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Buccilli B. Exploring new horizons: Emerging therapeutic strategies for pediatric stroke. Exp Neurol 2024; 374:114701. [PMID: 38278205 DOI: 10.1016/j.expneurol.2024.114701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/31/2023] [Accepted: 01/23/2024] [Indexed: 01/28/2024]
Abstract
Pediatric stroke presents unique challenges, and optimizing treatment strategies is essential for improving outcomes in this vulnerable population. This review aims to provide an overview of new, innovative, and potential treatments for pediatric stroke, with a primary objective to stimulate further research in this field. Our review highlights several promising approaches in the realm of pediatric stroke management, including but not limited to stem cell therapy and robotic rehabilitation. These innovative interventions offer new avenues for enhancing functional recovery, reducing long-term disability, and tailoring treatments to individual patient needs. The findings of this review underscore the importance of ongoing research and development of innovative treatments in pediatric stroke. These advancements hold significant clinical relevance, offering the potential to improve the lives of children affected by stroke by enhancing the precision, efficacy, and accessibility of therapeutic interventions. Embracing these innovations is essential in our pursuit of better outcomes and a brighter future for pediatric stroke care.
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Affiliation(s)
- Barbara Buccilli
- Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, 1 Gustave L. Levy Pl, New York, NY 10029, United States of America.
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Effects of repetitive transcranial magnetic stimulation combined with action-observation-execution on social interaction and communication in autism spectrum disorder: Feasibility study. Brain Res 2023; 1804:148258. [PMID: 36702183 DOI: 10.1016/j.brainres.2023.148258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 01/12/2023] [Accepted: 01/20/2023] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To investigate the feasibility of a combined high-frequency rTMS (HF-rTMS) with action observation and execution (AOE) on social interaction and communication in children with Autistic Spectrum Disorder (ASD). MATERIALS AND METHODS Fifteen children underwent 10 sessions of 5-Hz HF-rTMS on the right inferior frontal gyrus combined with AOE. An experimental group received the real HF-rTMS while the control group received the sham one. For the AOE protocol, they were instructed to watch and imitate a video showing the procedure, including reaching and grasping tasks, gustatory tasks, and facial expressions. Their behavioural outcomes were evaluated using the Vineland Adaptive Behaviour Scale (VABS) and electroencephalograms (EEGs) recorded at three time points: baseline, immediately after each treatment, and at the 1-week follow-up after the 10th treatment. RESULTS There were increased VABS subitem scores in the experimental group, including the receptive, expressive, domestic, and community scores but no such increase was observed in the control group. For the EEG, the beta rhythm at C3 and C4 increased in the experimental group. Additionally, positive correlations were observed between changes in the scores for the expressive subitem and changes in the beta rhythm on the C4 electrode at baseline and immediately after treatment in the experimental group. The control group showed no significant differences in any items for both observation and imitation times. CONCLUSION Ten sessions of HF-rTMS combined with AOE could improve both the subitems of communication and daily living skills domain in children aged 7-12 years with ASD. Although it is still inconclusive, this behavioural improvement may be partly attributable to increased cortical activity, as evidenced by beta rhythms.
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Muacevic A, Adler JR, Varma A, Sharma NS, Vagha JD, Naqvi WM, Besekar S. Pediatric Patients With Hemiplegia: A Systematic Review of a Randomized Controlled Trial. Cureus 2023; 15:e34074. [PMID: 36843815 PMCID: PMC9946895 DOI: 10.7759/cureus.34074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/23/2023] [Indexed: 01/24/2023] Open
Abstract
Hemiplegia is the medical term for paralysis of one side of the body. It results in muscular wasting on the affected side, impairs gait, reduces motor abilities, and causes instability and a loss of grasping capacity. The patient's quality of life is impacted by hemiplegia because it impairs brain and spinal cord functions. Consequently, a range of therapeutic options, including physical therapy, medical health management, and other multidisciplinary care, are accessible. The effects of treatments on juvenile patients with hemiplegia who are participating in a randomized controlled trial (RCT) are examined in this systematic review. Using the Boolean operator "AND," the research process entailed searching for keywords like "Hemiplegia" and "Pediatrics." Based on the inclusion and exclusion criteria, a total of six RCTs were included in the study. According to the study's findings, hemiplegic patients benefited from Kinesio taping (KT), botulinum toxin type-A (BoNT-A), hyaluronic acid injections, and bimanual treatment.
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Xu G, Hao F, Zhao W, Qiu J, Zhao P, Zhang Q. The influential factors and non-pharmacological interventions of cognitive impairment in children with ischemic stroke. Front Neurol 2022; 13:1072388. [PMID: 36588886 PMCID: PMC9797836 DOI: 10.3389/fneur.2022.1072388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/23/2022] [Indexed: 12/23/2022] Open
Abstract
Background The prevalence of pediatric ischemic stroke rose by 35% between 1990 and 2013. Affected patients can experience the gradual onset of cognitive impairment in the form of impaired language, memory, intelligence, attention, and processing speed, which affect 20-50% of these patients. Only few evidence-based treatments are available due to significant heterogeneity in age, pathological characteristics, and the combined epilepsy status of the affected children. Methods We searched the literature published by Web of Science, Scopus, and PubMed, which researched non-pharmacological rehabilitation interventions for cognitive impairment following pediatric ischemic stroke. The search period is from the establishment of the database to January 2022. Results The incidence of such impairment is influenced by patient age, pathological characteristics, combined epilepsy status, and environmental factors. Non-pharmacological treatments for cognitive impairment that have been explored to date mainly include exercise training, psychological intervention, neuromodulation strategies, computer-assisted cognitive training, brain-computer interfaces (BCI), virtual reality, music therapy, and acupuncture. In childhood stroke, the only interventions that can be retrieved are psychological intervention and neuromodulation strategies. Conclusion However, evidence regarding the efficacy of these interventions is relatively weak. In future studies, the active application of a variety of interventions to improve pediatric cognitive function will be necessary, and neuroimaging and electrophysiological measurement techniques will be of great value in this context. Larger multi-center prospective longitudinal studies are also required to offer more accurate evidence-based guidance for the treatment of patients with pediatric stroke.
