Making “Righty” Right Again: Treatment of Pediatric Hemiparesis

Making “Righty” Right Again: Treatment of Pediatric Hemiparesis
Megan Blaufuss, OTR/L, MS, CPAM November 19, 2017 Privileged and Confidential

Privileged and Confidential
Background Pediatric Specialty Hospital Provides comprehensive health care for three populations Pulmonary Feeding Rehabilitation Part of Children’s Health system, which provides full continuum of care Privileged and Confidential

Objectives To understand the role of foundational concepts: International Classification of Functioning, Disability and Health (ICF) Model Neuroplasticity Upper Limb Training Protocol To understand the efficacy and practical application of specific treatment interventions: Bimanual upper extremity training Constraint Induced Movement Therapy (CIMT) Vibration Dynamic orthoses Strapping tape Neuromuscular electrical stimulation (NMES) Privileged and Confidential

Foundational Concepts
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International Classification of Functioning, Disability and Health (ICF) Model Privileged and Confidential

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: Molecular Cellular Systems Behavior Occurs in response to: Environment Learning Disease Therapy Ex. of Disease: Development of late onset epilepsy months or years after cerebral trauma Privileged and Confidential

Neuroplasticity in Pediatrics
Injury to developing brain can result in: Changes in synapses and neurons Restriction 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) Bullet 2: Ex. hemispherectomy in young child vs. CVA in older adult Bullet 3: For kittens, inactivation of primary motor cortex during weeks 5-7 leads to seemingly permanent contralateral motor skill, but with “CIMT” can reverse deficits when carried out at weeks 8-13, but less effective during weeks 20-24 Privileged and Confidential

Principles of Neuroplasticity
1. USE IT OR LOSE IT Failure to drive specific brain functions can lead to functional degradation. 2. USE IT AND IMPROVE IT Training that drives a specific brain function can lead to an enhancement of that function. 3. SPECIFICITY The nature of the training experience dictates the nature of the plasticity. 4. REPETITION MATTERS Induction of plasticity requires sufficient repetition. 5. INTENSITY MATTERS Induction of plasticity requires sufficient training intensity. Repetition: animal studies show necessary repetitions of reps/day, for humans rec >90 hours of practice Intensity: animal studies show problem-solving tasks at greater levels of complexity elicit greater activity in cerebral cortex than simpler tasks (Kleim & Jones, 2008) Privileged and Confidential

Principles of Neuroplasticity
6. TIME MATTERS Different forms of plasticity occur at different times during training. 7. SALIENCE MATTERS The training experience must be sufficiently salient to induce plasticity. 8. AGE MATTERS Training-induced plasticity occurs more readily in younger brains. 9. TRANSFERENCE Plasticity in response to one training experience can enhance the acquisition of similar behaviors. 10. INTERFERENCE Plasticity in response to one experience can interfere with the acquisition of other behaviors. Salience: studies of monkeys and rodents found that motor activity alone (pressing a bar) without acquiring a motor skill does not promote neurophysiological changes in cortical areas (Kleim & Jones, 2008) Privileged and Confidential

Upper Limb Training Protocol Treatment Progression Hierarchy for Coordinated Movement Practice UPPER LIMB Muscle activation in synergy Single joint movement in synergy TRAINING Single joint movement, out of synergy Multiple joint movement, out of synergy Alternating joint movement (flexion and extension) PROTOCOL Task component practice Full Functional Task Practice (McCabe et al., 2015) Privileged and Confidential

Treatment Interventions: Bimanual Upper Extremity Training

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 restraint Addresses learned non-use but children with hemiplegia have “developmental non-use” Unimanual intervention doesn’t address deficits in bimanual coordination Practice, not restraint, what leads to success of CIMT (Charles & Gordon, 2006) Privileged and Confidential

Bimanual Upper Extremity Training - Background Methodology focuses on: Structured practice with increasing complexity Functional activities requiring bimanual hand use Child-friendly intervention with emphasis on participant’s goals and parental involvement Incorporates whole-task and part-task practice Whole-task: activity performed continuously for minutes Part-task: symmetrical movements for 30 seconds at a time (typically repeated X 5 trials) Avoids encouraging participants to utilize affected UE Lack of constraint can make it more challenging for interventionists (Charles & Gordon, 2006) Privileged and Confidential

