‘Electro-acupuncture in a child with mild spastic hemiplegic cerebral palsy’
SIR-Spasticity in childhood cerebral palsy (CP) causes problems with posture and movement. Different treatments such as physical therapy, orthotics, use of casts at night, oral and intramuscular drugs, and surgical interventions have all been used to reduce spasticity. However, every approach has its limits and no satisfactory long-lasting treatment for spastic muscles in children with CP has yet been discovered. Different modes of electrical stimulation have been reported recently to reduce spasticity and improve function in CP.1-3 Also, it has been found that acupuncture may possibly reduce painful muscle spasm in children with dyskinetic CP.4 These findings led us to investigate the effects of electro-acupuncture in a male child with spasticity in the left gastrocnemius muscles who had been scheduled for surgery (achillotenotomy).
The 7-year-old male with left spastic hemiplegic CP was given acupuncture in an attempt to reduce local ankle spasticity. The ankle had stiffened increasingly to zero degrees range of motion (ROM) due to ‘toe walking’, in spite of several years of night casting and muscle stretching. The child’s mobility was impaired due to decreased ROM and strength in the ankle plus poor coordination of the muscles in the leg which affected his performance when playing football and ice hockey. The child was intellectually normal and accepted participation in the study. He completed the treatment without discomfort or distress. His physical activities remained the same during the study.
Informed consent was obtained from the parents and one parent was present at every treatment session. The study was approved by the Ethical Committee at Umea University, Sweden.
Acupuncture needles were positioned in the calves and the chosen points, segmentally related to the tibialis nerve regulating the gastrocnemius muscles (i.e. in the middle of the hollow of the knee [BL 40], and in the middle of the dorsal surface of the calf where the gastrocnemius muscle the enters belly of the soleus muscle [BL 57]). The sterile stainless soft needles (Seirin; Kasei & Co. Steingrund, Germany) were 0.30 x 30mm and were inserted to depths of between 0.4-0.8cm. An IC-1107 stimulator (Wilkris and Co AB, Stockholm, Sweden) supplied biphasic pulses: width 0.1ms, frequency 80Hz, intensity 2-4 mA so that non-painful paresthesia was achieved. The course comprised eight sessions twice weekly and each session lasted 20 minutes.
Before and after each acupuncture session and at 1, 3, 6, and 12-months follow-up, muscle tone, passive ROM, and muscle strength were measured in the left ankle with the child in supine position with knees extended. The length of time the child was able to stand on the left leg, the ability to walk step by step on a line 4 meters long and perform alternating ski-jumps (standing with one leg in front of the other and jumping, shifting the position of the legs during the jump) were all registered before acupuncture and at 12-months follow-up. One person made all the assessments.
The muscle tone in gastrocnemius was measured once in each assessment session using the modified Ashworth scale5 (manually moving the foot through the ROM to stretch the muscle grading the passive resistance). Dorsiflexion of the ankle was measured by manual goniometry once in each assessment session. The instrument was applied with one shank against the bench and the other aligned to the lateral aspect of the foot sole. Muscle strength in plantar- and dorsiflexors was registered three times at each session by a digital instrument (Handy Scale; model no 393, Bonso Electronics Ltd, distributed by Sagitta, Mariestad, Sweden) attached to a spring balance (Lark; distributed by Sagitta, Mariestad, Sweden). A loop of a rope attached to the instrument was applied to the foot proximal to the metatarsal heads. The instrument was fixed to the wall and was situated above the child’s head when measuring strength in plantar flexion and below the feet in dorsiflexion assessments. To evaluate the effect of acupuncture in this paired observation, 95% confidence intervals (CIs) for the mean difference were performed for plantarflexors and dorsiflexors.
Results showed that muscle tone decreased successively from approximately grade 2 (more marked increase in muscle tone through most of the ROM but affected part easily moved) to 0 (no increase) during the series and remained reduced at the 1 and 3 months follow-ups. A deterioration was detected after 6 months with a return to grade 2 one year after the treatment. ROM was increased from 0 to approximately 10 degrees after the eight acupuncture sessions and was maintained at the follow-ups at 1, 3, 6, and 12 months after the series. The immediate acupuncture effect on muscle strength after each session was a non-significant tendency towards a decrease in the plantar flexor strength and a significant increase in the dorsiflexor strength. Mean of the eight differences, one from each acupuncture session, in the plantarflexors was -3.08N (95% CI, -6.41 to 0.26).
