PowerPoint Presentation

Technology for Children with Cerebral Palsy and other Disabilities

Deborah Gaebler-SpiraXIII International ORITEL ConferenceFoundational and First General Assembly of the Latin American Academy on ChildDevelopment and Disability

Rehabilitation Institute of Chicago2

RIC: Historical Perspective3

Gave examples of roboticsRIC technologyAcross the ICF

Give examples of available usable available technology Across ICF

Santiago Meeting --------Asuncin Meeting4

Describe the forces that drive technology Identify how technology improves quantification of impairment or body structure and function-use of ultrasoundRobotic gait technology-enhance for activities-lokomat-integrate low techTouch on a few substitution technologies-access to all-Go baby GoObjectives

Vision has always been to create opportunities through technologyTechnology Vision and Reality

4 Reasons Driving Technology-Roboticsmore accurately quantify impairments control content and dose of therapy and measure clinical outcomesIncrease practice-can deliver more therapy improves cost benefitNew innovative equipment and treatments-ENGAGE both child, parents and clinicians

Health Condition (disorder or disease)ActivitiesParticipationBody Functions & Structures-quantificationEnvironmental FactorsPersonal FactorsWorld Health Organization-International Classification of Function

Interactions between components of the ICF

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1) Passive stiffness, 2) neurally-mediated reflex stiffness, 3) active muscle stiffnessContractureJoint range of motionInterventions (e.g. bracing, lengthening surgeries)

Measuring muscle stiffness Why does it matter?

Want to both be able to quantify patient-specific changes in muscle activity both to inform fidelity of models, but also to improve treatment9

Physiologic functions of the bodyAnatomical parts of the bodyBody Structure and Function10

Ultrasonic Evaluation Medial GastrocnemiusNon-invasive method to quantify biomechanical propertiesAnalyzed both passive and active muscle properties

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Muscle Fascicle and tendon changes in CPUltrasonography and Biomechanical Evaluations

SoleusMTJ

Calcaneus

Achilles Tendon

Cross-sectional area ofAchilles Tendon

Proximal

Distal

MedialLateral

GS Fibers in Spastic Hypertonia Fiber length & pennationin spastic muscles

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Passive stiffness Qualitative measures, estimates of joint stiffness, or groups of muscles (De Vlugt et al., 2010; Roy et al., 2011; Sinkjaer et al., 1994; Katz et al., 1989)Elastography (e.g.Debernard et al., 2011; Muthupillai et al., 1995)Shear wave elastography (e.g. Bercoff et al., 2004; Gennisson et al., 2005; Zhao et al. 2009)

Measuring muscle stiffness in vivo

Want to both be able to quantify patient-specific changes in muscle activity both to inform fidelity of models, but also to improve treatment14

Shear wave ultrasound elastographyCan measure stiffness of a materialMeasures shear wave velocityQuick, non-invasive

Shear wave velocity Stiffness

Goal - evaluate and compare muscle material properties of the more-affected and less-affected limbs of individuals with hemiplegic cerebral palsy-hemiplegic-age ave 9Influence of muscle and fascicle length impairment leveltorque

What are the errors if we use generic passive muscle properties?16

011.5Shear wave velocity (m/s)More- affected sideLess-affected side

Medial gastrocnemius

Why is this important?Local measurement of material properties increased passive stiffness in more-affected muscle across ROM and fascicle strainPassive stiffness (collagen, titan, extracellular matrix)With different level of activation, can distinguish type altered stiffness Neurophysiological and muscular changes sequence of eventsEvaluate treatments e.g. bracing, boNT-A, lengthening surgeries

Ultrasound-you can use everyday

easy

Health Condition (disorder or disease)Activities-motor learningParticipationBody Functions & StructuresEnvironmental FactorsPersonal FactorsInternational Classification of Function

Interactions between components of the ICF

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Execution of a task or action by an individualCP walking, feeding , transfers, dressing-school workActivities backdrop of development21

Technologies to address activitiesActivities Walkingtask-specific repetition, sensory feedback and feedback about performance are thought to enhance the effects of practice

Lange observed 31 physical and occupational therapy sessions at 7 different settingsAverage number of repetitions of task specific , functional movement was 32Animal studies use 600 repetitions per session to induce plasticity

Can you increase practice at home?Practice Intensity

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Automated repetitive practice

Goal To Walk Further and Quicker, Participate in PlaygroundN.R. 6 y/o adopted, CP spastic diplegia, mild component of dystoniaGMFC-3FMS-2,2,1Described as slow and wanderingOn oral baclofen 10 mg TID, artane 2 mg TIDHamstrings interfering, with stride lengthBotulinum toxin A to SM,ST 3 weeks prior