Bimanual Upper Extremity Training - Background
Inclusion criteria (Gordon et al., 2007): 20* wrist and 10* MCP extension from full flexion 50% difference between affected and unaffected UE on Jebsen-Taylor Test of Hand function Ability to lift UE >6 inches from surface of table Score within 1 SD of mean on Kaufman Brief Intelligence Test Frequency and Intensity: 6 hours/day for 10 days with 1 hour home practice ~50% time-on-task Privileged and Confidential

Bimanual Upper Extremity Training - Background Brandao et. al, 2013 RCT, N = 22 Examined HABIT with structured practice group (SPG) vs. unstructured practice group (UPG) – no skill progression in children with hemiplegic CP Intervention 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 groups Intensive training may not require structured practice SPG group showed superior improvements in functional goals Benefit of including goal training Privileged and Confidential

Bimanual Upper Extremity Training - Research
Weinstein et. al., 2015 Serial test, convenience sample, N = 11 Examined 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 Privileged and Confidential

Gordon et. al., 2011 RCT, N = 42 Examined HABIT vs. CIMT in children with hemiplegic CP Intervention 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 period Findings: Similar improvements in primary measures (AHA and JTTHF) Maintained at 6 month follow up HABIT group made better progress on chosen, practiced goals as well as transfer to unpracticed goals But CIMT group with greater gains at 6 month post-test Privileged and Confidential

Deppe et al., 2013 RCT, single blind, N = 47 Examined 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 training 80 hours of bimanual training Findings: 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 mCIMT Outcome not age-dependent Privileged and Confidential

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

Dong et al., 2013 Systematic 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 Privileged and Confidential

In comparison to CIMT (Gordon, 2011): Bimanual may be better for children with: Mild impairments Inability to grasp Poor tolerance to restraint Constraint 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” Privileged and Confidential

Bimanual Upper Extremity Training – Demo

Treatment Interventions: Constraint Induced Movement Therapy (CIMT)

CIMT - Background Involves the use of restraint on unaffected UE to force use of affected UE Developed in response to learned nonuse – conditioned suppression of movement (Gillen, 2012) Factors: Neurological suppression of movement Negative reinforcement from attempts to use affected side Positive reinforcement from one-handed performance Rehab emphasis on compensation Privileged and Confidential

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 reorganization Empirical evidence of clinical efficacy Supported by controlled randomized studies Improves daily, real world use Effects sustained for at least 2 years after intervention Considered “Gold Standard” Anecdotal evidence of neuroplastic changes “spreading” to other areas such as speech and gait (Pidcock et al., 2009) Privileged and Confidential

CIMT - Research Chen et al., 2014 Systematic review and meta-analysis, N = 27 studies (children with hemiplegic CP) Findings: At post-test, medium effect for activity level, and small effect for participation At 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 without Home-based CIMT therapy had largest effect size, followed by clinic and then camp-based Time of follow-up negatively associated with study effect size Privileged and Confidential

CIMT - Research Rocca et al., 2013 Non-randomized control trial, N = 14 Examined effectiveness of CIMT in children with chronic hemiplegia (congenital or acquired BI), as well as MRI results as predictor of treatment success Intervention 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-intervention Measures of lesional damage can predict clinical improvement Privileged and Confidential

CIMT - Research DeLuca et al., 2012 RCT, multi-site, parallel group, N = 18 Examined effects of dosage levels of CIMT for children with hemiplegic CP Intervention 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 Privileged and Confidential

CIMT – Videos Privileged and Confidential

Treatment Interventions: Vibration

Vibration - Background
Involves the use of vibratory stimulus to facilitate AROM of specific muscles Two Types (Constantino, Galuppo, & Romiti, 2014): Whole-body Repeated local vibration of a single muscle Functions: 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) Privileged and Confidential

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 TMS Tendon 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) Privileged and Confidential

Vibration - Research Noma et al., 2012 RCT, N = 36 Investigated 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) Privileged and Confidential

Vibration - Research Liepert & Binder, 2010 Non-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 rest Subjects reported greater ease in opening hand after vibration Privileged and Confidential

Vibration - Research Caliandro et al., 2012 Pilot RCT, double blind, parallel-group, N = 49 Examined clinical effectiveness of repetitive muscle vibration on motor function of arm one month after treatment in adults with chronic stroke Intervention 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 groups Significant improvements in Wolf Motor Function Test scores over time only for vibration group Privileged and Confidential

