XIII Congreso Internacional ORITEL

1. 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

2. Grant/Research Support
NIDRR,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

3. Rehabilitation Institute of Chicago
3

4. 20121954 1964 1968 1974 2000 2001 2006 2010
RIC: Historical Perspective
4

5. • Gave examples of
robotics
• RIC technology
• Across the ICF
• Give examples of
available usable
available technology
• Across ICF
Santiago Meeting --------Asunción Meeting
5

6. • 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

7. Vision has always
been to create
opportunities
through technology
Technology — Vision and Reality

8. 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

9. Health Condition (disorder
or disease)
Activities Participation
Body Functions
& Structures-
quantification
Environmental
Factors
Personal Factors
World Health Organization-International
Classification of Function
Interactions between components of
the ICF
9

10. • Physiologic functions of
the body
• Anatomical parts of the
body
Body Structure and Function
10

11. 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

12. Ultrasonic Evaluation
Medial Gastrocnemius
• Non-invasive method to
quantify biomechanical
properties
• Analyzed both passive and
active muscle properties
12

13. Muscle Fascicle and tendon changes in CP
Ultrasonography and Biomechanical Evaluations
Soleus MTJ
Calcaneus
Achilles Tendon
Cross-sectional area of
Achilles Tendon
Proximal Distal Medial Lateral
M ed ial G astrocn em iu s
M T J
F ascicle
Aponeurosis
A t rest
5 cm



14. GS Fibers in Spastic Hypertonia
 Fiber length & 
pennation
in spastic muscles
M edial G astrocnemius
M T J
F ascicle
Aponeurosis
N ormal
Stroke
F ascicle
Aponeurosis
M T J
-40 -30 -20 -10 0 10 20
40
50
60
Musclefiberlength@
PF<-- Ankle angle --> DF
-40 -30 -20 -10 0 10 20
30
35
40
45
50
55
FLEX60
Musclefiberlength@5cm
PF<-- Ankle angle --> DF

15. 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, USA
2 Northwestern University, Chicago, IL, USA
3 University of Washington, Seattle, WA, USA

16. • 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?

17. • 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

18. Goal - evaluate and compare muscle
material 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

19. 0 11.5
Shear wave velocity (m/s)
More- affected sideLess-affected side
Medial gastrocnemius

20. S8
MG - Neutral MG - Maximum dorsiflexion
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
0
4
8
12
0
4
8
12
More-affected side (MG): greater shear wave
velocity
More-affected side
Less-affected side
(p = 0.024)14% greater
7/8
6/8
Neutral Dorsiflexion
Shearwavevelocity(m/s)

21. 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

22. Sample Ultrasound
M ed ial G astrocn emiu s
M T J
F ascicle
Aponeurosis
A t rest
S timu lation
F ascicle
Aponeurosis
M T J
5 cm
5 cm




easy

23. Health Condition (disorder
or disease)
Activities-motor
learning
Participation
Body Functions
& Structures
Environmental
Factors
Personal Factors
International Classification of Function
Interactions between components of
the ICF
23

24. Execution of a task or
action by an individual
CP — walking, feeding ,
transfers, dressing-
school work
Activities — backdrop of development
24

25. Technologies to address activities
• Activities Walking
task-specific repetition, sensory feedback and
feedback about performance are thought to
enhance the effects of practice

26. • 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
26

27. Place a
demand on
a system
Synchronous
sensory and
motor fibers
RhythmicalTask defined
Purposeful-
engaged
Automated repetitive practice

28. 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

29. Lokomat training
29
3/week for 4 weeks
20-40 minutes with Lokomat partial supported bodyweight

30. 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

31. • 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

32. 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 !

33. Practical Recommendations for use of Lokomat
33Aurich 2015 J of Neuropediatrics

35. • 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
35

36. 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

37. Database Simple looking for partners

38. 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
NumbersinarrowsshowimprovementfromMarchtoMay
2015

39. • 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

40. Defining Levels of Activity
Tudor-Locke 2008,

41. 41
81 youth with CP, aged 10-13 years, GMFCS I to III (Bjornson et al. 2007)

42. 42
Pedometers to sensors- to monitor steps
Unobtrusive Sensing and Wearable Devices-REAL WORLD DATA

43. Engagement-Participation

44. Health Condition (disorder
or disease)
Activities
Participation-
Substitution
Body Functions
& Structures
Environmental
Factors
Personal Factors
International Classification of Function
Interactions between components of
the ICF
44

45. Involvement of
a life situation
Cp-home, -
school, sports,
arts
Participation-backdrop of culture and community

46. Rehabilitation
• Stem cell, influence environmental of the
injured site (or prevent 2 damage)
• Plasticity-motor learning
Neural
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

47. Mind-controlled exoskeleton kicks off World
Cup

48. 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)

49. 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.

50. 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?

51. 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.”

52. Go baby Go

53. • "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

54. • 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

55. 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

56. Before we had machines we had relationships