1. FES Applications in Pediatric SCI and Psychosocial Aspects of FES Therese E. Johnston, PT, PhD, MBA Shriners Hospitals for Children Philadelphia, PA USA

2. Freehand System for Children

3. Research with Children Extra lead is placed in areas along the upper or lower limb and the chest wall to allow for growth. The technique is based on previous animal work (Akers, 1999, IEEE Trans Rehab Eng). Growth is estimated via size of the growth plates and on growth charts. As the child grows, electrodes are monitored

4. System Use Adults report using it most for eating and personal grooming Adolescents report school use in addition to the above. One 14 year old male gained the ability to self-catheterize. Preliminary work with children shows the most use for play & school, and with self care.

5. Lower Extremity Implant for Upright Mobility in Children and Adolescents with Complete Paraplegia Johnston, 2003, Spinal Cord Betz RR, 2002, Journal of Spinal Cord Medicine.

6. Purpose of Shriners Study Compare an implanted FES system to long leg braces during 7 upright mobility activities. Evaluate the effects of growth for children who are not skeletally mature

7. Ten Subjects Ages 7 to 20 years C7 to T11 level of injury 1 to 11 years post injury

8. Muscles Implanted Gluteus maximus and posterior fibers of adductor magnus for hip extension Femoral nerve for knee extension Gluteus medius for hip abduction

9. FES System Internal 8 channel stimulator (same as Freehand® system) External control unit worn around the waist

10. 7 upright activities & system donning Activities were scored based on time and independence Data were collected post training and at annual intervals Data Collection

11. Results FES decreased completion time & increased independence for : – Donning – Stand and reach – High transfer – Floor to stand – Bathroom transfer The younger children showed the most gains in independence.

12. User Reports Users report liking the system for standing up from the wheelchair for activities such as –reaching items inaccessible from the chair –cooking & doing dishes –looking eye to eye with friends –writing on a chalkboard –performing grooming at a sink –reaching clothing in a closet –placing the wheelchair in a car –getting on and off of an airplane –playing pool

13. Discussion FES decreased the time required to perform important functional activities. –The most significant involved sit to stand transitions More importantly, FES was preferred for most activities by these subjects.

14. Outcomes of Cycling and/or Electrical Stimulation for Children with Spinal Cord Injury Therese E. Johnston, Brian T. Smith, Oluwabunmi Oladeji, MJ Mulcahey, Randal R. Betz, Richard T. Lauer Shriners Hospitals for Children, Philadelphia Funding: Shriners Hospitals for Children, Grant #8540

15. Background Children with SCI are at risk for secondary complications –Cardiovascular –Respiratory –Musculoskeletal Cycling with FES has led to improvements for adults with SCI. However, these same effects have not been studied in children.

16. Study Design Children randomly assigned to 1 of 3 groups (all stimulation done with surface electrodes) –FES cycling –Passive cycling –Electrical stimulation only Home exercise –1 hour 3X/wk for 6 months Data Collection –Baseline and 6 months

17. Subjects 14 boys and 9 girls Age: 9.6 ± 2.4 years Years post SCI: 5.1 ± 2.8 Injury levels: C7 to T11 ASIA classification: 19 A, 4 B Cause of injury: 20 MVA, 1 birth, 1 intrauterine, 1 chemotherapy

18. Data Collection Cardiovascular –Progressive upper extremity ergometer test (HR & VO2/kg) –Fasting lipid profile Musculoskeletal –Stimulated isometric force (quadriceps & hamstrings) –Hip & knee bone mineral density

19. Results (trends only) Cardiovascular –  Resting HR for all but most with FES –  Peak VO2/kg for FES,  with others –  Triglycerides in all groups Musculoskeletal –  stimulated quadriceps force for FES & e- stim (FES > e-stim) –  Hip BMD for FES & passive –  Knee BMD for FES

20. Results: Neurological ASIA –No trends noted for changes within groups Further analysis is being performed –Despite no trends, children from each group report Increased sensation not detectable by ASIA (deep sensation) –Potential issues with children

21. Results: Neurological Subject –11 year old female –C8 ASIA B –7 years post SCI –Passive cycling group ASIA Scores Baseline 6 months –Motor 42 46 –Light touch 67 80 –Pinprick44 56

22. Results: Neurological Subject –8 year old male –T5 ASIA B –8 years post SCI –FES cycling group ASIA Scores Baseline6 months12 months –Motor 50 48 50 –Light touch* 97 80 87 –Pinprick 61 67 80

23. Discussion Subjects in the FES group appear to be making greater gains. Although subjects in the PC and ES groups are also showing changes. FES cycling may be the better method for achieving musculoskeletal, cardiovascular, and respiratory changes Subjects are continuing to be recruited to determine if any differences reach statistical significance.

24. Psychosocial Aspects of FES

25. FES for Hand Function Adolescents reported preferring Freehand -“ It makes me look more normal” -“It makes it (the activity) easier” -“I don’t have to bend utensil handles” -“I don’t need splints or equipment” 6 y/o child reported (Davis, 1998, J Spinal Cord Med) –Increased satisfaction with self- identified ADLs –Being able to perform new activities

26. FES for Standing/Walking  in self concept (Tennessee Self Concept Scale) &  in depression (Beck Inventory) after 11 weeks of Parastep use (Guest, 1997, Arch Phys Med Rehab) Better overall health and general well-being with implanted system in adults (Agarwal, 2003, J Rehab Res Dev) and adolescents (Moynahan, 1996,Arch Phys Med Rehab)

27. FES for Standing/Walking  Comments from children –Can see eye to eye with friends –Like seeing leg muscles turn on and look better –Feel more normal Reciprocal vs. swing through gait –Some children wanted a more “normal” reciprocal pattern –All abandoned this due for functional reasons –Similar results with teens/young adults

28. FES Cycling Children report –Liking seeing and “feeling” their muscles working –Feeling better about how their legs look One adult user & researcher (Fitzwater, 2002, Artif Organ) –Improved mood, similar to what he used to get from running –Improved body image

29. FES for Bladder/Bowel Reported benefits of Vocare system include ( Kachourbos & Creasey, SCI Nursing, 2000) –Increased independence leading to less social isolation –Increased sense of control –Increased feelings of self-worth –Overall improvement in QOL

30. Thank you! Therese E. Johnston, PT, PhD, MBA Shriners Hospitals for Children 3551 N. Broad Street Philadelphia, PA 19140 001-215-430-4089 tjohnston@shrinenet.org