Interface of Neuromodulation, Rehabilitation and Biomedical Engineering

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Neuromodulation and Rehabilitation: Overview

W. Jerry Mysiw, M.D.Bert C. Wiley Chair of Physical Medicine and Rehabilitation

Chairman, Department of Physical Medicine and Rehabilitation

The Ohio State University

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Health care reform TeleRehabilitation

Emerging technology Assistive technology

Advances in neurosciences

Advances in neuroimaging

Neuromodulation

Disability Statistics

Almost one-third of Americans entering the work force today (3 in 10) will become disabled before they retire.

Over 51 million Americans - 18% of the population - classify themselves as fully or partially disabled.

8 million disabled wage earners, over 5% of U.S. workers, were receiving Social Security Disability (SSDI) benefits at the conclusion of June, 2010.

In June of 2010, there were nearly 2.5 million disabled workers in their 20s, 30s, and 40s receiving SSDI benefits.

Common causes of disability

According to CDA’s 2010 Long-Term Disability Claims Review the following are the leading causes of new disability claims in 2009:

Musculoskeletal/connective tissue disorders caused 26.2% Nervous System-Related disorders caused 13.7% Cardiovascular/circulatory disorders caused 13.1%Cancer was the 4th leading cause of new disability claims at 8.4%.

Approximately 90% of disabilities are caused by illnesses

rather than accidents. Neurological disorders consume over one

third of the global chronic disease health burden

Stroke Related Disability Stroke is a leading cause of adult disability in the

US. Data from GCNKSS/NINDS studies show that

about 795,000 people suffer a new or recurrent stroke each year. About 610,000 of these are first attacks

About 6,400,000 stroke survivors are alive today In 2010, stroke will cost the US $73.7 billion in

health care services, medications, and lost productivity.

With timely treatment, the risk of death and disability from stroke can be lowered.

Early poststroke complications deprive patients of approximately 2 years of optimum health. Greater numbers of complications are associated with greater loss of healthy life-years.

CDC; AHA

Stroke Rehabilitation Outcomes

80% -Independent Mobility 70% -Independent Personal Care 40% -Independent Outside the Home 30%- Work

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Stroke is the leading cause of Adult Disability

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Depressive symptoms

Poor motor function

Ambulation/gait restricted

Verbal expression deficits Cerebrovasc Dis 2009;27:456–464

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One year after stroke/TIA, 66% of patients reported a worsening of life satisfaction compared with the prestroke level. The SF-36 physical component

summary was reduced throughout the observation period.

The SF-36 mental component summary deteriorated between the 6-and 12-months follow-up

The SF-36 domains “physical functioning” and “social functioning” deteriorate between 6 and 12 months post stroke

Neurological status and the degree of disability remained stable

Post Stroke Impairments: Predictors of Disability Motor deficits

Hemiplegia Spasticity

Neglect syndromes Apraxia Aphasia Dysphagia Depression Cognition

Dementia Executive Dysfunction

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Other Quality of Life Issues

Sexuality Spirituality Driving Employment Education Recreation Family Involvement

January 2005Slide 12

TBI in the United States

An estimated 1.4 million people sustain a TBI annually; of these: 50,000 die 235,000 are hospitalized 1.1 million are treated and released from an ED

The number reported with TBI underestimates the magnitude of the problem because the following are not included: TBIs treated by private physicians Individuals who did not seek medical care

FACTThe annual

incidence of TBI is

more than that of MS, spinal cord

injury, HIV/AIDS, and breast

cancer

COMBINED.

TBI as Chronic Illness(the “Silent Epidemic”) 80,000-90,000 new TBI survivors experience onset of long-

term disability annually About 1 in 4 adults with TBI is unable to return to work 1 year

after injury 5.3 million Americans (2% of U.S. population) currently live

with TBI-related disabilities Based on hospitalized survivors only

65% of costs are accrued among TBI survivors Annual acute care and rehab costs of TBI = $9 - $10 billion * Estimated annual lifetime costs of TBI survivors in year 2000 =

$60 billion *** NIH Consensus Development Panel on Rehabilitation, 1999

** Finkelstein E, Corso P, Miller T, et al. The Incidence and Economic Burden of Injuries. New York,

Oxford Univ Press, 2006

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Sensorimotor

Impairm

ents

Pre-injury

Function Injury S

everit

y

Disability secondary to

Traumatic Brain Injury

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Modified Institute of Medicine Enabling – Disabling Process

