Interface of Neuromodulation, Rehabilitation and Biomedical Engineering

1. Interface of Neuromodulation, Rehabilitation and Biomedical Engineering 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

2. Health care reform • TeleRehabilitation • Emerging technology • Assistive technology • Advances in neurosciences • Advances in neuroimaging • Neuromodulation NeuroRehabilitation in Transition

3. 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.

4. Common causes of disabilityAccording 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

5. 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

6. Stroke Rehabilitation Outcomes • 80% -Independent Mobility • 70% -Independent Personal Care • 40% -Independent Outside the Home • 30%- Work

7. Stroke is the leading cause of Adult Disability

8. Depressive symptoms • Poor motor function • Ambulation/gait restricted • Verbal expression deficits Cerebrovasc Dis 2009;27:456–464 Burden of Caregivers of People withStroke

9. 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 Timecourse of health-related quality of life as determined3, 6 and 12 months after stroke:Relationship to neurological deficit,disability and depressionJ Neurol (2002) 249 : 1160–1167

10. Post Stroke Impairments: Predictors of Disability • Motor deficits • Hemiplegia • Spasticity • Neglect syndromes • Apraxia • Aphasia • Dysphagia • Depression • Cognition • Dementia • Executive Dysfunction

11. Other Quality of Life Issues • Sexuality • Spirituality • Driving • Employment • Education • Recreation • Family Involvement

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

13. FACT The annual incidence of TBI is more than that of MS, spinal cord injury, HIV/AIDS, and breast cancer COMBINED.

14. 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

15. Pre-injury Function Injury Severity Behavior Changes CognitiveImpairments Sensorimotor Impairments Disabilitysecondary to Traumatic Brain Injury

16. Modified Institute of Medicine Enabling – Disabling Process Person – Environment Interaction The Person Biology Environmental Lifestyle    Disability QOL The Environment social social physical

17. Modified Institute of Medicine Model The Enabling – Disabling Process Transitional Factors Biology Environmental Lifestyle No Disabling Condition  Pathology  Impairment  Functional Limitation Quality of Life

18. The Goals of NeuroRehabilitation • Prevent and Manage ComorbidConditions • 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

19. Body Weight-Supported Treadmill Training • Pedaling • Biofeedback • Electrical Stimulation • Constraint-Induced Muscle Training • Robotic-Assisted Therapeutic Exercise New Activity Based Rehabilitation Interventions

20. Alternative and Augmentative Communication • Environmental Controls • Brain Machine interface • Orthotics/Prosthetics • Neuralprosthesis • Mobility Aids • Exoskeletal systems • Therapeutic aids • Robotics • Virtual reality Assistive Technology

21. Emerging Assistive Technologies

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

23. The provision of therapy at a distance Augmented communication Cognitive rehabilitation Motor/Mobility rehabilitation Vocational rehabilitation Prevention and management of complications TeleRehabilitation

24. Spinal Cord Injury • Pain • Spasticity • Mobility • NeuralModulation • Deep Brain Stimulation • Spinal cord stimulation • Peripheral nerve stimulator • Intrathecal Pumps • rTMS • Functional electrical stimulation • Stroke • Spasticity • Central pain • Mobility • Plasticity? • Traumatic Brain Injury • NeuroBehavior changes • Cognitive changes • Movement disorders • Central Pain • Plasticity? • Headaches

25. The Ohio State University Medical CenterNeuroModulation Center Clinical Programs REHABILITATION SERVICESCognitive behavioral therapyInpatient rehabilitationOutpatient comprehensive rehabilitation Vision rehabilitationAssistive technologyFunctional reconditioningFunctional capacity/vocational rehabilitationWork hardening

26. 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

27. REHABILITATION PROGRAMS AT OSUMC CORE PROGRAMS SPECIALIZED SERVICES Ohio Valley Center for TBI Prevention/Rehab STROKE REHABILITATION PSYCHOLOGY Traumatic Brain Injury NEUROVISIONREHABILITATION ARTHRITIS SPINAL CORD INJURY AMPUTATION METABOLIC BONE PEDIATRIC SEATING/ADAPTIVE EQUIPMENT QUANTITATIVE MOTION ANALYSIS MUSCULOSKELETAL/SPINE/PAIN SCI NEURORECOVERY NETWORK Improve Peoples Lives through… NEUROMODULATION QUANTITATIfiedNEURORECOVERY ASSISTIVETECHNOLOGY • TeleRehabilitation NEW PROGRAMS

28. 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

29. 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

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