The use of therapeutic electrical stimulation in the treatment of hemiplegic cerebral palsy

Effects of the Inerventions method on gross motor function in children with spastic cerebral palsy

AIM OF THE STUDY

To investigate the effect of the Inerventions method on gross motor function in children with spastic cerebral palsy (CP).

CLINICAL RATIONALE FOR THE STUDY

The Inerventions method is the type of transcutaneous electrical nerve stimulation (TENS) delivered through a full-body garment (Mollii suit) that aims to prompt reciprocal inhibition via the antagonist to reduce spasticity in selected muscle groups. Although Mollii is approved by the European Union as a medical device, independent clinical tests have not yet been performed.

MATERIALS AND METHODS

16 children with spastic CP, aged 4.7 ± 1.3 were recruited and then willingly assigned to the Inerventions method (n = 8) and control groups (n = 8). In the Inerventions method group, TENS was applied 1 h per session, 3 days weekly for 3 weeks. Children of the control group received functional exercises program for the same duration, frequency and length. Outcome measures included the Gross Motor Function Measure, passive range of motion (PROM), the Modified Tardieu Scale, and the Timed Up and Go test.

RESULTS

While both groups experienced improvements in gross motor function and mobility, the difference in improvement between children treated with the TENS and physiotherapy did not reach statistical significance. No change occurred in PROM and spasticity in either group following the interventions.

CONCLUSIONS

There is no superior efficacy of the Inerventions method compared to conventional physiotherapy.

The orthotic and therapeutic effects following daily community applied functional electrical stimulation in children with unilateral spastic cerebral palsy: a randomised controlled trial

BACKGROUND

The purpose of this study was to determine the orthotic and therapeutic effects of daily community applied FES to the ankle dorsiflexors in a randomized controlled trial. We hypothesized that children receiving the eight-week FES treatment would demonstrate orthotic and therapeutic effects in gait and spasticity as well as better community mobility and balance skills compared to controls not receiving FES.

METHODS

This randomized controlled trial involved 32 children (mean age 10 yrs 3 mo, SD 3 yrs 3 mo; 15 females, 17 males) with unilateral spastic cerebral palsy and a Gross Motor Function Classification System of I or II randomly assigned to a FES treatment group (n = 16) or control group (n = 16). The treatment group received eight weeks of daily FES (four hours per day, six days per week) and the control group received usual orthotic and therapy treatment. Children were assessed at baseline, post FES treatment (eight weeks) and follow-up (six weeks after post FES treatment). Outcome measures included lower limb gait mechanics, clinical measures of gastrocnemius spasticity and community mobility balance skills.

RESULTS

Participants used the FES for a mean daily use of 6.2 (SD 3.2) hours over the eight-week intervention period. With FES, the treatment group demonstrated a significant (p < 0.05) increase in initial contact ankle angle (mean difference 11.9° 95% CI 6.8° to 17.1°), maximum dorsiflexion ankle angle in swing (mean difference 8.1° 95% CI 1.8° to 14.4°) normalized time in stance (mean difference 0.27 95% CI 0.05 to 0.49) and normalized step length (mean difference 0.06 95% CI 0.003 to 0.126) post treatment compared to the control group. Without FES, the treatment group significantly increased community mobility balance scores at post treatment (mean difference 8.3 units 95% CI 3.2 to 13.4 units) and at follow-up (mean difference 8.9 units 95% CI 3.8 to 13.9 units) compared to the control group. The treatment group also had significantly reduced gastrocnemius spasticity at post treatment (p = 0.038) and at follow-up (dynamic range of motion mean difference 6.9°, 95% CI 0.4° to 13.6°; p = 0.035) compared to the control group.

CONCLUSION

This study documents an orthotic effect with improvement in lower limb mechanics during gait. Therapeutic effects i.e. without FES were observed in clinical measures of gastrocnemius spasticity, community mobility and balance skills in the treatment group at post treatment and follow-up. This study supports the use of FES applied during daily walking activities to improve gait mechanics as well as to address community mobility issues among children with unilateral spastic cerebral palsy.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Register ACTRN12614000949684 . Registered 4 September 2014.

