Podcast | Episode 26: Center for Innovation (Live at AAP in Phoenix)

Tracy Davis:

Welcome to the Brooks Rehabilitation Podcast. My name is Tracy Davis. We have a very special on location episode for you this time. Excited for you to listen to this one. It is about our Center for Innovation. This episode was recorded at the AAP Conference, which is the Association of Academic Physiatrists, which was in Phoenix, Arizona this year. On our panel for the Center for Innovation is Dr. Mark Bowden. He’s a physical therapist and the vice president of clinical integration and research here at Brooks. We have Dr. Kenneth Ngo. He is the medical director of Brooks Rehabilitation Hospital University Campus, and our Center for Innovation. And Robert McIver, he’s a physical therapist and director of our Center for Innovation.

We really appreciate you listening in to this episode. And just a reminder to go to brooksrehab.org to learn all about everything we have going on at Brooks. Follow us on social media @brooksrehab, check out our YouTube channel. We’ve got lots of videos, lots of things for you to discover and find out more about us. We have a lot going on and we really appreciate you listening. So let’s get right into the episode.

Mark Bowden:

Welcome to the Brooks Rehabilitation Podcast. My name is Mark Bowden. I’m the vice president for clinical integration and research at Brooks Rehab, and one of the elements that’s underneath that umbrella is the Center for Innovation. So I’m joined by my colleagues at the Center for Innovation. Do you guys want to introduce yourselves?

Dr. Kenneth Ngo:

Absolutely. Welcome again, I’m Dr. Kenneth Ngo. I’m the medical director for the Brooks Center for Innovation. Clinically, I take care of patient with brain injury and I’m also the medical director for the Brain Injury Program at Brooks. And lastly, because I’ve been there for so long now, almost 15 years at Brooks, I’m also the medical director for Brooks Rehab Hospital in Jacksonville.

Robert McIver:

Well, I’m Bob McIver. I’m the director of the Center for Innovation, also director over our Neuro Recovery centers, which are some advanced community programs utilizing technology to help our patients. I’ve been a clinician for 20-some years at this point. I hate to admit that all the time, but at least there’s no camera on this so nobody can assign that to me. But have a lot of years, a lot of experience with orthopedics, pediatrics, neurologics. I primarily now specialize in neurologic and technology-based applications and rehab.

Mark Bowden:

So our topic for this podcast is really highlighting the Center for Innovation and the idea of moving the science of rehabilitation forward. So how do we do that through innovative practices and the study of technology? So I’m going to open it up for you guys because you’ve been in this space a whole lot longer than I have at Brooks. Give me the history of how this got started and how long you guys been working together and what’s the background?

Robert McIver:

Well, how long have we been working together? We’ve been working together for over 15 years at Brooks. We started the same-

Dr. Kenneth Ngo:

Since my first day of employment.

Robert McIver:

Yeah, met him on the brain injury floor. Really the way that the center of Innovation started is Dr. Ngo and myself would keep getting approached by different technology vendors and patients and having questions and they come up to you and they say, “What did you think of this piece of technology?” Or, “How would you use this?” Or, “Would this be beneficial to you? We’d like to understand what it is you’re trying to do.” And really it turned into years and years of that question coming up over and over from multiple technology vendors and patients alike and even fellow clinicians. And so in the end, we culminated maybe what it was almost five years ago now, about five years ago that we sat down and decided we really needed to make this an option and a thing for Brooks and a thing for us. To create more structure around it so we could create an area where innovative ideas can grow, not just based on technology, but even just policies and ways that we do clinical practice. You want to add?

Dr. Kenneth Ngo:

Yeah. Because of the size of Brooks and the number of patients that we serve, we’re always looking at ways to help patient recover quicker and faster. The patients kind of demand the need to recover quicker. They often say rehab is slow, recovery is slow. And at Brooks we pride ourselves in being innovative, looking for solutions to deliver the quicker, faster recovery. We see the technology plays a big role in that and because of the number of patients that we serve, the innovation arm and the technology arm kind of grew with us. And we are quick to adopt technologies to help care for our patients. And it grew to what it is now. If you want to share where we are with the Center for Innovation and what kind of the future of the center and how it relates to patient care and research.

