The Side of Neuroplasticity Dr. Subhasis Banerji Using - - PowerPoint PPT Presentation

Using wearable biofeedback technology to undo unconscious habits which restrict recovery from disorders and disability

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The Side of Neuroplasticity

• Dr. Subhasis Banerji

Is all neuroplasticity positive?

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TM Good adaptations Not so good adaptations No adaptations Not so bad adaptations Bad adaptations You assume you are here! Adaptations Unconscious Conscious Unconscious Electrical responses Actions Choices Habits Experiences Plasticity led learning and structural change Backward Bicycle

Neuroplasticity

• CNS structural changes occur because of interaction

between biological 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 Adaptation

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Popular knowledge says neuroplasticity leads to…..

• Memorizing a new fact
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Mastering a new skill

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Adjusting in a new environment

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Recovery from brain injuries

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Overcome cognitive disabilities

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The dark side of neuroplasticity leads to…..

• Forgetting a fact
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Deterioration of a skill

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Mal-adjusting in a new environment

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Ingraining disability after brain injuries

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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 inputs

through the sensory modalities.

• These signals are then relayed via neural networks to

higher cortical areas.

• Cortical areas respond with efferent responses affecting

muscle, thus recreating “Experience”!

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General Approach

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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 fibre levels 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 behaviour

embedded 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

• r 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 model

TM 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 Up

TM 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

• f 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 1-15 Y axis - % improvement at Week 3 wrt Week 0 baseline assessment score Although control group subjects started

• ut 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 “ TM

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

• utlier) 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”. TM

ICF Outcomes

10 20 30 40 50 60 70 80 Mental function

• f 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” TM

ICF Outcomes

20 40 60 80 100 120 Carrying out daily routine Lifting and carrying

• bjects

Fine hand use Hand and arm us Driving Washing

• neself

Caring for body parts Toileting Dressing Eating Drinking

IMPROVEMENTS IN ICF CODES FOR “ACTIVITY” TM

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 environment EEG – 8 Brain acticity EMG – 8 Muscle activity HRV Heart tracking External environment Temp Room temp Humidity Room humidity Decibel level Surrounding noise Accelerometer Posture, Tremor Gyroscope Posture, Orientation changes SELF REPORTS: Pain – Sw/mobile Fatigue, Nausea, Discomfort - Sw Function, Activity, Ease of Use -mobile TM

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

New Wireless Version for Home Use

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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, Hebbian

manner (“wire together”) through “self-correction”

• Use of feed forward (imitation) along with real-time feedback
• Simple User Interface using cartoon characters aids process by

reducing 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 Synphne system in treatment group

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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

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Subject Demographics - Control

Subject Age Gender Months/Days post CVA Nature of Stroke Side of Stroke Affected limb N

• Location

MCG002 63 M 4 days Left Right F MRI could not be done due to nailing in femur and left hand MCG003 53 M 4 days Infarct Right Left F Partial Anterior Circulation Stroke MCG005 72 M 45 days Infarct Left Right F Posterior Circulation Stroke MCG006 65 M 3 days Infarct Left Right F Basal Gangalia MCG007 65 F 6 months Infarct Right Left R Total Anterior Circulation Stroke MCG008 30 F 24 months Infarct Right Left F Total Anterior Circulation Stroke MCG009 74 F 45 days Infarct Left Right F Partial Anterior Circulation Stroke MCG010 46 M 5 months Haemorrhage Left Right F Basal Ganglia / Thalamus/subcortical MCG011 61 M 30 days Infarct Left Right F Partial Anterior Circulation Stroke MCG012 67 M 20 months Both Left Right R For Infarct:Partial Anterior Circulation Stroke For Haemorrhage:Basal Ganglia / Thalamus/subcortical MCG013 48 M 4 months Haemorrhage Left Right F Basal Ganglia / Thalamus/subcortical MCG014 60 M 15 days Infarct Right Left F Partial Anterior Circulation Stroke MCG015 71 M 10 days Infarct Right Left F Partial Anterior Circulation Stroke MCG016 74 M 3 days Infarct Left Right F Infarct in Left Corona Radiata MCG017 41 M 15 days Infarct Left Right F Partial 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). TM

Assessment

The 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 N Wrist Flexor 1 1 Elbow Flexor 1 1 Shoulder 0 1 Hip Flexor 1+ 2 Hip Add. 2 2 Hams 2 2 TA 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 function Gross motor GRIP and release - PRESENT (RT>LT) Object transfer- present (rt>lt) Fine motor Tip to tip- partial present (fair) Pad to pad- poor Manipulation- poor Three 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)

143 Sec 170 Sec 116 Sec 153 Sec

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 month 1 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 month 1 4/2

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