Electrical Stimulation in Pediatrics
Electrical stimulation (e-stim) is a hot topic in rehabilitation. In this blog, we focus on the stimulation of specific muscles or nerves in pediatrics, with a glimpse into the future of spinal stimulation.
Even though electrical stimulation is widely used in adults, its use in pediatrics is present depending on your healthcare guidance. As with most therapies, research has been more extensive with adults. Conducting research on individuals under the age of 18 is more guarded for the safety of the growing child and the establishment of long-term effects. This is a great safety plan, but it does leave some parents wondering why there are fewer findings related to children. Questions about electrical stimulation in pediatrics should be addressed to your child’s care provider. The following may answer some global questions that you may have.
There is a range of types of electrical stimulation. Individuals of all ages take advantage of these processes but do not distinguish between them or perhaps may not realize electrical stimulation is being performed. Often, treatments are called something else, like the name of the device, stimulation, or other words.
In pediatrics, electrical stimulation is used in ages from three months to 21 years. Common diagnoses for electrical stimulation treatment are cerebral palsy, spina bifida, spinal cord injury, and brain injury, among many others. Specific purpose uses include healing pressure injuries, enabling swallowing, stimulating gut metabolism, leg lengthening procedures, seizure control, pain, tone (spasticity), function, and many others. Other types of well-known electrical stimulators are cochlear implants, vagal nerve stimulators, cardiac pacemakers, diaphragmatic pacemakers, and defibrillators.
It is important to note that not all children will respond to stimulation, meaning their muscles may not respond. For this reason, before stimulation is considered, children often go through an evaluation to see how muscles do respond.
The thought of putting an electrical current on your child can be overwhelming and frightening. Electrical stimulation is NOT like putting your finger in a socket. A therapist may refer to the pads delivering stimulation as electrodes and the stimulator as a small computer.
For children with sensation, milder electrical stimulation treatments may be used to minimize discomfort, whereas children with decreased sensation may tolerate stronger simulation. However, most stimulators can be adjusted to lessen discomfort and as a child becomes used to the stimulator, the stimulation can be increased. You can have the therapist use the stimulator on your child first to see how it feels and when appropriate, your child increases the stimulation to their tolerance. You will see other children in the clinic using the stimulators without trauma.
Types of Electrical Stimulation
In general, electrical stimulation uses electricity to increase or decrease activity in nerves or muscles. Terms for electrical stimulation vary based on the intended use and/or the type of stimulation.
Transcutaneous electrical nerve stimulation (TENS) is a low-level stimulator for pain control. TENS produces an interruption in the transmission of pain impulses to the brain. It also helps relieve muscle pain.
Electrical muscle stimulation (EMS) is electrical stimulation used in the general population (typically athletes) for strengthening or repairing muscles. In pediatric habilitation and rehabilitation, EMS can be used for muscle strengthening, endurance, and muscle recovery. It is stronger than TENS. EMS is most often considered to be the use of low-frequency stimulation. However, there are high-frequency stimulation options as well (sometimes called Russian electrical stimulation).
Neuromuscular electrical stimulation (NMES) stimulates muscles and nerves. This is similar to EMS but is used more in rehabilitation settings. Uses in rehabilitation include reducing muscle tone (spasms), increasing blood flow, and enhancing range of motion.
Functional electrical stimulation (FES) is electrical stimulation that serves the purpose of creating function in the body where movement is limited. FES has the benefits of reducing muscle tone (spasms), increasing muscle mass, improving circulation and range of motion, and educating the nervous system to stimulate new pathways or repair to allow nerve messaging.
Benefits of Electrical Stimulation
In general, the benefits of electrical stimulation can be quite significant. Because of the intense treatment, benefits can be seen rather quickly in physical attributes such as increased muscle mass, strength, range of motion, and decreased tone (spasticity).
There have been improvements in a variety of body functions such as arm use, walking speed, foot and ankle positioning for walking, bone density, urinary tract infections and function, and bowel function. An example is electrical stimulation to improve sitting balance as a therapeutic treatment with excellent results. Once the child’s body and mind have learned sitting posture, it is possible, in some diagnostic categories, to eliminate the therapy while others use it for longer periods of time.\
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Cautions of Electrical Stimulation in Pediatrics
There are some effects of electrical stimulation that can be of concern for pediatric individuals. Electrode placement (pads) can lead to skin irritations or minor burns if not placed correctly or if the electrode pad has exposed wires. Electrode pads should not be placed on the child if there are openings on the skin, such as pressure injury in the location of placement or childhood illnesses such as measles, chicken pox, or rashes. Your child’s individual healthcare provider can address these issues if they are these applicable to your child.
Improper placement of electrode pads may stimulate tone (spasticity) rather than reduce it as with proper electrode placement.
