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Electrical Stimulation In
Cerebral Palsy
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Barry M.J. (1996) Physical
therapy interventions for patients with movement disorders due to cerebral
palsy. J. Child Neurol. 11 Suppl 1, S51-S60.
Abstract: The purpose of this paper is to present evidence of the efficacy of
physical therapy interventions for patients with cerebral palsy and identify
goals for these patients. Studies suggest that neurodevelopmental treatment and
Vojta techniques improve postural control. Little evidence supports the efficacy
of early intervention, but researchers have not yet studied effects on the
family. Strengthening, electrical stimulation, the use of orthoses, and seating
show positive effects in studies of small numbers of subjects. For severely
involved children, ease of care and comfort are important goals, as well as
prevention of deformity, which is important for all children. To the extent
possible, therapy should prepare a child for independent adult life. In early
intervention through school age, therapy focuses on promoting communication,
self-care, and mobility. Independence is a key issue for adolescents
transitioning into adulthood. The rehabilitation and health needs of adults with
cerebral palsy need to be addressed. Research needs to determine the effects of
physical therapy not only on impairment but also on function and disability
Bensman A.S. and Szegho M.
(1978) Cerebellar electrical stimulation: a critique. Arch. Phys. Med.
Rehabil. 59, 485-487.
Abstract: Cerebellar electrical stimulation has been advocated as a beneficial
treatment device for improving function in cerebral palsy, but a review of the
literature raises questions as to its efficacy and safety. Evaluation of one
reported study showed that only 32% of people with implanted cerebellar
stimulators had significant improvement in function. This is in contrast to 68%
to 92% improvement levels claimed by advocates of the procedure. There is
evidence of potential long-term damage to the cerebellum from the device.
Further studies are indicated, following the criteria established by the 1976
Medical Device Amendment to the Drug and Cosmetic Act dealing with medical
device regulation and control
Bergstrom M.R., Johansson
G.G., Laitinen L.V., and Sipponen P. (1966) Electrical stimulation of the
thalamic and subthalamic area in cerebral palsy. Acta Physiol Scand. 67,
208-213.
Bogey R.A., Perry J.,
Bontrager E.L., Gronley J.K. (2000) Comparison of across-subject EMG profiles
using surface and multiple indwelling wire electrodes during gait. J
Electromyogr Kinesiol 10, 255-259.
Botte M.J., Keenan M.A.
(1987) Reconstructive surgery in the upper extremity in the patient with head
trauma. J Hand Trauma 2, 34-45.
Botte M.J., Waters R.L.,
Keenan M.A. (1988) Orthopaedic management of the stroke patient: Part I:
Pathophysiology, limb deformity and patient evaluation. Orthop Rev 27,
637-647.
Botte M.J., Bruffey J.D.,
Copp S.N., Colwell C.W. (2000) Surgical reconstruction of acquired spastic foot
and ankle deformity. Foot Ankle Clin 5, 381-416. Abstract: With the
aging population and improved methods of emergency transport, the number of
surviving stroke and brain injury patients continues to increase. Aggressive
rehabilitation of appropriate candidates is justified. In the period of
spontaneous recovery, efforts are made to prevent fixed contractures using
passive mobilization, splinting, nerve blocks, and electrical stimulation. If
deformity persists and the patient is no longer recovering, operative management
can help alleviate the functional and hygiene problems associated with these
limb deformities.
Brandell B.R. (1982)
Development of a universal control unit for functional electrical stimulation (FES).
Am. J. Phys. Med. 61, 279-301.
