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
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 Health care reform
 TeleRehabilitation
 Emerging technology
 Assistive technology
 Advances in neurosciences
 Advances in neuroimaging
 Neuromodulation
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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
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
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Post Stroke Impairments:
Predictors of Disability
 Motor deficits
 Hemiplegia
 Spasticity
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Neglect syndromes
Apraxia
Aphasia
Dysphagia
Depression
Cognition
 Dementia
 Executive Dysfunction
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Other Quality of Life Issues
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Sexuality
Spirituality
Driving
Employment
Education
Recreation
Family Involvement
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
January 2005
Slide 12
FACT
The 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 longterm 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
Disability
secondary to
Traumatic Brain Injury
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Modified Institute of Medicine Enabling – Disabling Process
Person – Environment Interaction
The Person
Biology
Environmental


Lifestyle

QOL
The Environment
social
physical social
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Disability
Modified Institute of Medicine Model
The Enabling – Disabling Process
Transitional Factors
Biology
Environmental
Lifestyle
No Disabling Condition  Pathology  Impairment  Functional Limitation
Quality of Life
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The Goals of NeuroRehabilitation
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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
 Alternative and Augmentative
Communication
 Environmental Controls
 Brain Machine interface
 Orthotics/Prosthetics
 Neuralprosthesis
 Mobility Aids
 Exoskeletal systems
 Therapeutic aids
 Robotics
 Virtual reality
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Emerging Assistive Technologies
Exoskeleton Robotic Applications in
Rehabilitation Populations
‘Forced Application of Technology’ EWJ
TeleRehabilitation
The provision of therapy at a distance
 Augmented communication
 Cognitive rehabilitation
 Motor/Mobility rehabilitation
 Vocational rehabilitation
 Prevention and management of complications
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
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NeuralModulation
•Deep Brain Stimulation
•Spinal cord stimulation
•Peripheral nerve stimulator
•Intrathecal Pumps
•rTMS
•Functional electrical stimulation
The Ohio State University Medical Center
NeuroModulation Center Clinical Programs
Physical Medicine and
Rehabilitation
-neurobehavior changes
-spasticity/paralysis
-chronic low back pain
-neuropathic pain
-central pain
-headache
Psychiatry
-OCD
-depression
Neurological Surgery
-deep brain stimulation
-intrathecal pump
-spinal cord stimulator
-peripheral nerve stimulator
REHABILITATION SERVICES
Cognitive behavioral therapy
Inpatient rehabilitation
Outpatient comprehensive rehabilitation
Vision rehabilitation
Assistive technology
Functional reconditioning
Functional capacity/vocational rehabilitation
Work hardening
Neurology
-Parkinson
- tremors
-pain
-spasticity
OSU Center for Neuromodulation:
Multidisciplinary Practitioners
The neuromodulation program involves multiple specialties at OSU and provides
comprehensive and holistic care of disabled patients.
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Neurosurgeon
Neurologists
Psychiatrist
Psychologists
Physical Medicine and Rehabilitation (OT, PT, RT, Speech, Gait)
Pain Management
Neuro-radiology
Biomedical engineering
Neuroscientists
Ethicists
Social workers
REHABILITATION PROGRAMS AT OSUMC
CORE PROGRAMS
STROKE
SPECIALIZED SERVICES
Ohio Valley Center for TBI Prevention/Rehab
REHABILITATION PSYCHOLOGY
Traumatic Brain Injury
NEUROVISION REHABILITATION
ARTHRITIS
AMPUTATION
METABOLIC BONE
SPINAL CORD INJURY
PEDIATRIC
SEATING/ADAPTIVE EQUIPMENT
QUANTITATIVE MOTION ANALYSIS
MUSCULOSKELETAL/SPINE/PAIN
SCI NEURORECOVERY NETWORK
Improve
Peoples
Lives through…
NEUROMODULATION
QUANTITATIfied NEURORECOVERY
ASSISTIVE TECHNOLOGY
•TeleRehabilitation
NEW PROGRAMS
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