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Affiliation(s)
- Gang Xu
- Rehabilitation Branch, Tianjin Children's Hospital/Tianjin University Children's Hospital, Tianjin, China
| | - Fuchun Hao
- Medicine & Nursing Faculty, Tianjin Medical College, Tianjin, China
| | - Weiwei Zhao
- Chinese Teaching and Research Section, Tianjin Beichen Experimental Middle School, Tianjin, China
| | - Jiwen Qiu
- Research Center of Experimental Acupuncture Science, Tianjin University of Traditional Chinese Medicine, Tianjin, China,School of Medical Technology, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Peng Zhao
- Rehabilitation Branch, Tianjin Children's Hospital/Tianjin University Children's Hospital, Tianjin, China,*Correspondence: Peng Zhao
| | - Qian Zhang
- Child Health Care Department, Tianjin Beichen Women and Children Health Center, Tianjin, China,Qian Zhang
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Wu Q, Peng T, Liu L, Zeng P, Xu Y, Yang X, Zhao Y, Fu C, Huang S, Huang Y, Zhou H, Liu Y, Tang H, He L, Xu K. The Effect of Constraint-Induced Movement Therapy Combined With Repetitive Transcranial Magnetic Stimulation on Hand Function in Preschool Children With Unilateral Cerebral Palsy: A Randomized Controlled Preliminary Study. Front Behav Neurosci 2022; 16:876567. [PMID: 35449560 PMCID: PMC9017424 DOI: 10.3389/fnbeh.2022.876567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/02/2022] [Indexed: 11/13/2022] Open
Abstract
Constraint-induced movement therapy (CIMT) combined with repetitive transcranial magnetic stimulation (rTMS) have shown great potential in improving function in schoolchildren with unilateral cerebral palsy attributed to perinatal stroke. However, the prospect of application in preschool children with unilateral cerebral palsy (UCP) attributed to various brain disorders remains unclear. In this prospective, assessor-blinded, randomized controlled study, 40 preschool children with UCP (aged 2.5–6 years) were randomized to receive 10 days of CIMT combined with active or sham rTMS. Assessments were performed at baseline, 2 weeks, and 6 months post-intervention to investigate upper limb extremity, social life ability, and perceived changes by parents and motor-evoked potentials. Overall, 35 participants completed the trial. The CIMT plus active stimulation group had greater gains in the affected hand function (range of motion, accuracy, and fluency) than the CIMT plus sham stimulation group (P < 0.05), but there was no significant difference in muscular tone, social life ability, and perceived changes by parents between the two groups (P > 0.05). In addition, there was no significant difference in hand function between children with and without motor-evoked potential (P > 0.05). No participants reported severe adverse events during the study session. In short, the treatment of CIMT combined with rTMS is safe and feasible for preschool children with UCP attributed to various brain disorders. Randomized controlled studies with large samples and long-term effects are warranted.
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Affiliation(s)
- Qianwen Wu
- Department of Rehabilitation, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Tingting Peng
- Department of Rehabilitation, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Liru Liu
- Department of Rehabilitation, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Peishan Zeng
- Department of Rehabilitation, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yunxian Xu
- Department of Rehabilitation, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xubo Yang
- Department of Rehabilitation, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yiting Zhao
- Department of Rehabilitation, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Chaoqiong Fu
- Department of Rehabilitation, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Shiya Huang
- Department of Rehabilitation, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yuan Huang
- Department of Rehabilitation, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
- School of Medicine, South China University of Technology, Guangzhou, China
| | - Hongyu Zhou
- Department of Rehabilitation, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yun Liu
- Department of Rehabilitation, Kunming Children's Hospital, Kunming, China
| | - Hongmei Tang
- Department of Rehabilitation, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Lu He
- Department of Rehabilitation, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
- Lu He
| | - Kaishou Xu
- Department of Rehabilitation, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
- *Correspondence: Kaishou Xu ; orcid.org/0000-0002-0639-3488
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Giovannini E, Giorgetti A, Pelletti G, Giusti A, Garagnani M, Pascali JP, Pelotti S, Fais P. Importance of dashboard camera (Dash Cam) analysis in fatal vehicle-pedestrian crash reconstruction. Forensic Sci Med Pathol 2021; 17:379-387. [PMID: 34013466 PMCID: PMC8413177 DOI: 10.1007/s12024-021-00382-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2021] [Indexed: 11/30/2022]
Abstract
The reconstruction of dynamic of traffic injuries remains a challenge in forensic pathology and is often based on circumstantial data. Dash Cams are digital video recorders which can be located inside a vehicle and continuously record the view through the windscreen, thus providing objective evidence. Here we present the case of a traffic crash in which a pedestrian was hit by an articulated lorry. The analysis of a video recorded from a Dash Cam retrieved inside the vehicle during the death scene investigation (DSI) was crucial in the reconstruction of the manner of death. Indeed, the death, which was initially assumed to be accidental, was finally deemed as a suicide on the basis of the video recording, which showed an intentional and sudden rush of the victim to the middle of the roadway. Advantages and disadvantages of the use of Dash Cams will be discussed, focusing on the profound differences in the related national and international regulations. Based on the present case, in traffic crashes, the search for Dash Cams during the DSI may be recommended and the video recordings should be analyzed in the setting of a multidisciplinary and multimodal evaluation of the case, for a proper reconstruction of the facts.
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Affiliation(s)
- Elena Giovannini
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy
| | - Arianna Giorgetti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy
| | - Guido Pelletti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy.
| | - Alessio Giusti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy
| | - Marco Garagnani
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy
| | - Jennifer Paola Pascali
- Department of Cardiologic, Thoracic and Vascular Sciences, University of Padova, Via Giustiniani, 2 35127, Padova, Italy
| | - Susi Pelotti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy
| | - Paolo Fais
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy
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7
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Perinatal stroke: mapping and modulating developmental plasticity. Nat Rev Neurol 2021; 17:415-432. [PMID: 34127850 DOI: 10.1038/s41582-021-00503-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 02/04/2023]
Abstract
Most cases of hemiparetic cerebral palsy are caused by perinatal stroke, resulting in lifelong disability for millions of people. However, our understanding of how the motor system develops following such early unilateral brain injury is increasing. Tools such as neuroimaging and brain stimulation are generating informed maps of the unique motor networks that emerge following perinatal stroke. As a focal injury of defined timing in an otherwise healthy brain, perinatal stroke represents an ideal human model of developmental plasticity. Here, we provide an introduction to perinatal stroke epidemiology and outcomes, before reviewing models of developmental plasticity after perinatal stroke. We then examine existing therapeutic approaches, including constraint, bimanual and other occupational therapies, and their potential synergy with non-invasive neurostimulation. We end by discussing the promise of exciting new therapies, including novel neurostimulation, brain-computer interfaces and robotics, all focused on improving outcomes after perinatal stroke.
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O'Leary GH, Jenkins DD, Coker-Bolt P, George MS, Kautz S, Bikson M, Gillick BT, Badran BW. From adults to pediatrics: A review noninvasive brain stimulation (NIBS) to facilitate recovery from brain injury. PROGRESS IN BRAIN RESEARCH 2021; 264:287-322. [PMID: 34167660 DOI: 10.1016/bs.pbr.2021.01.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Stroke is a major problem worldwide that impacts over 100 million adults and children annually. Rehabilitation therapy is the current standard of care to restore functional impairments post-stroke, however its effects are limited and many patients suffer persisting functional impairments and life-long disability. Noninvasive Brain Stimulation (NIBS) has emerged as a potential rehabilitation treatment option in both adults and children with brain injury. In the last decade, Transcranial Magnetic Stimulation (TMS), Transcranial Direct Current Stimulation (tDCS) and Transcutaneous Auricular Vagus Nerve Stimulation (taVNS) have been investigated to improve motor recovery in adults post-stroke. These promising adult findings using NIBS, however, have yet to be widely translated to the area of pediatrics. The limited studies exploring NIBS in children have demonstrated safety, feasibility, and utility of stimulation-augmented rehabilitation. This chapter will describe the mechanism of NIBS therapy (cortical excitability, neuroplasticity) that underlies its use in stroke and motor function and how TMS, tDCS, and taVNS are applied in adult stroke treatment paradigms. We will then discuss the current state of NIBS in early pediatric brain injury and will provide insight regarding practical considerations and future applications of NIBS in pediatrics to make this promising treatment option a viable therapy in children.
