Use of Electrical Stimulation under the
Principles of Conductive Education:
A Case Study in a Child with Spastic Diplegic Cerebral Palsy
Angela HO, Mandy DAI
Physiotherapist, Jockey Club
Effectiveness of Electrical Stimulation
Implementation of Electrical Stimulation in a Conductive Education
Setting
Neuromuscular
electrical stimulation is the application of electrical current
transcutaneously to innervated, superficial muscles to stimulate muscle fibres.
It is usually applied as an adjunct to physical therapy in the management of
children with neuromuscular impairment to reeducate muscle, strengthen muscle
and improve gait.1-4 It is recommended that electrical stimulation
be used while the child is engaged in task-specific, goal-directed activities
so that the child can take an active role in the process of motor learning.5
This approach is consistent with the principle of conductive education.
Conductive education adopts an educational model instead of a medical model in
the habilitation of children with neurological impairments. It believes that
active learning through a holistic approach and a facilitative learning
environment are the keys to success in the habilitation of children with
disabilities. A description of the use of electrical stimulation under the principle
of conductive education is illustrated in the following case example.
HY was a
five-year-old girl diagnosed with cerebral palsy, spastic diplegia. She had
normal intelligence. She ambulated with two quadripods independently indoors
and outdoors. Due to spasticity in the calf muscles, she walked with a
toe-walking gait which was partially corrected by a pair of AFO. She was a
boarder and went back home in weekends.
The physical
training that HY previously received in the Conductive Learning Centre was
delivered in the form of group motor programmes and daily functional routine
training. The motor programmes and daily routine training focused on education
on postural awareness as well as body and movement concepts; control and
coordination of ankle, knee and hip movement; standing balance; gait training;
stretching; and motor planning. Electrical stimulation was added to HY's
physical training when she was five years old. Electrical stimulation was
implemented in a strengthening and endurance programme.
Before
electrical stimulation was administered, an introductory session was given to
the staff, explaining the use of electrical stimulation and how it was
implemented in the daily schedule of the child. A familiarisation session was
given for the child to know the function of electrical stimulation and be
familiar with the sensation of electrical stimulation. Electrical stimulation
was used an average of three times a week. Each session took about 40 minutes
in the morning free play time when the boarders finished breakfast. Electrical
stimulation was not given within the group motor programmes since the former
focused more on strength and endurance while the latter focused more on
coordination and balance. Electrical stimulation was applied to bilateral calf
muscles while the child was engaged in gait and pre-gait activities including
rising on heels, stepping up and down a low stool, exercising on the stepper,
walking on the treadmill and walking on the ground. Besides actively involved
in the core physical training, the child was also given responsibility to help
prepare the material and apply the electrode pads on the muscles, set the time
for training, solve the problem of getting in and out of the treadmill or
stepper, clean up the legs after treatment finished, and give feedback during
and after treatment. The child received electrical stimulation within the
conductive education setting for a period of eight months.
Response Select
(Empi, Inc.,
Progress on
gait was recorded by videocamera and analysed by Photoshop software. Progress on gross motor abilities was assessed
by Gross Motor Function Measure (GMFM) which is a standardized assessment to
test gross motor functional changes in children with cerebral palsy. Since the
operation of electrical stimulation involved getting the child out of her peer
group during the morning free play session, a survey was distributed to staff
to help observe the influence of electrical stimulation on the psycho-social behaviour and learning routine of
the child.
Before
electrical stimulation was used, the child has been receiving physical training
from conductive education programmes. Continuous improvement was made the one-year conductive education
programme. The child progressed from using a posterior walker to using two quadripods to walk, indicating an
improvement in postural stability and balance. Also the child has attained the
ability to walk without support for a few steps and the ability to climb up and
down stairs holding onto rail. Moreover, gait was improved in terms of
increased step length. However, there was no change in foot contact area during
gait and walking speed.
When electrical
stimulation implemented in strengthening and endurance programme was added,
further improvement was made in gait and motor abilities. The mean step length
of the left foot increased from
The staff
working with HY commented that while administration of electrical stimulation
during the morning free-play time did take up some of the child's time to play
and interact with other children, there was no adverse effect shown in the
psycho-social behaviour of the child. As well, although sometimes the child was
slightly late for the first lesson, the influence on learning was minimal. When
the psycho-social and cognitive learning goals of the child set for this year
were reviewed at the end of the training period, nearly all the goals were
fulfilled, indicating that the training didn't bring alone any adverse effect
on the child's learning.
