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Neuro rehab technology

New horizons in spinal tech



The power of exoskeletons was shown to the world earlier this year when Simon Kindleysides became the first paralysed man to complete the London Marathon on 

Simon (pictured) was paralysed from the waist down due to an inoperable brain tumour. Thanks to an exoskeleton, and sheer perseverance, he crossed the line after 36 hours.

This follows the epic, 17-day London Marathon feat completed by Claire Lomas,
 a paralysed 32-year-old, in a bionic suite in 2012.

Such positive displays of technology’s role in overcoming adversity are music to
 the ears of Jon Graham, clinical director of PhysioFunction.

While Simon is a client of
 his Northamptonshire firm and received vital support from it in his marathon bid, Graham is also a passionate advocate for exoskeletons generally.

In fact, as a global expert in both neurological physio and rehab technology, he is a keen supporter of any devices that boost independence and recovery.

This partly comes from a former life in
 the computer industry, which included investigations into artificial intelligence and its relevance to medical diagnostics.

Today Graham works closely with technology firms, bridging the gap between the lab and 
client sessions.

“People read about stories like Simon’s and still think these technologies are in the research stage, but they are commercially available in centres, so it’s just about getting the word out,” he says.

Graham is a well-placed guide through current and emerging technologies for 
the spinally injured. His company stocks exoskeletons and numerous other devices fresh from the world’s brightest innovators.

Graham, meanwhile, has been pioneering new tech in this field for over 15 years.

Exoskeletons, perhaps the most promising innovation for people with spinal cord injuries, can loosely be put into two categories.

There are hands-free models, controlled via a joypad/stick, that can be driven by the carer or, with minimal effort,
by the user, effectively serving as a walking wheelchair.

Secondly, are the models which require a walking aid such as elbow crutches to supplement balance. In the latter category, upper limb power is used to move from a sitting to a standing positon and to maintain balance.

Access to exoskeletons in the UK is almost entirely provided by the private sector – a fact Graham is eager to change.

Working closely with an exoskeleton manufacturer, he is in ongoing talks with several NHS rehabilitation services about potentially trialling exoskeletons, specifically the hands-free variety.

Technology companies are also regularly demoing their exo products to NHS trusts, but a major breakthrough is yet to happen.

Unlike private individuals,
 who may buy an exoskeleton because of the functionality it gives them at home and in
life generally, NHS buyers have much stricter conditions.

“For the NHS to buy into exoskeletons, they have to see how much they contribute to rehabilitation. If our patient has one of these, can we treat them with less physios, or shorten their hospital stay because the device is providing a therapy that we can’t provide? That is the case that needs to be proven for the NHS to invest.

“They won’t replace physios – they are an adjunct that helps the physio. It is the physio’s clinical reasoning and what the physio does with the robot, that leads to rehabilitation.

“However, in the rehab environment, when used by skilled therapists, it can allow you to do treatments that you just can’t do safely with therapists alone.
 The machines take a lot of the strain of the lifting and moving. So not only are you using less physios, but the physios you are using are less exposed to physical risk.

“The NHS needs to see that these devices will free up staff, protect staff and potentially reduce inpatient stays because they produce therapy goals earlier. It’s chicken and egg
 as they need to see that proven before they buy one – but they can’t do so until someone makes that first investment.

“If we can get these questions answered, 
then the doors will open because suddenly 
it doesn’t seem like a daunting cost as it will save money in the long run.”

The training burden of exoskeletons on staff is another possible concern of NHS purchasers. A study into this very issue, at Moseley Hall Hospital in Birmingham, delivered positive results, says Graham.

“Their three-month audit looked at how easy it was to train members of staff to use the exoskeleton and it was very successful.”

The resistance of the NHS to exoskeletons
– currently only available publicly in 
Sheffield as far as Graham is aware – may soften over time.

The ballpark price range 
for exoskeletons is £84,000 to £120,000,
 with models having an estimated five-year lifespan.

