Investigation of the effects of neuromuscular electrical stimulation in the treatment of drooling in children with cerebral palsy

Öz

Purpose: Drooling is an important problem that causes dysfunction in children with cerebral palsy and makes it difficult for children’s care. In our study, we aimed to investigate the effects of Neuromuscular Electrical Stimulation (NMES) on saliva control, tongue thrust and swallowing in children with Cerebral Palsy (CP) with drooling problems.

Methods: Fourty children with CP were included in the study and randomly divided into two groups (20 control, 20 NMES). All cases were assessed by using Gross Motor Function Classification System (GMFCS), Tongue Thrust Rating Scale (TTRS), Drooling Severity and Frequency Scale (DSFS), Swab test for salivation flow rate evaluation, and Water Swallowing Test (WST) for swallowing. Oral Motor Exercise Therapy (OMET) program including intraoral stimulation, orofacial massage, and passive tongue movements as a home program was given to the control group. The NMES group received a low frequency NMES for 20 minutes to be applied bilaterally to the masseter, orbicularis oris, and suprahyoidal muscles for two sessions per week for 4 weeks, in addition to the home program.

Results: A significant difference was found in both groups in the evaluation of salivary flow rate (control group p=0.030; NMES group p<0.001) after the treatment. Comparing the groups, there was no significant difference in the analysis of saliva flow rates after the treatment (p=0.617). There were also no significant differences regarding to TTRS, DSFS and WST levels in both groups after the treatment.

Conclusion: Among children with CP having drooling problems, NMES application with home exercise program did not have an effect on saliva control, tongue thrust, and swallowing after four weeks period.

Anahtar Kelimeler

• Cerebral palsy,Drooling,Electrical stimulation

Serebral palsili çocuklarda salya probleminin tedavisinde nöromusküler elektrik stimülasyonunun etkinliğinin araştırılması

Öz

Amaç: Salya problemi serebral palsili (SP) çocuklarda fonksiyon bozukluğuna yol açan, çocukların bakımını zorlaştıran önemli bir problemdir. Çalışmamızda salya problemi olan SP’li çocuklarda Nöromusküler Elektrik Stimülasyonu (NMES) uygulamasının salya kontrolü, dilin itme refleksi ve yutma üzerindeki etkilerinin araştırılması hedeflenmektedir.

Yöntem: Çalışmaya SP’li 40 çocuk dahil edildi ve rastgele yöntemle randomize olarak iki gruba ayrıldı (20 kontrol, 20 NMES). Tüm olgular; Kaba Motor Fonksiyon Sınıflandırma Sistemi (KMFSS), Dil İtme Refleksi Değerlendirme Skalası (DİRS), Salya Kontrol Problemi Sıklık ve Şiddeti Skalası (SKŞS), Salya Akış Oranının değerlendirilmesi için sünger testi ve yutma yeteneği için Su Yutma Testi (SYT) ile değerlendirildi. Kontrol grubuna intraoral uyarı, orafasyal masaj, pasif dil hareketleri içeren oral motor egzersiz tedavi (OMET) programı, ev programı olarak verildi. NMES grubuna, ev programına ilave olarak haftada 2 seans, 4 hafta boyunca bilateral masseter, orbicularis oris ve suprahiyoidal kaslara 20 dakika düşük frekanslı NMES uygulandı.

Bulgular: Tedavi sonrası grup içi karşılaştırmada salya akış oranlarının değerleri her iki grupta anlamlı (kontrol grubunda p=0,030; NMES grubunda p<0,001) bulunurken, gruplar arası karşılaştırmada istatistiksel olarak anlamlı bir fark bulunmadı (p=0,617). Tedavi sonrası DİRS, SKŞS düzeyleri ve SYT değerleri her iki grupta grup içi ve gruplar arası değerlendirmeler arasında anlamlı bir fark bulunmadı.

Sonuç: Salya problemi olan SP’li çocuklarda ev programına ek olarak yapılan NMES uygulamasının 4 haftalık uygulama süreci sonunda salya kontrolü, dilin itme refleksi ve yutma üzerindeki etkilerinin olmadığı görülmüştür.

