|Year : 2016 | Volume
| Issue : 1 | Page : 27-31
Coupling effect of neuromuscular electrical stimulation on glutei and transcutaneous electrical nerve stimulation on hip adductors in scissoring gait
Khurshid Shaik1, Lakshmana Prasad Gadde1, Naveen Kumar Balne1, Aniruddh Kumar Purohit2
1 Department of Physiotherapy, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
2 Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
|Date of Web Publication||10-Aug-2016|
Department of Physiotherapy, Nizam's Institute of Medical Sciences, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Introduction: Spasticity and weakness are the two most important factors effecting gait in children with spastic diplegia. Spasticity in hip adductors and associated weakness in hip extensors and abductors leads to scissoring gait pattern. Proximal muscle stability is essential for distal mobility; this study focuses more on proximal muscle group facilitation for correction of deviations in scissoring gait.
Objective: The objective of this study was to study the coupled effect of neuromuscular electrical stimulation (NMES) on glutei and transcutaneous electrical nerve stimulation (TENS) on hip adductors in improving gait parameters.
Materials and Methods: The experimental group received NMES to hip extensors and hip abductors followed by TENS to hip adductors as an adjunct to conventional therapy for a period of 3 weeks whereas the control group received only conventional therapy. In experimental group, NMES was applied to gluteus maximus and medius for 10 min each and were asked them to perform the muscle action voluntarily. Later, TENS was applied to hip adductors for 10 min with passive hip abduction (HAB). Both the group received home program for the next 2 months.
Results: A significant improvement was noted in spasticity, active range of motion (AROM) to HAB, extension, and gait parameters with P < 0.05.
Conclusion: The coupled effect of NMES on glutei and TENS on hip adductors in children with scissoring gait gives rise changes in muscle tone, AROM, and gait parameter. All these contribute in improving the gait. These gains persist atleast for 3 months compared to the individuals who receive only conventional therapy. The improvement is seen within a short period of 3 weeks time compared to conventional therapy alone group which takes longer period of 12 weeks time.
Keywords: Neuromuscular electrical stimulation, scissoring gait, transcutaneous electrical nerve stimulation
|How to cite this article:|
Shaik K, Gadde LP, Balne NK, Purohit AK. Coupling effect of neuromuscular electrical stimulation on glutei and transcutaneous electrical nerve stimulation on hip adductors in scissoring gait. Indian J Cereb Palsy 2016;2:27-31
|How to cite this URL:|
Shaik K, Gadde LP, Balne NK, Purohit AK. Coupling effect of neuromuscular electrical stimulation on glutei and transcutaneous electrical nerve stimulation on hip adductors in scissoring gait. Indian J Cereb Palsy [serial online] 2016 [cited 2017 Aug 22];2:27-31. Available from: http://www.ijcpjournal.org/text.asp?2016/2/1/27/188154
| Introduction|| |
Cerebral Palsy (CP) is described as group of developmental disorders of movement and posture, causing activity limitation, that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant's brain.  Spastic diplegia which is common and constitutes about 50% of spastic Cerebral Palsy population have lower limbs affected more than upper limbs. The main issue in spastic diplegia is walking difficulty which is caused mainly due to spasticity  and weakness of the muscles  leading to slowness in gait.  This abnormal gait patterns causes increased energy consumption and ultimately fatigue.  Scissoring gait is a coronal plane pathology,  in which the advancing leg trends to cross over the stance leg, especially during swing phase, due to spastic hip adductors.
Muscle weakness is the major factor for final gait pattern in CP.  Gluteus maximus and medius have an important role in maintaining pelvic stability.
Neuromuscular electrical stimulation (NMES) is defined as "the application of electrical currents to neural tissue for the purpose of restoring a degree of control over an abnormal or absent body function" (Ragnarsson and Baker, 2001 p. 723). Electrical stimulation increases muscular strength in nonstimulated muscles through cross-education; produce neural adaptations resulting in increased muscle activation, and cause central fatigue and is frequently used modality in neurological conditions. 
