Effects of neuromuscular electrical stimulation and Kinesio Taping applications in children with cerebral palsy on postural control and sitting balance

Abstract

BACKGROUND:

Neurodevelopmental treatment (NDT), neuromuscular electrical stimulation (NMES), and Kinesio Taping (KT) applications are separately used to improve postural control and sitting balance in children with cerebral palsy (CP).

OBJECTIVE:

The aim of this study is to examine the combined effect of NDT, NMES and KT applications on postural control and sitting balance in children with CP.

METHODS:

Forty five children, in 3 groups, between the ages 5–12 years were included in the study. Group 1 received NDT; group 2 received NDT $+$ NMES; and the group 3 received NDT $+$ NMES $+$ KT for 6 weeks. Sitting function evaluated by the sitting section of the gross motor function measure (GMFM), and postural control assessed with the seated postural control measurement (SPCM).

RESULTS:

Seating section of GMFM was improved significantly in all the groups; however, increases in the group 3 were higher than groups 1 and 2 ( $p=$ 0.001). While significant differences were observed in all groups in the SPCM posture ( $p<$ 0.001), function ( $p<$ 0.001), and the total scores ( $p<$ 0.001); the change in the third group was higher according to the comparison of the three groups within each other.

CONCLUSIONS:

Implementation of the NMES, and KT additionally to NDT improve the sitting posture, postural control, seating function, and gross motor function in children with CP.

Keywords

Motor control physiotherapy kinesio taping electrical stimulation cerebral palsy

1. Introduction

Cerebral Palsy (CP) is a neuromuscular disorder developing due to a lesion in the brain in antenatal, perinatal and postnatal period [1]. Abnormal muscle tone, muscle weakness, postural control disorders, and primitive reflex patterns observed in children with CP cause motor problems. For these reasons, insufficiencies are observed in such motor milestones as seating, crawling, and walking in children with CP [2].

Decrease in the postural control is one of the main problems observed in children with CP. Disorders observed in motor behaviours and this cause a decrease in postural control, such a decrease causes deterioration in static and dynamic stabilization in all the activities of the child [3]. Sitting is a position in which the child can conduct numerous functional activities, communicate with their surroundings, and gain trunk control by purposefully using upper extremities. So, seating ability should be improved as early as possible. Also, sitting without support provides the child with dynamic stabilization [4, 5].

An individualized physiotherapy programme consist of numerous exercises oriented towards trunk is implemented for individuals with CP in order to increase the trunk muscle strength and control to enable them to use trunk muscles more efficiently during the activities in the daily life. NDT includes the active participation of the children which normal movement is associated with function and that is based on the facilitation, stimulation, and communication principles [5, 6, 7].

In clinical settings, electrical stimulation and Kinesio Taping (KT) applications are conducted separately on individuals with CP in order to increase trunk control and sitting balance in addition to the exercise programme. By the application of NMES to the upper extremities, it was observed that sensory awareness increased in children, which has contributed to the motor control, coordination, and that the upper extremity functionality [8]. By the administration of the NMES to the lower extremities, it was reported that the heel strike and dorsiflexion was increased, which has improved the gait parameters [9, 10]. In another study conducted on balance in children with CP, the High Voltage Pulsed Galvanic Stimulation (HVPGS) was applied on back and hip extensor muscles, and it was reported that the balances of children improved both in the exercise group and the group that received electrical stimulation following the treatment, and that the improvement was higher in the stimulation group [11].

KT is implemented in addition to current exercise programme in such paediatric age group diseases as CP. There are ongoing studies to prove its efficiency in the paediatric age group [12]. KT applications utilised in CP rehabilitation are used especially to maintain postural control. It was reported that the KT in children with CP increased proprioceptive and tactile senses, brought muscles to optimal length, stabilised hypermobile joints, assisted static and dynamic balance, maintained the control of trunk movements, and thus helped children in improving seating balances of children [13, 14].