Anahtar Kelimeler

• Serebral palsi,Salya kontrol problemi,Elektrik stimülasyonu

Kaynakça

1. 1. Gulati S, Sondhi V. Cerebral Palsy: An Overview. Indian J Pediatr. 2018;85:1006-1016.
2. 2. Lin X, Wu W, Zhang C, et al. Prevalence and distribution of developmental enamel defects in children with cerebral palsy in Beijing, China. Int J Paediatr Dent. 2011;21:23-28.
3. 3. Naghavi SE, Jalali MM. Management of drooling for patients in the north of Iran: Analysis of the surgical management. J Res Med Sci. 2010;15:1-5.
4. 4. Erasmus CE, Van Hulst K, Rotteveel JJ, et al. Clinical practice swallowing problems inCerebral Palsy. Eur J of Pediatr. 2012;171:409-414.
5. 5. Lespargot A, Langevin MF, Muller S, et al. Swallowing disturbances associated with drooling in cerebral palsied children. Dev Med Child Neurol. 1993;35:298-304.
6. 6. Meningaud JP, Pitak-Arnnop P, Chikhani L, et al. Drooling of saliva: A review of the etiology and management options. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101:48-57.
7. 7. Logemann JA. Swallowing physiology and pathophysiology. Otolaryngol Clin North Am. 1988;21:613-623.
8. 8. Tahmassebi JF, Curzon MEJ. The cause of drooling in children with cerebral palsy-hyper salivation or swallowing defect? Int J Paediatr Dent. 2003;13:106-111.

