Abstract
Objective We investigated the preliminary efficacy of cathodal transcranial direct current stimulation (tDCS) combined with bimanual training in children and young adults with unilateral cerebral palsy based on the principle of exaggerated interhemispheric inhibition (IHI). Methods Eight participants with corticospinal tract (CST) connectivity from the lesioned hemisphere participated in an open-label study of 10 sessions of cathodal tDCS to the nonlesioned hemisphere (20 minutes) concurrently with bimanual, goal-directed training (120 minutes). We measured the frequency of adverse events and intervention efficacy with performance (bimanual—Assisting Hand Assessment (AHA)—and unimanual—Box and Blocks), self-report (Canadian Occupational Performance Measure (COPM), ABILHAND), and neurophysiologic (motor-evoked potential amplitude, cortical silent period (CSP) duration, and motor mapping) assessments. Results All participants completed the study with no serious adverse events. Three of 8 participants showed gains on the AHA, and 4 of 8 participants showed gains in Box and Blocks (more affected hand). Nonlesioned CSP duration decreased in 6 of 6 participants with analyzable data. Cortical representation of the first dorsal interosseous expanded in the nonlesioned hemisphere in 4 of 6 participants and decreased in the lesioned hemisphere in 3 of 4 participants with analyzable data. Conclusions While goal achievement was observed, objective measures of hand function showed inconsistent gains. Neurophysiologic data suggests nonlinear responses to cathodal stimulation of the nonlesioned hemisphere. Future studies examining the contributions of activity-dependent competition and cortical excitability imbalances are indicated.
Highlights
Children with unilateral cerebral palsy (UCP) due to perinatal stroke or periventricular leukomalacia exhibit great variability in clinical presentation
In addition to activity-dependent influences on the corticospinal tract (CST) during development, a potential maladaptive influence is an imbalance in interhemispheric inhibition (IHI) observed in adults with stroke, which may limit motor recovery [4]
37.5% (3 participants) reported minor adverse events related to active transcranial direct current stimulation (tDCS) in more than one tDCS session, with the most common symptom being unusual feelings on the skin of the
Summary
Children with unilateral cerebral palsy (UCP) due to perinatal stroke or periventricular leukomalacia exhibit great variability in clinical presentation. This heterogeneity may be partially attributed to neuroplastic influences, both developmental and maladaptive, on the corticospinal tract (CST). The CST is established through competitive withdrawal of bilateral CST projection fibers early in infancy driven in part by activity-dependent influences [1]. A lack of competitive withdrawal is compounded by decreased activity of the weaker, or more affected, hand during early development [3]. In addition to activity-dependent influences on the CST during development, a potential maladaptive influence is an imbalance in interhemispheric inhibition (IHI) observed in adults with stroke, which may limit motor recovery [4]. One factor that may influence the response to novel intervention, such as combined noninvasive brain stimulation (NIBS) and rehabilitation protocols, is altered patterns of underlying brain circuitry of the CST in pediatric populations with neurologic deficits [10]
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