Introduction:Perinatal brain injury is a leading cause of cerebral palsy. Single-pulse transcranial magnetic stimulation (spTMS) provides a non-invasive method for investigating motor pathway development; however, data on the safety and feasibility of its repeated use in infants are limited. This study provides the first longitudinal evaluation of the safety, tolerability, and feasibility of spTMS in infants with perinatal brain injury. Methods:Twenty infants with perinatal brain injury (corrected age 3-25 months) participated in 46 spTMS sessions while awake. Safety and tolerability were systematically assessed using heart rate, respiratory rate, and the Modified Behavioral Pain Scale (MBPS). Feasibility was quantified by session completion, participant retention, and acquisition of motor-evoked potentials (MEPs) from bilateral wrist flexors. Results:Across 2,527 pulses, no adverse events occurred. Physiological measures and MBPS scores remained stable from pre- to post-stimulation. Analyzable electromyography (EMG) was obtained in 100% of sessions, with MEPs successfully elicited in 44/46 sessions (95.7%) across 19/20 infants (95%). A high longitudinal retention rate (85%) further demonstrated excellent protocol acceptability. Discussion:These findings establish a safe, reproducible framework for longitudinal spTMS in a vulnerable infant population. This methodological advance enables future investigations into neuroplasticity and corticospinal tract development after early brain injury, with the potential to yield biomarkers that guide the timing and targets of early interventions.

Background/Objectives: Cerebral palsy (CP), often caused by early brain injury such as perinatal stroke or hemorrhage, is the most common lifelong motor disability. Early identification of at-risk infants and timely access to rehabilitation interventions are essential for improving long-term outcomes. The General Movements Assessment (GMA), performed in the first months of life, has high sensitivity and specificity to predict CP; however, the neurological correlates of general movements remain unclear. This analysis aimed to investigate the relationship between white matter integrity and general movements in infants with perinatal brain injury using advanced neuroimaging techniques. Methods: Diffusion-weighted MRI data were analyzed in 17 infants, 12 with perinatal brain injury and 5 typically developing infants. Tractography was used to identify the corticospinal tract, a key motor pathway often affected by perinatal brain injury, and tract-based spatial statistics (TBSS) were used to examine broader white matter networks. Diffusion parameters from the diffusion tensor imaging (DTI) and neurite orientation dispersion and density imaging (NODDI) models were compared between infants with and without typical general movements. Results: Corticospinal tract integrity did not differ between groups when averaged across hemispheres. However, infants with asymmetric general movements exhibited greater corticospinal tract asymmetries. A subset of infants with atypical general movement trajectories at <6 weeks and 3–5 months of age showed reduced corticospinal tract integrity compared to those with typical general movements. TBSS revealed significant differences in white matter integrity between infants with typical and atypical general movements in several white matter pathways, including the corpus callosum, the right posterior corona radiata, bilateral posterior thalamic radiations, the left fornix/stria terminalis, and bilateral tapetum. Conclusions: These findings support and expand upon previous research suggesting that white matter integrity across multiple brain regions plays a role in the formation of general movements. Corticospinal integrity alone was not strongly associated with general movements; interhemispheric and cortical-subcortical connectivity appear critical. These findings underscore the need for further research in larger, diverse populations to refine early biomarkers of neurodevelopmental impairment and guide targeted interventions.

