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This post is to share insight on the use of spinal stimulation for part of a treatment plan for children with spina bifida.

Spinal Stimulation Photo

What is Spinal Stimulation

Spinal stimulation (now referred to as non-invasive spinal electrical stimulation, or NISE) is one of many types of therapeutic electrical stimulation. This method of treatment, specifically for children with spina bifida, was developed, in 2017, by physical therapist, Gerti Motavalli, along with Dr. Gad Alon PT, Ph.D. Gerti was the first physical therapist to consider placing the electrodes right over the spine, as previous instruction was always to avoid placing an electrode directly over the spine or any other bony process. (Check out Gerti’s Website here)!

How Does Spinal Stimulation Help an Individual with Spina Bifida?

In most cases of spinal cord injury or neural tube defect, there is still a remaining neural connection within the spinal cord (3). If the nerve is completely severed, there would be no response to the electrical stimulation. So, during the testing, if the therapist is able to generate an activation of the muscle, there is still some neural connectivity to improve upon. So the idea is to build upon and strengthen the activation of those neurons that are still conducting within the spinal cord (3).

Spinal stimulation is bi-directional and improves the communication between:

  • The brain and spinal cord
  • The spinal nerve root
  • The peripheral nerve

Applying the electrode over the spinal cord is exciting the posterior nerve roots and this causes nerve impulse peripherally (to the muscles) but also goes back into the spinal cord and begins to modulate the connectivity within the spinal cord, and also communicates back to the brain.

Spina Bifida Conditions Treated:

  1. Scoliosis
  2. Club Foot (or other maligned foot position)
  3. Excessive knee valgus or varus
  4. Scissoring Gait
  5. Inability to stand
  6. Excessive lordosis or kyphosis of the spina
  7. Muscle weakness
  8. Neurogenic Bladder
  9. Neurogenic Bowel
  10. Poor circulation
  11. Core weakness

Possible Outcomes:

  • Postural correction:
    • Scoliosis, excessive lumbar lordosis, excessive thoracic kyphosis
  • Improved excitability– less intensity needed for same nerve response (motor or sensory)
  • Improved bowel function
  • Improved anal wink reflex
  • Improved bladder function
  • Bone strength from muscle activation
  • Improved circulation (warmer feet)
  • Improved overall functional mobility by hopefully improving voluntary muscle activation by strengthening the neural connectivity between the dorsal nerve root and the peripheral nerve
  • Improved gait mechanics
  • Ability to perform sit to stand
  • Ability to sit unsupported
  • Improved crawling pattern
  • Improved coughing force
  • Decreased respiratory illness
  • Improved respiration

What Sets Spinal Stimulation Apart From Other Types of Therapeutic Electrical Stimulation ?

Spinal Stim photo
  1. The placement of the electrodes.
    • With spinal stimulation, the electrodes are placed directly over the spine, ideally over the level of the lesion. This placement of the electrodes is thought to stimulate the spinal nerve roots and improve neural connectivity between the spinal nerve root, the weakened muscle, and the brain.
    • It’s also stimulating the motor cortex, which improves muscle activation and strength, the sensory cortex for improved sensation, and the autonomic nervous system, which improves circulation, bowel and bladder function, and respiration.
    • With this placement, there is also simultaneous stimulation to the peripheral nervous system (the muscles) and the central nervous system (brain and spinal cord). This is a feedback loop that can be strengthened with regular use of spinal stimulation.
      • An MRI study showed that the area of the brain controlling the muscles lit up when the distal muscle was stimulated along with spinal stimulation (6).
  2. The settings of the stimulation.
    • With spinal stimulation, the idea is to generate a strong muscle contraction. Sensation is the limiting factor. If there is any pain, the intensity is decreased or discontinued. However, if there is not a sensory limitation, the intensity of the stimulation can be set pretty high to generate a stronger contraction of the muscle.
  3. The goal:
    • Spinal stimulation is neuromodulation, with the goal of strengthening the nerve signal between the spinal cord, the nerve roots, and the peripheral nerves to the muscles.

** Please be advised: This requires a specific protocol tailored to each individual patient. I cannot stress enough the importance of seeking a trained physical therapist to initiate this treatment.

Who is Qualified to Provide Spinal Stimulation?

It is important to begin this process with a physical therapist, who has been trained in spinal stimulation. A physical therapist, trained in spinal stimulation will understand the necessary parameters to help regenerate a peripheral nerve and at the same time ensure that the parameters are safe and effective for each individual patient. An initial screening is necessary to ensure that the patient is a good candidate for spinal stimulation.

The physical therapist’s role is to:

  1. Perform a thorough evaluation of the patient, including extensive medical history
  2. Go through the testing protocol for motor response
    • This will give a base functioning of each individual muscle group and their response to electrical stimulation
  3. Go through the testing protocol for sensory response
    • This will give a baseline of sensory input over each area tested
  4. Determine appropriate size of electrodes
  5. Determine appropriate and safe treatment parameters
  6. Determine the targeted muscle groups
  7. Tailor the program to the specific patient needs and goals

On an electrical stimulation device, there are many different settings and parameters. It is important to ensure that the appropriate protocol is established by a trained professional. Once testing is done and appropriate treatment is determined, the protocol can be performed by parent or other treating therapist.

