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Functional electrical stimulation (FES) for children and young people with cerebral palsy
PERSONAL PRACTICE
Functional electrical stimulation (FES) for children and young people with cerebral palsy
treatment. The service has received 390 paediatric referrals including 245 children with CP. Currently 150 children with CP are receiving treatment and using a FES device making this the largest Paediatric FES service in the UK. The youngest child referred was 2 years old and the current average age of referral is between 7 and 11 years. FES for children is a growing area of interest with increasing evidence and experience but there is a lack of awareness in the many applications of FES as a form of treatment for children. This article aims to share our clinical experience in using FES for children with CP to assist in addressing this knowledge gap.
Christine Singleton Helen Jones Lizz Maycock
What is FES? Functional Electrical Stimulation (FES) uses a small medical device to provide electrical stimulation through the peripheral nervous system to activate muscle contractions to assist in functional activities when nervous or musculo-skeletal systems are damaged. The device operates with a 9 volt battery, uses surface electrodes, connecting wires, a footswitch for activation whilst walking, or a programmed automatic pattern of activation for exercise function. A number of parameters can be adjusted by treating clinicians according to patient requirements. Activity is recorded by the device for patient and clinician information. Technical development of devices has occurred through patient and clinician feedback, from analogue to digital and more recently bluetooth technology. There are a variety of commercial devices which range in price from hundreds to thousands of pounds. FES can be combined in a timely manner with other treatment options such as botulinum toxin injections for spasticity, orthotic devices and lycra splinting for limb support, walking aids for balance and exercise equipment to enhance rehabilitation. There are inclusion and exclusion criteria for electrical stimulation. Not every individual is suitable for FES treatment due to clinical or non-clinical factors.
Abstract Evidence for functional electrical stimulation (FES) as a treatment option in adult neurological conditions has grown over the last 25 years. Children and young people with neurological conditions can also benefit from FES treatments but there are gaps in clinical knowledge, awareness and evidence which need addressing. Some of the known benefits of FES include safe walking with facilitation and exercise of ‘normal’ movement, muscle strengthening, joint range and proprioceptive improvements as well as spasticity reduction. There are similarities but also differences and challenges in applying FES between the adult and paediatric age groups. It is important to recognize these differences together with the need to alter techniques in applying FES for children. Birmingham has the largest paediatric FES service in the UK and the aim of this article is to share our knowledge and experience in providing FES as a treatment option for children and young adults with cerebral palsy.
Keywords cerebral palsy; challenges; CP; differences; FES; functional dropped foot and exercise stimulators; functional electrical stimulation; neurological rehabilitation; treatment options; young people
Introduction
What are the applications for FES?
The Birmingham Functional Electrical Stimulation (FES) clinic is the second largest NHS provider of FES treatment for neurological conditions in the United Kingdom, currently treating 1400 patients. FES has been clinically available since 1994 as a treatment option for people with Multiple sclerosis (MS), stroke (CVA), incomplete spinal cord injury (ISCI), traumatic brain injury (TBI) and adult cerebral palsy (CP) being the main cohorts. Over the last 10 years the service has been accepting children with a variety of neurological conditions for FES
The applications for FES with children are similar to those for adults. The most common application of the FES device is to stimulate dorsiflexor muscles whilst mobilising. This can be unilateral or bilateral. The stimulator is activated on initial swing-through phase of walking to lift the foot into dorsiflexion with slight eversion through to heel strike and mid-stance as illustrated in Figure 1. Control of the ankle foot alignment is important for many neurological patients to prevent falls, trips, catching the foot and unstable ankle positioning on heel strike and mid-stance. In addition, the use of FES can strengthen muscle activity and reduce spasticity of the opposing muscle group, in this case the plantar flexors. Range of movement into dorsiflexion with slight eversion is facilitated thus preventing contractures of the plantar flexors. Confidence in walking in different environments is increased due to improved control and sensory awareness of ankle foot alignment. Effort of walking is reduced due to the flexor withdrawal component of electrical stimulation. This spinal reflex activity assists with hip and knee flexion as well as lateral rotation of the leg and dorsiflexion/eversion of the foot.
Christine Singleton MSc Grad Dip Physiotherapy FES Service, West Midlands Rehabilitation Centre, Birmingham, UK. Conflicts of interest: none declared. Helen Jones Grad Dip Physiotherapy Dip Paed Physio (Advanced) FES Service, West Midlands Rehabilitation Centre, Birmingham, UK. Conflicts of interest: none declared. Lizz Maycock BSc (Hons) Physiotherapy FES Service, West Midlands Rehabilitation Centre, Birmingham, UK. Conflicts of interest: none declared.
PAEDIATRICS AND CHILD HEALTH 29:11
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Ó 2019 Elsevier Ltd. All rights reserved.