Transcutaneous electrical nerve stimulation (TENS) is one of the simple and noninvasive ways in reducing spasticity. It should be considered first before preceding any invasive interventions.  Hip adductors spasticity causes many functional limitations and increases the chance of hip dislocation and also causes structural and biomechanical variations. Though it is difficult to treat adductor spasticity, TENS has been used to reduce spasticity and improve gait. 
Coupling the effect of NMES on gluteus maximus and medius in improving the strength and TENS on hip adductors to decrease spasticity is the purpose of the study.
| Materials and methods|| |
Thirty children with age from 4 to 11 years (mean age: 7.6 years) and male:female ratio of 2:1 were taken into the study. The children were randomly allocated into experimental and control groups based on the following criteria.
Children with spastic diplegic cerebral palsy having age range of 4-11 years, modified Ashworth scale (MAS) of hip adductors 1, 2, or 3, who are able to stand and walk (with or without assistance), and follow instructions.
- Cognitive impairment
- Inability to stand and walk
- Associated hip pathology such as limb length discrepancy, fractures, or dislocations
- Spine deformities
- On botulinium toxin A
- Obturator nerve selective motor fasiculotomy
- Visual and hearing impairment.
Transcutaneous electrical nerve stimulator, neuromuscular electrical stimulator, adhesive electrodes, a video camera to record the gait pattern, couch, and a mat.
The parameters collected from each group are MAS, voluntary control grading (VCG), Tardieu scale, active range of motion (AROM) of hip abduction (HAB) and extension, gait parameter - step length, stride length, and cadence and observational gait analysis on baseline (1 st day), end of 3 rd week and 12 th week.
The data were collected on the 1 st day, at the end of 3 rd week, and at 12 th week.
Neuromuscular electrical stimulation program
Once the child arrived at the Physiotherapy Department, he/she was asked and helped to remove clothing and exposing the treatment area. The child is placed in the prone position. The sites of gluteus maximus were cleaned. The electrodes were placed bilaterally over the target sites; the active electrode was placed over the belly of the muscle while the other electrode was placed 1 cm below the active electrode in the longitudinal axis. The intensity was increased till the maximum contraction of the muscle was felt. The child is asked to perform active or active-assisted hip extension. The treatment session lasts for 10 min.
Now the child was given 5 min rest, and is placed in supine lying position. Electrodes are placed bilaterally over gluteus medius with active electrode over muscle belly and other electrode 1 cm below the active in longitudinal axis. The intensity was then increased till strong contraction was felt. The child was asked to perform active or active-assisted HAB and adduction. The treatment session lasted 10 minutes.
The parameters used for NMES are asymmetrical biphasic waveform, pulse width of 2-200 μs and frequency of 2-100 Hz.
Transcutaneous electrical nerve stimulation program
The child was placed in supine position. The electrodes are placed bilaterally over the hip adductors. The negative electrode was placed on the belly of the adductor longus muscle while the positive electrode was placed 3 cm distally in line with the negative electrode. The electrodes were connected to the TENS unit. With pulse duration of 0.25 ms and frequency of 100 Hz, the intensity was increased gradually until the child reported a comfortable feeling of a tingling sensation. The treatment program lasts for about 10 min.
- Active or active-assisted exercises for upper and lower limbs
- Passive stretching for spastic muscles
- Strengthening exercises for hip abductors, hip extensors, knee extensors, abdominals, and back extensors.
Prone on elbows, prone on hands, quadruped, kneeling, and half kneeling.
Trunk control exercises
The child is made to sit on a chair. By showing the objects in different directions, the child is asked to reach the objects with both hands.
Gait training is performed in the parallel bar with mirror in front. Foot prints are made on the floor. The step length of the foot prints is placed according to the age and height of the subjects. By adjusting the height of the parallel bar, the children are made to walk. The therapist will give the tactile or auditory cues to prevent any deviations while walking.
Standing in the parallel bar in front of a mirror for visual cue, the child is asked to perform weight shifts between the lower limbs. Therapist will stabilize the pelvis and position the pelvis in neutral.
