Engineers are essential to the high-tech world of healthcare, from developing new diagnostic tools and rehabilitative treatments to maintaining and improving the vast amount of system support required for modern medicine. In paediatric medicine, in particular, four Ontario engineers are revolutionizing the way hospitals care for children with disabilities.
“There is no question that helping children is always a great reward as a biomedical engineer,” says Mario Ramirez, P.Eng., director of medical engineering at the Hospital for Sick Children (Sick Kids) in Toronto, Ontario. “It is sad to see somebody suffering, especially a little one. It is also very rewarding to see how resilient they are. And then, to see the biomedical engineering that we are applying in the hospital is helping them to come out healthy—sometimes still with some problems—still growing and advancing and they can do things on their own.”
Ramirez brings 35 years of experience to his field, with a history of applying his skills at St. Michael’s Hospital in Toronto and the IWK Health Centre (originally named the Izaak Walton Killam Hospital for Children between construction in 1967 and opening in 1970, and then informally nicknamed the IWK) in Halifax, Nova Scotia, before moving to Sick Kids 15 years ago.
“Specifically, at Sick Kids, what medical engineering—we call it medical engineering; some people call it clinical engineering—does, is we are really responsible for all the technology that is applied to patient care,” says Ramirez. “This could be a physiological monitor; it could also be an ultrasound machine or an MRI or CT scanner.”
Ramirez’s team assists in the selection and acquisition of the technology for the hospital and the machine repair and maintenance they might require through the useful equipment life.
“A clinician is then able to perform the care they need to—not only now but for the next five to 10 years,” he adds. “So, for example, we help the clinicians in developing the technical specifications for imaging systems they are going to use—whether it’s an MRI or a CT scanner or any other imaging system. We understand and relay clinical needs into technical needs so we can propose those to manufacturing companies. And then we help them through the process of comparing and developing technical evaluations on the equipment.”
The work is the difference between safe and unsafe equipment used to evaluate the medical condition of children ranging from newborn, infancy to adolescence, and the goal is to acquire machines and software that can be upgraded and used for up to a decade. Once it is a permanent fixture in the hospital, Ramirez’s team is responsible for all repair and maintenance of the equipment. Overseeing its efficacy is essential in paediatrics, as children are not only in vulnerable positions, but they are also growing and changing rapidly.
“We may have to deal with a baby who is 500 grams, up to a boy or a girl who is 17 or 18 years old,” says Ramirez. “So, we have to have the equipment that can treat that population. But, in particular, we face challenges with the smaller patients. In imaging and x-rays, we’re trying to make sure that we are not exposing the children to x-rays more than needed because radiation can damage a baby later on. We are always advocating for the little ones. They need the care.”
GIVING CHILDREN A VOICE
It’s not simply the structuring and maintaining of ultrasound equipment that makes up an engineer’s contribution to paediatric care. At Holland Bloorview Kids Rehabilitation Hospital in Toronto, engineers like Tom Chau, PhD, P.Eng., Elaine Biddiss, PhD, P.Eng., and Jan Andrysek, PhD, P.Eng., are creating new tools for children with physical disabilities and developmental delays.
“We have created a whole suite of technologies, many of which are now accessible to clients and families,” says Chau, vice president of research at Holland Bloorview Kids Rehabilitation Hospital, director of the Bloorview Research Institute, Raymond Chang Foundation chair in access innovations, and professor at the Institute of Biomaterials and Biomedical Engineering, University of Toronto. “They’re basically technologies that provide children access to their environment, access to communication, access to computers, through a means other than speech and gestures. The challenge with the population that my lab is working with is that these kids don’t have functional speech, and they don’t have functional movements. If you’re not able to speak, and you’re not able to move, how do you communicate with your family, your peers, your teachers, everybody in your environment?”
One such creation is The Hummer, a computing device that allows a child with cerebral palsy or other neurological delays to communicate through the vibration of their vocal folds.
