Using wearable biofeedback technology

to undo unconscious habits which

restrict recovery from

disorders and disability

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The Side of NeuroplasticityDr. Subhasis Banerji

Is all neuroplasticity positive?

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Good adaptations

Not so good adaptations

No adaptations

Not so bad adaptations

Bad adaptations

You assume you are here!

Adaptations

UnconsciousConscious

Unconscious Electricalresponses

Actions Choices Habits Experiences

Plasticity led learning and structural change Backward Bicycle

Neuroplasticity

• CNS structural changes occur because of interactionbetween biological and environmental factors

• 100 billion neurons constantly lay down new pathwaysfor neural communication and to rearrange existing onesthroughout life thereby aiding the processes of:-

Learning

Memory

Adaptation

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Popular knowledge says 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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The dark side of neuroplasticity leads to…..

• Forgetting a fact

• „ Deterioration of a skill

• „„ Mal-adjusting in a new environment

• „ Ingraining disability after brain injuries

• „ Reinforcement through adaptation of cognitive disabilities

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Mechanisms of neural plasticity

• First documented in Development Biology (Smith & Gasser, 1985)

• The organism interfacing with its environment(stimulus)

• “Experience” enters the brain by way of afferent inputsthrough the sensory modalities.

• These signals are then relayed via neural networks tohigher cortical areas.

• Cortical areas respond with efferent responses affectingmuscle, thus recreating “Experience”!

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General ApproachTM

General approach…

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What people want…TM

Low immediate relevance

Emotional mismatch

Resistance

Disengagement – Brain/Muscle

Changes in function and its effect on biology

Brain led changes on the dark side…..

• Long term inappropriate use (learned behaviour) of brain and muscle results in altered function at neuron and muscle fibrelevels resulting in “plateaus”.

• It thus becomes a self-perpetuated disease.

• It can be “unlearned”.

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 function and its effect on biology

Muscle led changes on the dark side…..

• 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

• Musculoskeletal overuse-underuse yo-yo is learned behaviourembedded in the brain not by evolution but by experience.

• Can be “unlearned” by bringing attention to muscle

(Taub et al, 1993; Bach-y-Rita, 1990)

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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) – whether we consciously intend it to or not!

• Such repeated patterns of firing get imprinted into the neuro-muscular system

• At a fundamental level, these patterns are electrical-like in nature.

The difficult part is understanding which reactions need to be activated and inhibited in both the brain and muscle.

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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

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Can we use Physio-Neuro Training to re-architecture biology (and health) 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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The SynPhNe neuroplasticity modelTM

The SynPhNe Effect

Stepping Stones to “Self-Correction”

• Re- map the Brain using movement – disrupt existing homeostasis

• “Self-correct” muscle tone, synergy, hemispheric activation depending on personalized starting point

• Modify habitual muscle fibre / neuron response simultaneously

• 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

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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 spent on a patient

– Is affordable to own or rent

– Reduces fatigue and pain

– Is easy to deliver by home caregiver

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Exercises, Tasks

Warm Ups – 20 min

5 reps each warm up

Task Practice – 20 min

5 - 10 reps each task

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Set UpTM

Muscle self-correction Sess 3

Muscle self-correction Sess 12

Spatio-temporal training

A randomized 30-subject clinical trial of the SynPhNe system on hemiplegic

stroke patients to improve recovery of hand function after stroke.

Collaboration Study between Max Super Speciality Hospital, New Delhi and Nanyang Technical University, Singapore

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Singapore Trials - Recovery depends significantly on Relaxation & Inhibition

Association of muscle contraction, relaxation and number of repetitions

The number of repetitions performed successfully is dependent on muscle relaxation as much as on muscle contraction.

79% of subjects showed positive changes in ARAT.60% of subjects showed positive changes in Box and Block Test.