Equipment Needed for Spinal Stimulation for Spina Bifida

  1. Control unit
    • The Chattanooga Continuum device is recommended for spinal stimulation
      • This specific device is recommended, due to it’s ability to generate a strong contraction of the muscle
      • With peripheral nerve damage, a strong input to the muscle is needed
      • The Chattanooga Continuum is the strongest battery powered e-stim device on the market.
  2. Lead Wires
    • These connect the control unit to the electrodes
    • You need a 2 pack (but also good to have extras)
    • You can purchase on Amazon here
  3. Electrodes
    • Electrodes deliver the current through the skin to the muscle
    • They come in different shapes and sizes
  4. Hand Switch
    • The hand switch is very necessary, both for testing and treatment
    • You can purchase a hand switch here, on the Chattanooga site
    • Or here on Amazon (although it is significantly more expensive here)
  5. Clear fanny pack or other bag
    • This is the only item on this list that isn’t necessary however, it’s very helpful and recommended and also the least expensive item.
    • Here is one on amazon. (Gerti also has this on her site)
Starting Cost is around $460

Order Through Gerti

The best place to order in the beginning is through Gerti’s website here. She has a list of everything you will need to get started and there is a bundle you can order with everything.

How Does Spinal Stimulation Help with Bowel and Bladder Function?

  1. Placement of electrodes on the spine stimulates the ANS (autonomic nervous system) toward homeostasis (high or low tone in bladder towards more normal tone)
    • The autonomic nervous system is what helps to coordinate the storing and release of urine, as the nerves carry messages between the bladder and the spinal cord and brain (2).
  2. Placement of the electrodes near the anal sphincter could help stimulate activation of the glutes and hopefully stimulate the sphinctor muscle, which could help with bowel continence
  3. The electrodes can be placed over the sacral nerve roots, which are what innervate the bowl and bladder, so the hope would be to improve this neural connection and communication (similar to point number 1).

Who Can Benefit from Spinal Stimulation?

It is really a case by case determination. Initial testing and thorough assessment by a trained medical professional is highly necessary.

Spinal stimulation is safe to do with programmable VP shunts, most spinal cysts, and metal from other surgical procedures (1).

Spinal Stimulation for Spina Bifida Works Best in Conjunction with Physical Therapy

The best outcomes are when the spinal stimulation is conducted in conjunction with functional movements, for instance, when working on sitting, kneeling, quadruped, or standing. This will optimize the communication to the brain, in hopes of improving functional outcomes. The goal is for the stimulation to help eventually produce voluntary contractions during a desired activity or functional movement with less use or less intensity of the electrical stimulation.

When Can My Child Start Spinal Stimulation?

A spinal stimulation protocol can be started as early as 3 months after the surgical scar from the back has been determined healed and stable. If the closure was performed in utero, spinal stimulation may be started as early as 6 weeks old, as long as the baby is medically stable and the skin can tolerate the stimulation (3). The earlier the better!

Spina Bifida Scar

Possible Complications of Spinal Stimulation

  1. Skin burn or irritation
  2. Burning of the skin
  3. Inability to get any sensory or motor response
  4. Electric induced Muscle fatigue

** In current research, there are no long-term or short-term adverse reactions to spinal stimulation (3).

Precautions to Spinal Stimulation

  1. Skin burn or irritation
  2. Decreased Sensation – It is expected that individuals with spina bifida will have decreased sensation, but that means they won’t be able to feel any irritation of the skin, so it is important to monitor this closely each time.
  3. Impaired cognition
  4. Over area of spinal fusion or any hardware that is conductive
  5. Seizures or spilepsy
  6. Cancer
  7. Thrombosis or thrombophleblitis
  8. Heart problem or unstable arrhythmias
  9. Electrodes placed over carotid sinus

Contraindications for electrical stimulation

  1. Presence of implanted electrical device, such as pacemaker
  2. Pregnancy

Medical Disclaimer

The information on this website is intended solely for educational purposes and cannot substitute for professional medical advice. Please seek input from your primary medical provider if you would like to begin a low pressure fitness program.

About the Author

Sierra Rehrer is a board certified Doctor of Physical Therapy, who now specializes in the use of spinal stimulation for spina bifida. In 2020, she had a son born with spina bifida, which has lead her down the road of this specialty type of treatment. In 2022, she became Level 1 certified in spinal stimulation through Gerti Motavalli’s Course. She also did some one on one training with Gerti in early 2023.

Sierra Rehrer, DPT
Spinal Stim photo

For Questions or More Information Regarding Spinal Stimulation

PLEASE REACH OUT!

Resources for this post:

  1. Information – Spinal Stimulation – Gerti Motavalli PT, MPT. Spinal Stimulation – Gerti Motavalli PT, MPT. Published December 6, 2022. Accessed February 7, 2024. https://spinalstim.net/information/
  2. Neurogenic Bladder. Hopkinsmedicine.org. Published November 19, 2019. Accessed February 7, 2024. https://www.hopkinsmedicine.org/health/conditions-and-diseases/neurogenic-bladder#:~:text=The%20muscles%20and%20nerves%20of,to%20either%20tighten%20or%20release.
  3. wiredondevelopment. Spinal Stimulation in Spina Bifida with Gerti Motavalli and Dr Gad Alon. wiredondevelopment. Published June 23, 2023. Accessed February 9, 2024. https://www.wiredondevelopment.com/single-post/spinal-stimulation-in-spina-bifida-with-gerti-motavalli-and-dr-gad-alon
  4. Smith GV, Alon G, Roys SR, Gullapalli RP. Functional MRI determination of a dose-response relationship to lower extremity neuromuscular electrical stimulation in healthy subjects. Experimental Brain Research. 2003;150(1):33-39. doi:https://doi.org/10.1007/s00221-003-1405-9