The use of evidence-based interventions in CP treatment has gradually increasing and the results of the studies are promising. There are some studies that show the effects of electrical stimulation, KT and neurodevelopmental treatment in children with CP and the results are conflicting [15, 16, 17, 18]. However, to the best knowledge of the authors comparative effects of NMES, KT and NDT on the postural control and sitting balance have not been studied in children with CP. It is assumed that KT, NDT and NMES separately increase proprioceptive feedback and gross motor function, motor control and activities of daily living. Accordingly, the aim of this study was to investigate the effects of these applications in children with CP. In particular, KT in conjunction with the other therapeutic interventions may improve motor performance and sitting balance. So, it is hypothesized that the implementation of those three interventions together might improve the motor performance and sitting balance in children with CP with a triple effect.

Table 1
Demographic data of the children with cerebral palsy

Treatment type	Exercise ( $n=$ 15)	Exercise $+$ NMES ( $n=$ 15)	Exercise $+$ NMES $+$ KT ( $n=$ 15)	$P$
Age (year) (Mean $\pm$ SD)	7.8 $\pm$ 2.61	6.8 $\pm$ 2.11	9.07 $\pm$ 2.91	0.08
Height (cm) (Mean $\pm$ SD)	109.46 $\pm$ 12.23	106.13 $\pm$ 11.81	112.07 $\pm$ 12.36	0.41
Weight (kg) (Mean $\pm$ SD)	22.2 $\pm$ 8.62	19,87 $\pm$ 6.18	20.07 $\pm$ 8.87	0.72
BMI (kg/m ${}^{2}$ ) (Mean $\pm$ SD)	21.73 $\pm$ 8.58	17.21 $\pm$ 2.43	15.33 $\pm$ 3.74	0.14
Gender (F/M)	8/7	7/8	7/8	0.91
CP type (Q/D)	9/6	13/2	14/1	0.10
GMFCS 4	5	7	3
5	10	8	12	0.31

CP, cerebral palsy; NMES, Neuromuscular electrical stimulation; KT, Kinesio Taping; GMFCS, gross motor function classification system; SD: Standard deviation; F, Female, M, Male; Q, quadriparetic, D, diparetic. BMI, Body mass index.

2. Methods

This cross-sectional study includes a total of 45 children with CP, 9 spastic diplegia, 36 quadriplegia, referred to the Department of Physiotherapy and Rehabilitation by a physical medicine and rehabilitation specialist. The inclusion criteria were; age between 5 and 12 years; classified in levels IV, V of the GMFCS; and able to follow and accept verbal instructions and communication. The exclusion criteria were (1) any orthopaedic surgery or Botulinum toxin injection in the past 6 months, (2) any contracture and/or dislocation at the hip, (3) severe spasticity (4 and/or 5 according to Ashword Scale, (4) children with any allergic reactions to the Kinesio Tape (Patch test was used to exclude contact allergy). Study was approved by the local ethics committee of Gazi University.

