Neuromodulation for Children With Hemiparesis and Perinatal Stroke
Authors: Hilderley Alicia J. , Dunbar Mary , Andersen John , Fehlings Darcy , Metzler Megan , Carlson Helen L. , Zewdie Ephrem , Hodge Jacquie , O’Grady Kathleen , Carsolio Lisa , Dlamini Nomazulu , Giuffre Adrianna , Cole Lauran , Kuo Hsing-Ching , Bourgeois Anna , Hollis Asha , Maiani Meghan , Ciechanski Patrick , Jadavji Zeanna , Craig Brandon , Kelly Dion , Keough Joanna , Wrightson James , Fay Linda , Switzer Lauren , Pajevic Maya , Ramsey Alana , Sametz Michael , Brooks Brian L. , Yaskina Maryna , Batara Jesse , Hill Michael D. , Kirton Adam 
Published: February 2025

ImportanceCurrent upper-extremity therapies provide inconsistent outcomes for children with unilateral cerebral palsy. Noninvasive brain stimulation, specifically transcranial direct current stimulation, may enhance motor gains when combined with therapy.ObjectiveTo determine whether the addition of neurostimulation to upper-extremity therapy enhances motor function in children with perinatal stroke and unilateral cerebral palsy.Design, Setting, and ParticipantsThis multicenter, randomized, sham-controlled phase 3 trial was conducted from July 2017 through March 2023. Investigators, treating therapists, outcome assessors, parents, and participants were blinded to intervention allocation. The study took place at 3 tertiary care Canadian pediatric rehabilitation hospitals. From a population-based sample of children 6 to 18 years old with perinatal stroke and disabling unilateral cerebral palsy, 196 children were approached and 107 were excluded.InterventionParticipants were randomly assigned in permuted blocks of 2 (1:1) to receive daily sham or cathodal stimulation to the contralesional motor cortex during 10 days of high-dose, child-centered intensive upper-extremity therapy.Main Outcomes and MeasuresThe primary end points were changes from baseline to 6 months posttherapy in affected hand function and attainment of child-identified functional goals assessed by the Assisting Hand Assessment and Canadian Occupational Performance Measure. Safety was assessed, including any decrease in the function of either hand. Analysis was intention to treat.ResultsEighty-nine children were enrolled with 45 randomized to sham (62% male, 38% female; mean [SD] age, 10.7 [2.8] years) and 44 to stimulation (52% male, 48% female; mean [SD] age, 10.7 [2.1] years). Eighty-three participants had complete outcome data (42 sham, 41 stimulation). High proportions of children in both groups demonstrated significant functional gains sustained at 6 months (P &amp;lt; .001) with large effect size (Cohen d &amp;gt; 1). There were no differences between groups for mean (SD) change in hand function (5.2 [5.3] vs 4.6 [5.7]; P = .63) or goal attainment (3.0 [2.0] vs 3.6 [2.3]; P = .25). Procedures were safe and well tolerated with no serious adverse events.Conclusions and RelevanceIn this study, results showed that patient-centered intensive motor learning programs could produce marked and sustained improvements in upper-extremity function in children with perinatal stroke and unilateral cerebral palsy. The addition of 1 milliampere contralesional motor cortex transcranial direct current stimulation did not improve outcomes compared with sham stimulation.Trial RegistrationClinicalTrials.gov Identifier: NCT03216837