Abstract: In collaboration with the College of Engineering the author has
developed a laboratory, or clinic, based, battery operated "universal" control
system, designed to improve disabled gait in upper motor neuron disabilities,
especially stroke, hemiplegia, and cerebral palsy, by applying several channels
of FES (Functional Electrical Stimulation) to the lower limb muscles while the
patient is walking. The timing of the FES pulses, which can be applied to as
many as six of the patient's muscles, is determined by potentiometer controlled
one-shot timers, which are triggered by any of three switches in the sole of
either shoe. Combinations of inverters, flip flops, AND gates and OR gates in
the externally connected logic circuits determine the sequence of delays and
pulses applied to the patient's muscles. This paper describes and diagrams some
of the logic circuits and as an example of the possible application of the
concept of a "universal" control unit reports the modifications of gait induced
in a hemiplegic, four year post-stroke, patient. The characteristics of this
patient's gait with FES in comparison to its characteristics without FES are
demonstrated with motion picture frames, EMG recordings and graphic tracings of
her right knee and ankle joint positions. They include more symmetrical timing
of her right and left stance and swing phases, increased dorsiflexion of her
right ankle in the swing phase, followed by a more distinct heel strike, and
improved flexion--extension sequences of the knee and ankle joints and an
increased heel rise in the stance phase. The author concludes that the gait
characteristics of some hemiplegic patients will improve as they become adapted
over a period of weeks or months to a control logic, which lessens their
functional limitations by the use of a properly timed and amplified sequence of
FES pulses. He suggests that the FES control requirements for individual
patients should be determined experimentally with a control system "universally"
adaptable to a wide range of disabilities, and that these control parameters
could then determine the design of portable units, which may be used on a long
term basis. These units would include only the operational options needed to
duplicate the gait corrections found to be practicable for each individual
patient, by the testing procedure, through a universal logic unit as described
in this paper
Campbell J.M., Ball J.
(1978) Energetics of Walking In Cerebral Palsy. In: Waters R., et al: Energetics:
Application to the Study and Management of Locomotor Disabilities. Ortho Clin
No Am 9:351-377.
Campbell J.M., Meadows P.M.
(1992) Therapeutic FES: From Rehabilitation to Neural Prosthetics. Assistive
Technology 4, 4-18.
Carmick J. (1993) Clinical
use of neuromuscular electrical stimulation for children with cerebral palsy,
Part 1: Lower extremity. Phys. Ther. 73, 505-513.
Abstract: This report, part 1 of a two-part case report on the clinical use of
neuromuscular electrical stimulation (NMES) for children with cerebral palsy,
documents the functional changes that occurred with the application of NMES to
the lower extremity of three male children, 1.6, 6.7, and 10 years of age, all
with hemiplegia due to cerebral palsy. Neuromuscular electrical stimulation was
used in conjunction with a dynamic-systems, task-oriented model of motor
learning. The children tolerated NMES well and at times demonstrated carryover
after the removal of NMES. The youngest child showed immediate change in the
ability to walk and run symmetrically. The two older boys demonstrated
significant improvement in locomotor efficiency in a short time, although they
were of an age when this improvement was not expected. One boy's Physiological
Cost Index (PCI) measurement (a measure of locomotor efficiency) improved
fourfold, and the other boy's PCI measurement improved by a factor of two. The
results show preliminary evidence for the usefulness of NMES as an adjunct to
the physical therapy program for improving function in children with cerebral
palsy
Carmick J. (1993) Clinical
use of neuromuscular electrical stimulation for children with cerebral palsy,
Part 2: Upper extremity. Phys. Ther. 73, 514-522.
Abstract: This report, part 2 of a two-part case report on the clinical use of
neuromuscular electrical stimulation (NMES) for children with cerebral palsy,
documents the functional changes that occurred with the application of NMES to
the upper extremity of two children, 1.6 and 6.7 years of age, with hemiplegia
due to cerebral palsy. The NMES was used as an adjunct to a dynamic-systems,
task-oriented physical therapy program. The youngest child showed immediate
improvement in the ability to crawl and use both hands together. The older child
demonstrated increased sensory awareness and use of the nonfunctional hand.
Preliminary findings suggest that NMES may be a useful physical therapy tool for
enhancing muscle strength increasing sensory awareness, and assisting motor
learning and coordination
Carmick J. (1995) Managing
equinus in children with cerebral palsy: electrical stimulation to strengthen
the triceps surae muscle. Dev. Med. Child Neurol. 37, 965-975.
Abstract: A new therapeutic proposal for the management of equinus in children
with cerebral palsy is to strengthen the calf muscles instead of weakening them
surgically. Prior research indicates that in children with cerebral palsy the
triceps surae muscle is weak and needs strengthening. Neuromuscular electrical
stimulation (NMES) was used as an adjunct to physical therapy. A portable NMES
unit with a hand-held remote switch stimulated an active muscle gait cycle.
