Effect of Transcranial Direct-Current Stimulation Combined with Treadmill Training on Balance and Functional Performance in Children with Cerebral Palsy: A Double-Blind Randomized Controlled Trial

Background: Cerebral palsy refers to permanent, mutable motor development disorders stemming from a primary brain lesion, causing secondary musculoskeletal problems and limitations in activities of daily living. The aim of the present study was to determine the effects of gait training combined with transcranial direct-current stimulation over the primary motor cortex on balance and functional performance in children with cerebral palsy. Methods: A double-blind randomized controlled study was carried out with 24 children aged five to 12 years with cerebral palsy randomly allocated to two intervention groups (blocks of six and stratified based on GMFCS level (levels I-II or level III).The experimental group (12 children) was submitted to treadmill training and anodal stimulation of the primary motor cortex. The control group (12 children) was submitted to treadmill training and placebo transcranial direct-current stimulation. Training was performed in five weekly sessions for 2 weeks. Evaluations consisted of stabilometric analysis as well as the administration of the Pediatric Balance Scale and Pediatric Evaluation of Disability Inventory one week before the intervention, one week after the completion of the intervention and one month after the completion of the intervention. All patients and two examiners were blinded to the allocation of the children to the different groups. Results: The experimental group exhibited better results in comparison to the control group with regard to anteroposterior sway (eyes open and closed; p<0.05), mediolateral sway (eyes closed; p<0.05) and the Pediatric Balance Scale both one week and one month after the completion of the protocol. Conclusion: Gait training on a treadmill combined with anodal stimulation of the primary motor cortex led to improvements in static balance and functional performance in children with cerebral palsy. Trial Registration Ensaiosclinicos.gov.br/RBR-9B5DH

Critérios de elegibilidade e efeitos da rizotomia dorsal seletiva sobre a função motora e marcha de crianças e adolescentes com paralisia cerebral: revisão sistemática

Introdução: A espasticidade pode ser considerada como uma das mais impactantes alterações secundárias à paralisia cerebral. Nosúltimos anos, a Rizotomia Dorsal Seletiva (RDS) tem sido destacada como um procedimento cirúrgico eficaz para o tratamento da espasticidade dos membros inferiores de crianças com paralisia cerebral. Objetivos: Verificar por meio de uma revisão sistemática da literatura os efeitos em médio e longo prazo, da RDS sobre a função motora grossa e a marcha em crianças e adolescentes com paralisia cerebral. Além de averiguar se existe um consenso na literatura sobre oscritérios de indicação da RDS. Métodos: Uma pesquisa foi realizada na rede internacional nos bancos de dados de acordo com os seguintes critérios de inclusão: (1) desenho: estudos envolvendo o acompanhamento pós-operatório longitudinal; (2) população: crianças e adolescentes com paralisia cerebral espástica; (3) intervenção: RDS; (4) grupo controle com intervenção diferente ou sem intervenção; (5) desfecho: melhora da função motora, melhora da espasticidade e desempenho da marcha. Resultados: Foi encontrado um total de seis artigos que preencheram os critérios de inclusão e foram utilizadosnesta revisão. Nos estudos analisados, foram observadas melhoras significativas na variável cinemática da marcha com diminuição da espasticidade no grupo RDS. Conclusão: A RDS diminui a espasticidade com efeitos positivos sobre a função motora grossa e a marcha de crianças e adolescentes com paralisia cerebral, porém estudos adicionais são necessários para esclarecer a eficácia da RDS aplicada em grupos musculares de membros inferiores.

