs). Another classification, based on the most obvious movement abnormalities
resulting from common brain lesions yields spastic, dyskinetic and ataxic types. The degree of
severity of cerebral palsy varies greatly, and the designations mild, moderate, severe are often
applied within types. The gross motor function classification system(GMFCS) is a five level, age
categorized system that places children with cerebral palsy into categories of severity that
represent clinically meaningful distinctions in motor function.5
Although the proportions of the various subtypes of cerebral palsy vary with the reporting
source a study from Sweden reported that hemiplegia accounted for 36.4%,diplegia41.5%,quadriplegia-7.3%,dyskinesia-10%,ataxia-5%.6
Spastic diplegia historically known as Little disease ,is a form of cerebral palsy that is a
neuromuscular condition of hypertonia and spasticity in the muscles of lower extremities of the
human body usually those of legs ,hips and pelvis.7
An electrical current is a flow of charged particles. The charged particles may be either
electrons or ions .Electrical currents have been applied to biological systems to change
physiological processes.8
During 1830 Faraday discovered that bidirectional electrical currents could be induced by a
moving magnet .He called this current Faradic current .Faradic current can be used to produce
muscle contraction.10 Today electrical stimulation has a wide range of clinical applications in
rehabilitation. These include muscle strengthening,11,12, pain control,

13,14,

Facilitating the healing

of recalcitrant wounds15, & resolution of edema. and inflammatory reactions following injury or
surgery.16
According to the specificity theory since electrical stimulation causes larger fast
twitch(type2) muscle fibers ,electrical stimulation should be able to produce greater strength
gains.17,18,19

HYPOTHESIS
Experimental HypothesisThere will be significant improvement in mobility of Spastic diplegic children by stimulating
gluteus maximus; gluteus medius, quadriceps and tibialis anterior muscle by neuromuscular

electric stimulation over functional progressive resistance exercise.


Null HypothesisThere will be no significant improvement in mobility of Spastic diplegic children by
stimulating Gluteus maximus, Gluteus medius , Quadriceps and tibialis anterior muscle by
neuromuscular electric stimulation over functional progressive resistance exercise
6.2 Review of Literatures
Kerr et al.53 performed a randomized trial of ES in CP.NMES & TES were used to
strengthen the quadriceps in 60 children with CP. Eighteen children were in the NMES group,20
in the TES group,&22 in the placebo group. NMES was applied for 1 hour per day,5 days per
week,& TES was applied 8 hours per night for 5 nights per week .No statistically significant
difference in strength or function was observed for either NMES or TES versus placebo
statistically significant differences were found between both NMSE & TES versus placebo for
impact on disability at the end of 16 week of treatment ,but only between TES & placebo at the
end of 6-week follow-up.The authors concluded that the use of surface electrodes resulted in the
stimulation of non receptors, consequently limiting the intensity of stimulation to patient
tolerance & reducing the level of muscular contraction attainable.53 of interest is that these
author used an objective measure of compliance with ES programs(using a timer in the
stimulator)&the recorded compliance was substantially lower than that previously self-reported.
Kang et al. 54 assessed that additive effect of adjuvant ES (surface stimulations on the
gastrocnemius) on botulinum toxin A (BoNT-A) injection for spastic calf muscles in children with
CP. Partial denervation of spastic muscle by BoNT-A diminishes hyper excitability

and

hypertonicity and improves motor control and gait ability. Also relaxation of spastic muscles
facilitate limb growth and reduces the frequencies of fixed contractures.ES improves ROM
,strengthens muscles, and reduces spasticity . it also accelerate the internalization of BoNT-A into
the nerve terminals .55 stimulation was applied for 30 minute ,twice per week ,for
2weeks.Eighteen children with CP dynamic foot equines were injected with BoNT-A into the
calf; seven of these participants also received electrical stimulation. A significant increase in
passive ROM was noted 2 weeks after injection in the treatment group and after 3 months in
both groups. subscales of the physicians rating scale were

significantly

improved in the

treatment group ,but not in the control group ,3 month after injection .The authors concluded that

