Sp 8. AT Innovation Lab at Blythedale Children's: on innovations in pediatric AT, role of rehabilitation engineers, and gaming as a form of rehabilitaiton

Welcome to Gears of Progress, a perfect place to learn about research in rehab engineering and assist up tech. As usual, I'm your host, Sasha, a research scientist at the University of Washington. And this is special episode number eight. Today we have André Guerrero, he's a rehabilitation engineer at Blightale and we have Jean-Marie Florkovsky, who is a senior assistive technology professional as well as a senior occupational therapist by training. And we are going to be discussing how they integrate rehabilitation engineering with clinical side at Blightale Children's Hospital. So welcome in. Super excited to have both of you. I always like to ask how people got to where they are now. So I guess we can start with André. I know you are a mechatronics engineer by training. How did you end up going from mechatronics engineering into rehabilitation engineering in a children's hospital? So yes, I am a mechatronic engineer. I did my undergraduate in Ecuador. Then I did a master on design and commercialization in the University of Alabama at Birmingham. And the whole university over there is totally based on medicine because of the hospitals over there. So all the programs, all the topics for designing was about a specific case in medicine. And the project that I had to work on was something to help children with limited movements. So with my team, with how about the professor, we were thinking something like that they can use at home and they can increase their relative for them to do the same exercise that they will be doing with the therapies, with the equipment that they use at home. So we start working on a libtical machine for this specific case. And after that, I was, okay, this is something that I am really interested to do as a career. I really like being able to use all the knowledge I got on my undergraduate to be able to design because that was really my passion to become an engineer and to do something that could really change somebody's life. For that, I found the opportunity to find on the rest of the website the Jeff Positions Blightle that they were in New York. So I had to go through some interviews, talk with the team. And I'm so glad and happy that I found this Jeff Positions because it was something I have never heard before. But now I really love it. And we love you too. That's great to hear. Jean-Marie, do you mind sharing? I did my undergraduate and then wasn't sure what I wanted to do, but volunteered at a few places and observed an OT session and kind of fell in love with just the approach of helping somebody, nurturing somebody. And it was a very good fit, I think, for my personality and kind of who I am. So I went in and I completed a dual bachelor's master's program. And I ended up doing a field work at Blightle Children's Hospital. And after my field work, there was a job opening and I applied. And from that moment on, I've been here since. We had a few, I guess, that was like 24 years ago. And there was a assistive technology in-house and we were using it. I fell in love with the fact that there was an ability to tap into those children that could appear quite passive in their day and really make them active participants in their world. And I fell in love with the technology and the advances. So I'm happy to have been supported here to receive and go from my ATP and have division along with other ATP members that we have on staff to create the sense of disciplinary team here at Blightle. I see. So assistive technology plays a very big part in the kind of services you provide at Blightdale. How does ATP in a raid in your daily practice as an OT? As we were here, many of the therapists here have a level of familiarity or expertise in reusing assistive technology. When we have children here, our population is quite unique and quite diverse in their needs. Assistive technology fits very well into our building, whether it's inpatient or day program or attached, you know, mountain, pleasant Blightdale school. We have different ages, different needs and most of our children do have a level of motoric impairment that we want to be able to offer them something that they're going to be able to complete all the tasks that a child, their age outside of this is doing and we want to make sure that in-house, they're able to have the same opportunities, just it might be in a different way. And that's how assistive technology can kind of bridge that gap for them. I see. What kind of AT-DU offer at Blightdale? And for me, I'm also kind of curious if are the ATs that you provide specifically created for kids or do you oftentimes end up kind of taking something that's intended for the adult population and just trying to fit it to the pediatric population? Our areas that we really hone in on is, I mean, when you look at it from a sort of an umbrella perspective is we all look at alternate access and how is that person going to access, you know, their device, whether that is their computer, their AAC device. Their power chair, their environment overall. And we kind of look at all those areas for some of our children. Some children here have needs in all of those areas and some of our children might only have a need in one of those areas. But those predominantly are the ones that we try to tackle for our children here at Blightdale. And as for the layers of use and how, you know, we look at it, I think technology is emerging so quickly now and evolving, you know, at a speed that, you know, we weren't prepared for, but we actually are receiving