Though children with cerebral palsy (CP) often require significant rehabilitative and surgical support, most often each service is provided in the individual specialty itself. Patients and their families frequently experience a great deal of stress coordinating care, getting to appointments, keeping track of medications and managing treatments on their own.
However, the CP program at Children’s National Hospital, co-led by an orthopaedic surgeon, Sean Tabaie, M.D., and a pediatric rehabilitation specialist, Olga Morozova, M.D., working together and in collaboration with Shannon Kelly, M.D., (Orthopaedics) and Jeff Rabin, D.O., (Physical Medicine and Rehabilitation) has evolved into a truly comprehensive approach. The program is designed to meet the needs of these children from infancy through young adulthood with the goal of improving function and preventing musculoskeletal deformities and complications.
Providing children and their families with a single point of care coordination allows the care team to track and anticipate a multitude of potential challenges for each child as early as possible and intervene in smaller ways before they bring pain and long-term complications or require major surgical interventions. Key highlights of this collaborative program include:
- Hip surveillance: Patients with CP are followed closely to identify hip pathology prior to serious subluxation or dislocation. Early identification allows for the use of medical or surgical interventions to prevent a minor issue from becoming a major one.
- Serial casting for children with early signs of muscle contractures: Dr. Morozova uses agents to relax the muscles and Dr. Tabaie applies the cast in the operating room followed by continued weekly serial casting in the clinic. “Proper medical management and bracing at regular intervals can improve muscle function and prevent the need for larger surgeries and more intense rehabilitation later,” says Dr. Morozova.
- Advanced coordination between physical therapy in the hospital and outpatient services in the region, building on the hospital’s partner agreement with the HSC Health Care System.
- Single event multi-level surgeries (SEMLS): Ensuring that surgical procedures capture all surgical needs at one time by assessing the entire anatomy and scheduling multiple surgical or pharmaceutical interventions to occur in a single session.
The doctors point out that offering these services in one cohesive location and combining treatments into the same appointment or procedure date is something that many patients with CP and their families truly appreciate.
“I think families of children with CP will travel great distances if the care they receive is comprehensive and eliminates some of the back and forth travel they do now,” says Dr. Tabaie.
Today, the team sees close to 100 patients with CP per month and hopes to expand to reach as many families in the region and beyond who need them.
Dr. Tabaie says, “Our goal is to identify patients early and start managing them to help their quality of life today, prepare them to grow as healthily and in as little pain as possible and set them up to be as healthy as they can possibly be as adults, too.”
The novel ankle rehabilitation robot built at Children’s National to help children with cerebral palsy build ankle strength and control through video gaming is taking a big step forward. Engineers have created a smaller, more affordable version of the robotic platform using 3D printed parts, to explore the effectiveness of a home-based therapy program.
“We’re seeing preliminary success in our trial for in clinic use of the Pedbot. Now we’re hoping to see if making the technology accessible at home means that 1) Kids use it more often and 2) More frequent, regular use over time leads to better range of motion,” says Kevin Cleary, Ph.D., the Sheikh Zayed Institute for Pediatric Surgical Innovation’s bioengineering technical director and engineering lead for Pedbot.
Pedbot’s video game, designed by software engineer Hadi Fooladi, M.S., allows kids to pilot an airplane through a series of hoops at varying speeds as determined by the therapist and programmer. The game isn’t the only thing that’s unique about this therapeutic robot, however.
Just like the clinic version, the home model moves in three translational directions (x, y and z) and rotates about three axes (the x, y and z axes), similar to the movement of a flight simulator. The result is a robot that helps the patient exercise across a greater range of motion and build muscle strength in a way that more closely mimics real-life ankle function.
Pedbot Home potentially eliminates an additional major therapeutic barrier – the clinic appointment.
“The great thing about Pedbot is you’re constantly working to reach a moving target, and the therapist can vary the movement type as much or as little as needed for each patient,” says Catherine Coley, DPT, a physical therapist at Children’s National who is a member of the Pedbot development team. “We think the home version might make it easier for the child to succeed with a long term therapy program by removing the need for repeat clinic visits.”
“What if a child could come home from school and do their therapy at home after dinner? Would doing it every day for 20 minutes benefit the child more than just coming to see us once or twice a week for an hour? Can we make it easier for our patients to cooperate and follow through with therapy homework? These are some of the questions that we hope we can answer during our trial for the home version,” says Sally Evans, M.D., division chief of Pediatric Rehabilitation Medicine at Children’s National and clinical lead for the project.
