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com
Review
1Department of Clinical
Sciences and Medical
Engineering, Salisbury District
Hospital, Salisbury, Wiltshire,
UK
2Douglas Bader Rehabilitation
Centre, Queen Mary’s
Hospital, Roehampton,
London, UK
3Centre for Biomedical
Engineering, University of
Surrey, Guildford, Surrey, UK
4 School of Design, Engineering
and Computing, University of
Bournemouth, Bournemouth,
Dorset, UK
Correspondence to
Dr Philip Wright, Department
of Clinical Sciences and
Medical Engineering, Salisbury
District Hospital, Salisbury,
Wiltshire SP2 8BJ, UK;
philip.wright@salisbury.nhs.uk
Accepted 7 September 2011
364
Neuromuscular electrical stimulation for children
with cerebral palsy: a review
Philip A Wright,1 Sally Durham,2 David J Ewins,2,3 Ian D Swain1,4
ABSTRACT
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.
INTRODUCTION
Electrical stimulation is not a new technique. It
dates back to the Ancient Greeks who used rubbed
amber and torpedo fish to produce a number of
physiological responses, primarily to cause muscu-
lar contractions. Its development followed advances
in physics by Volta and Faraday during the 18th and
19th centuries which led to more reliable, control-
lable sources of electricity, as well as advances in
neurophysiology as a result of the work of Galvani
and Duchenne. Following this, various researchers
showed that denervated muscles only responded
to stimulation by connecting and disconnecting a
direct current source and not to alternating current.
However, in upper motor neuron conditions, such
as cerebral palsy (CP), it was found that muscle con-
traction may result from stimulation of an intact
motor neuron by an alternating current.
There are a number of different types of electri-
cal stimulation ranging from low-level stimulation,
such as that used for pain relief, transcutaneous
electrical nerve stimulation (commonly known as
TENS) and threshold electrical stimulation where
there is no activation of the muscle, to neuromus-
cular electrical stimulation (NMES) where there
is an actual muscle contraction. This last type of
Arch Dis Child 2012;97:364–371. doi:10.1136/archdischild-2011-300437
electrical stimulation, NMES, is the subject of this
review and can either be used cyclically as an exer-
cise, or linked to a functional goal where it is usually
known as functional electrical stimulation (FES).
NMES has been used to treat a wide range of clini-
cal conditions. Readers can consult the web sites of
the International Functional Electrical Stimulation
Society (www.ifess.org) and the International
Neuromodulation Society (www.neuromodula-
tion.com) for additional information.
The vast majority of NMES research has been
directed at adults with disabilities resulting from
a wide range of neurological conditions affecting
the upper motor neuron system, including stroke,
multiple sclerosis, spinal cord injury and head
injury. Nevertheless, there is a growing body of
evidence supporting the application of NMES for
children with CP.1–4
The aim of this review is to present a succinct
clinically oriented evaluation of the current evi-
dence base underpinning the use of NMES treat-
ment regimes to improve gait or upper limb function
in children with CP. In addition, specific consider-
ation is given to the use of NMES alongside the use
of adjunct orthotic interventions and local injection
of botulinum toxin type A (BTX-A). While four
lower limb reviews have been published to date in
MEDLINE-cited journals on the use of NMES for
CP, only Kerr et al1 and Merrill3 have also reviewed
concurrently the important topic of upper limb
applications of NMES. The present review is timely
because a number of studies relevant to the scope of
this paper were not analysed in the reviews by Kerr
et al1 5–25 or Merrill.3 6 9 11 14 16–18 23 26–28 Moreover,
the nature of this review as being a succinct clini-
cally oriented analysis differs from Merrill’s review,
which was a preface to an extended discussion of
potential future technological developments.
METHODS
A search for English language articles was con-
ducted on MEDLINE using the terms ‘electrical
stimulation’ and ‘CP’. This literature was comple-
mented with appropriate cross-referenced articles.
Given editorial constraints, only articles that the
authors considered to be of major interest or rel-
evance were included.
NMES for gait improvement
We can consider the application of NMES to the
lower limb of children with CP under four headers:
▶ NMES applied for exercise.
▶ NMES applied during gait cycle.
▶ Combined use of NMES and BTX-A.
▶ Developments in percutaneous and implanted
electrical stimulation.
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Much of the literature on the application of NMES both as
exercise and during the gait cycle has been reviewed extensive-
ly.1 4 Kerr et al1 concluded that many studies recorded improve-
ments in strength and function, but these often had limited
statistical power. In addition, they suggested there was a need
for further work with more rigorous study designs and fol-
low-up, larger sample sizes and homogeneous patient groups.
The meta-analyses conducted by Cauraugh et al4 demonstrated
that electrical stimulation produced ‘medium effect’ sizes on
gait outcomes. They considered that their fi ndings corrobo-
rated earlier work by Kerr et al1 and Hazlewood et al. 26
A subsequent review of FES for gait assistance also noted
that further research on stimulation protocols was needed to
provide clinically relevant results. 2 There has, however, been
relevant work published in this area which was not included in
these reviews or which given the purpose of this paper merits
further amplification. All the papers reviewed are summarised
in table 1.
NMES applied for exercise
Improvements in hamstring spasticity and lower limb
function, 5 and quadriceps–hamstring co-contraction,19 have
been recorded through an extended period of quadriceps
exercise stimulation. Khalili and Hajihassanie18 also found
improvements in hamstring spasticity (and passive knee exten-
sion) when stimulation of the quadriceps was added to a pas-
sive stretching regime, however, they considered the change
for the experimental group as a whole not to be clinically rel-
evant. They concluded that the marginal size of the effect may
be due to the short duration (30 min, three times per week
for 4 weeks) and relatively low-intensity regimen investigated,
and that larger sample sizes are required. Stackhouse et al20
investigated the effects of strength training using percutane-