Wide-pulse-high-frequency neuromuscular electrical stimulation in cerebral palsy

OBJECTIVE

The present study assesses whether wide-pulse-high-frequency (WPHF) neuromuscular electrical stimulation (NMES) could result in extra-force production in cerebral palsy (CP) patients as previously observed in healthy individuals.

METHODS

Ten CP and 10 age- and sex-matched control participants underwent plantar flexors NMES. Two to three 10-s WPHF (frequency: 100 Hz, pulse duration: 1 ms) and conventional (CONV, frequency 25 Hz, pulse duration: 50 μs) trains as well as two to three burst-like stimulation trains (2s at 25 Hz, 2s at 100 Hz, 2s at 25 Hz; pulse duration: 1 ms) were evoked. Resting soleus and gastrocnemii maximal H-reflex amplitude (Hmax) was normalized by maximal M-wave amplitude (Mmax) to quantify α-motoneuron modulation.

RESULTS

Similar Hmax/Mmax ratio was found in CP and control participants. Extra-force generation was observed both in CP (+18 ± 74%) and control individuals (+94 ± 124%) during WPHF (p<0.05). Similar extra-forces were found during burst-like stimulations in both groups (+108 ± 110% in CP and +65 ± 85% in controls, p>0.05).

CONCLUSION

Although the mechanisms underlying extra-force production may differ between WPHF and burst-like NMES, similar increases were observed in patients with CP and healthy controls.

SIGNIFICANCE

Development of extra-forces in response to WPHF NMES evoked at low stimulation intensity might open new possibilities in neuromuscular rehabilitation.

Electrical Stimulation Following Botulinum Toxin A in Children With Spastic Diplegia: A Within-Participant Randomized Pilot Study

AIMS

To determine whether electrical stimulation (ES) following botulinum toxin A (BoNT/A) injection increases passive extensibility of the hamstring muscles in children with spastic diplegia.

METHODS

Six children undergoing bilateral BoNT/A injections to the hamstrings participated in this within-participant single blind randomized controlled trial. One leg of each child was randomised to the experimental condition and the other to the control condition. The experimental leg received daily stretch and ES to the hamstrings for 12 weeks, while the control leg received only daily stretch. The primary outcome was passive hamstring extensibility reflected by popliteal angle measured with a standardised torque. Secondary outcomes were two goniometric measures of popliteal angle using the Modified Tardieu Scale (R1 and R2), and parents' perceptions of treatment effectiveness. Outcomes were measured at baseline, 4 weeks, 12 weeks and 6 months.

RESULTS

The mean between-group difference (95% CI) at 4 weeks was 2° (-2 to 5) for popliteal angle measured with a standardised torque, favouring the experimental leg. Tardieu results for R1 and R2 were 0° (-4 to 3) and 7° (0 to 14), respectively.

CONCLUSION

ES does not improve passive extensibility of the hamstring muscles at 4 weeks over any possible effects of BoNT/A alone.

Effects of short-term daily community walk aide use on children with unilateral spastic cerebral palsy

PURPOSE

To determine the effects of functional electrical stimulation (FES) on the main impairments affecting gait in children with unilateral spastic cerebral palsy.

METHODS

A 20-week, multiple single-subject A-B-A design included a 6-week pre-FES phase, an 8-week FES phase, and a 6-week post-FES phase. Twelve children, aged 5 to 16 years, wore an FES device (the Walk Aide) daily for 8 weeks. Weekly measures included ankle range of motion, selective motor control, dorsiflexion and plantar flexion strength, gastrocnemius spasticity, single-limb balance, Observational Gait Scale (OGS) score, and self-reported toe drag and falls in the community.

RESULTS

Compared with the pre-FES phase, the FES phase showed significant improvements in ankle range of motion, selective motor control and strength, and reductions in spasticity, toe drag, and falls, but no change in OGS score. These improvements were maintained during the post-FES phase.

CONCLUSIONS

Intermittent, short-term use of FES is potentially effective for reducing impairments affecting gait in children with unilateral spastic cerebral palsy.

Effect of functional electrical stimulation on activity in children with cerebral palsy: a systematic review

PURPOSE

To determine whether functional electrical stimulation (FES) is effective and whether it is more effective than activity training alone.