Vibration - Research Tavernese et al., 2013 RCT, single-blind, N = 44 Examined 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 movement Differences persisted two weeks after completion of therapy Privileged and Confidential

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

Vibration - Research Casale et al., 2014 RCT, double-blind, N = 30 Examined 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 robot Effects of vibration on spasticity extends at least 48 hours past application Privileged and Confidential

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

Vibration – Videos Privileged and Confidential

Treatment Interventions: Dynamic Orthoses

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 reflex Immediately following muscle contraction at a certain length, stable bonds formed between actin and myosin which “resets” the muscle spindle Privileged and Confidential

Dynamic Orthoses - Research
Farrell et al., 2007 Phase 1 trial, N = 13 Examined effectiveness of SaeboFlex on UE ROM, tone, and function in adults with chronic stroke Intervention 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 extension Significant improvements in Fugl-Meyer and Motor Status Assessment, as well as MAS Privileged and Confidential

Jeon et al., 2012 Randomized pre-test/post-test control group design, N = 10 Assessed feasibility of intensive training using SaeboFlex for adults with chronic stroke Intervention 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) Privileged and Confidential

Franck, Timmermans & Seelen, 2013 Single case experiment (ABA), N = 8 Examined 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 routine Findings: All patients improved on ARAT and ABILHAND, but after detrending for baseline trends, only significant improvement for ABILHAND Patients rated use of Saeboflex very favorably Privileged and Confidential

Stuck, Marshall & Sivakumar, 2014 Clinical case series, N = 7 Examined feasibility and efficacy of SaeboFlex in adults with acute stroke (< 84 days post-stroke) with moderate/severe weakness Intervention 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 Privileged and Confidential

Dynamic Orthoses – Videos

Treatment Interventions: Strapping Tape

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 function Recommend 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 Privileged and Confidential

Strapping Tape - Research
Hayner, 2012 Interrupted time series quasi-experimental single-subject ABA design, N = 10 Examined effectiveness of California Tri-Pull Taping Method for inferior subluxation in adults with stroke Intervention 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 intervention Reduction 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 Privileged and Confidential

Link to YouTube video yRXM/view?usp=sharing Link to handout Privileged and Confidential

Strapping Tape – Videos

Treatment Interventions: Neuromuscular Electrical Stimulation

Electrical Stimulation
NMES - Types Electrical Stimulation NMES FES TENS ESTR Privileged and Confidential

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 activity Transcutaneous 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 (Bracciano, 2008) Privileged and Confidential

NMES - Functions Improves muscle strength Enhances range of motion Inhibits muscle spasticity or spasms Improves endurance Re-educates muscles Controls edema Replaces orthoses (PAMPCA, LLC) Privileged and Confidential

NMES - Contraindications
Lower back or uterus during 1st trimester Metastasis Osteomyelitis Thrombosis Patients on diuretics Over craniofacial or cervical region if history of seizure or CVA Near phrenic nerve or bladder stimulators Over carotid sinus Near diathermy devices Over or near metal pins, plates or hardware Patients with infection or active hemorrhage Cardiac pacemakers (PAMPCA, LLC) Privileged and Confidential

NMES - Precautions Fracture Decreased sensation Decreased cognitive ability Pregnancy Sensitive skin (PAMPCA, LLC) Privileged and Confidential

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) Privileged and Confidential

NMES - Pathophysiology
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 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) Privileged and Confidential

NMES - Pathophysiology
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) AFFERENT EFFERENT Privileged and Confidential

NMES - Research Hsu et. al, 2010 RCT, single-blind, N = 66 Compared High NMES (60 min/day), Low NMES (30 min/day), and control in adults with acute stroke Findings: 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.” Privileged and Confidential

NMES - Research Lin & Yan, 2011 RCT, single-blind, N = 46 Examined standard treatment vs. standard treatment + NMES in adults with acute stroke NMES 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 treatment The average scores in NMES group statistically better than control group. Privileged and Confidential

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

NMES - Research McCabe et al., 2015 RCT, single-blind, N=39 Compared motor earning (ML) training vs. ML + FES vs. ML + robotics in adults with chronic stroke ML 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.” Privileged and Confidential

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 size Unable to draw conclusions regarding whether FES improves participation or if benefits are long-lasting Privileged and Confidential