adjuvant electrical stimulation for a short period after BoNT-A injection had a positive effect on
early improvement in ROM and maintenance of gait.
Stackhouse et al.56 performed a preliminary study to compare volitional isometric strength
training versus isometric NMES in children with spastic diplegic CP. This was an evaluations of
NMES to increase muscle strength in CP using high force contractions with low repetitions. low
muscle force in children with CP may be caused by decreased CNS motor unit recruitment and
discharge rates,.increased antagonist co- activation during agonist contractions ,and changes in
muscle morphology, including atrophy. There has been a bias against strength training for patient
with CNS dysfunction because of the substantiated belief that high effort voluntary contractions
may increase muscle spasticity. The NMES techniques used in this study entailed implanting
percutaneous electrodes in the quadriceps femoris and triceps surae. Eleven children with cerebral
palsy were assigned to either an NMES group or volitional group (who trained with maximal
effort contraction force) with low repetitions (1x15,15s on and 45s off, thrice weekly).The
NMES group had greater increases in normalised force production in both muscle groups ,and
only the NMES group had increased walking speed. The authors hypothesized that the increased
force production with NMES is due to the ability to train at force levels beyond what can be
produced volitionally.
Katz etal.57 reported on enhancement of muscle activity by ES in cp as a case control
study. The objective was to compare the effects of low-level stimulation of the quadriceps in
children with cp under two conditions: reconditioning by long-term training of the muscle versus
real time assist to the muscle during motion (neural orthosis mode).In the long term mode; the
muscle has been reported to Undergo fiber transformation from fast-to-slow-twitch, increasing in
strength and decreasing spasticity.58 In the neural orthosis mode, muscle force is increased
because of the combined effects of volitional and electrically assisted activation. Five children
were evaluated. Surface stimulation was used. There was significant increase in motion activity
and a decrease in motion jerk in both modes. there was a significant decrease in quadricepshamstrings co-contraction following long term training, but not during stimulation-assisted
motion. 5-Carmick41 reported on the clinical use of NMES for children with cerebral palsy.
NMES was applied to the lower extremities of three children, using different muscles. This was
used with a task- oriented model of motor learning, along with physical therapy .All three

children demonstrated rapid functional changes along with increase in muscle strength.
Daichman et al.43 reported case study on the effects of an NMES home programe on
impairments and functional skills of a child with spastic diplegic cerebral palsy. They concluded
that NMES may allow a child with poor motor control to participate in a progressive strengthtraining programme. nmes may also lead to motor learning. Daichman et al studied the effects of
NMES applied to the quadriceps every other day for 6 weeks .After treatment, quadriceps
strength increased substantially but hamstring spasticity decreased. The child demonstrated
several newly attained skills.
Van der Linden et al.44 evaluated ES of the gluteus maximus in children with cerebral
palsy and effects on gait characteristics and muscle strength. Gluteus maximus stimulation was
studied in22 children for the purpose of improving hip extensor strength, decreasing excessive
passive and dynamic internal hip rotation, and improving gross motor function .Eleven children
were in the stimulation group and eleven were in the control group. Surface stimulation was
used .parents of seven of the 11 treated children thought treatment made significant difference.
Barbos et al.39 evaluated the therapeutic effects of ES on manual function of two children
with CP. Children with CP develop movement disorders not only because of the primary
neurological deficit but also because of secondary adaptations. 40 Muscle weakness and
alterations in passive stiffness are common. Stimulation of the wrist extensors or extensors and
flexors was performed in two children using surface stimulation. Significant performance gains
were observed in both children, especially with combined extensor and flexor stimulation.
Kamper et-al.38 reported on the effects of NMES treatment with respect to potential
impairment mechanisms. This pilot study evaluated eight patients with CP who received 3 months
of NMES targeting wrist flexor and extensor muscles .The goal was to examine quantitatively the
impact of NMES on potential impairment mechanisms. Surface stimulation was applied to the
wrist extensors and flexors. Seven of eight participants demonstrated significant improvement in
wrist extention ROM as well as extensor strength.
Daichman,joni DPT, JOHNSTON, Therese E MSPT ,Evans, Kelly MSPT,
Techlin ,Jan Stephen PT NMES was administered to the rt quadriceps muscle every other day
for 6 weeks. Pre and post testing include assessment of strength using a hand held dynamometer,

spasticity using a kin com, isokinetic dynamometer ,gait spatiotemporal parameters using GAIT
Rite R &functional motor performance with the use of the pediatric evaluation of Disability
Inventary (PEPI).