METHOD

MEDLINE, CINAHL, EMBASE, Cochrane, Web of Science, and PEDro databases were searched for randomized trials. Studies of randomized trials were included if the participants were children (<18 years old) with spastic cerebral palsy, who underwent a program of FES that involved electrical stimulation during practice of an activity. Measures of activity that best reflected the activity trained were examined.

RESULTS

Five randomized trials were included. Three trials reported statistically significant between-group differences in favor of FES compared with no FES. Two trials reported no statistically significant between-group differences of FES compared with activity training alone.

CONCLUSION

The available evidence suggests that FES is more effective than no FES but that it has a similar effect as activity training alone in cerebral palsy.

SBOTE study: extracorporeal shock wave therapy versus electrical stimulation after botulinum toxin type a injection for post-stroke spasticity-a prospective randomized trial

Research is on-going to identify new methods of biostimulation to increase the effect of botulinum toxin type A (BTX-A) in the treatment of spasticity. The Spasticity treated by Botulinum Toxin and ESWT (SBOTE) study is a prospective, randomized controlled trial assessing the effectiveness of extracorporeal shock wave therapy (ESWT) given immediately after BTX-A injections compared with electrical stimulation (ES) given immediately after BTX-A therapy for the management of focal upper limb spasticity in stroke patients. ES was given for 30 min twice a day for 5 days starting at 5 Hz; ESWT was given once a day for 5 days. At study follow-up, patients treated with BTX-A injections and ESWT showed a statistically greater significance and continuous decrease of spasticity measure (modified Ashworth scale [MAS]: 1.37, 1.75 and 1.58 at 15, 30 and 90 days post-treatment, respectively), of spasms (spasm frequency scale [SFS]: 0.8 and 0.25 at 30 and 90 days post-treatment, respectively) and of pain (visual analogue scale [VAS]: 1.94 and 1.87 at 30 and 90 days, respectively) compared with patients treated with BTX-A injections and ES (MAS: 2.37, 2.18 and 2.18, respectively) (p < 0.05) (SFS: 1.5 and 1.06, respectively) (p < 0.05) (VAS: 2.44 and 2.69 respectively) (p < 0.05). ESWT enhances the effect of BTX-A to a greater extent than ES, probably by modulating rheology of the muscle and neurotransmission at the neuromuscular junction.

Children with cerebral palsy: a systematic review and meta-analysis on gait and electrical stimulation

Objective: To conduct a systematic review and meta-analysis using the International Classification of Functioning to determine the summary effect of electrical stimulation on impairment and activity limitations relevant to gait problems of children with cerebral palsy.

Methods: We identified 40 cerebral palsy and electrical stimulation studies, and 17 gait studies qualified for inclusion. Applying enablement classification methods to walking abnormalities created two subgroups: impairment (N = 14) and activity limitations (N = 15). Overall, 238 participants experienced electrical stimulation treatments and 224 served as a no stimulation control group. Calculations followed conventional data extraction and meta-analysis techniques: (a) individual standardized mean differences, (b) summary effect size, (c) I 2heterogeneity test, (d) fail-safe N analysis and (e) moderator variable analyses.

Results: Common outcome measures associated with impairment (n = 3) and activity limitations (n = 6) were submitted to separate random effects models meta-analyses, and revealed significant cumulative effect sizes: (a) impairment = 0.616 (SE = 0.10) and (b) activity limitations = 0.635 (SE = 0.14). I 2indicated low and medium amounts of dispersion, whereas fail-safe analyses revealed high N-values for both disablement categories. Moderator variable analyses further confirmed the positive treatment effects from both functional and neuromuscular stimulation.

Conclusions: The present systematic review and meta-analyses determined medium effect sizes for electrical stimulation on walking impairment and activity limitations of children with cerebral palsy.

