Over and Out

So there we have it! A comprehensive look at TES that has hopefully answered all of your questions.

There have been an array of studies presented, each commenting on the validity of such a treatment, none more so than Karen Pape. From the beginning, Pape has remained a strong advocate for the use of TES as a treatment for paediatric neurological conditions. A pioneer of this particular treatment, Pape has published multiple papers on the positive effects of TES and in a collaborative effort, has since established the treatment protocol for application. She continues to be a prominent voice on the issue of TES in children with neuromuscular conditions and remains a leader in forward thinking in similar areas of research, as amply demonstrated in her current blog. For more information on these areas, we would recommend visiting http://www.karenpapemd.com/.

Karen Pape. MD

As previously mentioned, TES remains a controversial treatment, to which we can merely provide you with the facts and the opinions of others, but the decision is ultimately yours. After combing through the literature it has become increasingly evident that further long term, large scale investigations are required to scrutinise the effects of TES and provide a definitive answer to the unyielding question… Is TES a useful treatment for paediatric neuromuscular conditions?

In our opinion TES may have a place as an “add on” treatment for some children, however, a comprehensive Physiotherapy regime should be the backbone of any paediatric neuromuscular treatment.

Dosage and Dollars

For many people the idea of attaching any electrical device to a child may seem unsettling. When applied correctly TES consists of a lower dose than most other electrical stimulation treatments which is one of the characteristics that makes it more favourable in children. In fact children themselves have referred to TES as feeling like ‘butterfly kisses’ or a ‘tickle machine’. While these descriptions may quite adequately describe what the child is feeling lets look a little more ‘technically’ at some of the parameters.

Dosage:

As mentioned previously TES is often considered alongside NMES as both are used to treat muscle weakness in similar conditions. The treatment parameters and mechanism of action however are markedly different.

The key characteristic that differentiates TES from other electrical stimulation modalities such as NMES is that it is applied at the patients sensory threshold (2-10mAmps). This means it is applied at an intensity where the child can feel it (tickles or butterfly kisses!) but it does not cause muscle contraction and certainly isn’t painful. When selecting between NMES and TES the initial strength of the muscle should be considered. A grading of 3+/5 or less should be treated with TES. Higher than this and NMES or a combination of daytime NMES and night time TES may be used.

During TES and NMES treatment the total current applied can be the same but the duty cycle differs. Instead of a short duration high intensity stimulus as in NMES, TES provides a longer duration, lower intensity stimulus.

Dosage Parameters for NMES Vs TES. Pape (2004)

Individual treatment sessions occur overnight for 8-12 hours 6 times per week. It can take 6-8 weeks to increase muscle volume and 6-12 months to improve function. This long time to effect may be one of the reasons that many experiments don’t produce meaningful results as they simply aren’t allowing enough time for effects to develop.

Total program length varies greatly between individuals. This has been investigated in children with CP and studies so far suggest that mildly affected children require 18months to 2years and severely affected children require 3-4 years. Secondary treatment may be required during puberty as the body grows and changes rapidly.

Summary Table

Parameter	Value
Intensity	Sensory Threshold; 2-10mAmps
Treatment Duration	8-12 Hours
Treatment Frequency	6x/wk
Time to effect: ·         Muscle Volume ·         Function	6-8Wks 6-12Months
Total Program Duration	18months-4 years

Cost:

As we all know medical bills can add up very very quickly!!! While it would be wonderful to have an unlimited healthcare budget, unfortunately cost is something that has to be considered. The good news is that TES is a cost effective treatment modality. The ability to use it as a home based treatment reduces the cost of health care appointments (not to mention the hassle and cost of driving there!!) – every little bit counts!

The cost of a TES machine itself is about US$825. It can only be ordered by a registered medical professional such as your physiotherapist. As mentioned in previous posts TES must be integrated into an appropriate physiotherapy program in order to turn TES induced muscle growth into functional improvement. The cost of such a program is hugely variable between individuals, practices, treatments and countries.

Unfortunately, in the USA and likely in other areas of the world TES treatment is not subsidised by Medicare due to the inconclusive research base.

With all things considered, if TES is safe and beneficial for an individual child it is one of the more time and cost effective treatment options in today’s physiotherapy world.



References:

Advanced Muscle Stimulators, LLC

http://www.advancedmusclestimulators.com/page17.html

Dali, C., Hansen, F., Pedersen, S., Skov, L., Hilden, J., Bjornskov, I., Strandberg, C., Christensen, J., Haugsted, U., Herbst, G. & Luskjser, U. (2002). Threshold electrical stimulation (TES) in ambulant children with CP: a randomized double-blind placebo-controlled clinical trial. Developmental Medicine and Child Neurology, 44, 364-369.

DeLisa, J. & Walsh, N. (2005). Physical medicine and rehabilitation principles and practice.(4^th ed) (p.437).