Effectiveness
of Electrical Stimulation
It was shown in
this case example that electrical stimulation together with strengthening and
endurance training refined gait and motor performance in children with spastic
diplegia, built on the substantial physical improvement gained from conductive
education programmes. Especially, electrical stimulation helped to increase
foot contact area during gait. This result is consistent with the results of
other studies which demonstrated positive effect of electrical stimulation on
gait and motor abilities in children with cerebral palsy.1-4,6
However, the improvement shown in this case example could not be attributed
solely to the effect of electrical stimulation since both electrical
stimulation and strengthening and endurance training were delivered to the
child at the same stage. Strength training programmes are known to be able to
increase strength and motor activities in children with cerebral palsy without
adverse effects.7
In this case
example, only the sensory level of the electrical stimulation was used. In
fact, during the process of selecting appropriate candidates for electrical
stimulation, one of our children even demonstrated an adverse response of
tensing up the muscles of the whole body when the sensory level of electrical
stimulation was given. Previous studies on electrical stimulation used the motor
level electrical stimulation to demonstrate the effect of electrical
stimulation on children with physical impairment. The age of the children in
these studies were as young as twenty months of age.1,3,4 However,
there has been no report on the use of electrical stimulation on children who
cannot tolerate the motor level electrical stimulation. Recently, a number of
studies investigated the use of low amplitude sensory stimulation as a
treatment alternative. Investigators are especially interested in the effect of
therapeutic electrical stimulation (TES), a night-time delivery of low
amplitude electrical stimulation, which claims to able to improve motor
abilities in children with cerebral palsy through improved muscle bulk.6,8
However the effect of TES is controversial.9 Apart from being used as the TES
protocol, the sensory level electrical stimulation can be used as a
facilitative tool through its sensory input to enhance sensory awareness. A few
children reported to us that the tickling or tapping sensation allowed them to
¡¥feel¡¦ the muscle in use. For those children with poor perception of movement
and without adverse responses toward the sensation of electrical stimulation,
the sensory input is likely to facilitate motor learning.
This case
example indicates that electrical stimulation implemented in strengthening and
endurance programme is beneficial to children with spastic diplegia,
specifically in the improvement of area of foot contact during gait. Even
though electrical stimulation may not be used at the motor level in some
children, its sensory input may serve to facilitate sensory perception of
movement in these children, provided that these children demonstrate no adverse
response toward the sensation of electrical stimulation.
Implementation
of Electrical Stimulation in a Conductive Education Setting
Besides that
the electrical stimulation with strengthening program itself brought about
therapeutic effect on gait and motor ability, this case example also
illustrates that the way the program introduced to the child and her learning
environment could enhance the management of the child in a wider scope.
When the
electrical stimulation with strength training programme was introduced in the
Conductive Learning Centre, it was not regarded solely as a physiotherapy
programme that only the physiotherapist involved could play an active role.
Instead, it was introduced in a holistic manner, paying respect to the
transdisciplinary team approach. First, the introduction of the modality to the
staff working with the child helps to enhance transdisciplinary understanding
on the management of the child and facilitates team cooperation in
administrating the programme. Second, the child was requested to be actively involved
in an all-round manner in the training session, based on what she has learned
in the conductive education environment, including a sense of
self-responsibility, knowledge on body concept and movement concept and motor
planning. As such, the child had all-round benefits, besides the motor benefit,
under the educational principle. Third, the training sessions were carefully
scheduled so that it would not interfere or interrupt the child's core learning
time. The child in this case example had satisfactory psycho-social development
and her major learning goal was on the physical aspect. As such, her
psycho-social development was not affected by the reduction in free play time
with peers. Besides, since HY had a higher functioning ability than her peers, it
is necessary to provide her with more specific and more challenging motor tasks
apart from the group motor programmes. However, for children whose learning
goals involve social interaction as well, in order not to interfere the core
learning time including free play session, their motor group programmes and
daily routine have to be re-structured so that the training with electrical
stimulation and strengthening could be implemented in the programmes.
This case
example illustrates that, first, conductive education and electrical
stimulation with strengthening programme could be compatible and complement
each other as long as the educational principle and holistic view of management
are well taken. Second, in order to obtain optimal results from the electrical
stimulation programme, appropriate candidates should be selected; mainly are
those who do not have adverse response toward electrical stimulation and whose
major learning goal is on the motor aspect.
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