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Children’s National performs first ever HIFU procedure on patient with cerebral palsy

February 9, 2024

HIFU is a non-invasive therapy that utilizes focused ultrasound waves to thermally ablate a focal area of tissue.

In January, a team of multidisciplinary doctors performed the first case in the world of using bilateral high intensity focused ultrasound (HIFU) pallidotomy on Jesus, a 22-year-old patient with dyskinetic cerebral palsy.

The procedure is part of a clinical trial led by Chima Oluigbo, M.D., pediatric neurosurgeon at Children’s National Hospital.

“The primary objective of the study is to evaluate the safety of ExAblate Transcranial MRgFUS as a tool for creating bilateral or unilateral lesions in the globus pallidus (GPi) in patients with treatment-refractory secondary dystonia due to dyskinetic cerebral palsy,” Dr. Oluigbo explained. “The secondary purpose is to assess the impact of HIFU pallidotomy on dyskinetic cerebral palsy movement disorder in pediatric and young adult patients.”

In addition, the impact of bilateral pallidotomy on motor development, pain perception, speech, memory, attention and cognition in these patients will be assessed.

“We hope that the trial will help us find results that lead to treatments that can reduce the rigidity and stiffness which occurs in cerebral palsy so we can help these children who do not have any effective treatment,” Dr. Oluigbo added.

“This new, first of its kind, non-invasive therapeutic approach – without even a skin incision – will open the door to offering hope for a number of kids with movement disorders who have failed conventional therapy,” said Robert Keating, M.D., chief of neurosurgery at Children’s National. “We are at the beginning of a new era for treating functional disorders in the pediatric patient.”

How it works

HIFU is a non-invasive therapy that utilizes focused ultrasound waves to thermally ablate a focal area of tissue. In the past, Children’s National successfully used HIFU to treat low-grade type tumors located in difficult locations of the brain, such as hypothalamic hamartomas and pilocytic astrocytoma, as well as for epilepsy and other movement disorders.

This most recent procedure was another successful milestone for the hospital, discharging Jesus the following day without any complications.

The team comprised neurosurgeons, MRI techs, anesthesiologists and radiologists, to name a few.

Originally, Jesus came to Children’s National in 2006 when he started working with the Physical Medicine and Rehabilitation team to help him with his muscle hypertonia management as well as equipment, orthoses and therapy concerns.

“As he continued to grow, his muscle hypertonia became more pronounced and caused difficulty with his care, positioning and comfort,” said Olga Morozova, M.D., pediatric rehabilitation specialist at Children’s National. “We have tried multiple oral medications however he has had significant side effects from the majority of the medications.”

Dr. Morozova and Julie Will, M.S.N., F.N.P., the nurse practitioner that worked with Jesus, referred him to Dr. Oluigbo after they learned about HIFU being an option to treat Jesus using a non-invasive approach.

Moving the field forward

This clinical trial highlights the expanding indications for focused ultrasound.

“We are excited about the potential for these innovative treatment strategies in neurosurgery to transform the lives of pediatric patients who suffer from challenging diseases, such as brain tumors, epilepsy, and movement disorders,” said Hasan Syed, M.D., co-director of the Focused Ultrasound Program at Children’s National. “We are redefining what is possible in neurosurgery.”

From low-intensity focused ultrasound (LIFU) treatments for our young DIPG patients to now the groundbreaking research on HIFU for pediatric movement disorders, the dedication to cutting-edge techniques highlights the team’s commitment to patients and transforming pediatric neurosurgical care.

A holistic and proactive approach to the management of the patients with cerebral palsy

February 11, 2020

The cerebral palsy program at Children’s National Hospital takes a comprehensive approach to meet children’s needs from infancy through young adulthood.

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.”

New robotic therapies for cerebral palsy

February 27, 2018

The hippobot is a mechanical horseback riding simulator that provides hippotherapy for children.

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

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.

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.