The Future of Rehabilitation. Matt Wilks, PT Richmond Stroke Symposium 2011

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1 The Future of Rehabilitation Matt Wilks, PT Richmond Stroke Symposium 2011

2 Disclosure Information Matt Wilks, PT, Director of Therapy Innovative Practices in Stroke Rehabilitation Financial Disclosure: No relevant financial relationship exists.

3 Talk Overview Objective: Define a likely future for stroke rehabilitation from onset to recovery Acceleration of current stroke systems and response Based on products which are currently being developed, but not yet mainstream Extension of current theoretical constructs

4 Imagine You are 30 years older than you are right now and you have a stroke. It is early in the morning and you realize that you cannot move your right arm or leg, and your tongue feels thick.

5 At Home You ask your telecomputer to call the emergency center for you. While the cardiovascular response squad (CRS) is on their way, you reach into your night stand for the stroke kit. You push the button to start the included stopwatch. Then, you selfinject a cocktail of neuoprotective drugs that your doctor has prescribed based on your high risk discovered during a recent genetic screen 1,2.

6 On the Way The CRS arrive quickly since your address is in their database of highrisk individuals. They administer a mobile scan of your brain to help determine profusion and general stroke type. A doctor at the emergency center reads the mobile results and diagnoses an ischemic stroke. She directs the CRS to give you an injection of advanced clot busting agents.

7 Arrival at EC The doctor, who was expecting you, performs other more detailed scans that reveal the extent of brain involvement. She determines the exact size of the lesion, and through diagnostic electrical testing along the entire motor and sensory path, she pinpoints and marks functional brain areas that are involved using fmri.

8 Recovery Suite Your stroke was severe, but due to the very rapid response, damage was limited. Acute medical management is applied by specially trained nurses. Repeat scans are administered at bedside and read via mobile monitor by your doctor. You still have limited movement in your arm and leg, but your speech is clearing. Once you have stabilized, just hours after your stroke, a therapist enters the room and fits you with robotic limbs and a funny looking hat 3.

9 Brain Computer Interface (BCI)

10 Customized Activities Based on your interests 4, and the brain areas that are involved, you are prescribed specific treatments for walking, leg coordination, and reaching and finger dexterity. Your therapy team and doctor use an evidence based plan to determine exact dosages and intensities.

11 Motor Learning 101 Your therapist spends time educating you. You still cannot move your arm or leg on your own, but with the help of the lightweight robotic exoskeletons, FES, and your magic hat, you are able to move a little. The robots are set to augment and magnify your intended movement. They will decrease their assistance as your movement increases.

12 Activity Monitors The robots have sensors which measure the number of times each joint is moved. They keep count such that every 10 minutes during the day, if you have not moved enough, you are prompted to perform a functional task which you and your therapist agreed upon. You also have sensors on your uninvolved wrist and ankle that communicate with your robotic limbs. If there is too much activity on the sound side, you are prompted to perform the activity with the involved side 5,6.

13 Transition to Recovery Center It has been a long couple of days, but you are now medically stable and ready to begin your recovery in earnest. You are told that you will be occupied with therapy for 6 hours a day 13. Your physical medicine doctor talks to you about your statistical likelihood of recovery based on the national stroke survivor database. Your odds of a full recovery are 70%, and 90% for only minor disability. But it will take a lot of hard work.

14 Tennis, Golf, Bowling, and Strolling On your first day, after 3 hours of evaluation, you roll into a bright green room with no windows and only one door. It is a large room and is green on the ceiling and moveable floor too. There is a robotic box with thin wires stretched tightly between opposite walls that attaches to a harness around your trunk. You have a great deal of freedom. Sometimes you stumble, but you never fall 7,8.

15 VR - Motivation and Learning 9

16 Intensity and Repetition You worked for hours, but the time flew by. You particularly liked walking through the city park with your family member beside you 4. With the help of your robotic limbs and the body weight support, you walked nearly 3 miles or 10,000 steps. You also used your arm to point at objects, pick things up, and swing a golf club nearly 1000 times 10,11.

