New Technologies and Their Role in Enhancing Neurological Recovery

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1 REHABILITATION CARE 2014: under the ACA Patient Centered Medical Home for Persons with Disability: Acute Neurology, Medicine, Surgery services seamlessly blending into Acute inpatient Rehabilitation Ambulatory primary, specialty and Rehabiliation Care New Technologies and Their Role in Enhancing Neurological Recovery

2 The Affordable Care Act Coverage for many more residents of USA Expansion of Medicaid Move toward Managed Care for All Incentives have shifted: Preventive Care Patient Experience Patient Centered Medical Home More medical/surgical outcome measures Readmission penalties

3 What does this mean for Rehabilitation Care?

4 Rehabilitation redefined Primary Care for persons with disability throughout the lifespan. Prevent complications, promote health, promote genuine restoration of function for the long term. Stay out of the hospital. Which means expand outpatient care.

5 Conditions through the lifespan Developmental Disorders (CP, Autism, Epilepsy) Neurotrauma (spinal injury, brain injury) Neurovascular (stroke, other) Neurodegenerative/Progressive (MS, PD, ALS) Orthopedic (limb loss, spine) Complications of Chronic Disabling Conditions: urological, diabetes, cardiac, pressure ulcers

6 Shift to the community for care. Prevention Ongoing rehab Fewer $$$$ (managed care model) Some solutions: technologies: Telemedicine M-Health Pamsys Robotics

7 Overview: example stroke Acute Stroke Unit at RLANRC Secondary Stroke Prevention at RLANRC SUSTAIN (Systematic Use of STroke Averting Interventions) Patient-Centered Medical Home for Stroke New approaches to Rehabilitation through the lifespan

8 Background: Los Angeles County Los Angeles County Most populous county in United States (~10 million) Department of Health Services (LAC-DHS) serves ~800,000 persons/year 4 hospitals (3 with EDs) 63% outpatients uninsured Problems with stroke care in LAC-DHS no dedicated stroke units overcrowded EDs TIAs discharged from ED prolonged hospital admissions delays in diagnostic evaluations (ALOS 8 days) inconsistent initiation of secondary stroke prevention medications delays in transfer to inpatient rehabilitation poor outpatient follow up

9 Objectives of Stroke Unit (ASTK) Decompress ACUTE CARE Reduce time from stroke onset to inpatient rehabilitation Improve the quality of care provided to TIA and stroke patients in LAC-DHS Start rehabilitation sooner

10 Patient Flow LAC+USC ICU Harbor UCLA ICU LAC+USC ER Harbor UCLA ER LAC+USC floor Harbor UCLA floor SNF Rancho Inpatient Rehab Rancho ATSK Rancho Day Rehab Home No Therapy Home with Rancho outpatient therapy

11 Discharge Destination of Stroke Population, n=440 Discharge Destination % Home 72 Inpatient Rehabilitation 12 Outside Hospital 4 Skilled Nursing Facility 3 Other 2 Outpatient Therapy Needed % Physical Therapy 29 Occupational Therapy 30 Speech Therapy 16

12 ASTK Measures of success Rancho: primary site for TIAs, strokes in LAC-DHS Average length of stay: 3 days Time from stroke onset to admission to inpatient rehabilitation Prior to ASTK: 18 days Now: 7 days Proportion transferred back to referring hospital: 4% urgent carotid intervention

13 Continuum of Care Medical complications are common after stroke Complications impact stroke recovery Recognizing and avoiding complications is a part of excellent stroke care

14 Patient Centered Medical Home Primary care is provided through the lifespan (internal medicine/family practice) Primary physician has a panel of patients Primary physician works closely with experts in the neighborhood Goals for the Enhanced PCMH: post stroke prevention, reduce risk factors for other medical complications, promote recovery of neurological function Keep them healthy! Use newest technologies!

15 Paradigm Shift in Neuroscience Myth and Legend: Traditional care assumes that brain is hardwired and cannot recover once sensorimotor areas are destroyed Reality: New understanding: after stroke and other neurological injuries motor learning and relearning occurs and may be influenced by experience

16 Paradigm Shift in Neuroscience

17 Paradigm Shift in Rehabilitation MIT introduced a paradigm shift in clinical practices in 1989 by initiating the development of MIT-Manus a novel tool for neuro-rehabilitation Problem: Therapy for neurologic injury is labor-intensive Solution: Combine robotics and information technology into an efficient, effective tool for clinical therapy to harness and take advantage of plasticity to maximize recovery

18 CSP558 Veteran Affairs Randomized Clinical Trial CSP558: Robotic Assisted Upper-Limb Neurorehabilitation in Stroke Patients

19

20 For Stroke Care MIT Manus Developed in 1989 and in the commercial market since 1998 Lokomat (Hocoma) In the market since 2001

21 Robotics at Rancho Today Argo Re-Walk paraplegics IMT shoulder,wrist, hand (stroke and Cerebral Palsy) Interactive Lokomat (stroke, CP, Brain injury) Ankle-bot Brain Computer Interface Robot (locked in, ALS, CP, starting with C4 complete tetraplegics.

22 IMT-Upper Extremity Robot

23 Better Device Design i. Prevent slacking ii. iii. Reduce complexity Increase intensity

24 Increase Intensity Lang et al observed 312 physical and occupational therapy sessions at seven rehabilitation hospitals Average number of repetitions of task-specific, functional upper extremity movements was 32 per session Animal studies use ~600 repetitions per session to induce plasticity

25 Framework/Hypothesis The most effective rehabilitation treatments will provide appropriate challenge This such treatments may well require technology to augment the human touch. Treatment may rely on relatively simple movements Ultimately, we will transform mobility by combining technology-based training with new therapeutics.combination therapies is forthcoming

26 Other Technologies and Programs Brain computer interface Bionics Pamsys Robotic therapies Transcranial Magnetic Stimulation Curing Epilepsy

27 Questions????????????

28 Thank You

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