it and feel blessed by it as well. So I think, under as you can kind of join in, we look at what's commercially available and first and what could match, not necessarily the child's age, we go more on what their need is. If it could be a mouse or it could be a device that could be used both pediatrics and adults, we don't look at it based on age, but really what skills, you know, are needed to actually use that device. And then, you know, on dress being on our team, we kind of can do a middle layer of that. Maybe we can use something commercialized that might need a little tweaking or a little modification. It goes all the way to then another layer of it might just have to be customized, brand new kind of a thought that we kind of created together as a team and go in that direction. So yeah, as I think also this will explain a little bit, the way that we work here as a team and assistive technology department, basically we work, you know, T's, BTs, speech therapies, and in my case, also as we have engineered, we try to all of us work together, see what is available in market as a gym say, what it could be used either is for children specific, either is for other population, or even is not even a medical device. For example, a wow, the thing that we have done is, a mount for cameras could work perfect for a mount for switches as well. You can get a really low cost in Amazon, and it worked perfect for these kind of scenarios because they could be easily adjust, it could be small. So those kind of things we are trying to look not only think that are specifically for children, but that could solve the solutions in a way. And as a gym say, like if sometimes here it could be used as a dish, or here and light that we have our laboratory for prototyping that we can customize the device, so it can work for each of our child that are here. I see. So I guess a perfect question. question for Andreas following this is what is the role of a rehab engineer at a children's hospital and what is your day to day work looks like? As I say, I work directly with assisted technology team. So regular case will be, you know, one therapy is working with a kid. They feel like they would like to try something for access or for mobility. They will go with their senior and say, hey, do we have something here at the hospital that we can try? After meeting the team, we discuss which element we can provide them. As I said, we will figure out what is available, what we have, what we not, in the case that there's nothing available, then they come to me and it's like, okay, I have this idea, I have this need, I see the patient, I see the therapies and try to figure out all the needs so I can start making a design for them. Design that, as I say, could be something that I can't customize from existing device or that I will have to come with a whole new idea because we're really trying not to do, as many people say, reinvent the wheel. Trying to find efficient, quick solutions that we can be able to do here. Tested and have the patient try it. So that's what I'm trying to do as well here. Come to my computer, start working on the design, could be something mechanical, could be something that requires electronics. And as soon as I can have something like a prototype that we can be able to try it with the patient. I see. Do you mind sharing some of the current projects you're working on right now? As I said, I work with so many different therapists here at Vlido. So I jump from one project to another. So sometimes I do things that are, for example, feeding tools. In the next moment, I can do customizations for poor mobility, like a special handle for the joystick. I can be doing writing tools. I can be doing key guards. Some of the projects that I'm also working now is being able to treat the splints. I start working with making ring splints. Now I'm trying to do something a little bit more bigger. I got bigger and more specialized printer. So I can start doing, for example, arm splints. So as I say, I'm basically jumping from one project to to other. I think as problem sort of surface for us as therapists, we have a really strong knowledge base in knowing what level of function a child's at and how their diagnosis might either impact function at that moment. Do we anticipate a level of recovery for these children or do we anticipate a level of regression for certain diagnoses? They could look very, very different. So I think what we've learned to do is, which is key, is really communicate as a team. I think Andres came on with a really strong ability to listen to us as well as us having that conscious ability to listen to his side of things as well. And what we ended up doing is we always have ideas as therapists. We really bring them forth and we're like, yes, we want to do that. Yes, we want to do that. But our knowledge foundation sort of we get to a certain level and we sort of hit a block. And once we hit that wall, we needed somebody to help us chip it down a little bit and we felt like that was our missing link and not having a rehab engineer on our team. And Andres brings to the table such a strong design principle, knowing properties of materials and what will work to make something happen. So I feel like for us what it offered us is again, it increased our learning of what we can, what we need to think about when we're looking at solutions. But I also feel like from us what he offered us was more efficiency in the solutions timing, the turnaround time that a solution might be created for that child, which is wonderful for the family and the child to not have to wait on us. And then also to just the less errors. So the errors