The cost of exoskeletons prevents most spinally injured people from buying them outright. 
Individuals not funded by a compensation pay-out, crowdfunding campaign or considerable personal wealth can, however, access regular exoskeleton sessions through providers such as Graham’s.

“People sometimes just come to the clinic to have a chance to walk so you can access them relatively inexpensively on a regular basis in the same way you may go to a gym.

“It changes your life. Psychologically you are back on your feet and you are communicating with other people on an eye-to-eye level. Time and again users tell us, the walking is great but, for a husband being able to look at his wife at eye level again, for example, it is something else.

“Tall men with that physical presence in particular seem to suffer with being in a chair. They get a huge boost being back at their original stature.”

Pain relief is also a pull factor.
 “A client described their neuropathic pain
 to me as feeling like his feet were being crushed, stung with stinging nettles and

on fire all at the same time.

“People don’t know where to put themselves with that 
sort of pain. Medication that gets on top
 of it can wipe people out to the point
 where they are not functional. They have to balance the medication so that they are just very uncomfortable but can still have a conversation.

“By enabling the limbs to move around, the exoskeleton seems to reduce the pain. The information relayed in the nervous system, because the limbs are moving, seems to dampen down the pain.”

Graham recognises that exoskeletons have much room for improvement.

“When Simon did the London Marathon, it took two days. The suit couldn’t go any faster – it was doing about a mile every 45 minutes, compared to normal walking speed of one every 12 to 15 minutes. Speed is still an issue. We’ve found that they can get across pedestrian crossings but it means going from the moment they turn green and finishing at the 
flashing amber.”

Cost reduction will also be key in broadening the appeal of exoskeletons.

“As more people have them, that could create the economy of scale that brings the price down. Also, with the development of 3D printing, the manufacturing costs could come down. Pressing and moulding is quite an expensive process. If you could print it, prices may come down, especially with experiments currently going on around printing with alloys rather than plastic.”

The dawn of so-called ‘smart materials’, meanwhile, could take exoskeleton manufacturing in a completely different direction. Think Batman’s cape – the dark, modern version, not Adam West’s 60s silk. When an electric current is applied, it stiffens, enabling the caped crusader to soar high over Gotham.

The same principle could shape the development of exoskeletons, says Graham. “If you had a jump suit, you could pass current through the front of it to stand the user
 up. You could then alternate the current to different parts, mimicking human muscles by tensing and relaxing.”

The quantum leap for exoskeletons is to swap controls for raw brain power. Being able to think ‘stand up’ or ‘walk’ and then have the exoskeleton respond accordingly is already possible, albeit in a somewhat cumbersome way.

Graham caught a glimpse of how transformative this brain-machine interface could be on a trip to a robotics conference in Rome two years ago. He introduced a client to developers from Texas who had melded exoskeletal and brain sensor technologies.

“The guy we took out was ventilated and
 had virtually no activity. He could just about balance his head on his shoulders. Yet by thinking about walking he was able to control the exoskeleton. He said ‘this is the first time since my injury I’ve thought ‘walk’ and I’ve actually walked and moved through my environment’.

The challenge ahead is in making the technology more user-friendly. The set-up
 for the brain-powered device in Rome took around 40 minutes, involving a skull cap and the careful injection of gel at 46 points for optimum brain monitoring.

“Once fitted, the computer took only a few minutes to tune into the user’s brainwaves. Streamlining 
this whole process will be pivotal to the development of exoskeleton technology.

“There is quite a lot of eye-gaze technology where eye movements are picked up, but you really have to work your eyes, which can tire them out. Whereas, if it’s just thought, it’s
the most natural thing in the world. This is something that’s going to come.

“The big development is going to be technology that picks up brainwaves in a really light touch kind of way. It could be just a headband or something like Google glasses. I also think, with all the devices, we’ll see the development of motors and sensors that allow them to work without balancing aids.

