|Year : 2016 | Volume
| Issue : 1 | Page : 43-47
Effect of vibrotactile stimulation on motor performance in a child with cerebral palsy: A case study
Chetana Ashok Kunde, Suvarna Shyam Ganvir, Mayuri Mahaveer Agrawal
Department of Neurosciences, PDVVPF's College of Physiotherapy, Ahmednagar, Maharashtra, India
|Date of Web Publication||10-Aug-2016|
Chetana Ashok Kunde
24, Swaroop Nagar, Near Swawlambi Nagar, Nagpur - 440 022, Maharashtra
Source of Support: None, Conflict of Interest: None
The purpose of this study is to report unexpected quick and highly effective result of vibrotactile stimulation on gross motor ability in a child with cerebral palsy. This is a 9-year-old male child with sensory motor disorder. Gross motor function classification system level classified as V. On somatosensory examination and sensory profile caregiver questionnaire, the child had tactile hypersensitivity. Outcomes were assessed using gross motor function measure (GMFM). For the first 4 weeks, child was given sensory stimulation with different texture (soft to hard) + neurodevelopmental therapy (NDT). For another 4 weeks, sensory stimulation was added with vibration + soft to hard texture + NDT. Vibration of 50-60 Hz was given for 10 min for 6 days/week on the sole of foot, ankle, and knee joint. There was minimal motor improvement in the first 4 weeks of hard and soft texture stimulation combined with NDT. Following this, an another 4 weeks of vibrotactile stimulation showed appreciable improvement in the dimensions A, B, C, and D, of GMFM (pre: 28.97%, post: 33.20%). Vibrotactile stimulation helps to decrease tactile hypersensitivity in children with cerebral palsy and thus improves gross motor function abilities in 4-week period.
Keywords: Cerebral palsy, tactile hypersensitive, vibrotactile
|How to cite this article:|
Kunde CA, Ganvir SS, Agrawal MM. Effect of vibrotactile stimulation on motor performance in a child with cerebral palsy: A case study. Indian J Cereb Palsy 2016;2:43-7
|How to cite this URL:|
Kunde CA, Ganvir SS, Agrawal MM. Effect of vibrotactile stimulation on motor performance in a child with cerebral palsy: A case study. Indian J Cereb Palsy [serial online] 2016 [cited 2017 Mar 24];2:43-7. Available from: http://www.ijcpjournal.org/text.asp?2016/2/1/43/188161
| Introduction|| |
Somatosensory perception plays a key role in the early stages of human development. Among all sensory systems, the tactile sense develops earliest.  Tactile and proprioceptive sensory experiences arise from active movement. Bobath believed that "we do not learn movements, but the sensations of movement." If the sensory information perceived is minimal or abnormal, movement is likely to be impaired. 
The development of gross motor skills depends heavily on the somatosensory system.  Accurate tactile and proprioceptive sensation is important for the development of motor skills.  Tactile feedback from mechanoreceptors in the skin and joints critically guides the online modulation of gross motor functions. 
Children with cerebral palsy (CP) are also more likely to have sensory dysfunction associated with insufficient sensory experiences.  Two main types of tactile sensory dysfunction are tactile hypersensitive and tactile hyposensitive. Tactile defensiveness is defined as a hyperreactive and/or aversive response to tactile stimuli that most people would consider innocuous such as light touch or clothing texture. 
Previous studies have shown that individuals with cerebral palsy display poorer tactile discrimination and proprioception, , as well as enhanced pain than healthy control. , Moreover, studies have proven that reduced touch sensitivity are associated with increased pain sensitivity in children with early brain injury,  suggesting a potential link between abnormal somatosensory experiences in early life and long-term changes in pain processing. 
Researches had proved the effect of vibration therapy. Vibrations of various frequencies 31, 35, 40, and 44 Hz decrease touch-pressure sensitivity at 10 min after exposure,  decrease pain sensitivity in cerebral palsy child,  improve balance and motor function, and reduce the secondary complications associated with CP. 