9. 9. Hegde AM, Pani SC. Drooling of saliva in children with Cerebral Palsy- Etiology, prevalence and relationship to salivary flow rate in an Indian population. Spec Care Dentistry. 2009;29:163-168.
10. 10. Novak I, Mcintyre S, Morgan C, et al. A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev Med Child Neurol. 2013;55:885-910.
11. 11. Gosa MM, Carden HT, Jacks CC, et al. Evidence to support treatment options for children with swallowing and feding disorders: A systematic review. J Pediatr Rehabil Med. 2017;19:107-136.
12. 12. Clawson EP, Kuchinski KS, Bach R. Use of behavioral interventions and parent education to address feeding difficulties in young children with spastic diplegic cerebral palsy. Neuro Rehabilitation. 2007;22:397-406.
13. 13. Sigan SN, Uzunhan TA, Aydinli N, et al. Effects of oral motor therapy in children with cerebral palsy. Ann Indian Acad Neurol. 2013;16:342- 346.
14. 14. Domaracki LS, Sisson LA. Decreasing drooling with oral motor stimulation in children with multiple disabilities. Am J Occup Ther. 1990;44:680-684.
15. 15. Arvedson J, Clark H, Lazarus C, et al. The effects of oral-motor exercises on swallowing in children: an evidence-based systematic review. Dev Med Child Neurol. 2010;52:1000-1013.
16. 16. Carnaby-Mann GD, Crary MA. Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis. Arch Otolaryngol Head Neck Surg. 2007;133:564-571.
17. 17. Wright PA, Durham S, Ewins DJ, et al. Neuromuscular electrical stimulation for children with cerebral palsy: a review. Arch Dis Child. 2012;97:364-371.
18. 18. Rice KL. Neuromuscular electrical stimulation in the early intervention population: A series offive case studies. Internet J Allied Health Sci Pract. 2012;10:1-7.
19. 19. Christiaanse ME, Mabe B, Russell G, et al. Neuromuscular electrical stimulation is no more effective than usual care for the treatment of primary dysphagia in children. Pediatr Pulmonol. 2011;46:559-565.
20. 20. Clark H, Lazarus C, Arvedson, et al. Evidence- based systemic review: effects of neuromuscular electrical stimulation on swallowing and neural activation. Am J Speech Lang Pathol. 2009;18:361-375.
21. 21. Crary M, Carnaby GD. Adoption into clinical practice of two therapies to manage swallowing disorders: exercise based swallowing rehabilitation and electrical stimulation. Curr Opin Otolaryngol Head Neck Surg. 2014;22:172- 180.
22. 22. Song WJ, Park JH, Lee JH, et al. Effects of neuromuscular electrical stimulation on swallowing functions in children with Cerebral Palsy: A pilot randomised controlled trial. Hong Kong J Occup Ther. 2015;25:1-6.
23. 23. Palisano R, Rosenbaum P, Backett P, et al. Gross Motor Function Classification System Expended and Revised [Kaba Motor Fonksiyon Sınıflandırma Sistemi Genişletilmiş ve Yeniden Düzenlenmiş Şekli (Kerem Günel M, Mutlu A, Livanelioğlu A, El Ö, Baydar M, Peker Ö, vd. Çev)]. Dev Med Child Neurol. 2007;39:214-223.
24. 24. Thomas-Stonell N, Greenberg J. Three treatment approaches and clinical factors in the reduction of drooling. Dysphagia. 1988;3:73-78.
25. 25. Erasmus CE, Van Hulst K, Rotteveel LJ, et al. Drooling in Cerebral Palsy: Hypersalivation or dysfunctional oral motor control? Dev Med Child Neurol. 2009;51:454-459.
26. 26. Brauner JS, Townsend VH. Tongue Thrust Classification. Angle Orthod. 1965;35:106-112.
27. 27. Serel Arslan S, Demir N, Karaduman AA. Reliability and validity of a tool to measure the severity of tongue thrust in children: The Tongue Thrust Rating Scale. J Oral Rehabil. 2017;44:119-124.
28. 28. Kubota T, Mishima H, Hanada M. Paralytic disyphagia in cerebrovascular disorder screening tests and their clinical application. Sogo Rehabilitation. 1982;10:271-276.
29. 29. Carmick J. Managing equines in children with cerebral palsy: Electrical stimulation tostrengthen the triceps surae muscle. Dev Med Child Neurol. 1995;37:965-75.
30. 30. Kerr C, McDowell B, Cosgrove A, et al. Electrical stimulation in cerebral palsy: a randomized controlled trial. Dev Med Child Neurol. 2006;48:870-876.
31. 31. Park EY, Kim WH. Effect of neurodevelopmental treatment-based physical therapy on the change of muscle strength, spasticity, and gross motor function in children with spastic cerebral palsy. J Phys Ther Sci. 2017;29:966-969.
32. 32. Tan C, Liu Y, Li W, et al. Transcutaneous neuromuscular electrical stimulation can improve swallowing function in patients with dysphagia caused by nonstroke diseases: A meta-analysis. J Oral Rehabil. 2013;40:472-480.
33. 33. Chen YW, Chang KH, Chen HC, et al. The effects of surface neuromuscular electrical stimulation on post-stroke dysphagia: a systemic review and meta-analysis. Clin Rehabil. 2016;30:24-35.
34. 34. Arslan SS, Humbert IA. Suprahyoid bölgeye uygulanan yüzeysel nöromusküler elektrik stimülasyonunun yutmanın zamansal parametrelerine etkisi. V. Yutma Bozuklukları Kongresi. 2017;Ankara, Türkiye.
35. 35. Oh DH, Park JS, Kim WJ. Effect of neuromuscular electrical stimulation on lip strength and closure function in patients with dysphagia after stroke. J Phys Ther Sci. 2017;29:1974-1975.
36. 36. Park JW, Kim Y, Oh JC, et al. Effortful swallowing training combined with electrical stimulation in post-stroke dysphagia: A randomized controlled study. Dysphagia. 2012;27:521-527.
37. 37. Suiter DM, Leder SB, Karas DE. The 3-ounce (90-cc) water swallow challenge: a screening test for children with suspected oropharyngeal dysphagia. Otolaryngol Head Neck Surg. 2009;140:187-190.
38. 38. Senner JE, Logemann J, Zecker S, et al. Drooling, saliva production, and swallowing in cerebral palsy. Dev Med Child Neurol. 2004;46:801-806.
39. 39. Sipal MS, Demir N, Serel Arslan S, et al. Spastik ve diskinetik tip serebral palsili çocuklarda salya kontrol probleminin ve salivasyonun incelenmesi. Turk J Physiother Rehabil. 2018;29:85-94.