Physiotherapy 90 (2004) 8290

Effect of Functional Electrical Stimulation on asymmetries in gait of children with hemiplegic cerebral palsy
S. Durham a, , L. Eve b , C. Stevens c , D. Ewins a,c
a

Gait Laboratory, Rehabilitation Centre, Queen Marys Hospital, Roehampton Lane, London SW15 5PN, UK b One Small Step Gait Laboratory, Guys Hospital, London, UK c Centre for Biomedical Engineering, University of Surrey, Guildford, UK

Abstract Background and purpose The gait of children with hemiplegic cerebral palsy is often characterised by toe walking and asymmetry in other temporal spatial parameters. Persistent toe walking impairs balance, resulting in shortening of the musculo-tendinous unit and reduced function. Current interventions to maintain range of movement at the ankle and improve walking patterns show mixed results. An alternative may be Functional Electrical Stimulation (FES), which is effective in assisting walking in adults, however there is limited research assessing its effectiveness or acceptability in children. The aims of this study were to quantify gait asymmetries, assess the effect of FES on these in an ambulant group of hemiplegic children and evaluate user perspective. Methods A ABA design was used, with stimulation applied in phase B, replacing any splint normally worn. Heeltoe contact pattern and other temporal spatial parameters of gait were measured in 12 children, before, during and after applying FES to the ankle dorsiexors. Acceptability of the intervention and user perspective were investigated through use of a questionnaire. Results The greatest asymmetries were in heeltoe contact patterns and double stance times. Heeltoe contact pattern and symmetry were both improved with stimulation. There was a clear trend toward reduction in affected side pre-swing double stance time and a move toward symmetry. Mean swing and stance times were close to symmetry with and without stimulation. Electrical stimulation was generally well tolerated. Conclusions Electrical stimulation may be an effective intervention, when used functionally, to improve asymmetrical walking patterns. Further research is needed to rene selection criteria of subjects who may benet and to optimize use of stimulation. 2004 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Keywords: Cerebral palsy; Electrical stimulation; Gait; Symmetry

Introduction The gait of children with hemiplegic cerebral palsy is often characterised by asymmetry in heeltoe foot contact pattern and other temporal and spatial parameters of walking. Typically the toe of the affected leg contacts the oor before the heel or there may be a complete absence of heel contact. Toe walking (equinus) adversely affects balance [1] and stability by altering the base of support on one side. The instability can result in asymmetry in stance time, step length, swing time, double support time and stride length [2]. Equinus in the swing phase compromises foot clearance
Corresponding author. Tel.: +44-20-8355-2175; fax: +44-20-8355-2953. E-mail address: sally.durham@swlondon.nhs.uk (S. Durham).

and results in compensatory adjustments such as vaulting or increased knee and hip exion. Current physiotherapy practice (e.g. exercises and stretches), attempts to correct the equinus and asymmetries, encourages a heeltoe walking pattern and maintains muscle length. Other interventions including serial casting, splinting, botulinum toxin injections and surgery are also directed towards this end [3]. However, outcomes from all these interventions are mixed with some having temporary results and some being poorly tolerated. Electrical stimulation is an alternative intervention, whereby electrical pulses are applied through surface electrodes using a small, lightweight, battery powered unit, causing muscle contractions. Electrical stimulation has been used successfully in adults with hemiplegia to correct foot drop during the swing phase of gait [4] and to improve

0031-9406/$ see front matter 2004 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2004.02.003