Hence, the purpose of this study is to report unexpected quick and highly effective result of vibrotactile stimulation on gross motor ability in a child with cerebral palsy.
| Case report|| |
A 9-year-old male child presented with chief complaint of unable to stand and walk. He is the second child born with normal vaginal delivery in rural hospital. He had a history of delayed cry after birth and Neonatal Intensive Care Unit stay was delayed by 4 days. At initial assessment, according to gross motor evaluation, he was unable to transit from sit to stand and was not able to stand independently and even with support.
On musculoskeletal examination, he had no muscle tightness and contracture and his tone was absolutely normal. Sensory examination pursued by the therapist with different textures on the sole of the foot, hands, and legs. Soft texture was given with cotton, hair brush, and velvet cloth, and hard texture was given with bath scrubber, rough blanket, and sand paper. Child showed pain and withdrawal response to hard texture.
On sensory profile caregiver questionnaire, child had tactile hypersensitivity. The sensory profile is a caregiver questionnaire which provides information of sensory processing of a child's daily performance. It provides information regarding behavioral tendencies in response to stimuli and identifies which sensory systems are likely to contribute to, or create barriers during functional activities. It consisting of 14 sections (total of 125 items) that reports the frequency of behavioral occurrences that are used to measure the patterns of performance indicative of difficulties experienced in sensory processing.  His gross motor function classification system (GMFCS) level was classified as V and Gross motor abilities on gross motor function measure (GMFM)-66 scores was 28.97%.
As the sensory profile report indicates that the child has more problems with touch processing and which mainly suggest tactile hypersensitive response, therefore the aim of treatment protocol was to normalize the tactile response to make changes in gross motor function [Figure 1].
Therapy was given for 6 days/week in a hospital setup. First 4 weeks, treatment was started with tactile stimulation with different texture (soft to hard texture) for 10 min. This was followed by neurodevelopmental therapy (NDT) for 30 min in which child was exposed to training like sit to stand, kneeling, and standing on tilt board. Adaptive equipments used in therapy were ball, bolster, and tilt board so that child is constantly exposed for sensory integration program combined with NDT.
For another 4 weeks, vibrotactile therapy was started with a body massage vibrator. This instrument transmits graded vibratory stimuli at 50-60 Hz through a rounded flat surface (7 inch) at the sole of foot, ankle, and knee joint for 10 min and rest of the treatment was same for these weeks. Apart from therapy at the hospital, vibratory simulation was given by parents for 10 min, 2 times/day.
| Results|| |
As per the scales of evaluation, score on GMFM on day 1 was 28.97%. On GMFCS, he was at Level V, as he was ambulated in a manual wheelchair.
At the end of 4 th week of therapy, child was able to take tactile stimulation to some extent as compared to before, but he still resisted during sit to stand and was crying while standing. There was no change in score of GMFM and GMFCS level.
At the end of 8 th week, his resistance to touch had decreased to such an extent that he could perform sit to stand with minimal assistance at the trunk and stand against support of furniture for maximum 5 min, this rapid change in motor performance was seen after adding vibrotactile stimulation. GMFM level was improved to 33.20% in dimensions A, B, C, and D. There was no change in GMFCS level in such a short period [Figure 2].
| Discussion|| |
Children with cerebral palsy also present with sensory problems, especially tactile processing.  Researches have less focused on treatment related to sensory problems in children with cerebral palsy.
The present study reveals that intensive training of somatosensory processing by vibrotactile stimulation may reduce tactile hypersensitiveness by its analgesic effect. A major component of vibrotactile analgesia is likely related to A-beta mediated afferent inhibition of dorsal horn nociceptive neurons.  Moreover, another component of central modulation of peripheral noxious input by vibrotactile stimulation at the somatosensory cortex (S1). 