PERSONAL PRACTICE
Figure 1 Heel rise to heel strike gait pattern with FES. Reproduced with permission from National Clinical FES Centre, Salisbury.
FES can also be used for exercising various muscles to strengthen, maintain joint range, increase circulation, reduce spasticity and facilitate initiation of muscle activity and to provide a memory of movement. Exercise stimulation can also be used in the acute setting to maintain muscle function and reduce the risk of developing contractures. It may be used following an acute neurological incidence such as an acquired brain injury or following a period of inactivity and deconditioning due to their condition or other incident e.g. trauma. FES can be used for pre and post elective surgery treatment, for example, the multi-level orthopaedic interventions or selective dorsal rhizotomy. Muscle groups treated using FES either for walking or exercise include the quadriceps, hamstrings, gluteal muscles, trunk for core stability, shoulder girdle, biceps, triceps, supinator, wrist and finger flexor and extensor muscles. FES also provides a sensory/proprioceptive awareness of movement and muscle relaxation and can be used where there is neglect or inattention.
Further differences relate to the speed of movement associated with learning to walk and run. Children do not have so far to fall and are less fearful as risk takers. Whilst this is important for their development it can lead to inappropriate walking patterns. Short levels of attention and concentration make it harder for children to change patterns of movement but FES reduces the need to think so hard as it works automatically in walking or as an exerciser. Children accept technology quickly with many of our young children independently operating the device and enjoying being different and ‘cool’ amongst their peers and siblings. Younger children need to understand the device is not a toy and may need to rely on parents to operate it for safety reasons. Whilst parental involvement may add to their already busy schedules the device can assist the parent in ensuring stretches are completed at regular intervals automatically while a child is reading a book, playing on their electronic devices or watching television.
Clinical considerations for applying FES to children
Focusing attention on the upper limb
There are important challenges when providing FES for children compared to adults. The developmental stages of the neurological system, its neuroplasticity and the lack of learned function are the main differences. More frequent FES reviews are necessary due to constant growth and neuro-developmental changes. Children with CP require education of an activity or function they may not have ever experienced or felt. They lack understanding of normal movement patterns which their peers will have refined through daily play and repetition of successful motor activities as they grow. Facilitating normal movement can be difficult for children as the neurological plasticity will adapt and develop around their disability leading to habits of movement which are difficult to change. Many children develop a toe walking pattern which re-enforces shortening of muscles and tendons together with an increase in spasticity from this learned pattern of walking. Muscle atrophy and connective tissue changes are widely reported in children with CP, with research suggesting that muscle size is directly related to mobility and level of physical activity. A flaccid or spastic muscle tone can be treated with FES to provide a repeatable, consistent contraction. This is much harder to achieve if there is a significant element of dystonia, which may exclude FES treatment.
In the early years gaining safe mobility is often the major concern for the parent, however for the child upper limb disability becomes a major barrier to function at home and school. Visible deformity in the upper limb as the child develops can be a major cause of low self-esteem. Our experience has shown FES for the upper limb needs to be part of a coordinated treatment programme in conjunction with lower limb needs.
PAEDIATRICS AND CHILD HEALTH 29:11
Programme of FES treatment The referred child is assessed with the device and if appropriate follows a programme of treatment and support which is modified and mutually agreed with the child and parent/guardian. Education by a Physiotherapist on device operation is provided with instructions booklets and supporting photos of electrode positions for parents and children. FES support is provided between appointments and continues for as long as the person is using the device. Treatment can be for a short time frame or for many years. In the first year of treatment there are usually five face to face treatment sessions and thereafter the treatment is reviewed every six months. The review appointments are to ensure the medical device is fit for purpose with appropriate adjustments
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Ó 2019 Elsevier Ltd. All rights reserved.
PERSONAL PRACTICE
made to the parameters of the device due to changes in the child’s condition or abilities. Young people are encouraged to take control of their rehabilitation and maintain function through self-management with the FES device. Of our current 150 paediatric FES users, 29 patients started treatment with the walking device. A further 87 patients progressed to using the walking device after building tolerance and muscle endurance to stimulation with an exercise device. 34 children only use the exercise device.
Active movement by the child can follow this ‘awakening’ although the muscles will be weak and need further electrical stimulation to improve their physiology. If appropriate, following their assessment, a child is provided with a device to take home; our clinic routinely provides Odstock Medical Limited devices. Full verbal and written instructions are provided for the child’s parent or guardian. An information leaflet for the school is also provided if the child uses their device in class.