Undiagnosed medical issues can become an issue. Undiagnosed concerns in the skeletal structure can lead to complications. This can include poor bone density leading to fractures (broken bones), undiagnosed hip dysplasia, can cause hip issues, among other bone displacements. Hidden blood clots can be dislodged.
Decreased body awareness and sensation can lead to fatigue if treatment is advanced too quickly. As with all activities, treatment should begin slowly and advance at the rate of tolerance of the child. Fatigue may show up in other ways, such as headaches, crying, or general discomfort.
Autonomic dysreflexia (AD) is a disturbance in the autonomic nervous system in some children with cervical or thoracic spinal cord injuries and some brain injuries. AD can be triggered by activity. When instituting electrical stimulation therapy, monitor blood pressure for changes as well as periodically during treatments to assess for silent AD.
Other Forms of Electrical Stimulation
New research is investigating different types of electrical stimulation. Instead of focusing on particular muscle groups and nerves, more direct spinal stimulation is being done. This can be done by surgically placing electrodes beneath the skin and bone, on top of the spinal cord. Alternatively, electrode pads can be placed on the skin over the spine, which is less invasive, but may not be as easy to target specific functions. Research is still ongoing, but there may be some ‘hangover’ effects that allow functions to continue without the device for a period of time. Although scientists are still trying to understand how this type of stimulation works, and different stimulators may work in different ways, the goal is to help the spinal cord be more efficient to help nerves and pathways fire that might not otherwise do so. Currently spinal stimulators are not available in adults except for pain management, but stimulators placed on the skin over the spine may soon be available to improve movement in the arm and hand when combined with rehabilitation. It is not clear when these devices will be available for adults and the timeline may different for children.
I am interested in electrical stimulation for my child, what do I do next?
Always have your child’s healthcare professional determine if electrical stimulation is right for them in their unique situation. They will also determine the type and level of electrical stimulation that can be tolerated by your child based on their level of sensation. This is a highly specialized treatment that requires an educated professional to get started. You will learn how to provide electrical stimulation as your child progresses.
Be sure you take advantage of the expertise of healthcare professionals who are proficient in electrical stimulation. These individuals will be able to select the appropriate treatment for your child and will be able to avoid the pitfalls of the cautions of electrical stimulation. There are a few complications and great benefits.
Further Reading
Bosques G, Martin R, McGee L, Sadowsky C. Does therapeutic electrical stimulation improve function in children with disabilities? A comprehensive literature reviews. J Pediatr Rehabil Med. 2016 May 31;9(2):83-99. doi: 10.3233/PRM-160375. PMID: 27285801.
Carmick J, Clinical Use of Neuromuscular Electrical Stimulation for Children with Cerebral Palsy, Part 2: Upper Extremity. 1993; 73:514-522.PHYS THER. https://www.researchgate.net/profile/Judy-Carmick/publication/14862538_Clinical_Use_of_Neuromuscular_Electrical_Stimulation_for_Children_With_Cerebral_Palsy_Part_1_Lower_Extremity/links/55f1f79d08aef559dc493176/Clinical-Use-of-Neuromuscular-Electrical-Stimulation-for-Children-With-Cerebral-Palsy-Part-1-Lower-Extremity.pdf
Casal Beloy I, García-Novoa MA, García González M, Somoza Argibay I. Update on sacral neuromodulation and overactive bladder in pediatrics: A systematic review. Arch Esp Urol. 2021 Sep;74(7):699-708. English, Spanish. PMID: 34472439. https://www.aeurologia.com/EN/Y2021/V74/I7/699
Cobo-Vicente F, San Juan AF, Larumbe-Zabala E, Estévez-González AJ, Donadio MVF, Pérez-Ruiz M. Neuromuscular Electrical Stimulation Improves Muscle Strength, Biomechanics of Movement, and Functional Mobility in Children with Chronic Neurological Disorders: A Systematic Review and Meta-Analysis. Phys Ther. 2021 Oct 1;101(10): pzab170. doi: 10.1093/ptj/pzab170. PMID: 34184031.
Özen N, Unlu E, Karaahmet OZ, Gurcay E, Gundogdu I, Umay E. Effectiveness of Functional Electrical Stimulation - Cycling Treatment in Children with Cerebral Palsy. Malawi Med J. 2021 Sep;33(3):144-152. doi: 10.4314/mmj. v33i3.1. PMID: 35233271; PMCID: PMC8843188. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8843188/
Propp R, Gill PJ, Marcus S, Ren L, Cohen E, Friedman J, Mahant S. Neuromuscular electrical stimulation for children with dysphagia: a systematic review. BMJ Open. 2022 Mar 25;12(3): e055124. doi: 10.1136/bmjopen-2021-055124. PMID: 35338059; PMCID: PMC8961156. https://pubmed.ncbi.nlm.nih.gov/35338059/