Combined Transcranial Direct Current Stimulation and Robotic Upper Limb Therapy Improves Upper Limb Function in Adults with Cerebral Palsy

K. M. Friel1,3, P. Lee1, , H.-C. Kuo2, D. Gupta1, A. Barachant1, A. R.P. Smorenburg1, M. Marneweck2, D. J. Edwards1,3 1Burke Medical Research Institute, White Plains, NY; 2Teachers College, Columbia University, New York, NY; 3Weill Cornell Medical College, New York, NY

OBJECTIVE

To determine feasibility and efficacy of upper limb therapy plus excitatory tDCS for adults with cerebral palsy.

Combined tDCS + Robotic Training: 3x/wk, 12 weeks (36 sessions)

Side Effects: Mild transient scalp tingling, headache. Dissipated <10 min.

CONCLUSIONS Robotic therapy combined with tDCS shows promise as a therapy to

safely improve upper extremity deficits in adults with cerebral palsy.

Funding: David and Agnes Carvel Foundation, NICHD 084971

Shoulder/Elbow Robot Reaching Accuracy  

Accuracy in Drawing Circles Circle drawing was not a trained task. We tested circle drawing

accuracy to evaluate transfer of skill from a trained to an untrained task.

Reaching range, accuracy, and smoothness improved during therapy.

Circle drawing accuracy and smoothness improved during therapy.

STUDY DESIGN AND METHODS Trained task, performed 1000x/session

Outcome Measure Participant #1 Participant #2 Before After Before After

Wolf Motor Function Test 45 52 51 55

Fugl-Meyer 10 13 40 46

Grip Strength Affected Hand 21 lbs 23 lbs 27 lbs 31 lbs

Upper Extremity Motor Outcome Measures  

Motor Outcomes: • Wolf Motor Function Test • Fugl-Meyer • Grip Strength • Robotic kinematics

Neurophysiology Outcomes: • Motor mapping (transcranial magnetic stimulation)

of the paretic hand representation • Electroencephalography during motor task

BASELINE MEASURES

SESSION PROCEDURES

tDCS: 2mA anodal, 20 min, targeted to motor map of

paretic hand

Robotic Therapy: training of shoulder/elbow or wrist (alternating sessions), 1 hr, 1000 movements/session

FOLLOW-UP MOTOR AND NEUROPHYSIOLOGY OUTCOMES

Scan this QR code to watch a video of the training

Suppression of Sensorimotor Rhythm (EEG)  

Expansion of the Motor Map of the Paretic Wrist  

The motor map of the paretic flexor carpi radialis increased in size and amplitude of the motor response to TMS after therapy.

•  Movement of the non-paretic hand showed normal SMR suppression in the uninjured hemisphere as expected, both before and after tDCS-robotics.

•  During movement of the

paretic hand, SMR suppression was spread over a wider area around the injured motor cortex after training compared to before training.

9 blocks - 10x right + 10x left per block BACKGROUND

Cerebral Palsy is caused by a nonprogressive brain injury or stroke during the first two years of life. Unilateral spastic cerebral palsy (USCP) causes weakness and motor deficits on one side of the body.

Few therapies exist for upper extremity rehabilitation in adults with USCP.

Robotic therapy has demonstrated significant reductions in impairment of the affected limb of stroke .

Transcranial direct current stimulation (tDCS) is a safe , non-invasive technique for modulating neural excitability that is transient. TDCS can augment the efficacy of robotic when delivered immediately before training.

PARTICIPANTS - 37 y/o male; acquired left side USCP at age 18 months

- 25 y/o female; congenital right side USCP

HARDWARE AND SOFTWARE •  Soterix 1x1 tDCS device •  Magstim200 transcranial magnetic stimulator •  Brainsight (Rogue) frameless stereotaxy •  NeuroConn EEG/EMG system •  MATLAB (Mathworks)