- Tardieu scale
- Gait analysis.
| Results|| |
Independent t-test for Tardieu of hip adductors, AROM of HAB, and extension was significant, with P < 0.05 and therefore, a significant difference exists between the groups with greater improvement was noticed at the end of 3 rd week in experimental group compared with control group where in it took 12 weeks [Table 1].
|Table 1: t score for tardieu of hip adductors, active range of motion of hip abduction and extension and step length|
Click here to view
Stride length and cadence showed greater improvement in experimental group at the end of 3 rd week and 12 th week when compared to control group [Table 2].
[Table 3] shows the mean ranks of Friedman test on day 1, 3 rd week, and 12 th week of hip adductors MAS, VCG of hip abductors, and hip extensors are represented, respectively, with P < 0.05 in experimental (Exp) group. The mean rank showed greater improvement in 3 rd week of experimental group.
|Table 3: The mean ranks of friedman test on day 1, 3rd week and 12th week of hip adductors MAS, VCG of hip abductors and hip extensors|
Click here to view
| Discussion|| |
As an extension to the work done by Alabdulwahab and Al-Gabbani  who have applied NMES to bilateral hip abductors in one study and TENS to hip adductors in another study during walking in cerebral palsy children, this study included the application of NMES to bilateral gluteus medius and maximus one after another followed by the application of TENS to hip adductors. The limitation in the study conducted by ML van der Linden et al. has been addressed and NMES was applied to gluteus maximus in functional way.
The possible explanation for this reduction can be explained by the following ways. First, TENS inhibits excessive α-motor neuron activity by stimulating Ia afferent nerve which are large diameter fibers causing presynaptic inhibition (Goulet et al. and Joodaki et al.). Thus, this supports the findings of Ray-Yau Wang et al. Second, NMES application to HAB causes reciprocal inhibition to hip adductors. Hence, there was a reduction of spasticity in hip adductors in this study.
Application on NMES to hip abductors and extensors as explained by Judy Carmick in her case study regarding the application of NMES to the right foot showed improvement in ankle dorsiflexion. The mechanism of NMES is it works through overload principle and selectively recruiting the slow twitch fibers, thus activating the muscles and improving range of motion.
The results of this study showed that targeting hip musculature produces Better improvement in gait (Graphs 1-4 shows improvement in major and minor devaitions in experimental group) and its parameters (step length, stride length, and cadence) because proximal stability is very important for distal mobility and also for normal gait performance. This stability is attributed by gluteus medius and maximus which are the main pelvic stabilizers.
| Conclusion|| |
In spastic cerebral palsy, the coupling of NMES and TENS along with conventional therapy improves scissor's gait much more and that too within a short period of 3 weeks compared to conventional therapy alone group which gives lesser improvement and takes longer period (12 weeks). The improvement occurs due to reduction in spasticity with this therapy programme.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N, Dan B, et al.
Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol 2005;47:571-6.
Kalirathinam D, Arumugam J. Gait training on spastic diplegic children - A physiotherapy approach. IOSR- JNHS; 2012;1:1-5.
Kerr Graham H, Selber P. Musculoskeletal aspects of cerebral palsy. J Bone Joint Surg Br 2003;85:157-66.
Jerome A. Effects of quadriceps femoris muscle strengthening on spastic diplegic children. Int J Pharm Sci Health Care 2012;5:33-40.
Johnston TE. Energy cost of walking in children with cerebral palsy: Relation to the gross motor function classification system. Dev Med Child Neurol 2004;46:34-8.
Berker N. The HELP Guide to Cerebral Palsy. Istanbul, Turkey: Global-Help Publication; 2005.
Dean JC, Yates LM, Collins DF. Turning on the central contribution to contractions evoked by neuromuscular electrical stimulation. J Appl Physiol (1985) 2007;103:170-6.
Miller L, Mattisson P. Effect of transcutaneous electrical nerve stimulation on muscle spasticity. Physical therapy reviews 2005;10:201-8.
Alabdulwahab SS, Al-Gabbani M. Transcutaneous electrical nerve stimulation of hip adductors improves gait parameters of children with spastic diplegic cerebral palsy. NeuroRehabilitation 2010;26:115-22.
[Table 1], [Table 2], [Table 3]