Outcome measures
Children aged 7e11 years Children in Primary school years 3e6 often lead packed lives. Physiotherapy exercises and stretches have to compete with busy school, clubs, sport and family schedules. FES offers an opportunity to strengthen muscles whilst eating breakfast, walking to school, watching TV or all of the above. There can be some difficulty with finding precise electrode placement for small muscles in growing children. In clinic, once the correct electrode positions are established, we use marker pens to draw around the electrodes, take photographs and identify landmarks (e.g. two finger widths’ to the left of the shin bone, 1 cm below the large mole etc.) to speed along correct electrode placement at home. A cardboard template may be used to enable swift and precise positioning of electrodes. The FES devices used in Birmingham allows the clinician flexibility of electrode positioning to find the most responsive and comfortable location for stimulation. Regular reviews are required as the electrode position will change with growth and bulking of the muscle being stimulated. In the later years of primary school or with the transition to secondary school, children may feel increasingly self-conscious about their differences from classmates. Visible upper limb splints and AFOs can become disliked and rejected; they can also become uncomfortable due to the child’s rapid growth. FES can be used in combination with some splints or instead of them. There may also be a reduced need for more aggressive clinical interventions such as botulinum toxin injections and prolonged serial casting with the additional benefit of less school hours missed for appointments. The active nature of the FES adds value to the correct positioning of a joint, being achieved dynamically, using the child’s own muscles. There are a variety of ways to ‘wear’ FES devices to keep them as hidden and discrete as possible, although the trend for ‘skinny-fit’ trousers and leggings have made this more difficult. The walking device can be worn in a lycra leg cuff at the shin with short wires connecting to the electrodes and foot switch. Using longer wires hidden under clothing, the FES device can also be worn on a belt, placed in a pocket at the waist, or kept in a bum bag or mobile phone style case. Each child and parent can choose the most convenient way for the child to ‘wear’ their device. There is the option to use the device in a completely silent mode, or to listen to a beep when the machine is turned on/ off or when the power dial is adjusted. If a child feels too self-conscious to cope with the walking device in the school setting, they may choose to use the device only at home or in the community. For some individuals using the exercise-only option at home may be the most they can manage. FES is a significant tool we can offer a child to help meet their physical goals. Like all tools we consider the device to be an adjunct to their wider therapy intervention plan which can be
Outcome measures currently used are: visual analogue scales for: spasticity, frequency of tripping, quality of life, pain on walking, muscle weakness, fatigue passive and active range of movement videoed gait pattern ease of use, or requirement of orthotics frequency of requiring botulinum toxin injections or surgery mobility e including distance walked, use of aids, balance Child Hand Experience Questionnaire Change in frequency of therapy and other medical appointments
Age-related considerations Children aged 2e6 years The initial introduction to using any FES device needs to be in a positive and calm manner using a play therapy approach if required. Young children respond in a variety of ways to their first experience with FES. For some there is an excited laughter when the first buzzing sensation of the ‘tickle machine’ or the first involuntary movement via the ‘magic box’ emerges. Others may become overwhelmed and distressed at the simple application of sticky electrodes on the skin, before the device is even switched on. If a child has sensory processing difficulties they may not be able to tolerate FES. Adapted toys that mimic the device can be used and the child can practice putting the smallest sticky electrodes on and off a parent’s arm or on a doll before trying on their own skin. This reduces the anxiety of the child and the parents. If the child needs longer to adjust to the experience of using the device they can borrow the play equipment for home use. It is useful if a parent can experience the sensation of the stimulation to enable them to understand the sensitivity of the output levels. There is often a good window of opportunity to introduce FES to pre-schoolers who can be encouraged by parents or guardians to cooperate with this exciting new opportunity. Slightly older children may feel intimidated by a clinical setting and be more nervous once they have some concept of electricity. It is essential that sufficient information about the device and its uses is provided to the parent and child before, during and after the assessment so that they can proceed with the electrical stimulation device at home with confidence. Occasionally, on assessment, the device will ‘awaken’ a new movement by producing a muscle contraction that the child has never experienced before. A parent may be heard declaring, “Look at that! She has never moved her foot like that before in her life!”
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Ó 2019 Elsevier Ltd. All rights reserved.
PERSONAL PRACTICE
FES for 15 months and had a review with their orthopaedic consultant. The improvement over 9 months of FES treatment means there is no longer a requirement for surgery or botulinum toxin treatment in the near future. Now able to stand unsupported and has improved gait pattern walking unaided with less effort. The plan is to use the exercise device for the glutei and to progress to using the walking device.
used at any stage of their rehabilitation journey. In some cases it may be appropriate to wait until the child is older and more able to tolerate the sensation and understand the effects of the device. Young people 12e18 years As teenagers continue to grow through puberty, their interest and cooperation with FES can be variable. Enabling young people to take more independent control of their use of FES, and ensuring their autonomy is respected with regards to how and when the device is used is key to maintaining compliance with treatment. An interesting anecdotal finding has been that girls may become particularly sensitive to the sensation of FES during menstruation. It is essential that young people are given the opportunity and privacy to discuss their individual experiences freely with their clinician. The recent addition of a patient-accessible step counter within the PACE walking device can act as a motivational tool for young people to monitor and set daily or weekly targets for steps achieved with FES. In this age group there is often a reported reduced quality of life. The impact of poor quality of movement affecting function in the upper limb for someone with hemiplegia, the effect of fatigue reducing the ability to participate in social activities with their peers and the visibility of the larger orthotics that may be required to maintain a foot position for walking are contributing factors. The potential for FES to aid in the functional ability and reduce need for orthotics is very motivating. The Birmingham FES service provides a seamless transition from paediatric to adult care which is valued by parents and children.