ously implanted stimulation to quadriceps femoris and triceps
surae. In this preliminary study, greater increases in norma-
lised force production were seen in both muscle groups when
compared with results from a group undertaking volitional
training only. An improvement in walking speed in the stimu-
lation group was also noted.
In addition to quadriceps stimulation, stimulation to glu-
teus medius bilaterally has been shown to result in a signifi-
cant improvement in gait temporal spatial parameters and in
hip adductor tone.6 Stimulation was applied during the gait
cycle so in that sense it was used functionally, but it was not
synchronised with stepping. These individual studies seem
to support the conclusions reached in the review by Kerr
et al1 and echoed by Cauraugh et al4 that many studies recorded
improvements in strength and function.
The use of NMES to strengthen lower limb muscles and
increase range of motion, and the resultant effect of this on gait
has also been investigated. 21 26 29 Stimulation was not applied
during a functional task in these studies, and any changes in
range of motion and strength did not result in improvements
in walking pattern. Some authors have suggested that it may
be more effective to combine NMES with task-specific or func-
tional training. 30
NMES applied during gait cycle
The two main approaches reported using NMES during walk-
ing to improve swing dorsiflexion have been largely contradic-
tory, either targeting the anterior tibial muscles during swing
or conversely the calf muscles during stance phase. In some
other cases, both muscle groups have been recruited, mim-
icking neural fi ring patterns. Van der Linden et al22 reported
Arch Dis Child 2012;97:364–371. doi:10.1136/archdischild-2011-300437
Review
statistically significant improvements in peak dorsiflexion
in swing and in foot–floor angle at initial contact through
stimulation of the dorsiflexors in swing. Furthermore, clini-
cally significant improvements in dorsiflexion during swing
and at initial contact were seen in three of five children while
stimulation was being applied to the dorsiflexor muscles in
individually tailored programmes of NMES during walking.7
Nevertheless, equivocal results were observed in the remain-
ing three children in this study who received stimulation for
both ankle dorsiflexion during swing and knee extension (dur-
ing swing or stance as appropriate).7 Another study described
an immediate effect of applying percutaneous intramuscular
NMES in eight children with CP.8 The authors reported a
trend towards improved ankle kinematics while stimulation
was applied to tibialis anterior during swing. However, they
observed statistically significant outcomes when calf stimula-
tion during stance was added. This was presumed to be due to
improved coordination of muscle activation and sensory feed-
back provided by stimulation to the muscles around the joint at
the appropriate time during the gait cycle. These small studies
have concentrated on the immediate changes seen on apply-
ing stimulation functionally. Longer-term changes such as
improvements in the asymmetries of temporal spatial data fol-
lowing stimulation of the anterior tibial muscles during swing
in children with hemiplegic CP have also been investigated. 23
Plastic changes occurring in response to a repeated stimulus
are suggested as the mechanism for this ‘motor learning’.
Other investigators report positive effects on swing phase
kinematics following stimulation of the calf muscles (figure 1).
The rationale for targeting the calf muscles for a duration
slightly longer than the stance phase is based on the premise
that stimulation has the potential to: interrupt the constant
state of activity in the spastic gastrocnemius; allow reciprocal
inhibition of tibialis anterior; generate a stretch reflex to the tib-
ialis anterior; and strengthen the weak calf muscle. 27 Further,
assuming a potential for motor relearning, these changes may
be maintained after the intervention period. Case studies by
Carmick reported improvements in selective control, range of
active dorsiflexion and foot position at initial contact during
and following prolonged periods (3–12 months) of stimulation
of the calf during stance combined with gait training. 31 32 In
addition, increased dorsiflexion at initial contact was observed
following both calf stimulation during stance, and calf stimu-
lation with anterior tibial muscle stimulation during swing,
in a group of 14 children. 27 Defi nitive studies still need to be
undertaken in this area, but the review by Seifart et al2 would
suggest that stimulation of the gastrocnemius with or with-
out tibialis anterior may effect greater gait improvements than
stimulating the tibialis anterior alone.
Combined use of NMES and BTX-A
BTX-A, acting as a neuromuscular junction block, can reduce
tone and offer a time window in which NMES may be used to
stretch the agonist and strengthen the antagonist muscles in
children with spasticity.7 Table 2 gives details of studies inves-
tigating what benefit, if any, can be offered by introducing an
NMES regime post injection of BTX-A in the lower limb of
children with CP.
Some authors have concluded that combined BTX-A and
NMES is not superior to BTX-A alone for the treatment of
equinus in CP.9 However, others have found NMES offered
some benefits over BTX-A in early improvement of range of
motion and maintenance of gait improvement in dynamic
equinus.10 There were similarities in terms of muscles injected
365
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Review
and review protocols; however, as shown in table 2, there were
differences in the stimulation regime. The effect of NMES on
the injected muscles with stimulation timed to the walking
cycle in three children who started NMES at different intervals
post injection has also been investigated.11 NMES was found
to improve isometric plantarflexor muscle strength, but did not
produce changes in self-selected walking speeds or isometric
dorsiflexor muscle strength. These results also suggested that
starting NMES 32 days post injection was most effective in
this small study.
Further investigation is required to establish if NMES is a
valuable adjunct to BTX-A, and if so, what regimes should be
used and when should they start.
Developments in percutaneous and implanted electrical
stimulation
Most reported NMES work has involved surface electrodes,
that is, electrodes placed on the skin. This approach is non-inva-
sive, but it has the following limitations: accurate placement of