Results are discussed for four children, who showed improved gait, balance,
posture, active and passive ankle range of motion, and foot alignment. The toe
walkers became plantigrade and the equinovalgus posture of the foot decreased.
Spasticity did not increase
Carmick J. (1997) Use of
neuromuscular electrical stimulation and [corrected] dorsal wrist splint to
improve the hand function of a child with spastic hemiparesis. Phys. Ther.
77, 661-671.
Abstract: This case report describes a program for a child with spastic
hemiparesis who had previously received physical therapy with neuromuscular
electrical stimulation (NMES). After a year without physical therapy, he
returned to continue to receive NMES to strengthen muscles, increase sensory
awareness, and improve hand function. The child quickly regained his previous
level of functioning and made additional progress. After 38 sessions, he still
lacked adequate wrist stability for independent hand function. A dorsal wrist
splint was used to stabilize the wrist while NMES facilitated muscle activity of
the hand and wrist. While wearing the splint, the child could use his hand
independently without adult interference or "assistance," thus allowing motor
learning to occur. After 24 additional sessions (i.e., 9 months of using the
splint), the child could use the hand for activities such as tying his shoelaces
without the splint. No increase in spasticity was seen in spite of strengthening
the spastic finger flexors
Cooper I.S., Upton A.R., and
Amin I. (1980) Reversibility of chronic neurologic deficits. Some effects of
electrical stimulation of the thalamus and internal capsule in man. Appl.
Neurophysiol. 43, 244-258.
Abstract: Stimulation of the thalamus and internal capsule with Medtronic deep
brain stimulation electrodes produced improvement in pain, hemiparesis, dystonia,
torticollis, tremor. speech impairment and epilepsy. Stimulation at voltages
above or below clinically effective levels (e.g., 6 V, 0.3 ms, 74 Hz) resulted
in a loss of clinical efficacy. Somatosensory evoked responses (short and long
latency) and depth electrode recordings were helpful in localisation and 'biocalibration'
of electrical stimulation
Dubowitz L., Finnie N., Hyde
S.A., Scott O.M., and Vrbova G. (1988) Improvement of muscle performance by
chronic electrical stimulation in children with cerebral palsy. Lancet 1,
587-588.
Galanda M. and Zoltan O.
(1987) Motor and psychological responses to deep cerebellar stimulation in
cerebral palsy (correlation with organization of cerebellum into zones). Acta
Neurochir. Suppl (Wien. ) 39, 129-131.
Abstract: The study includes 68 cases of cerebral palsy stereotaxically operated
on from 1977. Deep cerebellar stimulation treatment was performed. The motor and
psychological responses to electrical stimulation of 305 points of subcortical
regions of cerebellum, mostly lobus anterior were analysed. The characteristic
response--slight motor jerk immediately-- followed by relaxation and feeling of
pleasure, even laughing, to the electrical stimulation from selected points was
always found. The level of stimulating current must be adjusted individually.
The higher current increased pathological posture, muscular tonus and was
conducted with the state of fear. The lower current was without detectable
influence on the patient. On the trajectory of electrode, nearly perpendicular
to the sagittal plane were narrow areas, which recurred as the strips, from
where it was possible or not to elicit characteristic response. The most
convenient target is in the region of brachia conjunctiva cerebelli.
Localization of the point of stimulation in respect to organization of
cerebellum into sagittally oriented zones and the parameters of stimulation seem
to contribute to the diversity of responses to cerebellar stimulation
Galanda M. and Hovath S.
(1997) Different effect of chronic electrical stimulation of the region of the
superior cerebellar peduncle and the nucleus ventralis intermedius of the
thalamus in the treatment of movement disorders. Stereotact. Funct. Neurosurg.
69, 116-120.
Abstract: The stereotactic target for essential tremor is usually restricted to
the nucleus ventralis intermedius of the thalamus, where total immediate
suppression of tremor is obtained by continuous chronic electrical stimulation.