Mark Bowden:

Sure. I think that part of what they have described thus far, Brooks really became recognized as being a very high adopter of technology and a high user of the most innovative things. But the question that we got lots of times was, “How do we get our product in front of your patient?” And because of all of those requests and the need to really be able to understand how this technology works and how it might be used with other technology near the therapies, we kind of changed our approach. Instead of saying, “We want to be a high user of the technology”, we want to be able to understand it.

And so we started working more in doing more trials with industry sponsored work, answering questions, anything from safety and feasibility, FDA trials, getting them off the ground all the way up to phase three randomized clinical trials. And that has really opened the door more companies to be able to access the knowledge base that Bob and Dr. Ngo and the clinicians at Brooks have been able to offer these companies through the years except now we do it in a very formal project-oriented fashion. Anything you want to add to that, Bob?

Robert McIver:

I was going to say, I think the biggest part of what we also do is everybody wants to be in this, you’re on rehabilitation because you want to help patients, we want to help more patients and more things. And that’s really the whole key behind the Center for Innovation is we have a lot of patients at Brooks. We treat a lot of patients every year. And through the main center, one of the ones that I run, we have 350 unique patients of varying clinical diagnoses. And so for these technology companies, it’s one thing to bring it to us and understand as a clinician what it is that they want. What are they trying to sell you? What are they trying to get you to buy into, put their best practice in front of you. And this is my best patient of course, but with the 350 patients we now have our patients we can put in front of them and we could see how the technology could actually impact the patient and allow the patient to actually have insight into the product development and what pieces we had.

So that was, I think a big key piece of also the Center for Innovation of really formalizing the process of, we have the expertise, we have the patients and then we have the product. How can we apply this to make the best rehab product out there for our patients?

Mark Bowden:

So I’ll give an example. Right now, CMS came out last April that there’s funding for robotic exoskeletons for home use. And so CMS will fund up to $91,000 for a personalized robotic exoskeleton to be used in the community. So there used to be two, maybe three companies that were out there that built these exoskeletons for rehabilitation. Now we’ve had six companies in the last two months contact us to be able to test these devices to be able to get them into the US market. So we’ve had companies from, let’s see where all? Switzerland, Italy, France, lots of places in Europe to want to be able to break in to be able to do the early FDA trials to be able to get them on the market. Part of that is because we have the reputation of being a high utilizer for robotic exoskeletons. Do you guys want to talk a little bit about Cyberdyne, because that’s where a lot of this background started?

Robert McIver:

Sure. One of our primary exoskeletons that we utilize is Cyberdyne’s Hybrid Assistive Limb. And what it is it uses EMGs. So you have sensors that go on the legs and they detect major EMGs inside the legs, allows the patient to accentuate their movement, basically prevents any sort of compensation that the patient has as they’re trying to get up and move. So it’s different than a powered exoskeleton where a patient is in a powered exoskeleton, you’re more of a passenger, you’re kind of riding along with it even though they have variable assist modes, but they’re good for a specific type of patient. How’s it different? Because it’s more of an Iron Man suit, it’s highlighting what it is that the patients do. It adds a hundred pounds of torque to each little joint that’s there. We can turn up the microphone to look for even a small EMG before the patient even has any muscle contraction that you can see. And it turns that into that movement.

And then we have the ability, we can tweak the signal so we can highlight extension or flexion. So if they’re having the co-contractions, we can really drive the system and drive neuroplasticity. And it’s a unique technology that’s out there that really nobody else has used in the United States. It’s used in other spots throughout the world, but we really piloted and pioneered how to use it in a different way, how to use all the different modes. And so we now also teach internationally at different clinics that get these devices of how you can use what Cyberdyne’s developed to better benefit your patients to get higher overall outcomes and prevent a lot of compensatory pieces. And so that’s really one of the big pieces that has driven patients and products, excuse me, the technology companies to us in order to look at these types of devices because we’ve been seen as the expert of not just powered, but also looking at these variable types of controls of exoskeletons.

Mark Bowden:

And it’s really interesting because I mean if Cyberdyne was the answer for everything, we would stop there and be done, but it doesn’t have a home unit. And actually while you can take it off of a treadmill and not using body weight support, it’s pretty challenging. So in our environment, we’re always on a treadmill with body weight support when we’re using that device. So we’ve wanted to kind of think outside the box and outside of what we currently have to be able to offer other solutions for our patients while they’re inpatients, while they’re outpatients, and then when they go home also and what does that look like? And so some of them are exactly what Bob described where you put them in the device and the device walks you and it’s effectively a mobile standing frame. All right.