These findings indicate that neuromuscular electric stimulation was an

effective therapeutic technique to improve strength and motor function of a child with spastic
diple
Developmental medicine and child neurology Volume 52 ,2010- Fifty one children with
spastic uni and bilateral cp were randomized to the intervention group. The intervention group
trained for 12 weeks, three times a week, on a five exercise circuit, which included a leg press
and functional exercises. The training load progressively increased based on the childs maximum
level of strength, determined by the eight repetition maximum.Muscle strength, mobility and
spasticity were evaluated before, during, directly after and 6 weeks after the end of training by
blinded research assistants.
6.3 Objectives of the study :

To find the effect of neuromuscular electric stimulation of Gluteus maximus, Gluteus


medius, Quadriceps and Tibialis anterior muscle in improving the mobility of spastic

diplegic children.
To find the effect of functional progressive resistance exercise in improving the mobility

of spastic diplegic children.


To compare the effectiveness of neuromuscular electric stimulation of Gluteus maximus,
Gluteus medius, Quadriceps and Tibialis anterior muscle over functional progressive
resistance exercises in improving he mobility of spastic diplegic children.

7.1

Source of Data
Subjects for the study will be selected from Goutham Physiotherapy And

Rehabilitation Centre; Swanthana children home and Karnataka spastic society Bangalore.
Methods of Collection of DataPrimary data will be collected from the subjects and 30 subjects with Spastic diplegic
children will be included for the study based on the selection criteria
Study design

This study is an Experimental study design involving the pre and post test analysis of
data.
Sampling methodThirty subjects for the study will be selected on the basis of Convenient Sampling (NonProbability)method.
Materials used

Bed sheet roll

Parallel bar

Stool according to height of child

Firm and compliant floor mats

Stairs

Weight cuffs

Inclusion Criteria

Spastic diplegic children.

Level 2 and 3 according to Gross Motor Function Classification(GMFC).

Children with age group between 4-8 years.

Ambulatory children.

Both male and female children.

Exclusion Criteria

Mentally retarded spastic diplegic. Children.

Any other type of cerebral palsy children.

Children with any other systemic illness.

Children with congenital deformities.

Children with contractures and deformities in lower limbs.

Parameters:
Mobility of spastic diplegic children will be considered s the parameter of the study and it
will be assessed using the

Sit to stand test

Lateral step up test

7.3 Intervention to be conducted on participants(methodology):


30 Subjects will be selected based on selection criteria. They will be divided into two
groups namely Group-1 and Group-2 consisting of 15 subjects each. The

parents will be

informed about the treatment procedure before assessment.


Group-1 will receive the following Conventional Physiotherapy daily for duration of 12 weeks.
Icing and stretching to hip adductors, hip flexors; knee flexors and plantar flexors for 10
minutes. Each stretching will be given for 2 - 3 repetitions with 5 secs of rest in between. weight
bearing exercise in developmental pattern like kneeling half kneeling etc. Bilateral leg press-it
will be given for 10 repetitions .Stepping Exercise-It will be given with the subjects stepping up
and down on one or two steps. Sitting to Standing-It will be given by making the patient to be
seated on a stool and then making the subject to stand which will be repeated for 5 counts. Gait
training will be given initially in the parallel bar and then trained outside the parallel bar for a
duration of 10 minutes.
Following conventional physiotherapy various activities of functional progressive resistance
exercise will be given as follows:
Each training session consisted of one exercise on a child adapted leg press (Enraf Nonius, Delft,
the Netherlands) and three functional exercises(sit to stand, lateral step up, half knee rise)loaded

with a weighted vest. During the training, intensity progressively increased, based on repeated
estimation of the eight repetition maximum.
Group-2 (Experimental group) will receive the above mentioned conventional Physiotherapy
and neuromuscular electric stimulation will be additionally given alternate day for duration of 12
weeks.
Prior to the neuromuscular electric stimulation the following preparations will be done.
-Before every treatment neuromuscular electric stimulator machine tested.
-Electrodes should be cleaned properly.
The subjects will be given neuromuscular electric stimulation to Quadriceps, Gluteus maximus,
Gluteus medius and tibialis anterior muscle bilaterally with mild visible contractions with pulse
frequency 35-80pps pulse duration 150-200 micro seconds,10-20 min to produce 10-20
repetitions.
While giving neuromuscular electric stimulation to muscles subjects are kept at positions- Supine
with slightly knee flexed by keeping pillow below the knee for Quadriceps muscle, prone position
for Gluteus maximus muscle, side lying position for Gluteus medius muscle, supine with foot out
of couch for Tibialis anterior muscle.

