Episode Transcript
00:00:00
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00:00:03
Host: Hello and welcome to this edition of Doc Talk. It's a very busy day here in the Child Life Zone at Cook Children's so you may hear a little background noise.
I'm really excited to talk with Dr. Christos Papadelis about the use of robotic rehabilitation in children with cerebral palsy. But before we dive in, here's a little about our guest.
Dr. Papadelis is Assistant Vice President of Neuroscience Research at the Jane and John Justin Institute for Mind Health at Cook Children's. He is also Professor of Research in Bioengineering at the University of Texas Arlington, as well as Professor of Pediatrics at the Burnett School of Medicine at Texas Christian University.
Dr. Papadelis is nationally and internationally renowned for his work in neuroscience research. Recently, he, along with his research teams, have been recognized for groundbreaking discoveries including the pinpointing of epileptic seizure origins in pediatric brains and the ability to map the onset of electrical activity before a seizure even occurs. Welcome, Dr. Papadelis, and thanks for being here today.
00:01:09
Dr. Papadelis Oh, it's great pleasure to be here.
00:01:12
Host: For kids with cerebral palsy, selective dorsal rhizotomy is already a real game changer in improving their motor skills. Your research has shown that robotic assisted training therapy is also beneficial in the recovery and improvement of motor deficits for children with cerebral palsy. To get us started, talk a little about the Cook Children's Neuroscience Research Center and what your team is currently working on to improve care for kids with neurological conditions, and how it has led to your work with robotic rehabilitation for cerebral palsy,
00:01:42
Dr. Papadelis: Yeah, sure. Thank you for the invitation. It's great pleasure to talk about the work we're doing here at Cook Children's. The neurosciences program was founded back in 2019 through the generous support of Cook Children's Health Foundation. Actually, the primary objective of this program is to establish Cook Children's as a leading player in the national arena of pediatric neuroscience research, and this is by making novel discoveries that they can benefit the children with several neurological disorders and diseases such as epilepsy, movement disorders and autism. The center, like, consists of several scientists from all over the world who work really hard on several projects, like by covering many areas of pediatric neurological research.
One of these projects, like, focuses on cerebral palsy. Cerebral palsy is a common neurological disorder that causes like, significant motor and sensory deficits in both the upper and lower extremities of children who struggle with this disorder. The underlying cause of cerebral palsy is an insult that takes place in the brain of these children, either during pregnancy or at birth. To compensate for this damage, the human brain reorganizes itself in order to achieve better sensory and motor functions, a process that we call neuroplasticity. The child's brain, like has high levels of neuroplasticity compared to the adults, and that's why children they have higher also chances of improving their symptoms through rehabilitation training.
In a project like we run in my research center, like we use a robotic system what's called Amadeo. This system performs rehabilitation of upper extremities in children with cerebral palsy by using video games. The actual children, they control the video game through continuous movements of their fingers. They actually receive intensive rehabilitation training while playing a video game, and then this has shown to improve significantly their sensory and motor functions. We have received funding for this project through the National Pediatric Rehabilitation Resource Center of NIH, together with my postdoctoral research fellow, Sadra Shahdadian, who is doing a phenomenal job on this project.
00:03:59
Host: Sounds fantastic, and are there specific types of cerebral palsy that show greater improvement with robotic rehabilitation?
00:04:06
Dr. Papadelis:
Yeah, actually, this project, like focuses mostly on children with a specific type of cerebral palsy, what's called congenital hemiplegia, or hemiplegic cerebral palsy. Children with hemiplegia, they have one side of their body mostly affected because there's brain damage in the opposite side, what's called contralateral side. And generally with congenital hemiplegia, they have like motor and sensory deficits in both their upper and lower extremities. And these deficits, they actually significantly affect their fine motor movements, their dexterity and their general quality of life, since, like human hands, like are extremely useful tools in our everyday life,
00:04:47
Host: This is very true. So are there patient characteristics that indicate a good candidate for robotic rehabilitation, such as age range, cognitive abilities, level of spasticity? The presence of contractures, motivation, and are there any characteristics that disqualify a patient from participating in this therapy?
00:05:09
Dr. Papadelis: So children who have a relatively high level of cognition, who are able to follow instructions, and comply with the requirements of the study are well suited for this study. Moreover, like we should consider like that the rehabilitation protocol is quite intense. It actually requires like the child to come every single evening for at least 15 consecutive days here at Cook Children's, in order to receive the treatment. This visit like lasts for at least two hours. So, all this protocol needs time and effort. And, also, we should consider like that, usually, children with mild or moderate levels of spasticity are the most treatable ones, since the video game requires some intense finger movements. In this sense, like children with relatively severe spasticity may not benefit from this study.