The effect of an auxiliary stimulation on motor function restoration by FES

Functional Electrical Stimulation (FES) is a technology to generate neural activity in an artificial way to activate muscles. However, as reported by some researchers, the human responses to FES are likely to be affected by several factors, such as spasticity, muscle fatigue, nerve habituation and so forth. Consequently, the function restoration by FES is neither durable, nor stable. In order to realize long-term and stable FES assistance, this study investigated whether and why an Auxiliary Stimulation (AS) to the Gastrocnemius, with current frequency ranged from 2000 to 6000 Hz, could alleviate the symptom of spasticity and muscle fatigue caused by the stimulation to the Tibialis Anterior. We have developed a portable auxiliary stimulator, and performed experiments to verify its effectiveness. The results showed that our approach enabled comparatively stable and durable function restoration assistance. Moreover, for understanding underlying neuromuscular processes elicited by the AS and its qualitative nature, this study also measured the Hoffmann-reflex (H-reflex) in soleus muscle before and after the AS, to interpret the effect of the Auxiliary Stimulation.

H-reflex measurement and a simulation model for interpreting the effect of an auxiliary electrical stimulation on FES

As reported by some researchers, human responses to Functional Electrical Stimulation (FES) are likely to be affected by several factors, such as spasticity, muscle fatigue, nerve habituation and so forth. In our previous study, it has been shown that, an sub-threshold Auxiliary Stimulation (AS) to the Gastrocnemius, with current frequency ranged from 2000 to 6000Hz, could alleviate the symptom of spasticity and muscle fatigue caused by the stimulation to the Tibialis Anterior, enable comparatively stable and durable function restoration assistance. To understand the underlying neuromuscular processes elicited by the auxiliary electrical stimulation and its qualitative natures, we have measured the Hoffmann-reflex (H-reflex) in human soleus muscle before and after the AS in this study,, and proposed a mathematical model which takes into consideration not only the efferent but also afferent neural pathways, to interpret the effectiveness of the AS. Based on the results from the experiment it can be noted that: H(max)/M(max) became lower after AS, AS could reduce the excessive excitability of Alpha MNs. The mathematical model of pre-synaptic inhibition could help us to understand the underlying neuromuscular processes elicited by electrical stimulation and its qualitative nature, and used it to predict the states of spinal cord more easily, quickly, and reasonably in clinic experiment as a medical evaluation method for the paralyzed humans.

Therapeutic effects of electrical stimulation on manual function of children with cerebral palsy: Evaluation of two cases

PURPOSE

To investigate changes in hand function associated with electrical stimulation for children with hemiplegic cerebral palsy.

METHOD

An ABCA single-subject design, replicated in two children, was used in this study. Each baseline (phase A) lasted 4 weeks. Intervention consisted of electrical stimulation of wrist extensors (phase B) and of wrist extensors and flexors (phase C) for 15 minutes three times a week. Intervention phases also lasted 4 weeks. Active wrist extension range of movement and three timed manual tasks were tested two times a week every week. Data analysis included the Celeration Line and Two Standard Deviation Band methods in addition to visual analysis.

RESULTS

Significant performance gains were observed for both children, especially in phase C, when both extensors and flexors were stimulated. After intervention withdrawal, significant performance decreases were observed on most analysed variables.

CONCLUSIONS

The observed performance changes seem to be associated with the presence of intervention and suggest that electrical stimulation can be a useful adjunct to improve hand function of children with cerebral palsy.

Assessment of the efficacy and safety of low frequency, low intensity magnetic fields in patients after knee endoprosthesis plasty. Part 2: a clinical study

The purpose of this clinical study was to assess low frequency, low intensity magnetic fields in the enhancement of the physical rehabilitation of patients after knee endoprosthesis surgery. The study included 62 patients who underwent total knee arthroplasty. Group A consisted of 32 patients who were physically rehabilitated. Group B consisted of 30 patients who were physically rehabilitated and treated additionally with pulsing magnetic fields (5 mT, 30 Hz, 20 min once a day, 5 days weekly). Therapy lasted 3 weeks for both groups. The rehabilitation process was evaluated using a goniometer, tensometer, goniometric pendulum test, Lysholm scale for knee function, and a visual analogue scale (VAS) questionnaire for pain and activity. The changes of measured rates were comparable in both groups. Low frequency and low intensity magnetic fields of examined parameters were not demonstrated to effectively improve the rehabilitation of patients after knee endoprosthesis surgery.

Does electrical stimulation reduce spasticity after stroke? A randomized controlled study

OBJECTIVE

To investigate the therapeutic effect of electrical stimulation on plantarflexor spasticity in stroke patients.

