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Feasibility of remote transcranial direct current stimulation for pediatric cerebral palsy during the COVID-19 pandemic

Open AccessPublished:October 22, 2020DOI:https://doi.org/10.1016/j.brs.2020.10.010
      Dear Editor,
      Brain injury and stroke early in life occur during a time of heightened neuroplastic potential.[
      • Ballantyne A.O.
      • Spilkin A.M.
      • Hesselink J.
      • Trauner D.A.
      Plasticity in the developing brain: intellectual, language and academic functions in children with ischaemic perinatal stroke.
      ] Non-invasive brain stimulation (NIBS) technology including transcranial direct current stimulation (tDCS) are a promising way to enhance standard therapies and pediatric rehabilitation interventions by harnessing neuroplasticity.[
      • Saleem G.T.
      • Crasta J.E.
      • Slomine B.S.
      • Cantarero G.L.
      • Suskauer S.J.
      Transcranial direct current stimulation in pediatric motor disorders: a systematic Review and meta-analysis.
      ] Our experience in pioneering applications of NIBS during pediatric development has demonstrated its safety and efficacy when combined with rehabilitation strategies e.g. constraint induced movement therapy (CIMT).
      • Gillick B.
      • Rich T.
      • Nemanich S.
      • et al.
      Transcranial direct current stimulation and constraint-induced therapy in cerebral palsy: a randomized, blinded, sham-controlled clinical trial.
      ,
      • Gillick B.T.
      • Krach L.E.
      • Feyma T.
      • et al.
      Safety of primed repetitive transcranial magnetic stimulation and modified constraint-induced movement therapy in a randomized controlled trial in pediatric hemiparesis.
      Despite advances in pediatric tDCS over the past decade, little work has established the specific adaptations needed for remote pediatric tDCS. Considering the need for cutting-edge rehabilitation interventions to optimize outcomes for a lifetime, and the impact of COVID-19 “stay-at-home mandates” on access to rehabilitation research, there is a critical need to determine how to develop alternative strategies to laboratory-based tDCS. tDCS is tolerable, portable, low cost and compatible with rehabilitation and thus is ideal for at home, remote neuromodulation.[
      • Aree-uea B.
      • Auvichayapat N.
      • Janyacharoen T.
      • et al.
      Reduction of spasticity in cerebral palsy by anodal transcranial direct current stimulation.
      • Nemanich S.T.
      • Rich T.L.
      • Chen C.Y.
      • et al.
      Influence of combined transcranial direct current stimulation and motor training on corticospinal excitability in children with unilateral cerebral palsy.
      • Nemanich S.T.
      • Rich T.L.
      • Gordon A.M.
      • Friel K.M.
      • Gillick B.T.
      Bimanual skill learning after transcranial direct current stimulation in children with unilateral cerebral palsy: a brief report.
      ] Guidelines for performing remote tDCS in adult populations have been published by Charvet and colleagues, who have demonstrated the efficiency of their protocol in adults with neurological disorders.
      • Charvet L.E.
      • Kasschau M.
      • Datta A.
      • et al.
      Remotely-supervised transcranial direct current stimulation (tDCS) for clinical trials: guidelines for technology and protocols.
      ,
      • Charvet L.E.
      • Shaw M.T.
      • Bikson M.
      • Woods A.J.
      • Knotkova H.
      Supervised transcranial direct current stimulation (tDCS) at home: a guide for clinical research and practice.
      To our knowledge, however, there are no studies which have investigated remote tDCS in a pediatric population. A critical unanswered question remains – Can the remote tDCS workflow can be performed by a “parent-child team” without compromising the efficiency, quality and comfort of administration?
      Using our laboratory’s pediatric data-base we recruited 7 parent-child teams to undergo a “mock” at-home tDCS session repeated over 3 consecutive days. Inclusion criteria for children included parent reported history of cerebral palsy and or stroke/brain bleed. This study was approved by the University of Minnesota Institutional Review Board (IRB). Parent-child teams were remotely informed of study procedures via a Zoom call and provided their written informed consent/assent. Participants performed the steps that would typically be required during a remote tDCS study including headgear setup, use of sponge electrodes, and preparation of the scalp surface.
      • Charvet L.E.
      • Kasschau M.
      • Datta A.
      • et al.
      Remotely-supervised transcranial direct current stimulation (tDCS) for clinical trials: guidelines for technology and protocols.
      ,
      • Charvet L.E.
      • Shaw M.T.
      • Bikson M.
      • Woods A.J.
      • Knotkova H.
      Supervised transcranial direct current stimulation (tDCS) at home: a guide for clinical research and practice.