00:05:59
Host: How does a patient's cognitive function influence the effectiveness of robotic rehabilitation?
00:06:06
Dr. Papadelis: The child should be able to follow instructions and play a video game that requires some level of cognitive function and ability. For example, like very young children who have significantly diminished levels of cognitive functions do not qualify for this study.
00:06:21
Host: What specific motor functions or skills can be improved with robotic rehabilitation in cerebral palsy like gait speed, endurance, balance, upper limb function, hand dexterity, gross motor function, those things?
00:06:35
Dr. Papadelis: We have, so far, collected preliminary data from six children with congenital hemiplegia and different underlying etiologies. We have quite impressive findings in five out of the six children, the ones who were engaged actually in the protocol, and they followed the instructions quite closely. These children, they came to Cook Children's like for 15 consecutive days, as I mentioned before, to receive treatment on a regular basis. The robotic rehabilitation with the Amadeo system actually focuses exclusively on the upper extremities and the finger movements. And the most striking improvements we have seen so far, is on the range of finger motion and the hand dexterity.
00:07:16
Host: So, Dr. Papadelis, what are the expected improvements in standardized outcome measures after a typical course of robotic rehabilitation.
00:07:24
Dr. Papadelis: Actually, improvements cannot be seen after a single session. Plus, this needs time. So we actually have seen improvements in both sensory and motor functions after intense training of at least 15 days. And we have seen mostly improvements in the touch sensitivity, the two point discrimination tests, and the motor test that’s called a Melbourne assessment two test, that actually evaluates the upper extremity functions of range of motion, accuracy, dexterity and fluency. So we see improvements in both sensory and motor aspects of upper extremity functions but, more specifically, on the dexterity of the movement.
00:08:04
Host: So how does robotic rehabilitation compare, then, to traditional rehabilitation methods?
00:08:09
Dr. Papadelis: So it's easier to apply and is more child friendly compared to the traditional rehabilitation methods. Actually for children with hemiplegic cerebral palsy, one of the main treatment options is what is called a constraint movement therapy. With this therapy, it's a kind of a form of rehabilitation that improves upper extremity function by increasing the use of their affected upper limb. It actually involves rehabilitation of the weaker arm while we restrain the stronger arm in a cast. And, as you can imagine, like this quite challenging for the child not to be able like to move at all, is non-parity hand, the hand that like, other hand that he used mostly. So compared to these traditional treatments, for example, like rehabilitation with a robotic arm, which all the kids, they love playing video games, is much more appealing for the child.
00:08:56
Host: So what is the impact of robotic rehabilitation on other aspects of a child's life, such as participation in daily activities and overall quality of life?
00:09:06
Dr. Papadelis: Kids who participate in our protocol, they are expected to have improved dexterity in finger movements and improved sensory functions. And as we know, like finger movements are critically important in everyday life because they enable a wide range of tasks which are essential for independence, communication and productivity. Like precise finger control is essential for holding a pen or typing on a keyboard or texting on the phone. Or other examples, like opening containers or preparing food requires these coordinated finger movements. Also, it will help like other everyday life tasks like brushing our teeth, combing our hair, dressing or buttoning clothes, like which are all relying heavily on finger dexterity.
So we actually expect children with hemiplegic cerebral palsy to see improvements in their everyday life through motor skills improvements in all of these tasks. Also, it's equally important improvements in the sensory functions, because sensory input provides critical feedback information to the brain through what we call sensory motor integration process and the learning motor skills. So every time we touch something or we feel a sensory input to the brain, like, receives this information helps to learn how to perform different motor tasks.
00:10:29
Host: Must be interesting for these children, when they're going through this to, like, discover when they can actually do something maybe that they couldn't do before?
00:10:37
Dr. Papadelis: Yeah, and I spoke with some of the patients, they have seen significant improvements, and they proved they last, even like for several months after the training. So, we follow up with them to see whether these improvements that we have observed already, like they remain. They're still there.
00:10:51
Host: So what are the typical training protocols for robotic rehabilitation in cerebral palsy, and how are they individualized for the patient? What parameters can be adjusted by the therapist, or the robot itself.
00:11:04
Dr. Papadelis: If you speak with other experts in the field … like I have frequent discussions with Dr. Warren Marks, who has now been retired but he works closely with our group, they will always tell you that what we're doing wrong is that we provide the treatments according to our convenience, our busy schedule and the availability of the facilities and the experts in the treatment. So, we actually provide treatment sessions on a weekly basis, for example, like, instead of a more intense and compact training. And this is, like, where our protocol makes the difference, like, has been specifically designed to provide to these children, like, intensive training for a short period of time, for example, like 15 days or even more, every single evening. And regarding the parameters like that, you ask, like, we are still working on the parameters of the game, but mostly we adjust the difficulty level and the range of motion based on the individual child's needs.