that maybe I might have to trial an era of a piece of a solution that I might offer a child might be a lot more than almost Andres comes in and kind of says, yeah, I'll figure out a prototype and we try it in our therapy session. We give him what's working, what's not. He's like brings it back and he designs something else. And he's, it's just, it's a smooth transition for us to be able to say, here's our solution. You know, Andres has his specialty of creating this and then we can re, you know, start integrating it into the child's day for them. I see. I know that when you work in such an interdisciplinary team, communication is key, but it can also be difficult because the clinicians speak one language that is very clinical. The engineers speak other language that is very engineering. And then you also have different clinicians speaking. I feel like from my engineering perspective, speaking very different languages, when they're specialized in very different things. And when they work with very different populations. Andres, as a free hub engineer, how do you ensure that you're up to date on all of your jargons and understanding of the clinician side and the words they use? Or do you walk with a dictionary like today? I'm talking to an OT. Okay. Here's the OT to engineer. Right. Like it was like really challenging at the beginning for me. I was coming from literally more like a manufacturing shop environment, doing stuff like building things with my hands and doing the machine and talking with other engineers all the time. And suddenly coming to a hospital, it was a whole different word for me. I feel like one big part of the success of this model of work that we have here is really the assistive technology department. I think they are that these specific therapies are like the link in between the rest of the therapist community and the engineering part. I feel like they are also so creative and they are so good at their job, but also they knew a lot about technology. Even with their own words, sometimes not the same that we some words that we'll use as an engineer, for example, with poor wheelchairs when we're talking about the sensibility of the movement of a joystick. So you push the joystick a little bit and it's going to take a moment for the poor wheelchair to react. And I will call it, yeah, that's going to be almost like the acceleration of it. And it's like, okay, that's how you call it. But well, yeah, that's where at the point of view as an engineer, I will see it. That's how it's like, surely the motors of the poor wheelchair will work. So I was at the beginning, I was like trying to learn everything translated to my understanding. And then also trying to figure out what will be the best way to explain things for them. So it could be easy for them to understand. But as I said, as a genius, about materials, about the instrument that I use. So it could be like a great way to communicate. And yeah, I try to try really hard to learn. I am also working good to get my rehab engineer from Resna certification. So I spend a lot of time reading books and getting prepared and learning more about this world. Yeah, I just have a comment where I usually work. My research has primarily been on upper extremities. And I feel like, you know, almost working for a decade in that space. I really hometown the my nomenclature when talking to clinicians. And then right now we switch to lower extremities. And that entire jargon is just out the window. And I have to learn everything from scratch. It's a totally different language, although it's still, you know, in a way, I'm still in the biomechanics realm as what we call it. But it's very different. And what you do is very different. So yeah, it's tough. I think it goes both ways. Yeah, it goes both ways on that. Sometimes I have to, you know, be honest with myself and let Andres know, hold on a minute, reverse, you know, explain it a different way for me until I understand it. I think yeah. I think the language he's learned from us and we've learned from him. But I think when you're working with the team, again, that openness, you know, being not just that free word of just saying, "Oh, we collaborate. Oh, we collaborate." I think it's a conscientious collaboration that we offer each other. And I think that's another, it's a deeper level. And I think if you're open to that, it sort of works. Or I always say like we kind of, as an AT team here at Blightail, we kind of drop our expertise in a bowl and we stir it and kind of pour out this amazing blended perspective that really shapes our outcomes. And we're seeing that. And the way we see it is children are doing great jobs here. They're, you know, children that we didn't think we're going to be able to do certain tasks are now doing it. I think so. And we end, you know, harmonizing our skill. We kind of want this, you know, we're playing that a good musical tune, I think, in the end by harmonizing our skill and understanding and being respectful of what each person can offer and also being respectful of our own weaknesses. Sometimes I have to take a, you know, back seat and say, "You take the lead. I'm not sure, you know, I have the mindset for now. I have a good idea for that at that moment in time." And that's why it's so important to have, you know, we have physical therapists, speech therapists, OT's, you know, rehab engineer, I think making sure all those perspectives are kind of on the plate at any given time. And that was our vision when we created this team was that, you know, even to evaluate a child. Normally in the past it was always one, you know, therapist or one clinician doing that of Val. And