 Philadelphia, USA: Lippincott Wiliams & Wilkins.

Pape KE. (1997) Therapeutic electrical stimulation (TES) for the treatment of disuse muscle atrophy in cerebral palsy. Pediatr Phys Ther  9 110–112. 

Pape. K. (2004). Threshold Electrical Stimulation (TES) and the TASC network modelof recovery from brachial plexus injury (BPI). Retrieved from: http://www.drnathbrachialplexus.com

Can I or Can’t I?

Hello fellow TES researchers! We have picked over articles and reputable sites in order to gather information in the hopes of enlightening you on the precautions and contraindications of the application of TES. In the following we have found some obvious and not so obvious contraindications (we cannot use this particular treatment), precautions (we need to take care) and some general good sense advice.

The Ideal Candidate:

With TES being one of the less invasive and restrictive treatment options when compared to others such as surgery and bracing, it would be nice to say that it was an appropriate option for all children with motor deficits. However, as the research literature shows the results of TES treatment are quite variable and are limited by contraindications. Perhaps the key to optimising the effectiveness of TES is in selecting the individual children who are likely to benefit. 

Ø  As the treatment regime is lengthy it is important that both the child and the family have the ability and desire to adhere to the program
Ø  Candidates and their support system must be motivated to work hard towards change/improvement
Ø  The severity and type of the child’s disorder must be TES appropriate
Ø  Specific ages where children are most likely to benefit have not yet been established. It has been suggested that during puberty the body is geared up for growth and therefore may respond to TES with a greater increase in muscles bulk

Contraindications and Precautions:

Before the application, any site that is to receive the treatment should be tested for sensitivity. This will include hot-cold and sharp-blunt discrimination tests to ensure the patient has adequate sensory ability to detect any equipment (or practitioner) malfunction. These tests are standard and provide quick and easy feedback to eliminate easily preventable problems. It should be noted that children receiving treatment need to be able to provide appropriate feedback to ensure the TES is received at the correct threshold. Cognitive impairments and infancy may therefore become a contraindication.

The following contraindications are generalized for low level electrical stimulation such as TES;

Ø  Cancerous tissue (malignancy)

Ø  Specialised tissue (e.g eyes and testes)

Ø  Active implants such as pacemakers

Ø  Tissue bleeding

Ø  Broken tissue

Ø  Epilepsy and

Ø  Active epiphysis

Active epiphysis.
Retrieved from: http://www.gla.ac.uk/ibls/US/fab/tutorial/generic/growth4.html

We think the key point is to remember that each child is an individual and needs to be treated and assessed as so. Each will have their own opinions and response to treatment. If a child finds the tingling sensation disrupts their sleep this may hinder their physical and emotional development and hence the cost will ultimately outweigh the benefits. 

Precautions are not absolute but they do dictate the call for diligence while applying TES especially on children. The precautions associated with low level electrical stimulation include;

Ø  Any peripheral neuropathies
Ø  Current pain
Ø  Recent trauma to the treated areas and surrounding tissue
Ø  Devitalised tissue and
Ø  Local circulatory insufficiencies

A noteworthy point is to be cautious with adipose tissue. Unfortunately in today’s society we are seeing an increase incidence in childhood obesity and with treatments such as TES and other electrical stimulation, higher intensities are needed to reach the sensory threshold or stimulate the deep underlying tissues which may cause pain or autonomic reactions.

A good physiotherapist will also;

Ø  Check for redness under the adhesive pad in case of allergies or incomplete adhesion of pad which may cause burns

Ø  Maintain TES device as well as electrodes and adhesive pads

Ø  Apply device to themselves before patient application

Ø  Educate on use at home



Electrode burns.
Retrieved from: http://radiographics.rsna.org/content/24/1/41/F3.expansion.html



Most machines have built in safety features such as an automatic shut off to prevent burns or shocks and an output limiter to prevent overstimulation. Despite the list of contraindications and precautions TES is safe and effective when applied in accordance to guidelines.

 We know this is a lot to process (and this is the short of it!) but hopefully, so far, we have made Michaels Jacksons pre-teen afro seem like a military short back and sides. So again, we have braved the literature, bleary eyes and all, to bring you our digestible summary of specific dosages and costs associated with TES application… Coming Soon!

References:

Dali, C., Hansen, F., Pedersen, S., Skov, L., Hilden, J., Bjornskov, I., Strandberg, C., Christensen, J., Haugsted, U., Herbst, G. & Luskjser, U. (2002). Threshold electrical stimulation (TES) in ambulant children with CP: a randomized double-blind placebo-controlled clinical trial. Developmental Medicine and Child Neurology, 44, 364-369.

