Evaluation of Repetitive Transcranial Magnetic Stimulation as an Adjunct to Modified Constraint Induced Movement Therapy in Improving Upper Limb Function in Children With Hemiparetic Cerebral Palsy Aged 5 - 18 Years

Study Overview
=================
Brief Summary
-----------------
The investigators aim to evaluate efficacy of TMS as an adjunct to CIMT, assess its safety and tolerability and study cortical excitability with help of TMS which are both rehabilitative therapies for hemiplegic cerebral palsy.

Detailed Description
-----------------
Cerebral palsy is the most common motor disability of childhood and Hemiparetic cerebral palsy accounts for about one third of cases. Improving spasticity and upper limb function in these children can lead to better functional outcome and quality of life. TMS is an upcoming rehabilitative modality which has shown promising results in western studies. It has benefits of being non-invasive and has shown to have additive effect when used with CIMT which is standard of care in hemiparetic CP. However, randomized controlled clinical trials comparing it with CIMT alone in hemiparetic CP are very few, none from India so far. The dose, type and duration of TMS and its feasibility in resource limited set up needs to be investigated in children .Therefore, the investigators aim to evaluate efficacy of TMS as an adjunct to CIMT, assess its safety and tolerability and study cortical excitability with help of TMS.

Official Title
-----------------
Evaluation of Repetitive Transcranial Magnetic Stimulation as an Adjunct to Modified Constraint Induced Movement Therapy in Improving Upper Limb Function in Children With Hemiparetic Cerebral Palsy Aged 5 - 18 Years - A Randomized Controlled Trial

Conditions
-----------------
Hemiparetic Cerebral Palsy

Intervention / Treatment
-----------------
* Device: mCIMT with real rTMS
* Device: mCIMT with sham rTMS


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: • Age 5 - 18 years Hemiparetic Cerebral Palsy (perinatal brain injury) Intelligence Quotient >70 (Binet Kamat Test/Malin's Intelligence Scale for Children) Modified Ashworth scoring 1-3 for affected limb Can sit independently or with support (GMFCS stage : 1-4 and Manual Ability Classification System stage: 1-3) Preserved vision and hearing (with or without correction) Exclusion Criteria: • Uncontrolled epilepsy as defined by seizure frequency >1/month for preceding 3 months Severe concurrent illness or disease not associated with CP or unstable medical conditions like pneumonia Genetic or syndromic associations Children diagnosed with Autistic Spectrum Disorders Modified Ashworth Scale Score more than 3 at shoulder/elbow/wrist Contractures of affected limb Severe movement disorder like dystonia, choreo-athetosis or ballismus interfering with purposeful limb movement Any congenital brain malformation detected on conventional MRI brain Recent surgery/cast/splint in affected limb Botulinum toxin/phenol block in affected limb in past 6 months or planned to receive in study period Those receiving tone modifying agents within two weeks before enrolment (Tizanidine, baclofen, benzodiazepines, dantrolene) mCIMT received in last 6 months Any contraindications for TMS - implanted electronic device and non-removable metallic objects near coil e.g. Pacemaker, cochlear implant

Ages Eligible for Study
-----------------
Minimum Age: 5 Years
Maximum Age: 18 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: mCIMT with real rTMS<br>Modified Constraint Induced Movement Therapy (mCIMT) with real Repetitive Transcranial Magnetic Stimulation (rTMS). 10 sessions of mCIMT will be administered using physical rehabilitation protocol along with real rTMS over contralateral primary motor cortex. | Device: mCIMT with real rTMS<br>* Modified constraint induced movement therapy will be provided to all children according to predefined protocol. rTMS will be provided using figure of eight shaped coil and TMS stimulator ((Magventure Denmark, X100 with mapoption) over contra-lesional primary motor cortex over 10 sessions of 20 minutes each spread over 4 weeks. Each session will comprise priming ( 10 minutes of 6Hz rTMS at 90% of resting motor threshold, delivered in two trains per minute with 5 seconds per train and 25-seconds intervals between trains (a total of 600 priming pulses)). Priming will be followed immediately by additional 10 minutes of 1Hz rTMS at 90% of resting motor threshold without interruption (a total of 600 low-frequency pulses).<br>|
| Sham Comparator: mCIMT with sham rTMS<br>Modified Constraint Induced Movement Therapy with sham Repetitive Transcranial Magnetic Stimulation (using sham coil). 10 sessions of mCIMT will be administered using physical rehabilitation protocol along with sham rTMS over contralateral primary motor cortex using sham coil which simulated sound and touch of real coil but has no electro-magnetic waves. | Device: mCIMT with sham rTMS<br>* Modified constraint induced movement therapy will be provided to all children according to predefined protocol. Sham rTMS will be given using a sham coil.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Efficacy of 4 weeks of mCIMT with sham/real rTMS | ◦ To evaluate the efficacy of repetitive Transcranial Magnetic Stimulation (rTMS) as an adjunct to modified Constraint Induced Movement Therapy (mCIMT) for 4 weeks in improving the Upper Limb Function as per increase in total QUEST score by 5 in 5-18 years old children with Hemiparetic Cerebral Palsy | Within 1 week of end of 4 weeks of mCIMT with sham/real rTMS | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| To evaluate improvement in dissociated movements, grasp, weight bearing and protective extension in each group at the end of 4 weeks | To evaluate improvement in dissociated movements, grasp, weight bearing and protective extension in each group at the end of 4 weeks | within 1 week of end of 4 weeks of mCIMT with sham/real rTMS | 
| To evaluate improvement in speed of upper limb movements in each group at the end of 4 weeks | To evaluate improvement in speed of upper limb movements in each group at the end of 4 weeks | within 1 week of end of 4 weeks of mCIMT with sham/real rTMS | 
| To evaluate improvement in muscle strength in each group at the end of 4 weeks | To evaluate improvement in muscle strength in each group at the end of 4 weeks | within 1 week of end of 4 weeks of mCIMT with sham/real rTMS | 
| To assess improvement in quality of life after the intervention in each group | To assess improvement in quality of life after the intervention in each group | within 1 week of end of 4 weeks of mCIMT with sham/real rTMS | 
| To assess compliance to therapy in each group by Daily Compliance Log | To assess compliance to therapy in each group by Daily Compliance Log | within 1 week of end of 4 weeks of mCIMT with sham/real rTMS | 
| To study for adverse events of TMS | To study for adverse events of TMS | within 1 week of end of 4 weeks of mCIMT with sham/real rTMS | 
| To evaluate cortical excitability with TMS at baseline and the end of 4 weeks | To evaluate cortical excitability with TMS at baseline and the end of 4 weeks | within 1 week of end of 4 weeks of mCIMT with sham/real rTMS | 
| • To evaluate sustenance of improvement by change in QUEST score at the end of 12 weeks, 8 weeks after stopping supervised treatment in both the groups | • To evaluate sustenance of improvement by change in QUEST score at the end of 12 weeks, 8 weeks after stopping supervised treatment in both the groups | within 1 week of end of 4 weeks of mCIMT with sham/real rTMS | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Transcranial Magnetic Stimulation (TMS), modified Constraint Induced Movement Therapy (mCIMT)