Background: Perinatal brain injury is a leading cause of developmental disabilities, including cerebral palsy. However, further work is needed to understand early brain development in the presence of brain injury. In this case report, we examine the longitudinal neuromotor development of a term infant following a significant loss of right-hemispheric brain tissue due to a unilateral ischemic stroke. Our analysis focuses on the integrity and development of the corticospinal tract (CST) from the lesioned hemisphere. This case provides a unique opportunity to evaluate CST development after loss of the majority of the motor cortex. Methods: Evaluations were conducted when the infant was 4 (Visit-1), 18 (Visit 2), and 25 (Visit 3) months old. Assessments included magnetic resonance imaging (MRI) to characterize the lesion and quantify CST structural integrity, single-pulse transcranial magnetic stimulation (spTMS) to evaluate CST functional circuitry, and neuromotor assessments. Results: At Visit 1, bilateral CSTs were identified through diffusion-weighted MRI (dMRI) despite an estimated loss of 92.7% (7.3% retained) of age-typical motor cortex from the right hemisphere. Both hemispheres exhibited bilateral motor-evoked potential in response to stimulation with spTMS, which remained when reassessed at Visits 2 and 3. Longitudinal MRI showed distinct developmental trajectories of CST integrity in each hemisphere, with the lesioned hemisphere exhibiting initial increases in integrity between Visits 1 and 2 followed by a decrease in integrity between Visits 2 and 3. The non-lesioned hemisphere showed increased integrity from Visit 1 to Visit 2, which remained stable at Visit 3. Motor assessments at all visits indicated a high risk of cerebral palsy. Conclusions: This report highlights the utility of MRI and spTMS in studying neuromotor development. The findings reveal preserved functional bilateral CST circuitry despite majority loss of the right-hemispheric motor cortex as well as distinct developmental trajectories in CST integrity between hemispheres. These results underscore the potential for neural plasticity after perinatal brain injury. Clinical Trials Registration: NCT05013736.

Background:Motor evoked potentials (MEPs) elicited through transcranial magnetic stimulation (TMS) may provide valuable insights into neuromotor development in pediatric populations. However, the reliability of identifying MEPs using rater-based approaches, particularly in infants, remains poorly defined. This study addresses this gap by evaluating interrater reliability (IRR) and consensus rates for MEP identification in adolescents and infants. Methods:Three experienced TMS researchers independently scored 5,738 electromyography (EMG) trials from 18 adolescents and 5,086 trials from 20 infants using a 5-point confidence scale. Scores reflected the raters' confidence in MEP presence, guided by predefined electrophysiological criteria. IRR, measured by intraclass correlation coefficients (ICC), and scoring consensus were compared across age groups, and signal characteristics were analyzed to identify predictors of disagreement. Results:IRR for adolescent MEP scores was excellent, ICC(C,3) = 0.973, 95% confidence interval (CI) [0.972, 0.974], while infant MEPs showed good IRR, ICC(C,3) = 0.784, 95% CI [0.773, 0.794]. Consensus rates were significantly lower for infant data (76.8%) compared to adolescent data (89.1%) (p < 0.001). Greater baseline EMG variability and lower post-stimulation peak-to-peak amplitudes were strongly associated with reduced consensus (p < 0.001 for both). Conclusions:MEP identification using a rater-based scoring protocol is feasible in pediatric cohorts but presents greater challenges in infants due to distinct neurophysiological and behavioral factors. Despite these difficulties, good reliability can still be achieved when multiple trained raters independently score EMG trials. These findings support the need for consensus-driven best practices to guide MEP identification in early developmental research.

Evidence-based assessment pathways inform early detection of cerebral palsy and access to intervention. This study investigated the relationships between early evidence-based assessments, diagnosis timeline, and rehabilitation intervention access in a population of children with cerebral palsy who were seen between 2010 and 2022 at the University of Wisconsin Waisman Center Newborn Follow Up Clinic. Cerebral palsy-specific assessments were increasingly integrated after the publication of early detection guidelines by Novak et al. in 2017. Age at cerebral palsy first mention (high risk for cerebral palsy) decreased over time, although age at diagnosis remained similar. Infants who received multiple evidence-based assessments were diagnosed at a younger age. Ninety-nine percent of children were referred to rehabilitation therapies before diagnosis. Infant age at referral to outpatient therapies decreased over time. This study provides novel clinical data on diagnosis timelines and identifies remaining gaps related to implementation feasibility toward improved early diagnosis and intervention access.