The cross-functional Pedbot team includes engineers Reza Monfaredi Ph.D. and Tyler Salvador, B.S., as well as additional physical therapists, Stacey Kovelman, P.T. and Justine Belchner, P.T., and Sara Alyamani, B.A. Future expansions will include the addition of electromyography measurements in collaboration with Paola Pergami, M.D., Ph.D. and incorporation of other patient populations with Beth Wells, M.D.
Pedbot Home is currently being piloted in the home setting, with the goal of enrolling additional families to participate in a trial within the next year. The work is supported by a $500,000 federal grant from the Department of Health and Human Services’ National Institute on Disability, Independent Living, and Rehabilitation Research.
Cerebral palsy is the most common type of movement disorder in children, affecting 1 in 500 babies born each year. For these infants, learning to sit up, stand and walk can be a big challenge which often requires years of physical therapy to stretch and strengthen their muscles. A team led by Kevin Cleary, Ph.D., technical director of the Bioengineering Initiative at Children’s National Health System, and Sally Evans, M.D., director of Pediatric Rehabilitation Medicine at Children’s National, has created two new types of robotic therapy that they hope will make physical therapy more enjoyable and accessible for children.
Hippobot equine therapy simulator
One of the most effective types of therapy for children with cerebral palsy is hippotherapy, which uses horseback riding to rehabilitate children with neurological and musculoskeletal disabilities. The movement of horses helps riders with cerebral palsy improve endurance, balance and core strength, which in turns helps them gain the ability to sit without support. If a child with cerebral palsy does not master independent sitting early in life, he or she may never gain the ability to stand or walk. Unfortunately, many children never have the chance to experience hippotherapy due to geographical constraints and cost issues.
To increase patient access to hippotherapy, the bioengineering team (Reza Monfaredi, Ph.D.; Hadi Fooladi Talari, M.S.; Pooneh Roshani Tabrizi, Ph.D.; and Tyler Salvador, B.S.) developed the hippobot — a mechanical horseback riding simulator that provides hippotherapy for children ages 4 to 10 in the office setting. To create the hippobot, the researchers mounted a carousel horse on a six-degree of freedom commercial motion platform (the platform moves in the x, y and z directions and rotates about roll, pitch and yaw axes). They then programmed the platform to simulate a horse walking, trotting and cantering.
“Several experienced horse riders have tried the motion platform and commented that it gives a realistic feel,” says Dr. Cleary.
The team then incorporated optical tracking of the hippobot rider’s spine and pelvis to monitor their posture and created a virtual reality video display that simulates a horse moving down a pier. As other animals come towards the horse, the rider must lean right or left to avoid them. The trackers on their back show which way they are leaning and feed that information into the gaming system.
“We wanted to see how the patient’s spine reacts as the horse moves through different patterns, and if the patients get better at maintaining their posture over several sessions,” says Dr. Cleary.
To date the system has been used with several children with cerebral palsy under an IRB-approved study. All of the participants enjoyed riding the horse and came back for multiple sessions.
The hippobot system was developed in close collaboration with the Physical Medicine and Rehabilitation Division at Children’s National, including Olga Morozova, M.D., Justin Burton, M.D., and Justine Belschner, P.T.
Pedbot ankle rehabilitation system
More than half of children with cerebral palsy also have gait impairment as a result of excessive plantar flexion and foot inversion/eversion, or equinovarus/equinovalgus at their ankle and foot. To help these patients, Dr. Cleary’s team developed the pedbot — a small robot platform that enables better strengthening, motor control and range of motion in the ankle joint.
“Children with cerebral palsy have difficulty walking in part because they have trouble controlling their feet,” explains Dr. Evans. “Use of pedbot as part of therapy can help to give them increased control of their feet.”
Most ankle rehabilitation robots are limited in their movements, and have only one or two degrees of freedom, focusing on ankle dorsiflexion/plantarflexion and sometimes inversion/eversion. Pedbot is unique in that it has three degrees of freedom with a remote center of motion in the ankle joint area that allows it to move in ways other devices can’t.
The pedbot platform can move in three translational directions (x, y and z) and also rotate about three axes (the x, y and z axes). As an analogy, this is similar to the movement of a flight simulator. The system also includes motors and encoders at each axis and can be used in passive and active modes.