Effect of transcranial direct current stimulation combined with gait and mobility training on functionality in children with cerebral palsy: study protocol for a double-blind randomized controlled clinical trial

Background: The project proposes three innovative intervention techniques (treadmill training, mobility training with virtual reality and transcranial direct current stimulation that can be safely administered to children with cerebral palsy. The combination of transcranial stimulation and physical therapy resources will provide the training of a specific task with multiple rhythmic repetitions of the phases of the gait cycle, providing rich sensory stimuli with a modified excitability threshold of the primary motor cortex to enhance local synaptic efficacy and potentiate motor learning. Methods/design A prospective, double-blind, randomized, controlled, analytical, clinical trial will be carried out.Eligible participants will be children with cerebral palsy classified on levels I, II and III of the Gross Motor Function Classification System between four and ten years of age. The participants will be randomly allocated to four groups: 1) gait training on a treadmill with placebo transcranial stimulation; 2) gait training on a treadmill with active transcranial stimulation; 3) mobility training with virtual reality and placebo transcranial stimulation; 4) mobility training with virtual reality and active transcranial stimulation. Transcranial direct current stimulation will be applied with the anodal electrode positioned in the region of the dominant hemisphere over C3, corresponding to the primary motor cortex, and the cathode positioned in the supraorbital region contralateral to the anode. A 1 mA current will be applied for 20 minutes. Treadmill training and mobility training with virtual reality will be performed in 30-minute sessions five times a week for two weeks (total of 10 sessions). Evaluations will be performed on four occasions: one week prior to the intervention; one week following the intervention; one month after the end of the intervention;and 3 months after the end of the intervention. The evaluations will involve three-dimensional gait analysis, analysis of cortex excitability (motor threshold and motor evoked potential), Six-Minute Walk Test, Timed Up-and-Go Test, Pediatric Evaluation Disability Inventory, Gross Motor Function Measure, Berg Balance Scale, stabilometry, maximum respiratory pressure and an effort test. Discussion This paper offers a detailed description of a prospective, double-blind, randomized, controlled, analytical, clinical trial aimed at demonstrating the effect combining transcranial stimulation with treadmill and mobility training on functionality and primary cortex excitability in children with Cerebral Palsy classified on Gross Motor Function Classification System levels I, II and III. The results will be published and will contribute to evidence regarding the use of treadmill training on this population. Trial registration ReBEC RBR-9B5DH

Transcranial direct current stimulation combined with upper limb functional training in children with spastic, hemiparetic cerebral palsy: study protocol for a randomized controlled trial

The aim of the proposed study is to perform a comparative analysis of functional training effects for the paretic upper limb with and without transcranial direct current stimulation over the primary motor cortex in children with spastic hemiparetic cerebral palsy

Gait and postural control patterns and rehabilitation in Down syndrome: a systematic review

: [Purpose] To describe (1) the current knowledge on gait and postural control in individuals with Down syndrome in terms of spatiotemporal, kinematics and kinetics, and (2) relevant rehabilitation strategies. [Methods] Randomized and non-randomized clinical trials published between January 1997 and October 2019 were selected by searching four scientific databases. We included studies on patients with Down syndrome involving gait analysis or postural control. A custom data-extraction and appraisal form was developed to collect the key features of each article. The PEDro Scale was used to evaluate the methodological quality of the studies. [Results] A total of 37 out of 146 cross-sectional and longitudinal studies were included in the review. The main abnormalities included: reduction of gait velocity and step length, poor static balance with increased anteroposterior and mediolateral oscillations and a larger step width. [Conclusion] A number of compensatory patterns during movement was observed, with a direct influence on improvements in stability and postural control throughout daily life. Intensive gait training at an early age appears to produce long-term improvements in this population. Future research should focus on the interaction between the motor and cognitive function, and on the functional effects due to the exposure to an enriched environment

Motor Cortex Plasticity in Children With Spastic Cerebral Palsy: A Systematic Review

A review of the literature was performed to answer the following questions: Does motor cortex excitability correlate with motor function? Do motor cortex excitability and cortex activation change after a rehabilitation program that results in improvements in motor outcomes? Can the 10–20 electroencephalography (EEG) system be used to locate the primary motor cortex when employing transcranial direct current stimulation? Is there a bihemispheric imbalance in individuals with cerebral palsy similar to what is observed in stroke survivors? the authors found there is an adaptation in the geometry of motor areas and the cortical representation of movement is variable following a brain lesion. The 10–20 EEG system may not be the best option for locating the primary motor cortex and positioning electrodes for noninvasive brain stimulation in children with cerebral palsy

