Int J Physiot her Res 2014;2(3):507-10. ISSN 2321-1822 507
Original Article
EFFECT OF HIGH FREQUENCY TENS VERSUS SHAM TENS ON
SPASTIC PLANTAR FLEXORS IN CHILDREN W ITH CEREBRAL PALSY
Arati patel *
1, Shraddha diwan
2.
*1 M .PT (Neurological condit ions), 2 M .PT (Rehablitat ion).
S.B.B college of physiot herapy ,Vadilal sarabhai hospital, Ahmedabad, Gujarat , India.
Objective:To evaluat e t he Effect of high TENS w it h convent ional t herapy in com parison t o sham TENS w it h convent ional t herapy on spast icit y of plantar flexors in cerebral palsy children.
Design: Experim ental t rial.
Subject s: 34 pat ient s, diagnosed as cerebral palsy w ere select ed and random ly assigned in t o t w o groups experim ental group (n=18 ) and cont rol group (n=16).
M ethod: Pat ient s included in bot h t he groups att end regular physiot herapy session. In addit ion t o convent ional t herapy, pat ient s in experim ental group received high TENS (f =100hz, pulse w idt h =0.1m s, int ensit y-according t o individuals sensory t hreshold) t o t he spast ic plant ar flexors for 15 m inut es ,once per a day, 6 days in w eek, for 4 w eek. In cont rol group everyt hing w as sam e only int ensit y w as not increased.
Results:W it hin group com parison of t he variables w as done w it h w ilcoxon m atched pair t est and bet w een group com parisons w it h m ann-w hit ney U t est . Experim ent al group show ed stat ist ically significant im provem ent in M AS score for plant ar flexors at 5%level of significance t hen cont rol group but not in D and E dim ension of GM FM 88 and act ive ankle dorsiflexion ROM .
Conclusion: High TENS along w it h ot her convent ional t herapy is m ore effect ive t han convent ional t herapy alone in reduct ion of spast icit y of plantar flexors in cerebral palsy children.
KEYW ORDS:Spast icit y, Cerebral palsy, TENS (t ranscutaneous elect rical nerve st im ulat ion)
Quick Response code
Access this Article online
International Journal of Physiotherapy and Research
ISSN 2321- 1822
w w w.ijmhr.org/ ijpr.html
Received: 06-04-2014 Accepted: 14-04-2014
Published: 11-06-2014
ABSTRACT
BACKGROUND
Address for correspondence: Dr. Arat i patel (PT), 37/ Sarvam angal Societ y, Opposite Trim urt i Com p l ex, In d i a Co lo ny Ro ad, Bap u n agar, Ah m ed abad -380024, Gu j arat , In d ia. Email: arat i1407@gmail.com
International Journal of Physiotherapy and Research, Int J Physiother Res 2014, Vol 2(3):507-10. ISSN 2321-1822
Peer Review : 06-04-2014
Cerebral palsy (CP) describe a group of disorders of t he development of movement and post ure causing act ivit y limitat ion t hat are att ributed t o non progressive dist urbances t hat occurred in developing fetal or infant brain w hich includes mot or disorders accompanied by dist urbances o f sen sat i on , co gn it i o n , co m m u n icat io n , percept ion and/ or behaviour and/ or by a seizure disorders.1 Spast ic cerebral palsy is t he m ost
commonest t ype of CP.2
Spasticity is noted as major impairment in spast ic cerebral palsy w hich is characterized by velocit y
dependent increase in t onic st retch reflex w it h exaggerated tendon jerks.3,4
Spast icit y m ay have bot h t he posit ive and negat ive effect s. Spast icit y is helpful t o maintain ant igravit y post ure ,preser ve m uscle bulk, preserve bone densit y but it s severit y leads t o rest rict ion in grow t h of m uscles and bone according t o age, cont ract ure, defor m it ies, abn or m al m o vem en t , ab no r m al po st u re, abnormal gait , pressure sore, pain and so it also increase energy consumpt ion.5,6,7,8
Int J Physiot her Res 2014;2(3):507-10. ISSN 2321-1822 508
M ATERIALS AND M ETHODS
in the stabilisat ion of column vertebralis.9 plantar
flexors spast icit y is t he primary problem t hat hampers standing and walking abilit y. 10 Equines
is t he most common foot deformit y in spast ic cerebral palsy.11
So, reduction of spast icit y is only one of t he many facet s of t he overall m anagem ent of m ot or disorder of cerebral palsy. There are various pharmacological, surgical and physical t herapy approaches for t he t reat ment of t he spast icit y.
In t he physical t herapy dif ferent elect r ical st imulat ions are used t o reduce spast icit y.