DESIGN

A randomized controlled clinical trial study.

SETTING

Rehabilitation clinic of Semnan University of Medical Sciences.

SUBJECTS

Forty stroke patients (aged from 42 to 65 years) with ankle plantarflexor spasticity.

INTERVENTION

Fifteen minutes of inhibitory Bobath techniques were applied to one experimental group and a combination of 9 minutes of electrical stimulation on the dorsiflexor muscles and inhibitory Bobath techniques was applied to another group for 20 sessions daily.

MAIN MEASURES

Passive ankle joint dorsiflexion range of motion, dorsiflexion strength test, plantarflexor muscle tone by Modified Ashworth Scale and soleus muscle H-reflex.

RESULTS

The mean change of passive ankle joint dorsiflexion in the combination therapy group was 11.4 (SD 4.79) degrees versus 6.1 (SD 3.09) degrees, which was significantly higher (P = 0.001). The mean change of plantarflexor muscle tonicity measured by the Modified Ashworth Scale in the combination therapy group was -1.6 (SD 0.5) versus -1.1 (SD 0.31) in the Bobath group (P = 0.001). Dorsiflexor muscle strength was also increased significantly (P = 0.04) in the combination therapy group (0.7 +/- 0.37) compared with the Bobath group (0.4 +/- 0.23). However, no significant change in the amplitude of H-reflex was found between combination therapy (-0.41 +/- 0.29) and Bobath (-0.3 +/- 0.28) groups.

CONCLUSION

Therapy combining Bobath inhibitory technique and electrical stimulation may help to reduce spasticity effectively in stroke patients.

Cerebral palsy

Cerebral palsy (CP) is the leading cause of childhood disability. This article reviews common presentations of CP and its possible causes. The management of common problems seen in affected children is discussed in a system-based approach. Many treatment options are available for CP, with varying degrees of evidence and acceptance. As individuals who have CP transition into adulthood, they face unique issues that are not well recognized in the medical community. This article briefly reviews the psychosocial impact of this chronic disease on individuals and their caregivers and family.

Neuromuscular electrical stimulation versus volitional isometric strength training in children with spastic diplegic cerebral palsy: a preliminary study

BACKGROUND

To date, no reports have investigated neuromuscular electrical stimulation (NMES) to increase muscle force production of children with cerebral palsy (CP) using high-force contractions and low repetitions.

OBJECTIVE

The aims of this study were to determine if isometric NMES or volitional training in children with CP could increase muscle strength and walking speed and to examine the mechanisms that may contribute to increased force production.

METHODS

Eleven children with spastic diplegia were assigned to an NMES training group or to a volitional training group. Participants in the NMES group had electrodes implanted percutaneously to activate the quadriceps femoris and triceps surae muscles. The volitional group trained with maximal effort contractions. Both groups performed a 12-week isometric strength-training program. Maximum voluntary isometric contraction (MVIC) force, voluntary muscle activation, quadriceps and triceps surae cross-sectional area (CSA), and walking speed were measured pre- and post-strength training.

RESULTS

The NMES-trained group had greater increases in normalized force production for both the quadriceps femoris and triceps surae. Similarly, only the NMES group showed an increase in walking speed after training. Changes in voluntary muscle activation explained approximately 67% and 37% of the changes seen in the MVIC of the NMES and volitional groups, respectively. Quadriceps femoris maximum CSA increased significantly for the NMES group only.

CONCLUSIONS

This study was the first to quantitatively show strength gains with the use of NMES in children with CP. These results support the need for future experimental studies that will examine the clinical effectiveness of NMES strength training.

