NR Times speaks to Stephanie Clarke, physician and Professor Emeritus at the Faculty of Biology and Medicine in Lausanne, about the current state of neuro-rehab research and care.
With rapid advancements in technology over the last few decades, the potential of robotics, virtual reality and new brain research is transforming care approaches for patients in neuro-rehab.
Equally, considering individual needs and characteristics, such as motivation, psychological, and spiritual needs, as well as using real-world evidence and micro-level studies, can inform new and personalised rehabilitation pathways.
Here, Stephanie Clarke, a member of the World Federation for Neurorehabilitation’s (WFNR) Task Force which focuses on the global burden of neuro-rehab, speaks to NR Times about the current state of care and research.
Can you tell us about the WFNR and the work of your Task Force?
The WFNR is a Federation of national societies which are involved in different aspects of neuro-rehab. Every two years we hold a World Congress to give an update on established rehabilitation strategies, provide teaching courses for younger people, and hold talks about translational research, explaining what is in the pipeline.
For instance, there are new advances in behaviour interventions, there are contributions of neuroimaging, understanding what’s happening in the brain when we do rehab and how we can use it for patients.
Brain stimulation is also something which is in the pipeline, and then there are robotic approaches. Some of them are in clinical practice, but some of them are really in between research wise.
In what ways are robotics being applied to this field?
Today, you can have robotics which help patients to train. For example, walking robots, which help patients to walk, train their gait, or retrain arm movements. Then you have robotics which help people to become independent. For example, an exoskeleton which supports somebody who has lost muscular function to a certain degree, taking the weight off the leg so that the patient can walk.
However, you can also have very sophisticated robots, where you make an interface with the brain which can help paralytic patients walk again.
These robots use brain signals to drive implants in the spinal cord so that the patients can start walking again. This is a fascinating field at the moment, but it cannot be applied to every patient – patients are selected who have the best chance of succeeding.
Stephanie Clarke
How is virtual reality being applied in neuro-rehab?
VR allows us to train a lot more functions. In the real world, it’s less motivating, but with VR, you can make it more attractive. You can also change visual motor perception in VR in a very conformed way and you can improve certain aspects like tension.
There is a condition called Left Neglect, where patients do not pay attention to things on the left side. In VR, you can shift the visual world for a while, you can reorganise the brain so that they are able to pay attention to the things on the left. This was previously done with glasses which deviate, but now we can start doing this with VR as it is much more adaptable to clinical practice.
What are the challenges of applying these technologies in clinical practice?
There are some issues however, as, in medicine, you need clinical trials that are randomised and controlled to show that this approach is better than the control. In neuro-rehab, and especially for cognitive functions, it’s very critical for some patients, but for others, the evidence is not convincing.
For example, with Left Neglect, when some approaches are run in clinical trials they are not convincing. We have started to look at why this could be by looking into the brain mechanisms.
We found that when you expose patients to this visual motor deviation, you make them adapt, you change brain organisation so that they can use a compensatory system in the brain for further attention.
Now, there are patients in whom this compensatory system is preserved and there are others where it’s damaged as well. It’s logical then, that this therapeutic approach cannot help the people whose compensatory system is damaged.
There are other examples where there are patients who will respond to a treatment and those who don’t, and because of these negative results in clinical trials, a whole series of treatments would be thrown away and patients will not be able to benefit from them.
This is a very important message for the industry because when they start a treatment, they of course would like to present it as something miraculous, which will work for a large number of patients, but they need to make sure they understand who the responders and non responders are otherwise clinical trials which will be done afterwards may be negative.
Are there any advancements in neuroimaging that could potentially improve the area of neuro-rehab?
There are two types of studies in patients. With motor function for instance, we know how it works in normal subjects or what is activated if I do these movements with my hand, or when I speak or when I read, and so on. This is reorganised in the patients.
One type of study is understanding of how this normal functioning breaks down with specific regions and how the deficits reflect in this reorganisation. The next is understanding what is the best prognosis if a patient has, for instance, left hemispheric lesion and he has problems with speech and language. Some patients will recover and some don’t.
Now, these are studies which help us to understand recovery and brain plasticity. In individual patients, there is a limited use of functional imaging. There are a few conditions in which we know that the recovery will not take place because the critical structures which could help with the recovery have been destroyed. Instead of engaging in two weeks of rehabilitation, there is a possibility to do good brain imaging to know that the reason is sometimes functional, and to see if some aspects of cognitive function have been disturbed.
Some patients don’t recover because there are very critical lesions, and in these patients, it is worthwhile to start other types of communication so that they can get used to it, and use it with their families. We can work on better compensation instead of trying to rehabilitate something which will not come.
Other aspects that brain imaging helps with is personalised medicine, or precision medicine. This comes to neurorehabilitation with the imaging data, which gives a very precise history of the patient. We can design a rehabilitation pathway for this specific patient. Brain imaging contributes a lot to that.
I think that precision rehabilitation is something which we need to consider, and very likely it will be pushed even further with cellular, perhaps even molecular indicators. For the moment, this is basic translational research, but in oncology, for instance, you have huge examples.
In what other way can neuro-rehab patients be supported?
It is very important that all the needs of the patients are included, like the retraining of the specific functions, but also the psychological and spiritual needs of the patients.
Usually these patients face a huge loss of what their life was before, and even if they recover, it’s not complete. How they deal with it is not only a question for neuro-rehab, but for all big problems, such as cancer, for instance.
I think it’s very important that patients can draw on all resources.
I would like to express my admiration for patients and their families because it’s a very difficult time for them, life changing and myself and my colleagues are always extremely impressed by how they take it.
Stephanie Clarke is physician, Professor Emeritus at the Faculty of Biology and Medicine in Lausanne. As former Head of the Neuropsychology and Neurorehabilitation Clinic at the University Hospital, Lausanne, Switzerland, she was closely
involved in neurorehabilitation to in- and outpatients in post-acute and chronic stages of brain lesions, with particular emphasis to neuropsychological rehabilitation and speech therapy.