According to authors' experience in cerebral palsy, chronic stimulation of the
region of the superior cerebellar peduncle can diminish spasticity and
dyskinesias. The effect of this stimulation is gradual and persists, so
stimulation is applied 3-8 times daily for 15-20 min, and is accompanied by a
feeling of pleasure. After interruption of chronic stimulation, the effects last
for days or weeks. It is suggested that the changes in synaptic connections--
reactive synaptogenesis--can also contribute
Gill S., Curran A., Tripp
J., Melarickas L., Hurran C., and Stanley O. (2001) Hyperkinetic movement
disorder in an 11-year-old child treated with bilateral pallidal stimulators.
Dev. Med. Child Neurol. 43, 350-353.
Abstract: Pallidal stimulation is widely used in the treatment of movement
disorder in adults but is less well reported in the treatment of dystonia in
children. Despite inconsistent results in the past, its use in dystonia in
Parkinson's disease is again attracting interest with promising results.
Bilateral as well as unilateral pallidotomies have been performed and are felt
to be required in some cases of dystonia. Use of depth electrodes to provide
long-term electrical stimulation to pallidum and other basal ganglia structures
has recently become more widespread. This technique is felt to have a lower
morbidity, especially in bilateral procedures. Here we present the case of an
11- year-old boy with severe hyperkinetic movement disorder who showed sustained
improvement after bilateral pallidal stimulation implantation
Gottlieb G.L., Myklebust B.M.,
Stefoski D., Groth K., Kroin J., and Penn R.D. (1985) Evaluation of cervical
stimulation for chronic treatment of spasticity. Neurology 35, 699-704.
Abstract: Electrical stimulation of the spinal cord (SCS) to reduce spasticity
was evaluated in seven patients who, along with their physicians, perceived
significant and prompt benefit from stimulation. In two 24- hour test periods,
on or off stimulation, we used two independent methods of evaluation:
quantitative measures of joint compliance and stretch reflexes, and a
standardized neurologic examination. Neither method did better than chance in
determining whether SCS was actually being received. Problems with the
experimental protocol are discussed, but the results cannot be interpreted as
supporting the efficacy of SCS as a treatment for spasticity
Gracanin F. (1977) Use of
electrical stimulation in external control of motor activity and movements of
human extremities. Actual situation and problems. Med. Prog. Technol. 4,
149-156.
Abstract: Functional electrical stimulation (FES) is used in control of motor
activity and movements in patients suffering movement handicaps due to central
nervous system damage. The method is analyzed from the viewpoint of physical
medicine, biocybernetics and technological development. Systems developed to
date are presented and a critical survey of the method in light of indications
is provided. Special attention is devoted to the present applicability of the
systems of FES and to their potential use
Gracanin F. (1978)
Functional electrical stimulation in control of motor output and movements.
Electroencephalogr. Clin. Neurophysiol. Suppl 355-368.
Abstract: In patient with damaged upper motor neurones we show the therapeutic
effect of electrical stimulation (called FES) of peripheral mixed nerves on the
restoration of motor activity and movements. The results of neurophysiological,
kinesiological and clinical observations are presented. We discuss the possible
mechanisms, especially the spinal ones, which are fundamental for such a
rhythmic activity as gait. We discuss them also from the point of view of
activation of proprioceptive feedback mechanisms and of achieved sensory
reinforcement influencing the spinal reflex mechanisms as well as the preserved
supraspinal integrated activity which contributes to the long- term FES effect.
The stimulation modes, the control of stimuli in relation to the needs of
individual patients (hemiplegia in adults, paraparesis, cerebral palsy in
children and multiple sclerosis) as well as the motor deficit are discussed. We
conclude that the electronic system used for this purpose represents a
functionally active orthotic aid with therapeutic effects
Hazlewood M.E., Brown J.K.,
Rowe P.J., and Salter P.M. (1994) The use of therapeutic electrical stimulation
in the treatment of hemiplegic cerebral palsy. Dev. Med. Child Neurol.
36, 661-673.
Abstract: The effect of electrical stimulation of the anterior tibial muscles of
children with hemiplegic cerebral palsy was studied. 10 children received
electrical stimulation, applied by their parents daily for an hour for 35 days;
they were compared with 10 matched controls. Active and passive ranges of
movement of the ankle, and knee and ankle motion during walking were measured
before and after therapy using electrogoniometers. The results showed a
significant increase in passive range of movement among children receiving
electrical stimulation. Gait analysis of knee and ankle motion showed little
change
Keenan M.A., Perry J.,
Jordan C. (1984) Factors affecting balance and ambulation following stroke.