Application of a neuro-fuzzy network for gait event detection using electromyography in the child with cerebral palsy

An adaptive neuro-fuzzy inference system (ANFIS) with a supervisory control system (SCS) was used to predict the occurrence of gait events using the electromyographic (EMG) activity of lower extremity muscles in the child with cerebral palsy (CP). This is anticipated to form the basis of a control algorithm for the application of electrical stimulation (ES) to leg or ankle muscles in an attempt to improve walking ability. Either surface or percutaneous intramuscular electrodes were used to record the muscle activity from the quadriceps muscles, with concurrent recording of the gait cycle performed using a VICON motion analysis system for validation of the ANFIS with SCS. Using one EMG signal and its derivative from each leg as its inputs, the ANFIS with SCS was able to predict all gait events in seven out of the eight children, with an average absolute time differential between the VICON recording and the ANFIS prediction of less than 30 ms. Overall accuracy in predicting gait events ranged from 98.6% to 95.3% (root mean-squared error between 0.7 and 1.5). Application of the ANFIS with the SCS to the prediction of gait events using EMG data collected two months after the initial data demonstrated comparable results, with no significant differences between gait event detection times. The accuracy rate and robustness of the ANFIS with SCS with two EMG signals suggests its applicability to ES control.

Assessment of the short-term effect of antispastic positioning on spasticity

BACKGROUND

This study was performed in order to investigate the effect of antispastic positioning on spasticity by using different assessment methods.

METHODS

A total of 16 patients (11 males [68.75%] and five females [31.25%]), diagnosed as spastic diplegic and referred to the School of Physical Therapy and Rehabilitation, Paediatric Rehabilitation Unit for treatment, were included in this study. The mean age of patients was 6.43 +/- 1.99 years (range, 4-13 years). Passive dorsi-flexion movement was measured by using goniometer and intensity of spasticity was determined by using Modified Ashworth Scale (MAS) and electromyography. For the objective measurement of severity of spasticity, Hoffman reflex (H) and Hoffman reflex/motor response (H/M) ratios were used. Children were placed in an antispastic position for 20 min. The patient was placed in a sitting position, by a physiotherapist, with hips abducted at a 45 degrees angle and externally rotated, knees extended, and ankles placed in a neutral position.

RESULTS

The decrease in H responses, H/M ratios, MAS values and the increase in goniometric measurement values were found statistically significant after antispastic positioning (P < 0.05).

CONCLUSION

Our study supports that antispastic positioning can be used with neurodevelopmental treatment approaches when it is required. Antispastic positioning may help exercises to be performed more easily, and also has importance in a home exercise program to prevent muscle contractures and joint limitation in children with long-term spastic diplegia.

Use of functional electrical stimulation to augment traditional orthopaedic surgery in children with cerebral palsy

The purpose of this study was to compare the functional outcomes of traditional lower extremity orthopaedic surgery to more limited surgery augmented with functional electrical stimulation (FES) applied while walking. Seventeen ambulatory children with cerebral palsy participated in this prospective pretest-posttest control group study. The surgical group (nine subjects) underwent traditional orthopaedic procedures. The FES group (eight subjects) underwent placement of percutaneous intramuscular FES electrodes and limited orthopaedic surgical procedures. Postoperatively, they were provided with an FES home walking program. One year after intervention, all children (combined data) showed improvements in passive range of motion, gait spatiotemporal parameters, and gross motor function (P < 0.05). No differences were seen between groups before or after intervention. The FES group underwent 4.5 fewer ablative procedures per child than the surgical group. These results suggest that FES in combination with more limited surgery may provide similar functional gains with fewer ablative procedures than traditional orthopaedic surgery.

The treatment of cerebral palsy: What we know, what we don't know

The treatment of cerebral palsy is directed at repair of the injured brain and at the management of the impairments and disabilities resulting from developmental brain injury. Currently, there are no clinically meaningful interventions that can successfully repair existing damage to the brain areas that control muscle coordination and movement. However, several interventions are available to diminish the degree of impairment (eg, muscle spasticity) and to increase participation in activities of daily living. Data on treatment compatible with evidence-based medicine are now being collected.

Effect of sensory-level electrical stimulation of the tibialis anterior muscle during physical therapy on active dorsiflexion of the ankle of children with cerebral palsy

PURPOSE

The aim of the study was to determine whether add-on electrical stimulation (ES) at the sensory level improves ankle dorsiflexion in children with cerebral palsy.

METHOD

Seventeen children (three to nine years of age) with spastic hemiplegia or diplegia with weak or absent active ankle dorsiflexion received ES therapy applied to the tibialis anterior muscle during ordinary scheduled physical therapy sessions for one month. The ES was given at the sensory level alone with the aim of increasing the child's sensory awareness of the voluntary movement of the ankle.

