Technology for Children with Cerebral Palsy and other Disabilities

Deborah Gaebler-Spira

XIII International ORITEL Conference

Foundational and First General Assembly

of the Latin American Academy on Child

Development and Disability

Grant/Research SupportNIDRR,CPRR,CIHR

Allergan, Merz, CNS Therapeutics

Consultant Nothing to disclose

Speakers Bureau Nothing to disclose

Stock Shareholder Nothing to disclose

Other (identify) Nothing to disclose

Conflict of Interest Disclosures for

Deborah Gaebler-Spira

Rehabilitation Institute of Chicago

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20121954 1964 1968 1974 2000 2001 2006 2010

RIC: Historical Perspective

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• Gave examples of robotics

• RIC technology

• Across the ICF

• Give examples of available usable available technology

• Across ICF

Santiago Meeting --------Asunción Meeting

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• Describe the forces that drive technology

• Identify how technology improves quantification of impairment or body structure and function-use of ultrasound

• Robotic gait technology-enhance for activities-lokomat

• Touch on a few substitution technologies-access to all-Go baby Go

Objectives

Vision has always been to create opportunities through technology

Technology — Vision and Reality

4 Reasons Driving Technology-Robotics

• Technology has the potential to more accurately quantify impairments

• control content and dose of therapy and measure clinical outcomes

• Increase practice-can deliver more therapy –improves cost benefit

• New innovative equipment and treatments-ENGAGE both child, parent’s and clinicians

Health Condition (disorder or disease)

Activities ParticipationBody Functions & Structures-quantification

Environmental Factors

Personal Factors

World Health Organization-International Classification of Function

Interactions between components of the ICF

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• Physiologic functions of the body

• Anatomical parts of the body

Body Structure and Function

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Function Depends On

• Interplay of body structure and function-impairments

• Strength, tone, SMC, balance-understanding each and quantifying allows us to target therapy programs

Parse individual deficits contributions

Ultrasonic Evaluation Medial Gastrocnemius

• Non-invasive method to quantify biomechanical properties

• Analyzed both passive and active muscle properties

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Muscle Fascicle and tendon changes in CPUltrasonography and Biomechanical Evaluations

Soleus MTJCalcaneus

Achilles Tendon

Cross-sectional area ofAchilles Tendon

Proximal Distal Medial Lateral

M ed ia l G astrocn em iu s

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GS Fibers in Spastic Hypertonia

Fiber length & pennation

in spastic muscles

M ed ial G astrocn emiu s

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Aponeurosis

N ormal

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Shear wave speed in plantarflexors of individuals with cerebral palsy

Sabrina S.M. Lee1,2, Deborah Gaebler-Spira1,2 , Li-Qun Zhang1,2, William Z. Rymer1,2, Katherine M. Steele3

1 Rehabilitation Institute of Chicago, Chicago, IL, USA2 Northwestern University, Chicago, IL, USA

3 University of Washington, Seattle, WA, USA

• 1) Passive stiffness, 2) neurally-mediated reflex stiffness, 3) active muscle stiffness

• Contracture

• Joint range of motion

• Interventions (e.g. bracing, lengthening surgeries)

Measuring muscle “stiffness”Why does it matter?

• 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

Goal - evaluate and compare musclematerial properties

of the more-affected and less-affected limbs of individuals with hemiplegic cerebral palsy-hemiplegic-age ave 9

• Influence of

– muscle and fascicle length

– impairment level

– torque

0 11.5Shear wave velocity (m/s)

More- affected sideLess-affected side

Medial gastrocnemius

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Individual subjects

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GMFCS I GMFCS II

More-affectedLess-affected

MG- Maximum plantarflexion MG - Neutral

More-affectedLess-affected

MG - Maximum dorsiflexion

a) c)b)

S1 S2 S3 S4 S5 S6 S7 S8

GMFCS I GMFCS II

S1 S2 S3 S4 S5 S6 S7 S8

GMFCS I GMFCS II

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More-affected side (MG): greater shear wave velocity

More-affected sideLess-affected side

(p = 0.024)14% greater

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Neutral Dorsiflexion

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Why is this important?

• Local measurement of material properties – increased passive “stiffness” in more-affected muscle across ROM and fascicle strain

• Passive stiffness (collagen, titan, extracellular matrix)

• With different level of activation, can distinguish type altered stiffness

• Neurophysiological and muscular changes – sequence of events

• Evaluate treatments – e.g. bracing, boNT-A, lengthening surgeries

Sample Ultrasound

M ed ial G astrocn emiu s

M T J

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Aponeurosis

A t rest

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easy

Health Condition (disorder or disease)

Activities-motor learning

ParticipationBody Functions

& Structures

Environmental Factors

Personal Factors

International Classification of Function

Interactions between components of the ICF

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Execution of a task or action by an individual

CP — walking, feeding , transfers, dressing-school work

Activities — backdrop of development

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Technologies to address activities

• Activities 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 settings

• Average number of repetitions of task specific , functional movement was 32

• Animal studies use 600 repetitions per session to induce plasticity

Can you increase practice at home?