electrodes, isolation of a response from specific muscles, the
need for sensory tolerance and a practical limit on the number
of channels that can be used at a given time. 33 Therefore there
has been interest in the use of percutaneous and implanted
stimulation systems. Several authors have successfully used
percutaneous lower limb muscle stimulation in children with
CP.8 12 24 33 In one single case study,12 greater improvements in
dorsiflexion were found with percutaneous than with surface
stimulation (eg, mean increase of 10.6° in peak dorsiflexion dur-
ing swing with percutaneous stimulation and 4.6° with surface
stimulation when compared with the no stimulation condi-
tion). The authors found that (sagittal plane) ankle absorption
work decreased during the gait load phase with both types of
stimulation, but that ankle generation work was increased only
with percutaneous stimulation. In a recent review of NMES in
CP, potential limitations of percutaneous stimulation systems
were noted, including that the leads present a persistent infec-
tion route and that they may also wear and break, requiring
additional surgical interventions. 3 Although not reported in
the studies previously mentioned, these are important issues,
and restrict the use of these systems outside of research stud-
ies. An implanted system may offer a solution to the problems
presented by both surface and percutaneous systems, and an
approach for a fully implanted stimulator that may be appro-
priate is also outlined in that review. 3
NMES for restoration of upper limb function
There are fewer reported applications of NMES to the upper
limb of children with CP than the lower limb. We can consider
these under three headers:
▶ NMES to assist with muscle strength and function.
▶ Combined use of NMES and orthoses.
▶ Combined use of NMES and BTX-A.
NMES to assist with muscle strength and function
The fi rst case studies to demonstrate the feasibility of applying
NMES to the upper limbs of children with CP were reported
in the early 1990s. 28 34 Functional improvements such as
increased awareness and spontaneous use of the impaired arm
and hand, and enhanced grasp and release abilities were also
reported. 34 Nevertheless, they presented insufficient evidence
to reach a judgement on the general applicability of NMES for
the upper limb of children with CP. Further details of these
and other papers reviewed in this section are given in table 3.
In the fi rst report on the application of cyclic NMES as a
single intervention to the upper limb of a group of children
366
with CP, cyclic NMES was applied to the wrist extensor
muscles of eight children with hemiplegic CP. 35 Statistically
significant improvements in hand function and active wrist
extension were measured, although no significant changes
were observed in measurements of wrist extension moment.
These authors also included anecdotal comments from the
children and their parents, such as an increased awareness of
the limb, improved coordination of both hands used together,
or greater proficiency in carrying out tasks that required grasp
and release activity and hand manipulation which were con-
sistent with those of an earlier case report. 34
In a subsequent study, cyclic NMES was applied recipro-
cally to wrist flexor and extensor muscles of a group of eight
children with CP using a rationale similar to that previously
discussed in the lower limb example of stimulation of ankle
dorsiflexors and plantarflexors.13 The children were specifi-
cally asked to work with the NMES as it initiated movement.
Statistically significant improvements in active wrist exten-
sion were demonstrated (as in the previous study) 35 but also
in wrist extension moment. The authors concluded that a pos-
sible mechanism of NMES improving wrist extensor muscle
strength was through decreased flexor coactivation, noting
that a trend toward reduced coactivation of flexors and exten-
sors was observed in six children.
In a further study on the effect of reciprocal NMES of
wrist extensors and flexors of nine children with CP, thera-
pists maintained the wrist in an extended position, offering
manual resistance while children were encouraged to ‘com-
pete’ with the therapist.14 Significant increases in wrist exten-
sor and flexor strength were measured while the wrist was
maintained in an extended position. The wrist extensors also
demonstrated significant increases in strength in neutral. No
significant changes in passive stiffness of wrist flexors, hand
function or mean wrist angle during manual tasks was mea-
sured, possibly because the intervention may not have been
sufficiently prolonged or aggressive. The authors suggested
that the intervention had resulted in a shift of the wrist exten-
sor length–tension curve.
These studies lend mounting support to the premise that
NMES may assist with muscle strength and function in the
upper limb of children with CP and additional benefits may
occur when children also attempt to complement NMES with
volitional movement. However, the comment that previous
reviewers have made still applies; there is insufficient statisti-
cal power to provide conclusive evidence of this.1
Combined use of NMES and orthoses
In the fi rst case report of NMES used in combination with an
orthosis, a child who had previously used NMES was sup-
plied with a dorsal wrist splint made out of orthoplast that
maintained 10° of wrist extension and helped provide wrist
stability. 36 After 9 months of wearing the splint, supplemented
by weekly NMES sessions, the splint was discontinued as the
child could maintain hand function without it. Details of this
and other papers reviewed in this section are given in table 4.
Following this, a retrospective study was published on 19
children and young adults with CP who took part in a clinical
programme involving 1 h per day of NMES with an orthotic
intervention known as dynamic splinting (DS).25 In DS, a
restorative force is applied by an orthosis often by means of
a variable tension spring loaded hinge (figure 2). In this case,
NMES was applied to achieve wrist and fi nger extension while
DS promoted extension of the wrist and elbow joints. A static
splint was worn during the night to prevent wrist flexion.
Arch Dis Child 2012;97:364–371. doi:10.1136/archdischild-2011-300437
 Table 1 Details of studies in neuromuscular electrical stimulation to assist with muscle strength and function (lower limb) section
Age range
Reference Study design (years) n Muscles stimulated Results Session duration, frequency and mode