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Affiliation(s)
- Georgia H O'Leary
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Dorothea D Jenkins
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Patricia Coker-Bolt
- Division of Occupational Therapy, College of Health Professions, Medical University of South Carolina, Charleston, SC, United States
| | - Mark S George
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States; Ralph H. Johnson VA Medical Center, Charleston, SC, United States
| | - Steve Kautz
- Ralph H. Johnson VA Medical Center, Charleston, SC, United States; Department of Health Sciences and Research, Medical University of South Carolina, Charleston, SC, United States
| | - Marom Bikson
- Department of Biomedical Engineering, City College of New York, New York, NY, United States
| | - Bernadette T Gillick
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Bashar W Badran
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States.
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Lench DH, Simpson E, Sutter EN, Gillick BT. Feasibility of remote transcranial direct current stimulation for pediatric cerebral palsy during the COVID-19 pandemic. Brain Stimul 2020; 13:1803-1804. [PMID: 33132132 DOI: 10.1016/j.brs.2020.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/15/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022] Open
Affiliation(s)
- Daniel H Lench
- Department of Neurology, Medical University of South Carolina, 208 Rutledge Avenue, Charleston, SC, 29425, USA
| | - Emma Simpson
- Department of Rehabilitation Medicine, University of Minnesota, MMC 388, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Ellen N Sutter
- Department of Rehabilitation Medicine, University of Minnesota, MMC 388, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Bernadette T Gillick
- Department of Rehabilitation Medicine, University of Minnesota, MMC 388, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
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Hollis A, Zewdie E, Nettel-Aguirre A, Hilderley A, Kuo HC, Carlson HL, Kirton A. Transcranial Static Magnetic Field Stimulation of the Motor Cortex in Children. Front Neurosci 2020; 14:464. [PMID: 32508570 PMCID: PMC7248312 DOI: 10.3389/fnins.2020.00464] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 04/15/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Non-invasive neuromodulation is an emerging therapy for children with early brain injury but is difficult to apply to preschoolers when windows of developmental plasticity are optimal. Transcranial static magnetic field stimulation (tSMS) decreases primary motor cortex (M1) excitability in adults but effects on the developing brain are unstudied. OBJECTIVE/HYPOTHESIS We aimed to determine the effects of tSMS on cortical excitability and motor learning in healthy children. We hypothesized that tSMS over right M1 would reduce cortical excitability and inhibit contralateral motor learning. METHODS This randomized, sham-controlled, double-blinded, three-arm, cross-over trial enrolled 24 healthy children aged 10-18 years. Transcranial Magnetic Stimulation (TMS) assessed cortical excitability via motor-evoked potential (MEP) amplitude and paired pulse measures. Motor learning was assessed via the Purdue Pegboard Test (PPT). A tSMS magnet (677 Newtons) or sham was held over left or right M1 for 30 min while participants trained the non-dominant hand. A linear mixed effect model was used to examine intervention effects. RESULTS All 72 tSMS sessions were well tolerated without serious adverse effects. Neither cortical excitability as measured by MEPs nor paired-pulse intracortical neurophysiology was altered by tSMS. Possible behavioral effects included contralateral tSMS inhibiting early motor learning (p < 0.01) and ipsilateral tSMS facilitating later stages of motor learning (p < 0.01) in the trained non-dominant hand. CONCLUSION tSMS is feasible in pediatric populations. Unlike adults, tSMS did not produce measurable changes in MEP amplitude. Possible effects of M1 tSMS on motor learning require further study. Our findings support further exploration of tSMS neuromodulation in young children with cerebral palsy.
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Affiliation(s)
- Asha Hollis
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ephrem Zewdie
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alberto Nettel-Aguirre
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alicia Hilderley
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Hsing-Ching Kuo
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Helen L. Carlson
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Adam Kirton
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Nemanich ST, Rich TL, Chen CY, Menk J, Rudser K, Chen M, Meekins G, Gillick BT. Influence of Combined Transcranial Direct Current Stimulation and Motor Training on Corticospinal Excitability in Children With Unilateral Cerebral Palsy. Front Hum Neurosci 2019; 13:137. [PMID: 31105541 PMCID: PMC6492624 DOI: 10.3389/fnhum.2019.00137] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/08/2019] [Indexed: 11/13/2022] Open
Abstract
Combined non-invasive brain stimulation (NIBS) and rehabilitation interventions have the potential to improve function in children with unilateral cerebral palsy (UCP), however their effects on developing brain function are not well understood. In a proof-of-principle study, we used single-pulse transcranial magnetic stimulation (TMS) to measure changes in corticospinal excitability and relationships to motor performance following a randomized controlled trial consisting of 10 days of combined constraint-induced movement therapy (CIMT) and cathodal transcranial direct current stimulation (tDCS) applied to the contralesional motor cortex. Twenty children and young adults (mean age = 12 years, 9 months, range = 7 years, 7 months, 21 years, 7 months) with UCP participated. TMS testing was performed before, after, and 6 months after the intervention to measure motor evoked potential (MEP) amplitude and cortical silent period (CSP) duration. The association between neurophysiologic and motor outcomes and differences in excitability between hemispheres were examined. Contralesional MEP amplitude decreased as hypothesized in five of five participants receiving active tDCS immediately after and 6 months after the intervention, however no statistically significant differences between intervention groups were noted for MEP amplitude [mean difference = −323.9 μV, 95% CI = (−989, 341), p = 0.34] or CSP duration [mean difference = 3.9 ms, 95% CI = (−7.7, 15.5), p = 0.51]. Changes in corticospinal excitability were not statistically associated with improvements in hand function after the intervention. Across all participants, MEP amplitudes measured in the more-affected hand from both contralesional (mean difference = −474.5 μV) and ipsilesional hemispheres (−624.5 μV) were smaller compared to the less-affected hand. Assessing neurophysiologic changes after tDCS in children with UCP provides an understanding of long-term effects on brain excitability to help determine its potential as a therapeutic intervention. Additional investigation into the neurophysiologic effects of tDCS in larger samples of children with UCP are needed to confirm these findings.