Are there other things that can be built in variable assistance? Can EMG activate FES? We’ve got one company that claims to have a brain machine interface that can drive the lower extremities and drive the robot. And so we were actually just talking about it this morning. It would really be nice for a product of the Center for Innovation to be, how does a clinician make the decision as to which robotic exoskeleton they should go for? And if we had access to four or five that we just mentioned, what does the algorithm look like? When do they go to Cyberdyne? When did they transfer off of that? When do they not need the robot anymore and we transfer them to regular overground gait. So that’s kind of the trajectory in the future we would look for.

Dr. Kenneth Ngo:

I’ll take that thought a little bit further to ask physicians and treating clinicians questions like dosing. So are prescriptions for therapy or for a certain treatment, is our primary care physician dosing Lipitor for high cholesterol? What doses of Lipitor or how many hours of therapy, what kind of exoskeleton will give the best treatment? These are questions we don’t have answers at the moment, but it would be really neat to study that a few years down the road we can look back and say, “Well that patient who has T4 [inaudible 00:12:19] … “. “That patient with T4 [inaudible 00:12:30], who’s 52 years old, would need that particular dose of therapy. Maybe a combination of traditional with exoskeleton X number of hours and exoskeletons per week with specific exoskeleton too.” I think that would be really exciting.

Mark Bowden:

It really is a great point because the use of technology in and of itself might be the most effective thing, but it very likely needs to be partnered with other things as well. And we couldn’t, should not ignore all of the rules of rehabilitation that we know simply because we’re using technology. For example, one of the things that is very clear that we need to dose gait based on physiologic parameters of getting the heart rate high enough, whether it’s a percentage of max or percentage of heart rate reserve or rating of perceived exertion or whatever. It needs to be intense enough. A lot of the robots don’t allow us to do that. They don’t go fast enough to be able to get the heart rate up. And so it ends up being a modality that’s good for this aspect of gait training but not the comprehensive aspect of gait training. That’s one of the things with Cyberdyne that makes it more effective. Right?

Robert McIver:

You can go a lot faster than the powered exoskeletons. The powered one’s typically about 0.8 miles an hour and the fastest we’ve gotten a patient is about 2.5. So normal walking speed is about 1.8 to 2.2. And one of the companies we’re working with, again, sometimes people over-engineer things and they come into it, but the meeting where you’re sitting down and I said, “Well, how fast… “. One of the first questions I always ask is, “How fast does it go?” And they said, “We’ve gotten it up to 10 miles an hour.” And I was like, “Wow.” It’s like, “I don’t need to go 10 miles an hour.” But it was good to know that people were thinking that level. And then we started giving the parameters of when does neuroplasticity happen? When are we starting to get normal intensity? When do you get central pattern generators firing? So sharing our science with them in order to help get a better overall product.

And I think it spreads into a lot of different areas, not just exoskeleton. This is able to utilize our knowledge when it comes to what are all the different products that we’re seeing out there, to make better tools for rehab as a whole of how do we develop something that is going to be Procedurally more efficient for our clinician and enhance communication. So as we enhance communication more with our patients, something simple as a virtual reality with AI, they’re starting become more of the market pieces. And so we are starting to explore like, “Hey, what happens if we start to make our own applications.” But not make them applications is gamification because that’s really what you see out on the market is a game. And a game is good until you beat the game, until you’ve played the game so many times that is boring. My son has one of those Nintendo Switches and you know what? He’s not playing the same game he was playing two years ago.

So it’s the same thing with rehab tools. The more that we can formulate tools that can work in virtual reality and augmented reality and integrate AI, then they create options that a patient can carry with themselves, their own medical record and a cloud-based type of platform. And not going to get too far into the weeds of that one. But another big thing when you’re looking about that and what we work with with clientels is looking at how do we take that extra skeleton knowledge, how do we take the virtual reality knowledge and how do we apply it? Because traditionally physical therapists, occupational therapists, we’re very technology-averse. We want to be able to do it on our own. We want to be able to figure out how we’ve learned all these pieces in school.

