Neuroplasticity, also known as brain plasticity, is an umbrella term that describes lasting change to the brain throughout an animal's life course. The term gained prominence in the latter half of the 20th century, when new research showed many aspects of the brain remain changeable (or "plastic") even into adulthood.

1. 3/7/2016
a connected health
solution that helps people
train body and brain
together as ONE system
Alakananda Banerjee
Chairperson
Dharma Foundation of India
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2. The Disability Problem – Is it entirely clinical?
• The number of disabled people worldwide crossed 1 billion in
2012 (WHO Report, 2013)
• The mainstay of treatment is still manual therapy, which is
difficult to scale up to meet the exploding demand
• Therapists do not have any technology in the ward which
shows them what is happening “internally” at brain-muscle
levels while patient is practicing tasks and activities.
• Chronic conditions such as stroke, hypertension, diabetes and
brain injury all lead to mild or severe disability
3/7/2016 2
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How does “ability” affect biology?
• The brain has a fundamental capacity to remap itself
based on conscious and unconscious responses
• Neurons that “fire” together will “wire” together
(Hebb, 1949)
• Repeated patterns of use get imprinted into the
neuro-muscular system
The difficult part is understanding which reactions need to
be activated and inhibited in both the brain and muscle.

4. Neuroplasticity
• CNS structural changes occur because of interaction
between both genetic and environmental factors
• 100 billion neurons constantly lay down new pathways
for neural communication and to rearrange existing ones
throughout life thereby aiding the processes of:-
Learning
Memory and
Adaptation through new experience
(Jacqui Ancliffe, Senior Physio, RPH, WSC)
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Neuroplasticity leads to…..
• Memorizing a new fact
• „Mastering a new skill
• „„Adjusting in a new environment
• „Recovery from brain injuries
• „Overcome cognitive disabilities

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Mechanisms of neural plasticity
• The organism interfacing with its environment(stimulus)
• Experience “enters” the brain by way of afferent inputs
through the sensory modalities.
• These signals are then relayed via established neural
networks to higher cortical areas where a chain of
processes ensure proper disposition of these inputs.

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Concepts of neuroplasticity
1. Enhancement of
existing connections
• Functional plasticity
• Produces short term
functional changes
• Eg:- learning a new
task
1. Formation of new
connections
• Structural plasticity
• Long term
modification of
• Behaviour
• Eg:-skilled actions

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Changes in biology and its effect on
function
Brain led changes…..
• Long term inappropriate use of brain and muscle results in
altered function at neuron and muscle fibre levels resulting in
“plateaus”.
• It thus becomes a self-perpetuated disease.
Spike timing–dependent plasticity (STDP) (Corporale et al, 2008)
Manipulations of sensory experience (Merzenich et al, 1998)
Electrical activity plays crucial roles in the structural and functional refinement of neural circuits
(Gilbert, 1998, Katz & Shatz 1996)

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Changes in biology and its effect on
function
Muscle led changes…..
• Non-use of certain muscles results in tissue contraction,
excessive muscle tone(spasticity), low ROM, joint stiffness
• Excessive use of other muscles as compensation results in
chronic pain and repetitive injury
• Low functional use further reinforces maladaptation and brain
re-mapping
(Taub et al, 1993; Bach-y-Rita, 1990)

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How does “disability” affect biology?
The dark side of neuroplasticity
• Injured or affected joints and muscles alter the “map” within the
brain, diminishes co-ordination of muscles and joints, especially
stabilizers. The result is a less-than-stable platform for the arms
and legs to work from; the person then has to exert a greater
muscular force to achieve the results .In turn leads to earlier
fatigue, decreased performance, injuries or pain.
• Brain injury and trauma in turn may result in muscle disuse in
various body parts, leading to atrophy, tissue contracture ,
spasticity, high tone and a progressive change in fibre type and
quality.
Brain and Muscle affect each other biologically
at every stage of progression of chronic conditions

13. Can we use Physio-Neuro Training to
re-architecture biology via the
“function” route?
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The synergistic neuroplasticity model
Augmented
Feedforward
Augmented
Feedback
Augmented Feedforward
- Audio-video led imagery
Augmented Feedback
- EEG balance feedback
- EMG balance feedback