00:12:00
Host: Can robotic rehabilitation be combined with other therapies? And if so, what are the synergistic effects of that?
00:12:07
Dr. Papadelis: Oh, this is a very interesting question. Actually, we have in our mind future studies where the robotic rehabilitation will be combined with other kinds of treatment. For example, traditional physical therapy, or even like more advanced or new techniques, what's called transcranial magnetic stimulation, or current stimulation. And actually, together with my group, we are working on a protocol that combines the use of robotic rehabilitation, what we call repetitive TMS, or repetitive transcranial magnetic stimulation. These techniques apply to the brain like non-invasively, a series of strong magnetic fields directly to the primary motor cortex, with the aim to increase the sensitivity and excitability to different inputs. And we didn't try that yet. We are still working on that, and that's the main idea, but we believe that the combined effect of these two treatments will be beneficial for children with cerebral palsy.
00:13:08
Host: So how does the robot provide feedback to the patient and therapist during these sessions?
00:13:13
Dr. Papadelis: So by the end of each session like the robotic system offers an evaluation of the patient's performance in terms of different aspects of quality of movement, such as range of motion, dexterity and fluency. So we, after each session, we have a quick assessment of the patient's performance. But also, what I would like to mention is that part of this process is like to make an online assessment of what's going on in the brain, what we call brain plasticity, by using a technique that in which like my team specialists like what's called high density electroencephalography, or high density EG, we actually place a net with 64 electrodes on the child's head in order to measure the electrical activity which is generated by the human brain. And by using this technology, we are trying to capture during each session, possible changes in neuroplasticity in the brain of children with cerebral palsy as a result of the treatment. However, it's not so easy as it sounds. It's actually quite a difficult task, and this is because the signals, they are pretty weak, and we need advanced analysis methods like in order to obtain some useful information.
00:14:21
Host: What role does Virtual Reality play in conjunction with robotic rehabilitation?
00:14:27
Dr. Papadelis: So our project does not currently involve virtual reality, but this is within our plans. And one of the limitations of the robotic system is that it's bulky, so it's not portable. So the families, they cannot take it with them at home, but they have to come here to Cook Children's like in order to perform all this training. And as you can imagine, like this is difficult for the parents that you have to bring the kids like here every evening for some period of time. In order to deal with this problem, we have a collaboration with the University of Texas at Arlington Research Institute, which is called UTARI, in order to develop a glove that is connected with a virtual reality system for our rehabilitation at home. So as you can imagine, like this system eliminates the limitations for our robotic systems. It can be used at home for more frequent rehabilitation sessions.
00:15:15
Host: Are there any risks or side effects associated with robotic rehabilitation devices? And if there are, are there safety measures in place?
00:15:23
Dr. Papadelis: Actually? Yes, the kids muscles in their hands may feel tired after each session, and we always like tell to the child to inform us when they feel tired or they want to discontinue the session. And the robotic system is also equipped with a stop button that the operator or the child can press anytime to stop the robot's operation. But in the six kids like we perform this recording so far, and we perform all this training like this never happens, so they feel quite comfortable playing the game with this robotic system.
00:15:54
Host: What about potential issues, like skin irritation, discomfort, muscle fatigue? Or do those exist? And if so, how are they managed?
00:15:01
Dr. Papadelis: Yeah, as I mentioned, like it's mostly muscle fatigue, and this is due to intense training. And in this case, we just request like, frequent breaks in order for the child’s muscles to recover from the intense session. Also sometimes, like, we can adjust the difficulty level of the session in the robotic system. The system allows us to do that in order to make it more easy for the child depends on his needs.
00:16:25
Host: What kind of training is required for therapists to effectively utilize robotic rehabilitation devices?
00:15:31
Dr. Papadelis: The therapist, like they can receive training from the company that has built the system. Actually, all my staff, they were trained before start using the system on the different features they have and how they can use the system. But it's like, it's quite straightforward. So like the training, like last, like, no more than a week, and then the different therapies they are able, like, to make use of the system.
00::16:54
Host: And are there any limitations or challenges in implementing robotic rehabilitation more broadly for cerebral palsy patients?
00:17:01
Dr. Papadelis: Yeah, the main limitation is that the fact that the device is not portable, so the children should come here to the hospital for the training. Moreover, like the protocol is intensive and requires like frequent visits here to the hospital for at least 15 consecutive days. And this is challenging if we consider like curricular activities, school obligations, they prefer to stay home, playing with friends. That's why all the data we've collected so far for the process like we managed to collect them during the previous summer when the kids don't have school. Actually, I remember like we had the mother with her child who were coming every single day for 15 consecutive days from Dallas in order to receive this kind of treatment and participate in the protocol. But the child and the family, they were really excited to do that, and I saw them later in a conference for kids with cerebral palsy, and the child was so happy to see us. It was amazing.