Vibrotactile stimulation of 50-60 Hz used in the study has shown to decrease tactile hypersensitivity to much extent; it improves the child ability to stand pain-free against support in 2 weeks which is observed by the child response to therapy, therapist observation, and by parent reporting. Riquelme et al.  concluded that vibration therapy in combination with other sensory stimulation helps to decrease pain sensitivity in cerebral palsy children in 3 months. Vibrotactile stimulus up to 80 Hz reduces sensitivity to touch for short-term for 10 min after stimulation. Another study by Sonza et al. and Magnusson et al. , proves that whole body vibration acts on large diameter fibers and reduces touch-pressure sensitivity and influences the discharge of the skin's fast adapting receptors at 30 Hz. Hence, it is confirmed that reduced sensitivity of mechanoreceptor receptor has a relationship with motor performance. , Blakemore et al. stand with the controversial finding, that tactile perceptual threshold lowers with the vibrotactile stimulation of larger (200 Hz) compared to smaller (30 Hz) in autistics who are hypersensitive to tactile stimulus. 
Other thing noticed in this study was that child preferred soft tactile stimulation in the sole of foot and leg but showed rejection toward rough or hard object. Harder objects would provide the child with more proprioceptive information , than they would receive from the soft object, it indicates that child is more resistive to harder object, weight-bearing, and stretching exercises.
Second, child response was very aggressive as though it was very painful to hard texture and weight bearing during rehabilitation; studies have shown that children with developmental disability show specific tactile abnormalities that are pain response to noninjurious touch , and light pressure to multiple areas of the skin.
Studies have also proved that repetitive stimulation can improve tactile function in healthy individuals and patients with chronic pain, adult with cerebral palsy.  It is known that intensive training of somatosensory stimulation, may induce powerful changes in the organization of the primary somatosensory cortex in response to hyperstimulation. ,
Currently, intervention of this child focuses on improving motor function and functional skill of standing and walking. Hence, the treatment program oriented to improve somatosensory awareness and use of this information in motor performance. Umansky and Lyon suggested that an early sensory deficit influences the integration of the limb into the body scheme and the later functional use of the extremity, it would seem important to provide sensory rehabilitation as well as motor rehabilitation for young children with cerebral palsy. ,
| Conclusion|| |
Vibrotactile stimulation helps to decrease tactile hypersensitivity in children with cerebral palsy and improves gross motor function abilities in a 4-week period.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Montagu A. Touching: The Human Significance of the Skin. New York: Perennial Library; 1986.
Bobath B. Motor development, its effect on general development, and application to the treatment of cerebral palsy. Physiotherapy 1971;57:526-32.
Corbetta D, Snapp-Childs W. Seeing and touching: The role of sensory-motor experience on the development of infant reaching. Infant Behav Dev 2009;32:44-58.
Curry J, Exner C. Comparison of tactile preferences in children with and without cerebral palsy. Am J Occup Ther 1988;42:371-7.
Metcalfe JS, McDowell K, Chang TY, Chen LC, Jeka JJ, Clark JE. Development of somatosensory-motor integration: An event-related analysis of infant posture in the first year of independent walking. Dev Psychobiol 2005;46:19-35.
Silver CM, Litchman HM, Simon SD, Motamed M. Surgical correction of spastic thumb-in-palm deformity. Dev Med Child Neurol 1976;18:632-9.
Tachdjian MO, Minear WL. Sensory disturbances in the hands of children with cerebral palsy. J Bone Joint Surg Am 1958;40-A: 85-90.
Cascio CJ. Somatosensory processing in neurodevelopmental disorders. J Neurodev Disord 2010;2:62-9.
Sanger TD, Kukke SN. Abnormalities of tactile sensory function in children with dystonic and diplegic cerebral palsy. J Child Neurol 2007;22:289-93.
Wingert JR, Burton H, Sinclair RJ, Brunstrom JE, Damiano DL. Tactile sensory abilities in cerebral palsy: Deficits in roughness and object discrimination. Dev Med Child Neurol 2008;50:832-8.
McGlone F, Vallbo AB, Olausson H, Loken L, Wessberg J. Discriminative touch and emotional touch. Can J Exp Psychol 2007;61:173-83.