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standing balance and gait quality [5]. There is limited research to assess its effect on gait abnormalities in children with cerebral palsy. There are two apparently opposing approaches in the literature: stimulation of the anterior tibial muscles [69] and stimulation of the calf muscle [1012]. In the largest of these studies, Hazlewood [9] applied stimulation to tibialis anterior in a group of hemiplegic children for 30 min a day over 30 days as an exercise as opposed to during walking. They report an increase in range of passive and active dorsiexion, and an increase in strength of the affected anterior tibial muscle, but with little change in gait pattern. Gracanin [6,7] describes a positive result from using stimulation triggered by switches inside the shoes to facilitate ankle dorsiexion during the swing phase of gait. Carmick details a series of single case studies in which stimulation of the calf resulted in improvement in equinus foot position and foot contact pattern in walking, which were maintained after stopping stimulation. The optimum parameters of stimulation, the most appropriate muscle group to stimulate or duration of use is not clear. In this study, we used Functional Electrical Stimulation (FES) to stimulate the anterior tibial muscles during walking described as a functional orthosis, following the method used by Burridge et al. [4] to assist walking in adult hemiplegic subjects with drop foot. The aims of the study were to describe the nature of the asymmetry that results from toe walking, and to assess the immediate and longer term effect of FES on gait asymmetry in an ambulant group of hemiplegic children. Data from this preliminary study will be used to inform a power calculation for a larger study.

Ambulant children with a diagnosis of cerebral palsy, who walked with a toe gait, independent of aids were included. Children were excluded from the study if they had ankle plantarexion contracture with the knee extended, had had surgery or botulinum toxin injections within 6 months of starting this study, if they found the sensation of the stimulation unacceptable, or were unable to co-operate with the testing procedures. Ethical approval was obtained from Richmond, Twickenham and Roehampton NHS Trust. Full informed written consent was obtained from the parents of participating children. Study design and procedure A ABA design was chosen as suitable for a small study, with replication on 12 children. Due to the nature of the study neither the investigators nor the participant was blind to the intervention. Each phase of the study was of 12 weeks, with no intervention in the A phases, and stimulation applied in the B phase. Children attended an initial screening appointment where selection criteria were checked, and the programme was explained in detail. Kinetic, kinematic and split screen video data of the subjects during independent barefoot walking and then wearing normal footwear were collected in the gait laboratory at baseline, at week 1 and at the end of week 12. Height and leg length were also recorded. Data collected at baseline was not included in the analysis as the intention was to use this session to familiarize the participants with the gait laboratory. Intervention

Method Subjects Twelve children were recruited from local paediatric physiotherapy caseloads. Table 1 shows details of the 10 children who completed the study.
Table 1 Clinical data of participants who completed the study Subject 1a 2 3 4 5 6 7 8 9b 10c
a b c

After data collection at the end of week 12, the start of the intervention phase, the stimulator was set up on the affected leg. The child, parents and, where possible, the childs regular physiotherapist were instructed in set up and use. Photographs of electrode positions and written instructions were given.

Age (years) 7 8 13 11 7 6 8 8 12 15

Sex m f f m m m m f f m

Affected side Left Left Asymmetrical diplegia L > R Left Left Right Right Right Right Right

Orthosis Hinged AFO Hinged AFO None at time of study None at time of study Hinged AFO; 1 cm raise Hinged AFO None at time of study None at time of study None at time of study Hinged AFO

Leg length discrepancy (mm) 15 13 5 10 15 0 5 15 20 5

Soft tissue release medial aspect left forefoot at age 5. Adductor release and derotational osteotomy at age 6. Serial casts to stretch right TA completed 6 months prior to starting stimulation.

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Table 2 Stimulation parameters of the Odstock Drop Foot Stimulator III Asymmetrical bi-phasic waveform Output Pulse width Output time Rising edge ramp Falling edge ramp Extension Frequency Adaptive or xed timing 9 V (PP3) battery 15100 mA (1 k 3350 s 0.56 s 04 s 04 s 01.5 s 40 Hz load)