Vignette 3 Child age 9 with a diagnosis of cerebral palsy right hemiplegia. No cognitive impairment. Had tried different orthotics but found variable benefit and fell frequently due to poor balance. Initially started FES age 6 using the exercise device to stimulate right dorsiflexors. Now aged 9 years and has progressed to using the walking device at school in preference to using the Kidigait carbon fibre foot drop splint. Reports full confidence in walking, minimally increased effort compared to peers and rarely trips. Now is using the exercise device to help right wrist extension. Vignette 4 Child aged 8 years with a diagnosis of cerebral palsy left hemiplegia. Unable to recruit dorsiflexors in gait causing toe walking; used AFO for school. Commenced FES treatment with an exercise device daily to left dorsiflexors; progressed after 5 months to a walking device. Result: improved heel strike, increased toe clearance and consistent foot placement at end of swing phase. Now aged 10, child is independent with effective use of wireless FES device. In past year has not needed AFO or required serial casting thus reducing child and parental burden to attend frequent therapy and orthotic appointments.
FES use by children and young people e their experiences Vignette 1 Child age 4 with diagnosis of cerebral palsy left sided hemiplegia. No cognitive impairment. Referred due to frequent tripping and falling at least three times per day. Currently wears rigid AFO’s or insoles with boots. Has not had botulinum toxin treatment for spasticity. Gait pattern prior to FES treatment: constant toewalking when barefoot or in shoes, no heel contact at any point in the gait cycle, asymmetry in pelvic alignment. Child very anxious due to previous medical treatment at the hospital. Initially needed to use play equipment at home to become accustomed to the electrodes and wire. After 8 weeks had initial fitting for the exercise device and tolerated the set up and stimulation well. Provided with the equipment for home use and reviewed in 1 month. Now able to weight bear through the whole of the left foot during the gait cycle as evidenced by dirty socks under the foot where it had never been in contact with the floor previously. Parents are delighted with the improvement in walking.
Vignette 5 Adolescent aged 14 with diagnosis of Cerebral Palsy left hemiplegia. Main problems of fatigue on walking and difficulties with activities of daily living requiring bimanual upper limb function. Uses a carbon fibre drop foot splint and lycra glove but not used regularly as it gets in the way of daily activities. Unable to actively dorsiflex left ankle. Treatment started with exercise device for six weeks to develop tolerance of sensation and reduce muscle fatigue before being converted to wireless walking device. Result: No splint required to maintain a good foot alignment and has active dorsiflexion. Delighted with the change to mobility and no longer requiring use of splint. Left arm exercise device now used to improve wrist extension and supination.
Conclusion NICE guidance supports FES as a cost effective, safe, efficient treatment to help individuals to achieve their rehabilitation goals. Children with CP benefit from FES due to their neurological impairment affecting muscle activation and learning of movement. Our service has demonstrated that significant positive functional changes throughout the neuromusculoskeletal system can be achieved with FES treatment. Specialist neurological and paediatric physiotherapists ensure appropriate assessment and on-going support of FES treatment. The FES service in Birmingham provides a holistic care pathway liaising with all professionals involved with the child and young person’s care and wellbeing. Awareness of FES as a treatment option is required by
Vignette 2 Child age 6 with a diagnosis of cerebral palsy spastic diplegia and had a selective dorsal rhizotomy at age 3 ½ years old. No cognitive impairment. Started FES prior to 5th birthday. No independent standing balance, walking on toes with severe internal rotation at hips and knees in flexion. Under orthopaedic consideration for femoral osteotomies. Started using exercise device for dorsiflexors and has now progressed to using a walking device on exercise mode. Has used
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Ó 2019 Elsevier Ltd. All rights reserved.
PERSONAL PRACTICE
healthcare professional. Further evidence with case studies and research is required to influence policy documents for the care of children and young people. A
Cauraugh JH, Naik SK, Hsu WH, Coombes SA, Holt KG. Children with cerebral palsy: a systematic review and meta-analysis on gait and electrical stimulation. Clin Rehabil 2010; 24: 963e78. NICE. Functional electrical stimulation for drop foot of central neurological origin. 2009, http://www.nice.org.uk/Guidance/IPG278. Swain I, Taylor P. The clinical use of functional electrical stimulation in neurological rehabilitation. Horiz Med 2004; 16: 315e22.