Practice Intensity

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Place a demand on

a system

Synchronous sensory and motor fibers

RhythmicalTask defined

Purposeful-engaged

Automated repetitive practice

Goal — To Walk Further and Quicker, Participate in Playground

• N.R. — 6 y/o adopted, CP spastic diplegia, mild component of dystonia

• GMFC-3

• FMS-2,2,1

• Described as slow and wandering

• On oral baclofen 10 mg TID, artane 2 mg TID

• Hamstrings interfering, with stride length

• Botulinum toxin A to SM,ST 3 weeks prior

Lokomat training

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3/week for 4 weeks20-40 minutes with Lokomat partial supported bodyweight

Results

• Pre

• 6 minute -97 meters

• 10 meters- 35 sec

• Gmfm-41

• Tripping-2-3

• Post

• 6 minute-155 meters

• 10 meters-26 sec

• Gmfm-41

• Tripping-0

• Lokomat with pediatric legs shared by adult/pediatric PT services

• 4 sessions/wk for 30-50minutes/session; 12 sessions/pt

• Since 2008 treated over 200+ pediatric patients with CP

• Gait training CPT code 97116

RIC Clinical Experience

RIC Outcomes Reveal

• BWSTT using Lokomat improved overall function, as measured by the 6 minute walk test and 10 meter walk test

• GMFM Domains (A/B/E) improved in GMFCS IV

• GMFM domains D/E approaching significance

• Motor ‘learning’ effect in children with cp participating in daily BWSTT –maintenance of effect after study completion

• Effects of TT better in higher level GMFCS patients

• UNCLEAR on role !

Practical Recommendations for use of Lokomat

33Aurich 2015 J of Neuropediatrics

• Training schedules highly variable

• positive outcomes GMFM-D,E

• Standing, walking speed, 10 meter walk distance 6 minute

• Most improvement in younger and engaged

• No adverse effects

• Questions still remain-Can we work together and contribute to the combined data base?

Literature to Support RAGT-5 studies

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Artic Mission-possible collaboration

• Collect 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 through a sophisticated use of the devices

DatabaseSimple looking for partners

Data Status

• 7 centers are already contributing data• 1 center has recently received IRB/Ethical approval• 2 centers are awaiting IRB approval• 1 center contributes administratively

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• Transfer of skills from TT to OG is ‘hardly definitive’

• BWS limits ‘dynamic’ trunk control

• Restricted degrees of freedom

• Altered gait dynamics and passive training ‘patterns’ limit skill acquisition

• Minimal 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

Defining Levels of Activity

Tudor-Locke 2008, 2013

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

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Pedometers to sensors- to monitor steps

Unobtrusive Sensing and Wearable Devices-REAL WORLD DATA

Engagement-Participation

Health Condition (disorder or disease)

ActivitiesParticipation-Substitution

Body Functions & Structures

Environmental Factors

Personal Factors

International Classification of Function

Interactions between components of the ICF

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Involvement of a life situation

Cp-home, -school, sports, arts

Participation-backdrop of culture and community

Rehabilitation

• Stem cell, influence environmental of the injured site (or prevent 2 damage)

• Plasticity-motor learningNeural

recovery

• The over exuberant non-injured pathways enlarge, IPS lateral pathways or “other slower” tracks take over

• Plasticity

Compensation

• Eye gaze, power chair, Brain computer interface — wireless technology

Substitution

Mind-controlled exoskeleton kicks off World Cup

The problem

• Self-produced mobility plays a crucial role in a child’s 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, increased independence, and the emergence of new capacities to cope with environmental stressors.

• 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 problem

• Mobility devices such as motorized wheelchairs require a certain level of cognitive ability and maturity to operate

• When do is the child ready for a wheelchair?

• Wheelchairs introduced at school age

• Providing 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.

The problem

• How much does a wheelchair cost? A LOT

• How much do they weigh? A LOT

• issues

– How often do you replace?

– Battery malfunction?

– Insurance approval?

– Slow response?

– Social issues?

The solution

• At the University of Delaware, Cole Galloway launched the GoBabyGo project in 2006 with Sunil Agrawal.

• Goal 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.”

Go baby Go

• "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 friends—now 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

• Consistent—

• Can create intermittent reinforcement

• Can program for perfect practice

• Can be fun and tied to gaming

• Can provide feedback precise to follow progress

• Open worlds

Robotics

The Promise of Recovery

• Parent’s perception of therapy is key, though studies and meta analysis do not support large changes in motor prognosis with current ongoing therapy, common experience is parent’s perceive MORE is better, and generally expect more

• Are the expected outcomes of technology at the same level as parental expectations

Before we had machines we had relationships