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Outcomes Comparison

X axis – Subjects 1-15Y axis - % improvement at Week 3 wrtWeek 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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Outcomes Comparison

X axis – Subjects 1-15Y 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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ICF Outcomes

0

10

20

30

40

50

60

70

80

Mental functionof sequencing

complexmovements

Seeingfunctions

Proprioceptivefunction

Touch function sensory of pain Mobility of jointfunctions

Muscle powerfunctions

Muscle tonefunctions

Control ofvoluntary

movementfunctions

IMPROVEMENTS IN ICF CODES FOR “FUNCTION”

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ICF Outcomes

0

20

40

60

80

100

120

Carrying outdaily routine

Lifting andcarryingobjects

Fine handuse

Hand andarm us

Driving Washingoneself

Caring forbody parts

Toileting Dressing Eating Drinking

IMPROVEMENTS IN ICF CODES FOR “ACTIVITY”

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Percentage change in Treatment Group

We consider overall improvement above 5% wrt starting baseline to be clinically

relevant. (ref)These are supported by the ICF scores on the Problem Solving Form.

MRH016 223

MRH022 203.6

MRH017 214.5

MLH009 82.13

MLH021 86.34

MLH014 79.99

MRH015 66.07

MRH005 30.26

MRH020 30.26

MLH023 28.15

MRH019 13.8

MLH008 8.251

MRH013 3.355

MLH006 2.84

MLH003 -7.78

>40% OVERALL IMPROVEMENT

40%>% OVERALL IMPROVEMENT>5%

% OVERALL IMPROVEMENT< 5%

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Patient satisfaction TM

Enhancing Quality of Life

SynPhNe Wireless SENSORS:

Internal environmentEEG – 8 Brain acticityEMG – 8 Muscle activityHRV Heart tracking

External environmentTemp Room tempHumidity Room humidityDecibel level Surrounding noiseAccelerometer Posture, Tremor Gyroscope Posture,

Orientation changesSELF REPORTS:

Pain – Sw/mobileFatigue, Nausea, Discomfort - SwFunction, Activity, Ease of Use -mobile

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SynPhNe – The wearable, connected health solution that trains brain and muscle as ONE system.

New Wireless Version for Home UseTM

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How does SynPhNe work?

• Muscle activation and inhibition trained together

• Maps brain response in terms of symmetry, relaxation,alertness, inter-hemispheric inhibition

• Training of brain and muscle occurs in a time-locked, Hebbianmanner (“wire together”) through “self-correction”

• Use of feed forward (imitation) along with real-time feedback

• Simple User Interface using cartoon characters aids process byreducing attention demands

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Long term functional deficits in Chronic Neuro-degenerative cases

• Patient do not respond to the standard physiotherapy

• Patient compliance to home exercises is poor.

• Unavailability of physiotherapy facilities.

• Unavailability of caregivers, inadequate/unsafe transport facilities to accompany patient to rehabilitation.

• Access and affordability

• Heightened fatigue and persistent pain

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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 Synphnesystem in treatment group

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Subject Demographics – Treatment

Subject Age GenderMonths/Days

post CVA

Nature of

Stroke

Side of

Stroke

Affected

limbLocation

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

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Subject Demographics - Control

Subject Age GenderMonths/Days

post CVA

Nature of

Stroke

Side of

Stroke

Affected

limb

N

oLocation

MCG002 63 M4 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 cannotattempt

• In general, the control group subjects were found to be a higher functioninggroup 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 14.5months).

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AssessmentThe Quality of Upper Extremity Skills Test (QUEST)

• This measure evaluates quality of upper extremity function in four domains: dissociated movement, grasp, protective extension, and weight bearing.

• It is designed to be used with children who have neuromotor dysfunction with spasticity and has been validated with children from 18 months to 8 years of age

• Measures % of disability (of all four domains)

http://informahealthcare.com/doi/abs/10.1080/J006v13n02_01

• QUEST on 4/2/2015- 53.5%

Assessment Nine Hole Peg Test

• This test was originally introduced in 1971 as part of a study on strength and dexterity. (Kellor, Frost, Silberberg, Iversen, & Cummings).

• The Nine-Hole Peg Test (9HPT) is used to measure finger dexterity in patients with various neurological diagnoses

• Intended Population :Patients with Stroke, Brain Injury, Parkinson's Disease, cerebral palsy, multiple sclerosis

• Measures in seconds

4/2/2015 : RIGHT SIDE - 143 SEC

International Classification of Functioning

icf(1).xlsx

The WHO-ICF codes were used to assess and track progress in Activity and Participation using the Problem Solving Form (PSF) as per Steiner (2009).