for us it's been multidisciplinary. So every child is getting the perspective or the assessment of multiple disciplines, which for assistive technology, I think, Andres, you feel the same way, right? Like when you look at assistive technology and the needs, you really have to make sure each device is kind of working together for that child. So it's helpful if I know I'm going to have to, you know, we're going to have to mount an AEC device to a wheelchair. I need to have information on that wheelchair and those decisions that go through that so I think we all have our little specialty on the team, but I think we've done a really good job growing as a team. And I think it's been huge to have Andres kind of in that, you know, in the bowl with the shy say as we're being stirred around because I've learned so much from that position. That's pretty great. I know some of the work that you guys do at Blightdale, you create switch adaptive toys, which I had a couple of episodes on that. At this point, there's Husky Adapt, a whole organization at the University of Washington that is focused specifically on adapting toys. There's a PhD student at the University of Washington, Mia Hoffman, who's working on creating switch adaptive kits for clinicians to modify the toys and really not only the toys, but you know, even whatever you might be, might be of use in terms of like something that is part of the therapy to engage the child. How do you guys utilize the switch adaptive toys that you work on in your daily practice and kind of what are, are there any results that you're seeing from providing access to those? From a therapeutic point of view, we do switch access toys or switch toys to kind of as that first layer that a child needs to, you know, we learn kids learn to play, learn a lot through their play, you know, they grow and they nurture through just the activity of playing. And for some of our kids, that's a really challenging thing to do. And switch toys end up being their first layer of being able to play and do something, control something on their own. And that really does a lot for their motivation, for their kind of self-esteem, for their autonomy and knowing like, wow, I can control something I might want to do something else and kind of motivate them. So I think it's a really strong first step. I think it's a very, you know, that cause and effect of, you know, activating something and it's multi-sensory is very rewarding for kids. And as they're learning, it's less technical but more fun. And that's what we want to do as a pediatric facility here is, yeah, you're learning something but we want to make it motivating and fun. And I think for also the parents, I think educating the parents on, you know, switch toys and where to get them and, you know, understanding that. And I think we realize that also too, having Andress on the team, we can actually even dive deeper with the parents and have them learn how to create their own switch toys. And Andress has done a lot of workshops on, you know, tapping into that and having the parents then become comfortable with switch toys and what it can offer their child. Yes. Normally, I try to do like two every year, like a workshop that's open for therapies and also for parents and caretakers that they can come and we provide a toy with the tools that they will need it to adapt the toys and I will be here sometimes by myself or with other students that can give me a hand to help them like because they will learn how to use a solder solder iron, for example. And first, like on those workshops, what I'm trying to do is teach them how to use it. So it is really funny, really instructing for them at the end, they can take that toy with them for the kid with a customized 3d print switch that I made also for those workshops. And they can take it with their manual and some links to websites, for example, I was listening in the post because that you did with Husky. And I really like the website and how they have different toys that you can have video tutorials or have to adapt. So for example, that probably I will add it for next session. So they can have it also as a guide because you don't ever know. They always have parents saying like, I want to do this. Now I'm going to get my own solder iron. I'm going to do it for my kid. But I don't know what kind of toys I can do it. And it's like, okay, here, these are the toys that can be adapted. So you can get it as a project and make it for your kid. I found it to be, as Jim already said, it's really, really useful for a kid to have that cause of an effect. Toys are great for that, you know, like they are noisy, they have lights. Adapting a toy for them is cool. We really first step for them to later thing about access that device. So okay, we know what kind of switch this kid is using for their toy. Okay, so we can use the same switch later for communicating with a computer, with even with a poor wheelchair. So that's I feel like it is a really important first step for them to use toys. And now we are trying to go a little bit further with video games as well. That's the other part cause I was also listening to it too. Adapting Gaming was like a presentation that we actually went and see him doing at ATA. We were so inspired with that presentation that we actually got our own Xbox Adapting controller, all the switches. And we were like, okay, no, let's try it. Let's get our Mario Kart, great game, the best game for me for people that one like an adaptive game. I don't even know there's another one with that compromise on doing something that could be accessible for anybody. And now we are basically doing my own joysticks