provided at the same time as the functional task that is being practiced.3,6

WHAT DOES THE RESEARCH SAY ABOUT ELECTRICAL STIMULATION?

The benefits of NMES and FES have been well documented in the literature across multiple patient populations, across the lifespan.6 Recent studies have shown that ES promotes neural recovery in individuals with an impaired nervous system, something which was thought not possible.7 It also facilitates neuroplasticity (brain to form new connections) due to the frequent input.8 Multiple published studies have enumerated the various benefits of ES for children. It improves muscle bulk and strength, reduces muscle tone (hypertonicity), improves passive and active range of motion, and it improves walking speed and foot and ankle mechanics during walking.2,3,7,9–12 Many studies found that ES can lead to significant positive changes in walking in children with cerebral palsy.11 The use of ES has evolved from stimulating a pair of muscles to multiple muscles groups, with FES units during walking.13 Numerous studies have noted an improvement in upper extremity function in children with cerebral palsy, due to improved muscle length, reduction in tone and improved muscle strength.2,9,14,15 A study found that children who received FES during walking together with traditional treatment, underwent an average of 4.5 fewer surgical procedures than children who just received traditional therapy.16

HOW CAN ELECTRICAL STIMULATION HELP MY CHILD?

Here are some clinical examples describing how this therapeutic modality may help your child.

Hypotonia (low muscle tone): Hypotonia can be of central (Down's syndrome) or peripheral origin (spinal muscular atrophy).17 This article does not discuss ES application for hypotonia in progressive, degenerative conditions like spinal muscular atrophy. Children with hypotonia typically present with poor posture, like a slouched back, a protruding tummy, and flat feet, and they present with decreased general strength, and activity tolerance. 18 For these children, NMES can be used on the back and core muscles to help them assume and maintain an upright posture.19, 20 NMES or FES can also be used by placing electrodes on the child's feet to help strengthen the small muscles in the foot, for improving walking and balance skills.

Hypertonicity (high muscle tone): ES is very important for hypertonic muscles, because it can help the muscles 'reset' and decrease their tone, learn how to turn on and off, and develop true strength for functional movement. There are multiple applications for this in cerebral palsy, based on your child's gross motor func-

tion classification system (GMFCS) level of function. There are five levels within this classification system based on the motor skills attained by the child. Level 5 is the lowest functioning, where the child is bed or wheelchair bound and needs assistance for all activities. Level 1 is the highest functioning, and children in this level can walk, run, jump and go up and down stairs independently.

Levels 4-5: ES can be provided to reduce the hypertonicity in the muscles to help families perform hygiene tasks (like a diaper change, or bathing), to improve posture (in wheelchairs, standers, and gait trainers) and to assist with breathing (if it is used on the core muscles).19,20

Level 1-3: ES can be used to help a child develop the subskills which improve quality of movement for transitioning between positions from the floor to bed/chair/stand, for a controlled standing position, and to develop coordinated and energy efficient walking. To achieve these goals, a therapist may choose to apply e-stim to certain muscles of the legs, feet, and/or the torso. ES can also be used to help children gain the strength and control for higher level motor skills, like: fast walking, running and jumping.

Idiopathic Toe Walking: Children who walk on their toes benefit from e-stim to help them place their feet flat on the ground, realign their posture, and improve postural awareness for safe and energy efficient walking, as developed and taught by Dr. Hastings.21

"A study found that children who received functional electrical stimulation during walking together with traditional treatment, underwent an average of 4.5 fewer surgical procedures than children who just received traditional therapy."

HOW OFTEN SHOULD ELECTRICAL STIMULATION BE USED?

What is the dosage? Based on clinical experience, ES protocols are most successful when used 4-5 times a week (clinic and home program combined). Families are encouraged to use e-stim as part of a home exercise program, in between therapy sessions. The specific dosage and the number of muscles targeted will vary and be determined by the therapist, based on the child's level of function and the goal being worked on.

WHEN CAN I EXPECT TO NOTICE CHANGES IN MY CHILD'S MOTOR FUNCTION?

Changes in performance vary depending on the goals set for the child, as per their level of function. Changes like reduction in tone, improved posture, and improved components of balance can be seen within weeks. However, it takes up to 6 months of practice for a child to learn a new functional movement pattern and for that pattern to become permanent (indicates motor learning has taken place) as shown by multiple researchers. Factors like growth spurts and illness can impact change, as well. Additionally, carryover of the therapeutic benefits throughout the day at home and at school is important, and recommendations for compressive garments and foot orthoses are often made to assist with this. Overall, it is important to stay consistent with the treatment protocol and plan set by the therapist.

WHAT MACHINES CAN BE FOR THERAPY WITH ELECTRICAL STIMULATION?

It is good to use an electrical therapy unit that allows the therapist and family to select from a wide range of parameters for the individually designed treatment protocol. There are units that have remotes (hand held trigger) for the FES protocols. Safety features, such as an automatic lock to prevent the child from making adjustments and to stop if any components were to get loose, are a great