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Effects of Electrical Stimulation, Exercise Training & Motor Skills Training on Strength for Children… Dagenais, Lise; Lahay, Erin; Stueck, Kailey; White, Erin; Williams, Lindsay; Harris, Susan Jul 30, 2007

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Effects of Electrical Stimulation,  Exercise Training & Motor Skills  Training on Strength for Children  with Meningomyelocele: A Systematic Review  Liese Dagenais ‐ Erin Lahay ‐ Kailey Stueck ‐ Erin White – Lindsay Williams Supervisor ‐ Susan Harris  Acknowledgements Susan Harris Supervisor and mentor Charlotte Beck Reference Librarian  Outline  • Introduction • Purpose • Methods • Results • Discussion   Introduction  Spina bifida  • Congenital abnormality • Incomplete closure of the spinal     column1 • ~1/1000 births annually2 • 94% classified as meningomyelocele  Spina bifida  Meningomyelocele • Results in nerve damage below                      level of lesion1 • Common impairments1 – – – –  Muscle weakness  Muscle paralysis Sensory impairments Bowel & bladder                      dysfunction  Interventions  • Multidisciplinary approach to  treatment is ideal • Physical therapy plays a key role1 • Interventions include1 – – – –  Muscle strengthening Positioning Improving postural control Increasing independence  & mobility1  Existing Research • Limited evidence regarding efficacy  of physical therapy interventions for  children with meningomyelocele • Systematic review: Mazur JM & Kyle S,  20043 – Inconsistent results – No conclusive findings – Further research necessary  Cerebral Palsy Research • Current & high quality articles  available • Systematic review: Dodd KJ et al.,  20024 – 23 relevant articles – 11 high quality  Purpose  To provide an overview of the existing  research regarding the effects of  electrical stimulation, exercise training  and motor skills training on muscle  strengthening for children with  meningomyelocele  Methods  Literature Search •Electronic databases Limits: English language  •PEDro •Pubmed •CENTRAL  •Embase •DARE •Cinahl •CIRRIE •Medline •Cochrane database  •Hand Search  Reference lists of selected articles  Spina B  Mening  Spinal  ifida  omyelo  Dysrap  Search  cele  hism  Terms Functio  nal mob  Muscle  ility  strengt h  Gait / Ambul Physic ation al ther apy Physic al ther apy mo dalitie s Rehab ilitatio n Exerci se Electr ical st imulat i on  Inclusion & Exclusion Criteria • Inclusion – Participants diagnosed with  meningomyelocele – Participants 21 years of age and under – Study involves physical therapy intervention   • Exclusions – Book chapters  – Duplicate publications – Focus on surgical techniques, orthoses, bowel  & bladder function, cognition or scoliosis  Inclusion & Exclusion Criteria • Resulting 11 studies extremely     heterogeneous  • Therefore… STRENGTH  was used as an    outcome measure  PICO • Population: participants 21 years of age        and under with a diagnosis of  meningomyelocele • Intervention: Electrical stimulation,  exercise training & motor skills training • Comparison: N/A • Outcome: Strength  Potentially Relevant Citations  (N = 298) Failed to meet title inclusion/ exclusion criteria  (N=160) After Screening Titles  (N = 138) Failed to meet abstract inclusion/ exclusion criteria  (N=120) After Screening Abstracts  (N = 18) Obtained by Hand Searching  (N = 2) Retrieved for Evaluation  (N = 20) Failed to meet full text inclusion/ exclusion criteria  (N=9) After Screening Full Text  (N = 11) Did not use strength as an outcome measure  (N=5) Studies included in Review  (N =6)  Full Text Exclusions • 5 did not use ‘strength’ as outcome  measure • 3 duplicates  • 2 did not have a relevant physical therapy  intervention • 1 focused on scoliosis • 1 did not have a diagnosis of  meningomyelocele • 1 book chapter • 1 participants did not meet age  requirement  Included Studies 6  Studies  2  Electrical  Stimulation  3 Exercise  Training  1  Motor Skills  Training  AACPDM Levels of Evidence4 Level  Intervention (Group) Studies  I  Systematic Review of randomized controlled trials (RCT’s) Large RCT (with narrow confidence intervals) (n>100)   II  Smaller RCT’s (with wider confidence intervals) (n<100) Systematic Reviews of cohort studies “Outcomes research” (very large ecologic studies)  III  Cohort studies (must have concurrent control group) Systematic Reviews of Case Control Studies  IV  Case series Cohort study without concurrent control group (e.g. with historical  control group) Case‐control Study  V  Expert Opinion  Case Study or report Bench research  Expert opinion based on theory or physiologic research Common sense/anecdotes  Level of Agreement = 100%  AACPDM Quality Assessment4 Level II studies  1. Was inclusion criteria well described & followed? 