so we can try different things. We have so many cases of children that went from playing a game to discovering, oh, he has this movement now. Let's translate this movement to a poor wheelchair. And now he's driving a poor wheelchair. The same joysticks that he was using for gaming. And then we have the other situation. Kids that they become proficient at driving a poor wheelchair just grab exactly the configuration you have on your poor wheelchair, move it to your joystick for using on the Xbox Adapting controller. So you can still be able to access video games. This has really gave us so many ideas for kids to start integrating the different cases where they get in different games, different switches. And yeah, let's see where we can go with this kind of projects. And the gaming world is so popular and especially for certain age groups, but also for parents. know it's one of those. activities that we happen to see, wow, it could be a level of socialization for some of our children. If they're playing online, if they're battling each other in Mario Kart. So again, even though there is a solution of actually accessing it, the impact of adaptive gaming, we see is so much more. And that's why I think we went to those courses. We listened to those presentations and looking around here, we wanted to create something similar to that that was going to, we knew it was going to be a valuable tool. And it's really nice for kids that maybe have had a traumatic injury, such as a spinal cord, to understand that the first step that their new version of themselves can still do the things that they once knew that they knew how to do. So we have a child that was very into video gaming. And he now can video game, he just has to do it in a different way. And I think knowing that piece of it where the task is actually like, I didn't lose that ability to do a task, but I just have to do it in a different way. I think is really nice for us to be able to offer those children, especially when they're going through a hard time. I see, yeah, I want to say two things to that. There was one data collection study we did a few years ago with a colleague of mine and it was just on understanding novel ways of interacting with devices. So in that case was with muscle signals, especially I think it fits in line with the metast new wristband to that's reading your muscle signals. And so we explore that for the use with participants with upper body disabilities. And there was one comment that we really liked that we just basically, you know, we cite everywhere because we were trying to explore, you know, whether sometimes people are interested in doing more, let's say rehabilitative movements or like movements that are potentially more strainiest, but they provide a form of rehabilitation or they, you know, wanted to stick with something that is just kind of going with with the flow of the way their body was feeling at that time. And there was one comment that was made by one of the participants and they said that all movement is rehabilitative. And it stuck really strong with us throughout all the future work that we were doing. And I think that really resonates well with all of the adaptive gaming as well. And I wanted to add another, I think, another episode that is really great is the work that's done by Professor Mohan Rush to Rumele and that's from the University of Alabama, Birmingham. So I don't know if Andres knows him, but they do specifically they have a whole center that creates games that do have that rehabilitative focus and can be modified to the person, you know, to to provide them the game, but change the kind of rehabilitation that they achieve playing that game. So that's episode number 14. I don't know if you haven't listened to it, but I think it would be really cool for you to maybe see if that could be integrated at a blind day as well. And I love that phrase. I love that line. We always kind of think of similar way and even the tiniest movements can do big things and that's what we strive for in regards to access. And I think we've also realized that because of that and knowing that every movement has that potential, that we don't just offer a child a primary mode of access. We always are looking at a backup method. So if a child is an iGaJ user for communication or for, you know, other Windows control, but they may need a backup due to fatigue reasons or if there is a problem with their device, we want to make sure that they're still accessing their world, even if their device is, you know, under needs a level of repair. So I think we've really kind of between the gaming situation. I think we've come to realize that piece of the fact that, you know, we really do look at the child and assess and really look at what access sites we can find to make them as functional as possible. Right. And not only trying to have the kids adapt to what we offer them or what is available, we're trying that the device is all adapt to the needs of the kids have or the move that he can provide. Yeah, absolutely. What are you two most excited about in terms of the latest trend or the newest technology that is becoming more mainstream because 3D printing was a mainstream at some point. And then it became so anything that you're kind of looking forward to become more accessible for AT labs to make ATs even more better, more customizable, more accessible. I think in general for for my point of view, what, you know, this isn't really up and coming in new, but what I appreciate is just having, you know, platforms out there, whether it's Apple products, Android, Windows, just their accessibility features that they've started to kind of