FURTHER READING Baker LL. Neuromuscular electrical stimulation: a practical guide. 4th Edn. Los Amigos Research Institute, 2000.
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Ó 2019 Elsevier Ltd. All rights reserved.
Functional electrical stimulation (FES) for children and young people with cerebral palsy
treatment. The service has received 390 paediatric referrals including 245 children with CP. Currently 150 children with CP are receiving treatment and using a FES device making this the largest Paediatric FES service in the UK. The youngest child referred was 2 years old and the current average age of referral is between 7 and 11 years. FES for children is a growing area of interest with increasing evidence and experience but there is a lack of awareness in the many applications of FES as a form of treatment for children. This article aims to share our clinical experience in using FES for children with CP to assist in addressing this knowledge gap.
Christine Singleton Helen Jones Lizz Maycock
What is FES? Functional Electrical Stimulation (FES) uses a small medical device to provide electrical stimulation through the peripheral nervous system to activate muscle contractions to assist in functional activities when nervous or musculo-skeletal systems are damaged. The device operates with a 9 volt battery, uses surface electrodes, connecting wires, a footswitch for activation whilst walking, or a programmed automatic pattern of activation for exercise function. A number of parameters can be adjusted by treating clinicians according to patient requirements. Activity is recorded by the device for patient and clinician information. Technical development of devices has occurred through patient and clinician feedback, from analogue to digital and more recently bluetooth technology. There are a variety of commercial devices which range in price from hundreds to thousands of pounds. FES can be combined in a timely manner with other treatment options such as botulinum toxin injections for spasticity, orthotic devices and lycra splinting for limb support, walking aids for balance and exercise equipment to enhance rehabilitation. There are inclusion and exclusion criteria for electrical stimulation. Not every individual is suitable for FES treatment due to clinical or non-clinical factors.
Abstract Evidence for functional electrical stimulation (FES) as a treatment option in adult neurological conditions has grown over the last 25 years. Children and young people with neurological conditions can also benefit from FES treatments but there are gaps in clinical knowledge, awareness and evidence which need addressing. Some of the known benefits of FES include safe walking with facilitation and exercise of ‘normal’ movement, muscle strengthening, joint range and proprioceptive improvements as well as spasticity reduction. There are similarities but also differences and challenges in applying FES between the adult and paediatric age groups. It is important to recognize these differences together with the need to alter techniques in applying FES for children. Birmingham has the largest paediatric FES service in the UK and the aim of this article is to share our knowledge and experience in providing FES as a treatment option for children and young adults with cerebral palsy.
Keywords cerebral palsy; challenges; CP; differences; FES; functional dropped foot and exercise stimulators; functional electrical stimulation; neurological rehabilitation; treatment options; young people
Introduction
What are the applications for FES?
The Birmingham Functional Electrical Stimulation (FES) clinic is the second largest NHS provider of FES treatment for neurological conditions in the United Kingdom, currently treating 1400 patients. FES has been clinically available since 1994 as a treatment option for people with Multiple sclerosis (MS), stroke (CVA), incomplete spinal cord injury (ISCI), traumatic brain injury (TBI) and adult cerebral palsy (CP) being the main cohorts. Over the last 10 years the service has been accepting children with a variety of neurological conditions for FES
The applications for FES with children are similar to those for adults. The most common application of the FES device is to stimulate dorsiflexor muscles whilst mobilising. This can be unilateral or bilateral. The stimulator is activated on initial swing-through phase of walking to lift the foot into dorsiflexion with slight eversion through to heel strike and mid-stance as illustrated in Figure 1. Control of the ankle foot alignment is important for many neurological patients to prevent falls, trips, catching the foot and unstable ankle positioning on heel strike and mid-stance. In addition, the use of FES can strengthen muscle activity and reduce spasticity of the opposing muscle group, in this case the plantar flexors. Range of movement into dorsiflexion with slight eversion is facilitated thus preventing contractures of the plantar flexors. Confidence in walking in different environments is increased due to improved control and sensory awareness of ankle foot alignment. Effort of walking is reduced due to the flexor withdrawal component of electrical stimulation. This spinal reflex activity assists with hip and knee flexion as well as lateral rotation of the leg and dorsiflexion/eversion of the foot.
Christine Singleton MSc Grad Dip Physiotherapy FES Service, West Midlands Rehabilitation Centre, Birmingham, UK. Conflicts of interest: none declared. Helen Jones Grad Dip Physiotherapy Dip Paed Physio (Advanced) FES Service, West Midlands Rehabilitation Centre, Birmingham, UK. Conflicts of interest: none declared. Lizz Maycock BSc (Hons) Physiotherapy FES Service, West Midlands Rehabilitation Centre, Birmingham, UK. Conflicts of interest: none declared.
PAEDIATRICS AND CHILD HEALTH 29:11
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Ó 2019 Elsevier Ltd. All rights reserved.