Corresponding values for the dorsiflexor were mean 2.35N (1.10 to 3.60). The increase in mean strength over time in both plantar- and dorsiflexors remained augmented at 12-months follow-up compared with the initial values. Mean strength in the plantar flexors improved from 15.1 to 39.7N, and from 13.7 to 30.3N in the dorsiflexors.
The period of stance on the left leg increased from 4 to 50 seconds. Balance retaining actions with the arms at top speed were no longer necessary when walking the 4 metre line at the 12-month follow-up. Coordination of the leg movements improved, demonstrated by more symmetrical, and faster alternating ski-jumps and a rise from a maximum of 5 jumps to 37 before exhaustion. The parents declared that the child’s physical skill had improved after the fifth acupuncture session in such activities as skating backwards, kicking a football, and cycling with better flow in the leg movements. The boy stated at the end of the series and at follow-up that he felt less exhausted during sporting activities.
Taken together, the results show that muscle tone in the calf muscle decreased successively during the acupuncture series and remained reduced at 1- and 3-months’ follow-up. Dorsiflexion of the ankle increased from 0 to approximately 10 degrees after eight acupuncture sessions, and the ROM was maintained one year after the treatment series. The immediate effect on muscle strength after each session showed as a decrease in the plantar flexors and an increase in the dorsiflexors. Strength increased over time in both plantar-and dorsiflexors and remained augmented at the 12-month follow-up, compared with the initial values. The treatment possibly resulted in selective reduction of spasticity in the gastrocnemius muscle which improved the child’s mobility and removed the need for surgery.
Spasticity, defined as a velocity-dependent response of muscle to passive stretching may be among the most commonly acknowledged sequelae of CNS lesions.5 After such lesions, the descending suprasegmental control on the segmental reflex activity is interrupted.6 Although, knowledge of the neurophysiological mechanisms leading to spasticity is limited7 it is known that increased gamma-motorneuron activity, decreased inhibition by the specific interneurons, and altered common interneuron activity finally increases the alpha-motorneuron activity.6 It has been demonstrated that high-frequency stimulation enhances the release of dynorphin in the spinal cord resulting in an inhibition of the hyperactivity in the alpha-motorneurons.8,9 Low intensity, high frequency transcutaneous electrical nerve stimulation (TENS) is thought predominantly to activate large diameter afferents in the A[alpha]-Ass range 10,11 and it has been shown to decrease clinical spasticity, improve reflex functions of spastic plantarflexors, and improve voluntary control of paretic dorsiflexors in adult hemiparetic participants.12 Large diameter afferent conditioning via dorsal column stimulation has also been found to decrease spasticity.13 TENS differs from electro-acupuncture in that the former activates mainly superficial nerves and structures in the skin whereas electro-acupuncture activates deeper lying structures that are likely to include ergoreceptors.14 However, it is likely that both modes of stimulation activate similar mechanisms.
It is important to stress that this is only a case study and that the positive outcome may be explained by the assessment procedure used15-19 as well as maturation effects. However, the effects obtained may also be attributed to changes in neural plasticity following electro-acupuncture. Improvement in ankle dorsiflexion due to maturation is unexpected as impaired muscle growth has been reported in children with CP, resulting in shortening of the spastic muscles.1 It is well known that spasticity and limitations in ROM increase in children with CP at pre-school age19 leading to problems with posture and coordination. Thus children with CP have limited possibilities to develop increased coordination or strength during maturation. Many different approaches and treatments have been used to assist these children to perform functional tasks quicker and better. As electro-acupuncture was acceptable for the child and had possible long-term effects it was an attractive inexpensive treatment to improve motor ability and prevent surgery. Further investigations of sensory stimulation in children with spasticity are, therefore, of interest.
(a)Child and Youth Neurohabilitation Ornskoldsviks Hospital, Ornskoldsvik;
(b)Mid-Sweden Research and Development Centre Vasternorrlands County Council, Sundsvall;
(c)Department of Physiology and Pharmacology Karolinska Institutet, Sweden.
(a)Child and Youth Neurohabilitation
S-891 89 Ornskoldsvik
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Developmental Medicine & Child Neurology 2003, 45: 503-504
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