And so one of the big roles for our Center for Innovation is learning how to take the clinician and the technology and make it a feasible way that applies research and says this is a pattern that benefits just like we said with dosing, but also guiding the clinician of why is this a good technology and how can you use it? And almost walk them through hand-in-hand of like, “This is how we’re going to do this treatment session. This is how we’re going to think differently than what you’ve done before.” We’re still applying the same research concepts that are out there. We’re now just utilizing technology as a tool, not as a replacement. And it’s key to help clinicians to understand that technology is never to replace anybody, but it all has to have innovative thinking in order to enhance application.

When I lecture on this in the past, one of my opening lines with people, as I tell them, I was like, “Well, my last name is MacGyver.” And so most of the people are old enough and they remember that part of it. And I said, “So you give MacGyver technology, we can figure out a new way to apply things in order to help different patients.

Mark Bowden:

So the exoskeleton are likely a good example of technology that’s brought to us. We don’t have the rehab engineering department at Brooks Rehab, but we will absolutely work on how to be able to apply them. You mentioned VR, that’s probably the best example we have of where a company came to us and wanted the input from therapists on how to be able to create the product. Can you talk about that process a little bit and maybe give an example or two?

Robert McIver:

So we had a vendor that came through and we had a shared patient. [inaudible 00:17:24] was an older military guy, had a stroke, and I was actually a therapist way back when. So he grew up and really wanted to come up with a product and he was a software engineer, software specialist. And so he really wanted to figure out how can I use my knowledge base in order to help a patient after a stroke get better outcomes and have better rehab and more access to rehab. And so he and I really sat down and went over what his strengths were and we both had these grandiose of what could happen. And I was like, “Oh, you could have EMG driven sensors and you could be this virtual person in a world that you can see.” And he said, “Yes”. And we went back and forth and he came back with one little piece and he said, “Here’s a game that you can control with your bicep.” And I was like, “That was nothing at all while we were talking about.”

So it was a lot of things of how he came to us with what he wanted to do and then we had to start learning what languages do we share? So how do we educate based on the medical side of it of what is important or what are things we need to have? And then him from his engineering background coming back and also saying, “This is what I’m hearing from what you’re doing and what we’re trying to.” And so in working with there, learning the same language, then coming up with the idea of how to develop the product and the initial product we came up with and just evolved from there. We started seeing more possibilities, training simulators, how could you do patient, how can you do home simulation? All of the problems that we run into as clinicians, how can we solve this in a VR application?

And then it just became a whole part as we started working on coming up with a simple idea of a simple game that would measure range of motion of the shoulder and amplitude of movement. And it turned into an entire app that now actually measures that in real time and it measures it more accurately than a therapist would with a goniometer. And so now it adds to this and it’s a different interactive piece that’s a tool that now the patient can take home and then just gradually building onto those pieces and making a better and better product.

Mark Bowden:

So Dr. Ngo, ask you to elaborate on this a little bit. A lot of what we’re doing in the Center for Innovation, the end goals for it to be able to impact patient care. So start off the conversation about how does this center and the work that we’re doing there fit into the whole system of care at Brooks?

Dr. Kenneth Ngo:

That’s a great question and a big question. I wish we had another couple hours to go over that and we’re fortunate to have our audience here, two physicians or three physicians here joining us. As you’re hearing from Dr. Bowden and Bob describing the technologies and how they’re using technologies to help patient, I can imagine you’re thinking, “well, what is my role coming into all of this? What is the role of a physician in this?” I’ll give you a few example on that before answering Dr. Bowden’s question. To us physiatrists the approach to care is a team approach the care, right? That interdisciplinary approach. So as with traditional care minus the technology, we work together, we address medical barriers that prevent the patient from participating in therapy.

Similarly, if we have a patient in the VR device and they have vestibular issues, well we help treat the vestibular issues so the patient can benefit from the VR technology or these technologies that help mobilize patient. And we find out once the blood pressure has been treated when they’re sitting or lying and the minute they stand up, guess what happened? Blood pressure drops. Or in chronic patients who have bone health compromise like osteoporosis, osteopenia, that’s our job to treat them so that they are not prone to fractures. I can go on and on for examples like that. The theme is still the teamwork approach that good communications, developing these programs in your local communities to help more patient.