Introduction: Single-pulse transcranial magnetic stimulation (TMS) has many applications for pediatric clinical populations, including infants with perinatal brain injury. As a noninvasive neuromodulation tool, single-pulse TMS has been used safely in infants and children to assess corticospinal integrity and circuitry patterns. TMS may have important applications in early detection of atypical motor development or cerebral palsy.Areas covered: The authors identified and summarized relevant studies incorporating TMS in infants, including findings related to corticospinal development and circuitry, motor cortex localization and mapping, and safety. This special report also describes methodologies and safety considerations related to TMS assessment in infants, and discusses potential applications related to diagnosis of cerebral palsy and early intervention.Expert opinion: Single-pulse TMS has demonstrated safety and feasibility in infants with perinatal brain injury and may provide insight into neuromotor development and potential cerebral palsy diagnosis. Additional research in larger sample sizes will more fully evaluate the utility of TMS biomarkers in early diagnosis and intervention. Methodological challenges to performing TMS in infants and technical/equipment limitations require additional consideration and innovation toward clinical implementation. Future research may explore use of noninvasive neuromodulation techniques as an intervention in younger children with perinatal brain injury to improve motor outcomes.

Children with hemiparesis (CWH) due to stroke early in life face lifelong impairments in motor function. Transcranial direct current stimulation (tDCS) may be a safe and feasible adjuvant therapy to augment reha-bilitation. Given the variability in outcomes following tDCS, tailored protocols of tDCS are required. We eval-uated the safety, feasibility, and preliminary effects of a single session of targeted anodal tDCS based on individual corticospinal tract organization on corticospinal excitability. Fourteen CWH (age = 13.8 +/- 3.63) were stratified into two corticospinal organization subgroups based on transcranial magnetic stimulation (TMS)-confirmed motor evoked potentials (MEP): ipsilesional MEP presence (MEPIL+) or absence (MEPIL-). Subgroups were randomized to real anodal or sham tDCS (1.5 mA, 20 min) applied to the ipsilesional (MEPIL + group) or contralesional (MEPIL- group) hemisphere combined with hand training. Safety was assessed with question-naires and motor function evaluation, and corticospinal excitability was assessed at baseline and every 15 min for 1 h after tDCS. No serious adverse events occurred and anticipated minor side effects were reported and were self-limiting. Six of 14 participants had consistent ipsilesional MEPs (MEPIL + group). Paretic hand MEP amplitude increased in 5/8 participants who received real anodal tDCS to either the ipsilesional or contralesional hemisphere (+80% change). Application of tDCS based on individual corticospinal organization was safe and feasible with expected effects on excitability, indicating the potential for tailored tDCS protocols for CWH. Additional research involving expanded experimental designs is needed to confirm these effects and to determine if this approach can be translated into a clinically relevant intervention.

•Remotely-instructed tDCS is safe and tolerable in children and young adults with cerebral palsy.•Participants and caregivers reported and demonstrated that at-home tDCS setup was feasible.•Results support further studies to evaluate efficacy of remotely-instructed tDCS in children.

Hemiparetic cerebral palsy (HCP), weakness on one side of the body typically caused by perinatal stroke, is characterized by lifelong motor impairments related to alterations in the corticospinal tract (CST). CST reorganization could be a useful biomarker to guide applications of neuromodulatory interventions, such as transcranial direct current stimulation (tDCS), to improve the effectiveness of rehabilitation therapies. We evaluated an adolescent with HCP and CST reorganization who demonstrated persistent heightened CST excitability in both upper limbs following anodal contralesional tDCS. The results support further investigation of targeted tDCS as an adjuvant therapy to traditional neurorehabilitation for upper limb function.