Person – Environment Interaction

The Person

Environmental Lifestyle

Biology

The Environment

social

Disability

socialphysical

QOL

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Modified Institute of Medicine Model The Enabling – Disabling Process

Transitional Factors

Biology

Environmental Lifestyle

No Disabling Condition Pathology Impairment Functional Limitation

Quality of Life

The Goals of NeuroRehabilitation

Prevent and Manage Comorbid Conditions Decrease impairment Maximize Functional Independence Stabilize mood and self regulation

impairments Optimize Psychosocial Adaptation Facilitate Resumption of Prior Life Roles and

Community Reintegration Enhance Quality of Life Decrease costs and need for long term care

Body Weight-Supported Treadmill Training

Pedaling

Biofeedback

Electrical Stimulation

Constraint-Induced Muscle Training

Robotic-Assisted Therapeutic Exercise

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Alternative and Augmentative Communication

Environmental Controls Brain Machine interface Orthotics/Prosthetics

Neuralprosthesis

Mobility Aids Exoskeletal systems

Therapeutic aids Robotics Virtual reality

Emerging Assistive Technologies

Exoskeleton Robotic Applications in Rehabilitation Populations ‘Forced Application of Technology’ EWJ

TeleRehabilitationThe provision of therapy at a distance Augmented communication Cognitive rehabilitation Motor/Mobility rehabilitation Vocational rehabilitation Prevention and management of complications

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Spinal Cord Injury•Pain•Spasticity•Mobility

Stroke•Spasticity•Central pain•Mobility•Plasticity?

Traumatic Brain Injury•NeuroBehavior changes•Cognitive changes•Movement disorders•Central Pain•Plasticity?•Headaches

NeuralModulation•Deep Brain Stimulation•Spinal cord stimulation•Peripheral nerve stimulator•Intrathecal Pumps•rTMS•Functional electrical stimulation

The Ohio State University Medical CenterNeuroModulation Center Clinical Programs

REHABILITATION SERVICESCognitive behavioral therapy

Inpatient rehabilitationOutpatient comprehensive rehabilitation

Vision rehabilitationAssistive technology

Functional reconditioningFunctional capacity/vocational rehabilitation

Work hardening

OSU Center for Neuromodulation:Multidisciplinary Practitioners

The neuromodulation program involves multiple specialties at OSU and provides comprehensive and holistic care of disabled patients.

– Neurosurgeon– Neurologists– Psychiatrist– Psychologists– Physical Medicine and Rehabilitation (OT, PT, RT, Speech, Gait)– Pain Management– Neuro-radiology– Biomedical engineering– Neuroscientists– Ethicists– Social workers

ImprovePeoples Lives through…

NEW PROGRAMS

CORE PROGRAMS SPECIALIZED SERVICES

REHABILITATION PROGRAMS AT OSUMC

ARTHRITIS AMPUTATION

SPINAL CORD INJURY

STROKE

NEUROMODULATION

ASSISTIVE TECHNOLOGY

MUSCULOSKELETAL/SPINE/PAIN

PEDIATRICSEATING/ADAPTIVE EQUIPMENT

METABOLIC BONE

SCI NEURORECOVERY NETWORK

Ohio Valley Center for TBI Prevention/Rehab

REHABILITATION PSYCHOLOGY

NEUROVISION REHABILITATION

QUANTITATIVE MOTION ANALYSIS

QUANTITATIfied NEURORECOVERY

•TeleRehabilitation

Traumatic Brain Injury

OSUMC Center for Neuromodulation Chronic Disabilities Initiative

In-patient and out-patient Home based therapeutic exercise program Vocational rehabilitation, recreational therapy

Physical, speech, occupational therapy Rehabilitation psychology Case management

Gait therapy with quantitative motion analysis and body weight support therapy

Assistive technologies

Summary

NeuroRehabilitation is an important transition Healthcare reform Advances in Neuroscience New neuroimaging techniques

New modalities on horizon Neuromodulation Assistive Technology

The new modalities are complements not replacements for the work of therapists and other clinicians

 

Creating the future of medicine to improve people's lives through personalized health care