Daichmann et al5 Case study 13 1 Right QR Increase in right QR strength, decrease in right HS spasticity, improvements Approximately 30 min every other day for 6 weeks.
in mobility elements of PEDI results Exercise only
Al-Abdulwahab et al6 Pre/post test design. 7.4±2 21 GM bilaterally ↑↑Temporal spatial parameters (apart from step width) and ↓↓hip adductor 15 min three times per day for 7 days. Stimulation applied
Data compared with tone of the treated group mainly during walking but not timed to the gait cycle
healthy (n=20) and
control CP (n=10)
groups
Postans and Granat7 ABAB 8.9–17.5 8 DF, PF, QR (determined For NMES to AF only group (n=5), clinically significant changes in stance Used functionally during testing on 2 days
through gait analysis) phase kinematics for three children
Orlin et al8 AB 7.9–11.8 8 Percutaneous ↑*Peak DF in swing (more affected extremity) and DF at initial contact (less Used functionally for 1 week for each NMES set up (TA only,
stimulation of TA and affected extremity) for TA+GA condition. Trends of improvement in DF TA and GA, and GA only) for approximately 2 × 45 min daily.
GA of involved limb kinematics seen for TA and GA only conditions Four-channel and two-channel stimulation used for diplegic
and hemiplegic children, respectively
Pierce et al12 Comparison of surface 11 1 DF with balanced Increases in DF at initial contact, peak in swing and mean in swing, greater Assessed functionally during walking (one test day)
and percutaneous eversion and inversion with percutaneous stimulation. Ankle absorption work improved (decreased)
stimulation with both types of stimulation. Ankle generation work increased only with
percutaneous stimulation. Greater isometric force produced with
percutaneous than surface stimulation

