Advances in Neurological Rehabilitation

Baptist Hospital Miami

Past, Present, & Future

Neurological Rehabilitation


Helping people to regain functional independence from disability caused by injuries or diseases effecting the

nervous system


PARALYSIS DUE TO:

STROKE

TRAUMATIC BRAIN INJURY

SPINAL CORD INJURY

Neurological RehabilitationPast to Present

Traditional Approaches to Rehabilitation Two basic approaches

Teach compensatory techniques Promote neurological recovery


Traditional Approaches to Rehabilitation Teach compensatory techniques

Train to compensate for lost function with unaffected side

Adaptive equipment to compensate for lost function

Crutches, Walkers, Wheelchairs Braces etc


Traditional Approaches to Rehabilitation Promote neurological recovery

Traditional – Neuromuscular Facilitation EMS (Electrical Muscle Stimulation) Vibration Biofeedback PNF (Proprioceptive Neuromuscular Facilitation) NDT (Neuro Developmental Training)


Traditional Inpatient Rehabilitation


Traditional Inpatient Rehabilitation Coordinated Team Approach


Physical Therapy Exercise

Strength


Physical Therapy Exercise

Endurance


Physical Therapy Transfer Training Gait Training


Speech Therapy Communication Swallowing


Occupational Therapy ADL

Cooking



Bathing



Dressing


Recreational therapy


Rehab Nursing Traditional nursing Carry-over of skills

learned in therapy


Psychology Coping Motivation

Nurturing


Psychology Motivation

Coaxing


Social work Emotional

support Family and

discharge planning


New trends in Stroke Rehabilitation Increased emphasis on treatment techniques

and technology to promote neurological recovery

Advances in NeuroRehab

Promoting Neurologic Recovery Theory vs Fact

Are we really doing anything to promote brain recovery, or are we just mitigating the effects of inactivity while the brain recovers naturally?

Recent technology has allowed us to begin to answer the question of what is going on in the brain in response to our treatment


Techniques for Demonstrating Neurologic Recovery fMRI (functional MRI) PET (Positron Emission Tomography) TMS (Transcranial Magnetic Stimulation)

Doesn’t require volitional activity Can only stimulate brain tissue near the scalp

NIRS/NIRI (Near Infrared Spectroscopy/Imaging)

Only maps superficial cortex (1cm depth) Limited resolution Low cost, portable


Techniques for Demonstrating Neurologic Recovery fMRI (functional MRI)

Stroke

Cortical activation with hand tapping one month after R MCA

stroke (Feydy)

StrokefMRI pre and post 3 week course of grasp-release therapy with Hand-Wrist Assistive Robot. Takahashi et al. U Cal Irvine

Stroke

fMRI studies show: The brain is capable of reorganization

We can increase activity in various areas of the brain after stroke

This activity pattern can be affected by various rehabilitation therapies

Improvement can be made even YEARS after a stroke


These techniques are showing that cortical

restructuring is taking place in the brain in

response to the treatment we provide[ Neuroplasticity ]


Resultant changes in the approach to stroke rehab New technologies to promote

neuroplasticity New therapeutic techniques Counseling patients re: potential

chronic improvement Long-term exercise programs


New techniques to promote neuroplasticity Therapeutic robotics Functional Electrical Stimulation (FES)


New Technologies in Rehab Therapeutic Robotics

Passive/active-assisted , robotically aided motion

Robot assists in producing the lost motion Accurate, reproducible repetitions Results in functional improvement in acute and

chronic stroke patients ? Induces structural reorganization in the brain



works by repetitive motion training


Therapeutic Robotics UE

MIT-Manus: upper limb active-assisted exercise Palo Alto MIME (mirror image movement

enabler) RIC ARM guide (Assisted Rehab & Measurement) RUPERT (Robotic UE Repetitive Therapy) Reo

LE Lokomat system HealthSouth autoambulator (body weight

supported treadmill testing) InMotion Technology Lower Extremity Robot


RIC ARM Guide: passive and active-

assisted reaching on a linear track


MIT Manus P/AAROM Back-drivable “Video Game”

interface Improve Function Results can be

assessed with precise measurement of active motion by the computer interface


MIT Manus

http://www.youtube.com/watch?v=hvnXY5ZirjI

http://www.youtube.com/watch?v=hvnXY5ZirjI


ReoGoVideo InterfaceMonitors ProgressAdjustable:

speedforceamount of

asst


Palo Alto MIMEMotion: preprogrammed mirrored motion of

the unaffected limb


RUPERT (Robotic Upper Extremity Repetitive Therapy) – Arizona State University wearable pneumatic

muscles to assist Sh/Elb/Hand motion

Repetitive exercise to mimic natural motion


Lokomat system


AutoAmbulator


MIT AnkleBot



Pros Reproduction of motion is more accurate than

manual therapy (should improve training effect) Achieves more reps per session than manual

therapy Accurate documentation of results Very cool (fun to use = increased motivation)