PERSONAL PRACTICE
Figure 1 Heel rise to heel strike gait pattern with FES. Reproduced with permission from National Clinical FES Centre, Salisbury.
FES can also be used for exercising various muscles to strengthen, maintain joint range, increase circulation, reduce spasticity and facilitate initiation of muscle activity and to provide a memory of movement. Exercise stimulation can also be used in the acute setting to maintain muscle function and reduce the risk of developing contractures. It may be used following an acute neurological incidence such as an acquired brain injury or following a period of inactivity and deconditioning due to their condition or other incident e.g. trauma. FES can be used for pre and post elective surgery treatment, for example, the multi-level orthopaedic interventions or selective dorsal rhizotomy. Muscle groups treated using FES either for walking or exercise include the quadriceps, hamstrings, gluteal muscles, trunk for core stability, shoulder girdle, biceps, triceps, supinator, wrist and finger flexor and extensor muscles. FES also provides a sensory/proprioceptive awareness of movement and muscle relaxation and can be used where there is neglect or inattention.
Further differences relate to the speed of movement associated with learning to walk and run. Children do not have so far to fall and are less fearful as risk takers. Whilst this is important for their development it can lead to inappropriate walking patterns. Short levels of attention and concentration make it harder for children to change patterns of movement but FES reduces the need to think so hard as it works automatically in walking or as an exerciser. Children accept technology quickly with many of our young children independently operating the device and enjoying being different and ‘cool’ amongst their peers and siblings. Younger children need to understand the device is not a toy and may need to rely on parents to operate it for safety reasons. Whilst parental involvement may add to their already busy schedules the device can assist the parent in ensuring stretches are completed at regular intervals automatically while a child is reading a book, playing on their electronic devices or watching television.
Clinical considerations for applying FES to children
Focusing attention on the upper limb
There are important challenges when providing FES for children compared to adults. The developmental stages of the neurological system, its neuroplasticity and the lack of learned function are the main differences. More frequent FES reviews are necessary due to constant growth and neuro-developmental changes. Children with CP require education of an activity or function they may not have ever experienced or felt. They lack understanding of normal movement patterns which their peers will have refined through daily play and repetition of successful motor activities as they grow. Facilitating normal movement can be difficult for children as the neurological plasticity will adapt and develop around their disability leading to habits of movement which are difficult to change. Many children develop a toe walking pattern which re-enforces shortening of muscles and tendons together with an increase in spasticity from this learned pattern of walking. Muscle atrophy and connective tissue changes are widely reported in children with CP, with research suggesting that muscle size is directly related to mobility and level of physical activity. A flaccid or spastic muscle tone can be treated with FES to provide a repeatable, consistent contraction. This is much harder to achieve if there is a significant element of dystonia, which may exclude FES treatment.
In the early years gaining safe mobility is often the major concern for the parent, however for the child upper limb disability becomes a major barrier to function at home and school. Visible deformity in the upper limb as the child develops can be a major cause of low self-esteem. Our experience has shown FES for the upper limb needs to be part of a coordinated treatment programme in conjunction with lower limb needs.
PAEDIATRICS AND CHILD HEALTH 29:11
Programme of FES treatment The referred child is assessed with the device and if appropriate follows a programme of treatment and support which is modified and mutually agreed with the child and parent/guardian. Education by a Physiotherapist on device operation is provided with instructions booklets and supporting photos of electrode positions for parents and children. FES support is provided between appointments and continues for as long as the person is using the device. Treatment can be for a short time frame or for many years. In the first year of treatment there are usually five face to face treatment sessions and thereafter the treatment is reviewed every six months. The review appointments are to ensure the medical device is fit for purpose with appropriate adjustments
499
Ó 2019 Elsevier Ltd. All rights reserved.
PERSONAL PRACTICE
made to the parameters of the device due to changes in the child’s condition or abilities. Young people are encouraged to take control of their rehabilitation and maintain function through self-management with the FES device. Of our current 150 paediatric FES users, 29 patients started treatment with the walking device. A further 87 patients progressed to using the walking device after building tolerance and muscle endurance to stimulation with an exercise device. 34 children only use the exercise device.
Active movement by the child can follow this ‘awakening’ although the muscles will be weak and need further electrical stimulation to improve their physiology. If appropriate, following their assessment, a child is provided with a device to take home; our clinic routinely provides Odstock Medical Limited devices. Full verbal and written instructions are provided for the child’s parent or guardian. An information leaflet for the school is also provided if the child uses their device in class.