Arch Dis Child 2012;97:364–371. doi:10.1136/archdischild-2011-300437

Khalili and Randomised (within 11.6–14 11 QR Marginal improvement in HS spasticity and passive knee extension 30 min three times per week for 4 weeks. Exercise only
Hajihassanie18 child), one child
dropped out
Katz et al19 Case controlled 2.8–4.1 5 Right QR (Seated tests) ↑average motion velocity and a decrease in motion jerk and in 30 min daily for 3 months. Exercise only. Stimulation also
knee torque after training; ↓QR–HS co-contraction following training, but not used orthotically during tests
during stimulated assisted motion
Stackhouse et al20 Group comparisons. 8–12 11 Percutaneous ↑TS maximum voluntary isometric contraction normalised to body weight for 15 min for each muscle group, three times per week for 12
NMES (n=6); volitional stimulation of QS and TS NMES group compared with volitional group, ns for QS. ↑Walking speed for weeks. Exercise only
control (n=5); one child NMES group, ns walking speed for volitional group following intervention
in NMES group
excluded from analysis
Kerr et al21 Randomised (NMES 5–16 60 QR (vastus medialis) For NMES: ns in strength or function compared with placebo; ↓impact of NMES: 1 h daily 5 days per week for 16 weeks.
n=18; placebo n=22; bilaterally disability at end of treatment (not at 6-week follow-up) Exercise only
and TES n=20)
Van der Linden et al22 Randomised (NMES 5–13 14 DF with balanced ↑Peak DF angle and foot–floor angle for both groups when comparing walking NMES: 1 h daily to either DF (n=5) or QS (n=2) 6 days per
n=7; control n=7); one eversion and inversion with and without FES. ↓Walking speed for both groups when comparing week for 2 weeks. Exercise only. Followed by FES of DF and
child (NMES group, QS) and QR walking with and without FES; ns between NMES and control groups in QR during gait for 8 weeks.
dropped out deviation of gait pattern from normal, foot–floor angle, DF in swing angle, or Stimulation also used orthotically during tests for both NMES
passive DF when comparing before and after intervention results and control groups
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Durham et al23 ABA, two children 6–15 12 DF Heel–toe contact pattern and symmetry both improved following intervention FES of DF during gait for 12 weeks
dropped out with FES (no statistical analysis)

Johnston et al24 Group comparisons. 6–12 17 BF, GM, Gmax, PAM, VL, ns differences in passive range, temporal spatial parameters or gross motor 4-week (minimum) exercise for no more than 1 h per day,
NMES with limited sur- VM, Sol, TA (not all used function between groups before or 1 year after intervention. FES group followed by functional use
gery (n=9); traditional in all children) underwent 4.5 fewer ablative procedures per child
surgery (n=8)

Hazlewood et al26 Randomised (NMES 5–12 20 TA of involved limb ↑Passive DF in NMES group. ↑Active DF in NMES group compared with 1 h daily for 35 consecutive days. Exercise only
n=10; control n=10) control group post intervention but not pre intervention. ↑TA muscle
power in NMES group
Review

continued

367
 Continued

368
Table 1

Age range
Reference Study design (years) n Muscles stimulated Results Session duration, frequency and mode
Review

Comeaux et al27 ABCA (n=7), 9.1±3.8 14 GA and TA ↑*DF during gait for both ‘targeted’ FES interventions ‘Targeted’ FES of GA during 15-min therapy session three
ACBA (n=7) times a week for 4 weeks followed/preceded by a similar
programme with GA and TA
Van der Linden et al29 Randomised (NMES 8.5±2.8 22 GMax For NMES: ns in hip extensor strength, gait analysis, passive limits of hip NMES: 1 h a day 6 days per week for 8 weeks.
n=11; control n=11) rotation, section E of gross motor function measure when comparing NMES Exercise only
group with control group
Carmick31 Case series 1.6–10 3 TA, TS, GA, Sol, Gmax, HS Improvements in physiological cost index measured in two children Approximately weekly sessions of unspecified duration of
(not all used in all patients) together with observations of improved gait function and symmetry ‘targeted’ FES for between 6 weeks and 8 months
Carmick32 Case series 1.7–4.7 4 TA, TS, Gmax, HS (not all Improvements in heel strike, foot alignment, function, balance, active and passive Unspecified frequency and duration of ‘targeted’ FES
used in all patients) DF range of movement and walking speed. (Not all observed in all children) sessions as required
Bertoti et al33 Case series percutane - 6 2 Gmax, GM, VM, VL, GA, Measured improvements in lower extremity ranges of motion, spatial gait Two 15-min sessions of FES 5 days per week for between
ous stimulation TA characteristics, improved gross motor function 7 and 10 months. Children asked to ‘work with’ FES
Skin surface electrodes used unless stated otherwise.
↑↑, ↑, ↑* indicates statistically significant (p<0.001, p<0.05 and p<0.0055, respectively) increase; ↓↓ and ↓ indicates statistically significant (p<0.001 and p<0.05, respectively) decrease; ns indicates no statistically significant
difference (p>0.05); ± indicates plus or minus one SD.
AB, baseline-intervention; ABC, baseline-intervention1-Intervention2; ABAB, baseline1-intervention-baseline2-intervention; ABA, baseline-intervention-follow-up; ABCA, baseline-intervention1-intervention2-follow-up; AF, ankle flexors;
BF, biceps femoris; CP, cerebral palsy; DF, dorsiflexion; FES, functional electrical stimulation; GA, gastrocnemius; GM, gluteus medius; Gmax, gluteus maximus; HA, hip adductors; HS, hamstrings; NMES, neuromuscular electrical stim-
ulation; PAM, posterior adductor magnus; PEDI, pediatric evaluation of disability inventory; PF, plantarflexion; QR, quadriceps; Sol, soleus; TA, tibialis anterior; TES, threshold electrical stimulation; TS, triceps surae; VL, vastus lateralis;
VM, vastus medialis.