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Affiliation(s)
- Samuel T Nemanich
- Divisions of Physical Therapy and Rehabilitation Science, Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Tonya L Rich
- Divisions of Physical Therapy and Rehabilitation Science, Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Chao-Ying Chen
- Divisions of Physical Therapy and Rehabilitation Science, Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, United States.,Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Jeremiah Menk
- Clinical and Translational Science Institute, Biostatistics, Design, and Analysis Center, University of Minnesota, Minneapolis, MN, United States
| | - Kyle Rudser
- School of Public Health, Division of Biostatistics, University of Minnesota, Minneapolis, MN, United States
| | - Mo Chen
- Non-invasive Neuromodulation Laboratory, University of Minnesota, Minneapolis, MN, United States
| | - Gregg Meekins
- Department of Neurology, University of Minnesota, Minneapolis, MN, United States
| | - Bernadette T Gillick
- Divisions of Physical Therapy and Rehabilitation Science, Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, United States
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Hoare BJ, Wallen MA, Thorley MN, Jackman ML, Carey LM, Imms C. Constraint-induced movement therapy in children with unilateral cerebral palsy. Cochrane Database Syst Rev 2019; 4:CD004149. [PMID: 30932166 PMCID: PMC6442500 DOI: 10.1002/14651858.cd004149.pub3] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Unilateral cerebral palsy (CP) is a condition that affects muscle control and function on one side of the body. Children with unilateral CP experience difficulties using their hands together secondary to disturbances that occur in the developing fetal or infant brain. Often, the more affected limb is disregarded. Constraint-induced movement therapy (CIMT) aims to increase use of the more affected upper limb and improve bimanual performance. CIMT is based on two principles: restraining the use of the less affected limb (for example, using a splint, mitt or sling) and intensive therapeutic practice of the more affected limb. OBJECTIVES To evaluate the effect of constraint-induced movement therapy (CIMT) in the treatment of the more affected upper limb in children with unilateral CP. SEARCH METHODS In March 2018 we searched CENTRAL, MEDLINE, Embase, CINAHL, PEDro, OTseeker, five other databases and three trials registers. We also ran citation searches, checked reference lists, contacted experts, handsearched key journals and searched using Google Scholar. SELECTION CRITERIA Randomised controlled trials (RCTs), cluster-RCTs or clinically controlled trials implemented with children with unilateral CP, aged between 0 and 19 years, where CIMT was compared with a different form of CIMT, or a low dose, high-dose or dose-matched alternative form of upper-limb intervention such as bimanual intervention. Primarily, outcomes were bimanual performance, unimanual capacity and manual ability. Secondary outcomes included measures of self-care, body function, participation and quality of life. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts to eliminate ineligible studies. Five review authors were paired to extract data and assess risk of bias in each included study. GRADE assessments were undertaken by two review authors. MAIN RESULTS We included 36 trials (1264 participants), published between 2004 and 2018. Sample sizes ranged from 11 to 105 (mean 35). Mean age was 5.96 years (standard deviation (SD) 1.82), range three months to 19.8 years; 53% male and 47% participants had left hemiplegia. Fifty-seven outcome measures were used across studies. Average length of CIMT programs was four weeks (range one to 10 weeks). Frequency of sessions ranged from twice weekly to seven days per week. Duration of intervention sessions ranged from 0.5 to eight hours per day. The mean total number of hours of CIMT provided was 137 hours (range 20 to 504 hours). The most common constraint devices were a mitt/glove or a sling (11 studies each).We judged the risk of bias as moderate to high across the studies. KEY RESULTS Primary outcomes at primary endpoint (immediately after intervention)CIMT versus low-dose comparison (e.g. occupational therapy)We found low-quality evidence that CIMT was more effective than a low-dose comparison for improving bimanual performance (mean difference (MD) 5.44 Assisting Hand Assessment (AHA) units, 95% confidence interval (CI) 2.37 to 8.51).CIMT was more effective than a low-dose comparison for improving unimanual capacity (Quality of upper extremity skills test (QUEST) - Dissociated movement MD 5.95, 95% CI 2.02 to 9.87; Grasps; MD 7.57, 95% CI 2.10 to 13.05; Weight bearing MD 5.92, 95% CI 2.21 to 9.6; Protective extension MD 12.54, 95% CI 8.60 to 16.47). Three studies reported adverse events, including frustration, constraint refusal and reversible skin irritations from casting.CIMT versus high-dose comparison (e.g. individualised occupational therapy, bimanual therapy)When compared with a high-dose comparison, CIMT was not more effective for improving bimanual performance (MD -0.39 AHA Units, 95% CI -3.14 to 2.36). There was no evidence that CIMT was more effective than a high-dose comparison for improving unimanual capacity in a single study using QUEST (Dissociated movement MD 0.49, 95% CI -10.71 to 11.69; Grasp MD -0.20, 95% CI -11.84 to 11.44). Two studies reported that some children experienced frustration participating in CIMT.CIMT versus dose-matched comparison (e.g. Hand Arm Bimanual Intensive Therapy, bimanual therapy, occupational therapy)There was no evidence of differences in bimanual performance between groups receiving CIMT or a dose-matched comparison (MD 0.80 AHA units, 95% CI -0.78 to 2.38).There was no evidence that CIMT was more effective than a dose-matched comparison for improving unimanual capacity (Box and Blocks Test MD 1.11, 95% CI -0.06 to 2.28; Melbourne Assessment MD 1.48, 95% CI -0.49 to 3.44; QUEST Dissociated movement MD 6.51, 95% CI -0.74 to 13.76; Grasp, MD 6.63, 95% CI -2.38 to 15.65; Weightbearing MD -2.31, 95% CI -8.02 to 3.40) except for the Protective extension domain (MD 6.86, 95% CI 0.14 to 13.58).There was no evidence of differences in manual ability between groups receiving CIMT or a dose-matched comparison (ABILHAND-Kids MD 0.74, 95% CI 0.31 to 1.18). From 15 studies, two children did not tolerate CIMT and three experienced difficulty. AUTHORS' CONCLUSIONS The quality of evidence for all conclusions was low to very low. For children with unilateral CP, there was some evidence that CIMT resulted in improved bimanual performance and unimanual capacity when compared to a low-dose comparison, but not when compared to a high-dose or dose-matched comparison. Based on the evidence available, CIMT appears to be safe for children with CP.
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Affiliation(s)
- Brian J Hoare
- Monash Children's HospitalVictorian Paediatric Rehabilitation Service246 Clayton RdClaytonVictoriaAustralia3168
| | - Margaret A Wallen
- Australian Catholic UniversitySchool of Allied Health, Faculty of Health SciencesNorth SydneyAustralia
| | - Megan N Thorley
- Royal Children's HospitalRehabilitationHerston RoadBrisbaneQueenslandAustralia4006
| | - Michelle L Jackman
- John Hunter Children's HospitalPaediatric Occupational TherapyLambton RoadNew LambtonNew South WalesAustralia2310
| | - Leeanne M Carey
- Florey Institute of Neuroscience and Mental Health, The University of MelbourneNeurorehabilitation and Recovery, Stroke DivisionMelbourneVictoriaAustralia3081
| | - Christine Imms
- Australian Catholic UniversityCentre for Disability & Development ResearchLevel 2, Daniel Mannix Building17 Young StreetMelbourneVictoriaAustralia3065
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Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2019; 50:e51-e96. [DOI: 10.1161/str.0000000000000183] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Xiang H, Sun J, Tang X, Zeng K, Wu X. The effect and optimal parameters of repetitive transcranial magnetic stimulation on motor recovery in stroke patients: a systematic review and meta-analysis of randomized controlled trials. Clin Rehabil 2019; 33:847-864. [PMID: 30773896 DOI: 10.1177/0269215519829897] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The primary aim of this meta-analysis was to evaluate the effects of repetitive transcranial magnetic stimulation (rTMS) on limb movement recovery post-stroke and cortex excitability, to explore the optimal parameters of rTMS and suitable stroke population. Second, adverse events were also included. DATA SOURCES The databases of PubMed, EBSCO, MEDLINE, the Cochrane Central Register of Controlled Trials, EBM Reviews-Cochrane Database, the Chinese National Knowledge Infrastructure, and the Chinese Science and Technology Journals Database were searched for randomized controlled trials exploring the effects of rTMS on limb motor function recovery post-stroke before December 2018. REVIEW METHODS The effect sizes of rTMS on limb motor recovery, the effect size of rTMS stimulation parameters, and different stroke population were summarized by calculating the standardized mean difference (SMD) and the 95% confidence interval using fixed/random effect models as appropriate. RESULTS For the motor function assessment, 42 eligible studies involving 1168 stroke patients were identified. The summary effect size indicated that rTMS had positive effects on limb motor recovery (SMD = 0.50, P < 0.00001) and activities of daily living (SMD = 0.82, P < 0.00001), and motor-evoked potentials of the stimulated hemisphere differed according to the stimulation frequency, that is, the high-frequency group (SMD = 0.57, P = 0.0006), except the low-frequency group (SMD = -0.27, P = 0.05). No significant differences were observed among the stimulation parameter subgroups except for the sessions subgroup ( P = 0.02). Only 10 included articles reported transient mild discomfort after rTMS. CONCLUSIONS rTMS promoted the recovery of limb motor function and changed the cortex excitability. rTMS may be better for early and pure subcortical stroke patients. Regarding different stimulation parameters, the number of stimulation sessions has an impact on the effect of rTMS.
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Affiliation(s)
- Huifang Xiang
- 1 Department of Rehabilitation Medicine, Chonggang General Hospital, Chongqing, China
| | - Jing Sun
- 2 Department of Gastrointestinal Neonatal Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xiang Tang
- 3 Department of Neurology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kebin Zeng
- 3 Department of Neurology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiushu Wu
- 3 Department of Neurology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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EMG breakthrough during cortical silent period in congenital hemiparesis: a descriptive case series. Braz J Phys Ther 2018; 24:20-29. [PMID: 30471965 DOI: 10.1016/j.bjpt.2018.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 10/30/2018] [Accepted: 11/06/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The cortical silent period is a transient suppression of electromyographic activity after a transcranial magnetic stimulation pulse, attributed to spinal and supraspinal inhibitory mechanisms. Electromyographic breakthrough activity has been observed in healthy adults as a result of a spinal reflex response within the cortical silent period. OBJECTIVES The objective of this case series is to report the ipsilesional and contralesional cortical silent period and the electromyographic breakthrough activity of 7 children with congenital hemiparesis. METHODS TMS was delivered over the ipsilesional and contralesional primary motor cortices with resting motor threshold and cortical silent period measures recorded from first dorsal interosseous muscle. RESULTS Seven children (13±2 years) were included. Ipsilesional and contralesional resting motor thresholds ranged from 49 to 80% and from 38 to 63% of maximum stimulator output, respectively. Ipsilesional (n=4) and contralesional (n=7) cortical silent period duration ranged from 49 to 206ms and 81 to 150ms, respectively. Electromyographic breakthrough activity was observed ipsilesionally in 3/4 (75%) and contralesionally in 3/7 (42.8%) participants. In the 3 children with ipsilesional breakthrough activity during the cortical silent period, all testing trials showed breakthrough. Contralesional breakthrough activity was observed in only one of the analyzable trials in each of those 3 participants. The mean peak amplitude of breakthrough activity ranged from 45 to 214μV (ipsilesional) and from 23 to 93μV (contralesional). CONCLUSION Further research is warranted to understand the mechanisms and significance of electromyographic breakthrough activity within the cortical silent period in congenital hemiparesis. Understanding these mechanisms may lead to the design of tailored neuromodulation interventions for physical rehabilitation. TRIAL REGISTRATION NCT02250092 (https://clinicaltrials.gov/ct2/show/NCT02250092).
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Gillick B, Rich T, Nemanich S, Chen CY, Menk J, Mueller B, Chen M, Ward M, Meekins G, Feyma T, Krach L, Rudser K. Transcranial direct current stimulation and constraint-induced therapy in cerebral palsy: A randomized, blinded, sham-controlled clinical trial. Eur J Paediatr Neurol 2018; 22:358-368. [PMID: 29456128 PMCID: PMC5899638 DOI: 10.1016/j.ejpn.2018.02.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 01/22/2018] [Accepted: 02/01/2018] [Indexed: 12/16/2022]
Abstract
We investigated the safety, feasibility, and efficacy of transcranial direct current stimulation (tDCS) combined with constraint-induced movement therapy (CIMT) in children and young adults with unilateral cerebral palsy. Twenty participants were randomized to receive active or sham tDCS. The intervention consisted of 10 consecutive weekday sessions of tDCS applied to the non-lesioned hemisphere (20 min) concurrently with CIMT (120 min). Participants, caregivers, and interventionists were blinded to group assignment. The primary safety outcome investigated adverse events. The primary behavioral outcome was the Assisting Hand Assessment. All 20 participants (mean age = 12.7 yrs, range = 7.4-21.6 years) were evaluated for the primary outcomes. No serious adverse events occurred, and the most commonly reported minor adverse events were headache and itchiness. Both groups demonstrated a significant improvement in hand function after the intervention, although no significant effect of tDCS was observed (between-group difference = -2.18, 95% CI = [-6.48, 2.12], p = 0.30). Although hand function improved overall, no significant differences between intervention groups were found. Children with preserved corticospinal tract circuitry from the lesioned hemisphere, compared to those without, showed greater improvement in hand function (mean difference = 3.04, 95% CI = [-0.64, 6.72], p = 0.099). Our study demonstrates the safety and feasibility of serial sessions of tDCS, and presents preliminary evidence for the effect of CST circuitry on outcomes following tDCS/CIMT. Future work in children with unilateral cerebral palsy should focus on the optimal dosing and consider individual brain circuitry when describing response to combined interventions. CLINICAL TRIALS REGISTRATION Clinicaltrials.govNCT 02250092.
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Affiliation(s)
- Bernadette Gillick
- Department of Rehabilitation Medicine, University of Minnesota, 420 Delaware St SE, MMC 388, Minneapolis, MN, 55455, USA.
| | - Tonya Rich
- Department of Rehabilitation Medicine, University of Minnesota, 420 Delaware St SE, MMC 388, Minneapolis, MN, 55455, USA
| | - Samuel Nemanich
- Department of Rehabilitation Medicine, University of Minnesota, 420 Delaware St SE, MMC 388, Minneapolis, MN, 55455, USA
| | - Chao-Ying Chen
- Department of Rehabilitation Medicine, University of Minnesota, 420 Delaware St SE, MMC 388, Minneapolis, MN, 55455, USA
| | - Jeremiah Menk
- School of Public Health, Division of Biostatistics, University of Minnesota, 420 Delaware St SE, MMC 303, Minneapolis, MN, 55455, USA
| | - Bryon Mueller
- Department of Psychiatry, University of Minnesota, 2450 Riverside Ave. S, Minneapolis, MN, 55454, USA
| | - Mo Chen
- Institute for Engineering and Medicine, University of Minnesota, 420 Delaware St. SE, MMC 609, Minneapolis, MN, 55455, USA
| | - Marcie Ward
- Gillette Children's Specialty Healthcare, 200 East University Ave., St. Paul, MN, 55101, USA
| | - Gregg Meekins
- Department of Neurology, University of Minnesota, 420 Delaware St SE, MMC 295, Minneapolis, MN, 55455, USA
| | - Tim Feyma
- Gillette Children's Specialty Healthcare, 200 East University Ave., St. Paul, MN, 55101, USA
| | - Linda Krach
- Courage Kenny Rehabilitation Institute, 800 East 28th St., Minneapolis, MN, 55407, USA
| | - Kyle Rudser
- School of Public Health, Division of Biostatistics, University of Minnesota, 420 Delaware St SE, MMC 303, Minneapolis, MN, 55455, USA
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Understanding Brain Reorganization in Infants With Perinatal Stroke Through Neuroexcitability and Neuroimaging. Pediatr Phys Ther 2017; 29:173-178. [PMID: 28350777 PMCID: PMC5560124 DOI: 10.1097/pep.0000000000000365] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE The primary aim of this proposed study is to evaluate brain reorganization patterns in infants with perinatal stroke between 3 and 5 months of age using transcranial magnetic stimulation and magnetic resonance imaging, with the addition of the General Movements Assessment. A secondary aim is to demonstrate feasibility and safety of infant-appropriate brain assessment protocols. METHODS Ten infants with perinatal stroke will be enrolled. In this exploratory study, infants will first receive magnetic resonance imaging scanning during natural sleep to examine their corticospinal tract integrity. Infants will then receive transcranial magnetic stimulation to assess their corticomotor excitability. A General Movements Assessment video of at least 5 minutes will also be recorded. DISCUSSION Study results will enhance our understanding of brain reorganization in infants with perinatal stroke. We expect these results will also guide the development of early interventions designed to mitigate maladaptive neuroplastic changes and improve long-term motor outcomes.
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Rich T, Cassidy J, Menk J, Van Heest A, Krach L, Carey J, Gillick BT. Stability of stereognosis after pediatric repetitive transcranial magnetic stimulation and constraint-induced movement therapy clinical trial. Dev Neurorehabil 2017; 20:169-172. [PMID: 26985568 PMCID: PMC5490365 DOI: 10.3109/17518423.2016.1139008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Poor sensibility affecting stereognosis, the ability to discriminate objects without visual input, can potentiate disuse of the paretic limb following stroke. The purpose of this study was to examine potential change in stereognosis after intervention. METHODS Stereognosis testing in a secondary subgroup of 10 children with hemiparesis and baseline stereognosis deficits (ages 11-16) after a 13-day clinical trial of real or sham repetitive transcranial magnetic stimulation (rTMS) and constraint-induced movement therapy (CIMT) is reported. All children received 10 h of CIMT while wearing a cast full-time. RESULTS Post-trial, 80% of participants from both intervention groups demonstrated improvement in stereognosis (95% CI: 44.4%-97.5%). Pre-trial to long-term follow-up (range: 21-57 months), 60% retained gains or improved (95% CI: 26.2%-87.8%). Between-group differences were not detected. DISCUSSION Children demonstrated stereognosis change following intervention. Research on this change and potential minimal clinically important differences are indicated.
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Affiliation(s)
- Tonya Rich
- Department of Physical Medicine and Rehabilitation Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Jessica Cassidy
- Department of Physical Medicine and Rehabilitation Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Jeremiah Menk
- Biostatistician Clinical and Translational Science Institute, Minneapolis, MN, USA
| | - Ann Van Heest
- Department of Orthopedic Surgery, Minneapolis, MN, USA
| | - Linda Krach
- Courage Kenny Rehabilitation Institute, part of Allina Health, Minneapolis, MN, USA
| | - James Carey
- Department of Physical Medicine and Rehabilitation Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Bernadette T. Gillick
- Department of Physical Medicine and Rehabilitation Medical School, University of Minnesota, Minneapolis, MN, USA
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Safety of Transcranial Magnetic Stimulation in Children: A Systematic Review of the Literature. Pediatr Neurol 2017; 68:3-17. [PMID: 28216033 PMCID: PMC5346461 DOI: 10.1016/j.pediatrneurol.2016.12.009] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 12/02/2016] [Accepted: 12/19/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Data and best practice recommendations for transcranial magnetic stimulation (TMS) use in adults are largely available. Although there are fewer data in pediatric populations and no published guidelines, its practice in children continues to grow. METHODS We performed a literature search through PubMed to review all TMS studies from 1985 to 2016 involving children and documented any adverse events. Crude risks were calculated per session. RESULTS Following data screening we identified 42 single-pulse and/or paired-pulse TMS studies involving 639 healthy children, 482 children with central nervous system disorders, and 84 children with epilepsy. Adverse events occurred at rates of 3.42%, 5.97%, and 4.55% respective to population and number of sessions. We also report 23 repetitive TMS studies involving 230 central nervous system and 24 children with epilepsy with adverse event rates of 3.78% and 0.0%, respectively. We finally identified three theta-burst stimulation studies involving 90 healthy children, 40 children with central nervous system disorder, and no epileptic children, with adverse event rates of 9.78% and 10.11%, respectively. Three seizures were found to have occurred in central nervous system disorder individuals during repetitive TMS, with a risk of 0.14% per session. There was no significant difference in frequency of adverse events by group (P = 0.988) or modality (P = 0.928). CONCLUSIONS Available data suggest that risk from TMS/theta-burst stimulation in children is similar to adults. We recommend that TMS users in this population follow the most recent adult safety guidelines until sufficient data are available for pediatric specific guidelines. We also encourage continued surveillance through surveys and assessments on a session basis.
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Rich TL, Menk J, Krach LE, Feyma T, Gillick BT. Repetitive Transcranial Magnetic Stimulation/Behavioral Intervention Clinical Trial: Long-Term Follow-Up of Outcomes in Congenital Hemiparesis. J Child Adolesc Psychopharmacol 2016; 26:598-605. [PMID: 26905272 PMCID: PMC5335747 DOI: 10.1089/cap.2015.0157] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to examine long-term outcomes of nonpharmacological intervention in children and adolescents with stroke utilizing repetitive transcranial magnetic stimulation (rTMS) to the primary motor cortex combined with constraint- induced movement therapy (CIMT) to improve motor function in the paretic hand. Outcome measures included function, satisfaction, and medical status review. METHODS Fourteen of the original 19 participants (74%) from our rTMS/CIMT clinical trial (real rTMS+CIMT, n = 8; and sham rTMS+CIMT, n = 6) were evaluated. The median age of the subjects at follow up was 13.4 years (range 11-20 years old, 50% male). Median time to follow-up was 47.5 months (range 21-57 months). Descriptive statistics were conducted using frequencies and counts. Motor performance was measured using the Assisting Hand Assessment (AHA) and Canadian Occupational Performance Measure (COPM). Satisfaction was reported with use of the COPM and TMS Tolerance Survey. Open-ended interview was conducted for feedback on study experience and subjective perspectives of current functional status. RESULTS Overall, seven of eight individuals who received real rTMS and five of six individuals who received sham rTMS maintained or improved AHA scores. Six of 14 participants reported new onset of co-occurring conditions (four individuals in the real rTMS group, two individuals in the sham rTMS group). The majority (86%) of participants reported study satisfaction. Review of medical status revealed co-occurring conditions including: Epilepsy, obsessive-compulsive disorder, anxiety, depression, unspecified mood disorder, and undiagnosed inattentiveness. CONCLUSIONS Long-term outcomes of rTMS/CIMT in pediatric stroke were investigated. Variability in performance and unattributed symptoms were noted. Considering the prevalence of co-occurring conditions in children and adolescents with stroke, new-onset symptoms were not attributed to original intervention. With the small sample size, the impact of rTMS on long-term outcomes cannot be fully determined from these data. Characterizing long-term outcomes through performance, participant perspectives, and medical status allows comprehensive assessment of rTMS/CIMT intervention efficacy.
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Affiliation(s)
- Tonya L. Rich
- Rehabilitation Science, University of Minnesota, Minneapolis, Minnesota
| | - Jeremiah Menk
- Clinical and Translational Science Institute, Minneapolis, Minnesota
| | - Linda E. Krach
- Courage Kenny Rehabilitation Institute, part of Allina Health, Minneapolis, Minnesota
| | - Timothy Feyma
- Gillette Children's Specialty Healthcare, St. Paul, Minnesota
| | - Bernadette T. Gillick
- Department of Physical Medicine and Rehabilitation, Program in Physical Therapy, University of Minnesota, Medical School, Minneapolis, Minnesota
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Rosa M, De Lucia S, Rinaldi VE, Le Gal J, Desmarest M, Veropalumbo C, Romanello S, Titomanlio L. Paediatric arterial ischemic stroke: acute management, recent advances and remaining issues. Ital J Pediatr 2015; 41:95. [PMID: 26631262 PMCID: PMC4668709 DOI: 10.1186/s13052-015-0174-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 09/21/2015] [Indexed: 01/06/2023] Open
Abstract
Stroke is a rare disease in childhood with an estimated incidence of 1-6/100.000. It has an increasingly recognised impact on child mortality along with its outcomes and effects on quality of life of patients and their families. Clinical presentation and risk factors of paediatric stroke are different to those of adults therefore it can be considered as an independent nosological entity. The relative rarity, the age-related peculiarities and the variety of manifested symptoms makes the diagnosis of paediatric stroke extremely difficult and often delayed. History and clinical examination should investigate underlying diseases or predisposing factors and should take into account the potential territoriality of neurological deficits and the spectrum of differential diagnosis of acute neurological accidents in childhood. Neuroimaging (in particular diffusion weighted magnetic resonance) is the keystone for diagnosis of paediatric stroke and other investigations might be considered according to the clinical condition. Despite substantial advances in paediatric stroke research and clinical care, many unanswered questions remain concerning both its acute treatment and its secondary prevention and rehabilitation so that treatment recommendations are mainly extrapolated from studies on adult population. We have tried to summarize the pathophysiological and clinical characteristics of arterial ischemic stroke in children and the most recent international guidelines and practical directions on how to recognise and manage it in paediatric emergency.
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Affiliation(s)
- Margherita Rosa
- Department of Translational Medicine-Section of Pediatrics, Federico II University, Naples, Italy.
| | - Silvana De Lucia
- Department of Paediatrics, Aldo Moro University of Bari, Bari, Italy.
| | | | - Julie Le Gal
- Paediatric Migraine & Neurovascular diseases Unit, Department of Paediatrics, Robert Debré Hospital, Paris Diderot University, Sorbonne Paris Cité, Paris, France.
| | - Marie Desmarest
- Paediatric Migraine & Neurovascular diseases Unit, Department of Paediatrics, Robert Debré Hospital, Paris Diderot University, Sorbonne Paris Cité, Paris, France.
| | - Claudio Veropalumbo
- Department of Translational Medicine-Section of Pediatrics, Federico II University, Naples, Italy.
| | - Silvia Romanello
- Paediatric Emergency Department, Robert Debré Hospital, Paris Diderot University, Sorbonne Paris Cité, Paris, France.
| | - Luigi Titomanlio
- Paediatric Migraine & Neurovascular diseases Unit, Department of Paediatrics, Robert Debré Hospital, Paris Diderot University, Sorbonne Paris Cité, Paris, France.
- Paediatric Emergency Department, Robert Debré Hospital, Paris Diderot University, Sorbonne Paris Cité, Paris, France.
- Pediatric Emergency Department, INSERM U-1141 AP-HP Robert Debré University Hospital, 48, Bld Sérurier, 75019, Paris, France.
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Cassidy JM, Carey JR, Lu C, Krach LE, Feyma T, Durfee WK, Gillick BT. Ipsilesional motor-evoked potential absence in pediatric hemiparesis impacts tracking accuracy of the less affected hand. RESEARCH IN DEVELOPMENTAL DISABILITIES 2015; 47:154-164. [PMID: 26426515 PMCID: PMC4670029 DOI: 10.1016/j.ridd.2015.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 09/01/2015] [Accepted: 09/14/2015] [Indexed: 06/05/2023]
Abstract
This study analyzed the relationship between electrophysiological responses to transcranial magnetic stimulation (TMS), finger tracking accuracy, and volume of neural substrate in children with congenital hemiparesis. Nineteen participants demonstrating an ipsilesional motor-evoked potential (MEP) were compared with eleven participants showing an absent ipsilesional MEP response. Comparisons of finger tracking accuracy from the affected and less affected hands and ipsilesional/contralesional (I/C) volume ratio for the primary motor cortex (M1) and posterior limb of internal capsule (PLIC) were done using two-sample t-tests. Participants showing an ipsilesional MEP response demonstrated superior tracking performance from the less affected hand (p=0.016) and significantly higher I/C volume ratios for M1 (p=0.028) and PLIC (p=0.005) compared to participants without an ipsilesional MEP response. Group differences in finger tracking accuracy from the affected hand were not significant. These results highlight differentiating factors amongst children with congenital hemiparesis showing contrasting MEP responses: less affected hand performance and preserved M1 and PLIC volume. Along with MEP status, these factors pose important clinical implications in pediatric stroke rehabilitation. These findings may also reflect competitive developmental processes associated with the preservation of affected hand function at the expense of some function in the less affected hand.
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Affiliation(s)
- Jessica M Cassidy
- Department of Physical Medicine and Rehabilitation, University of Minnesota, Minneapolis, MN, United States.
| | - James R Carey
- Department of Physical Medicine and Rehabilitation, University of Minnesota, Minneapolis, MN, United States
| | - Chiahao Lu
- Department of Neurology, University of Minnesota, Minneapolis, MN, United States
| | - Linda E Krach
- Courage Kenny Rehabilitation Institute, Minneapolis, MN, United States
| | - Tim Feyma
- Pediatric Neurology, Gillette Children's Specialty Healthcare, Saint Paul, MN, United States
| | - William K Durfee
- Department of Mechanical Engineering, University of Minnesota, Minneapolis, MN, United States
| | - Bernadette T Gillick
- Department of Physical Medicine and Rehabilitation, University of Minnesota, Minneapolis, MN, United States
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Gillick B, Menk J, Mueller B, Meekins G, Krach LE, Feyma T, Rudser K. Synergistic effect of combined transcranial direct current stimulation/constraint-induced movement therapy in children and young adults with hemiparesis: study protocol. BMC Pediatr 2015; 15:178. [PMID: 26558386 PMCID: PMC4642615 DOI: 10.1186/s12887-015-0498-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/27/2015] [Indexed: 11/10/2022] Open
Abstract
Background Perinatal stroke occurs in more than 1 in 2,500 live births and resultant congenital hemiparesis necessitates investigation into interventions which may improve long-term function and decreased burden of care beyond current therapies (http://www.cdc.gov/ncbddd/cp/data.html). Constraint-Induced Movement Therapy (CIMT) is recognized as an effective hemiparesis rehabilitation intervention . Transcranial direct current stimulation as an adjunct treatment to CIMT may potentiate neuroplastic responses and improve motor function. The methodology of a clinical trial in children designed as a placebo-controlled, serial –session, non-invasive brain stimulation trial incorporating CIMT is described here. The primary hypotheses are 1) that no serious adverse events will occur in children receiving non-invasive brain stimulation and 2) that children in the stimulation intervention group will show significant improvements in hand motor function compared to children in the placebo stimulation control group. Methods/design A randomized, controlled, double-blinded clinical trial. Twenty children and/or young adults (ages 8–21) with congenital hemiparesis, will be enrolled. The intervention group will receive ten 2-hour sessions of transcranial direct current stimulation combined with constraint-induced movement therapy and the control group will receive sham stimulation with CIMT. The primary outcome measure is safety assessment of transcranial direct current stimulation by physician evaluation, vital sign monitoring and symptom reports. Additionally, hand function will be evaluated using the Assisting Hand Assessment, grip strength and assessment of goals using the Canadian Occupational Performance Measure. Neuroimaging will confirm diagnoses, corticospinal tract integrity and cortical activation. Motor cortical excitability will also be examined using transcranial magnetic stimulation techniques. Discussion Combining non-invasive brain stimulation and CIMT interventions has the potential to improve motor function in children with congenital hemiparesis beyond each intervention independently. Such a combined intervention has the potential to benefit an individual throughout their lifetime. Trial registration Clinicaltrials.gov, NCT02250092Registered 18 September 2014
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Affiliation(s)
- Bernadette Gillick
- University of Minnesota, 420 Delaware Street SE, MMC 388, Minneapolis, MN, 55455, USA.
| | - Jeremiah Menk
- Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis, MN, 55455, USA.
| | - Bryon Mueller
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, 55455, USA.
| | - Gregg Meekins
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA.
| | - Linda E Krach
- Courage Kenny Rehabilitation Institute, part of Allina Health, 800 East 28th Street, Minneapolis, MN, 55407, USA.
| | - Timothy Feyma
- Department of Neurology, Gillette Children's Specialty Healthcare, 200 University Ave E, Saint Paul, MN, 55101, USA.
| | - Kyle Rudser
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA.
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Takeuchi N, Izumi SI. Combinations of stroke neurorehabilitation to facilitate motor recovery: perspectives on Hebbian plasticity and homeostatic metaplasticity. Front Hum Neurosci 2015; 9:349. [PMID: 26157374 PMCID: PMC4477170 DOI: 10.3389/fnhum.2015.00349] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 05/31/2015] [Indexed: 12/12/2022] Open
Abstract
Motor recovery after stroke involves developing new neural connections, acquiring new functions, and compensating for impairments. These processes are related to neural plasticity. Various novel stroke rehabilitation techniques based on basic science and clinical studies of neural plasticity have been developed to aid motor recovery. Current research aims to determine whether using combinations of these techniques can synergistically improve motor recovery. When different stroke neurorehabilitation therapies are combined, the timing of each therapeutic program must be considered to enable optimal neural plasticity. Synchronizing stroke rehabilitation with voluntary neural and/or muscle activity can lead to motor recovery by targeting Hebbian plasticity. This reinforces the neural connections between paretic muscles and the residual motor area. Homeostatic metaplasticity, which stabilizes the activity of neurons and neural circuits, can either augment or reduce the synergic effect depending on the timing of combination therapy and types of neurorehabilitation that are used. Moreover, the possibility that the threshold and degree of induced plasticity can be altered after stroke should be noted. This review focuses on the mechanisms underlying combinations of neurorehabilitation approaches and their future clinical applications. We suggest therapeutic approaches for cortical reorganization and maximal functional gain in patients with stroke, based on the processes of Hebbian plasticity and homeostatic metaplasticity. Few of the possible combinations of stroke neurorehabilitation have been tested experimentally; therefore, further studies are required to determine the appropriate combination for motor recovery.
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Affiliation(s)
- Naoyuki Takeuchi
- Department of Physical Medicine and Rehabilitation, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Shin-Ichi Izumi
- Department of Physical Medicine and Rehabilitation, Tohoku University Graduate School of Medicine Sendai, Japan
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Page SJ, Cunningham DA, Plow E, Blazak B. It takes two: noninvasive brain stimulation combined with neurorehabilitation. Arch Phys Med Rehabil 2015; 96:S89-93. [PMID: 25813373 DOI: 10.1016/j.apmr.2014.09.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 07/02/2014] [Accepted: 09/09/2014] [Indexed: 10/23/2022]
Abstract
The goal of postacute neurorehabilitation is to maximize patient function, ideally by using surviving brain and central nervous system tissue when possible. However, the structures incorporated into neurorehabilitative approaches often differ from this target, which may explain why the efficacy of conventional clinical treatments targeting neurologic impairment varies widely. Noninvasive brain stimulation (eg, transcranial magnetic stimulation [TMS], transcranial direct current stimulation [tDCS]) offers the possibility of directly targeting brain structures to facilitate or inhibit their activity to steer neural plasticity in recovery and measure neuronal output and interactions for evaluating progress. The latest advances as stereotactic navigation and electric field modeling are enabling more precise targeting of patient's residual structures in diagnosis and therapy. Given its promise, this supplement illustrates the wide-ranging significance of TMS and tDCS in neurorehabilitation, including in stroke, pediatrics, traumatic brain injury, focal hand dystonia, neuropathic pain, and spinal cord injury. TMS and tDCS are still not widely used and remain poorly understood in neurorehabilitation. Therefore, the present supplement includes articles that highlight ready clinical application of these technologies, including their comparative diagnostic capabilities relative to neuroimaging, their therapeutic benefit, their optimal delivery, the stratification of likely responders, and the variable benefits associated with their clinical use because of interactions between pathophysiology and the innate reorganization of the patient's brain. Overall, the supplement concludes that whether provided in isolation or in combination, noninvasive brain stimulation and neurorehabilitation are synergistic in the potential to transform clinical practice.
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Affiliation(s)
- Stephen J Page
- School of Health and Rehabilitation Sciences, The Ohio State University Medical Center, Columbus, OH; B.R.A.I.N. Laboratory, Columbus, OH.
| | - David A Cunningham
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH; School of Biomedical Sciences, Kent State University, Kent, OH
| | - Ela Plow
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH; Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Brittani Blazak
- School of Health and Rehabilitation Sciences, The Ohio State University Medical Center, Columbus, OH; Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
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Krishnan C, Santos L, Peterson MD, Ehinger M. Safety of noninvasive brain stimulation in children and adolescents. Brain Stimul 2014; 8:76-87. [PMID: 25499471 DOI: 10.1016/j.brs.2014.10.012] [Citation(s) in RCA: 160] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 10/03/2014] [Accepted: 10/21/2014] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Noninvasive brain stimulation (NIBS) techniques such as transcranial magnetic stimulation (TMS) and transcranial current stimulation (tCS) have the potential to mitigate a variety of symptoms associated with neurological and psychiatric conditions, including stroke, cerebral palsy, autism, depression, and Tourette syndrome. While the safety of these modalities has been established in adults, there is a paucity of research assessing the safety of NIBS among children. OBJECTIVE To examine the existing literature regarding the safety of NIBS techniques in children and adolescents with neurologic and neuropsychiatric disorders. METHODS An electronic search was performed on online databases for studies using NIBS in individuals less than 18 years of age. Non-English publications, diagnostic studies, electroconvulsive therapy, single/dual pulse TMS studies, and reviews were excluded. Adverse events reported in the studies were carefully examined and synthesized to understand the safety and tolerability of NIBS among children and adolescents. RESULTS The data from 48 studies involving more than 513 children/adolescents (2.5-17.8 years of age) indicate that the side effects of NIBS were, in general, mild and transient [TMS: headache (11.5%), scalp discomfort (2.5%), twitching (1.2%), mood changes (1.2%), fatigue (0.9%), tinnitus (0.6%); tCS: tingling (11.5%), itching (5.8%), redness (4.7%), scalp discomfort (3.1%)] with relatively few serious adverse events. CONCLUSION Our findings indicate that both repetitive TMS and tCS are safe modalities in children and adolescents with various neurological conditions, especially when safety guidelines are followed. The incidence of adverse events appears to be similar to that observed in adults; however, further studies with longer treatment and follow-up periods are needed to better understand the benefits and tolerance of long-term use of NIBS in children.
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Affiliation(s)
- Chandramouli Krishnan
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Luciana Santos
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Mark D Peterson
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Margaret Ehinger
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI, USA
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