Outcome measures
Children aged 7e11 years Children in Primary school years 3e6 often lead packed lives. Physiotherapy exercises and stretches have to compete with busy school, clubs, sport and family schedules. FES offers an opportunity to strengthen muscles whilst eating breakfast, walking to school, watching TV or all of the above. There can be some difficulty with finding precise electrode placement for small muscles in growing children. In clinic, once the correct electrode positions are established, we use marker pens to draw around the electrodes, take photographs and identify landmarks (e.g. two finger widths’ to the left of the shin bone, 1 cm below the large mole etc.) to speed along correct electrode placement at home. A cardboard template may be used to enable swift and precise positioning of electrodes. The FES devices used in Birmingham allows the clinician flexibility of electrode positioning to find the most responsive and comfortable location for stimulation. Regular reviews are required as the electrode position will change with growth and bulking of the muscle being stimulated. In the later years of primary school or with the transition to secondary school, children may feel increasingly self-conscious about their differences from classmates. Visible upper limb splints and AFOs can become disliked and rejected; they can also become uncomfortable due to the child’s rapid growth. FES can be used in combination with some splints or instead of them. There may also be a reduced need for more aggressive clinical interventions such as botulinum toxin injections and prolonged serial casting with the additional benefit of less school hours missed for appointments. The active nature of the FES adds value to the correct positioning of a joint, being achieved dynamically, using the child’s own muscles. There are a variety of ways to ‘wear’ FES devices to keep them as hidden and discrete as possible, although the trend for ‘skinny-fit’ trousers and leggings have made this more difficult. The walking device can be worn in a lycra leg cuff at the shin with short wires connecting to the electrodes and foot switch. Using longer wires hidden under clothing, the FES device can also be worn on a belt, placed in a pocket at the waist, or kept in a bum bag or mobile phone style case. Each child and parent can choose the most convenient way for the child to ‘wear’ their device. There is the option to use the device in a completely silent mode, or to listen to a beep when the machine is turned on/ off or when the power dial is adjusted. If a child feels too self-conscious to cope with the walking device in the school setting, they may choose to use the device only at home or in the community. For some individuals using the exercise-only option at home may be the most they can manage. FES is a significant tool we can offer a child to help meet their physical goals. Like all tools we consider the device to be an adjunct to their wider therapy intervention plan which can be
Outcome measures currently used are: visual analogue scales for: spasticity, frequency of tripping, quality of life, pain on walking, muscle weakness, fatigue passive and active range of movement videoed gait pattern ease of use, or requirement of orthotics frequency of requiring botulinum toxin injections or surgery mobility e including distance walked, use of aids, balance Child Hand Experience Questionnaire Change in frequency of therapy and other medical appointments
Age-related considerations Children aged 2e6 years The initial introduction to using any FES device needs to be in a positive and calm manner using a play therapy approach if required. Young children respond in a variety of ways to their first experience with FES. For some there is an excited laughter when the first buzzing sensation of the ‘tickle machine’ or the first involuntary movement via the ‘magic box’ emerges. Others may become overwhelmed and distressed at the simple application of sticky electrodes on the skin, before the device is even switched on. If a child has sensory processing difficulties they may not be able to tolerate FES. Adapted toys that mimic the device can be used and the child can practice putting the smallest sticky electrodes on and off a parent’s arm or on a doll before trying on their own skin. This reduces the anxiety of the child and the parents. If the child needs longer to adjust to the experience of using the device they can borrow the play equipment for home use. It is useful if a parent can experience the sensation of the stimulation to enable them to understand the sensitivity of the output levels. There is often a good window of opportunity to introduce FES to pre-schoolers who can be encouraged by parents or guardians to cooperate with this exciting new opportunity. Slightly older children may feel intimidated by a clinical setting and be more nervous once they have some concept of electricity. It is essential that sufficient information about the device and its uses is provided to the parent and child before, during and after the assessment so that they can proceed with the electrical stimulation device at home with confidence. Occasionally, on assessment, the device will ‘awaken’ a new movement by producing a muscle contraction that the child has never experienced before. A parent may be heard declaring, “Look at that! She has never moved her foot like that before in her life!”
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FES for 15 months and had a review with their orthopaedic consultant. The improvement over 9 months of FES treatment means there is no longer a requirement for surgery or botulinum toxin treatment in the near future. Now able to stand unsupported and has improved gait pattern walking unaided with less effort. The plan is to use the exercise device for the glutei and to progress to using the walking device.
used at any stage of their rehabilitation journey. In some cases it may be appropriate to wait until the child is older and more able to tolerate the sensation and understand the effects of the device. Young people 12e18 years As teenagers continue to grow through puberty, their interest and cooperation with FES can be variable. Enabling young people to take more independent control of their use of FES, and ensuring their autonomy is respected with regards to how and when the device is used is key to maintaining compliance with treatment. An interesting anecdotal finding has been that girls may become particularly sensitive to the sensation of FES during menstruation. It is essential that young people are given the opportunity and privacy to discuss their individual experiences freely with their clinician. The recent addition of a patient-accessible step counter within the PACE walking device can act as a motivational tool for young people to monitor and set daily or weekly targets for steps achieved with FES. In this age group there is often a reported reduced quality of life. The impact of poor quality of movement affecting function in the upper limb for someone with hemiplegia, the effect of fatigue reducing the ability to participate in social activities with their peers and the visibility of the larger orthotics that may be required to maintain a foot position for walking are contributing factors. The potential for FES to aid in the functional ability and reduce need for orthotics is very motivating. The Birmingham FES service provides a seamless transition from paediatric to adult care which is valued by parents and children.
