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Functioning in children and adolescents with Down syndrome on a population level: scientific opportunities and community care

lation and the functional context. In a broader context of biomedical devices for electrical stimulation to other organs (such as the brain or heart), the use of more precise terminology is required. Any electrical stimulation that positively impacts function can be considered FES; for example, electrical stimulation for pain relief can cause functional improvements. Walking is a predictive, cyclical movement and can be used as a functional task in which NMES might prove beneficial. Particularly in children with unilateral spastic CP, achieving appropriate foot clearance during the swing phase of gait has the potential for reducing the risk for falls and injuries. More importantly, appropriate swing phase kinematics can influence not only the kinematics in the sequential stance phase but can also improve propulsion and force generation capacity at terminal stance. In addition, the use of NMES-assisted foot clearance in swing can also potentially improve selective motor control for ankle dorsiflexion. Previously, using NMES during gait was shown to increase tibialis anterior muscle thickness and gait parameters, compared to baseline and the contralateral side. Unfortunately, it is not known if this was more effective than traditional therapies, if complete cessation of treatment had a carryover effect, and if it had any effect on the strength of not just the tibialis anterior but also other important muscles of gait such as the gastrocnemius. Pool et al. report on the beneficial effects of an 8-week NMES-assisted gait program on muscle strength and volume of the tibialis anterior and gastrocnemius, as well as selective motor control compared to conventional therapy. With all therapies the question of effectiveness needs to be answered in the context of therapeutic control (criterion standard/conventional therapies) and a non-therapeutic control (e.g. contralateral leg), and if a therapeutic effect or carryover remains after ending the therapy. The results of this elegant randomized controlled trial in a community-based setting provide evidence for the therapeutic potential for NMES-assisted gait programs. However, we still need to evaluate the duration, frequency of treatment, the actual timelines of change, and its effects on any meaningful changes in gait as well as associated reduction in metabolic costs. Furthermore, while this impairment level analysis is clearly useful the effectiveness of NMES-assisted gait also needs to be understood at the level of activity and participation. Finally, at a more biological level, basic science studies have shown that during the postnatal period muscle stem cells (i.e. satellite cells) are required for muscle growth and repair. Their absence leads to impaired muscle development and regeneration capacity and there is an age-related decline in muscle stem cell number and functionality. New evidence suggests muscle contractures in children with CP have a much lower number of satellite cells which may be related to their poor muscle growth. A recent uncontrolled study in the elderly reported a positive effect of NMES on muscle strength and an increase in muscle stem cell number. In order to understand the biological basis of NMES-based muscle strength and volume gains it would be important to know if this was mediated by a concomitant increase in number and functionality of muscle stem cells in children with CP.