"The parent is the holder of the child’s vision. Parents need to learn what is possible and then set the goals for their children that will create their future."

The development of TES therapy came about as a fortuitous happenstance. It was a question of seeing what didn’t work, modifying it and coming up with a happy result. As a neonatologist working in 1985 at Toronto’s Hospital for Sick Children, I had a patient, a " hopeless case" born with a severe spinal cord injury. When she recovered from spinal shock, it gradually became obvious that her injury was a partial one, as each of her muscles was capable of movement. But Michelle was still unable to move her body against gravity and at age 3 she lived in hospital on a ventilator. She had lost muscle strength due to disuse muscle atrophy during the period of paralysis. We tried high intensity electrical stimulation, as used by athletes, to try to strengthen her muscles. Unfortunately, Michelle couldn’t tolerate it. So we tried low intensity/long-duration therapy applied in her sleep. This was the start of Threshold Electrical Stimulation.

After the first year of TES she could sit, stand and walk with a walker. At 10, she was off the ventilator all day and living at home. She’s now in her late teens, on a ventilator only at night. She walks, talks and lives independently in her college residence.

I opened the Magee Clinic in 1989 and we did studies on all kinds of patients learning the best ways to use TES and to understand how it interacts with other therapies. We developed machines, basically modified from commercially available stimulators, for patients to use safely overnight at home. By 1994, I realized it was essential to train the child’s therapists in the protocols of use. TES grows the muscle, but the therapist has to strengthen it. There are now more than 1000 therapists in 47 states able to do TES. A prescription from your doctor and an evaluation by a trained therapist are required to enter the program.

As a general rule, we start TES at the age of 2 years. For children with brachial plexus injury (BPI), we start earlier. Brachial plexus injury can range from stretching or a bruise to complete tearing and disruption of the nerve. In all but the most extreme cases, children go through two to four years of nerve reinnervation, during which time, the movements are impaired and there is disuse muscle atrophy. We’ve seen that TES can help.

TES is not a substitute for proper diagnostics and surgical intervention when indicated. It will not help a totally denerved limb. However, it can be used very effectively in both pre and post-operative periods. Treatment protocols start from the area of injury and move down the arm with the reinnervating nerve to help grow muscle. So basically, when the nerve gets to the muscle, the muscle is healthy.

Adding TES to ongoing therapy management has the benefit of showing results in a very short time. In the area between the electrode pads you’ll see if there’s been new muscle growth after 6-8 weeks of use. Parents can actually see whether the therapy is working or not.

Mayatek Inc, the company that distributes TES equipment, offers a "no questions" refund if it doesn’t produce some change after 60 days. The unit and supplies are widely covered by insurance programs with a first year cost of unit, wires and electrodes at about $1600 with an on-going disposables cost of roughly $300 per year.

TES emits a low-level barely perceptible stimulation and is therefore easily tolerated. Children call it the "tickle machine" and say it feels like butterfly kisses.

Everyone with BPI has the problem of weak muscles and impaired awareness of how the arm works. In addition to growing muscle, TES may act to improve both sensory awareness and nerve growth.

A remarkable improvement occurred in a 35-year old nurse with severe congenital BPI. All branches of the plexus were involved and as an adult, her left arm was shorter, there was little muscle movement and the hand had no sensation. As a child, her hand was frequently burned and injured because she was not aware of it. After two years of TES, she recovered sensory awareness. While bone growth was impossible at her age, there was muscle development. She is now able to use that arm effectively as a propping, helping limb. The extent of her response has been gratifying and warrants further study. Intriguing possibilities present themselves as working hypotheses for investigation, but there has not yet been funding for formal research studies.

We know that TES stimulates blood flow during sleep when hormones, which encourage growth and repair, are being secreted. It is possible that the TES stimulation "tricks" the body into growing in the area of stimulation. In children with BPI, they may also have a developmental apraxia, which is seen when children tend to "forget" a damaged limb and don’t use it at all, even if they could. TES provides a repeated sensory level stimulation for hours each night, which might encourage better wiring in the brain to remember the muscles.

In animal studies there is substantial evidence that low-level electrical fields increase both the rate and the extent of reinnervation. More human studies are needed to see if this is in fact what occurs in children.

Patience is the operative virtue in managing brachial plexus injury. It takes the first four years of life for the nerve to reinnervate, and another four to eight years for the child to actively and intelligently learn to use the recovered function. They simply are unable to practice, strengthen and compensate until their brain development catches up with them. In puberty, with abstract reasoning, progress can be rapid. Because the child’s brain takes years to attain adult thought and reasoning, the parent must be the holder of the child’s vision of recovery. This is a vital and underestimated role that plays a huge part in progress and recovery. If you don’t expect change you don’t get change. I start with the premise that everyone has the potential for full recovery and I work down from that. No one has ever gotten angry with me for aiming too high.

As a parent, it is possible to become a very focused expert in your child’s specific injury. Goals need to be considered in the context that a child who is five years old now has at least 75 years of life ahead, in a world where the rate of change is exponential. Twenty years ago we didn’t have any of the techniques currently available. Marvelous developments in surgery allow the repairing of nerves as well as the transplanting of muscles and nerves. Therapists now use taping, casting, splinting and other treatments as part of a great basket of goodies in which TES is one more technique. It may take another twenty- five years to know exactly which children should get which procedure at what time and in what order. "Best practice" still needs to be figured out. Parents need to remember that even if nothing seems possible right now other than keeping the limb straight and helping it grow, the problem may be curable five years from now.

The BMT NT 2000-TES unit  is FDA approved for nightime use in children and has many safeguards built into it. Some of the features include instant shut-off if an electrode fails or falls off or if fluid spills on the unit. It also has a lock button that makes the settings less accessible to a child.

Mayatek, Inc. is the sole distributor of the BMR NT2000-TES unit. You can contact them at (800) 351-0016 or at their website www.mayatek.com.

There is specialized training for therapists to learn about the unit, the protocols and the strategies for placement of the electrodes. These trainings are run by the TASCnetwork. Contact TASC at (877) 827-2242 or at www.tascnetwork.net.

To find a therapist who is trained in the TES program, contact either Mayatek or TASC. If you order a unit, it will be shipped directly to that therapist.

There are specific placements and protocols for children with brachial plexus injuries that only a TASC trained therapist will have.

TES is a long-term commitment.

Visit www.injurednewborn.com/maia/estim.html to learn about the different kinds of electrical stimulation and more about TES specifically.