00:17:52
Host: That's fantastic. What about after those 15 days? Is there ongoing care, or is there follow up care over a period of time?
00:18:00
Dr. Papadelis: We don't have follow up care, but we have follow up assessments. We perform assessment like few months after the treatment, and we have confirmed that, like the improvements, they last for so long time. So it's not just an effect that cured and then disappeared, but they are still there. We don't know for how long that's the case, but that's why we apply for a new funding now through NIH, like to receive the extra funding for supporting this study further to bring the kids in again and again and to see follow up long periods of time, like maybe years, ideally.
00:18:33
Host: Are there ongoing clinical trials or research initiatives that referring physicians can direct their patients to, and how can they participate?
00:18:40
Dr. Papadelis: Our study is actually a clinical trial. It has been funded by NIH and if a parent or a physician wants to refer a child to our clinical trial, they should simply contact either me or my team here at Cook Children's Neuroscience Research, and we'll be more than happy like to enroll them in our study, if they qualify.
Host 19:00
What does the future look like for patients with cerebral palsy using robotic rehab? And do you foresee this going beyond their upper extremities, but also the lower extremities?
00:19:11
Dr. Papadelis: Yeah, the parents now they have several options for rehabilitations for their kids. Actually, years ago, the cerebral palsy was regarded as a disorder for which there's nothing you can do. One of my participants, he's 17 years of age, so when he was diagnosed, long time ago, I spoke with his mother, and she told me, during this time, like there was not so much that you can do. Actually, the physicians, they told her, like that there's nothing you can do to help your child. But the child, like he'd start playing guitar by himself and his mother, like, reported significant improvements, after playing the guitar, in his motor functions. And, of course now, like the situation’s like totally different. We have now all these technological solutions and advanced therapies that help children with cerebral palsy, to live a better life. And I'm pretty sure, like, this will be the future, and we'll keep working on that. There's also exoskeletons for helping lower extremities, and that's my plan. With a new five-year expansion of the neuroscience research plan, we expect to bring an expert here who will focus exclusively on this project and how also to develop these kind of treatments for upper and lower extremities for kids with cerebral palsy.
00:20:19
Host: That is just fantastic. I remember a story of one of the patients here. His hand had completely closed, and this was, I think, through surgery, but he was able to, like, hold a ball, drop the ball, and then his dog would put the ball in his lap, and he could pick the ball back up and drop it. And the thrill for a child who had not been able to do anything like that, so I can only imagine what they're feeling all the time, every day, and how exciting that must be for you and your team.
00:20:45
Dr. Papadelis: Yeah, it's very exciting, and these are the most rewarding moments for the team, because in research in our profession, like always, we celebrate scientific publications in top tier journals or grant funding, but the real moments, like we feel really excited is like when we see a child like that has been helped from our treatment or our protocols.
00:21:07
Host 21:07
As we're wrapping up. Is there anything that we haven't talked about, we haven't asked you about, that you'd like to add?
00:21:13
Dr. Papadelis: There's a project that we run currently with my team that is very close to the robotic rehabilitation. The robotics like the treatment we provide to the kids, and that's the most important. But it's also equally important to know what's going on in the brain in terms of neuroplasticity before. So without any treatment like how the brain is wired in these kids, because it's totally different than healthy kids. For example, several of these kids, like you observed, what we call mirror movements. When the child, like move his right hand, then you see the same mirror movements on the other hand in a fully automated fashion. And this is because the brain tried to compensate the damage and then rewires like so we have two hemispheres that control like both hands. And with my team, we have a project right now with different neuroimaging techniques. We try to understand all these patterns of neuroplasticity in the kids with cerebral palsy, because at which baseline they start, it's very important to understand what kind of treatment and how they will respond to the treatment with the robotic or other kind of therapeutic approaches.
00:22:18
Host: This is a really exciting time for you and your team, and for Cook Children's. And also for families and even for other physicians who might want to refer kids in. Thank you so much for being here today and sharing about this great research and breakthrough for kids with cerebral palsy.
00:22:32
Dr. Papadelis: Yeah, thank you for the invitation, and it's always like great pleasure to talk about my work and my team.
00:22:38
Host: And for our listeners, if you'd like to make a referral visit the Neuroscience Research website at Cook children’s dot org. You can also access clinical pathways on the health professionals section of the website. And while you're there, sign up for our Doc Talk newsletter. Want more Doc Talk get our latest episodes delivered directly to your inbox when you subscribe to our Cook Children's Doc Talk podcast from your favorite podcast provider/ And thank you for listening.
00:23:23
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