ResultsPre 6 minute -97 meters 10 meters- 35 secGmfm-41Tripping-2-3Post6 minute-155 meters10 meters-26 secGmfm-41Tripping-0

3-4 sessions/wk for 30-50minutes/session; 12-18 sessions/ptSince 2008 treated over 200+ pediatric patients with CPGait training CPT code 97116

RIC Clinical Experience

RIC Outcomes RevealBWSTT using Lokomat improved overall function, as measured by the 6 minute walk test and 10 meter walk testGMFM Domains (A/B/E) improved in GMFCS IVGMFM domains D/E approaching significanceEffects of TT better in higher level GMFCS patientsUNCLEAR on role !

Less effect based on limited degrees of freedom when stepping in sagittal plane, passive training system.

SO increased intensity in task specific activity such as repeated stepping in multiple planes of motion may translate when walking at home/school 28

Practical Recommendations for use of Lokomat29Aurich 2015 J of Neuropediatrics

Training schedules highly variable

positive outcomes GMFM-D,EStanding, walking speed, 10 meter walk distance 6 minuteMost improvement in younger and engaged

No adverse effectsQuestions still remain-Can we work together and contribute to the combined data base?Literature to Support RAGT-5 studies31

Artic Mission-possible collaborationCollect data to develop guidelines as well as to answer scientific questions with regards to the use of robotic devices in rehabilitation to improve patient outcome

Database

Simple looking for partners

Data Status7 centers are already contributing data1 center has recently received IRB/Ethical approval2 centers are awaiting IRB approval1 center contributes administratively

Numbers in arrows show improvement from March to May 2015

Transfer of skills from TT to OG is hardly definitiveBWS limits dynamic trunk control Restricted degrees of freedom Altered gait dynamics and passive training patterns limit skill acquisitionMinimal to modest functional outcomes in ambulation Stroke literature points to importance of daily # steps and speed of TT D. Damiano 11; J. Moore 10 What does the Literature tell us about current RGT

Steps GMFCS36

81 youth with CP, aged 10-13 years, GMFCS I to III (Bjornson et al. 2007)

37Pedometers to sensors- to monitor steps-inexpensive way to monitor Unobtrusive Sensing and Wearable Devices-REAL WORLD DATA

Health Condition (disorder or disease)ActivitiesParticipation-SubstitutionBody Functions & StructuresEnvironmental FactorsPersonal FactorsInternational Classification of Function

Interactions between components of the ICF

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Involvement of a life situationCp-home, -school, sports, artsParticipation-backdrop of culture and community

Rehabilitation strength has been in subsitution

Mind-controlled exoskeleton kicks off World Cup

The problemSelf-produced mobility plays a crucial role in a childs cognitive and psychosocial development (Piaget 1952, Erikson 1963, Paulsson and Christofferson 1984, Verburg et al. 1984, Butler 1986).linked to the development of spatial cognition, emotional skills, self-awareness. inability to move independently has a significant negative impact on cognitive, perceptual, and/or motor development (Zubek et al. 1963, Tatlow 1980, Brinker and Lewis 1982, Verburg 1987)

The problemMobility devices such as motorized wheelchairs require a certain level of cognitive ability and maturity to operateWhen do is the child ready for a wheelchair?Wheelchairs introduced at school ageProviding daily mobility between the ages of 1 and 5 is critical, given that significant learning, brain and behavioral development is dependent on mobility during this time.

Wheelchairs introduced at school age- some studies are trying to develop a objective measurement of readoness for wheelchair operation43

The problemHow much does a wheelchair cost? A LOTHow much do they weigh? A LOT issuesHow often do you replace?Battery malfunction?Insurance approval?Slow response?Social issues?

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The solutionGoal to provide mobility to kids who have trouble moving on their own. Modifying off-the-shelf toy racecars to provide mobility to children with crawling and walking problems, empowering them to be part of the action at home, in the daycare center, and on the playground.

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"Interacting with kids and adults out in the world and gaining a little independence are crucial to early development. The disability no longer causes them to miss out on playtime or making friendsnow they are able to participate. Other kids see the girl in the Barbie car and say, 'Wow, can I play with you?- Cole Galloway, PhD

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ConsistentCan create intermittent reinforcementCan program for perfect practiceCan be fun and tied to gamingCan provide feedback precise to follow progressOpen worldsRobotics

The Promise of RecoveryAre the expected outcomes of technology at the same level as parental expectations

Is More always Better