TENS is most commonly used forms of elect ro analgesia w hich act on gate cont rol theory. lately, it has been used t o reduce spast icit y in different neurological condit ion like cerebral palsy 5,12,
m u lt ip le sclerosi s13, spin al cord in j ur y 14 ,1 5
st roke16, 17.
So, purpose of t he present st udy was t o find out t he effect of high TENS on spast ic plantar flexors in cerebral palsy.
34 pat ient s w it h cerebral palsy suited t o t he select ion criteria w ere included in the st udy and randomly dist ributed in group A [N=18, mean age -5.36 + 1.8 year] & group B [N=16, mean age -5.31 + 0.9 year] .
Inclusion criteria: 1) age group >3year, 2) cerebral palsy pat ient s having spast ic plantar flexors, 3) able to follow 3 step command and cooperat ive, 4)GM FCS level 1-3. Exclusion criteria: 1) pat ient s w it h sensory affect ion, 2) surgery done for plant ar flexors, 3) bot ox inject ion t o plant ar flexors before 6 mont hs.
Treat m ent procedure w as explained t o t he pat ient s and parent s, inform ed consent w as t aken and w ere evaluat ed according t o t he proforma.
Before the staring of TENS therapy pat ient s w ere given few familiarizat ion session of high TENS. M inimum 10 days gap was kept bet w een end of familiarisat ion session and beginning of st udy in order t o avoid t he carryover effect of prot ocol.
Bot h group received convent ion al t herapy regularly w hich consisted 1] passive, act ive and assist ive exercise 2] st retching exercise 3]balance t raining 5]gait t raining according t o requirement of pat ient s.
In experimental group [A], TENS w as given in prone lying posit ion. Skin of t he calf area of affect ed low er ext remit y was cleaned w it h a spirit t o reduce skin resistance before elect rode placement . Tw o carbonised rubber elect rodes w ere used t o st imulate t he area. Ult rasonic gel w as app l i ed t o t h e el ect r od e t o i ncr ease conduciveness. Then t he elect rode w ere placed over posterior aspect of patient s leg over t he calf area linearly and fasten w it h Velcro st raps. The frequency was set t o 100 Hz w it h a pulse w idt h of 0.1 ms. The intensit y was raised up t o t he sensory t hreshold of pat ient s. The pat ient w ere prompt ly advised t o inform t he t herapist if t hey felt any discomfort during t he t reat ment . High TENS was given t o t he plantar flexors for 15 minute cont inuously once per day, 6 days per w eek for a period of 4 w eek.
In cont rol group [B] everyt hing was same only intensit y was not increased.
Outcomes w ere assessed pre and post t o t he w hole t reat ment prot ocol of 4 w eek
· Plantar flexors spast icity assessed by modified ashw ort h scale.
· Act ive Ankle Dorsiflexion range of m ot ion assessed by universal goniometer.
· Gross M ot or funct ion measure by D[standing] & E [walking, running, jumping]dimension of GM FM -88 scale.
RESULTS
Statistical analysis
Pre and post all t hree outcome measure
· Individually W it hin group A & group B w ere analysed by using W ilcoxon matched pair test .
· Bet w een group A & group B w ere analysed by using M ann Whit ney U test
The level of significance was set at 5%.
DISCUSSION
In t h i s st u dy exper i m en t al gr ou p sho w ed stat ically significant difference in reduct ion of plantar flexors spast icit y. [Table-1]
Gabbani et al suggested t hat convent ional TENS act ivate sensory Ia afferent fibers sw itching on pre synapt ic inhibit ion mechanisms leading t oo reduct ion in spast icit y. 5 Pot isk et al reported
Int J Physiot her Res 2014;2(3):507-10. ISSN 2321-1822 509 t hat a signif icant reduct ion in exaggerat ed
st retch reflex act ivit y and decreases resist ive t orque of calf m uscles im m ediat ely aft er 45 m inut es of high TENS in chronic hem iplegic pat ient s. 16 Goulet et al in 1996 explain t hat high
TENS st im ulate low t hreshold afferent w hich project t o gam m a m ot or neuron and modify t heir excit abilit y w hich leads t o reduct ion in spast icity.It seems t hat alpha and gamma mot or neurons are cont rolled by pat hw ays largely i nd ep en d ent o f each o t h er. Th is abo v e explanat ions could be underlying mechanism of reduct ion of spast icit y by using high TENS in present st udy. 15
Intervent ions used in convent ional t herapy may also helpful in improvement of all 3 outcome measure w it hin bot h of t he groups [Table1,2]. In t he present st udy group A [experim ental] show ed significant reduct ion in plant ar flexor spast icit y compare t o group B [Cont rol] w hich
Table- 1: M ean difference in M AS scale for plantar flexors, dorsiflexion range of m ot ion, GM FM -88 w it hin group A.