Clin Orthop Rel Res 182, 165-171.
Keenan M.A., Perry J. (1990)
Evaluation of upper extremity motor control in spastic brain-injured patients
using dynamic electromyography. J Head Trauma Rehabil 5, 13-22.
Kerrigan D.C., Gronley J.K.,
Perry J. (1991) Stiff-legged gait in spastic paralysis: a study of quadriceps
and hamstring activity. Am J Phys Med 70, 294-300.
Leyendecker C. (1975)
[Electrical stimulation therapy and its effects on the general activity of motor
impaired cerebral palsied children; a comparative study of the Bobath
physiotherapy and its combination with the Hufschmidt electrical stimulation
therapy (author's transl)]. Rehabilitation (Stuttg) 14, 150-159.
Abstract: The purpose of this study was to answer the following questions: (1)
Is it more effective to treat spastic cerebral palsy with the Hufschmidt
electrical stimulation therapy combined with the Bobath neuro- development
treatment or only with the Bobath therapy? (2) Can a general increase in
activity be obtained by the electrotherapeutic muscle stimulation? A test group
(combined Hufschmidt/Bobath therapy) and a control group (Bobath), both
consisting of 10 subjects, were observed for four months. The duration of
observation was divided into two four months treatment periods with a rest
interval of two months in between. At the start of therapeutic measures, motor
activity and psychic condition were tested with corresponding motormetric and
psychodiagnostic techniques; three check-up examinations were carried out at the
end of the first, and at the beginning and end of the second period of
treatment. The motor-metric control examination showed that at the end of the
first period the test group had achieved by far the better results, but at the
end of the second therapeutic period, both groups were equally successful. The
combined electrophysiotherapy hence reached in a relatively shorter t
Metherall P., Dymond E.A.,
and Gravill N. (1996) Posture control using electrical stimulation biofeedback:
a pilot study. J. Med. Eng Technol. 20, 53-59.
Abstract: The investigation studied the effects of biofeedback on the sitting
posture of a 14 year old girl with cerebral palsy. The subject's posture was
quantified using a video analysis technique which established the threshold of
poor posture at 30 degrees from the vertical plane. A stimulator system was
designed using an adapted drop foot stimulator and a custom made controller with
a mercury tilt switch as the posture angle transducer. If posture became greater
than 30 degrees tactile electrical stimulation was administered to the subject's
lower back. Repetitive stimuli occurred on non-correction of posture, with a
maximum of 4 consecutive stimuli, upon which an alarm was activated. 10 training
sessions of 20 min duration were completed over a 4 week period, monitored using
a data logger. Following initial improvement the daily results show a gradual
deterioration in posture, whilst post-trial video analysis indicates a
significant improvement in posture. An improved response to the alarm stimulus
is observed. Reasons for these conflicting findings are discussed
Miyazaki M.H., Lourencao M.I.,
Ribeiro Sobrinho J.B., and Battistella L.R. (1992) [Functional electric
stimulation (FES) in cerebral palsy]. Rev. Hosp. Clin. Fac. Med. Sao Paulo
47, 28-30.
Abstract: Our study concerns a patient with cerebral palsy, submitted to
conventional occupational therapy and functional electrical stimulation. The
results as to manual ability, spasticity, sensibility and synkinesis were
satisfactory.
Montgomery J., Perry J.
(1987) Stroke patient gait and orthotics indications. In: Brandstater M.,
Basmajian J. [Eds]: Stroke Rehabilitation. Baltimore, Williams & Wilkins.
Mooney V., Perry J., Nickel
V.L. (1969) Surgical and non-surgical orthopaedic care of stroke. In: American
Academy of Orthopaedic Surgeons [Eds]: Instructional Course Lectures, Vol
XVIII, J2. St. Louis, C.V. Mosby Co.
Pape K.E., Kirsch S.E.,
Galil A., Boulton J.E., White M.A., and Chipman M. (1993) Neuromuscular approach
to the motor deficits of cerebral palsy: a pilot study. J. Pediatr. Orthop.
13, 628-633.
