tACS-combined Motor Training for the Rehabilitation of the Upper Limb in Children and Young People With Cerebral Palsy: a Randomized, Sham-controlled Trial
试验速览
- 阶段
- 不适用
- 状态
- 尚未招募
- 发起方
- 入组人数
- 44
- 试验地点
- 2
- 主要终点
- Assisting Hand Assessment (AHA)
研究概览
简要总结
The present study aims to assess, through a randomized controlled trial (RCT), the efficacy of transcranial alternating current stimulation (tACS) in enhancing the functional changes due to an intensive motor training in children and adolescents with Cerebral Palsy (CP). Particularly, in two different groups active or sham tACS will be paired with the Hand-Arm Bimanual Intensive Therapy Including Lower Extremities (HABIT-ILE) and we will assess the effects on the upper limbs motor ability and daily functioning in 6 to 17 years old patients with CP having mild-to moderate upper limb deficits. The investigators hypothesized that, thanks to the intensive bimanual training, both the active and the sham group will improve in motor functioning. However, in light of findings showing that tACS effectively improves motor learning, the investigators hypothesized that active tACS might improve in a greater and more lasting extent than sham tACS the motor functioning. Moreover, as suggested by previous studies investigating the effect of non-invasive brain stimulation (NIBS) in pediatric population, the investigators expected that the treatment will be safe and well tolerated. Such a result would encourage the use of NIBS to boost the rehabilitative training of motor abilities in children and adolescents with CP.
详细描述
This represents one of the two RCTs of the project "Bottom-up and tOp-down neuromOdulation of motor plaSTicity in cerebral palsy" (BOOST; FRRB 3438840).The study will be a randomized, sham controlled, pre-test/post-test study involving 44 children and adolescents with CP. Patients will be treated in pairs, with a matching of motor deficit severity, IQ, or age. Each pair will be randomly assigned to the active or to the sham tACS group, stratifying the pairs between the two groups based on motor deficit severity, IQ, or age. Both groups will undergo a bimanual training in an ecological and highly motivating environment during the application of the tACS. During the training, starting from a set of proposals the choice of the type of activities to be practiced in each session will be left to patients, boosting the motivational aspect of the training. This will also ensure an individualized and goal directed approach. The therapists will monitor and modify the activities within each pair to ensure that the intervention maintains the quality of the individualized intervention. The positions performed during bimanual tasks and the activities of daily living will be designed to systematically engage postural control of the trunk and lower limbs according to Habit-ILE protocol. The rehabilitation treatment will be carried out for 5 consecutive days for 3h/day for 2 weeks (30 hours of intervention overall). Children and adolescents will be assessed before the start of treatment (T0), immediately after the end of intensive treatment (T1) and three months after the end (T2). The overall RCT will be structured as follows. In the first session prior the beginning of the training (t0), the RCT will include the administration of all clinical assessment measures and the patients will be asked to perform for 10 minutes an ad-hoc computer based Visuomotor task (please refer to the outcome sessions for more detailed description). Cortical rhythms will be recorded by electroencephalogram (EEG) both before (during rest) and during the execution of the Visuomotor task. Analysis of the resting-state EEG will be conducted to derive the Individualized Gamma Frequency (IGF), which will be matched to each patient's specific stimulation frequency delivered through tACS during the training. Patients will undergo the 10 days treatment. For each training day, the treatment will last three hours. During the first 20 minutes of treatment the active or sham tACS (according to the group allocation) will be delivered. Before starting and 20 minutes after the end of the stimulation the vital parameters will be checked. After the end of the stimulation, patients will be also asked to rate the sensations experienced during the stimulation through Visual Analogue Scales and through child-friendly Likert scales. Then, they will continue the training for the remaining session time without stimulation. Soon after the end of all the training sessions, patients will carry the t1 evaluation. As for the t0 session, this session will include the administration of the clinical assessment measures and execution for 10 minutes of the Visuomotor task. Three months after the end of the training (t2) the follow up assessment will be conducted, following the same exact procedure of t0.
Primary outcomes will include the following clinical measures: the Assisting Hand Assessment (AHA), the Box and Block Test (BBT) and the performance at the Visuomotor task. Secondary outcome will include the scores at the following tests: the Children's Hand Experience Questionnaire (CHEQ), the Canadian Occupational Performance Measure (COPM), the Gross Motor Function Measure (GMFM-66), the Melbourne Assessment-2 (MA2) scale, the Vineland Adaptive Behavior Scale Version 2 (VABS 2), the Pediatric Quality of Life Inventory (PEDS-QL), and the cortical rhythms registered via EEG at rest and during the Visuomotor task. Vital parameters (the oxygen saturation (SPO2) and the Heart Rate (HR)), and the scores at the questionnaires assessing stimulation- induced sensations will be also checked to assess the safety and the tolerability of the stimulation. Lastly, the feasibility and the acceptability of the training will be assessed by considering, respectively, the number of patients completing the training/the number of sessions for each patient and the response to ad hoc questionnaires for the patients and their guardians.
All primary and secondary outcomes will be collected at each time point, except for the PedsQL and VABS-II, that will be administered only at T0 and T2. Furthermore, vital parameters and the questionnaires assessing stimulation-induced sensations will be examined during each stimulation session. The acceptability questionnaires will be administered only after the end of the training (t1).
