Contralaterally-controlled functional electrical stimulation and video games with pediatric populations

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Contralaterally-controlled functional electrical stimulation and video games with pediatric populations Anna Curby, MS, OTR/L Cleveland Clinic Children s Hospital for Rehabilitation Cleveland

1 Contralaterally-controlled functional electrical stimulation and video games with pediatric populations Anna Curby, MS, OTR/L Cleveland Clinic Children s Hospital for Rehabilitation Cleveland Clinic Children s Pediatric Rehabilitation Symposium October 7-8, 2016 Disclosures The following work was funded by NIH/NCATS UL1TR and by a research award from the Pedal-with-Pete Foundation. 1

Presentation Objectives Motivation: neural injury still debilitates millions Why use virtual environments for neuro-rehab? Principles and mechanisms important for learning What is available today?

2 Presentation Objectives Motivation: neural injury still debilitates millions Why use virtual environments for neuro-rehab? Principles and mechanisms important for learning What is available today? Efficacy and recommended use How are we advancing the field? Hemiplegia from stroke and cerebral palsy Hand Hemiplegia Clinical Needs Problem: 30% of individuals with cerebral palsy have hemiplegia Effective interventions for hemiplegic hand function are lacking Less affected hand preferred for daily life More affected hand eventually does not participate in daily activities Intensive Tx work, but are not viable for moderate/severe impairment Significance: We developed a functional electrical stimulation technique to increase affected hand participation in motor training Innovation: Cyclic and EMG-trig FES difficult to use during task practice User cannot control stim onset and grade intensity 2

Contralaterally Controlled FES Chae Knutson Stronger Hand Weaker Hand

with motor execution Provides visual and somatosensory feedback Enhance

Neurons that fire together wire together Existing CCFES 12 wk treatment

Repetitive opening/closing based on audio cue Not Optimal for Motor

3 Contralaterally Controlled FES Chae Knutson Stronger Hand Weaker Hand Opening of stronger hand assists weaker hand opening Syncs motor intent with motor execution Provides visual and somatosensory feedback Enhance Hebbian neural plasticity Neurons that fire out of sync lose their link Neurons that fire together wire together Existing CCFES 12 wk treatment Lab: Twice weekly for 2 hr per day Home practice 5x/wk for 2 hr/day Repetitive opening/closing based on audio cue Not Optimal for Motor Relearning Not goal oriented Low task variability Video Games May Enhance CCFES 3

Mechanistic Model: Hebbian Plasticity Virtual/Physical Motor Task Feedback Visual Proprioceptive Somatosensory Task Performance Motor Execution Video Games Motivate Intense Practice Functional Tasks

4 Mechanistic Model: Hebbian Plasticity Virtual/Physical Motor Task Feedback Visual Proprioceptive Somatosensory Task Performance Motor Execution Video Games Motivate Intense Practice Functional Tasks Transfer motor skills to activities of daily living Motor Intent Neuromuscular Electrical Stimulation Promotes peripheral plasticity via synced FES Promotes central plasticity via task practice Pediatric Cerebral Palsy Protocol N = 20 (age 6-17) 6 week treatment period 60 hrs therapy duration 2 lab visits in wks 1-3 (2 hrs each) 1 lab visit in wks 4-6 (2 hrs each) 45 min functional task practice 3 15-min Video games 10 home sessions (1 hr each) 3 15-min game sessions 3-min rest breaks between games 4

Pediatric Hemiplegic Cerebral Palsy 3 males completed,

2% FMA (Max 66) AHA (Max 100) AHA (Max 100) FMA (Max

(lower better) Pediatric Hemiplegic Cerebral Palsy

by reduced function Bothered by reduced function Time

5 Pediatric Hemiplegic Cerebral Palsy 3 males completed, ages 7, 8 and 12 ID 1 2 Adherence 99.6% 94.2% FMA (Max 66) AHA (Max 100) AHA (Max 100) FMA (Max 66) Tracking Error (lower better) Tracking Error (lower better) Pediatric Hemiplegic Cerebral Palsy Children s Hand-Use Experience Questionnaire Bothered by reduced function Bothered by reduced function Time needed vs peers Grasp effectiveness Grasp effectiveness Time needed vs peers 5

6 Pediatric Hemiplegic Cerebral Palsy AHA Video Hemiplegic CP RCT (NIH R21) Video Games vs CCFES+Video Games Aim 1 Will HTVG + CCFES improve motor outcomes? Aim 2 Does proprioception fidelity moderate outcomes? Aim 3 Does # motor repetitions mediate outcomes? Impact score 14 (2 percentile) Start date Fall

Acknowledgements Anna Curby, OTR/L, MS John

7 Acknowledgements Anna Curby, OTR/L, MS John Chae, MD Ryan Suder, OTR/L, MS Jayme Knutson, PhD Mary Harley, OTR/L Terri Hisel, OTR/L Alfred Connors, MD Benjamin Katholi, MD Robyn Busch, PhD Richard Rudick, MD (Biogen Corp) Special Thanks: Beth Sypke, Peggy Maloney, Greg Naples, Lisa Ferguson Actively Recruiting Studies Adult Stroke Studies 1. Tele-Rehab 2. Arm & Hand CCFES < 2 years post stroke Upper limb hemiplegia Refer to: mmaloney@metrohealth.org Pediatric Cerebral Palsy Studies 1. CCFES + Video Games for CP 2. CCFES + Video Games for CP RCT Ages 6-12 Upper limb hemiplegia Refer to: curbya2@ccf.org 7

8 References Adult Stroke Fu, M. J., Knutson, J. S. & Chae, J. Stroke Rehabilitation Using Virtual Environments. Phys Med Rehabil Clin N Am 26, (2015). Cerebral palsy Rostami 2012: CIMT + VR /NRE Chen 2014: /PEP Chiu 2013: / Sandlund 2014: /

Novel Treatments in Stroke Rehabilitation Electrical Stimulation 2012 International Stroke Conference New Orleans, LA

Novel Treatments in Stroke Rehabilitation Electrical Stimulation 2012 International Stroke Conference New Orleans, LA John Chae, MD Physical Medicine and Rehabilitation Biomedical Engineering Cleveland