Of course I’m preaching to the choir who’s also in physiatry. You recognize the importance of teamwork and the multidiscipline that are needed to care for our patients, which are quite complex. Each one of us cannot take care for the patient ourselves. We really rely on one another and each other’s expertise. And sometimes we’ll sit down and go over parameters on blood pressure, on heart rate, talk about the intensity. That’s a whole topic we can talk about for another 30 minutes on intensity of therapy. I certainly, I’m not the expert in that, Dr Bowden is. And that’s where we work together to push that boundaries. Yes, we can get that patient’s blood pressure or that heart rate to 80% of [inaudible 00:21:55]. It’s okay, it’s not scary, we can do it. And I think that’s the kind of approach we use at Brooks. What was your question again, Bowden?

Mark Bowden:

So how do our results fit into the system of care? How do we translate and implement?

Dr. Kenneth Ngo:

Yeah. Well maybe I’ll answer that question with an example. I think one of the newest technology that you may have heard of is Vivistim. Have you heard of Vivistim? It’s a technology that stimulates the vagus nerve. So it’s an implantable device that is implanted on the chest. It’s kind of size of a pacemaker with a wire that goes up to the neck and stimulate the vagus nerve. The stimulation is obviously much closer to the brain and has been shown to increase activation in the cortex to help with motor recovery. So at Brooks, we were one of the clinical sites for that study to look at efficacy. And in that six week study after implantation with a certain protocol of therapy, we find that the patient who had the implantable Vivistim device pairing with six weeks of therapy had much better outcome than their control group that had the same intensity of therapy.

So in that six week, we saw a significant change in improvement and we hypothesized that if in six weeks those patients make that much improvement, imagine if they had three months of therapy or six months of therapy. And at that point it was still a hypothesis or we have data for six weeks, question mark on three months and six months, but we hypothesized that likely the patient will continue to improve. So thankfully the technology was approved for the indication of post-stroke, it’s chronic post-stroke, upper limb weakness. We adopted that technology quickly at Brooks, offer that to patients. And so far we’ve had about two dozen patients or so implanted over the last two years or so since it was approved. And lo and behold, yes, the patient continues to improve at three months, at six months and really roll it out to our entire system and offer that to all patients who were qualified for that indication.

And remember prior to this, there’s really no other technology that helps patient with chronic post-stroke improve other than peripheral stem, which does give some improvement. But this technology drastically change the trajectory recovery and it’s phenomenal to see.

Mark Bowden:

And I think that’s a wonderful example because it leads into the other thing I was wanting to talk about, which was we can measure that and because we have a developing learning health system, and so we have standardized outcomes from inpatient to outpatient to home health to skilled nursing to our day treatment program. So by diagnosis, by discipline, we’ll have this consistent set of outcomes. And so for Vivistim, it’s primarily looking at upper extremity recovery. So we have this standardized battery of upper extremity assessments, but the mechanism that Vivistim works is by releasing more excitatory neurotransmitters in the brain. Well, I don’t think the upper extremity neurons are the only ones that uptake those neurotransmitters. So it’s very likely that it’s going to impact gait, balance, mobility, speech, cognition and all sorts of things. And so we’ll be able to examine some of those other elements through the standardized collection.

And I think that one of the links between what we do in the Center for Innovation and the rest of the organization is to be able to test these products and then go to a clinic and say, “These are the outcomes that we got when we tested this in one of our clinics.” So Bob oversees the clinic at the Neuro Recovery Center, and that’s going to transition into kind of a research-based laboratory clinic to be able to be the ground point zero for the Center for Innovation and the learning health system. So instead of taking a piece of equipment out to a clinic and say, “This is the latest and greatest, here’s the article that was published in print in a perfectly controlled research lab and we think you ought to use it.” You can say, “Here’s the data that we got from our clinic, part of the organization, in a pragmatic trial with real patients and this is how it might offer improvement over what you’re currently doing.” I think that’s a way different way to implement something than relying on laboratory published data.