tact was made to check on use of the stimulator fortnightly through phase B. Data collection Kinematic data was collected using a six camera MacReex 60 Hz passive marker detection system (Qualisys AB, Partille, Sweden). Retroreective markers were attached to the left and right acromion processes, sacrum, left and right anterior superior illiac spines, thighs, lateral epicondyles, shanks, at the level of the lateral malleoli, and second and third metatarsals. The coordinate data of the markers for standing and walking were collected over four 10-m walks for each condition; barefoot, and with shoes and splints if worn, in both A phases; and wearing shoes with and without stimulation in the intervention phase. Weight and kinetic data were obtained from a dual 3.3-m long force platform [13]. Sagittal and frontal plane video images were recorded and displayed using a split screen TV monitor. The video record was used to aid the analysis of the kinematic data. Leg length was measured with a tape measure as the distance from the anterior superior illiac spine to the base of the medial malleolus. Height was measured with a wall mounted measure. Both the parent and childs user perspective was sought through a questionnaire developed in conjunction with the Clinical Audit Department at Queen Marys Hospital. Outcome measures Primary outcome measure Heeltoe interval, the sequence and timing of foot contact pattern visually determined using the z-coordinates of the ankle and toe markers at heel and toe contact. Secondary outcome measures Changes in the asymmetry of the temporal spatial parameters of gait (dened in Table 3) using the marker data. Acceptability of the intervention from a user perspective. This paper reports the immediate effect of applying FES to the ankle dorsiexors during the swing phase of walking, and changes after 12 weeks of use of the stimulation during walking activities.

Application was checked and any immediate problems the child or parents had encountered were dealt with at an appointment on the following day. All measurements were then repeated with the child wearing their normal footwear but no splint, with and without stimulation. These measurements were repeated under the same conditions at the end of 12 weeks using the stimulator. Stimulation was discontinued and measurements were repeated, barefoot and with shoes, at the beginning and end of the nal phase (A2). The Odstock Drop Foot Stimulator III (see Table 2 manufactured by Department of Medical Physics and Biomedical Engineering, Salisbury District Hospital, Salisbury, Wiltshire, UK, SP2 8BJ) was used as it had been shown to be reliable in use with adults [4], is commercially available and inexpensive. No adaptations were made to the equipment. The stimulator was worn clipped to a belt around the childs waist. Self-adhesive electrodes (PALS Ultraex 38 mm round, Nidd Valley Medical Limited) were placed on the childs shank at the points where the best response from the ankle dorsiexors was achieved. Stimulation envelope timings were adjusted to optimise improvements in the movement of the leg and foot during gait. Leads connected the stimulator to the electrodes and to a low prole switch, a force sensitive resistor, inside the shoe. This switch controlled the on/off cycle, timed to stimulate the ankle dorsiexors at toe off and stop just after foot contact. In all subjects, the switch was placed under the metatarsal heads to achieve reliable triggering of stimulation because of inconsistent heel strike. The child was instructed to gradually increase the use of the stimulator over the rst week and then to use it instead of any orthosis throughout the intervention phase. Each childs usual physiotherapy program was continued throughout the study. The child either attended the gait lab or telephone conTable 3 Denitions Heeltoe interval (s) Step length (m) Stance time (s) Affected double stance (s) Unaffected double stance (s) Swing time (s) The The The The The The

time between heel contact and toe contact anterior posterior distance between contact of one foot and contact of the contralateral foot time from initial contact of one foot to toe off of the same foot time for which both feet are in contact with the ground pre-swing for the affected leg time for which both feet are in contact with the ground pre-swing for the unaffected leg time for which the foot is not in contact with the ground

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Data processing Mean values for all variables from at least 10 representative steps were calculated for each leg. Data for step length and speed was normalised to height to account for the effects of changes due to growth [14]. Heeltoe interval, stance, double support and swing times were normalised to speed. To assess symmetry, a ratio index was calculated for each parameter by dividing the mean value for the affected side by the mean value for the unaffected (R = Xa /Xc ) [15]. A symmetry ratio value of greater than 1 denotes the affected side value to be larger than the unaffected, less than one, that the affected side value was smaller than the unaffected. A ratio value of one reects symmetry. As the asymmetry pattern was mixed with the affected limb having a lower value than the contralateral limb for some cases and a higher value in others, a second ratio was calculated by dividing the smaller value by the larger value irrespective of side to avoid the symmetry index for these parameters tending erroneously to 1 (R = Xs /Xl ) [16]. Statistical analysis For the purposes of this paper, it was decided to use descriptive statistics only. Results Seventeen children were screened. Five children were not enrolled onto the study either because they had complex