BACKGROUND:Pediatric applications of non-invasive brain stimulation using transcranial direct current stimulation (tDCS) have demonstrated its safety with few adverse events reported. Remotely monitored tDCS, as an adjuvant intervention to rehabilitation, may improve quality of life for children with cerebral palsy (CP) through motor function improvements, reduced treatment costs, and increased access to tDCS therapies. Our group previously evaluated the feasibility of a remotely monitored mock tDCS setup in which families and children successfully demonstrated the ability to follow tDCS instructional guidance.METHODS AND DESIGN:Here, we designed a protocol to investigate the feasibility, safety, and tolerability of at-home active transcranial direct current stimulation in children with CP with synchronous supervision from laboratory investigators. Ten participants will be recruited to participate in the study for 5 consecutive days with the following sessions: tDCS setup practice on day 1, sham tDCS on day 2, and active tDCS on days 3-5. Sham stimulation will consist of an initial 30-second ramp up to 1.5 mA stimulation followed by a 30-second ramp down. Active stimulation will be delivered at 1.0 - 1.5 mA for 20 minutes and adjusted based on child tolerance. Feasibility will be evaluated via photographs of montage setup and the quality of stimulation delivery. Safety and tolerability will be assessed through an adverse events survey, the Box and Blocks Test (BBT) motor assessment, and a setup ease/comfort survey.DISCUSSION:We expect synchronous supervision of at-home teleneuromodulation to be tolerable and safe with increasing stimulation quality over repeated sessions when following a tDCS setup previously determined to be feasible. The findings will provide opportunity for larger clinical trials exploring efficacy and illuminate the potential of remotely monitored tDCS in combination with rehabilitation interventions as a means of pediatric neurorehabilitation. This will demonstrate the value of greater accessibility of non-invasive brain stimulation interventions and ultimately offer the potential to improve care and quality of life for children and families with CP.TRIAL REGISTRATION:October 8, 2021( https://clinicaltrials.gov/ct2/show/NCT05071586 ).

PURPOSE:Perinatal brain injury is a primary cause of cerebral palsy, a condition resulting in lifelong motor impairment. Infancy is an important period of motor system development, including development of the corticospinal tract (CST), the primary pathway for cortical movement control. The interaction between perinatal stroke recovery, CST organization, and resultant motor outcome in infants is not well understood.METHODS:Here, we present a protocol for multimodal longitudinal assessment of brain development and motor function following perinatal brain injury using transcranial magnetic stimulation and magnetic resonance imaging to noninvasively measure CST functional and structural integrity across multiple time points in infants 3 to 24 months of age. We will further assess the association between cortical excitability, integrity, and motor function.DISCUSSION:This protocol will identify bioindicators of motor outcome and neuroplasticity and subsequently inform early detection, diagnosis, and intervention strategies for infants with perinatal stroke, brain bleeds, and related diagnoses.

Transcranial magnetic stimulation (TMS) is an increasingly popular tool for stroke rehabilitation. Consequently, researchers have started to explore the use of TMS in pediatric stroke. However, the application of TMS in a developing brain with pathologies comes with a unique set of challenges. The effect of TMS-induced electric fields has not been explored in children with stroke lesions. Here, we used finite element method (FEM) modeling to study how the electric field strength is affected by the presence of a lesion. We created individual realistic head models from MRIs (n = 6) of children with unilateral cerebral palsy due to perinatal stroke. We conducted TMS electric field simulations for coil locations over lesioned and non-lesioned hemispheres. We found that the presence of a lesion can strongly affect the electric field distribution. On the group level, the mean electric field strength did not differ between lesioned and non-lesioned hemispheres but exhibited a greater variability in the lesioned hemisphere. Other factors such as coil-to-cortex distance have a strong influence on the TMS electric field even in the presence of lesions. Our study has important implications for the delivery of TMS in children with brain lesions with respect to TMS dosing and coil placement.

OBJECTIVES:The aim of this study was to determine the impact of the COVID-19 pandemic on access to rehabilitation therapies and the impact of changes in therapy access on the physical and mental well-being of children with motor impairment and their caregivers.DESIGN:Caregivers of children younger than 18 yrs with childhood-onset motor impairment (primarily cerebral palsy) completed an anonymous survey through the online platform REDCap between May 5 and July 13, 2020.RESULTS:The survey was completed by 102 participants. Before the pandemic, 92 of 102 children (90%) were receiving one or more therapies; at the time surveyed, 55 children (54%) were receiving any therapies (P < 0.001). More than 40% of the sample reported increased child stress, decreased physical activity, and/or decline in mobility/movement. Participants who reported a decrease in number of therapies at the time surveyed more frequently reported lower satisfaction with treatment delivery (P < 0.001), a decline in child's mobility (P = 0.001), and increased caregiver stress (P = 0.004). Five qualitative themes were identified from open-ended question responses related to therapies and well-being.CONCLUSIONS:Access to pediatric rehabilitation therapies was disrupted during COVID-19. Disrupted access may be related to impact on physical and mental health. With the expansion of telehealth, caregiver and child feedback should be incorporated to optimize benefit.