intervention.
improvements.

ful for further work.

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Centre, Salisbury District Hospital, Salisbury, UK).

electrical stimulation to stimulate right gastrocnemius muscle

Stimulator (Odstock Medical Limited, The National Clinical FES

vention will be necessary to maintain any clinical gains.

Figure 1 Surface electrodes positioned to apply neuromuscular

activity. The electrodes are connected to an Odstock Dropped Foot

Participants also demonstrated improvements in quality of

onstrate a greater impact on upper limb function in children

the same research group in order to determine whether the

DS, its use was investigated in six children with CP with fi xed
ture were observed only in the group receiving the combined

NMES and DS was shown to be feasible and there was good

ular review and an ongoing programme of the combined inter-

NMES with DS may be appropriate for improving function,
tion that incorporated assistance with supination could be use-
tistically significant improvements in hand function and pos-
applied for 1 h per day). Over the 6-month intervention sta-
of either intervention alone.15 Twenty-four children with CP
combined use of NMES and DS was more effective than use

spastic hemiplegic CP. The literature to date suggests that reg-

strength and hand posture in the upper limb of children with
There is strong evidence that the clinical application of
and metacarpophalangeal joints), or DS with NMES (each
A randomised trial was carried out by some members of

from the intervention. A combined NMES and DS interven-

the main reasons why some children failed to benefit more
involved identified that difficulty with supination was one of
who were treated for wrist contractures. However, clinicians
participant compliance. The intervention appeared to dem-
contractures at the wrist or elbow.16 The combined use of
In a more recent study on the combined use of NMES and
were allocated randomly to three groups: NMES, DS (wrist
improved their Zancolli classification by two grades or more. 37

the authors noted that continued application of the interven-

movement and better control and use of their hand. However,

tion, albeit less intensively, was necessary to maintain these

Arch Dis Child 2012;97:364–371. doi:10.1136/archdischild-2011-300437

Following at least 3 months of intervention, most participants
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Review

Table 2 Details of studies in combined use of neuromuscular electrical stimulation and botulinum toxin type A (lower limb) section
Age range Muscles Results (differences Session duration,
Reference Study design (years) n stimulated BTX-A sites with NMES) frequency and mode

Detrembleur et al9 Controlled (control n=6; 4.75–6 12 Soleus Soleus and medial and For a range of clinical and 30 min six times a day
NMES group n=6) and GA lateral GA. HA in 7 gait variables, combined for 3 days, beginning on day
patients treatment not superior to BTX-A of treatment with BTX-A.
(3 NMES and 4 control) alone at 1, 3 and 6 months post Exercise only
BTX-A injections
Kang et al10 Controlled (control n=11; 1.3–10 18 GA Soleus and medial and ↑#Passive ankle ROM after 2 30 min twice a week for
NMES group n=7) lateral GA. HS and PT in weeks in NMES group only 2 weeks, immediately
two children (in both groups at 3 months). postinjection. Exercise only
↑#Total PRS and foot equinus
scores in NMES group at
3 months after injection
Seifart et al11 Single child 3.3–6.3 5 TA and GA ‘Calf’ muscles Two children did not use 30 min 5 days a week for
NMES. Trend towards 4 weeks. Used function-
increased isometric PF muscle ally—timed to foot switches.
strength. No changes in self- Five different start times
selected walking speeds or used: 3, 7, 14, 32 and 35
isometric DF muscle strength days postinjection

Skin surface electrodes used unless stated otherwise.