pathology unlikely to benet from a single channel of stimulation, disliked the sensation, or were too young to cooperate. Of the 12 accepted onto the study 2 did not complete, due to non-compliance in one case and family circumstances in the other. Patterns of asymmetry The patterns of asymmetry prior to stimulation are detailed in Table 4. The greatest asymmetries were in pattern of foot contact (measured by the heeltoe interval), and duration of pre-swing double stance. Symmetry ratio (Xa /Xc ) for double stance was affected by one outlying value. On the affected side, mean pre-swing double stance was 43% greater than the contralateral side, whereas asymmetry was much less for mean swing time (7% greater) and mean stance time (5% less) than the contralateral side. At the end of the intervention phase the pattern of asymmetry of all parameters was the same as at pre-intervention, although absolute values changed (Table 5). The immediate effects of applying stimulation, at the beginning of the intervention phase are shown in Table 4. Fig. 1 shows the foot contact patterns and Fig. 2 shows the asymmetry of double stance. A 67% increase in the heeltoe interval of the affected side, and a reduction in the asymmetry of heeltoe contact pattern (Fig. 1). Pre-swing double stance times for both sides reduced, as did the asymmetry. The affected side reduced from 43 to 35% greater than the unaffected side. Symmetry in seven of the nine subjects increased (Fig. 2).

Table 4 Normalised temporal spatial parameters without and with stimulation at the start of the intervention phase Parameter Mean (S.D.) Affected leg No stimulation (n = 10) Foot contact pattern (measured by heeltoe interval)c Step lengthd Stance timec Double stancec Swing timec Speedd With stimulation (n = 10) Foot contact pattern (measured by heeltoe interval)c Step lengthd Stance timec Double stancec Swing timec Speedd
a b c d e

Symmetry ratio index Unaffected leg 1.14 0.38 6.09 0.72 4.05 (0.38) (0.04) (1.72) (0.64) (1.40) Xa /Xc a 0.10 0.99 0.95 3.04 1.08 (0.56) (0.16) (0.09) (7.21)e (0.14) Xs /Xl b 0.10 0.90 0.92 0.38 0.89 (0.56) (0.09) (0.06) (0.51) (0.08)

0.24 (0.65) 0.38 (0.08) 5.8 (1.71) 1.03 (0.59) 4.32 (1.23) 0.28 (0.05) 0.40 0.39 5.25 0.84 4.14 0.30 (0.54) (0.07) (1.49) (0.54) (1.20) (0.05)

1.07 0.39 5.58 0.62 3.86

(0.26) (0.05) (1.51) (0.53) (1.27)

0.30 0.99 0.94 1.57 1.08

(0.45) (0.11) (0.07) (1.26)e (0.08)

0.30 0.92 0.93 0.53 0.91

(0.45) (0.05) (0.05) (0.41) (0.04)

Xa /Xc ratio calculated as value of the affected side divided by the value of the unaffected side for that parameter. Xs /Xl ratio calculated as the smaller value divided by the larger value irrespective of side. Normalised to speed. Normalised to height. Data presented from nine subjects for this parameter because of a problem with processing symmetry ratio index for one subject.