Purpose Recruitment for pediatric non-invasive brain stimulation (NIBS) studies is often challenged by low enrollment. Understanding parental perceptions regarding NIBS is crucial to develop new communication strategies to increase enrollment. Design/methodology/approach Integrating a crossed-disciplinary approach, the authors conducted a survey at the 2018 Minnesota State Fair querying the perception of risk and preferences of current and future parents associated with pediatric NIBS research. The survey consisted of 28 closed-text questions including demographics, photographs portraying NIBS, terminologies and factors related to NIBS studies. Findings Complete surveys were analyzed from 622 parent participants. A significant number of participants (42.8%) perceived the photographs of NIBS as “risky.” Additionally, 65.43% perceived the term “Non-invasive brain therapy” as not risky, a word combination not currently being used when recruiting potential participants. Over 90% (561/622) of participants chose the photograph of child-friendly MRI suite. Research limitations/implications Although this survey identified aspects crucial in recruitment for pediatric NIBS research, there were limitations. For example, the authors did not record the sex or demographic distribution (e.g. rural versus urban setting) of the participants. These factors may also influence recruitment messaging. Originality/value For important medical research to impact and improve the lives of the potential remedies, participation by the public in clinical trials is necessary. Often the general public perceives the trials as risky as a result of poor marketing communication recruitment material. This study sought to be understood if how the message is encoded has an impact on the decoding by the receiver.

Mirror movements (MM) can be a clinical manifestation of unilateral cerebral palsy (UCP) causing involuntary movements when attempting to use either hand for functional activities. Atypical development of the corticospinal tract (CST) contributes to impairments in observed motor movements and functional activities. However, little is known about the underlying neurophysiology and contribution of the CST to MM. The current case study characterizes MM in 13 children and young adults with UCP ranging in age from 7 to 19 years and includes clinical and neurophysiologic variables. Clinical profiles included MM of each hand (ie, Woods and Teuber), bimanual coordination and hand use (Assisting Hand Assessment [AHA]), and perception of performance (Canadian Occupational Performance Measure [COPM]). We measured the strength of motor-evoked potentials (MEP) elicited from single-pulse transcranial magnetic stimulation (TMS) of each hemisphere to create a ratio of hemispheric responses. Our sample included three types of CST circuitry: ipsilateral (n = 5), bilateral (n = 3), and contralateral (n = 4). The MEP ratio ranged from 0 to 1.45 (median 0.11) with greater MM observed in participants with ratios greater than 0.5. We observed a positive relationship between the MEP ratio and the more-affected MM score, meaning participants with larger ipsilateral responses from contralesional stimulation (eg, the contralesional hemisphere was stimulated with TMS resulting in an ipsilateral MEP response), as compared with contralateral responses, displayed greater MM than those that did not. There was no relationship between MM and function as measured by the AHA or COPM. These findings suggest a role of the contralesional hemisphere to MM, which could serve as a therapeutic target for interventions.

