Integrating Transcranial Direct Current Stimulation into an Existing Inpatient Physiotherapy Program to Enhance Motor Learning in an Adolescent with Traumatic Brain Injury: A Case Report

Abstract

Purpose

Describe how transcranial direct current stimulation (tDCS) was incorporated into an inpatient physiotherapy program for an adolescent with severe traumatic brain injury (TBI), detail the motor learning focus of the physiotherapy sessions, and summarize gross motor progress.

Method

This case report describes an adolescent who received 20 minutes of anodal tDCS immediately prior to 16 physiotherapy sessions over four weeks. Potential side effects were tracked pre/post tDCS. Gross motor outcomes were measured pre-intervention, post-intervention, and three months post-intervention. Physiotherapy session content was analyzed using therapist documentation and the Motor Learning Strategies Rating Instrument.

Results

The youth tolerated tDCS well. The primary side effect was itchiness under the electrodes during tDCS sessions. His mobility progressed from wheelchair use pre- ‘tDCS + physiotherapy’ to ambulation with a walker post-intervention. His Gross Motor Function Measure score increased 33.1% points pre/post intervention. Session tasks often had several foci (e.g., skill acquisition, strength, and balance) with task focus changing as the youth progressed. Various motor learning strategies were layered within tasks to support performance and learning.

Conclusions

tDCS was successfully integrated into an existing inpatient physiotherapy program for an adolescent with TBI. This protocol provides a structure for implementing, monitoring, and measuring tDCS + physiotherapy in pediatric rehabilitation.

Keywords:

• Brain injuries
• motor learning
• motor skills
• pediatrics
• physical therapy
• transcranial direct current stimulation

Acknowledgements

We would like to thank Ethan, the physiotherapy staff in the inpatient ABI program (assessment, treatment), Anna Tendera (tDCS), Gloria Lee (consent), Dr. Alysha Ladha (medical screening), and Madhu Pinto (randomization) for their contributions to this study.

Additional information

Funding

This study was funded by the Holland Bloorview Centre For Leadership.

Notes on contributors

Jennifer L. Ryan

Jennifer L. Ryan, PT, PhD, is a recent graduate of the doctoral program in the Rehabilitation Sciences Institute at the University of Toronto. She is a physiotherapist in the acquired brain injury program at Holland Bloorview Kids Rehabilitation Hospital. Dr Ryan’s postdoctoral research at SickKids (Toronto, Canada) involves exploring the impact of exercise on motor, cognitive, and neural outcomes in pediatric brain tumour survivors.

Deryk S. Beal

Deryk S. Beal, PhD, Reg. CASLPO, CCC-SLP, is a Senior Scientist at Bloorview Research Institute and an Assistant Professor in the Department of Speech-Language Pathology and Rehabilitation Sciences Institute at the University of Toronto. Dr Beal’s research explores the neurobiology of childhood brain-based disorders and the impact of neuromodulation on clinical outcomes.

Danielle E. Levac

Danielle E. Levac, PT, PhD, is an Associate Professor in the Faculty of Medicine, School of Rehabilitation at the University of Montreal, and a researcher at the CHU Sainte-Justine Research Centre. Dr Levac’s research explores the sustainable integration of virtual reality and other technologies in pediatric rehabilitation.

Darcy L. Fehlings

Darcy L. Fehlings, MD, is a Senior Clinician Scientist at Bloorview Research Institute, a Developmental Pediatrician at Holland Bloorview Kids Rehabilitation Hospital, and an Associate Professor in the Department of Paediatrics and Rehabilitation Sciences Institute at the University of Toronto. Dr Fehlings’ research evaluates neurorehabilitation treatments for children and youth with cerebral palsy.

F. Virginia Wright

F. Virginia Wright, PT, PhD, is a Senior Scientist at Bloorview Research Institute and a Professor in the Department of Physical Therapy and Rehabilitation Sciences Institute at University of Toronto. Dr Wright’s research involves developing and validating pediatric outcome measures, and evaluating rehabilitation interventions aimed at enhancing physical activity and participation.