“So, they are walking/balancing suits. Running is probably a long way off but the next five years could see better brain controls emerge.”

Graham believes video games, bolstered by Hollywood-eclipsing budgets, will speed the development of such technologies.
“I think this will come from the gaming industry, which has phenomenal budgets,” he says.

“What limits a lot of people in terms of gaming is the lack of manual dexterity to use controllers. If the gaming industry could develop something whereby a person could slip something onto their head and control the game by thinking, that would open up amazing things in the medical industry, as well as in gaming.”

The gaming industry has already heavily influenced the virtual reality (VR) systems used in rehab centres.

“There is immersive VR, where you put on head goggles and feel like you are in a certain environment. This can be expensive and may cause people to feel nauseous afterwards.

“At the other end, there is VR where your body movements are replayed back to you on a screen in a computer-created environment. The Xbox Kinect is a good example of this from a domestic point of view.”

The modern history of this tie-up between mainstream gaming and rehab perhaps dates back to the 2006 launch of the Nintendo Wii.

While other consoles had made tentative attempts at it, this was the first mass-market console to truly put physical motion at the heart of its games.

Shifting weight on the Wii balance board and rapid arm movements with the controllers, made avatars run, ski, shoot and swing.

The result, aside from massive profits for Nintendo and a global spate of living room injuries, was increased interest from the rehab community in home gaming. Things have moved on since then, but old challenges remain.

“The problem with the Wii was that the games were all designed for able-bodied individuals and were too fast for many disabled users. Also, it was too easy to cheat, for example by moving your arms up and down instead
of actually running on the spot as you were supposed to.

“The biggest problem was that you couldn’t tie movement to success in the game, and therefore positive feedback for the individual, because they were designed for abled bodied individuals.”

Although recently discontinued by Microsoft as a home gaming product, the Xbox Kinect remains “a really powerful device that picks up body segment movements,” says Graham.

“Software is being added to make rehabilitation games work for potentially severely disabled individuals. They link success with tiny body movements, which allows the brain to start relearning. If the brain gets positive feedback, chemicals are released that help with neuro-plasticity.”

On access to VR technology generally, he adds: “The future of immersive VR depends on the cost of headsets and sensor gloves coming down. That would make the technology more widely available and could be a game changer. People could then start using it in an inpatient environment even earlier.

“You could have somebody in a hospital bed with the headset and gloves, picking up the tiniest movements.”

An emerging trend is using VR systems in the home, with physiotherapists in remote contact with clients, monitoring their performance.

“It’s like having your own physiotherapist at home – we can dial in with Skype to see the screen and the patient and carry out tele-rehabilitation.”

Particularly relevant to neuro-rehab is MindMotion, a gamified VR system developed by neuroscientists, neurologists and therapists for rehabilitation specialists.

It provides a large variety of engaging gamified activities that therapists can calibrate and customise to individual patient needs or abilities.

It brings together innovative virtual environments and novel neuro-rehab gaming content to engage and motivate patients in both the clinic and at home.

Each activity 
is designed to train a specific movement to reach a therapeutic goal for hand, arm, trunk or lower limb impairment.

Movements such as reaching, grasping, pointing, moving and manipulating virtual objects in functional tasks (as recommended by NICE guidelines for stroke rehab, for example) are featured on the platform. Meanwhile, the longer-term future of spinal injury treatment could be dominated by implanted technology.

“The future of spinal injury tech will be implanted electrical units,” says Graham. “Stem cell studies seem to have ground to a halt, whereas interest in electrical implants seems to be increasing.”

News from university campuses around the world certainly suggests the development
 of electrical implants is gathering pace.

In February, the University of British Columbia proved that electrical implants could be used to o set the invisible but debilitating effects of spinal injury.

Isaac Darrel, injured in a diving accident, found that epidural stimulation via surgically implanted electrodes was able to control his usually fluctuating blood pressure.