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Table 5 Normalised temporal spatial parameters without and with stimulation after 3 months of intervention Parameter Mean (S.D.) Affected leg No stimulation (n = 9) Foot contact pattern (measured by heeltoe interval)c Step lengthd Stance timec Double stancec Swing timec Speedd With stimulation (n = 9) Foot contact pattern (measured by heeltoe interval)c Step lengthd Stance timec Double stancec Swing timec Speedd 0.19 0.40 5.07 1.34 3.47 0.31 0.37 0.39 5.05 1.10 3.47 0.31 (0.45) (0.07) (1.08) (0.76) (0.83) (0.04) (0.43) (0.06) (1.19) (0.39) (0.79) (0.04) Unaffected leg 1.08 0.41 5.29 0.79 3.10 (0.21) (0.03) (0.76) (0.24) (0.95) Symmetry ratio index Xa /Xc a 0.16 0.97 0.95 1.68 1.14 (0.42) (0.18) (0.08) (0.59) (0.12) Xs /Xl b 0.16 0.91 0.92 0.63 0.86 (0.42) (0.07) (0.04) (0.14) (0.05)

1.04 0.42 5.25 0.83 3.29

(0.23) (0.04) (0.82) (0.33) (1.09)

0.34 (0.41) 0.94 (0.09) 0.96 (0.15) 1.39 (0.38) 1.1 (0.19)

0.34 0.91 0.90 0.76 0.85

(0.41) (0.06) (0.07) (0.18) (0.10)

Data for nine subjects for all parameters because of problems with data collection for one subject at this session. a X /X ratio calculated as value of the affected side divided by the value of the unaffected side for that parameter. a c b X /X ratio calculated as the smaller value divided by the larger value irrespective of side. s l c Normalised to speed. d Normalised to height.

There was a clear trend toward a reduction in affected and contralateral side stance times, but a very small increase in asymmetry of stance time. There were changes in asymmetry of swing time or step length when calculated as Xa /Xc . As expected, changes in the asymmetry of heeltoe contact pattern were identical when calculated as Xs /Xl . A similar improvement was seen in asymmetry of the double stance
Start of the stimulation phase 2

phase. There was a small improvement in the asymmetry of the other parameters and mean walking speed increased by 7%. After 3 months of the intervention the immediate effects of applying stimulation were similar (Table 5). The heeltoe interval of the affected limb increased by 95% and all subjects demonstrated a clear move toward symmetry of foot contact pattern (Fig. 1).
After three months of intervention 2

1.5

1.5

0.5

0.5

-0.5

-0.5

-1 no stimulation with stimulation

-1 no stimulation with stimulation

n=10

n=9

Fig. 1. Effect of applying stimulation on the heeltoe interval of the affected leg at the start of the stimulation phase and after 3 months of intervention (normalised data). Note: data from one subject not included at 3 months because of problems with data collection at this session.

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Start of the stimulation phase 1.2 1 0.8 0.6 0.4 0.2 0 -0.2 -0.4 -0.6 -0.8 no stimulation with stimulation 1.2 1 0.8 0.6 0.4 0.2 0 -0.2 -0.4 -0.6 -0.8 no stimulation with stimulation After three months of intervention

87

n=10

n=9

Fig. 2. Effect of applying stimulation on the symmetry ratio (Xs /Xl ) of pre-swing double stance at the start of the stimulation phase and after 3 months of intervention (normalised data). Note: data from one subject not included at 3 months because of problems with data collection at this session.

An improvement in the mean symmetry ratio of pre-swing double stance time. Affected side values reduced from 70 to 33% greater than the unaffected side. As at baseline, symmetry in seven of the subjects was improved (Fig. 2). A small reduction in the asymmetry of swing time and stance time. A small increase in the asymmetry of step length. Again as expected, changes in the asymmetry of heeltoe contact pattern were identical when calculated as Xs /Xl . A similar improvement was seen in asymmetry of the double stance phase. There was no change in symmetry of step length and a small reduction in symmetry of stance and swing times. There was no change in mean walking speed on applying stimulation at the end of the 3-month stimulation phase. Changes between the beginning and end of the intervention phase Table 6 compares the symmetry ratio indices at the beginning and end of the intervention phase (B), with no stimulation applied, to determine the therapeutic or carry over effect. There was a 60% reduction in the asymmetry of foot contact pattern. However, this change is small when compared to the effect of applying stimulation, indicating a small therapeutic effect and primarily an orthotic effect for this parameter. Symmetry ratio indices for pre-swing affected side double stance had improved.