“Swallowing, coughing, moving your head, etc., generate different types of vibrations of the vocal folds,” says Chau, who won an Ontario Professional Engineers Award in the Young Engineer category in 2005 for his innovative research. “It’s easy to vibrate your vocal folds. You just have to hum, or try to hum. What we found early on is that for most of the kids who couldn’t sustain an audible sound, they could still hum. That’s how this technology started. We built it around one child, and once that solution was developed, we quickly found that there were many other kids who had that same ability. Now we have several dozen kids who use that as their primary access pathway. They’re able to use the computer at school, surf the Internet, operate devices in their environment, simply by humming.”
Additionally, Chau and his team are working on Blink Switch, through which children who are completely paralyzed, save for the ability to blink, can communicate through a headband sensor, and Snap Switch, which employs sensors on a child whose only reliable motor ability is a snap. With all three devices, the sensors must be able to distinguish a deliberate hum, blink or snap from an involuntary muscle movement.
“The engineering design principles and problem solving come into play on many, many aspects of this problem and its solution,” explains Chau. “First of all, it comes into play with the instrumentation—being able to harness non-invasively these electrical and optical signals requires technical knowhow. We have to be able to filter out all kinds of noise. The body and brain are inherently noisy. The resting brain is incredibly active. We develop the algorithms to teach the computer how to recognize these different types of brain patterns. And these brain patterns are individual. All of that requires engineering technical skills, not limited to one genre of engineering. I’ve applied skills from electrical and computing engineering—those would be the obvious ones—but I’ve also had students from mechanical, chemical, and even civil engineering work with us.”
EVOLUTION OF VIDEO GAME THERAPY
The importance of applying multidisciplinary engineering skills to the uniqueness of each child is something Elaine Biddiss, PhD, P.Eng., brings to her work daily.
“Each child is their own person with their own therapy needs and personality,” says Biddiss, scientist, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, and assistant professor at the Institute of Biomaterials and Biomedical Engineering, University of Toronto. “When you know exactly who you’re designing for, then the challenge of an engineer is fairly straightforward, but when you’re trying to design one system that can accommodate hugely different users, there are greater challenges.”
With her team of researchers, Biddiss has created mixed reality video game therapy for children with cerebral palsy, brain injuries and developmental delays. She says the evolution of this genre of therapy finds its roots in neuroplasticity.
“For brain plasticity you need four key ingredients: repetition, increasing challenge, feedback and reward for when you achieve something within the process,” explains Biddiss. “That’s why our team was so interested in video games. Video games provide a great framework for all four ingredients. That creates a nice environment in the brain for neuroplasticity and forming new motor pathways. We’ve seen that neuroplasticity can occur through video games, with seeing patients’ new motor skills and through brain imaging.”
One such game, Botley’s Bootle Blast, aims to meet a child’s therapy goal. The game involves a story about a robot named Botley who creates a mini-robot called a Bootle to help him with his daily chores. When Botley sees how well the Bootle works, he replicates the mini-robot. But he replicates too many, and Botley asks the player to help him collect all of the Bootles by playing mini-games. These mini-games target specific therapy movements. Using Microsoft Kinect, the game applies a sensor that includes a video camera, a microphone array and a depth sensor. By tracking the skeleton of a person moving in front of it, the device follows body movements. Biddiss and her team also develop techniques to enable children to interact with tangible objects within the virtual world. This helps to ensure that the video game play translates to real-world function. Mini-games within each child’s virtual world are tailored to their specific needs. A range of movement is calibrated to further target a patient’s therapy requirements, and the games are multiplayer so that children can play with each other and develop their socialization with children of various abilities.
“One thing that distinguishes how we apply our engineering skills here is that it is so interdisciplinary,” says Biddiss. “A child is not just solving equations. We’re also considering the psychology of children.”
Consulting with patients and their families has been an integral part of what Biddiss finds rewarding about her work: “We keep circling back to the kids as well. They consult and contribute to the design.”
DURABLE AND AFFORDABLE PROSTHESES
Also at Holland Bloorview is Jan Andrysek, PhD, P.Eng., whose team focuses primarily on children with amputations. A mechanical engineer by background, Andrysek has been developing prostheses that can work with a child’s body and allow them to interact more comfortably in their environment.
