Dr. Peter Smith explains a brittle bone disorder osteogenesis imperfecta, treatment, and how motion analysis provides personalized care for orthopedic conditions.
Dr. Peter Smith, M.D. (Guest): Hello. Osteogenesis imperfecta is a rare genetic condition where individuals have low bone density, low bone quality and a predisposition to fracture, so they have more fractures than usual.
Melanie: And you’re doing some exciting research in special bone rodding technique used to stabilize OI patients’ bones and they were developed at Shriners Hospital for Children in Chicago.
Dr. Smith: That’s right. Actually, I inherited the most – the busiest or the oldest osteogenesis imperfecta clinic, at least in the United States and it has been area of specialty of our hospital since the 1940s and I have had the honor to be the head of that clinic now for about 25 years and we have made some tremendous improvements over the years, but we still use a technique called intermedullary rodding where we put rods inside the bone. These are metal rods to straighten them and to prevent them from fracturing so much so that our kids and adults can lead more normal lives.
Melanie: That’s fascinating. Let’s talk a little bit about gait in children. What are some normal variations in gait? What are some abnormal variations? What would a parent, Dr. Smith notice when a child is young and crawling, starting to learn to walk, are there some common gait presentations that a parent would notice?
Dr. Smith: Yes, so we see kids all the time for different things and one of the chief complaints that we see kids for is difficulty walking or abnormal walking. Most of us know when someone is limping because everything is not smooth. There is a lot of dipping going on or and then we see kids that turn in too much or turn out and the parents are very good observers of this and what we do with our experiences, we direct a physical exam to the area that we think is causing the problem and one of the areas that we can use, if these are severe enough gait problems, is use a motion lab to really quantify exactly what’s going on with some of these complicated gait patterns.
Melanie: As you say and before we talk about the motion lab; as you say, parents are a great indicator of what they should be looking for. Are there certain red flags you want a parent to notice if a leg is dragging during crawling or anything of that nature?
Dr. Smith: Well you know as kids learn to walk, they do all kinds of different things and every kid has their own pattern of doing it for a while, but as they become smoother then if they are always doing something or always limping if you will, then yes, then they should seek medical attention because often with bracing or therapy or something like that, then we can help those children get around better.
Melanie: Tell us about the high-tech lab, the motion analysis center or gait lab that can make moving images of how kids walk or roll to help you doctors provide them the best treatment.
Dr. Smith: Yeah, so this technology is actually what the motion picture industry uses to make all their films and actually a lot of the gaming systems use it too to depict how the figures in motion is. But actually, this was developed first by doctors to evaluate the gait, how children walk, maybe thirty years ago. We put markers on different anatomic landmarks and then the kids walk back and forth in our gait lab which is a – just a big area that has 16 specially adapted cameras that use infrared to bounce the signals of off these markers and capture exactly the motion of each of the different segments of the leg and upper body during gait. And we have normal values and we have done a lot of research on what normal gait is and now we have done a lot of research on what the different abnormal gait patterns are and we use that all the time in making decisions about how to treat the kids.
Melanie: So, what’s an evaluation like for the child. I would imagine that for some children, this is pretty cool to see some of this equipment.
Dr. Smith: Yeah, so there are no needles involved but they do have to have – spend about two hours with us in the laboratory. There are some nice physical therapists and kinesiologists who do some measurements. We take some very high-quality videos. We put the markers on and they just have to walk back and forth and actually some of it is interactive. Now they can actually see their avatar, if you will or their skeleton walking up and down in the laboratory, almost in real time, which is really interesting. So, it is almost like they are part of a video game. And they usually – we usually bribe them with some kind of toy or stuffed animal or basketball or something. So, they usually have a pretty good time. And a lot of them will come back every year, particularly if they have ongoing problems with their gait and we monitor their treatment that way. So, none of them have any fear of that. It is usually just some time that they put.
Melanie: Well kids do like video games and I imagine it makes it much less scary for them and even a little bit exciting for them to see how that all works. And does this include specialized orthopedic care for kids who have club foot? Are you using it for that as well?
Dr. Smith: Yeah, so we have obviously a lot of highly trained engineers who are interested in research. We are a major teaching program for some doctoral and post-doctoral engineers and they really drive us to make our treatments better. We have done a lot of long-term follow-ups of a condition called club foot where we treat infants and very small children for curvature deformity of the foot and we have looked at the results of the different treatments 25 up to 30 years after treatment. So, we have the adults come back and we have done some research on that and looked at different treatment methods and found ways to improve our treatment of the little ones based on these long-term results.
Melanie: Dr. Smith, give us a little blueprint for research to improve care for future children that might have specialized orthopedic conditions across the country. What are you seeing or what do you think in your opinion is going to be the outcome of some of this amazing research you are doing?
Dr. Smith: Yeah, so that the engineering is tremendous and the revolution in computers and the way that we can look at imaging and data is definitely going to help the day to day treatments of kids with problems like cerebral palsy, osteogenesis imperfecta, and club foot. I think that it’s a really good collaboration with engineers. We can measure things exactly, look at long-term results, modify our treatments. We are looking at computer learning too, where from our database we have of treatments we have done and then the results with the motion analysis we can look at how the computer can help us learn what the best treatments for some of these complicated problems. So, I envision a day when we will have instant access to all kinds of information which will help us for individual patients. For example, for osteogenesis imperfecta, we can take data from our motion lab, develop - with some imaging models of the skeleton, predict fractures perhaps, custom make the particular kind of rod or other treatment that this child needs; all of that based on very sophisticated data. So, it really will drive us to treat each individual to the best that we can.
Melanie: In summary, wrap it up for us Dr. Smith. Give us your best advice about gait analysis and our children, what you want parents to know about the motion analysis center or the gait lab at Shriners Hospital for Children – Chicago.
Dr. Smith: Well, I would say I am very fortunate to work here. The Shriners have put a lot of effort and resources into making the care of the children the best that we can, and we can treat the kids regardless of their ability to pay so it’s really an ideal job. We like to see kids with all kinds of different complicated things and get referrals from all over the Midwest for that. It is a specialty too that’s we try to make it non threatening for the kids and some of the treatments they have like casting or surgery are scary but it’s really a fairly friendly environment. And then we are trying to take that opportunity to do research to make the field as a whole better, because we have resources at the Shriners that are not available in the community for that and are not particularly easy to do without the support of a big hospital system that is interested in research.
Melanie: Thank you so much for such interesting information Dr. Smith. this is Pediatric Specialty Care Spotlight with Shriners Hospital for Children – Chicago. For more information, please visit www.shrinerschicago.org . That’s www.shrinerschicago.org . I’m Melanie Cole. Thanks so much for listening.
About the Speaker
Peter Smith, M.D.
Peter Smith, M.D., is an attending orthopedic surgeon and director of the osteogenesis imperfecta clinic at Shriners Children's Chicago. Additionally, Dr. Smith is the medical director of the hospital’s motion analysis center.
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