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Stepping Stones to “Self-Correction”
• Re- map the Brain using movement – disrupt existing
homeostasis
• “Self-correct” muscle tone, synergy, hemispheric activation
• Modify habitual muscle fibre / neuron response
• Re-architecture brain-muscle responses by bringing hitherto
unconscious responses within conscious control
• Reinforce repeatedly and gently till it is imprinted into biology
– achieve new homeostasis
Thus leveraging principles of neuroplasticity
can affect biology at tissue and function levels

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Using wearable technology to
accelerate re-structuring of
function and health
Solving the clinical and socio-economic
problem as parts of
one comprehensive solution

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Long term functional deficits in
Stroke/TBI/Chronic Neuro degeneartive
case
• Patient do not respond to the standard
physiotherapy
• Patient compliance to the home programmes.
• Unavailability of physiotherapy facilities.
• Unavailability of caregivers/inadequate or unsafe
transport facilities to accompany patient to
rehabilitation.

18. What is SynPhNe?
A wearable, portable, connected device that trains the
brain and body as ONE system
– Accelerates recovery
– Provides new insights to therapist
– Reduces therapist time
– Is affordable to own or rent
– Is easier on the caregiver
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How does SynPhNe work?
• Muscle activation and inhibition trained together, always
tracking ratios
• Maps brain response in terms of symmetry, relaxation,
alertness, inter-hemispheric inhibition
• Training of brain and muscle occurs in a time-locked, Hebbian
manner through “self-correction”
• Use of feed forward along with real-time feedback
• Simple User Interface using cartoon characters aids process by
reducing attention demands

20. Exercises, Tasks
 Warm Ups – 20 min
 5 reps each warm up
 Task Practice – 20 min
 5 - 10 reps each task
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21. Set Up
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22. EEG Cap and EMG Glove
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23. A randomized 20-subject clinical trial of
the SynPhNe stroke rehabilitation
system on hemiplegic stroke patients to
improve recovery of hand function after
stroke.
Collaboration Study between Max Super Speciality Hospital,Saket, New
Delhi and Nanyang Technical University, Singapore
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24. Study Objectives
• Primary objectives
– To compare clinical motor outcomes achieved using
Synphne system (treatment group) with standard clinical
care delivered by therapist (control group)
– To study effect sizes in treatment group over a 18 session
(6 week) treatment period
• Secondary objectives
– To assess pain and discomfort levels before and after
therapy session in treatment group
– To assess ease of use, enjoyment, usefullness of Synphne
system in treatment group
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25. Subject Demographics
• To establish applicability and feasibility in a wide
subject base, no restrictions were placed on location,
type of stroke, months post-stroke, gender or age.
• Subjects were allocated to treatment and control
group alternatively on first-come basis as they were
recruited/referred.
• Synphne system was installed in the therapy centre
so that it was in same environment as standard care
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Subject Demographics – Treatment
Subject Age Gender
Months/Days
post CVA
Nature of
Stroke
Side of
Stroke
Affected
limb
Location
MLH003 28 F 48 months Haemorrhage Right Left Haemorrhage - Others
MLH006 53 F 8 months Infarct Right Left Infarct - Lacunar Stroke
MLH008 76 F 10 months Infarct Left Left Infarct - Lacunar Stroke
MLH009 51 M 5 months Infarct Right Left Rt Bg And Rt Periventricural Infarct
MLH014 67 M 7 days Infarct Right Left Haemorrhage - Basal Ganglia / Thalamus/subcortical
MRH005 29 M 53 months Haemorrhage Left Right Haemorrhage - Others
MRH013 30 F 18 months Infarct Left Right Left Mca Territory In Fronto-Partietal
MRH015 75 M 22 months Infarct Left Right Lt Mca Infarct With Ganglinoc Capsular
MRH016 60 M 1 month Haemorrhage Left Right Basal Ganglia / Thalamus/subcortical
MRH017 30 M 12 months Infarct Left Right Partial Anterior Circulation Stroke
MRH019 58 M 20 months Haemorrhage Left Right Infarct - Lacunar Stroke
MRH020 66 M 15 days Infarct Left Right Infarct - Partial Anterior Circulation Stroke
MLH021 60 M 3 months Infarct Right Left Infarct - Total Anterior Circulation Stroke
MRH022 74 M 35 days Haemorrhage Left Right Haemorrhage - Basal Ganglia / Thalamus/subcortical
MLH023 43 M 16 months Infarct Right Left Infarct - Partial Anterior Circulation Stroke