↑#Indicates statistically significant (p<0.01) increase.
BTX-A, botulinum toxin type A (lower limb); DF, dorsiflexion; GA, gastrocnemius; HA, hip adductors; HS, hamstrings; NMES, neuromuscular electrical stimulation; PF, plan-
tarflexion; PRS, physician rating scale; PT, posterior tibial muscles; ROM, ranges of motion; TA, tibialis anterior.

Table 3 Details of studies in neuromuscular electrical stimulation to assist with muscle strength and function (upper limb) section
Study Age range Muscles Session duration and
Reference design (years) n stimulated Results frequency

Kamper et al13 ABC 5–15 8 Wrist flexors and ↑ROM, ns spasticity, ns passive 15–30 min daily for 3 months
extensors resistance, ↑wrist extensor strength,
ns coactivation
Vaz et al14 Pretest/post-test 7–11 9 Wrist flexors and ↑Wrist extensor and flexor strength, Three sessions per week
design extensors ns passive resistance wrist flexors, (unspecified duration) for 8 weeks
ns function of resisted exercises in extended
wrist range with NMES as adjunct
stimulus
Atwater et al28 Case series* 11 and 12.5 2 Wrist extensors ns function, ns ROM, ns overall motor As part of a 20 min intervention
development three times a week for 8 weeks
Carmick34 Case series 1.6 and 6.7 2 Anterior deltoid, shoulder Improvements in function, awareness Weekly to twice weekly,
flexors, triceps brachii, and spontaneous use of impaired unspecified duration sessions of
wrist extensors, finger upper limb described ‘targeted’ FES for between 6 weeks
flexors, thumb extensors, and 6 months
thumb abductors (not all
used in both patients)
Wright and Granat 35 ABA 5–15 8 Wrist extensors ↑Function, ↑ROM, ns wrist extension 30 min daily for 6 weeks
moment

↑Indicates statistically significant (p<0.05) increase; ns indicates no statistically significant difference (p>0.05).
*The two children who received upper limb NMES were a subgroup of 10 children in Atwater’s study. Although this study was not a case study, the subgroup results for
these children have been considered as such for the purposes of this review section.
ABA, baseline-intervention-follow-up; ABC, baseline-intervention1-intervention2; FES, functional electrical stimulation; NMES, neuromuscular electrical stimulation; ROM,
ranges of motion.

Combined use of NMES and BTX-A
This review identified only one pilot study that considered the
combined effect of NMES and BTX-A on the impaired upper
limb of 10 children with CP.17 Significant improvement in
hand function and non-significant changes in spasticity and
active wrist range of motion were reported. Clearly more work
is required to determine the efficacy and the optimal condi-
tions under which NMES and BTX-A may be applied to the
upper limb of children with CP.
DISCUSSION
The earlier review by Kerr et al1 provided limited evidence to
support the use of NMES during gait. The recent meta-anal-
ysis conducted by Cauraugh et al4 corroborates the fi ndings
by Kerr et al and cautiously advocates the use of electrical
stimulation (applied as either a lower limb exercise regime
or as a functional intervention) to minimise impairment
and activity limitations during gait. It is however prescient
to note that the changes seen in lower limb studies have
not always translated to improvements in gait. Most lower
limb NMES applications focus on tibialis anterior stimula-
tion either with or without gastrocnemius stimulation. This
review article has provided a detailed commentary on this
work. While it is certainly the case that positive effects of
tibialis anterior stimulation with or without gastrocnemius
stimulation have been identified, there is as yet insufficient
evidence to establish best practice guidelines. It is necessary
for larger scale randomised prospective trials to be under-
taken in order to inform such guidelines. It is recommended
that the estimates of sample sizes in the work by van der

Arch Dis Child 2012;97:364–371. doi:10.1136/archdischild-2011-300437 369

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Review

Table 4 Details of studies in combined use of neuromuscular electrical stimulation and orthoses section
Age range Muscles Orthoses Duration and frequency
Reference Study design (years) n stimulated applied Results of orthosis and NMES use