Olds, T., Tomkinson, G., Ferrar, K., Maher, C. (2010) Trends in the prevalence of childhood overweight and obesity in Australia between 1985 and 2008. International Journal of Obesity. 34, 57-66

Pape KE. (1997) Therapeutic electrical stimulation (TES) for the treatment of disuse muscle atrophy in cerebral palsy. Pediatr Phys Ther  9 110–112. 

Pape, K., Kirsch, S., Galil, A., Boulton, J., White, M., Chipman, M. (1993) Neuromuscular approach to the motor deficits of cerebral palsy: A pilot study. Journal of Paediatric Orthopaedics, 13 (5), 628-633

Walker, J.,  Ryan, S. & Coburn, T. (2010). Does threshold night time electrical stimulation benefit children with spina bifida? Clinical Orthopaedics and Related research, 469(5) 1297-1301

Watson, T. (2012) Contraindications. Electrotherapy on the web: An educational resource. Retrieved from: http://www.electrotherapy.org/modalities/contragrid.htm#tens

Conditions of Use

 "Doing the RIGHT thing at the RIGHT time, in the RIGHT order is crucial to achieving the best possible results." - Karen Pape.

The range of neurological disorders currently affecting the lives of children in Australia is varied and vast. The presentation and prognosis differs significantly between diverse disorders and individuals but each condition affects the brain, spinal cord, nerves and/or muscles to some extent.  Children with neurological disorders are often treated by a team of health care professionals utilizing a variety of methods. TES is one treatment option that has recently been researched in a number of different disorders. Perhaps one of the greatest attractions in the use of TES for children is the ability to deliver it at night, while the child sleeps. This provides a less invasive option for children who are often already experiencing a gruelling treatment plan and leaves their waking hours for playing, learning, socialising and to just be kids!

So now we will introduce you to some of the most common neurological disorders that TES has been used as a treatment option.

Cerebral Palsy

Movement of our bodies is influenced by the interaction between the muscles generating the movement (agonists) and the muscles opposing the movement (antagonists). In children with Cerebral Palsy (CP) this balance can be disrupted as agonist muscles become spastic and antagonist muscles waste away (atrophy) due to misuse. This ultimately results in a decline in motor function. TES has been proposed as a mechanism for recreating this balance and its use in CP is a hot topic amongst recent researchers.  Early research by Pape (1997) proposed and demonstrated the following mechanisms where the TES is applied to the atrophic muscle causing an increase in blood flow to the area. Furthermore, at night there is a natural increase in the secretion of trophic hormones. When these two principles are combined the result is growth of the atrophic muscle. Early research demonstrated this effect while more recent research has been somewhat inconclusive. Many of the recent randomised controlled trials (i.e. well-designed experiments!) have failed to show any significant benefits. Perhaps one of the key points to note is that further physiotherapy treatment needs to go hand in hand with TES to turn the muscle growth into improved function.

TES applied to upper arm and scapula muscles
Retrieved from: http://bpirehab.com/page7.html

Scoliosis

The benefits of TES in patients with scolios (curvature of the spine) have also been investigated and once again the research has provided mixed results. The proposed mechanism for treating scoliosis is to apply the TES to the convex side of the spinal curve. These muscles then become larger and stronger and help to move the spine into a straighter alignment and hold it there. However a review of many recent studies by Lenssinck et al (2005) found that there was little to no benefit from TES in adolescents either alone or as an add-on to other treatment options. As such it is not likely that TES will be embraced as treatment for scoliosis

Duchenne Muscular dystrophy

Applied TES over quadriceps.
Retreived from: http://www.mikereinold.com

Research by Scott et al. (1989) highlighted the potential of TES in treating children with Duchenne Muscular Dystrophy (DMD). By applying TES over the quadriceps (thigh) muscles they were able to increase the voluntary strength of these muscles. This particular finding is interesting as the quadriceps are integral for adequate gait function therefore TES could well have a very functional benefit in maintaining the ability to walk. For children affected by DMD difficulty walking is one of the most debilitating effects and many require a wheelchair by late childhood.



Threshold Electrical Stimulation (TES) machine



Spina Bifida

Many children with spina bifida experience paralysis of the legs and poor bladder function. Investigations by Walker et al. (2010) found that TES resulted in increased strength of targeted muscles and participants also reported improved bladder function.

These are just some of the more common neurological conditions where TES is used as a treatment option. Tune in again next week where we delve deep and report the contraindications, precautions for use and costs involved with TES. We hope this information helps in improving your decision making process on the uses and benefits that occur from TES use.

REFERENCES:

Anthem Medical policy: Functional Electrical Stimulation (FES) and Threshold Electrical Stimulation (TES) (2011) http://www.anthem.com/medicalpolicies/policies/mp_pw_a049573.htm

Grana, W., Fischer, S., Richards, B. (2007) Muscular Dystrophy. American Academy of Orthopaedic surgeons. Retrieved from: http://orthoinfo.aaos.org/topic.cfm?topic=a00384

Lenssinck, M., Frijlink, A. & Berger, M. (2005). Effect of bracing and other conservative interventions in the treatment of idiopathic scoliosis in adolescents: a systematic review of clinical trials. Physical Therapy, 85(12), 1329-1339.