Abstract: Six children with mild cerebral palsy (CP) entered a study of
overnight low-intensity transcutaneous electrical stimulation (ES) to the leg
muscles. After 6 months, statistically significant improvement was noted on the
Peabody Developmental Motor Scales scores in gross motor, locomotor, and
receipt/propulsion skills. When ES was withdrawn for 6 months, there was uniform
loss in scores. Reinstitution of ES resulted in further significant improvements
in total gross motor, balance, locomotor, and receipt/propulsion skills. In
selected cases, overnight ES may be a useful addition to standard rehabilitation
services
Penn R.D., Myklebust B.M.,
Gottlieb G.L., Agarwal G.C., and Etzel M.E. (1980) Chronic cerebellar
stimulation for cerebral palsy. Prospective and double-blind studies. J.
Neurosurg. 53, 160-165.
Abstract: The effects of chronic electrical stimulation of the cerebellum in
patients with cerebral palsy have been studied using objective tests of joint
compliance, and standardized assessments of developmental reflexes and motor
skills. Of 14 patients studied prospectively for 1 to 44 months, 11 showed
improvement in motor function. A double-blind test of 10 patients off and on
stimulation for an average 8-week period showed no significant changes. Thus, we
have no proof that the functional improvements seen with long-term stimulation
are the result of cerebellar stimulation
Perry J., Waters R.L.,
Perrin T. (1978) Electromyographic analysis of equinovarus following stroke.
Clin Orthop Rel Res 131, 47-53.
Perry J., Giovan P., Harris
L.J., Montgomery J., Azaria M. (1978) The determinants of muscle action in the
hemiparetic lower extremity (and their effect of the examination procedure).
Clin Orthop Rel Res 131, 71-89.
Perry J., Easterday C.S.,
Antonelli D.J. (1981) Surface versus intramuscular electrodes for
electromyography of superficial and deep muscles. Phys Ther 61, 7-15.
Perry J., Garrett M.,
Gronley J.K., Mulroy S.J. (1995) Classification of walking handicap in the
stroke population. Stroke 26, 982-989.
Perry J. (1998) The
contribution of dynamic electromyography to gait analysis. In: Rehabilitation
Research and Development Service [Ed]: Gait Analysis in the Science of
Rehabilitation. Washington D.C., Department of Veterans Affairs, pp 33-48.
Perry J. (1999) The use of
gait analysis for surgical recommendations in traumatic brain injury. J Head
Trauma Rehabil 14, 116-135.
Perry J., Waters R.L. (1975)
Orthopaedic evaluation and treatment of stroke patient. AAOS Instr Course
Lect 24, 40-44.
Pinder R.M., Brogden R.N.,
Speight T.M., and Avery G.S. (1977) Dantrolene sodium: a review of its
pharmacological properties and therapeutic efficacy in spasticity. Drugs
13, 3-23.
Abstract: Dantrolene sodium or dantrolene1 is 1([5-(nitrophenyl)furfurylidend]
amino) hydantoin sodium hydrate. It is indicated for use in chronic disorders
characterised by skeletal muscle spasticity, such as spinal cord injury, stroke,
cerebral palsy and multiple sclerosis. Dantrolene is believed to act directly on
the contractile mechanism of skeletal muscle to decrease the force of
contraction in the absence of any demonstrated effects on neural pathways, on
the neuromuscular junction, or on the excitable properties of the muscle fibre
membranes. Controlled trials have demonstrated that dantrolene is superior to
placebo in adults or children with spasticity from various causes, as evidenced
by clinical assessments of disability and daily activities, and by muscle and
reflex responses to mechanical and electrical stimulation. It is somewhat less
effective in patients with multiple sclerosis than in those with spasticity from
other causes. There has been a general clinical impression in controlled trials
that dantrolene caused less sedation than would have been expected from
therapeutically comparable doses of diazepam. In 2 controlled trials, there was
no significant difference between dantrolene and diazepam in terms of reductions
in spasticity, clonus, and hyperreflexia, but side-effects such as drowsiness
and inco-ordination occurred significantly more frequently on diazepam.
