I visited the Nikopol Children’s Neurorehabilitation Centre in the summer of 2015 for the second time. The first time was shortly after two coMra-Therapy devices were introduced to the centre more than 3 years ago: (see the Previous Blog article).
I found out that since my first visit many children had received coMra-Therapy as a part of their rehabilitation program. In 2014, for example, 235 children received coMra-Therapy during more than 3600 treatment sessions for conditions such as:
Paresis (all types) and Cerebral Palsy: 62 children;
Valgus/varus deformations: 56 children;
- Enuresis: 37 children.
Overall the medical staff at the Centre shared with me that:
Based on their extensive experience, coMra-Therapy was selected from a very large range of therapies and has become one of their most used tools;
The therapy is now an essential part of their rehabilitation program for paresis, cerebral palsy and varus/valgus deformities;
coMra-Therapy is a part of a small selection of treatment tools, evaluated over a period of time and based on experience;
No negative reactions (relapses) after coMra-Therapy were observed in children with epilepsy in remission;
coMra-Therapy was found to be highly effective for general health conditions in children such as enuresis and colds;
- Overall health improvements and strengthening of immunity remained for a long time after completing coMra-Therapy courses.
Visiting Nikopol Children’s Neurorehabilitation Centre
It was a warm summer day. I had arranged with Dr Irina Khmelevskaya MD, the chief neurologist and director of the Children’s Neurorehabilitation Centre, to come early on Friday by bus from Dnepropetrovsk. After quite a long journey, I arrived at the town, and was looking forward to the meeting.
Since I was early, I enjoyed a coffee at the café just beside the centre. Then I called Dr Khmelevskaya. She was ready for our meeting and asked me to come right away.
I knew that it was difficult for her to make time for me. While Nikopol is a rather small town, with population just over one hundred thousand people, this neurological rehabilitation centre is quite prominent in the region. With over 70 beds for continious stay and many children, you may imagine - she is quite busy.
A warm welcome, a few formalities to plan our time together and we are sitting down to talk. Sometime later, I know she is going to give me a case study material I had asked for earlier.
General discussion Dr Khmelevskaya:
MM: What therapies are you using today?
Dr Khmelevskaya: We actually do not use a lot of therapies today. Well, we don’t use any electrotherapies, like electrophoresis and sinusoidal modulated currents.
MM: I heard you mention epilepsy. Did you use coMra for epilepsy? What was your experience?
Dr Khmelevskaya: Yes we did.
We do not use electrotherapies for epilepsy, even during periods of remission when the child is receiving anticonvulsant medication. Epileptic symptoms often accompany cerebral palsy or congenital malformation of the brain. So when a child receives some type of anticonvulsant there is a period without seizures, a remission, even if electroencephalogram (EEG) shows some epileptic forms.
So in children with epilepsy in remission we use coMra-Therapy as prescribed in the User Guide. And up to date we have not had a single relapse. We are not overdoing the treatments but still we are quite thorough and there have been no seizures coming back after coMra-Therapy.
MM: This is quite important, I think. Is it generally considered that all types of electrotherapy have adverse effects and may provoke seizures?
Dr Khmelevskaya: Yes, exactly. And if you think about coMra-Therapy, the infrared light is not a contraindication for epilepsy, we have no information that it may be. Low Level Laser does not potentiate convulsions. Colour therapy – we don`t shine directly towards the eyes. Ultrasound – we switch it off during treatments to the head.
For children without epilepsy we use coMra over the head to treat conditions such as facial nerve neuropathy, nose and ear treatments. For children with epilepsy we do not treat the head directly and we have had no incidents of seizures whatsoever.
Exactly because of this lack of contraindications and because of the opportunity to do systemic treatments we use coMra quite widely in our Centre.
MM: Have you used many other therapies before?
Dr Khmelevskaya: Yes, yes. For example, we no longer use electrophoresis or sinusoidal electrotherapy.
Dr Khmelevskaya: You see, according to the “Academy of Childhood Disability” all therapeutic interventions for neurorehabilitation are classified into 3 types:
Effective, with proven track record,
Possibly effective – without substantial documented evidence,
- Not effective – with proven inefficiency.
Among effective therapies are botulinum toxin therapy for paresis, purposeful motor activity, kinesiotherapy.
Among possibly effective are those that are known in Europe and the United States as Bobath and Vojta therapy, as well as also aquatic therapy, equine-assisted therapy, reflexology. However in the United States Bobath and Vojta therapies are considered to be outdated practices and there has not been enough evidence-based research done.
Not effective are passive methods of physiotherapy such as old exercise therapy and massage as a separate method. Proven to be effective is a therapy with purposeful motor activity – where you motivate for action using kinesiotherapy. Because when you yourself move the patient’s leg or arm you do not improve tonus by doing that. Well, those old methods from the Soviet Union – exercise therapy and massage are not considered effective, because they are passive. We use massage, however as a supplemental therapy just before kinesiotherapy, because massage reduces tonus in the short term, for 2 hours for example, to increase joint movement, reduce pain syndrome, and relax extremities. Also electrotherapy such as galvanic therapy and sinusoidal modulated currents are not effective. The same concerns go for homeopathy and hyperbaric oxygen therapy, since those are considered as not effective for neurorehabilitation.