Table 6 Comparison of start and end of 3-month stimulation phase, affected leg, no stimulation Parameter Symmetry ratio index (1 = symmetry) Start B (n = 10) Xa /Xc Foot contact pattern Step length Stance time Double stance Swing time Mean speed
a a

End B (n = 9)
b

Xs /Xl

Xa /Xc a 0.16 (0.42) 0.97 0.95 1.68 1.14 0.31 (0.18) (0.08) (0.59) (0.12)

Xs /Xl b 0.16 (0.42) 0.91 0.92 0.63 0.86 (0.07) (0.04) (0.14) (0.05)

0.10 (0.56) 0.99 0.95 3.04 1.08 0.28 (0.16) (0.09) (7.21)c (0.14)

0.10 (0.56) 0.90 0.92 0.38 0.89 (0.09) (0.06) (0.51) (0.08)

Xa /Xc ratio calculated as value of the affected side divided by the value of the unaffected side for that parameter. b X /X ratio calculated as the smaller value divided by the larger value s l irrespective of side. c Data presented from nine subjects for this parameter because of a problem with processing symmetry ratio index for one subject.

There were very small changes in the asymmetry of the other parameters. User perspective Nine out of 10 questionnaires were returned after 3 months of using the stimulator. Three respondents reported problems with compliance, however all reported that they would like to continue using the system after completion of the trial. General comments were that the stimulator was large and the electrode wires could be difcult for the child

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to manage, especially if the system was to be worn all day in school.

Discussion In this group of children, FES to the ankle dorsiexors during swing resulted in an improvement in the heeltoe contact pattern of the affected leg and symmetry of foot contact patterns. Descriptive statistics show a clear trend toward a reduction in the high pre-swing double stance times of the affected leg and a move toward symmetry between sides. Wheelwright et al. [17] concluded that gait in normal children is not necessarily symmetrical. They found left and right values to vary by as much as 810% in an individual, with the greatest asymmetry seen in double stance. Double support asymmetry ratios for our entire group were greater than this, and consistently improved with stimulation. Although there was variability within the group, mean symmetry ratios for the other parameters (except heeltoe interval) were generally within the values reported by Wheelwright in normal children. However, there is a paucity of quantitative heeltoe interval data from a normal population with which we can compare our primary outcome measure. Further work to establish a normal range is in progress [18]. Completion of this will then permit a power calculation for a clinical trial. Other investigators have reported the typical pattern of asymmetry in children with cerebral palsy to be shorter stance on the affected side resulting in a shorter contralateral step length[2]. This is contrary to our data. Eight of the 10 subjects had shorter affected stance times, but ve of these had a longer contralateral step length, suggesting that swing is more compromised than stability in stance. Increased double stance times have been used as an indicator of reduced stability and gait deterioration [19]. The ratio between affected and non-affected sides are reported to be of value in the assessment of the severity of hemiplegia [20]. However, duration of single limb support is also a valuable index of limb stability [21,22]. In our group of children stability in stance on the affected leg did not appear to be a major problem, as mean stance and single stance times showed only small asymmetries (swing time for one leg represents single stance time for the contralateral leg). The increased pre-swing double stance time for the affected leg in this group could be attributed to a problem with foot clearance at terminal stance and pre-swing, not instability in stance. Affected side double stance times were markedly reduced with stimulation, which aids dorsiexion at toe off (and therefore toe clearance) and was associated with an increase in walking speed. Walking speed with no stimulation at the end of 3-month stimulation phase remained greater when compared to the start of the stimulation phase. This, together with the reduction in asymmetry of pre-swing double stance and less variability within the group, could indicate a therapeutic or carry over effect of stimulation.