Cons very expensive Limited availability out of the research setting,

but this is beginning to change


Functional Electrical Stimulation (FES) Using electricity to activate paralyzed

muscles in order to mimic the normal function of those muscles


Functional Electrical Stimulation (FES) Surface electrodes

Requires stronger shock Implanted electrodes

Requires an invasive procedure Risk of infection or rejection


Functional Electrical Stimulation (FES) Motion occurs when the muscle is

shocked Manually triggered Controlled by a computerized sequence of

shocks Controlled by a brain-computer interface


Functional Electrical Stimulation

Bioness L300

Walk Aide

Advances in NeuroRehabBioness L300

http://www.youtube.com/watch?v=p16pFcHMyVM

http://www.youtube.com/watch?v=p16pFcHMyVM

Contralaterally Controlled Functional Electrical Stimulation

Training

JS Knutson, PhD, John Chae, MD Metrohealth, Cleveland

CCFES Functional Training

http://www.youtube.com/watch?v=54QF3Pnqp5k


http://www.youtube.com/watch?v=54QF3Pnqp5k

CCFES Before and After

http://www.youtube.com/watch?v=boz0HQXQhKg


http://www.youtube.com/watch?v=boz0HQXQhKg


EXOSKELETAL DEVICES ReWalk

Sit to stand Stand to sit Walk Stairs


http://www.youtube.com/watch?v=gQRQs-N-ZIM




Exoskeletal Devices ReWalk

Now available for personal use throughout Europe Awaiting FDA approval for personal use in US


ReWalk Claire Lomas has T4

paraplegia from equestrian accident

She completed the 2012 London Marathon in 16 days with the help of a Re-Walk

http://cdn.arstechnica.net/wp-content/uploads/2012/09/Claire_Lomas_walking_the_2012_Virgin_London_Marathon.jpg


Exoskeletal Devices eLEGS– Berkeley Bionics (now called Ekso from

Ekso Bionics) Variable speed gait


Exoskeletal Devices - Ekso In clinical trials at Kessler

Gait and balance improve with training Increase in O2 consumption, heart rate, and ventilation

with activity with the Ekso (suggests that the activity is not just passive, and should have beneficial metabolic/cardio effects)

Muscle-firing found in leg muscles during Ekso walking Now in clinical use at Craig Rehab (April, 2012)


Exoskeletal Devices Rex (New Zealand)

Joy-stick control “walking wheelchair” “walking standing-table”

http://blog.ncpad.org/wp-content/uploads/2011/01/RexBionics.jpg


Exoskeletal Devices HAL (Japan) Hybrid Assistive Limb Cyberdyne Corporation 2 modes:

Myoelectric-triggered motion (Must have some muscle activity)

Robotic autonomous control mode (triggered by angle sensors and ground-reaction force)

http://blog.ncpad.org/wp-content/uploads/2011/01/HAL.jpg


Brain - Computer Interface


Brain - Computer Interface

http://www.youtube.com/watch?v=DJvlX-f5a28

http://www.youtube.com/watch?v=DJvlX-f5a28


Brain - Computer Interface 3D control of a robotic arm

http://www.youtube.com/watch?v=QRt8QCx3BCo&feature=player_detailpage


Brain - Computer Interface 3D control of a robotic arm

http://www.youtube.com/watch?v=QRt8QCx3BCo

http://www.youtube.com/watch?v=QRt8QCx3BCo


FutureDirections

Advances in NeuroRehabFuture Directions

The greatest promise lies with the potential to integrate these new

technologies

Brain-Computer Interface to initiate movement

Exoskeletons or FES to create movement Nanotechnology to make the devices

small enough and light enough to be user-friendly


Brain - Computer Interface Gather more information from the brain

Current technology uses a single chip implanted over a small area of the brain, gathering information from only a few of the billions of neurons in our brain

Goal: Use multiple chips to gather information from multiple areas of the brain


Brain - Computer Interface Improvement in software to more

precisely replicate normal muscle movements (natural

motion) Internal Power Source


Brain - Computer Interface Finding a power source for wireless transmission from

cortical implants

minute amounts of electricity that can be harvested from the pulse of a

blood vessel


Functional Electrical Stimulation (FES)Current studies use only a few

stimulators over key musclesFor fine motor control, we’ll need

multiple stimulators throughout the body.

Small enough and made from the right materials to minimize rejection

Self powered


Goal:

Regain control of the body using only thought waves to move the arms and

legs


Brain-Computer interface to FES :

Bypass the damaged area of the brain or spinal cord by sending thought

waves to electrical stimulators in the muscles


Brain-Computer interface to Exoskeletal Brace :

Bypass the damaged area of the brain or spinal cord by sending thought

waves to the motors controlling the brace.


Exoskeletal devicesLighter, more compact

Nanofiber suit

What might a nanofiber suit look like?

Take off the mask, add some clothes, and you’ll

blend right in

We’re Only Limited by Our Imagination

www.BradAiken.com

Advances in Neurological Rehabilitation

Health & Medicine

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