2. Were interventions well described & was there  adherence?  3. Were measures clearly described, valid & reliable? 4. Were there blind assessments? 5. Were appropriate statistical evaluations conducted &  reported? 6. Were dropouts reported and less than 20%?  7. Were appropriate methods for controlling  confounding variables & limiting potential biases  used?   Case Study Quality Assessment5  Level IV & V studies  1. Was the purpose clearly stated? 2. Was the hypothesis clearly stated? 3. Were participants described in sufficient detail? 4. Were interventions & treatment settings described  in sufficient detail? 5. Were measures clearly described, valid & reliable? 6. Was the effect size clinically important? 7. Were limitations of the study identified &  discussed?  Study Quality Study  Level  1  2  3  4  5  6  7  Total  AACPDM Quality Assessment4 Karmel‐Ross et al.6  II  √  √  √  √  Andrade et al.8  II  √  √  √  √  4 √  5  Case Study Quality Assessment5 O’Connell &  Barnhart9  IV  √  Mazliah et al.7  IV  √  Rapport & Bailey10  V  Manella & Varni11  V  Strong = score of 6‐7 Moderate = score of 4‐5  Weak = score of ≤ 3  √  √  √  √  5  √  √  √  √  6  √  √  √  √  √  5  √  √  √  √  √  4  Level of Agreement = 83%  Data Extraction & Analysis  • Standardized data extraction form • Summary tables • Descriptive synthesis method of data  analysis – Evaluating participants, interventions,  outcomes – Determine if findings can be generalized – Limitations investigated  Results  Electrical Stimulation Authors  Therapy  Interventions  Karmel‐Ross et  Applied to  al.6 quadriceps  femoris PRE TEST ‐ POST  unilaterally  Control  Intervention  Sample  Contralateral limb  N=5 (2 males; 3  females) ‐Children with  Spina Bifida; lesion  at level L2‐3  TEST CONTROL  Level II Quality 4/7  ‐30 minute  sessions 6x/wk  for 8 wks  Mazliah et al.7  Applied to  quadriceps  ONE GROUP PRE  femoris bilaterally TEST – POST  TEST  Level IV  Quality 6/7  ‐1‐2 hour sessions  daily for 6  months  ‐5‐21 years N/A  N=3  ‐ Children with  lumbar MM  ‐Knee flexion  contractures >15 ° ‐ 9‐12 years  Electrical Stimulation: Results Study  Outcome of  Interest  Measure  Result  Karmel Ross et  al.6  Quadriceps  femoris muscle  strength  Maximum isometric  2/5 statistically  voluntary knee  significant  extension torque improvement  Mazliah et al.7  Quadriceps  femoris muscle  strength  Isometric Torque  measurements   2/3 improved  Exercise Training Authors  Therapy  Intervention  Control  Sample Intervention  Andrade et al.8  Aerobic and UE  strengthening ‐1 hr/wk for 10 wks  Children not  attending  exercise  program  N=13 (7 males; 6  females) ‐ MM; lesion below T6 ‐ 8‐13 years  UE strengthening  N/A  N=6  ‐ MM (N=3); lesion  below T8  ‐ Children diagnosed  with CP (N=3)  ‐ 4‐16 years  N/A  N=1 (male) ‐ Child with MM  ‐ 8.5 years   PRE TEST ‐ POST  TEST CONTROL  Level II Quality 5/7 O’Connell &  Barnhart9  ONE GROUP PRE  ‐30 min 3x/wk for 9  TEST – POST TEST  Level IV Quality 5/7 Rapport &  Bailey10 SINGLE SUBJECT  Level V Quality 5/7  wks  Fine/gross motor  ‐Clinic: 90 min  1x/wk for 6 wks ‐Home: 30 min/day  5x/wk for 56 wks  Exercise Training: Results Study  Outcome of  Interest  Measure  Result  Andrade  et al.8  Strength  Isometric tests using  hand held  dynamometer  Ss (p<0.01)  O’Connell  Wheelchair  &  propulsion Barnhart9  6 repetition maximum  Ss (p= .018‐ .031)  Rapport &  UE fine motor Bailey10 UE gross motor  OSCO Pinchmeter  All Improved   Dynamometer grip  strength  All Improved  Motor Skills Training  Authors  Therapy Intervention  Manella &  Functional activities  Varni11 & behavioural  therapy SINGLE  SUBJECT  ‐Clinic: 30 min 4 wks ‐Home: 30 min daily Level V ‐Follow up:  Quality 4/7 1x/month for 5  months  Control  Intervention  Sample  N/A  N=1 (female) ‐Child with MM @ L3 ‐ 5 years  Motor Skills Training: Results  Study  Outcome of  Interest  Manella &  Independence  Varni11 in motor skills  Measure  Result  Quadriceps manual  muscle test   Improved grade 3  to grade 4  bilaterally  Discussion  This systematic review concludes there is a positive trend towards increasing muscle strength using electrical stimulation, exercise training and motor skills training for children with meningomyelocele.  