Robert McIver:

Exactly. And it also allows the clinician to have access to the person who did the research, how did we gather the data, why did we come up with that thinking? And that’s really when I look at the Center for Innovation and how it steps into our entire system of care is really the Center for Innovation is the starting point of thinking point. It’s an idea, it’s a pilot study. We have this idea that this technology or this way that we do work may help more patients. A great example of something we did with this in the past, there’s a program we call our hybrid program. And so we have inpatient therapists or inpatient patients who typically get three hours of inpatient rehab during their normal stay. What we did is found out that most of the equipment that was sitting around was sitting around after three o’clock and wasn’t being used by anybody, but patients kept wanting more and more treatment.

So we established a hybrid program where patients could sign up to use the technology in after hours and still have that rehab benefit. It wasn’t changing anything of what we did, it was just changing the way that we thought about it and it was implementing that new piece. And now that we’ve done that, the hybrid program has grown throughout our hospital, it’s grown into our other hospital, it’ll grown into this hospital that we’re building in Arizona. It’s just a way of thinking now, it’s the way that we apply and that we present to our patients. And so that center for innovation piece is here and I think that’s the unique part about the three of us is I’m always an idea guy. I want come up with something new. “How can we fix it? How can we go if this next part?” And Dr. Ngo has all the contacts and all the medical pieces and everything we’re bringing up, and also has an engineering background.

And then Mark when he stepped in, brought in the whole research part of it. So now we’re actually researching and understanding what it is of the decisions that we’re doing and how we’re applying our thinking to our patients and within our centers, and with and without technology. It’s so much easier to go out to a fellow clinician and say, “Here, do this. And this is why and this is what my thinking was behind it. And this is the data that Mark’s team got behind this and this is why we found that it works.” Or that it doesn’t work. “It only worked this way and we thought this happened and nope, it didn’t give an idea and we don’t need to keep going down that path.”

Mark Bowden:

So would you say that innovation is really pretty central to the principles of the organization? It’s actually one of the seven values. So our mission, vision and values, we have seven core ones and innovation is one of them because we always want to be at the forefront of not just how do we promote technology, but how do we think and how do we adapt and how do we problem solve. I know we have tons of examples. Bob, do you have either an example of a project that we’ve done or a product that you’re super excited about or both?

Robert McIver:

There’s always this one run process. I always like to just put it into any little spot that I talk with somebody, but people talk about FDA process and that’s one of the things we do at the Center for Innovation. We really like to do FDA trials, help companies help get their products out there. We can do that with our [inaudible 00:29:41], with our patient number, with our clinicians, people who are excited about technology and what they want to do. The typical FDA trial to get to safety and efficacy out on the market, especially getting clinical trials can take anywhere up to 10, 12, 14 months. So the fastest one that we’ve done that we’ve had with our patient population that we’re able to structure set everything up, it was eight hours and so we were able to get all the clinical data for clinicians, so safe clinical use, home use, all this for the vendor in eight hours and sent them on their way with all the data that they needed.

So that’s just one example of something that we worked with with a company specifically there. We’ve worked with other companies that just weren’t sure. We had one that was an upper extremity hand device, a larger piece of equipment. I think they were based out of Israel and their main piece is they wanted to understand where did they apply in the rehab market, “Where is the right center for us?” And we did a three months worth of testing on it. We figured out that the biggest impact for them would’ve been in an outpatient type of a setting is what we saw. That type of a patient is really good for that. They also had a price tag of $175,000. So $175,000 isn’t going to fly with an outpatient center. So we were able to kind of talk to them and coach to them that an inpatient rehab center is an ideal spot based on your price point because of the number of patients and volumes that you can use.

So help them to understand the rehab market. And then so that way it helped them come up with their idea of how to modify their thinking and modify their product to make a cheaper, more effective product that might be able to work in an outpatient setting. Then also how to add more tools to the bigger pieces of equipment so it could be more desirable in an inpatient. So that they were able to take that feedback that on just that simple three month trial and just take that back to be able to help with their development before they sought any further FDA testing.

Mark Bowden:

It really is interesting because the big topic of what we talk about with these companies is what is the return on investment for the consumer, us as rehabilitationists. So if we’re buying $100,000 device and we’re billing the same thing that we always bill, so we bill the code for gait training, but we’re doing it with $100,000 device, it becomes very inefficient. But there are certain devices that now there are codes to be able to bill for in addition to what you’re doing. So there’s a billing code for virtual reality, there’s a billing code for wearables, there’s a billing code for, the CMS code for exoskeletons when you go home. So that becomes a different part of the equation. And so I did not anticipate that being part of the center that we need to be able to stay on top of all those billing codes in the way. But that’s a really important thing.

