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“You can change the brain even after it looks fully recovered”

Pediatric stroke research turns rehab on its head

 

Physicians have little idea of what causes strokes in children and no strategies to prevent them, but Calgary’s Dr. Adam Kirton is determined that kids who experience a stroke will live full and healthy lives and make the best possible recovery.

“Rehab is a big issue in our world of perinatal stroke,” says Dr. Kirton, a HSF Canadian Partnership for Stroke Recovery researcher. “Our research program is interested in understanding how young brains try to recover after a stroke and how they reorganize during development. We’re trying to understand more so that we can push recovery in better directions.”

There are 10,000 children up to age 18 in Canada living with perinatal stroke – a stroke that happened before or shortly after birth. “These kids live with stroke for 80 years.”

Many of these children have a condition called hemiparetic or hemiplegic cerebral palsy (CP) – weakness on one side of the body, which is similar to the one-sided weakness experienced by adults after a stroke.

“Hemiplegic CP is a common type of cerebral palsy and most of those are due to stroke,” says Dr. Kirton, one of only a few pediatric neurologists in Canada who specializes in stroke.

“The term ‘cerebral palsy’ means you have a motor problem, a movement problem in development, related to something wrong with the brain that’s been there since birth,” he explains. “Stroke is a blockage in a blood vessel in the brain. Because it usually just involves one blood vessel, it just involves one side of the brain. That’s why just one side of the body is affected.”

Advanced imaging technology has only recently provided physicians with the tools to accurately diagnosis perinatal stroke. “There are more and more cases collected and described because we are better at defining it, diagnosing it, picking up the small ones, picking up all the kids who just thought they had cerebral palsy and never knew they had a stroke,” says Dr. Kirton, adding there is a huge need for research related to perinatal and childhood stroke.

He said the University of Calgary is a great place to focus that research because there is “a fabulous adult stroke program here.”

Dr. Kirton has pioneered innovative research for children that provides insight to help young stroke survivors all across Canada.

Working with Dr. Sean Dukelow, CPSR site leader at the Hotchkiss Brain Institute at the U of C, Dr. Kirton uses robotic technology to study kids with stroke and learn how their motor and sensory systems have been affected.

The research group is studying the use of non-invasive brain stimulation and intensive physical therapy for school-age kids with chronic stroke.

Stimulation and therapy are delivered over a two- to three-week period at a summer camp at Alberta Children’s Hospital (ACH), which Dr. Kirton has been running since 2010. “We have a whole team of occupational therapists and child-life and therapeutic arts specialists. They put together a full-day program that includes some intensive, focused therapy — and that’s where we incorporate the brain stimulation — but also all the other parts of a camp that are fun and other ways to get them to use their hand and arm.” ACH has a pool, gym and plenty of outdoor space.

Participants like Paralympic athlete Michael Sametz, who took part in the first camp six years ago, says the experience was great. “You find out a lot more people are dealing with the same frustrations as you are…You learn your challenges are not abnormal.”

Research completed at the camps has led to recent publications showing that two different kinds of brain stimulation can help the brain and motor systems learn so that kids with stroke achieve better outcomes. One study was published in Neurology earlier this year and the second study is in press.

“You can change the brain even after it looks fully recovered,” Dr. Kirton says. “I think that’s an important tenet of rehab that has been turned on its head.”

In summer 2017, Dr. Kirton’s group will begin the first multi-site trial of brain stimulation combined with intensive therapy for children with perinatal stroke and hemiparesis in Calgary, Edmonton, Toronto and Montreal. They are using transcranial direct current stimulation (TDCS) – a little box with two sponge electrodes that puts a very small current across the surface of the brain.

Researchers will also use imaging tools to map the kids’ brains before and after the intervention to help them understand the changes in the brain and how an individual’s brain map helps predict success. In addition, they are trying to understand how age, stroke type and other factors affect outcomes.

“This is the idea of personalized medicine, precision medicine,” Dr. Kirton says. “This is where the holy grail of rehab research is. Looking for the magic fix for the whole group is never going to happen. It has to be personalized and more specific.”

Brain stimulation is also being studied for the treatment of language loss. Communication disorders are common after stroke. “This is part of a new non-invasive neuro-stimulation network that is being built across the university and stroke rehab is one of the top priorities,” Dr. Kirton says. “It’s all brand new.”

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