Transcranial Direct-Current Stimulation (tCDS) and Robotics for Children With Hemiplegia
| Status: | Recruiting |
|---|---|
| Conditions: | Neurology |
| Therapuetic Areas: | Neurology |
| Healthy: | No |
| Age Range: | 6 - 17 |
| Updated: | 5/23/2018 |
| Start Date: | June 12, 2017 |
| End Date: | June 1, 2022 |
| Contact: | Kathleen Friel, PhD |
| Email: | kfriel@burke.org |
| Phone: | 9143683116 |
Hemiplegia occurs when the function of motor areas in the brain become impaired,
predominantly unilaterally, during perinatal development. Children with hemiplegia show
impairments in motor control of the affected side of the body. Impairments in use of the
upper extremity are common, and lead to functional disability throughout the lifespan of a
person with hemiplegia. Upper extremity impairments can severely affect a person's ability to
carry out activities of daily living.
The goal of this study at Blythedale Children's Hospital is to test the efficacy of
transcranial direct current stimulation (tDCS) and robotic upper extremity therapy in
improving upper extremity function in children with unilateral cerebral palsy. This study
will test the hypothesis that physical rehabilitation, provided by repetitive arm movements
guided by a robot, will improve upper extremity function in children with hemiplegia, and
that this improvement can be enhanced by transcranial direct current stimulation of motor
cortex immediately before robotic training.
predominantly unilaterally, during perinatal development. Children with hemiplegia show
impairments in motor control of the affected side of the body. Impairments in use of the
upper extremity are common, and lead to functional disability throughout the lifespan of a
person with hemiplegia. Upper extremity impairments can severely affect a person's ability to
carry out activities of daily living.
The goal of this study at Blythedale Children's Hospital is to test the efficacy of
transcranial direct current stimulation (tDCS) and robotic upper extremity therapy in
improving upper extremity function in children with unilateral cerebral palsy. This study
will test the hypothesis that physical rehabilitation, provided by repetitive arm movements
guided by a robot, will improve upper extremity function in children with hemiplegia, and
that this improvement can be enhanced by transcranial direct current stimulation of motor
cortex immediately before robotic training.
This sham-controlled, double-blind study will be completed at Blythedale Children's Hospital.
Detailed procedures
Robotic Device and Patient Position
The investigators will use existing robots at Blythedale, which are FDA approved robotic
devices that move the shoulder-and-elbow, or wrist-and-forearm, or the Typo Amadeo digit
training robot.
All robots: The subject will sit in a foam-padded chair facing the robot and a video screen.
Planar (shoulder-elbow) and wrist robots: The arm will be abducted, forearm supported, and
hand lightly grasping the robot handle, and velcro straps will lightly hold the forearm and
fingers secure. A cursor on the video screen will display the targets and track the movement
of the patient's arm.
Amadeo: The arm will be abducted, forearm supported, and digits attached to the robot with
magnets. Velcro straps will lightly hold the forearm and fingers secure. A cursor on the
video screen will display the targets and track the movement of the patient's fingers.
Robotic Training
Participants will receive a total of 12 sessions comprising 1 hour of interactive robotic
training. Participants will have two to four study visits per week. During one visit, the
child will receive tDCS + 1 hr training on the shoulder-elbow MIT Manus robot, and on the
second visit of the week, the child will receive tDCS + 1 hr training on the wrist MIT Manus
robot.
The interactive robot features involve visuomotor tasks, moving the robotic manipulandum
according to targets on a computer screen mounted at eye level. A key feature of MIT robots
is the low near isotropic inertia and reduced friction in the robot arm so that, when
appropriate, it can "get out of the way." The force required to move the robotic arm is
minimal, comparable to moving unrestricted, and if a patient cannot move the robot arm, it
will guide the limb to provide an adaptive sensorimotor experience.