Vignette 3 Child age 9 with a diagnosis of cerebral palsy right hemiplegia. No cognitive impairment. Had tried different orthotics but found variable benefit and fell frequently due to poor balance. Initially started FES age 6 using the exercise device to stimulate right dorsiflexors. Now aged 9 years and has progressed to using the walking device at school in preference to using the Kidigait carbon fibre foot drop splint. Reports full confidence in walking, minimally increased effort compared to peers and rarely trips. Now is using the exercise device to help right wrist extension. Vignette 4 Child aged 8 years with a diagnosis of cerebral palsy left hemiplegia. Unable to recruit dorsiflexors in gait causing toe walking; used AFO for school. Commenced FES treatment with an exercise device daily to left dorsiflexors; progressed after 5 months to a walking device. Result: improved heel strike, increased toe clearance and consistent foot placement at end of swing phase. Now aged 10, child is independent with effective use of wireless FES device. In past year has not needed AFO or required serial casting thus reducing child and parental burden to attend frequent therapy and orthotic appointments.
FES use by children and young people e their experiences Vignette 1 Child age 4 with diagnosis of cerebral palsy left sided hemiplegia. No cognitive impairment. Referred due to frequent tripping and falling at least three times per day. Currently wears rigid AFO’s or insoles with boots. Has not had botulinum toxin treatment for spasticity. Gait pattern prior to FES treatment: constant toewalking when barefoot or in shoes, no heel contact at any point in the gait cycle, asymmetry in pelvic alignment. Child very anxious due to previous medical treatment at the hospital. Initially needed to use play equipment at home to become accustomed to the electrodes and wire. After 8 weeks had initial fitting for the exercise device and tolerated the set up and stimulation well. Provided with the equipment for home use and reviewed in 1 month. Now able to weight bear through the whole of the left foot during the gait cycle as evidenced by dirty socks under the foot where it had never been in contact with the floor previously. Parents are delighted with the improvement in walking.
Vignette 5 Adolescent aged 14 with diagnosis of Cerebral Palsy left hemiplegia. Main problems of fatigue on walking and difficulties with activities of daily living requiring bimanual upper limb function. Uses a carbon fibre drop foot splint and lycra glove but not used regularly as it gets in the way of daily activities. Unable to actively dorsiflex left ankle. Treatment started with exercise device for six weeks to develop tolerance of sensation and reduce muscle fatigue before being converted to wireless walking device. Result: No splint required to maintain a good foot alignment and has active dorsiflexion. Delighted with the change to mobility and no longer requiring use of splint. Left arm exercise device now used to improve wrist extension and supination.
Conclusion NICE guidance supports FES as a cost effective, safe, efficient treatment to help individuals to achieve their rehabilitation goals. Children with CP benefit from FES due to their neurological impairment affecting muscle activation and learning of movement. Our service has demonstrated that significant positive functional changes throughout the neuromusculoskeletal system can be achieved with FES treatment. Specialist neurological and paediatric physiotherapists ensure appropriate assessment and on-going support of FES treatment. The FES service in Birmingham provides a holistic care pathway liaising with all professionals involved with the child and young person’s care and wellbeing. Awareness of FES as a treatment option is required by
Vignette 2 Child age 6 with a diagnosis of cerebral palsy spastic diplegia and had a selective dorsal rhizotomy at age 3 ½ years old. No cognitive impairment. Started FES prior to 5th birthday. No independent standing balance, walking on toes with severe internal rotation at hips and knees in flexion. Under orthopaedic consideration for femoral osteotomies. Started using exercise device for dorsiflexors and has now progressed to using a walking device on exercise mode. Has used
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healthcare professional. Further evidence with case studies and research is required to influence policy documents for the care of children and young people. A
Cauraugh JH, Naik SK, Hsu WH, Coombes SA, Holt KG. Children with cerebral palsy: a systematic review and meta-analysis on gait and electrical stimulation. Clin Rehabil 2010; 24: 963e78. NICE. Functional electrical stimulation for drop foot of central neurological origin. 2009, http://www.nice.org.uk/Guidance/IPG278. Swain I, Taylor P. The clinical use of functional electrical stimulation in neurological rehabilitation. Horiz Med 2004; 16: 315e22.
FURTHER READING Baker LL. Neuromuscular electrical stimulation: a practical guide. 4th Edn. Los Amigos Research Institute, 2000.
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