RESULTS

Statistically significant improvement occurred in active ankle dorsiflexion with the knee flexed and extended between the first (pre) test and the subsequent tests (zero, two, and nine months later). Active toe flexion and extension and active inversion and eversion of the feet improved significantly.

CONCLUSION

ES at the sensory level combined with physical therapy improves active and passive motion of the ankle and foot that persists months after stimulation component is removed.

Evaluation of force-sensing resistors for gait event detection to trigger electrical stimulation to improve walking in the child with cerebral palsy

Force-sensing resistors (FSRs) were used to detect the transitions between five main phases of gait for the control of electrical stimulation (ES) while walking with seven children with spastic diplegia, cerebral palsy. The FSR positions within each child's insoles were customized based on plantar pressure profiles determined using a pressure-sensitive membrane array (Tekscan Inc., Boston, MA). The FSRs were placed in the insoles so that pressure transitions coincided with an ipsilateral or contralateral gait event. The transitions between the following gait phases were determined: loading response, mid- and terminal stance, and pre- and initial swing. Following several months of walking on a regular basis with FSR-triggered intramuscular ES to the hip and knee extensors, hip abductors, and ankle dorsi and plantar flexors, the accuracy and reliability of the FSRs to detect gait phase transitions were evaluated. Accuracy was evaluated with four of the subjects by synchronizing the output of the FSR detection scheme with a VICON (Oxford Metrics, U.K.) motion analysis system, which was used as the gait event reference. While mean differences between each FSR-detected gait event and that of the standard (VICON) ranged from +35 ms (indicating that the FSR detection scheme recognized the event before it actually happened) to -55 ms (indicating that the FSR scheme recognized the event after it occurred), the difference data was widely distributed, which appeared to be due in part to both intrasubject (step-to-step) and intersubject variability. Terminal stance exhibited the largest mean difference and standard deviation, while initial swing exhibited the smallest deviation and preswing the smallest mean difference. To determine step-to-step reliability, all seven children walked on a level walkway for at least 50 steps. Of 642 steps, there were no detection errors in 94.5% of the steps. Of the steps that contained a detection error, 80% were due to the failure of the FSR signal to reach the programmed threshold level during the transition to loading response. Recovery from an error always occurred one to three steps later.

Current evidence for the use of botulinum toxin type A in the management of children with cerebral palsy: a systematic review

Management of children with cerebral palsy (CP) is the focus of considerable resources in many countries, so that evaluation of the efficacy for new and established treatments is imperative. Botulinum toxin type A (BTX-A) is a relatively new method of spasticity management in children with cerebral palsy. It has been the focus of extensive research since its application to cerebral palsy 10 years ago. In a systematic review relating to the management of the lower limb in cerebral palsy 156 papers were identified. These were categorized according to Sackett and the World Health Organisation International Classification of Impairments, Disabilities and Handicaps model. We identified 10 randomized trials evaluating the use of BTX-A in the lower limb in children with cerebral palsy in a systematic review. A meta-analysis showed the pooled risk difference between BTX-A and placebo in three trials was 0.25 (95% CI 0.13, 0.37) and 0.23 (95% CI -0.06, 0.53) for two trials of BTX-A and casting using the physicians rating scale. These represent moderate treatment effects that are dosage-dependent. Outcomes were also compared for function in five studies. The type of evidence for BTX-A was graded by each treatment indication and directions for future research were then drawn from the available evidence.

Knee joint kinematics in gait and other functional activities measured using flexible electrogoniometry: how much knee motion is sufficient for normal daily life?

The knee joint kinematics of a group (n=20) of elderly normal subjects (mean age=67 years) were investigated using flexible electrogoniometry. The flexion-extension angle of the knee was recorded during a range of functional activities performed as part of a circuit in and around the hospital. The functions analysed including gait, walking on slopes, stair negotiation, the use of standard and low chairs and a bath. The data were used to produce the pattern of joint angulation against the percentage of the cycle for each individual conducting each activity. Further the maximum and minimum knee joint angles and the excursion of the joint during the cycle were identified. The results indicate gait and slopes require less than 90 degrees of knee flexion, stairs and chairs 90-120 degrees of flexion and a bath approximately 135 degrees of flexion. The data suggests that 110 degrees of flexion would seem a suitable goal for the rehabilitation of motion in the knee. It is concluded that flexible electrogoniometry is a suitable and practical method for evaluating knee motion during a range of functional activities.