Cerebral Palsy

• Caused due to oxygen starvation/stroke in the womb

• Caused during childbirth

• Symptoms more pronounced as child grows

Case Study

Personal history

• Patient name : XYZ

• Age/Sex : 6 year/Male

• Right hand dominant

• Diagnosis :Mild cerebral palsy; Static Encephalopathy

• History

– Full term caesarean delivery

– Neonatal jaundice

– Seizure- 2 times, one- 3years of age, one- last year

Medical History

• Botox injection given in both lower limbs – twice

• On medication:

• Syndopa plus

• Valporate

MRI Findings

• Bilateral focal abnormalities in the thalamus and internal capsule, most likely sequelae of perinatal

hypoxic ischemic encephalopathy.

Complains

• Difficulty in bed mobility

• Dependent in daily living activities

• Difficulty in using both hand (eating and drinking)

Ongoing Rehab

• Had 22 sessions of Neuro Feedback (Cognitive) Training at Department of Neuropsychology, NIMHANS Bangalore (alpha/theta training)

• Patients attends regular physical and occupational therapy.

Using SynPhNe….

Target to improve difficulty in using right (dominant) hand for eating and drinking.

Manipulating numbers on a mobile phone keypad

Assessment

Tone (Modified Ashworth Scale)Right Left

Hand N NWrist Flexor 1 1Elbow Flexor 1 1Shoulder 0 1Hip Flexor 1+ 2Hip Add. 2 2Hams 2 2TA 3 3

Assessment

Voluntary control Right Left

Shoulder Good Good

Elbow Good Good

Hand Good Good

Hip Fair Fair

Knee Fair Fair

Ankle Poor-fair Poor

Patient response: Slow to initiation of movement

Assessment

Hand functionGross motor

GRIP and release - PRESENT (RT>LT)Object transfer- present (rt>lt)

Fine motorTip to tip- partial present (fair)Pad to pad- poorManipulation- poorThree jaw chuck- poor

Bowel and bladder- sensation present

Spinal disability- none

Outcomes – Clinical Scales

QUEST ( Quality of Upper Extremity Skill Test)

53.5%

58.5%

51

52

53

54

55

56

57

58

59

pre(04/02/2015) post (27/02/2015)

IQ changed from 72 to 102

right left right left

pre(04/02/2015) post (27/02/2015)

143Sec

170Sec 116

Sec

153Sec

NINE HOLE PEG TEST

Video after

•Difficulty in speaking

•Weakness in both arm and leg

•Abnormal movement in both arm and leg

•Difficulty in bed mobility

•Dependent in daily living activities

•Difficulty in using both hand

•Cant go to school independently

•Difficulty in reading/writing

•Unable to sit and stand independently

•Articulation- b320.2

•Basic cognitive function- b163.1

•Muscle power function-b730.2

•Control of voluntary movement

function- b760.1

•Copying- d130.2•Changing basic body position-d410.3•Maintaining body position- d415.2•Caring of body part- d520.2•Dressing-d540.2•Eating -d550.2• drinking--d560.2

•Right hand dominance ,cooperative

Cerebral palsy

•Fine hand use- d440.2 (holding a pen, using mobile phone, flipping a card)•Hand and arm use-d445.2(holding ,lifting, transfer and release)•Writing- d170.3•Reading- d166.3

Xyz

6 year

Botox injection Given last month1 4/2

•High living condition (over protection)- (e315.-2) •Immediate family support-(e310.+4)•Health professionals e355 +4

•Difficulty in speaking

•Weakness in both arm and leg

•Abnormal movement in both arm and leg

•Difficulty in bed mobility

•Dependent in daily living activities

•Difficulty in using both hand

•Cant go to school independently

•Difficulty in reading/writing

•Unable to sit and stand independently

•Difficulty in grasping

Articulation- b320.2

•Basic cognitive function- b163.1

•Muscle power function-b730.2

•Control of voluntary movement

function- b760.1

•Copying- d130.2• Changing basic body position-d410.3•Maintaining body position- d415.2•Caring of body part- d520.2•Dressing-d540.2•Eating -d550.2• drinking--d560.2

•Right hand dominance, cooperative

Cerebral palsy

•Fine hand use- d440.2(holding a pen, using mobile phone,flipping a card)•Hand and arm use-d445.2(holding ,lifting, transfer and release)•Writing- d170.3•Reading- d166.3

Xyz

6 year

Botox injection Given last month1 4/2

•High living condition (over protection)- (e315.-2) •Immediate family support-(e310.+4)•Health professionals e355 +4