In both modes, the patient sits on a therapy chair with their foot strapped to the robotic device. In the passive mode, the therapist assists the patient in training motions along each axis. The robot can then repeat the motion under therapist supervision while incrementally increasing the range of motion as desired by the therapist.
For the active mode or “gaming” mode, the team developed a video game based on an airplane motif. Patients use pedbot as an input device to pilot an airplane through a series of hoops. The level of the difficulty of the game can be easily adjusted based on the patient’s capability and physical condition.
To date, four patients have participated in an IRB-approved clinical trial for the pedbot. All of the patients enjoyed the game and they were willing to continue to participate as suggested by a physiotherapist.
The pedbot team, in addition to the engineers mentioned above, includes Catherine Coley, P.T.; Stacey Kovelman, P.T.; and Sara Alyamani, B.A. In future work, they plan to expand the system to include electromyography measurements with Paola Pergami, M.D.,Ph.D. They also are planning to develop a low cost, 3D printed version for the home market so children can do Pedbot therapy every day.
There was no effective treatment for uncontrolled, difficult, and sometime painful movements associated with movement disorders. That is, before the development of deep brain stimulation (DBS) techniques.
Children’s National Health System is one of only two children’s hospitals with fully integrated DBS programs. Chima Oluigbo, M.D., who leads the pioneering Deep Brain Stimulation Program within Children’s Division of Neurosurgery, is one of few pediatric deep brain stimulation experts in North America and cross-trained in pediatric and functional neurosurgery.
Dr. Oluigbo says the effects of DBS are often dramatic: 90 percent of children with primary dystonia show up to 90 percent symptom improvement.
A 6-year-old boy with dystonia so severe that his body curved like a “C” was one of the first patients to undergo the procedure at Children’s National. Six weeks later, he gained the ability to sit straight and to control his hands and legs. He also was able to smile, an improvement that brought particular joy to his parents.
Inside the brain with movement disorders
Patients with movement disorders experience difficulties due to neurological dysfunction that impact the speed, fluency, quality, and ease in which they move. In these cases, neurons in the brain’s motor circuits misfire. Through the use of DBS, neurosurgeons can synchronize neuronal firing and accomplish the previously impossible: restoring muscle control to patients with these disorders.
Movement disorders are common in children. “It’s not just numbers, it’s also about impact. Think about the potential of a child who is very intelligent and can contribute to society. When that child is not able to contribute because he or she is disabled by a movement disorder, the lost potential is very significant. It has an impact,” Dr. Oluigbo says.
What is deep brain stimulation?
DBS uses an implantable device to send continuous, low-level electrical impulses to areas deep within the brain. The impulses prevent the brain from firing abnormal signals that are linked to movement disorders and seizures. When a child is considered to be a candidate for the technique, here’s what happens next:
- Imaging: Magnetic resonance imaging (MRI) helps pinpoint the area of brain tissue responsible for movement disorders and informs the treatment plans.
- Neurotransmitter implant procedure: Using minimally invasive neurosurgery techniques, doctors access the brain through a tiny incision in the child’s skull and place thin, insulated wires (leads) in the area of brain tissue responsible for the condition.
- Pulse generator implant procedure: The pulse generator (neurostimulator) is a battery-operated device that sends low-level electrical impulses to the leads. During a separate procedure, the pulse generator is implanted near the child’s collarbone. Leads are threaded under the child’s skin to connect with the pulse generator.
- Stimulation treatments: Once the leads and pulse generator are connected, the child receives a continuous stream of electrical impulses. Impulses are generated by the neurostimulator, travel through the leads, and end up in the deep tissue of the brain. Here, they block abnormal signals that are linked to the child’s movement disorder.
- Follow-up care: The child will likely need deep brain stimulation throughout his or her lifetime to make sure the device is working correctly and to adjust the neurotransmitter settings to meet his or her changing needs.
Deep brain stimulation at Children’s National
Children’s National is currently conducting clinical trials seeking to expand the use of this procedure to patients with cerebral palsy, one of the most common dystonias. The effective use of deep brain stimulation requires ongoing attention from a multidisciplinary team (from neuropsychology to rehabilitation medicine), giving seamless care under one roof.
There is evidence to suggest that this technique could be used to aid people with memory disorders, patients in minimally conscious states, and patients with incurable epilepsies.