branch out and kind of tap into those areas has been so nice to see. It's been so beneficial. It's cost effective for a lot of our families. And it's just another avenue to say, oh, you know, we're using commercialized products. But again, those companies are looking at their, you know, their consumer and saying, all right, there is a very part of the population that we are missing. And let's tap into that because those are the people that need it the most often. And I really feel like for me, I love to see the upgrades and all that and seeing where that's going to go. And that would be one of mine. And just to have another. Well, something I always feel like it has a lot of potential, but I still hope one day could be something that we can start using and another method of access going to be the brain, computer interface. Yeah, I feel like I have seen the last couple of years already. Like people trying to see how to make something like really simple to use low cost. And you can access to your computer, your phone. So I hope that the technology next years will be there, but not for medical use. I am really hoping for just regular use because that means that the prices are going to be lower. It will be great to see like just a click. That's the only lecture I need. Just give me a click that it could be easy to record and use it in any device. And that will make a difference to so many people. Yeah, if you know technology is great, but if you don't have access to it, it's, you know, no one void for us in a way. So I think just having increased accessibility is kind of a golden opportunity for like even like Anders was saying, those brain interfaces and kind of trialing them and seeing if they work, especially with the pediatric population, you know, their their minds are still developing. And we I would love to see more kind of research and figuring all that specifically to pediatric population. Right, because that's definitely another problem. Like a lot of the products that you can find already being used are for adults or for a totally different population that we have here at White also. It will be nice to be able to see those kind of devices also for children. For example, the gloves that help with tremors is that something that we were seeing that we have a need here as well in the hospital, but all the ones that are coming are really expensive or are not cited for children. Or they're stemming from like that maybe the Parkinson's, you know, people at Parkinson's where we're trying to see is there something that we that's out there or that somebody will kind of tap into for those children with attack movements. And you know, it might be a little bit different, but we're wondering could that, you know, technology that works for that could that help an aid, you know, a child with a toxic movements. Yeah, yeah, BCI is definitely this is the question that I tend to ask as a wrap up at the end. And BCI has come up a lot recently. So yes, fingers crossed, it's going to become more accessible and hopefully eventually less invasive because it's still a very invasive procedure at the moment. And I know it can be a determinant in the decision of whether to use it or not. It was a pleasure chatting with you. Thanks so much. Oh, we appreciate this. Thank you for doing what you do too. Bringing awareness out there and formation. We love it. Your podcast we're doing are wonderful to listen to. So we have like just a couple of more things that yeah, definitely feel like it will be nice to mention is like Every year I open during the summer for the laboratory for students to come and do some internships here as well. You can go to our website at the assistive technology tab on the PlideAltyRain Hospital website. You can see more information about that, especially for any kind of engineering. It could be really useful. Mechanical electrical to remain in software engineer. I always feel like, "Okay, there's a lot of potential for work on the world access and gaming." So we need to make those things accessible as well. And you do get the involvement of the clinical team in your experience here as well as kind of working with the children here as well to see your creations kind of in real life working. So I think it's just a nice experience. Right. And we also have some over designs on the website. For example, as I said, we have a 3D switch that could be printed in any kind of 3D printer. So you can have the files, manual, how to assemble it, and it's totally for free. Just download it and also write in two if people are interested. To have those for them, they are totally free. And in the future, probably we're going to keep uploading different designs for 3D printer people that really, for makers that really feel like, "Okay, this, I could make some of them start giving to some population in my area." Perfect. Yeah, I'll include the links. That's awesome. Thanks so much. Thank you. This episode was powered by Create, the Center for Research and Education on Accessible Technology and Experiences at the University of Washington, and Resna, the Rehabilitation Engineering and Assisted of Technology Society of North America. Thanks for listening to this episode of Gears of Progress. If you enjoyed, please consider sharing it with your friends. Also, find Gears of Progress on LinkedIn to stay up to date on the latest information about releases. And as usual, stay tuned for the next episode. Welcome to Gears of Progress, a perfect place to learn about research and rehab engineering and assistive tech. As usual, I'm your host, Sasha, a research scientist at the University of Washington, and this is Special Episode #8.