Neuromuscular electrical stimulation for children with cerebral palsy: a review.

The aim of this review paper is to consider the application of neuromuscular electrical stimulation (NMES) to improve gait or upper limb function in children with cerebral palsy (CP). Although most NMES research has been directed at adults with neurological conditions, there is a growing body of evidence supporting its use in children with CP. In line with a recent meta-analysis, the use of electrical stimulation to minimise impairment and activity limitations during gait is cautiously advocated. A detailed commentary on one of the most common lower limb NMES applications, tibialis anterior stimulation (either with or without gastrocnemius stimulation) is given. Although there is a lack of randomised controlled trials and a predominance of mainly small studies, this review further concludes that the balance of available evidence is in favour of upper limb exercise NMES offering benefits such as increased muscle strength, range of motion and function in children with CP. The use of dynamic splinting with NMES has been shown to be more effective than either treatment on its own in improving function and posture. There is at present little published work to support the application of botulinum toxin type A to temporarily reduce muscle tone as an adjunct intervention to NMES in this population, although the presence of parallel applications to manage similar symptoms in other muscular disorders is noted.

Surface electromyographic activity of five residual limb muscles recorded during isometric contraction in transfemoral amputees with osseointegrated prostheses.

BACKGROUND: Femoral osseointegrated implants represent a new development in amputee rehabilitation, eliminating socket pressure discomfort, improving hip range of movement and facilitating prosthetic limb attachment. A clinical aspect that has not previously been reported on is the function of muscles in the residuum with implications concerning energy expenditure, hip-hiking and viability of the electrogram as a myoprocessor. Typically, amputees fitted with osseointegrated fixation have shorter residuums and weaker attachment of cleaved muscles. Function of muscle can be assessed by surface electromyography through changes in amplitude and median frequency of the signal. METHODS: Five male transfemoral amputees with osseointegrated fixations participated together with a control group comprised of ten adult males. Electrodes recorded surface electromyographic activity of five residual limb muscles or left lower limb muscles of control subjects. Isometric contractions were performed against resistance. The increase in mean rectified amplitude from resting to maximally contracting was calculated and median frequencies estimated. FINDINGS: The amputees were unable to maintain a maximum voluntary contraction of constant amplitude. Amplitude increase was lowest for rectus femoris and adductor magnus. The median frequency of adductor magnus was significantly greater (P=0.02) for the amputees than intact subjects and there was a significant difference (P<0.01) between gluteus maximus and adductor magnus for amputee subjects. INTERPRETATION: High electromyographic amplitude variability suggests that using residuum muscles singly as a myoprocessor might be challenging. Adductor magnus displayed a different sEMG profile compared to intact subjects indicating decreased function and neuromuscular changes. Further work into optimal muscle anchorage is required to ensure maximal mechanical performance.

The effect of neuromuscular electrical stimulation on congenital talipes equinovarus following correction with the Ponseti method: a pilot study.

The Ponseti method for clubfoot treatment offers satisfactory initial correction, but success correlates with abduction brace compliance, which is variable. Electrical stimulation as a dynamic intervention to prevent relapses was investigated. Data were compared to a control group. There was a significant improvement in ankle range of motion only in the study group after short-term intervention, and a trend toward greater increase in calf circumference in this group. Parental perception was positive with no compliance issues. This study suggests stimulation is feasible with potential to increase ankle range of motion and facilitate muscle activity. It could be an important adjunct in preventing relapses, however, further studies with larger groups and longer intervention and follow-up duration are necessary.

Intraobserver reliability of static measures in the normally developing infant foot and clubfoot.

Static measures data for infants are used in clinical practice and studies without published reliabilities. Intraobserver reliabilities for static measures were assessed in normally developing feet and clubfeet. Coefficient of repeatability was used for reliability. Variability in reliability was found. Ankle dorsiflexion, calf circumference and foot length were considered to be reliable in both groups. Foot width was considered unreliable and reliability for ankle plantarflexion knee flexed or extended does not seem to justify its use clinically. These results suggest that ankle dorsiflexion, calf circumference and foot length are reliable measures in infants and can be used for study conclusions and clinical decisions.

An evaluation of patient perceptions to the value of the gait laboratory as part of the rehabilitation of primary lower limb amputees.

The value of gait analysis for research and product development/evaluation in prosthetics is well understood. However, in the rehabilitation of amputees, the application of gait analysis beyond observation in the clinical setting is not routinely practiced, largely due to the cost and time taken to complete a fully instrumented data collection and analysis. To address the time issue, a weekly clinical gait service for primary amputees, based around a reduced data set from video and video vector technology, has been developed. In this clinic primary amputees are seen twice in the Gait Laboratory during their rehabilitation period, with the clinic time for each patient being no more than 15 minutes, which covers both data collection and review. A questionnaire was developed to evaluate the patients' perceptions of the clinic. The questionnaire was completed anonymously by 48 primary amputees over a 6-month period. The results from the questionnaire demonstrate that the clinic was perceived positively by the patients, and suggested areas of future development, e.g. the education of junior staff, and the need to include the patient's physiotherapist in the data collection and review process.

Assessment and validation of a simple automated method for the detection of gait events and intervals.

A simple and rapid automatic method for detection of gait events at the foot could speed up and possibly increase the repeatability of gait analysis and evaluations of treatments for pathological gaits. The aim of this study was to compare and validate a kinematic-based algorithm used in the detection of four gait events, heel contact, heel rise, toe contact and toe off. Force platform data is often used to obtain start and end of contact phases, but not usually heel rise and toe contact events. For this purpose synchronised kinematic, kinetic and video data were captured from 12 healthy adult subjects walking both barefoot and shod at slow and normal self-selected speeds. The data were used to determine the gait events using three methods: force, visual inspection and algorithm methods. Ninety percent of all timings given by the algorithm were within one frame (16.7 ms) when compared to visual inspection. There were no statistically significant differences between the visual and algorithm timings. For both heel and toe contact the differences between the three methods were within 1.5 frames, whereas for heel rise and toe off the differences between the force on one side and the visual and algorithm on the other were higher and more varied (up to 175 ms). In addition, the algorithm method provided the duration of three intervals, heel contact to toe contact, toe contact to heel rise and heel rise to toe off, which are not readily available from force platform data. The ability to automatically and reliably detect the timings of these four gait events and three intervals using kinematic data alone is an asset to clinical gait analysis.