MM: What is the place of coMra in all of this?
Dr Khmelevskaya: We use therapies that are classified as "possibly effective":
Aquatic therapy: movements in the water, whirlpool baths and hydro massage for sensory stimulation of the body;
Heat application to specific areas before kinesiotherapy and
MM: How does coMra-Therapy influence muscle tone? Do you have any observations?
Dr Khmelevskaya: It is difficult to answer this question because children do not receive coMra-Therapy as a monotherapy in our neurorehabilitation program, but in combination. However, I can say that previously we used a very wide range of physiotherapies and now since we switched to hydro, heat and coMra the therapeutic efficiency is better today. So through that one can draw one’s own conclusions.
MM: So from what I understand the overall efficiency of your Centre has increased?
Dr Khmelevskaya: Well, please bear in mind that generally we do not treat the same children all the time, although there are cases where we can see long-term changes. Later we will look into one such case where we can see specific changes over a long period of time.
Also, we have a group of children with cerebral palsy, but they were discharged a week ago. The results are very interesting! After several courses of coMra-Therapy combined with heat application we observed a significant reduction of muscle spasticity in the upper extremities, although some spasticity remained in the lower extremities.
And every time children with spasticity and high muscle tone come to our Centre they receive heat with kinesiotherapy and coMra-Therapy and no other physical therapies. In cases of hypotonia, low muscle tone, we do not use heat but only coMra and kinesiotherapy.
I also can say that our kinesiotherapists do like coMra-Therapy as they have observed changes in working with children.
MM: Any other conditions?
Dr Khmelevskaya: Well, I can mention enuresis where we use coMra extensively and the outcomes are much better.
Previously we used a standard recommended approach, sinusoidal modulated currents to the underbelly, but now we have stopped using it because coMra-Therapy is much more effective. Of course, you have to continue general training – habituate urination, defecation as well, teach to feel and react to the urge. You have to teach, because when children get home the parents usually forget everything.
Concerning nervous system disorders and specifically cerebral palsy I doubt that we could get the same results with kinesiotherapy alone. The addition of coMra-Therapy certainly makes a difference.
Now let us look into an individual case of a girl, where it has been possible to monitor progress for a considerable period and this gives some grounds for conclusions.
A case of a 4-year-old girl with diffuse muscular hypotonia treated with coMra-Therapy
Dr Khmelevskaya: The parents of this girl came to us when she was at the age of 7 months. At the very beginning, she had no coMra treatments because we did not have a device then. Now she is almost 4 years old and she has gone through 8 courses of coMra-Therapy. She has responsible parents and every time she comes to us she gets 15-16 sessions of coMra-Therapy. I will show you the treatment protocol that was designed specifically for her.
What was her condition? She had perinatal hypoxic nervous system damage that is intrauterine hypoxia that resulted in low muscle tone, diffuse muscular hypotonia. This condition is not a neuromuscular tissue pathology, meaning that there is no pathology in neuromuscular connections. This is a diffuse moderate muscular hypotonia of central origin which led to the delayed development of motor function. She started to sit and walk later than usual because of her flaccid muscles. When she started to walk, she would drag her feet, stumble and fall very often.
It would seem that she had insufficient motor coordination, but this was caused by low muscle tone.
The other development was a distortion of posture, i.e. flattening of the physiological curves of the spine. In the cervical part, we have lordosis, in the thoracic - kyphosis, in the lumbar part again lordosis. But she had quite a flat back.
As she started to walk, her body started to weigh down on her joints and since the muscles were too weak to hold her weight she developed valgus deformity of her knees, looking like the letter “A”. In addition, the rise of her feet was flat and her heels were here forming a letter “A” too.
Here’s how her knees were bent inward before and here’s how her feet were (Dr Khmelevskaya showed with her hands). Also she sat with a rounded back.
And now, after many courses of coMra-Therapy, what you see is remarkable and absolutely amazing.
What were the treatments? She received a combined therapy of kinesiotherapy, stimulating massage and coMra-Therapy for about 1 month at every visit. During each month, she received no less than 15 daily treatments on each visit. Sometimes as many as 20 treatments, depending on how other sessions permitted. Sometimes we also used equine therapy, although this was not for muscle tone as such, but for strengthening her back - there is no effect on the legs. So, over 8 visits she received this kind of combined therapy course.
MM: What kind of break did she have between courses?
Dr Khmelevskaya: Not big breaks - like 2-2.5 months and then a month’s course.
What we have today is diffuse muscle hypotonia: diffuse means uniform over the body. Diffuse is better than local. If it was focused on the legs only - it would be a lower flaccid paraparesis. She is smart, no retardation, her intelligence does not suffer, and she has no speech defects, besides normal age-related dyslalia. As of today – we still have diffuse hypotonia, but if you see (tapping with tendon reflex hammer) - if we had problems with neuromuscular tissue, we would not be able to call the tendon reflex at all. We still have hypotonia, but it is much lower now - i.e. muscle tone is much higher now, and there is still some flattening of the spine. However, before she was sitting with a rounded spine and now her spine is almost straight. We still have some valgus deformity too.
MM: Is it angled to exterior?
Dr Khmelevskaya: Still intact, but much less than before: