Brain wave behavior in children with down syndrome following cortical neuromodulation combined with sensorimotor stimulation: observational study.

BACKGROUND: Individuals with Down syndrome (DS) require more time to develop motor and/or cognitive skills. Neuromodulation is used to assist in this development. However, there is a gap in the literature on neurophysiological changes that may occur in the primary motor cortex in individuals with DS following neuromodulation. OBJECTIVE: Our objective was to investigate possible neurophysiological changes in brain wave behavior of the primary motor cortex following the administration of anodal transcranial direct current stimulation combined with sensorimotor training. METHODS: The study involved 12 participants with DS. EEG equipment was used to investigate brain activity. The participants received neuromodulation involving anodal tDCS for 20 minutes with a current of 1 mA combined with virtual reality (VR) training three times a week for a total of ten sessions. We analyzed EGG signals and 3D movement during a reaching movement of the dominant upper limb before and after the ten-session protocol. RESULTS: Significant differences in event-related desynchronization and event-related synchronization of the alpha and beta rhythms were found throughout the evaluations. Brain mapping revealed reductions in power and frequency, demonstrating changes in the patterns of these rhythms in the cerebral cortex. Revealed reorganization of the behavior of alpha and beta waves, as demonstrated by distribution of synchronization and desynchronization of these waves among the regions of the brain. CONCLUSION: The results suggest that anodal tDCS promotes the reorganization of brain impulses, redirecting these impulses to the required regions more efficiently and contributing to better motor planning.

Bicephalic Transcranial Direct-Current Stimulation Does Not Add Benefits to a Footdrop Stimulator for Improving Functional Mobility in People With Chronic Hemiparesis After Stroke: A Double-Blind, Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to assess the effects of applying transcranial direct-current stimulation (tDCS), a footdrop stimulator (FDS), and gait training simultaneously on functional mobility in people with chronic hemiparesis after stroke. METHODS: In this double-blind controlled trial, 32 individuals with mild, moderate, and severe chronic hemiparesis after stroke were randomized to tDCS plus FDS or sham tDCS plus FDS groups. Both groups underwent 10 concurrent tDCS and FDS gait training sessions 5 times per week for 2 weeks. Functional mobility was evaluated by the Timed "Up & Go" test (TUG). Secondary outcomes included spasticity of plantarflexors, knee extensors, and hip adductors; quality of life; and walking endurance (distance covered during each treadmill gait training session). Clinical assessments were performed before treatment, after treatment, and at a 1-month follow-up. A generalized estimating equation was used to compare the effects of time, group, and time × group interaction. RESULTS: No difference between groups was observed during performance of the TUG or other outcomes. TUG performance was improved in both the tDCS plus FDS group (before treatment = 24.29 [95% CI = 17.72-33.28]; after treatment = 21.75 [95% CI = 15.75-30.08]) and the sham tDCS plus FDS group (before treatment = 19.63 [95% CI = 16.06-23.0]; after treatment = 18.45 [95% CI = 15.26-22.3]). This improvement remained at the follow-up evaluation. Both groups also showed reduced spasticity of plantarflexors and knee extensors, increased quality of life, and increased total distance walked. CONCLUSION: This study provided no evidence that bicephalic tDCS improves functional mobility, spasticity, quality of life, or walking endurance in people with chronic hemiparesis after stroke. IMPACT: Bicephalic tDCS does not add relevant benefits to FDS and gait training in people who have chronic hemiparesis after stroke. Given that tDCS has few additional effects and given its costs for clinical practice, tDCS for rehabilitation in people with chronic hemiparesis after stroke is discouraged. FDS and gait training improve functional mobility, walking resistance, and quality of life in people with chronic hemiparesis after stroke.

Brain activity and upper limb movement analysis in children with Down syndrome undergoing transcranial direct current stimulation combined with virtual reality training: study protocol for a randomized controlled trial.

BACKGROUND: Children with Down syndrome have poorer functional and sensory skills compared to children with typical development. Virtual reality (VR) training could help improve these skills. Moreover, transcranial direct current stimulation (tDCS) has achieved promising results in terms of enhancing the effects of physical and sensory therapy by modulating cortical excitability. METHODS/DESIGN: Two investigations are proposed: (1) an observational study with a convenience sample consisting of children with Down syndrome (group 1-cognitive age of 6 to 12 years according to the Wechsler Abbreviated Scale of Intelligence) and children with typical development 6 to 12 years of age (group 2). Both groups will undergo evaluations on a single day involving a three-dimensional analysis of upper limb movements, an analysis of muscle activity of the biceps and brachial triceps muscles and an analysis of visuospatial and cognitive-motor variables. (2) Analysis of clinical intervention: a pilot study and clinical trial will be conducted involving individuals with Down syndrome (cognitive age of 6 to 12 years according to the Wechsler Abbreviated Scale of Intelligence). The sample will be defined after conducting a pilot study with the same methodology as that to be used in the main study. The participants will be randomly allocated to two groups: An experimental group submitted to anodal tDCS combined with a VR game and a manual motor task and a control group submitted to sham tDCS combined with a VR game and a manual motor task. The training protocol will involve 10 sessions of active or sham tDCS during memory and motor task games. Three 20-min sessions will be held per week for a total of 10 sessions. Evaluations will be performed on three different occasions: pre-intervention, post-intervention (after 10 sessions) and follow-up (1 month after the intervention). Evaluations will consist of analyses of electroencephalographic signals, electromyographic signals of the biceps and triceps brachii, and the three-dimensional reconstruction of the reaching movement. The results will be analyzed statistically with the significance level set at 5% (p ≤ 0.05). DISCUSSION: The optimization of the results obtained with virtual reality training is believed to be related to the interactive experience with a wide range of activities and scenarios involving multiple sensory channels and the creation of exercises, the intensity of which can be adjusted to the needs of children. Therefore, the proposed study aims to complement the literature with further information on tDCS and VR training considering different variables to provide the scientific community with clinical data on this combination of interventions. TRIAL REGISTRATION: Brazilian Clinical Trials Registry (REBEC) protocol number RBR-43pk59 registered on 2019 March 27 https://ensaiosclinicos.gov.br/rg/RBR-43pk59 and Human Research Ethics Committee number 3.608.521 approved on 2019 September 30. Protocol version 2021 October 20. Any changes to the protocol will be reported to the committees and approved. Informed consent will be obtained from all participants by the clinical research coordinator and principal investigator.

Effects of Transcranial Direct Current Stimulation Combined with Treadmill Training on Kinematics and Spatiotemporal Gait Variables in Stroke Survivors: A Randomized, Triple-Blind, Sham-Controlled Study.

The present study assessed the effects of anodal transcranial direct current stimulation (tDCS) combined with treadmill training on spatiotemporal and kinematic variables in stroke survivors using gait speed as the primary outcome. A randomized, sham-controlled, triple-blind, study was conducted involving 28 patients with hemiparesis allocated to two groups. The experimental group was submitted to treadmill training combined with anodal tDCS over the primary motor cortex (M1) of the damaged hemisphere. The control group was submitted to treadmill training combined with sham tDCS. Stimulation was administered (2 mA, 20 min) five times a week for two weeks during treadmill training. No significant differences (p > 0.05) in spatiotemporal variables were found in the intra-group and inter-group analyses. However, the experimental group demonstrated improvements in kinematic variables of the knee and ankle (p < 0.05) and these results were maintained one month after the end of the intervention. The inter-group analysis revealed significant differences (p < 0.05) with regard to the pelvis, hip and knee. Anodal tDCS over M1 of the damaged hemisphere combined with treadmill training did not affect spatiotemporal variables, but promoted improvements in kinematic variables of the pelvis, hip, knee and ankle and results were maintained one month after treatment.

Functional Electrical Stimulation for Foot Drop in Post-Stroke People: Quantitative Effects on Step-to-Step Symmetry of Gait Using a Wearable Inertial Sensor.

The main purpose of the present study was to assess the effects of foot drop stimulators (FDS) in individuals with stroke by means of spatio-temporal and step-to-step symmetry, harmonic ratio (HR), parameters obtained from trunk accelerations acquired using a wearable inertial sensor. Thirty-two patients (age: 56.84 ± 9.10 years; 68.8% male) underwent an instrumental gait analysis, performed using a wearable inertial sensor before and a day after the 10-session treatment (PRE and POST sessions). The treatment consisted of 10 sessions of 20 min of walking on a treadmill while using the FDS device. The spatio-temporal parameters and the HR in the anteroposterior (AP), vertical (V), and mediolateral (ML) directions were computed from trunk acceleration data. The results showed that time had a significant effect on the spatio-temporal parameters; in particular, a significant increase in gait speed was detected. Regarding the HRs, the HR in the ML direction was found to have significantly increased (+20%), while those in the AP and V directions decreased (approximately 13%). Even if further studies are necessary, from these results, the HR seems to provide additional information on gait patterns with respect to the traditional spatio-temporal parameters, advancing the assessment of the effects of FDS devices in stroke patients.

The Effects of Transcranial Direct Current Stimulation (tDCS) Combined With Proprioceptive Training for Blind Individuals: The Study Protocol for a Randomized Controlled Clinical Trial.

To maintain the balance, the postural system needs to integrate the three main sensorial systems: visual, vestibular, and somatosensory to keep postural control within the limits of stabilization. Damage of one of these systems, in this case, the vision, will have a great disturbance on the postural control influencing the behavior of the balance, resulting in falls. The aim of this study protocol for a randomized, controlled clinical trial is to analyze the effects of transcranial direct current stimulation (tDCS) combined with proprioceptive exercises on postural control in individuals with congenital and acquired blindness. In this randomized, controlled, double-blind, clinical trial, male, and female individuals with blindness between 18 and 55 years of age will participate in this study divided into three phases: 1-Determine differences in postural control and gait between individuals with congenital and acquired blindness with and without the use of a guide stick when wearing shoes and when barefoot; 2-A pilot study to analyze the effects a bilateral cerebellar anodal tDCS on postural on postural control and gait; and 3-A treatment protocol will be conducted in which the participants will be allocated to four groups: G1-active tDCS + dynamic proprioceptive exercises; G2-sham tDCS + dynamic proprioceptive exercises; G3-active tDCS + static proprioceptive exercises; and G4-sham tDCS + static proprioceptive exercises. Evaluations will involve a camera system for three-dimensional gait analysis, a force plate, and electromyography. Dynamic stability will be determined using the Timed Up and Go test and static stability will be analyzed with the aid of the force plate. The viability of this study will allow the determination of differences in postural control between individuals with congenital and acquired blindness, the analysis of the effect of tDCS on postural control, and the establishment of a rehabilitation protocol.

Effect of Transcranial Direct Current Stimulation Combined With Xbox-Kinect Game Experience on Upper Limb Movement in Down Syndrome: A Case Report.

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique used to enhance local synaptic efficacy and modulate the electrical activity of the cortex in neurological disorders. Researchers have sought to combine this type of stimulation with well-established therapeutic modalities, such as motor training involving Xbox Kinect games, which has demonstrated promising results. Thus, this study aimed to determine whether tDCS can enhance upper limb motor training in an eight-year-old child with Down Syndrome (DS) (cognitive age: five years, based on the Wechsler Intelligence Scale for Children). The evaluations consisted of three-dimensional analysis of upper limb kinematics during a reaching task performed before, after10 session, and one month after the intervention. The intervention protocol involved 1 20-min sessions of tDCS over the primary motor cortex at an intensity of 1 mA during Xbox Kinect game training involving an upper limb motor task. The analysis of the kinematic data revealed that in the pre-intervention evaluation, the dominant limb executed the task slowly and over a long path. These aspects improved at the post-intervention and follow-up evaluations, as demonstrated by the shorter total movement duration (3.05 vs. 1.58 vs. 1.52 s, respectively). Similar changes occurred with the non-dominant upper limb; a significant increase in movement velocity at the post-intervention and follow-up evaluations was observed (0.53 vs. 0.54 vs. 0.85 m/s, respectively). The present case report offers preliminary data from a protocol study, and the results confirm the notion that anodal tDCS combined with upper limb motor training leads to improvements in different kinematic variables.

Fugl-Meyer Assessment Scores Are Related With Kinematic Measures in People with Chronic Hemiparesis after Stroke.

BACKGROUND: Stroke often results in motor impairment and limited functional capacity. This study aimed to verify the relationship between widely used clinical scales and instrumented measurements to evaluate poststroke individuals with mild, moderate, and severe motor impairment. METHODS: This cross-sectional study included 34 participants with chronic hemiparesis after stroke. Fugl-Meyer Assessment and Modified Ashworth Scale were used to quantify upper and lower limb motor impairment and the resistance to passive movement (i.e., spasticity), respectively. Upper limb Motor performance (movement time and velocities) and movement quality (range of motion, smoothness and trunk displacement) were analyzed during a reaching forward task using an optoelectronic system (instrumented measurement). Lower limb motor performance (gait and functional mobility parameters) was assessed by using an inertial measurement unit system. FINDINGS: Fugl-Meyer Assessment correlated with motor performance (upper and lower limbs) and with movement quality (upper limb). Modified Ashworth scale correlated with movement quality (upper limb). Cutoff values of 9.0 cm in trunk anterior displacement and .57 m/s in gait velocity were estimated to differentiate participants with mild/moderate and severe compromise according to the Fugl-Meyer Assessment. CONCLUSIONS: These results suggest that the Fugl-Meyer Assessment can be used to infer about motor performance and movement quality in chronic poststroke individuals with different levels of impairment.

Bi-cephalic transcranial direct current stimulation combined with functional electrical stimulation for upper-limb stroke rehabilitation: A double-blind randomized controlled trial.

BACKGROUND: Stroke survivors often present poor upper-limb (UL) motor performance and reduced movement quality during reaching tasks. Transcranial direct current stimulation (tDCS) and functional electrical stimulation (FES) are widely used strategies for stroke rehabilitation. However, the effects of combining these two therapies to rehabilitate individuals with moderate and severe impairment after stroke are still unknown. OBJECTIVE: Our primary aim was to evaluate the effects of concurrent bi-cephalic tDCS and FES on UL kinematic motor performance and movement quality of chronic post-stroke subjects with moderate and severe compromise. Our secondary aim was to verify the effects of combining these therapies on handgrip force and UL motor impairment. METHODS: We randomized 30 individuals with moderate and severe chronic hemiparesis after stroke into tDCS plus FES (n=15) and sham tDCS plus FES (n=15) groups. Participants were treated 5 times a week for 2 weeks. Kinematic motor performance (movement cycle time, velocity profile) and movement quality (smoothness, trunk contribution, joint angles) were assessed during an UL reach-to-target task.Handgrip force and motor impairment were also recorded before and after the intervention. RESULTS: Participants allocated to the tDCS plus FES group improved movement cycle time (P=0.039), mean reaching velocity (P=0.022) and handgrip force (P=0.034). Both groups improved the mean returning phase velocity (P=0.018), trunk contribution (P=0.022), movement smoothness (P=0.001) and UL motor impairment (P=0.002). CONCLUSIONS: Concurrent bi-cephalic tDCS and FES slightly improved reaching motor performance and handgrip force of chronic post-stroke individuals with moderate and severe UL impairment. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02818608).

Upper-limb movement smoothness after stroke and its relationship with measures of body function/structure and activity - A cross-sectional study.

INTRODUCTION: After a stroke, upper limb (UL) motor impairments interfere with functional activities and quality of life. Even though a range of assessment tools has been developed to assess UL, few studies explore the interfaces between different levels of functioning after stroke. OBJECTIVES: (a) verify the correlation between movement smoothness and other measures of body function/structure [UL - Fugl-Meyer Assessment (FMA), and handgrip strength]; (b) verify which body function/structure [UL-FMA and/or handgrip strength] could predict UL movement smoothness; and (c) verify if movement smoothness could predict levels of activity, as assessed by the Box and Block Test (BBT). MATERIALS AND METHODS: Cross-sectional study. Thirty-four individuals with chronic hemiparesis after stroke were enrolled. Measurements of body function/structure included FMA, handgrip strength and kinematic measure of movement smoothness. Levels of activity were measured using the Box and Block Test (BBT). RESULTS: Movement smoothness showed strong correlation with FMA (r = 0.70, p < .001) and moderate correlation with handgrip strength (r = 0.63, p < .001). FMA explained 46.4% of the variation in movement smoothness. Movement smoothness was moderately correlated with BBT (r = -0.560, p < .005) and predicted 31% of the variation in BBT. CONCLUSION: We recommend the use of UL-FMA to predict movement smoothness in chronic post-stroke subjects. This study also showed that movement smoothness influences the level of activity. Then, movement smoothness may be emphasized during stroke rehabilitation to enhance the UL level of activity in chronic post-stroke subjects.

Effects of a single session of transcranial direct current stimulation on upper limb movements in children with cerebral palsy: A randomized, sham-controlled study.

INTRODUCTION: Motor impairment in children with spastic hemiparetic cerebral palsy (CP) is generally more prominent in the affected upper limb, leading to limitations in hand function stemming from deficiencies in motor coordination and selective motor control as well as muscle weakness, slower execution of movements and deficient integration of sensory-motor information. OBJECTIVE: Determine the effect of a single session of anodal transcranial direct current stimulation (tDCS) combined with functional training on the spatiotemporal variables of upper arm movements in children with spastic hemiparesis. METHOD: A randomized, sham-controlled trial with a blinded evaluator was conducted involving 20 children with CP between 6 and 12 years of age. The spatiotemporal variables of the upper limbs were analyzed by comparing the results of Evaluation 1 (before stimulation) and Evaluation 2 (immediately after stimulation). The protocol consisted of a 20-minute session of functional training of the paretic upper limb combined with tDCS administered over the primary motor cortex of the hemisphere contralateral to the motor impairment at an intensity of 1 mA. The participants were randomly allocated to two groups: experimental group (anodal tDCS) and control group (sham tDCS). RESULTS: Statistically significant (p < 0.05) reductions in total movement duration and returning movement duration were found in both the paretic and non-paretic limbs in the group submitted to active tDCS. No significant differences were found in the control group for any of the variables analyzed. CONCLUSION: A single session of anodal tDCS over the primary motor cortex of the hemisphere ipsilateral to the brain lesion led to momentary motor improvements in both upper limbs of the children with spastic hemiparetic CP analyzed in the present study.

Effect of Transcranial Direct Current Stimulation Combined With Virtual Reality Training on Balance in Children With Cerebral Palsy: A Randomized, Controlled, Double-Blind, Clinical Trial.

The authors' aim was to investigate the effects of continuous transcranial direct current stimulation (tDCS) combined with virtual reality training on static and functional balance in children with cerebral palsy (CP). Twenty children with CP (6 girls and 14 boys; M age = 7 years 6 months ± 2 years) were randomly allocated to two groups. The experimental group received active tDCS and the control group received sham stimulation during the 10 sessions of virtual reality mobility training protocols. The children were evaluated on 3 occasions (preintervention, postintervention, and 1-month follow-up). Static balance was evaluated using a force plate under 4 conditions: feet on force plate with (a) eyes open and (b) with eyes closed, and feet on foam mat with (c) eyes open and (d) with eyes closed. Functional balance was evaluated using the Pediatric Balance Scale and the Timed Up and Go Test. The analyses demonstrated statistically significant postintervention and follow-up effects favoring the experimental group over the control group with regard to the Pediatric Balance Scale, Timed Up and Go Test, and area of oscillation of the center of pressure when standing on the force plate with eyes open. The present findings suggest that tDCS can potentiate the effects of virtual reality training on static and functional balance among children with CP.

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

BACKGROUND: 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. METHODS: The sample will comprise 34 individuals with spastic hemiparetic cerebral palsy, 6 to 16 years old, classified at level I, II, or III of the Manual Ability Classification System. Participants will be randomly allocated to two groups: (1) functional training of the paretic upper limb combined with anodic transcranial stimulation; (2) functional training of the paretic upper limb combined with sham transcranial stimulation. Evaluation will involve three-dimensional movement analysis and electromyography using the SMART-D 140® system (BTS Engineering) and the FREEEMG® system (BTS Engineering), the Quality of Upper Extremity Skills Test, to assess functional mobility, the Portable Device and Ashworth Scale, to measure movement resistance and spasticity, and the Pediatric Evaluation of Disability Inventory, to evaluate performance. Functional reach training of the paretic upper limb will include a range of manual activities using educational toys associated with an induced constraint of the non-paretic limb during the training. Training will be performed in five weekly 20-minute sessions for two weeks. Transcranial stimulation over the primary motor cortex will be performed during the training sessions at an intensity of 1 mA. Findings will be analyzed statistically considering a 5 % significance level (P ≤ 0.05). DISCUSSION: This paper presents a detailed description of a prospective, randomized, controlled, double-blind, clinical trial designed to demonstrate the effects of combining transcranial direct current stimulation over the primary motor cortex and functional training of the paretic limb in children with cerebral palsy classified at level I, II, or III of the Manual Ability Classification System. The results will be published and evidence found may contribute to the use of transcranial stimulation for this population. TRIAL REGISTRATION: ReBEC RBR-6V4Y3K . Registered on 11 February 2015.