27. Subject Demographics - Control
Subject Age Gender
Months/Days
post CVA
Nature of
Stroke
Side of
Stroke
Affected
limb
N
o
Location
MCG002 63 M
4 days
Left Right First
MRI could not be done due to nailing in femur and
left hand
MCG003 53 M 4 days Infarct Right Left FirstPartial Anterior Circulation Stroke
MCG005 72 M 45 days Infarct Left Right FirstPosterior Circulation Stroke
MCG006 65 M 3 days Infarct Left Right FirstBasal Gangalia
MCG007 65 F 6 months Infarct Right Left RecurrentTotal Anterior Circulation Stroke
MCG008 30 F 24 months Infarct Right Left FirstTotal Anterior Circulation Stroke
MCG009 74 F 45 days Infarct Left Right FirstPartial Anterior Circulation Stroke
MCG010 46 M 5 months Haemorrhage Left Right FirstBasal Ganglia / Thalamus/subcortical
MCG011 61 M 30 days Infarct Left Right FirstPartial Anterior Circulation Stroke
MCG012 67 M 20 months Both Left Right Recurrent
For Infarct:Partial Anterior Circulation Stroke
For Haemorrhage:Basal Ganglia /
Thalamus/subcortical
MCG013 48 M 4 months Haemorrhage Left Right FirstBasal Ganglia / Thalamus/subcortical
MCG014 60 M 15 days Infarct Right Left FirstPartial Anterior Circulation Stroke
MCG015 71 M 10 days Infarct Right Left FirstPartial Anterior Circulation Stroke
MCG016 74 M 3 days Infarct Left Right FirstInfarct in Left Corona Radiata
MCG017 41 M 15 days Infarct Left Right FirstPartial Anterior Circulation Stroke
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Pre-Study Demographics Comparison
Group Gender Age
(yrs)
Post CVA
(months)
FMA ARAT Grip
strength
9 Hole
Peg Test
Treatment 11 male 53 14.5 39.13 23.27 2.447 79.12
4 female 6 cannot
attempt
Control 12 male 59 4.34 44.87 30.60 5.482 84.10
3 female 5 cannot
attempt
• In general, the control group subjects were found to be a higher functioning
group when compared to treatment group prior to start of study.
• The control group was also on average significantly early after stroke
(average 4.34 months) as compared to treatment group (average 14.5
months).

29. Outcomes Comparison
X axis – Subjects 1-15
Y axis - % improvement at Week 3 wrt
Week 0 baseline assessment score
Although control group subjects started
out as higher functioning individuals at
Week 0 assessment, we find from the
plot and two-tailed t-test that
percentage improvements in both
groups were not significantly different
for FMA (Fugl-Meyer Assessment of
Motor Recovery after Stroke) and ARAT
(Action Research Arm Test) scales.
We used FMA to understand “gross
movement” and ARAT to assess
Activities of Daily Living; Coordination;
Dexterity; Upper Extremity Function “
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30. Outcomes Comparison
X axis – Subjects 1-15
Y axis - % improvement at Week 3
wrt Week 0 assessment score
We find from the two-tailed t-test
that percentage improvements in
both groups were significantly
different for Grip Strength
(although may be attributed to an
outlier) and 9 Hole Peg Test scales
(could be attributed to more
chronic and severe subjects in
treatment group).
We used Grip Strength Assessment
to asses “strength” and 9 Hole Peg
Test to assess “dexterity”.
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31. Outcomes based on International
Classification of Functioning(ICF)
0
10
20
30
40
50
60
70
Treatment Group
Control Group
0
20
40
60
80
100
120
Treatment Group
Control Group
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32. ICF Outcomes
0
10
20
30
40
50
60
70
80
Mental function
of sequencing
complex
movements
Seeing
functions
Proprioceptive
function
Touch function sensory of pain Mobility of joint
functions
Muscle power
functions
Muscle tone
functions
Control of
voluntary
movement
functions
IMPROVEMENTS IN ICF CODES FOR “FUNCTION”
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33. ICF Outcomes
0
20
40
60
80
100
120
Carrying out
daily routine
Lifting and
carrying
objects
Fine hand
use
Hand and
arm us
Driving Washing
oneself
Caring for
body parts
Toileting Dressing Eating Drinking
IMPROVEMENTS IN ICF CODES FOR “ACTIVITY”
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34. Patient satisfaction
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