Long-term studies have indicated continuing benefit for patients taking
dantrolene, though the incidence of side- effects has often been high and there
has been a suggestion of exacerbation of seizures in children with cerebral
palsy. Dantrolene may be of value in the medical treatment of spasm of the
external urethral sphincter due to neurological and non-neurological disease,
and animal studies suggest a potential use in the management of malignant
hyperpyrexia. Chemical evidence of liver dysfunction may occur in 0.7 to 1% of
patients on long-term treatment with dantrolene, with symptomatic hepatitis in
0.35 to 0.5% and fatal hepatitis in 0.1 to 0.2%. The drug commonly causes
transient drowsiness, dizziness, weakness, general malaise, fatigue and
diarrhoea at the start of therapy. Muscle weakness may be the principal limiting
side-effect in ambulant patients, particularly in those with multiple sclerosis,
and therapy could be hazardous in patients with pre-existing bulbar or
respiratory weakness. The dosage of dantrolene has been fixed in most controlled
trials, though long-term studies have indicated the need for individualisation
of dosage. The initial dose is usually 25mg once daily, increasing to 25mg two,
three or four times daily, and then by increments of 25mg up to as high as 100mg
two, three or four times daily. The lowest dose compatible with optimal response
is recommended
Ray C.D. (1978) Electrical
stimulation: new methods for therapy and rehabilitation. Scand. J. Rehabil.
Med. 10, 65-74.
Abstract: Electrical stimulation is emerging as a new therapeutic and
rehabilitative agent. Reviewed are pain control, restoration of lost functions
and alteration of abnormal movement and other functions using electrical
stimulation. Reported for acute and chronic pain control use are transcutaneous,
dorsal column, spinal cord, peripheral nerve, and direct brain stimulation
methods and results. Overall success ranges up to 50% for chronic pain problems
and up to 80% for acute pain; e.g., postoperative incisional pain, sports
medicine, and trauma. Restoration of lost function has broad implications for
the future. These include phrenic nerve pacing for respiration, foot drop
control, restoration of bladder function, and grasp control in the spinal
cord-injured patient. Amelioration of abnormal function includes stimulation for
epilepsy and cerebral palsy, certain symptoms of multiple sclerosis and
scoliosis. The effects of electrostimulation are completely reversible and
nondestructive. Technical details of devices and stimulus waveforms are also
briefly considered
Scheker L.R., Chesher S.P.,
and Ramirez S. (1999) Neuromuscular electrical stimulation and dynamic bracing
as a treatment for upper-extremity spasticity in children with cerebral palsy.
J. Hand Surg. [Br. ] 24, 226-232.
Abstract: We have investigated a therapeutic regimen using neuromuscular
electrical stimulation (NMES) and dynamic bracing to assess their effectiveness
in reducing upper-extremity spasticity in children with cerebral palsy. Nineteen
patients between 4 and 21 years of age with documented diagnoses of spastic
cerebral palsy were treated. The patients included in the study followed a
regimen of two 30-minute sessions of NMES of the antagonist extensors combined
with dynamic orthotic traction during the day. A static brace was used at night.
Spasticity of the wrist and fingers was assessed periodically using the Zancolli
classification. Treatment ranged from 3 to 43 months. After treatment with
electrical stimulation and dynamic bracing, all the patients moved up 1 to 3
levels in the Zancolli classification and showed a marked improvement in
upper-extremity function. These results show that combining NMES and dynamic
orthotic traction dramatically decreases spasticity of the upper extremity in
young patients with cerebral palsy
Steinbok P., Reiner A., and
Kestle J.R. (1997) Therapeutic electrical stimulation following selective
posterior rhizotomy in children with spastic diplegic cerebral palsy: a
randomized clinical trial. Dev. Med. Child Neurol. 39, 515-520.
Abstract: A randomized controlled trial was carried out to determine the
effectiveness of therapeutic electrical stimulation (TES) in improving the
function of children with spastic cerebral palsy (CP), who had undergone
selective posterior lumbosacral rhizotomy more than a year previously. Children
were randomly assigned to groups to receive TES for 1 year, or to have no TES.