Children with CP complying with the inclusion criteria of the study were subsequently randomized to one of the three groups using a number allocation table. Each group was composed of 15 children. First group was administered NDT. NMES was administered to the paravertebral muscles in the second group in addition to the NDT programme. NMES was administered to the paravertebral muscles along with the KT in addition to the NDT programme in the third group. Treatment continued for 4 days every week for 6 weeks (24 sessions). NDT was administered in group 1 for 30 minutes. NDT programme included the elongation of the shortened muscles, postural control, functional strengthening of abdominal and back muscles, facilitation of the trunk extension, positioning the child in the seating position with the feet on the floor and facilitation of the upper extremities, balance training in sitting, reaching with arms and weight transfers in sitting position. NMES was administered by using High Voltage Pulsed Galvanic Stimulation (HVPGS), Compex device (Intelect, model 550 Portable HVS; Chattanooga Corporation, Chattanooga, TN, U.S.A.). HVPGS is a current with a double peak as the type of pulse. Pulse duration was established as 14.65 microseconds with a frequency of 60 Hz, and current strength was determined so as to form a tetanic contraction. Application duration was 15 minutes and the application frequency was 4 weeks/day. It was adjusted according to the child’s tolerance and enough to produce muscle contraction. NMES was administered to the paravertebral muscles when the patient was in sitting position. Children were asked to maintain the trunk extension during applications. “I” taping technic with 5 cm width KT was applied for facilitation on paravertebral muscles once a week and was made sure to stay on for 4 days. Taping was removed when the NMES was applied and was put on after the administration. The first taping was applied for the facilitation of the paravertebral muscles and performed longitudinally on the paravertebral muscles from sacrum up to the cervical region in the sitting position. Taping was conducted with 50% stretch of its resting length. The second taping was applied in order to provide proprioceptive input for the patient and to correct the sitting posture at the interscapular area with an “X” shape taping, when the patient was in the upright position and scapulae are in retraction [19]. The applications were applied in the physiotherapy unit. Initially and at the end of the treatment, patients were assessed by the same physiotherapist experienced in the field of paediatrics (K.U.A) for 10 years. Motor performance of the subjects were assessed according to the GMFCS. GMFCS is a standardized evaluation system that classify the individuals based on their gross motor functions in 5 levels [20]. Level 1 shows the mildest influence, and level 5 manifests the severest influence. GMFM is a measurement method used to measure the motor function and capacity in children with CP [21]. It is composed of five sub-sections that include laying down on back or on face and turning, sitting, crawling and standing on knees, standing up, walking, running and jumping. Sitting sub-section of GMFM was used in this study. SPCM is a standardized test that assesses postural control and functionality in sitting position. Along with the postural control of the child, the effect of sitting on the posture is evaluated [22]. The assessment was carried out when the child was in the seating position with the feet on the floor. Sitting posture was checked from anterior, lateral, superior and scores ranging from 1 to 4 were assigned as bad, weak, mild, and good. Then, the individuals were asked to use their upper extremities in the function noted in the test in order to assess the upper extremity function, and the manner of application was marked. Lastly, SPCM total score was estimated and evaluated.

Table 2
Comparison of the GMFM and SPCM scores

	PRE-TREATMENT median (25–75%)	POST-TREATMENT median (25–75%)	$p_{2}$
GMFM sitting section score
Exercise	66.6 (35–80)	71.6 (35–83.3)	0.002
Exercise $+$ NMES	55 (21.6–86.6)	68.3 (31.6–91.6)	0.001
Exercise $+$ NMES $+$ KT	31.6 (16.6–51.6)	41.6 (33.3–61.6)	$<$ 0.001
$p_{1}$	0.06
SPCM posture section score
Exercise	53 (45–56)	56 (47–57)	0.001
Exercise $+$ NMES	51 (48–54)	58 (54–61)	$<$ 0.001
Exercise $+$ NMES $+$ KT	48 (45–50)	62 (60–64)	$<$ 0.001
$p_{1}$	0.053
SPCM function section score
Exercise	27 (18–37)	27 (22–38)	0.011
Exercise $+$ NMES	32 (21–36)	35 (26–39)	0.002
Exercise $+$ NMES $+$ KT	23 (17–31)	29 (24–38)	$<$ 0.001
$p_{1}$	0.18
SPCM total score
Exercise	80 (64–89)	82 (71–96)	0.001
Exercise $+$ NMES	81 (71–91)	95 (83–99)	$<$ 0.001
Exercise $+$ NMES $+$ KT	71 (63–81)	90 (85–101)	$<$ 0.001
$p_{1}$	0.12

NMES, Neuromuscular electrical stimulation; KT, Kinesio Taping; GMFM, gross motor function measurement; SPCM, seated postural control measurement; SD: Standard deviation. $p_{1}$ : pre-treatment difference between the three groups. $p_{2}$ : pre- and post-treatment difference separately for each group.

Table 3

GMFM and SPCM score changes of the children with cerebral palsy

	CHANGE (Mean $\pm$ SD)	CHANGE (%)	$P$
GMFM sitting scores
Exercise	3.91 $\pm$ 4.8	6.8%
Exercise $+$ NMES	7.21 $\pm$ 6.54	13%	0.001
Exercise $+$ NMES $+$ KT	14.89 $\pm$ 7.72	27%
SPCM posture section score
Exercise	2.46 $\pm$ 1.59	4.9%
Exercise $+$ NMES	6.53 $\pm$ 3.85	14%	$<$ 0.001
Exercise $+$ NMES $+$ KT	14.13 $\pm$ 3.87	31.9%
SPCM function section score
Exercise	1.13 $\pm$ 1.3	4%
Exercise $+$ NMES	2.13 $\pm$ 2.16	7%	$<$ 0.001
Exercise $+$ NMES $+$ KT	5.26 $\pm$ 2.76	21.8%
SPCM total score
Exercise	7 $\pm$ 14	9.5%
Exercise $+$ NMES	8 $\pm$ 6.59	9.9%	$<$ 0.001
Exercise $+$ NMES $+$ KT	18.73 $\pm$ 5.70	25%