Statistical AnalysisThe effectiveness of treatment given within the groups will be analyzed statistically using
Dependent t Test and the significant difference between the groups will be analyzed using
Independent t test.
Ethical clearanceEthical permission for the study will be obtained from the institution where the subject
belongs to. A written consent will be taken from each subject who participates in the study.
8

List of References:1) scherzer & T scharnuter 1990: Early Diagnosis & Therapy in cerebral palsy. A primer on
Infant Developmental problems,2nd ed. NEWYORK : Marcel Dekker 1990.

2) Torts,CP,Vanden Berg,BJ &Oechsli,FW. Prenatal & Perinatal factors in the etiology of


CP. Journal of pediatrics 116:615 619,1990.
3) Nelson KB. The epidemiology of CP in term Infants, mental retardation &
developmental disabilities Research Reviews, 8:146 150 ,2002.
4) O shea 2002 -

cerebral palsy in very preterm infants new epidemiological insights.

Mental retardation & Developmental disabilities Research Review 8:135 145,2002.


5) Palisano et al , 1997 , Rasenbaum et al , 2002 - Development & reliability of a system to
classify gross motor function in children with cerebral palsy. Developmental Medicine &
child Neurology 39:214 -223,1997.
6) Hagbery et al , 1989 a Hagbery B, Hagbery G, Olow I , & vonwent L The
changing panorama of cerebral palsy in Sweden V . The birth year period 1979 82. Acto
paediatrica , scandinavica 78:283 290,1989 a.
7) www.the spastic centre.com.auThe spastic centre-Sydney Australia.
8) McNeal DR:2000years of electrical stimulation.In Hambrecht FT, Reswick jb
eds:Functional Electrical Stimulation:Applications in Neural prosthesis,New York,1977
Marcel Dekkar.
9) Cambridge NA:Electrical apparatus used in medicine before1900,Proc Roy Soc
Med,70:635-641,1977.
10) Duchene G.B:A Treatise on localized Electrization and Its Applications to Pathology and
Theraupeutics,London,1871,Hardwicke.
11) Currier, DP,Mann R:Muscular strength development by electrical stimulation in healthy
individuals,Phys Ther63:915-921,1983.
12) Krali A ,Acimovic R,stanic U:Enhancement of hemiplegic patient rehabilitation by means
of functional electrical stimulation,Prosthet Orthot Int Aug:17(2):107-1141993.
13) Melzack R Wall PD:Pain mechanisms: a new theory,Science150:971.979,1965.
14) Schuster G,Marsden B: Treatment of pain by transcutaneous electric nerve stimulation in

10

general practice,J Neurol orthop surg1:137-1141,1980.


15) Kloth,LC Feedar JA: Acceleration of wound healing with high voltage,monophasic,pulsed
current, Phys Ther68:503-508,1988.
16) Mendel FC ,WYlegala JA,Fish DR: Influence of high voltage pulsed current on edema
formation following impact injury in rats, Phys Ther72:668-673,1992.
17) Delitto A ,Rose SJ ,McKowen JM et al:Electric stimulation vs voluntary exercise in
strengthening thigh musculature after anterior cruciate ligament surgery, Phys
Ther68:660-663,1988.
18) Eriksson E,Haggmark T:Comparison of isometric muscle training and electrical
stimulation supplementing isometric muscle training in the recovery after major knee
ligament surgery, Am J Sports Med7:169-171,1979.
19) Godfrey CM, Jayawardena

H, Quance TA et al: Comparison of electro stimulation and

isometric exercise in strengthening the quadriceps muscle

11

Вам также может понравиться