Transcranial Direct Current Stimulation
A current up to 1.5mA current will be delivered using surface rubber-carbon electrodes
(35cm2) with surrounding saline soaked sponges (0.9% NaCl) by a battery driven, constant
current stimulator (maximum output 2mA). Participants will receive stimulation for 20 minutes
while seated (before robotic motor training), with the anode over the optimal site for first
dorsal interosseous (FDI) as identified using TMS, and the cathode on the contralateral
supraorbital area. Sham tDCS: comparable set-up to real tDCS, 30 sec real current ramping to
current up to 1.5mA at commencement, then after 5 sec a slow decrease but to no current
sustained for 20mins.
Detailed procedures
Robotic Device and Patient Position
The investigators will use existing robots at Blythedale, which are FDA approved robotic
devices that move the shoulder-and-elbow, or wrist-and-forearm, or the Typo Amadeo digit
training robot.
All robots: The subject will sit in a foam-padded chair facing the robot and a video screen.
Planar (shoulder-elbow) and wrist robots: The arm will be abducted, forearm supported, and
hand lightly grasping the robot handle, and velcro straps will lightly hold the forearm and
fingers secure. A cursor on the video screen will display the targets and track the movement
of the patient's arm.
Amadeo: The arm will be abducted, forearm supported, and digits attached to the robot with
magnets. Velcro straps will lightly hold the forearm and fingers secure. A cursor on the
video screen will display the targets and track the movement of the patient's fingers.
Robotic Training
Participants will receive a total of 12 sessions comprising 1 hour of interactive robotic
training. Participants will have two to four study visits per week. During one visit, the
child will receive tDCS + 1 hr training on the shoulder-elbow MIT Manus robot, and on the
second visit of the week, the child will receive tDCS + 1 hr training on the wrist MIT Manus
robot.
The interactive robot features involve visuomotor tasks, moving the robotic manipulandum
according to targets on a computer screen mounted at eye level. A key feature of MIT robots
is the low near isotropic inertia and reduced friction in the robot arm so that, when
appropriate, it can "get out of the way." The force required to move the robotic arm is
minimal, comparable to moving unrestricted, and if a patient cannot move the robot arm, it
will guide the limb to provide an adaptive sensorimotor experience.
Transcranial Direct Current Stimulation
A current up to 1.5mA current will be delivered using surface rubber-carbon electrodes
(35cm2) with surrounding saline soaked sponges (0.9% NaCl) by a battery driven, constant
current stimulator (maximum output 2mA). Participants will receive stimulation for 20 minutes
while seated (before robotic motor training), with the anode over the optimal site for first
dorsal interosseous (FDI) as identified using TMS, and the cathode on the contralateral
supraorbital area. Sham tDCS: comparable set-up to real tDCS, 30 sec real current ramping to
current up to 1.5mA at commencement, then after 5 sec a slow decrease but to no current
sustained for 20mins.
Inclusion Criteria:
- Age 6-17
- Participant and caregiver willing and able to provide informed consen/assent
- Diagnosis of hemiplegia
- Joint mobility: wrist extension, 20º, metacarpophalangeal and proximal interphalangeal
joints 10º
Exclusion Criteria:
- Cognitive deficits that impede understanding of study protocol
- Current medical illness unrelated to CP
- Visual problems (uncorrected by glasses/contact lenses)
- High motor ability in affected arm Pre-intervention screening measures; Motor activity
log, score > 2.5 ( > slight-to-moderate)
- Severe spasticity Pre-intervention screening measures; Modified Ashworth test, score >
3 ( > moderate)
- Lack of asymmetry in hand function
- Orthopedic surgery in affected arm within 2 years
- Dorsal root rhizotomy
- Botulinum toxin therapy in either upper extremity during last 2 months, or planned
during study period
- Currently receiving intrathecal baclofen
- Seizure beyond age 2, use of anti-seizure medication, history of epilepsy (in self or
first degree relatives), brain surgery, cranial metal implants, structural brain
lesion, devices that may be affected by TMS (pacemaker, medication pump, cochlear
implant, implanted brain stimulator)
- True positive response on the Transcranial Magnetic Stimulation Safety Screen
- Current use of medications known to lower the seizure threshold
- Previous episode of neurocardiogenic syncopy
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