Riquelme I, Montoya P. Developmental changes in somatosensory processing in cerebral palsy and healthy individuals. Clin Neurophysiol 2010;121:1314-20.
Schmelzle-Lubiecki BM, Campbell KA, Howard RH, Franck L, Fitzgerald M. Long-term consequences of early infant injury and trauma upon somatosensory processing. Eur J Pain 2007;11:799-809.
Sonza A, Robinson CC, Achaval M, Zaro MA. Whole body vibration at different exposure frequencies: Infrared thermography and physiological effects. ScientificWorldJournal 2015;2015:452657.
Riquelme I, Zamorano A, Montoya P. Reduction of pain sensitivity after somatosensory therapy in adults with cerebral palsy. Front Hum Neurosci 2013;7:276.
Katusic A, Alimovic S, Mejaski-Bosnjak V. The effect of vibration therapy on spasticity and motor function in children with cerebral palsy: A randomized controlled trial. NeuroRehabilitation 2013;32:1-8.
Dunn W. The Sensory Profile User′s Manual. San Antonio: The Psychological Corporation; 1999.
Kurz MJ, Becker KM, Heinrichs-Graham E, Wilson TW. Children with cerebral palsy have uncharacteristic somatosensory cortical oscillations after stimulation of the hand mechanoreceptors. Neuroscience 2015;305:67-75.
Salter MW, Henry JL. Physiological characteristics of responses of wide dynamic range spinal neurones to cutaneously applied vibration in the cat. Brain Res 1990;507:69-84.
Whitsel BL, Favorov O, Delemos KA, Lee C, Tommerdahl M, Essick GK, et al.
SI neuron response variability is stimulus tuned and NMDA receptor dependent. J Neurophysiol 1999;81:2988-3006.
Sonza A, Maurer C, Achaval M, Zaro MA, Nigg BM. Human cutaneous sensors on the sole of the foot: Altered sensitivity and recovery time after whole body vibration. Neurosci Lett 2013;533:81-5.
Magnusson M, Enbom H, Johansson R, Wiklund J. Significance of pressor input from the human feet in lateral postural control. The effect of hypothermia on galvanically induced body-sway. Acta Otolaryngol 1990;110:321-7.
Meyer PF, Oddsson LI, De Luca CJ. The role of plantar cutaneous sensation in unperturbed stance. Exp Brain Res 2004;156:505-12.
Hennig EM, Sterzing T. Sensitivity mapping of the human foot: Thresholds at 30 skin locations. Foot Ankle Int 2009;30:986-91.
Blakemore SJ, Tavassoli T, Calò S, Thomas RM, Catmur C, Frith U, et al.
Tactile sensitivity in Asperger syndrome. Brain Cogn 2006;61:5-13.
Danella EA. A study of tactile preference in multiply-handicapped children. Am J Occup Ther 1973;27:457-63.
Silva LM, Schalock M. Sense and self-regulation checklist, a measure of comorbid autism symptoms: Initial psychometric evidence. Am J Occup Ther 2012;66:177-86.
Baron R. Neuropathic pain: A clinical perspective. In: Canning B, Spina D, Hofmann F, editors. Handbook of Experimental Pharmacology. Vol. 194. New York: Springer; 2009. p. 3-30.
Pantev C, Engelien A, Candia V, Elbert T. Representational cortex in musicians. Plastic alterations in response to musical practice. Ann N Y Acad Sci 2001;930:300-14.
Schaefer M, Flor H, Heinze HJ, Rotte M. Dynamic shifts in the organization of primary somatosensory cortex induced by bimanual spatial coupling of motor activity. Neuroimage 2005;25:395-400.
Umansky R. The hand sock, an artificial handicap to prehension in infancy, and its relation to clinical disuse phenomena. Pediatrics 1973;52:546-5.
Lyon G. First signs and mode of onset of congenital hemiplegia. In: Little Club Clinics in Developmental Medicine: Hemiplegic Cerebral Palsy in Children and Adults. London: National Spastics Society; 1961. p. 33-9.
[Figure 1], [Figure 2]