Primed low‐frequency repetitive transcranial magnetic stimulation and constraint‐induced movement therapy in pediatric hemiparesis: a randomized controlled trial

• Published in: Developmental medicine and child neurology Vol. 56; no. 1; pp. 44 - 52
• Main Authors: Gillick, Bernadette T, Krach, Linda E, Feyma, Tim, Rich, Tonya L, Moberg, Kelli, Thomas, William, Cassidy, Jessica M, Menk, Jeremiah, Carey, James R
• Format: Journal Article
• Language: English
• Published: England 01-01-2014
• Subjects: Adolescent; Child; Exercise Therapy - methods; Feasibility Studies; Female; Functional Laterality; Humans; Leukomalacia, Periventricular - complications; Leukomalacia, Periventricular - physiopathology; Male; Motor Cortex - physiopathology; Movement; Paresis - etiology; Paresis - physiopathology; Paresis - therapy; Recovery of Function; Restraint, Physical; Stroke - complications; Stroke - physiopathology; Transcranial Magnetic Stimulation - methods; Treatment Outcome
• ISSN: 0012-1622; 1469-8749
• DOI: 10.1111/dmcn.12243

Aim
The aim of this study was to determine the feasibility and efficacy of five treatments of 6 Hz primed, low‐frequency, repetitive transcranial magnetic stimulation (rTMS) combined with constraint‐induced movement therapy (CIMT) to promote recovery of the paretic hand in children with congenital hemiparesis.
Method
Nineteen children with congenital hemiparesis aged between 8 and 17 years (10 males, nine females; mean age 10 years 10 months, SD 2 years 10 months; Manual Ability Classification Scale levels I‐III) underwent five sessions of either real rTMS (n=10) or sham rTMS (n=9) alternated daily with CIMT. CIMT consisted of 13 days of continuous long‐arm casting with five skin‐check sessions. Each child received a total of 10 hours of one‐to‐one therapy. The primary outcome measure was the Assisting Hand Assessment (AHA) and the secondary outcome variables were the Canadian Occupational Performance Measure (COPM) and stereognosis. A Wilcoxon signed‐rank sum test was used to analyze differences between pre‐ and post‐test scores within the groups. Analysis of covariance was used to compute mean differences between groups adjusting for baseline. Fisher's exact test was used to compare individual change in AHA raw scores with the smallest detectable difference (SDD) of 4 points.
Results
All participants receiving treatment finished the study. Improvement in AHA differed significantly between groups (p=0.007). No significant differences in the secondary outcome measures were found. Eight out of 10 participants in the rTMS/CIMT group showed improvement greater than the SDD, but only two out of nine in the sham rTMS/CIMT group showed such improvement (p=0.023). No serious adverse events occurred.
Interpretation
Primed, low‐frequency rTMS combined with CIMT appears to be safe, feasible, and efficacious in pediatric hemiparesis. Larger clinical trials are now indicated.
What this paper adds
Primed, low‐frequency rTMS was well tolerated in children with hemiparesis.
rTMS in combination with CIMT improved hand function in 8 out of 10 children.
Minor adverse events resolved within 24 hours, with the most common being headache (rTMS) and cast irritation (CIMT).
This article is commented on by Hoare on pages 5–6 of this issue.