Wrapping up Cerebral Palsy Month
It is the last week of Cerebral Palsy month and to wrap up this month we want to highlight our approach to treatment when working with children with Cerebral Palsy as it can take on many forms. Our treatment is with a multimodal approach; we use updated evidence-based interventions. In my practice, I am seeing a lot of improvements in the children when I use the principles of neuromuscular electrical stimulation (NMES)in conjunction with other interventions such as task specific training and treadmill training. NMES has had a huge impact on my daily practice and my patients. And thus, this topic deserves a blog post of its own.
Task Specific Electrical Stimulation (TASES)
Specifically, I use Task Specific Electrical Stimulation (TASES) during physical therapy sessions and for home programs for children with neuromuscular disorders. Judy Carmick coined the term TASES and she writes, “TASES is used with a dynamic systems approach and a mobile ankle-foot orthosis”. TASES focuses on stimulating muscles during the moment when they should be firing such as during stance or swing phase of gait. We use a switch to activate the muscle at the moment it should fire during the gait cycle. We repeat this process over and over and over while walking, often on a treadmill. I initially complete a thorough Physical Therapy evaluation to establish the gait deviations, determine the muscles that are not firing correctly, measure the range of motion around the joints, test the abnormal muscle tone within the musculature, and document the strength of the muscles in order to determine the best plan. This evaluation drives the plan. We ask: Which muscles? When? How long? How intense? What stretches? Which brace? What home program?
Cerebral palsy (CP) is complicated and presents with many problems including muscle weakness, contractions, and poor alignment which leads to decreased motor control and function. For the purpose of this post, I will explore the ankle and the spasticity and stiffness and loss of range of motion and function commonly seen in children with cerebral palsy around the ankle. Often, the preferred gold standard for treatment includes Botox, serial casting, and bracing to address loss of range of motion and control. Recent research shows BOTOX with serial casting is no more effective than casting alone. I include electrical stimulation, specifically, TASES to treat the ankle issues. Basically, we stimulate the usually spastic muscle, the gastroc-soleus, and we trigger this muscle during stance phase of gait and we practice walking while switching the muscle on during the appropriate moment in the gait cycle over and over and over. The results are amazing!
We used to think the spastic tight muscle was also strong, and should be paralyzed. However, actually the muscle is weak and needs strengthening. The gastroc-soleus muscle has to be super strong to hold us up against gravity. In my experience, electric stimulation actually decreases the spasticity in the muscle. Maybe, it’s the sensory input from the electric stimulation that relaxes the muscle? Maybe it is learning to activate properly so it relaxes? Stretching and range of motion exercises are easier following a good session of NMES or TASES. I also stimulate the usually tight hamstrings, and stretch following the stimulation with an elongated long duration stretch of at least over 5 minutes.
Task Specific training and treadmill training gets a green light and electric stimulation gets a yellow light for use of evidence-based therapy in motor impairment and is supported by studies supporting its effectiveness for children with cerebral palsy. Anecdotally, I see improved range of motion, improved gait and function, improved strength, and improved fit and tolerance of bracing.
Use of a multimodal approach, reading the research and letting go of interventions that are old and do not work has led me down a very successful and fulfilling road of treating neuromuscular disorders in children. I continue to explore, learn, push, and strive to serve my very best every day.
See below the attached article highlighting the level of evidence most physical therapy interventions receive in the published literature.
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