Pre
M ean±SD
M AS score
Right 1.96±0.36 0.0008
Left 1.81±0.25 0.0005
ROM
Right 7.07±2.58 0.0009
Left 9.50±3.75 0.0004
GM FM -88
GM FM -D -153 0.0003
GM FM -E -120 0.0007
GROUP A
Post
W P value
M ean±SD
1.17±0.35 105
1.15±0.23 120
Comparing t he difference in m ean ±SD of M AS w it hin group A w as found t o be significant
12.43±3.2 -105
14.19±4.1 -136
Comparing t he difference in m ean ±SD of dorsiflexion range of m ot ion w it hin group A w as found t o be significant
14±14.44 17.17±14.1
23.78±26.7 27.56±26.2
Comparing t he difference in m ean ±SD of D & E dimension of GM FM -88 w it hin group A w as found t o be significant
Pr e
M e an±SD
M AS scor e
Right 1.63±0.22 0.0011
Le ft 1.57±0.33 0.006
Right 9.20±3.84 0.0008
Le ft 10.21±4.3 0.0014
GM FM -8 8
GM FM -D -136 0.0004
GM FM -E -120 0.0007
1.26±0.25 66
GROUP B
Post
W P value
M e an±SD
1.25±0.33 36
Com paring t he diffe re nce in m e an ±SD of M AS w it hin group B w as found t o be significant
11.27±4.0 -105
17.19±13.4 20.25±15.2
Com paring t he diffe re nce in m e an ±SD of D & E dim e nsion of GM FM -8 8 w it hin gr oup B w as found t o be significant
ROM
12.29±4.6 -91
Com paring t he differ e nce in m e an ±SD of dorsifle xion range of m ot ion w it hin gr oup B w as found t o be significant
15.3±8.31 18.06±8.6
Table-2: M ean difference in M AS scale for plantar flexors, dorsif lexion range of m ot ion, GM FM -88 w it hin group B.
also explain t hat act ive TENS does not give placebo effect [Table-3].
Result s also suggested not significant difference of act ive ankle dorsiflexion ROM in bet w een gr ou p s m ay b e becau se i n t h is st u d y int ervent ions focused only on reduct ion of plantar flexor spast icit y, not on facilitat ion of dorsiflexor st rengt h but active joint ROM require bot h prope ext ensi bi lit y and sim ult aneous cont ractabilit y of repected muscles.
Limitat ions of t his st udy are unchecked indepen-dent effect of TENS, long term effect of inter-vent ion. Outcom e measures are re liable but validit y is not w ell est ablished. Fut ure st udy should be done w it h appropriate sample size, long term follow up & conjoin effect of high TENS t o appropriat e spast ic muscles w it h sim ult a-neous facilitat ion of opposite muscle group along w it h funct ional act ivit y.
Int J Physiot her Res 2014;2(3):507-10. ISSN 2321-1822 510
Arat i pat el et al., EFFECT OF HIGH FREQUENCY TENS VERSUS SHAM TENS ON SPASTIC PLANTAR FLEXORS IN CHILDREN WITH CEREBRAL PALSY.
Table-3: M ean difference in M AS scale for plantar flexors ,dorsiflexion range of m ot ion, GM FM -88 bet w een group A& B.
Group A Group B
M e an±SD M ean±SD
M AS score
Right 0.79±026 0.37±0.22 33 0.0004
Le ft 0.67±0.30 0.29±0.26 47 0.0027
ROM
Right 5.36±1.34 2.06±0.70 0 <0.0001
Le ft 4.69±1.35 2.07±1.14 16 <0.0001
GM FM -8 8
GM FM -D 3.35±1.93 2.68±1.45 111.5 0.38
GM FM -E 3.89±2.99 3.06±3.50 109 0.23
Com paring t he diffe re nce in m e an ±SD of D & E dim e nsion of GM FM -88 be t w e e n group A & B w as not found t o be significant
GROUP A& B
U P value
Com paring t he diffe re nce in m e an ±SD of M AS be t w e en group A & B w as found t o be significant
Com paring t he diffe re nce in m ean ±SD of dorsifle xion range of m ot ion bet w ee n group A &B w as not found t o be significant
CONCLUSION
The conclusion of t he present st udy is t hat high TENS along w it h convent ional t herapy is more ef fect ive for t he reduct ion of plant ar flexor spast icit y t hen convent ional t herapy alone in cerebral palsy children.
Acknow ledgements:
I w ish t o t hank my parent s & my colleagues for t heir support and encouragem ent t hroughout my st udy. I w ould like t o express m y very great appreciat ion t o all t he scholars w hose art icles cit ed and included in references of t his research w ork.
Source of funding: S B B College of physiot herapy, Gujarat .