17 Trans Cranial Magnetic Stimulation You have an hour of therapy remaining. You exit the green room and sit in front of a rounded projection screen with targets to reach and grab. Another funny looking hat is placed on your head. The powerful magnets change the firing potential of your neural cells and help them wire together more easily creating neuroplastic change faster 14.

18 1 Week After CVA Your doctor orders a follow-up fmri and compares functional areas to your baseline. The team uses imaging to correlate your function to your physiologic healing and neruoplastic changes. You are recovering as expected.

19 2.5 Weeks After CVA You are now able to walk without the assistance of your robotic leg exoskeleton, and use your arm for basic tasks including eating. You have performed over 150,000 steps during your 2 week recovery center stay, and 200,00 arm movements. Your major remaining deficits are in your arm and hand. You are headed home tomorrow.

20 Residual Problems Before you leave, implantable muscle and nerve stimulators are injected into your forearm and hand. They communicate with each other wirelessly to augment the motion that you begin to produce. Your therapist will follow your progress and gradually change the firing pattern to match your changing function via wireless device during telemedicine treatments.

21 Telemedicine Your therapist interacts with you 3 times a week and reviews information regarding your movement and your progress toward a full recovery. You also join a recovery club at a local hospital center. There you follow up with your therapist in person twice a week and have 6 hours of intensive reach and grab practice in the magnetic stimulator.

22 3 Months After CVA You have met with your doctor and reviewed your latest fmri scans. Based on that information and a report from your therapists, you are judged to have made a 95% recovery with only minor deficits in your finger dexterity. Your information is entered into the national stroke recovery database.

23 Critical Concepts Contrast with current rehabilitation practices: IP repetitions and approach OP LEAPS Trial

24 Critical Concepts Fast Response Information Exchange Early Rehab Intensity Repetition Task Specificity Error Motivation Telerehabilitation Cost

25 References 1. JF Meschia Subtyping in ischemic stroke genetic research, Seminars in Cerebrovascular Diseases and Stroke, JD Spence Measurement of intima-media thickness, genetic research and evaluation of new therapies, International Journal of Stroke, JJ Daly, et al. Feasibility of a new application of noninvasive brain computer interface: a case study of training for recovery of volitional motor control after stroke. Jour Neurol Phys Ther. 2009; 4: N MacLean, et al. Quality analysis of stroke patients motivation for rehab. BMJ 2000;321: S Mudge, NS Stott, et al. Criterion validity of the StepWatch activity monitor as a measure of walking activity in patients after stroke. Archives of physical medicine and Rehabilitation S Page, et al. Constraint Induced Movement Therapy post stroke. American Journal of Physical Medicine & Rehabilitation: November Volume 81 - Issue 11 - pp DJ. Reinkensmeyer, et al. Robotics, motor learning, and neurologic recovery, Annual Review of Biomedical Engineering 2004 Vol. 6:

26 References Continued 8. D Reisman, et al. Locomotor adaptation on a split-belt treadmill can improve walking symmetry post-stroke; Brain 2007; 130 (7) 9. D. Jack, et al. Virtual reality-enhanced stroke rehabilitation; Neural systems and rehab engineering 2001; G. Kwakkel. Impact of intensity of practice after stroke: Issues for consideration; Disability and rehabilitation; 2006, Vol. 28, No Page SJ: Intensity versus task-specificity after stroke: How important is intensity? Am J Phys Med Rehabil 2003;82: C. Lang, et al. Counting Repetitions: An Observational Study of Outpatient Therapy for People with Hemiparesis Post-Stroke; JNPT D. Jette, et al. Physical Therapy Interventions for Patients With Stroke in Inpatient Rehabilitation Facilities; Physical Therapy E. Khedr, et al. Therapeutic trial of repetitive transcranial magnetic stimulation after acute ischemic stroke; Neurology 2005

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