Ozer et al15 Randomised trial 3–18 24 Wrist extensors Dynamic splinting to promote ↑Function, ↑grip strength, 1 h daily for 6 months
elbow and wrist extension. Static ↑posture (Zancolli)
splint worn at night to prevent
wrist flexion
Postans et al16 Case study series 7–16 6 Wrist and elbow Dynamic splinting to promote ns function, ns ROM, ns 1 h daily for 12 weeks
extensors as clinically wrist and elbow extension as quality of life (significant
appropriate clinically appropriate changes unlikely in this
small cohort)
Scheker et al25 Retrospective 3–21 19 Wrist and finger Dynamic splinting to promote 17 children and young 1 h daily for variable lengths
extension elbow and wrist extension. adults improved Zancolli of time
Static splint worn at night to classification by two or
prevent wrist flexion more grades
Carmick36 Case study 7.7 1 Wrist extensors, finger Orthoplast dorsal wrist Improvements in function 9 months wearing splint for
flexors and extensors splint and use of impaired upper 6 h a day with weekly NMES
limb described sessions of unspecified length

↑Indicates statistically significant (p<0.05) increase; ns indicates no statistically significant difference (p>0.05). NMES, neuromuscular electrical stimulation; ROM,
ranges of motion.

offering benefits such as increased muscle strength, range of

Figure 2 A dynamic splint applied across the wrist. Neuromuscular
electrical stimulation is being applied simultaneously to stimulate
wrist extension motion.
Linden et al 22 are considered in the design of such trials. In
the authors’ experience, the most benefit from NMES during
gait can usually be gained when using it as a training tool
after school or at the weekend. The application of NMES
during walking for children with CP is frequently not toler-
ated well by children at school, although exceptions are not
unknown.
It has also been suggested that the use of BTX-A as an
adjunct treatment to NMES may enhance the treatment
effects by temporarily reducing muscle tone. Although the
rational for such an approach is logical, and there are cer-
tainly parallel applications to manage similar symptoms in
other muscular disorders, there is little published work to
support this approach in the lower limb (and almost none for
the upper limb). Further investigation is required to establish
if NMES is a valuable adjunct to the lower limb application
of BTX-A, and if so what regimes should be used and when
they should start. The option of delivering lower limb NMES
by percutaneous electrodes, or even with an implanted stim-
ulator, as outlined by Merrill 3 also remains a possibility.
There are fewer reported applications of NMES to the upper
limb of children with CP than the lower limb and to date no
meta-analysis of these studies has been published. Although
there is a lack of randomised controlled trials, the balance of
available evidence is in favour of upper limb exercise NMES
motion and function in children with CP. In addition, reduced
spasticity has been observed. However, as with lower limb
applications, it appears to be important that NMES is applied
for a sufficient time duration which relates to other literature
on neuroplasticity. 38 Generally, treatment effects are observed
when NMES is applied for 30–60 min per day for at least 6–8
weeks. The overall daily dose can be applied over two or even
three sessions.
Despite the small number of studies, the use of DS with
NMES for upper limb applications has been shown to be more
effective than either treatment on its own in improving func-
tion and posture.15 Patient selection will be important to deter-
mine who will benefit most from DS with NMES but current
evidence suggests that active grip and some release capability
is advantageous.
CONCLUSION
The application of NMES, as an exercise modality or as a
functional intervention, to minimise impairment and activ-
ity limitations during gait is cautiously advocated. In addi-
tion, a growing number of mainly small upper limb studies
tend to support the proposition that the use of NMES as an
exercise regime in the upper limb is also beneficial and can
lead to improvements in both strength and range of motion.
Furthermore, there is evidence to support the combined appli-
cation of NMES and DS in the upper limb. Further research is
however required in all these areas in order to determine best
practice guidelines.
The use of BTX-A as an adjunct treatment to NMES may
enhance the treatment effects by temporarily reducing muscle
tone. Although the rational for such an approach is logical,
and there are certainly parallel applications to manage similar
symptoms in other muscular disorders, there is little published
work to support this approach in the lower limb (and almost
none for the upper limb).
More research is needed to determine whether the applica-
tion of BTX-A acts as a useful adjunct to NMES by temporar-
ily reducing muscle tone and if so what treatment protocols
should be adopted.
Acknowledgements The authors would like to thank Ms Ingrid Wilkinson,
Department of Clinical Sciences and Medical Engineering, Salisbury District
Hospital for proofreading this article.

370 Arch Dis Child 2012;97:364–371. doi:10.1136/archdischild-2011-300437

 Downloaded from adc.bmj.com on June 20, 2014 - Published by group.bmj.com
Competing interest The majority shareholder of Odstock Medical Limited is
Salisbury NHS Foundation Trust. One author (IDS) is Clinical Director of Odstock
Medical Limited.
Patient Consent Obtained.
Provenance and peer review Commissioned; externally peer reviewed.
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Neuromuscular electrical stimulation for

children with cerebral palsy: a review
Philip A Wright, Sally Durham, David J Ewins, et al.

Arch Dis Child 2012 97: 364-371

doi: 10.1136/archdischild-2011-300437

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