Problems with bladder and bowel function were also alleviated.

Last October, the University of Louisville’s Kentucky Spinal Cord Injury Research Center credited their spinal cord epidural stimulation (scES) technique with helping to restore voluntary movement in a paralysed man’s legs.

Many other similar stories have been shared with the world in recent years, although the technology remains experimental. Graham is encouraged by what he sees and believes current technologies could pave the way for implanted treatments ahead of their eventual breakthrough.

“If electrical implant technology is 10 to 15 years from being available, then to have an exoskeleton now allows your body to be conditioned to be able to take advantage of that future technology.”

This will be particularly beneficial for young children unfortunate enough to suffer serious injury in their early years, Graham believes.

Exoskeleton suits for spinally injured children are currently in development, representing a major improvement on tradition devices
like callipers. They help to get young users on their feet, therefore giving them the weight bearing activity needed to develop ball and socket joints naturally.

“It means that those young people with spinal cord injuries now will have normal hip joints to allow them to walk in 15 or so years when the electrical technology is totally developed and has become an outpatient procedure.

“Exoskeletons may disappear at some point because we’ve replaced them with electrical implants which do the work of the spinal 
cord that isn’t being done due to the injury.

“That said, some spinal cord injuries are so catastrophic, for example when soldiers 
get shot in the back and have obliterated so much nervous material that potentially even electrical devices aren’t going to be able to bridge that gap. So perhaps there will always be a case for exoskeletons.”

Aside from exoskeletons and VR, lesser spotted technologies are helping the spinally injured to recover – and could actually prevent spinal injuries.

Balance training, delivered through a machine called the Balance Tutor, enables users to prepare for those slips, trips and falls that cause and intensify injuries.

“The cost of people falling to the NHS is £2bn per year, making it the single biggest dent
in its finances. We need to learn to react to unexpected events that cause falls.”

Falls are also the cause of 30 to 40 per cent of all spinal cord injuries – according to various studies. This is a rising number in the UK, a nation with an increasingly active, ageing population. Graham’s is the only clinic in
 the UK with a Balance Tutor machine.

his clients it is a rehab tool which can also prevent escalating problems for people with spinal injuries, and other conditions including neurological diseases and stroke.

He also believes it could be used to help people who are vulnerable to a fall, perhaps as they age, to steel themselves against potential accidents.

“It’s like riding on the tube, standing without
 a handrail when it’s throwing you about a bit. The treadmill changes direction, forcing you to balance as the belt moves backwards and forwards, or the motion platform it’s mounted on moves left and right.”

With users in a safety harness, the device recreates what physios call ‘perturbations’ – those unforeseen changes and threats; a wet kitchen floor or an icy pavement, for example.

“If someone had an incomplete spinal cord injury, on their feet their biggest fear is falling or losing balance. The typical therapy approach is to throw and catch balls with the client on the treadmill, push and shove them or stand them on a board that rocks.

“But that is all cortically driven. It all comes from the brain trying not to fall over. You are reacting to expected events and that’s different neuro-circuitry from learning to cope with an unexpected event.

“We use it for people with spinal cord
injury and stroke, who are walking but not necessarily functioning at the level they could be because of their fear of losing balance.”

It also serves sports people with ligament injuries and people with chronic back pain who need to retrain tiny back muscles via very small perturbations on the device.
 But Graham sees much wider scope for the technology, and is hopeful of proving its worth, through pilot schemes, to the NHS.

“We think this device in an NHS environment could make a massive difference to that £2bn-a-year falls cost.

“Everyone who has their first fall could go to 
a fall centre and use this device to re-educate their balance, and protect them from a second fall. Or you could have a screening process where, when you’re 65, your GP tests your balance.

“Those at risk of their first fall could then have a number of sessions on
 this device to pep up their balance to reduce that risk. If you save a few hundred million, that’s money available for exoskeletons and everyday NHS care.”