Dr. Kenneth Ngo:

I want to take a quick moment to pull us up to a 30,000-foot view. We’re fortunate to have young early career physiatrist here in the audience and what you’ve heard so far seems maybe overwhelming, but I hope to instill some excitement in you. This is I think the best time in rehab to have all these tools to help our patients improve. It’s not just two weeks inpatient and try to get the patient home. It’s much longer commitment than that, right? And that you mentioned earlier your love of neurorehab. Our commitment is not going to be that four weeks and inpatients stay, it’s going to be two months, a year, potentially lifelong. And now we have all of these tools that drastically change the course of recovery to full recovery for patients that in the past we couldn’t think that they would, “Oh my gosh, that patient would not be able to drive.” And now, “Yes, that patient’s going to go back to work.” Not just driving.

And how to take all of these technologies know-how and piece it together in the most efficient way to get the patient back to working and driving and go and have fun on the weekends like we are. I think that’s the exciting piece. I would also even add one more comment on what we’re doing, why we’re doing and the Center for Innovation is to look for ways to help patients recover quicker, but also in a cost-conscious manner. The idea for value-based care I think in the next 10 years or so will be even more relevant. We need to be able to deliver the best outcome and the quickest way as well as the most cost-effective way. And we at Brooks have the expertise in this area.

For example, going back to the Cyberdyne, we know it so well, we can predict a patient with spinal cord injury at certain rate of recovery that we’re willing to work with some insurance company and say, “We can guarantee this outcome for this patient with this profile and a certain amount of time for this fixed cost. If we deliver it, great, we deliver it earlier better for us. If we deliver it a little bit later, then we’ll eat up the cost.”

That’s where you put your money where your mouth is when you say value-based care, we know we can get the patient there and I think that’s going to be the future of rehab and that’s exciting. I think the most exciting part of all that is the patient who’s benefiting from this, right? It’s not just number of treatment, it’s the quality of treatment and the quality of the outcome, which is what they care about. “How fast can I go back to driving so I can go play off in the weekend.” That’s what our patients care about.

Mark Bowden:

It’s such a great point and I remember being a new physical therapist, graduated from PT school in ’95, and so around 1999, 2000, body weight support treadmill training for spinal cord injury patients became a hot topic. And I remember thinking this therapy is providing hope to a patient population that hasn’t experienced much hope before then because spinal cord rehab hadn’t changed a whole lot in the 20 to 30 years prior to that. Now we fast-forward 25 years, we’re going to be studying exoskeletons that are using brain waves to be able to drive the robotic arm. It’s going to be measuring the amount of force production that’s done at each joint and mapping that on to what forced production should be done at the speed at which they’re walking and give them a little bit of that extra boost.

That’s incredible to think about and how that changes the scope of recovery. I think it’s really incredibly exciting time to be in patient care. So before we get carried away with all the things we’re excited about, we wanted to pause for a second and see if you guys had any questions for us or anything you would like for us to discuss in more detail.

Speaker 5:

So I imagine this is a bit of a variable answer depending on the device or even the patient, but when you’re looking to recruit a participant to start working on one of these devices, at what stage in their recovery are you looking to implement this? Is this something that you’re trying to get going as early as possible? You’re kind of screening them day one at their acute inpatient rehab stay? Is this something more, you kind of identify someone and then circle back on it at later in the recovery process? Or when are you trying to implement this?

Mark Bowden:

Yes, to all of those. But it is an incredibly complex question because there’s natural recovery in all neurologic populations that’s going to occur over the first six months. So when you look at the literature, there’s way more literature on rehabilitation interventions, from a physical therapy standpoint at least, that happened six months or later in chronic populations. Well, that’s not where we treat patients. So I can tell you because we presented this last week at the national PT meeting, we’ve been working for the last five or six years to do a clinical practice guideline for walking recovery after stroke, traumatic brain injury and spinal cord injury. And we only looked at randomized control trials in the acute and subacute period. So less than six months, they had to have some gait outcome, all right, there were zero for traumatic brain injury and four for spinal cord injury that met the criteria.