Análise do equilíbrio estático em crianças com paralisia cerebral do tipo diparesia espástica com e sem o uso de órteses

Introdução: Crianças com paralisia cerebral (PC) do tipo diparesia espástica são frequentes usuárias de órtesespara membros inferiores, com a finalidade de proporcionar melhora funcional da postura ortostática e durante a marcha. Objetivo: analisar o equilíbrio estático de crianças diparéticas espasticas com PC, com e sem uso de órteses, por meio de parâmetros estabilométricos. Materiais e métodos: A amostra foi composta por 15 indivíduos com idades entre 4 e 14 anos (médias de 8,33 ± 2,74), sete do sexo masculino e oito do sexo feminino, divididos em dois grupos: o grupo controle (GC) com seis participantes e o grupo estudado(GE) com nove crianças com PC diparesia espástica. Para a análise do equilíbrio estático utilizou-se uma plataforma de pressão (Medicapteurs Fusyo) e a coleta foi realizada com a criança em pé, em duas condições:com órteses e sem órteses. Resultados: O GE sem órtese apresentou maiores oscilações, estatisticamente significantes, no sentido médio-lateral e na área total de oscilação quando comparado ao desempenho do GC. Conclusão: Os resultados apresentados sugerem que a utilização de órteses para membros inferiores possa influenciar no equilíbrio estático, diminuindo a oscilação durante a postura ortostática estática

Postural insoles on gait in children with cerebral palsy: Randomized controlled double-blind clinical trial

The aim of the present study was to assess the effect of postural insoles on gait performance in children with Cerebral Palsy (CP). Twenty four children between four and 12 years of age were randomly allocated either the control group (n = 12) or experimental group (n = 12). The control group used placebo insoles and the experimental group used postural insoles. Three-dimensional gait analysis was performed under three conditions: barefoot, in shoes and in shoes with insoles. Three evaluations were carried out: 1) immediately following placement of the insoles2) after three months of insole useand 3) one month after suspending insole use. Regarding the immediate effects and after three months use of insole, significant improvements in gait velocity and cadence were found in the experimental group, along with an increase in foot dorsiflexion, a reduction in knee flexion and a reduction in internal rotation. Conversely, these changes were not maintained in the third assessment, one month after withdrawal of the insoles. The use of postural insoles led to improvements in gait performance in children with CP. (C) 2017 Elsevier Ltd. All rights reserved.Conselho Nacional de Desenvolvimento Cientifico e Tecnologico (CNPq)Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior (CAPES)Fundacao de Amparo a Pesquisa (FAPESP)Univ Nove Julho, Sao Paulo, SP, BrazilUniv Sorocaba UNISO, Sorocaba, SP, BrazilBrazilian Coll Osteopathy CBO, Sao Paulo, BrazilCtr Pediat Neurosurg CENEPE Rehabil, Ave Dr Veiga Filho,350 Cj 604, BR-01229001 Sao Paulo, SP, BrazilUniv Fed Sao Paulo, NANI Educ & Saude Infancia & Adolescencia, Sao Paulo, SP, BrazilState Univ Midwest UNICENTRO, Physiotherapy Dept, Guairaca Coll, Guarapuava, Parana, BrazilUniv Nove Julho, Movement Anal Lab, Doctoral Program Rehabil Sci, Ave Francisco Matarazzo 612, BR-05001000 Sao Paulo, SP, BrazilPolitecn Milan, Dept Elect Informat & Bioengn, Via Giuseppe Colombo, I-20133 Milan, ItalyUniv Nove Julho, Movement Anal Lab, Master & Doctoral Programs Rehabil Sci, Ave Francisco Matarazzo 612, BR-05001000 Sao Paulo, SP, BrazilUniv Fed Sao Paulo, NANI Educ & Saude Infancia & Adolescencia, Sao Paulo, SP, BrazilFAPESP: 2015/14952-9Web of Scienc