      The tDCS head strap (the Soterix Medical SNAPstrap which connected to a (inactive) mini-CT device) had a preassembled bilateral motor cortex (M1) montage to minimize error and time burden on the participant. Supplies required for the study were mailed to participants and an online survey with standardized instructional videos was sent via REDCap.[
      • Harris P.A.
      • Taylor R.
      • Thielke R.
      • Payne J.
      • Gonzalez N.
      • Conde J.G.
      Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support.
      ] We evaluated the efficiency, quality and comfort of the tDCS setup workflow via a REDCap survey completed by the parent-child team each day. Efficiency was evaluated by measuring the time required to complete the workflow. Quality of performance was assessed by rating pictures of various steps completed by participants on a scale from 0 to 2 (“0” = incomplete, “1” = completed but incorrect, “2” = completed correctly). Stability of headgear position was assessed before and after 10 minutes of wearing the device. Comfort of the child was evaluated using written and verbal feedback.
      Results: Participants. All 7 children (sex: 3 males, 4 females; age (±SD): 13.86 years ±1.8, range: 11–16) had a diagnosis of CP and mild motor disability with a Gross Motor Function Classification System (GMFCS) score of I (6/7) or II (1/7). Of the 7 parent-child teams, all parents had a high school/GED level of education or higher. To evaluate the potential influence of head size on discomfort while wearing the tDCS headgear, head dimensions including the mean head circumference (±SD) (53.85 cm ± 1.5) were recorded. Efficiency. The time (in seconds ± SD) required to complete the tDCS workflow steps was 625 seconds ±344 on day one, 393 seconds ±142 on day two, and 331 seconds ±56 on day three. A one-way ANOVA demonstrated a trend toward a main effect of time (F (2,18) = 3.541, p = 0.051). Specifically, the time to perform the steps on day three was 294 seconds (95% CI: 49.2–537.9) faster than on day one (p = 0.021, uncorrected) (see Fig. 1a.). Quality of performance. Three steps (A-C) were evaluated using images uploaded by the “parent-child team” (see Fig. 1b.). Step A required the parent to align the arrow on the Soterix tDCS head-strap with the nasion of the child. Step B required participants to snap two electrode sponge pads to the Soterix tDCS head-strap. Step C required participants to connect the red and black electrodes to the mini-CT device. The number of parent-child teams who completed the steps successfully are shown in Fig. 1b. During the 10 minute sessions, the headgear moved in 1/7 participants on day one, in 4/7 on day two and in 1/7 on day three. For the sessions where the headgear moved, the overall average displacement was 0.73 cm ± 0.46. Participant Comfort. Individual responses are displayed in Fig. 1c. 4/7 had no discomfort during the session. 3/7 described tightness of straps and 1/7 reported a headache.
      Fig. 1
      Fig. 1a. Line plot showing the mean time to set up the modified tDCS headgear was reduced each day. The variability in setup time across participants was also reduced as experience with the device increased. ∗p < 0.05 b. Examples and ratings for tDCS workflow steps over the three days. c. Individual feedback about comfort of tDCS headgear.
      In summary, we demonstrate that the fundamental requirements to perform a remote tDCS workflow are possible for parent-child teams in the home setting. Specifically, this study emphasizes how standardized instructional videos, along with modified tDCS headgear, can be utilized to promote the successful setup of a M1 tDCS montage in a pediatric population with early brain injury. After just two days of practice with the device, participants improved the efficiency with which they could perform the tDCS protocol steps by nearly 50%. Across multiple days, the parent-child teams correctly positioned the device; however, error of alignment of the tDCS headgear did occur. Given these small but correctable errors, video conferencing with the family may be recommended to help ensure consistency in stimulation quality. Although we acknowledge this study does not encompass the delivery of an active tDCS session, all families self-reported the workflow was easy to perform. It is important to note that these results are specific to a modified set of headgear, electrodes and training protocols. Standard laboratory-based tDCS devices may require additional instruction and supervision. This study demonstrates, for the first time, the ability of parent-child teams to perform multi-step preparatory procedures for remote tDCS. Future studies with supervised delivery of remote tDCS have the potential to be combined with at-home rehabilitation. Ultimately, performing NIBS in a telerehabilitation setting would enable inclusion of children and families with limited mobility, financial resources, and access (e.g., those living rural communities without access to a clinic/medical center) during the COVID-19 pandemic and beyond.

      Funding support

      Gillick Pediatric Neuromodulation Laboratory, the Shepherd Trust/Jensen Family Award.

      Declaration of competing interest

      The authors declare no competing interests.

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