Neuromuscular electrical stimulation and dynamic bracing as a treatment for upper-extremity spasticity in children with cerebral palsy

We have investigated a therapeutic regimen using neuromuscular electrical stimulation (NMES) and dynamic bracing to assess their effectiveness in reducing upper-extremity spasticity in children with cerebral palsy. Nineteen patients between 4 and 21 years of age with documented diagnoses of spastic cerebral palsy were treated. The patients included in the study followed a regimen of two 30-minute sessions of NMES of the antagonist extensors combined with dynamic orthotic traction during the day. A static brace was used at night. Spasticity of the wrist and fingers was assessed periodically using the Zancolli classification. Treatment ranged from 3 to 43 months. After treatment with electrical stimulation and dynamic bracing, all the patients moved up 1 to 3 levels in the Zancolli classification and showed a marked improvement in upper-extremity function. These results show that combining NMES and dynamic orthotic traction dramatically decreases spasticity of the upper extremity in young patients with cerebral palsy.

Postural control in sitting children with cerebral palsy

Children with cerebral palsy (CP) display postural problems, largely interfering with daily life activities. Clarification of neural mechanisms controlling posture in these children could serve as a base for more successful intervention. Studies on postural adjustments following horizontal forward and backward displacements of a movable platform in ten school-age children with spastic diplegia and non-disabled controls revealed that sitting CP children, like standing CP children, show direction specific postural adjustments, indicating that the basic pattern of muscle coordination in these conditions is conserved. Dysfunctions are especially present in the modulation of the response pattern of ventral muscles during forward translations. They consist of: (1) a stereotyped and non-variable activation of all ventral muscles; (2) an abnormal top-down muscle recruitment; and (3) an excessive degree of antagonistic co-activation. The altered patterns of muscle coordination could be the result of two interacting mechanisms, the primary deficit due to the early brain damage and a compensation due to the postural instability. Especially the latter dysfunction furnishes opportunities for therapeutic help.

Therapeutic electrical stimulation for spasticity: quantitative gait analysis

Improvement in motor function following electrical stimulation is related to strengthening of the stimulated spastic muscle and inhibition of the antagonist. A 26-year-old man with familial spastic paraparesis presented with gait dysfunction and bilateral lower limb spastic muscle tone. Clinically, muscle strength and sensation were normal. He was considered appropriate for a trial of therapeutic electrical stimulation following failed trials of physical therapy and baclofen. No other treatment was used concurrent with the electrical stimulation. Before treatment, quantitative gait analysis revealed 63% of normal velocity and a crouched gait pattern, associated with excessive electromyographic activity in the hamstrings and gastrocnemius muscles. Based on these findings, bilateral stimulation of the quadriceps and anterior compartment musculature was performed two to three times per week for three months. Repeat gait analysis was conducted three weeks after the cessation of stimulation treatment. A 27% increase in velocity was noted associated with an increase in both cadence and right step length. Right hip and bilateral knee stance motion returned to normal (rather than "crouched"). No change in the timing of dynamic electromyographic activity was seen. These findings suggest a role for the use of electrical stimulation for rehabilitation of spasticity. The specific mechanism of this improvement remains uncertain.

Managing equinus in children with cerebral palsy: electrical stimulation to strengthen the triceps surae muscle

A new therapeutic proposal for the management of equinus in children with cerebral palsy is to strengthen the calf muscles instead of weakening them surgically. Prior research indicates that in children with cerebral palsy the triceps surae muscle is weak and needs strengthening. Neuromuscular electrical stimulation (NMES) was used as an adjunct to physical therapy. A portable NMES unit with a hand-held remote switch stimulated an active muscle gait cycle. Results are discussed for four children, who showed improved gait, balance, posture, active and passive ankle range of motion, and foot alignment. The toe walkers became plantigrade and the equinovalgus posture of the foot decreased. Spasticity did not increase.