The patients and their guardians, the personnel responsible for conducting the bimanual training and analysing clinical data will be kept blind to the group allocation. Instead, the coordinator of the study, the staff who will apply the tACS will be "not blind". With respect to the clinical assessment, whenever possible the staff administering and scoring the scales will be blinded to group allocation. Questionnaire scores and neuropsychological tests will not contain personal information about the subjects, who will be identified by an alphanumeric code. All records that contain names or other personal identifiers, such as informed consent forms, will be stored separately from study records identified by code number. In order to uphold the overall quality of the clinical trial, instances of code breaks should be limited to exceptional circumstances, where knowledge of the actual treatment is deemed absolutely necessary for the ongoing management of the patient.
The intensive treatment will take place at IRCCS E. Medea "Associazione La Nostra Famiglia" in Bosisio Parini (Lecco), at Fondazione Mondino IRCCS (Pavia) and at ASST Ospedali Civili di Brescia.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Treatment
- 盲法
- Triple (Participant, Care Provider, Outcomes Assessor)
入排标准
- 年龄范围
- 6 Years 至 17 Years（Child）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •clinical signs of unilateral or bilateral upper limb deficits (with a difference at least of 25% between more affected and less affected hand at Box and Block test);
- •Magnetic Resonance Imaging (MRI) confirmed diagnosis according to Surveillance of Cerebral Palsy (SCPE) criteria;
- •Manual Ability Classification System (MACS) level I,II,III;
- •Gross Motor Function Classification System (GMFCS) level I,II,III;
- •Visual Function Classification System (VFCS) I-II-III;
- •Intelligence quotient (IQ) > 50.
排除标准
- •presence of cochlear implant, cardiac pacemaker, ventriculoperitoneal shunt, neuro-stimulators, clips, fragments or metal splinters in the brain or skull except for titanium;
- •treatments for spasticity or functional surgery of the upper limb in the previous 6 months or planned during the duration of the study;
- •uncontrolled epileptic seizure in the last 2 years.
结局指标
主要结局
Assisting Hand Assessment (AHA)
时间窗: 1-2 days before the start of training (t0), 1-2 days after the end of the training (t1), three months after the end of the training (t2)
This scale enables to quantify the assistance provided by the more affected hand to the less affected hand during bimanual activities. This observation-based, criterion-referenced assessment highlights a person's typical performance, emphasizing practical functionality over maximal capacity, and serves as a reliable measure of change over time. The scale comprised 20 items, scored on a 4-point Likert scale, from 1 to 4. The total score indicates how well the more affected hand is used as an assisting hand. A score of 20 means poor performance (the hand is not used as an assisting hand); a score of 80 means that the hand is used effectively. The results are converted for each of the three scales to logits by a Rasch analysis, on a 0-to-100 scale (with higher scores suggesting better use).
Visuomotor task
时间窗: 1-2 days before the start of training (t0), 1-2 days after the end of the training (t1), three months after the end of the training (t2)
The visuomotor task is an ad hoc computer based task. It involves a mouse click- and-drag operation where an object appears at the center of the screen. The objective is to drag and drop the object to the location indicated by a previously presented arrow, pointing towards a target object within a configuration of objects. Participants are required to focus on the arrow's direction, swiftly and accurately moving the central object to its designated target location. This task enables the measurement of movement time (in milliseconds; consisting in the time necessary to move the object in the target position); precision error (calculated as the distance, in pixels, between the drop position of the object and the actual target position); the proportion of overtime errors (the percentage of trials in which responses are too slow). Smaller values of Movement time, Precision error and overtime errors will suggest better performance.
Box and Block Test (BBT)
时间窗: 1-2 days before the start of training (t0), 1-2 days after the end of the training (t1), three months after the end of the training (t2)
This test is designed to measure manual dexterity. It is quick, simple, and cost- effective. It involves a box with a partition in the middle placed on a table, with a total of 150 blocks on one side of the partition. The score of the test is given by the number of blocks transported within a minute. Higher values suggest better performance. The BBT provides a reliable and objective measurement of manual dexterity, making it valuable for evaluating functional outcomes and monitoring progress in rehabilitation programs over a short period of time.
次要结局
- Vineland Adaptive Behavior Scale Version 2 (VABS II)(1-2 days before the start of training (t0), three months after the end of the training (t2))
- Gross Motor Function Measure (GMFM-66)(1-2 days before the start of training (t0), 1-2 days after the end of the training (t1), three months after the end of the training (t2))
- Canadian Occupational Performance Measure (COPM)(1-2 days before the start of training (t0), 1-2 days after the end of the training (t1), three months after the end of the training (t2))
- Children's Hand-Use Experience Questionnaire (CHEQ)(1-2 days before the start of training (t0), 1-2 days after the end of the training (t1), three months after the end of the training (t2))
- Melbourne Assessment 2 (MA2)(1-2 days before the start of training (t0), 1-2 days after the end of the training (t1), three months after the end of the training (t2))
- Pediatric quality of life inventory PedsQL(cerebral palsy module), (PEDS-QL)(1-2 days before the start of training (t0), three months after the end of the training (t2))
- Cortical rhythms at rest and during the Visuomotor task(1-2 days before the start of training (t0), 1-2 days after the end of the training (t1), three months after the end of the training (t2))