Presented by Brad Aiken Doctor and science-fiction writer Brad Aiken presents on new and upcoming technologies in neurological rehabilitation. Topics include breakthrough advances that can help people recover from stroke, brain injury, and spinal cord injury. Current, cutting-edge technologies will be discussed, as well as likely upcoming advances in this field.

2. Past, Present, & Future
Neurological Rehabilitation

3. Neurological Rehabilitation
Helping people to regain functional independence
from disability caused by injuries or diseases
effecting the nervous system

4. Neurological Rehabilitation

5. Neurological Rehabilitation
PARALYSIS DUE TO:
STROKE
TRAUMATIC BRAIN INJURY
SPINAL CORD INJURY

6. Neurological Rehabilitation
Past to Present
 Traditional Approaches to Rehabilitation
 Two basic approaches
 Teach compensatory techniques
 Promote neurological recovery

7. Neurological Rehabilitation
 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

8. Neurological Rehabilitation
 Traditional Approaches to Rehabilitation
 Promote neurological recovery
 Traditional – Neuromuscular Facilitation
 EMS (Electrical Muscle Stimulation)
 Vibration
 Biofeedback
 PNF (Proprioceptive Neuromuscular Facilitation)
 NDT (Neuro Developmental Training)

9. Neurological Rehabilitation
 Traditional Inpatient Rehabilitation

10. Neurological Rehabilitation
 Traditional Inpatient Rehabilitation
 Coordinated Team Approach

11. Neurological Rehabilitation
 Physical Therapy
 Exercise
 Strength

12. Neurological Rehabilitation
 Physical Therapy
 Exercise
 Endurance

13. Neurological Rehabilitation
 Physical Therapy
 Transfer Training
 Gait Training

14. Neurological Rehabilitation
 Speech Therapy
 Communication
 Swallowing

15. Neurological Rehabilitation
 Occupational Therapy
 ADL
 Cooking

16. Neurological Rehabilitation
 Occupational Therapy
 ADL
 Bathing

17. Neurological Rehabilitation
 Occupational Therapy
 ADL
 Dressing

18. Neurological Rehabilitation
 Recreational therapy

19. Neurological Rehabilitation
 Rehab Nursing
 Traditional nursing
 Carry-over of skills
learned in therapy

20. Neurological Rehabilitation
 Psychology
 Coping
 Motivation
 Nurturing

21. Neurological Rehabilitation
 Psychology
 Motivation
 Coaxing

22. Neurological Rehabilitation
 Social work
 Emotional support
 Family and
discharge planning

23. Neurological Rehabilitation
 New trends in Stroke Rehabilitation
 Increased emphasis on treatment techniques and technology
to promote neurological recovery

24. 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

25. Advances in NeuroRehab
 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

26. Advances in NeuroRehab
 Techniques for Demonstrating Neurologic
Recovery
 fMRI (functional MRI)

27. Stroke
Cortical activation with hand
tapping one month after R MCA
stroke (Feydy)

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

29. 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

30. Advances in NeuroRehab
These techniques are showing that cortical
restructuring is taking place in the brain in
response to the treatment we provide
[ Neuroplasticity ]

31. Advances in NeuroRehab
 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

32. Advances in NeuroRehab
 New techniques to promote neuroplasticity
 Therapeutic robotics
 Functional Electrical Stimulation (FES)

33. Advances in NeuroRehab
 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

34. Advances in NeuroRehab
 New Technologies in Rehab
 Therapeutic Robotics
 works by repetitive motion training

35. Advances in NeuroRehab
 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

36. Advances in NeuroRehab
RIC ARM Guide:
 passive and active-assisted
reaching on a linear track

37. Advances in NeuroRehab
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

38. Advances in NeuroRehab
MIT Manus
http://www.youtube.com/watch?v=hvnXY5ZirjI

39. Advances in NeuroRehab
ReoGo
Video Interface
Monitors Progress
Adjustable:
speed
force
amount of asst

40. Advances in NeuroRehab
Palo Alto MIME
Motion:
 preprogrammed
 mirrored motion of the
unaffected limb

41. Advances in NeuroRehab
RUPERT (Robotic Upper
Extremity Repetitive
Therapy) – Arizona State
University
 wearable
 pneumatic muscles to
assist Sh/Elb/Hand
motion
 Repetitive exercise to
mimic natural motion