NMES, Neuromuscular electrical stimulation; KT, Kinesio Taping; GMFM, Gross motor function measurement; SPCM, Seated postural control measurement; SD: Standard deviation.

2.1 Statistical analysis

For the statistical analysis of the data, Statistical Package for Social Sciences (SPSS) 20 software was used. The variables were investigated using visual (histograms, probability plots) and analytical methods (Kolmogorov-Simirnov/Shapiro-Wilk’s test) to determine whether or not they are normally distributed. Descriptive analyses were presented using means and standard deviations for normally distributed and medians and interquartile range (IQR) for the non-normally distributed. One way variance analysis was used to analyse age, height, and weight analyses that reflect demographic characteristics of patients in all groups; gender, GMFCS, CP type values were analysed by Fisher’s Exact test. In order to compare pre- and post-treatment values of patients, Wilcoxon Signed-Rank Test were used. Following the treatment, changes between the 3 groups were first analysed by Kruskal-Wallis test. The Mann-Whitney U test was performed to test the significance of pairwise differences using Bonferroni correction to adjust for multiple comparisons. A $p$ -value of less than 0.05 was considered to show a statistically significant result.

3. Results

Demographic characteristics of the children are given in Table 1. There was no difference between the groups in age, height, and weight values ( $p>$ 0.05). There was also no difference between the groups in terms of gender, CP type, and GMFCS values ( $p>$ 0.05).

Although there was no difference between the gro- ups in the GMFM sitting sub-section, posture and function section of SPCM and SPCM total values; in post-treatment, a significant difference was observed in the GMFM sitting sub-section in the groups 1 ( $p=$ 0.002), 2 ( $p=$ 0.001), and 3 ( $p<$ 0.001) (Table 2). According to the comparison between the three groups, there was a significant difference between the groups 1 and 3 and groups 2 and 3 ( $p=$ 0.001) (Table 3).

In the posture section of SPCM, significant differences were observed in the post-treatment period between the groups 1 ( $p=$ 0.001), 2 ( $p<$ 0.001), and 3 ( $p<$ 0.001) (Table 2). When the three groups were analysed between each other, statistically significant differences were found between the groups 1 and 2, groups 1 and 3, and groups 2 and 3 ( $p<$ 0.001). The highest increase occurred in the groups 3, 2, and 1, respectively (Table 3).

In the function section of SPCM, significant differences were observed in the post-treatment period between the groups 1 ( $p=$ 0.01), 2 ( $p=$ 0.002), and 3 ( $p<$ 0.001) (Table 2). When the increase in these three groups were analysed, statistically significant differences were found between the groups 1 and 3, and groups 2 and 3 ( $p<$ 0.001) (Table 3).

A significant difference was found in the SPCM total scores after the treatment in the groups 1 ( $p=$ 0.001), 2 ( $p<$ 0.001), and 3 ( $p<$ 0.001) (Table 2). When the increase in three groups were analysed, a statistically significant difference was found between the groups 1 and 3, and groups 2 and 3 ( $p<$ 0.001) (Table 3).

4. Discussion

The purpose of this study was to examine whether the applications of NMES, KT and NDT had any effect on the postural control and sitting balance in children with cerebral palsy. Results of this study have shown that, combined use of these three interventions were more effective on postural control and sitting balance in children with CP.

