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

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Abstract

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-9B5DH7

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Most cited references 20

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Cerebral location of international 10-20 system electrode placement.

Richard Homan, John Herman, Phillip Purdy (1987)

We employed CT scanning to correlate scalp markers placed according to the international 10-20 system with underlying cerebral structures. Subjects were 12 normal volunteers. Measurements included assessment for cranial asymmetry to determine the effect of skull asymmetry on cortical location of electrodes. Results were correlated with the cortical histological map of Brodmann. Primary cortical locations agree well with previously published data and provide cortical localization in greater detail than previous studies. Variability of cortical electrode location was substantial in some cases and not related to cranial asymmetry. The results indicate that CT scanning or other neuroimaging techniques which reveal detailed cerebral anatomy would be potentially highly useful in defining the generators of electrocerebral potentials recorded from the scalp.

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Symmetry and limb dominance in able-bodied gait: a review.

Heydar Sadeghi, Paul Allard, François Prince … (2000)

As one of the most universal of all human activities, gait in the able-bodied has received considerable attention, but many aspects still need to be clarified. Symmetry or asymmetry in the actions of the lower extremities during walking and the possible effect of laterality on gait are two prevalent and controversial issues. The purpose of this study was to review the work done over the last few decades in demonstrating: (a) whether or not the lower limbs behave symmetrically during able-bodied gait; and (b) how limb dominance affects the symmetrical or asymmetrical behavior of the lower extremities. The literature reviewed shows that gait symmetry has often been assumed, to simplify data collection and analysis. In contrast, asymmetrical behavior of the lower limbs during able-bodied ambulation was addressed in numerous investigations and was found to reflect natural functional differences between the lower extremities. These functional differences were probably related to the contribution of each limb in carrying out the tasks of propulsion and control during able-bodied walking. In current debates on gait symmetry in able-bodied subjects, laterality has been cited as an explanation for the existence of functional differences between the lower extremities, although a number of studies do not support the hypothesis of a relationship between gait symmetry and laterality. Further investigation is needed to demonstrate functional gait asymmetry and its relationship to laterality, taking into consideration the biomechanical aspects of gait.

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Is Open Access

Cortical activation changes underlying stimulation-induced behavioural gains in chronic stroke

Charlotte Jane Stagg, Velicia Bachtiar, Jacinta O'Shea … (2011)

Transcranial direct current stimulation, a form of non-invasive brain stimulation, is showing increasing promise as an adjunct therapy in rehabilitation following stroke. However, although significant behavioural improvements have been reported in proof-of-principle studies, the underlying mechanisms are poorly understood. The rationale for transcranial direct current stimulation as therapy for stroke is that therapeutic stimulation paradigms increase activity in ipsilesional motor cortical areas, but this has not previously been directly tested for conventional electrode placements. This study was performed to test directly whether increases in ipsilesional cortical activation with transcranial direct current stimulation are associated with behavioural improvements in chronic stroke patients. Patients at least 6 months post-first stroke participated in a behavioural experiment (n = 13) or a functional magnetic resonance imaging experiment (n = 11), each investigating the effects of three stimulation conditions in separate sessions: anodal stimulation to the ipsilesional hemisphere; cathodal stimulation to the contralesional hemisphere; and sham stimulation. Anodal (facilitatory) stimulation to the ipsilesional hemisphere led to significant improvements (5–10%) in response times with the affected hand in both experiments. This improvement was associated with an increase in movement-related cortical activity in the stimulated primary motor cortex and functionally interconnected regions. Cathodal (inhibitory) stimulation to the contralesional hemisphere led to a functional improvement only when compared with sham stimulation. We show for the first time that the significant behavioural improvements produced by anodal stimulation to the ipsilesional hemisphere are associated with a functionally relevant increase in activity within the ipsilesional primary motor cortex in patients with a wide range of disabilities following stroke.

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Author and article information

Contributors

Barry J. Byrne: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, USA )

ISSN (Electronic): 1932-6203

Publication date Collection: 2014

Publication date (Electronic): 29 August 2014

Volume: 9

Issue: 8

Electronic Location Identifier: e105777

Affiliations

[1 ]Master Program in Rehabilitation Sciences, Movement Analysis Lab, University Nove de Julho, São Paulo, São Paulo, Brazil

[2 ]Doctoral Program in Rehabilitation Sciences, Movement Analysis Lab, University Nove de Julho, São Paulo, São Paulo, Brazil

[3 ]Dept. of Electronic Information and Bioengineering, Politecnico di Milano and IRCCS San Raffaele Pisana, Rome

[4 ]Laboratory of Neuromodulation & Center of Clinical Research Learning, Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America

[5 ]Professor, Master and Doctoral Programs in Rehabilitation Sciences, Movement Analysis Lab, University Nove de Julho, São Paulo, São Paulo, Brazil

Earl and Christy Powell University, United States of America

Author notes

* E-mail: natycarvalho_fisio@ 123456hotmail.com

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: ND LG MG FF CO. Performed the experiments: ND LG MG FF CO. Analyzed the data: ND LG MG FF CO. Contributed reagents/materials/analysis tools: ND LG MG FF CO. Wrote the paper: ND LG MG FF CO.

Article

Publisher ID: PONE-D-13-52650

DOI: 10.1371/journal.pone.0105777

PMC ID: 4149519

PubMed ID: 25171216

SO-VID: 71c51bcd-af8d-4237-8f42-6f9a186df5c9

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 2 January 2014

Date accepted : 24 July 2014

Page count

Pages: 8

Funding

The authors gratefully acknowledge financial support from the Brazilian fostering agencies Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), and Fundação de Amparo á Pesquisa (FAPESP - 2012/24019-0). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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

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Abstract

Background

Methods

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Conclusion

Trial Registration

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Most cited references 20

Cerebral location of international 10-20 system electrode placement.

Symmetry and limb dominance in able-bodied gait: a review.

Cortical activation changes underlying stimulation-induced behavioural gains in chronic stroke

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