The primary outcome was the change in the Gross Motor Function Measure (GMFM), a
quantitative and validated measure for use in children with spastic CP. There
was a statistically significant and clinically important improvement in outcome
for the treated children, with the mean change in the GMFM score at one year
being 5.5% compared with 1.9% in the untreated group (P = 0.001). TES was simple
to use, had no significant complications, and was well accepted by the children
and their caregivers, as indicated by an average compliance of 93% for the
application of TES on a nightly basis over the course of the study. It was
concluded that TES may be beneficial in children with spastic CP who have
undergone a selective posterior rhizotomy procedure more than 1 year previously
Taylor P.N., Burridge J.H.,
Dunkerley A.L., Lamb A., Wood D.E., Norton J.A., and Swain I.D. (1999) Patients'
perceptions of the Odstock Dropped Foot Stimulator (ODFS). Clin. Rehabil.
13, 439-446.
Abstract: OBJECTIVE: To determine the perceived benefit, pattern and problems of
use of the Odstock Dropped Foot Stimulator (ODFS) and the users' opinion of the
service provided. DESIGN: Questionnaire sent in a single mailshot to current and
past users of the ODFS. Returns were sent anonymously. SETTING: Outpatient-based
clinical service. SUBJECTS: One hundred and sixty-eight current and 123 past
users with diagnoses of stroke (CVA), multiple sclerosis (MS), incomplete spinal
cord injury (SCI), traumatic brain injury (TBI) and cerebral palsy (CP).
INTERVENTION: Functional electrical stimulation (FES) to correct dropped foot in
subjects with an upper motor neuron lesion, using the ODFS. MAIN OUTCOME
MEASURES: Purpose-designed questionnaire. RESULTS: Return rate 64% current users
(mean duration of use 19.5 months) and 43% past users (mean duration of use 10.7
months). Principal reason cited for using equipment was a reduction in the
effort of walking. Principal reasons identified for discontinuing were an
improvement in mobility, electrode positioning difficulties and deteriorating
mobility. There were some problems with reliability of equipment. Level of
service provided was thought to be good. CONCLUSION: The ODFS was perceived by
the users to be of considerable benefit. A comprehensive clinical follow-up
service is essential to achieve the maximum continuing benefit from FES-based
orthoses
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Surgical correction of gait abnormalities following stroke. Clin Orthop Rel
Res 131, 54-63.
Waters R.L., Garland D.E.,
Perry J. (1979) Stiff-legged gait in hemiplegia: Surgical correction. J Bone
Joint Surg 61A, 927-933.
Waters R.L., Frazier J.,
Garland D., Jordan C., Perry J. (1982) Electromyographic gait analysis before
and after treatment for hemiplegic equinus and equinovarus deformity. J Bone
Joint Surg 64A, 284-288.
Waters R.L., Botte M.J.,
Jordan C., Perry J., Pinzur M.S. (1990) SYMPOSIUM: Rehabilitation of Stroke
Patients – The Role of the Orthopaedic Surgeon. Contemporary Orthopaedics
20, 311-348.
Wright P.A. and Granat M.H.
(2000) Improvement in hand function and wrist range of motion following
electrical stimulation of wrist extensor muscles in an adult with cerebral
palsy. Clin. Rehabil. 14, 244-246.
Wright P.A. and Granat M.H.
(2000) Therapeutic effects of functional electrical stimulation of the upper
limb of eight children with cerebral palsy. Dev. Med. Child Neurol. 42,
724-727.
Abstract: Functional electrical stimulation (FES) of the upper limb has been
used for patients with a variety of neurological conditions, although few
studies have been conducted on its use on the upper limb of children with
cerebral palsy (CP). The aim of this study was to investigate the effect of
cyclic FES on the wrist extensor muscles of a group of eight children (five
boys, three girls) with hemiplegic CP (mean age 10 years). The study design
involved a baseline (3 weeks), treatment (6 weeks), and follow-up (6 weeks). FES
was applied for 30 minutes daily during the treatment period of the study.
Improvements in hand function (p < or = 0.039) and active wrist extension (p =
0.031) were observed at the end of the treatment period. These improvements were
largely maintained until the end of the follow-up period. No significant change
was observed in the measurements of wrist extension moment during the treatment
period (p = 0.274). Hand function in this group of children improved after they
were exposed to FES of wrist extensor muscles. This suggests that FES could
become a useful adjunct therapy to complement existing management strategies
available for this patient population.
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