Exercise treatments without a doubt, form the basis of the treatment in children with CP. Dewar et al. [15] in their compilation study established that, exercise-based treatments improved postural control in children with CP. Simon et al. [23], reported that muscle activity increased and head control was facilitated as a result of the NDT intervention in children with CP which was put forth by EMG of the neck muscles. In a study by Knox and Ewans [24], 15 children with CP at level five of GMFCS were administered NDT, they reported that the GMFM scores were improved as a result of the treatment. These findings were in line with the results of our study that significant difference was observed in GMFM sitting scores of children as a result of exercise treatments. We may conclude that whatever intervention you apply in the rehabilitation program of a CP child, exercise should be included.

In addition to the exercise, electrical stimulation applications are frequently used in the rehabilitation of children with CP in order to improve the sitting balance, develop motor functions, and increase the muscle strength [25, 26]. The application of NMES preferentially activates faster-contracting motor units, perhaps those that are normally only active at high exercise intensities under voluntary conditions [27]. In a study by Park et al. [16], GMFM sitting score was increased in the group receiving electrical stimulation compared to the control group. They claimed that the Cobb’s angle showed a significant change after the treatment only in the ES group and it might be considered as a consequence of the reduced trunk asymmetry due to the improved trunk control in the ES group. In their study, Sherief and Hamed [28] reported that head control of children with spastic diplegic CP was improved following the NMES application and that mere exercise programme was not sufficient in improving the head control by itself. In another study, Karabay et al. [29] reported that, as a result of functional electrical stimulation applications on abdominal and back muscles, the GMFM sitting scores were improved in children that received electrical stimulation compared to the control group and the kyphosis and the Cobb angles were decreased. The NMES is also used to improve the contractibility of a muscle. Since CP is a chronic neuromusculoskeletal disease, increased immobility, impaired muscle function and overstretched paravertebral muscles effect trunk control and sitting posture. Accordingly, in our study, electrical stimulation applied on the paravertebral muscles might have increased the muscles strength and improved trunk control; thus, it was observed that the sitting scores and posture were improved in groups that received NMES.

Recently, the KT is being used on paediatric patients as well. The purpose of the KT application is to create a tactile input on the applied region through stimulating the mechanoreceptors via the skin, to provide tactile and proprioceptive input, and to increase awareness on posture, by increasing the afferent input to the central nervous system [17]. In a study by Cepeda et al. [30] it was reported that the KT application on the abdominal muscles of hypotonic children were among the approaches that facilitate the transition from the lying to sitting position. In a study by conducted by Simsek et al. [18] following KT application on paravertebral muscles, sitting scores in GMFM of children with CP were improved. However, such an increase was manifested a similarity with the control group as well. They analysed sitting posture and showed that the head, neck, and feet positions and hand, arm functions.

This is the first study shows that the NMES and KT applications facilitated the paravertebral muscles and would provide more benefits when applied together in addition to the NDT program. The facilitation of the paravertebral muscles by ES, the increase of tactile and proprioceptive input to the central nervous system through the mechanoreceptors and additionally improvement of the muscle strength and motor control have improved the postural control and sitting balance in children with cerebral palsy which may affect the independency of the children with cerebral palsy. It is also concluded that, NDT was efficient in increasing the performance and postural control of children with CP; however, application of other treatment methods would also increase the success.

4.1 Limitations

By conducting studies with higher number of cases and that contain longer follow-up periods are believed to show better results. On the other hand, we will be in touch with the families and the children for a follow up study. We would like to assess the carry over effect of these intervention after 6 and 12 months of time.

5. Conclusions

The NDT, electrical stimulation, and KT applications separately improve sitting posture and balance in children with CP. They also increase the trunk control, thus effect the functional use of the trunk in the functions executed in the sitting position. However, combined use of these applications seem to be more effective on postural control and sitting balance in children with CP. So it is recommended to the combination of these three application in daily practice to improve the functions in the daily living activities for a better inclusion.

Footnotes

Conflict of interest

None to report.

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Effects of neuromuscular electrical stimulation and Kinesio Taping applications in children with cerebral palsy on postural control and sitting balance

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

Table 1 Demographic data of the children with cerebral palsy

Table 2 Comparison of the GMFM and SPCM scores

3. Results

4. Discussion

4.1 Limitations

5. Conclusions

Footnotes

Conflict of interest

References

Table 1
Demographic data of the children with cerebral palsy

Table 2
Comparison of the GMFM and SPCM scores