demystifying neuroplasticity
TRANSCRIPT
05/01/2023
a connected health solution that helps people train body and brain together as ONE system
Alakananda BanerjeeChairperson
Dharma Foundation of India
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05/01/2023 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
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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.
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:-
LearningMemory 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
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.
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
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
EEG Cap and EMG GloveTM
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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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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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 GenderMonths/Days
post CVANature of
StrokeSide of Stroke
Affected limb
No
Location
MLH003 28 F 48 months Haemorrhage Right Left FirstHaemorrhage - Others MLH006 53 F 8 months Infarct Right Left FirstInfarct - Lacunar Stroke MLH008 76 F 10 months Infarct Left Left FirstInfarct - Lacunar Stroke MLH009 51 M 5 months Infarct Right Left FirstRt Bg And Rt Periventricural Infarct MLH014 67 M 7 days Infarct Right Left FirstHaemorrhage - Basal Ganglia / Thalamus/subcortical MRH005 29 M 53 months Haemorrhage Left Right FirstHaemorrhage - Others MRH013 30 F 18 months Infarct Left Right FirstLeft Mca Territory In Fronto-Partietal MRH015 75 M 22 months Infarct Left Right FirstLt Mca Infarct With Ganglinoc Capsular MRH016 60 M 1 month Haemorrhage Left Right FirstBasal Ganglia / Thalamus/subcorticalMRH017 30 M 12 months Infarct Left Right FirstPartial Anterior Circulation StrokeMRH019 58 M 20 months Haemorrhage Left Right FirstInfarct - Lacunar StrokeMRH020 66 M 15 days Infarct Left Right FirstInfarct - Partial Anterior Circulation StrokeMLH021 60 M 3 months Infarct Right Left FirstInfarct - Total Anterior Circulation StrokeMRH022 74 M 35 days Haemorrhage Left Right FirstHaemorrhage - Basal Ganglia / Thalamus/subcorticalMLH023 43 M 16 months Infarct Right Left FirstInfarct - Partial Anterior Circulation Stroke
Subject Demographics - ControlSubject Age Gender
Months/Days post CVA
Nature of Stroke
Side of Stroke
Affected limb
No
Location
MCG002 63 M4 days
Left Right FirstMRI 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 StrokeMCG006 65 M 3 days Infarct Left Right FirstBasal GangaliaMCG007 65 F 6 months Infarct Right Left RecurrentTotal Anterior Circulation StrokeMCG008 30 F 24 months Infarct Right Left FirstTotal Anterior Circulation StrokeMCG009 74 F 45 days Infarct Left Right FirstPartial Anterior Circulation StrokeMCG010 46 M 5 months Haemorrhage Left Right FirstBasal Ganglia / Thalamus/subcorticalMCG011 61 M 30 days Infarct Left Right FirstPartial Anterior Circulation Stroke
MCG012 67 M 20 months Both Left Right RecurrentFor Infarct:Partial Anterior Circulation StrokeFor Haemorrhage:Basal Ganglia / Thalamus/subcortical
MCG013 48 M 4 months Haemorrhage Left Right FirstBasal Ganglia / Thalamus/subcorticalMCG014 60 M 15 days Infarct Right Left FirstPartial Anterior Circulation StrokeMCG015 71 M 10 days Infarct Right Left FirstPartial Anterior Circulation StrokeMCG016 74 M 3 days Infarct Left Right FirstInfarct in Left Corona RadiataMCG017 41 M 15 days Infarct Left Right FirstPartial Anterior Circulation Stroke
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Pre-Study Demographics ComparisonGroup 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).
Outcomes ComparisonX axis – Subjects 1-15Y 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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Outcomes ComparisonX 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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Outcomes based on International Classification of Functioning(ICF)
Mental
function of s
equen
cing c
omplex m
ovemen
ts
Seeing F
untions
Proprio
ceptive
function
Touch
function
sensory
of pain
Mobility o
f joint fu
nctions
Muscle p
ower functions
Muscle t
one functi
ons
Control o
f voluntar
y move
ment fu
nctions0
1020304050607080
Treatment GroupControl Group
Carryin
g out d
aily ro
utine
Lifting a
nd carry
ing objec
ts
Fine h
and use
Hand an
d arm us
Driving
Washing o
neself
Caring f
or body p
arts
Toileti
ng
Dressin
gEati
ng
Drinkin
g0
20
40
60
80
100
120
Treatment GroupControl Group
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ICF Outcomes
Mental
function of s
equen
cing c
omplex m
ovemen
ts
Seeing f
unctions
Proprio
ceptive
function
Touch
function
sensory
of pain
Mobility o
f joint fu
nctions
Muscle p
ower functions
Muscle t
one functi
ons
Control o
f voluntar
y move
ment fu
nctions0
1020304050607080
IMPROVEMENTS IN ICF CODES FOR “FUNCTION”
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ICF Outcomes
0
20
40
60
80
100
120
IMPROVEMENTS IN ICF CODES FOR “ACTIVITY”
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Patient satisfaction TM