It was felt relevant to calculate the symmetry index as Xa /Xc and then as Xs /Xl to accurately reect the pattern between the affected and unaffected sides as well as the overall asymmetry. The outcomes measured were considered to be ones that would demonstrate a clinical improvement. Wheelwright et al. [20] argue that measurement of the spatial temporal parameters represent the expression of the kinetic and kinematic variables which inuence walking and therefore provide an objective assessment of the degree of gait impairment. Some of these measures could be used in clinical practice. Heeltoe contact patterns and some temporal and spatial parameters could be estimated from slow motion video in the routine clinical setting. A functional scale, e.g. the Gross Motor Function Measure [23], was not used as it was unlikely it would have been sensitive enough to detect a change in this group. The questionnaire was designed to determine parents perception of their childs main problems, and functional changes. Limitations of the study This was a small study in which each childs performance was compared to his or her own baseline value. It was not possible to use a placebo or to double blind the study because of the nature of the intervention. Although statistical tests have not been used means and standard deviations suggest clear trends toward improvement in the most asymmetric parameters. Clinical measurements and gait data were collected by the same investigators at each measurement session and followed a clearly dened protocol in an attempt to reduce measurement variability. Data was processed and analysed by one investigator to facilitate repeatability. This investigator was not blinded, but was not involved in the setting up of, or monitoring use of the stimulation. There was no measure of how long each child used the stimulator for each day, or at what level. Participants were instructed to use stimulation throughout the day for all walking activities. This was clearly problematic for some children in the school setting. A diary card recording daily use, or a monitoring system within the stimulator would have provided more objective data.

Conclusions This study and others reviewed earlier [6,7,10] have suggested functional benets from the use of Functional Electrical Stimulation. However, further work is needed to determine selection criteria, the most appropriate muscle group to stimulate, and the optimum way of using stimulation, e.g. throughout the day or as part of a dedicated walking exercise. A second study is in progress to evaluate the effect of calf muscle stimulation in a similar group of children. We

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hope the results from the two studies will form the basis of a larger study, which will include a randomised control group. In parallel with this there is a need to overcome some of the practical problems in using Functional Electrical Stimulation with children. Generally the sensation was well tolerated and the children who normally wore splints said they preferred the stimulator. However, the equipment proved to be bulky and the wires from the electrodes and heel switch were inconvenient particularly for girls who wore dresses. Modications to the stimulator are needed, a wireless system or miniaturised version, worn on the shank, with a review of sensors which do not have to be in the shoe [24] would be preferable. Considerable resources in terms of expense, time and effort are directed toward preventing contracture and avoiding or delaying surgery in this group of children. Fixed equinus is a frequent indication for orthopaedic surgery in children with cerebral palsy. Uncorrected, equinus leads to development of muscle contracture, and joint deformity [25]. Bennett et al. [26] reported 94% of a series of children with hemiplegia to have developed an associated varus deformity. Secondary complications of this include the development of painful callosities, skin breakdown and degenerative joint changes which will in turn further compromise gait [27]. Electrical Stimulation represents an inexpensive and non-invasive intervention. Although requiring further investigation, previous work suggests that it may be a very useful alternative intervention to maintain muscle length. In this study electrical stimulation, when used functionally improved foot contact pattern and asymmetrical walking patterns in this group of children.

Thanks go to Faye Bater MCSP for help with the clinical measurements, Steve Edwards, Clinical Audit department at Queen Marys Hospital for help with the questionnaire and the Department of Statistics at St. Georges Hospital, London for statistical advice. Sally Durham is a member of STaRNet London. STaRNet London are funded by the NHS Directorate of Health and Social Care for London.

References
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Key messages Current physiotherapy practise attempts to correct the foot contact pattern and asymmetries of gait in children with cerebral palsy who toe-walk. Functional Electrical Stimulation improved foot contact pattern on the affected side and symmetry of the most asymmetrical temporal and spatial parameters of gait in this group of hemiplegic children. Functional Electrical Stimulation was generally well tolerated and may be a useful alternative to a conventional orthosis. Further work is needed to rene patient selection criteria and optimize use of stimulation.

Acknowledgements This study was supported by grants from Remedi and the Special Trustees of the South West London Community NHS Trust.

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