Individuals with Parkinson's disease (PD) experience postural instability, low-back pain (LBP), and anxiety. These symptoms increase the risk of falls and decrease quality of life. Research shows yoga improves balance and decreases LBP and anxiety in healthy adults, but its effects in PD are poorly understood. All participants were part of a larger intervention study. Participants received pretest and posttest evaluations, including the Balance Evaluation Systems Test (BESTest), Beck Anxiety Inventory (BAI), and Revised Oswestry Disability Index (ROSW). Total scores for each measure, as well as individual balance system section scores from the BESTest (biomechanical constraints, stability limits/verticality, transitions/anticipatory, reactive, sensory orientation, and stability in gait) were compared within groups pre- to posttest. Participants in the yoga group (n = 13) completed a twice-weekly 12-week yoga interve n t i o n , whereas controls (n = 13) continued their usual routines for 12 weeks. Both the yoga (Z = -3.20, p = 0.001) and control (Z = -2.10, p = 0.040) groups improved on the BESTest total score. The control group showed no changes in individual balance systems, whereas the yoga group improved in stability limits/verticality (Z = -2.3, p = 0.020), transitions/ anticipatory (Z = -2.50, p = 0.010), reactive (Z = -2.70, p = 0.008), and sensory orientation (Z = -2.30, p = 0.020). ROSW decreased in the yoga group only (Z = -2.10, p = 0.030). BAI did not change in either group. Yoga is a nonpharmacological intervention that can improve balance and LBP in people with PD. This study demonstrated that yoga is feasible for people with PD, and participants reported high levels of enjoyment and intent to practice yoga after the study.

Brain injury and stroke early in life occur during a time of heightened neuroplastic potential.[[1]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.Brain. 2008; 131: 2975-2985Crossref PubMed Scopus (185) Google Scholar] 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.[[2]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.Arch Phys Med Rehabil. 2019; 100: 724-738Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar] 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).[3]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.Eur J Paediatr Neurol. 2018; 22: 358-368Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar,[4]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.Arch Phys Med Rehabil. 2015; 96: S104-S113Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar 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.[5Aree-uea B. Auvichayapat N. Janyacharoen T. et al.Reduction of spasticity in cerebral palsy by anodal transcranial direct current stimulation.J Med Assoc Thai. 2014; 97: 954-962PubMed Google Scholar, 6Nemanich 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.Front Hum Neurosci. 2019; 13: 137Crossref PubMed Scopus (15) Google Scholar, 7Nemanich 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.Dev Neurorehabil. 2019; 22: 504-508Crossref PubMed Scopus (3) Google Scholar] 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.[8]Charvet L.E. Kasschau M. Datta A. et al.Remotely-supervised transcranial direct current stimulation (tDCS) for clinical trials: guidelines for technology and protocols.Front Syst Neurosci. 2015; 9: 26Crossref PubMed Scopus (115) Google Scholar,[9]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.Brain Stimul. 2020; 13: 686-693Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar 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.[8]Charvet L.E. Kasschau M. Datta A. et al.Remotely-supervised transcranial direct current stimulation (tDCS) for clinical trials: guidelines for technology and protocols.Front Syst Neurosci. 2015; 9: 26Crossref PubMed Scopus (115) Google Scholar,[9]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.Brain Stimul. 2020; 13: 686-693Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar 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.[[10]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.J Biomed Inf. 2009; 42: 377-381Crossref PubMed Scopus (25804) Google Scholar] 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. 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. Gillick Pediatric Neuromodulation Laboratory, the Shepherd Trust/Jensen Family Award.

People with Parkinson disease demonstrate increased gait variability, but the primary variability sources are poorly understood. People with Parkinson disease and freezing of gait (freezers) have greater gait impairments than people with Parkinson disease without freezing of gait (nonfreezers), which may relate to cerebellar dysfunction. Thirteen freezers and 31 nonfreezers completed backward, forward, and forward with dual task gait trials. Sagittal joint angle waveforms were extracted for the hip, knee, and ankle using 3D motion capture. Decomposition indices were calculated for the 3 joint combinations. Principal component analysis extracted variance sources from the joint waveforms. Freezers had significantly greater decomposition between hip-ankle (F1,42 = 5.1, P = .03) and hip-knee (F1,42 = 5.3, P = .03) movements. The principal component analysis did not differentiate freezers and nonfreezers; however, primary variance sources differed between conditions. Primary variance during forward and forward with dual task gait came from joint angle magnitude and peak angle timing. Backward gait showed primary variance from joint angle magnitude and range of motion. The results show that freezers decompose movement more than nonfreezers, implicating cerebellar involvement in freezing of gait. Primary variance differs between gait conditions, and tailoring gait interventions to address variability sources may improve intervention efficacy.