Graham hopes a privately funded pilot will generate the results needed for a full-scale feasibility test in the NHS.
 With his help, balance trainers and exoskeletons may well be coming to a
 spinal injury ward near you soon.

In the field of high tech equipment and rehabilitation the world opens up to those spinal cord injured clients who have a knowledgeable solicitor and access to funds.

It is astronomically expensive, but it is also an opportunity to make our clients’ rehabilitation the best it can be.

We will help clients, faced with living with a life-changing injury, by providing access to specialist expert professionals and to compensation on
 an interim basis to pay for it.

These specialists will set up a bespoke training programme for clients and let them test out different robotic suits or FES equipment and find their optimal solution.

It takes commitment to work on regular physio and to maximise physical ability, but many of our clients are not just willing but dedicated to that hard work.

One of my current clients wants to use an exoskeleton to be able
to stand in the kitchen and wash up (hands free which he cannot do on crutches).

Others talk about the benefit of being at eye level whether to walk down the aisle for a wedding or to stand in a pub at the bar with mates.

Then there are exceptional people like Claire Lomas out there walking marathons and inspiring SCI people in their hundreds.

It is not just an end in itself to have access to this hugely expensive equipment. It is the physical and psychological benefit 
of knowing you are working your body in an optimal fashion because, as Jon Graham says, who knows what future technology will become available and it is quite clear that the stronger the body, the better the chances are that you can benefit from it.

As their solicitor, we facilitate this rehab and it is an absolute privilege to watch our clients benefit from advances in technology we could not have imagined a decade ago.


Why tech access is a BASIC right

Without a legal case win behind them, people with spinal injuries may find access to the latest rehab tech beyond their means.

Being unemployed, perhaps as a direct result of the injury, makes it especially challenging to benefit from innovative equipment not provided in the NHS.

This is where BASIC, the Brain and Spinal Injury Centre, can step in.

The charity, based in Salford, is home to advanced virtual reality technology which was originally designed for the Israeli army.

Via self-referrals, people with brain and spinal injuries can access it for free, availability pending. BASIC also takes professional referrals at a commercial rate, which helps to fund the ongoing work of the charity.

CEO Wendy Edge says: “Our users have usually been discharged, most don’t have any compensation and the majority don’t have spare resources to pay for care. They may have had to give up their job and be reliant on benefits. We raise funds so that we can cover their rehabilitation.”

And the formula seems to work, even years after the original incident or injury.
“For example, we had two people come to
 us who had had strokes over 30 years ago. They actually made progress, improving their balance and walking, which shows if you put

people in the right environment, because of brain plasticity, it can rewire.”

In 2015, following Wendy’s fact-finding mission to Tel Aviv, BASIC invested around £500,000 in the Computer Assisted Rehabilitation Environment (CAREN) system.

It puts people at the centre of a life-sized video game, forcing them to use atrophied muscles and teaching the basic skills necessary to recover faster from brain and spinal injuries and other disorders.

Movement is analysed in real time, providing immediate feedback to therapists and the patient. Underlying so ware computes body movement in 300 muscle elements.

Ultimately, it offers exposure to physical environments without putting patients in danger.

“It has made a massive difference to people who use it, enabling us to take their recovery much further than we could previously,” says Wendy.

“It puts people in real-world scenarios; they can ski, drive through New York, play rugby or walk through the countryside. All the evidence suggests it speeds up their recovery, and improves their motivation.

“People often disengage from rehab because it’s boring 
or they are depressed but this equipment encourages them to push themselves in
a way they wouldn’t otherwise do in the outside world.”

At the last count, BASIC helped around 
50 people annually to get back into employment through its various services, including the CAREN.

To ensure the impact of the technology doesn’t fade, the charity is challenging PhD students to develop new virtual reality applications for the technology – adding to the 28 existing scenarios it offers.

See more at www.basiccharity.org.uk

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