42. Advances in NeuroRehab
Lokomat system

43. Advances in NeuroRehab
AutoAmbulator

44. Advances in NeuroRehab
MIT AnkleBot

45. Advances in NeuroRehab
 New Technologies in Rehab
 Therapeutic Robotics
 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)

46. Advances in NeuroRehab
 New Technologies in Rehab
 Therapeutic Robotics
 Cons
 very expensive
 Limited availability out of the research setting, but this is
beginning to change

47. Advances in NeuroRehab
 Functional Electrical Stimulation (FES)
 Using electricity to activate paralyzed muscles in
order to mimic the normal function of those muscles

48. Advances in NeuroRehab
 Functional Electrical Stimulation (FES)
 Surface electrodes
 Requires stronger shock
 Implanted electrodes
 Requires an invasive procedure
 Risk of infection or rejection

49. Advances in NeuroRehab
 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

50. Advances in NeuroRehab
Functional Electrical
Stimulation
Bioness L300
Walk Aide

51. Advances in NeuroRehab
Bioness L300
http://www.youtube.com/watch?v=p16pFcHMyVM

52. Contralaterally Controlled Functional
Electrical Stimulation Training
JS Knutson, PhD, John Chae, MD Metrohealth, Cleveland

53. CCFES Functional Training
http://www.youtube.com/watch?v=54QF3Pnqp5k
JS Knutson, PhD, John Chae, MD Metrohealth, Cleveland

54. CCFES Before and After
http://www.youtube.com/watch?v=boz0HQXQhKg
JS Knutson, PhD, John Chae, MD Metrohealth, Cleveland

55. Advances in NeuroRehab
 EXOSKELETAL DEVICES
 ReWalk
 Sit to stand
 Stand to sit
 Walk
 Stairs

56. Advances in NeuroRehab
http://www.youtube.com/watch?v=gQRQs-N-ZIM

57. Advances in NeuroRehab
 Exoskeletal Devices
 ReWalk
 Now available for personal use throughout Europe
 Awaiting FDA approval for personal use in US

58. Advances in NeuroRehab
 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

59. Advances in NeuroRehab
 Exoskeletal Devices
 eLEGS– Berkeley Bionics (now called Ekso from Ekso Bionics)
 Variable speed gait

60. Advances in NeuroRehab
 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)

61. Advances in NeuroRehab
 Exoskeletal Devices
 Rex (New Zealand)
 Joy-stick control
 “walking wheelchair”
 “walking standing-table”

62. Advances in NeuroRehab
 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)

63. Advances in NeuroRehab
 Brain - Computer Interface

64. Advances in NeuroRehab
 Brain - Computer Interface
http://www.youtube.com/watch?v=DJvlX-f5a28

65. Advances in NeuroRehab
 Brain - Computer Interface
 3D control of a robotic arm
http://www.youtube.com/watch?v=QRt8QCx3
BCo&feature=player_detailpage

66. Advances in NeuroRehab
 Brain - Computer Interface
 3D control of a robotic arm
http://www.youtube.com/watch?v=QRt8QCx3BCo

67. Advances in NeuroRehab
Future
Directions

68. Advances in NeuroRehab
Future 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

69. Advances in NeuroRehab
Future Directions
 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

70. Advances in NeuroRehab
Future Directions
 Brain - Computer Interface
 Improvement in software to more precisely replicate
normal muscle movements (natural motion)
 Internal Power Source

71. Advances in NeuroRehab
Future Directions
 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

72. Advances in NeuroRehab
Future Directions
 Functional Electrical Stimulation (FES)
 Current studies use only a few stimulators over
key muscles
 For fine motor control, we’ll need multiple
stimulators throughout the body.
 Small enough and made from the right
materials to minimize rejection
 Self powered

73. Advances in NeuroRehab
Future Directions
Goal:
Regain control of the body using only thought
waves to move the arms and legs

74. Advances in NeuroRehab
Future Directions
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

75. Advances in NeuroRehab
Future Directions
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.

76. Advances in NeuroRehab
Future Directions
 Exoskeletal devices
 Lighter, more compact
 Nanofiber suit

77. What might a nanofiber suit look
like?

78. What might a nanofiber suit look
like?

79. Take off the mask, add some clothes,
and you’ll blend right in

81. We’re Only Limited by Our Imagination
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