“We try to come up with better ways for these prostheses to work,” says Andrysek, scientist, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, and assistant professor and associate director, professional programs at the Institute of Biomaterials and Biomedical Engineering, University of Toronto. “We prototype and build them. We do a lot of clinical testing. We try to come up with more functional, more durable and more affordable devices. That’s one area where our research has had the most impact. We also try to develop better rehabilitation techniques with children who have amputations.”
A significant project Andrysek’s team is developing is called the Biofeedback Project, a system through which a child with a prosthetic limb can track how they are walking. It then determines whether the child could potentially do more with their range of movement.
“It will help promote good walking patterns and good, healthy movement within the body,” explains Andrysek, who won an Ontario Professional Engineers Award in the Research and Development category in 2017. “We’re still fairly early on in the process. We’ve developed some initial prototypes and are in the process of setting up a study. We’ve applied for funding to do additional studying with children.”
Last year, Andrysek’s team also created a paediatric prosthetic hand for infants, working closely with a two-year-old girl and her family. The team aimed to develop a custom hand that the child could take into her home environment, and the project was a great success.
Backed by his team’s prosthetic achievements, Andrysek co-founded LegWorks, a startup that aims to bring some of these technologies—most prominently a prosthetic knee—to the public.
“We have a global mission,” says Andrysek. “We’re in about 25 developed, some developing, countries, and our company is our way of getting us to the people. We’re focusing on working with non-profits and NGOs to bring affordable technologies to low-income countries and low-income individuals. So, we have a two-tiered mission. And now, as part of my work at Holland Bloorview, I’m working on the very small kid’s version of that knee. It was an invention that occurred in our lab, and then, throughout the years, we developed the technologies using clinical trials in a lot of places around the world. We got to the place where we wanted to commercialize it, so I ended up co-founding LegWorks. I’m not only the co-founder, but I’m also the chief technical officer.”
While Ramirez, Chau, Biddiss and Andrysek are adamant that their clinical partners are keen on continuing to develop their innovations through scientific research, financial backing is a constant obstacle.
“We’d love to continue on,” says Andrysek. “It’s challenging due to lack of funding.”
It’s a challenge facing all scientific researchers in Canada. An astonishing report, helmed by former University of Toronto president David Naylor, suggests that as much as $1.3 billion in funding is needed for science programs and research projects in Canada. In December 2017, the federal government started considering the implications—since Canada is lagging other developed countries in its science investments—when academic researchers began a campaign to convince political leaders to implement significant structural and operational improvements to how finances are distributed to academic trials.
PRIORITIES IN RESEARCH AND FUNDING
The concept of one baby step forward, two giant adult steps back, is not new to Ramirez.
“What I’ve seen is advances that have been able to help smaller and smaller children to be treated,” explains Ramirez. “The challenge that we encounter at the hospital is that a lot of funding is mostly for adults. Companies tend to develop a lot of things for whatever they’re going to sell …the majority of what they’re going to sell is for adults. When we’re looking for the equipment we have to push the companies to make sure they think about paediatrics. When we think about paediatrics we talk about sometimes two-year-old children, and a little bit older. But also, there are neonatal babies.”
Ramirez says more money could mean endless possibilities for paediatric medical engineering, pointing to recent in-womb surgeries by Mount Sinai Hospital and Sick Kids that have changed the course of physical development for babies.
“This in-womb surgery at Mount Sinai points to the future,” says Ramirez. “We need to develop the technology that will allow clinicians to continue these types of surgeries on very, very small babies. Clinicians could be able to correct issues within the womb. And then, when the baby is born, we may still need to take care of them with further surgeries. We need new imaging systems, good robotic surgical instruments, that will allow the clinicians and the surgeons to continue to care for those patients so that they can continue to grow and evolve to be healthy individuals for the future.”
These engineers each express the idea that children with disabilities are not looked at as a priority for research and funding because they are a rare or small demographic, but if the government only sees science as dollars and cents, they’re missing society’s broader picture.