Electrical Stimulation Karmel‐Ross et al.6  Mazliah et al.7  •Level II  •Level IV •Longer e‐stim application  & study duration  •Sedentary during e‐stim  •Functional activities  during e‐stim •Improvements in gait •Health & instructional issues  •No improvements in gait •Possible low adherence or  ineffective application  Exercise Training Andrade et al.8  O’Connell &  Barnhart9  Rapport &  Bailey10  •Level II •10 week program •Resistance  training  •Level IV •9 week program •Resistance  training  •Level V •56 week program •Functional  activities  Motor Skills Training  Manella & Varni12 •Task specific training •Behavioral therapy  Limitations • Limited search to English  • Limited search to published articles • Did not extensively search grey  literature • Descriptive synthesis vs.  meta‐analysis • Small sample sizes • Dated studies • Lack of literature and low levels of  evidence  Strengths of Review • Investigations of LE & UE • Relating strength gains to function • Extensive literature search • Monthly updates • 5 reviewers to limit bias • High inter‐rater reliability  • Spina bifida expert   Future Research • Effects of electrical stimulation on  ambulation ability6 & knee flexion                contractures7 • Effects of compliance,  motivation, education  & parental involvement  • Optimal treatment  protocols & duration  Conclusion Although this review supports               aspects of physical therapy  interventions, the literature is out of  date and scarce.   In order to ensure  physical therapy is  delivered in an  effective and efficient  manner, further  research is necessary tyJHY&mode=related&search=  References (1) Campbell S, Vander Linden D, Palisano R. Physical therapy for children. 3rd ed. Philadelphia: Saunders Elsevier Inc; 2006. (2) National Dissemination Center for Children with Disabilities. Spina Bifida Fact Sheet; 2004. [Cited 2007 May 18]. Available from: fs12txt.htm. (3) Mazur JM & Kyle S. Efficacy of bracing the lower limbs and ambulation training in children with myelomeningocele. Developmental Medicine & Child Neurology. 2004;46(5):352-356. (4) Dodd KJ, Taylor NF, Damiano DL. A systematic review of the effectiveness of strength-training programs for people with cerebral palsy. Arch Phys Med Rehabil. 2002 Aug;83(8):1157-64. (5) O’Donnel M., Darrah J, Adams R, Butler C, Roxborough L, Damiano D. AACPDM methodology to Develop Systematic Reviews of Treatment Interventions; 2004 [Cited 2007 April 17]. Available from: Methodology.pdf. (6) Dean E, Arscott S, Desaulles P, Hughes K, Kotzo S, Preto R. The effect of manual therapy on range of motion following lateral ankle sprains: a systematic review. 2006. (7) Center for reviews and dissemination. CRD Report 4 (2nd edition); March 2001 [Cited 1007 April 17]. Available from:  (8) Karmel-Ross K, Cooperman DR, Van Doren CL. The effect of electrical stimulation on quadriceps femoris muscle torque in children with spina bifida. Physical Therapy. 1992 Oct;72(10):723-730. (9) Mazliah J, Naumann S, White C, et al. Electrostimulation as a means of decreasing knee flexion contractures in children with spina bifida. Proceedings of the 6th annual conference on Rehabilitation Engineering 1983:63-65. (10) Andrade CK, Kramer J, Garber M, Longmuir P. Changes in self-concept, cardiovascular endurance and muscular strength of children with spina bifida aged 8 to 13 years in response to a 10-week physical-activity programme: a pilot study. Child Care Health Development 1991;17(3):183-196. (11) O'Connell DG, Barnhart R. Improvement in wheelchair propulsion in pediatric wheelchair users through resistance training: A pilot study. Archives of Physical Medicine & Rehabilitation 1995;76(4):368-372. (12) Rapport MD, Bailey JS. Behavioral physical therapy and spina bifida: a case study. J.Pediatr.Psychol. 1985 Mar;10(1):87-96. (13) Manella K, Varni J. Behavioral treatment of ambulatory function in a child with myelomeningocele: a case report. Physical Therapy 1984;64(10):15361539. (14) Levels of evidence and grades of recommendation. [Cited 2007 July 18]. Available from: (15) Falk B, Tenenbaum G. The effectiveness of resistance training in children. A meta-analysis. Sports Med. 1996;22:176–186.  Picture References • • • • • • • • • • • • • • • • • = _telescope.jpg 5.gif ll.jpg  Thank you  


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