NMES - Research Ramos & Zell, 2000 (Miami Children’s Hospital Brachial Plexus Program) Article Findings: “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.” Privileged and Confidential

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

CIMT - Research Xu et al., 2012 RCT, single-blind, N = 68 Examined 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 up CIMT plus NMES showed greater rate of improvement in Peabody visual-motor integration subtest All 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 Privileged and Confidential

CIMT - Research Xu et al., 2015 RCT, single-blind, N = 23 Examined 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-intervention Findings: 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 Privileged and Confidential

NMES - Research Gudlavalleti et. al., 2015 Non-randomized clinical trial, N = 126 Examined 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) Privileged and Confidential

NMES - Research Bosques, et al., 2016 Systematic review of use of NMES in children with disabilities, N = 37 articles Findings: 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 alone Articles 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 Privileged and Confidential

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.” Privileged and Confidential

NMES - Parameters Privileged and Confidential

NMES - Parameters Amplitude Distance of rise above or below baseline of each pulse Level of intensity Typically measured in milliamperes For NMES, must be high enough to elicit motor response (PAMPCA, LLC) Privileged and Confidential

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

NMES - Parameters Pulse Duration Length of time required to complete the wave shape Typically between microseconds Cycling Applies when using two channels Alternate – channels fire opposite one another Synchronous – channels fire at same time (PAMPCA, LLC) Privileged and Confidential

NMES - Parameters Ramp Time Lead time before wave reaches its peak May need to increase ramp time with spastic muscles Usually between seconds (PAMPCA, LLC) Rate Number of pulse cycles being delivered Generally expressed in pulses per second (pps) Usually between 20-50, most common for UE is 35 (Bracciano, 2008) Privileged and Confidential

NMES - Parameters Duty Cycle Also known as on/off ratio Amount of time stimulation is being delivered compared to amount of time stimulation is off Often expressed as a ratio (1:1, 1:2, etc) As condition improves, can increase duty cycle (Bracciano, 2008) Privileged and Confidential

NMES - Patient Comfort Studies examining whether differences in currents, waveforms and devices affect patient comfort have been inconclusive Encourage relaxation of antagonists When voluntary contraction is coupled with stimulated contraction, appears to lead to better tolerance (PAMPCA, LLC) Privileged and Confidential

NMES - Accomodation and Polarity
Automatic rise in threshold of excitation that occurs in tissues May need to increase intensity of stimulation after 5-10 minutes (PAMPCA, LLC) Polarity Not applicable when using symmetrical waveform With 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) Privileged and Confidential

NMES - Electrodes Must have adequate contact with skin Density 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 clean The greater the distance between electrodes, the deeper the current Should be placed no closer together than one half the diameter of the electrode (PAMPCA, LLC) Privileged and Confidential

NMES - Electrodes Greater effectiveness when electrodes placed parallel to muscle fibers Avoid removing by pulling on the wires, and if trimming electrode, do not cut through wire Apply few drops of tap water to tacky side when beginning to dry out Throw away once no longer adhesive (PAMPCA, LLC) Can use ultrasound gel to improve conductivity or to assist when finding motor unit Privileged and Confidential

NMES - Documentation Treatment goal Electrode placement Treatment time On/Off time Ramp time Intensity Subjective patient comments Objective observations related to movement Patient response to treatment (Bracciano, 2008) Privileged and Confidential

NMES - Units Saebo AvivaStim Cost: $195 (or $58 over 4 months) Pros: Has a trigger Does not lose intensity when paused Cons: Must use preset programs Does not allow for asymmetrical programs Cannot use with small (1.375” electrodes) Privileged and Confidential

NMES - Units ProM-720 TENS & Electro Muscle Stimulation Combination Unit Cost: $46.95 Pros: Has preset or customizable programs (including asymmetrical) Reasonably priced Can use all sizes of electrodes Cons: Can be difficult to configure Privileged and Confidential

NMES - Units Empi Units Cost: varies (~$350.00) Pros: Has preset or customizable programs (including asymmetrical) Fairly easy to program Can use all sizes of electrodes Cons: No longer commercially available by company Does not have a trigger Privileged and Confidential

NMES – Videos Privileged and Confidential

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

Making “Righty” Right Again: Treatment of Pediatric Hemiparesis

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