Pape, K. (1997). Therapeutic electrical stimulation (TES) for the treatment of disuse muscle atrophy in cerebral palsy. Pediatric Physical Therapy, 9, 110-112.

Scott, O., Hyde, S., Vrbova, G & Dubowitz, V. (1989). Therapeutic possibilities of chronic low frequency electrical stimulation in children with Duchenne muscular dystrophy.  Journal of the Neurological Sciences, 9(2) 171-182

Walker, J.,  Ryan, S. & Coburn, T. (2010). Does threshold nighttime electrical stimulation benefit children with spina bifida? Clinical Orthopaedics and Related research, 469(5) 1297-1301

Webster, R., Calvert, S., Riney, K., Wallace, G., Ryan, M., Sharpe, C. (2012)  Neurological Disorders in Childhood. The Australian and New Zealand Child Neurology Society. Retrieved from: http://www.anzcns.org.au/index.php

Dali, C., Hansen, F., Pedersen, S., Skov, L., Hilden, J., Bjornskov, I., Strandberg, C., Christensen, J., Haugsted, U., Herbst, G. & Luskjser, U. (2002). Threshold electrical stimulation (TES) in ambulant children with CP: a randomized double-blind placebo-controlled clinical trial. Developmental Medicine and Child Neurology, 44, 364-369.

TES - You're in control

Looking for an answer to the acronym TES? Google TES and you will find the following; Total Energy Solution, Thermal Emission Spectrometry, The Employment Solution, blah, blah, blah… You get our drift. But if what you’re looking for is information on “Threshold Electrical Stimulation” then you have come to the right place. So we’re guessing your first question is TES…?

Threshold Electrical Stimulation (TES) previously known as therapeutic electrical stimulation is the delivery of low intensity electrical stimulation (e-stim) during sleep via electrodes adhered to the skin.  TES is delivered at the specific sensory threshold of the patient, usually between 2 – 10 milliamps (mA). This means that the patient can detect the stimulus but the intensity is not high enough to cause the muscles to contract.

Current available TES machine

So what is TES used for? Its uses are predominantly aimed at children with neurological diseases particularly spastic diplegia related to Cerebral Palsy (CP) and other motor disorder (e.g Spina Bifida). These children are sometimes treated with an alternative e-stim called Neuromuscular Electrical Stimulation (NMES) which uses short periods of relatively high intensity to cause a muscle contraction to occur. A valid option, but recent research has found that some children report discomfort while receiving NMES and similar studies have found TES to be just as beneficial without the uncomfortable side effects.

How exactly does TES work? TES is commonly administered overnight for 8-12 hours, up to 6 nights a week. It’s aimed at patients with 3+/5 or less muscle weakness (a common pathology associated with neurological disorders) in the Medical Research Council (MRC) muscle assessment scale.

The mechanism of action of TES is relatively unknown however it has been reported that an increase in localised blood flow combined with the heightened secretion of trophic hormones (Hormones which target endocrine glands) during sleep can potentially result in increased muscle bulk to the target area. In addition TES in paediatrics has the potential to improve:

·         muscle strength

·         voluntary motor function

·         gait and step length

·         continence and  

·         risk of falls in patients with CP

Hopefully this has answered some of your initial questions. Drop in next week for some “stimulating” information on the use of TES in a selection of specific paediatric neurological conditions.

References:

Dali, C., Hansen, F., Pedersen, S., Skov, L., Hilden, J., Bjornskov, I. (2002) Threshold electrical

stimulation (TES) in ambulant children with CP: a randomized double-blind placebo-controlled

clinical trial. Dev Med Child Neurol.  44(6) pg 364-369.

Han, S., Kim, M., Kim, J., Hong, C., Kim, J., Noh, J. (2004) Intravesical electrical stimulation improves neurogenic bowel dysfunction in children with spina bifida. J Urol. 171 pg 2648–2650.

Kerr, C., McDowell, B., McDonough, S. (2004) Electrical Stimulation in Cerebral Palsy: A review of Effects on Strength and Motor Function. Develop Med Child Neurol  46 pg 205-213.

Pape KE. (1997) Therapeutic electrical stimulation (TES) for the treatment of disuse muscle atrophy in cerebral palsy. Pediatr Phys Ther  9 110–112. 

Steinbok, P,. Reiner, A,. Kestle, J. (1997) Therapeutic electrical stimulation following selective posterior rhizotomy in children with spastic diplegic cerebral palsy: a randomized clinical trial. Dev Med Child Neurol 39(8) pg 515-520.