Conflicts of interest: None
REFERENCES
5 . Al Ab d u l w ah ab , S.S. an d Al - Gab b an i , M . Transcut aneous elect rical nerve st im ulat ion of hip adduct ors im proves gait param et ers of chi ldren w i t h sp ast i c d i p l e gi c ce r e b r al p al sy N e u r o Rehabilitat ion; 26: 115-122, 2010.
6. Farm er SE, Jam es M . Cont ract ures in ort hopaedic and neurological condit ions: a review of causes and t reat m ent . Disabi l Rehabil. 2001;23:549–558. doi: 10.1080/09638280010029930.
7. Kulkarni et al. Text book of ort hopedic and t raum a 4t h edit ion. 2003:3504.
8. Tedrof f, Krist ina. Children w it h spast ic cerebral palsy : Aspect s of m uscle act ivit y and bot ulinum t oxin a t reat m ent . Publicat ion year: 2009 ISBN: 978-91-7409-211-0.
9. Ak b ayr ak T, Ar m u t l u K, Gu n el M K, N u r l u G. Assessm ent of sho r t t er m ef fect of ant ispast ic p o si t i o n i n g o n sp ast i ci t y. Ped i at r I n t . 2 00 5 Aug;47(4):440-5.
10. Wangjam , K. B., A. K. Joy Singh, N. Rom i Singh, L. Nilachandra, and N. Bim ol. EM G guided select ive t i bial neurect om y in reduct ion of gast ro-soleus spast icit y—it s role in t he t reat m ent of cerebral palsy. Indian J Phys M ed Rehabil 2001;12):1-5. 11. Cott alorda, J., V. Gaut heron, G. M ett on, E. Charm et ,
K. M aat ougu i, and Y. Ch avr i er. “ Predict ing t he out com e of adduct or t enot om y.” Int ernat io nal ort hopaedics 1998;22 (6):374-379.
12. Sultan HE, Helal AM , Aw aad YM , et al. M anagem ent of spast icit y in diplegic cerebral palsy: evaluat ion of bot ulinum t oxin A, t ranscut aneous elecr r ical st i m ul at i on an d ki nest h et i c gai t t r ai ni n g. Th e Egypt ion Jour nal of pediat r ic neuroscience 2005; 2 (2): 5-11.
13. Arm ut lu K, M eriç A, Kirdi N, Yakut E, Karabudak R. The ef f ect o f t r an scu t an eo u s elect r i cal n er ve st i m u lat io n on sp ast i ci t y in m u lt ip le sclero si s pat ient s: A pilot st udy. Neurorehabil Neural Repair. 2003 Jun;17(2):79-82.
14. Aydin G, Tom ruk S, Keleº I, Dem ir SO, Orkun S. Transcut aneous elect rical nerve st im ulat ion versus b acl o f e n i n sp ast i ci t y : cl i n i cal an d elect rophysiologic com par iso n Am J Phys M ed Rehabil. 2005 Aug;84(8):584-92.
15. Goulet C, Arsenault AB, Bourbonnais D, Laram ée M T, Lepage Y. Effect s of t ranscutaneous elect rical ner ve st im ulat ion on H-ref lex and spinal spast icit y. Scand J Rehabil M ed. 1996 Sep;28(3):169-76. 16. Po t i sk KP, Gr egor ic M , Vo do vni k L. Ef f ect s o f
t ranscutaneous elect rical nerve st im ulat ion (TENS) on spast icit y in pat ient s w it h hem iplegia. Scand J Rehabil M ed. 1995 Sep;27(3):169-74.
17. Joodaki M R, Olyaei GR, Bagheri H. The ef fect s of elect rical nerve st im ulat ion of t he low er ext rem it y on H-reflex and F-w ave param et ers. Elect romyogr Clin Neurophysiol. 2001 Jan-Feb;41(1):23-8. 1. Bax M , Goldst ein M , Rosenbaum P, Levit on A, and
Panet h N. Proposed definit ion and classificat ion of cer e b r al p al sy, De v.M ed .f o r Ch i l d neuro.2005;47:571-576.
2. Ross SA, En gsberg JR.: Rel at io nshi ps b et w een sp ast i ci t y, st rengt h , gai t an d t h e GM FM -66 in persons w it h spast ic diplegia cerebral palsy. Arch Phys M ed Rehabil, 2007, 88: 1114–1120.
3. Engsberg JR, Olree KS, Ross SA, Park TS. Quantitative cl in ical m easur e of sp ast icit y i n chi l dr en w i t h cer e b r al p al sy. Ar ch Ph y s M ed Reh ab i l . 1996;77:594–599.
4. Lance JW. Sym posium synopsis; in Feldm an RG, Young RR, Koella WP (eds): Spast icit y: Disordered M o t o r Co n t r o l . Ch i cago : Ye ar b o o k M ed i cal Publishers, 1980:484-495.