So there’s not a lot of literature that’s guiding this, which is why the learning health system becomes so important. So if we know what we do, what is the average outcome for a certain diagnosis or even subcategory of a diagnosis and then we implement something new, then we have at least a historical cohort to be able to compare it to. And so that’s what we would like to get to so we can be very efficient in generating the knowledge that you’re looking for. My least favorite rehabilitation research statistic is that it takes about 17 years from a good idea to the point that it’s actually implemented in a patient. There are steps along the way that have to be done, so we can’t skip those steps, but how do we condense that down to make it a reasonable fashion? And we think the learning health system is a way to be able to do that.

Robert McIver:

And I think another way to not really look at what your question is it also depends on if we have a technology, is where is it applying? What is their question? It is for that same company, they were looking at outpatient, subacute getting to chronic area, and they’re trying to understand, “Does it work and there, but it’s really expensive. So really we need to look at this as this patient are more early stages.” But we’ll get questions from vendors that just want to know, “Does it work?” “Does this work and does it do what it needs to?” Well, then we can look at it, we can say, “Well, what is the best clinical situation that we can determine does this work? Is it in a early stroke population that we know we’re going to have spontaneous recovery going to put on things? Is it doing what it says it’s doing?” And then that’ll give us that answer.

Obviously the vendor is included into the decision process, but if you’re also getting something where they say, “Hey, we know it works, we know it has this effect and it has this impact.” Obviously the chronic population is then where everybody starts to go to because as soon as our chronic, you’re assuming that most recovery has really happened by that point. So once they get to there, and if you can impact a change on a chronic patient, that’s where Vivistim is coming in, where their Cyberdyne studies have come in, they’ve shown that they’re impacting chronic patients and improving their function, then we actually can turn it back around and say, “Okay, we know it improves chronic function. Now how can we go back and look at the subacute population to see how much more impact can we take based on our data from the learning health system to say, ‘How much better are they getting now that we know all these things’?”

So it’s just like Mark said, it’s yes to all of those, but it just really depends from where the vendor’s coming from and they need what data and information they need. And then when we start to implement what our rehab questions are after we know exactly what they’re looking for as well.

Mark Bowden:

I think an untapped research question is if you can manage the complexity of doing rehab research in the acute and subacute space, it’s not just how much recovery you’re getting, but how much negative consequences are you avoiding? And if we can prevent maladaptive plasticity from occurring and avoiding secondary complications of disability, then that is a major win to be able to really think about this in a different fashion.

Dr. Kenneth Ngo:

Hey don’t let Dr. Bowden recruit you to this research team. Hey, being a clinician is pretty fun. And joking aside, as physicians, as physiatrists, our patients rely on us to tell them how they will be in three months or six months. I think that’s the greatest gift for us as physiatrists. And as we learn more relying on the learning health system, I think our prediction will be more accurate to give them more reassurance, to give them hope. We are kind of the cheerleaders and being able to give them that glimpse, “Yes, in three months you’re going to be able to walk, you’re going to be able to walk your daughter down the aisle.” Those are the things that we do that drives us. And to have these tools to help us with those discussions.

To Mark’s point earlier, all of the outcome data that you looked at was published a decade ago from data 20, 30, 40 years ago, intervention. We’re kind of past that now. So back on research, if you can give us a model where I can plug in the certain numbers and statistics, be able to spit out, “Hey, this is how the patient’s going to be in six months.” That would be super cool.

Mark Bowden:

I mean, there would be so much power in that I and so much hope and understanding on the part of the patients to be able to not go into this process as scared and data-less as they are right now. Yeah.

Robert McIver:

And even from the clinician too, just having that clinician understanding where is the data process and you’re a new clinician. I don’t have all the experience that Dr. Ngo has as in his years as a clinician. Where is my checklist to start? Where is my flow sheet?

Speaker 6:

Sure. And one thing that I’m interested in as well is vestibular rehab. And you mentioned VR for approaching vestibular rehab. Do you have any data of improving it? Because I assume that VR could either help or worsen the vestibular issue. So any data that you have in there as well.

Robert McIver:

We don’t have any existing data on the VR applications we’ve looked at. We have learned a lot about vestibular conditions. If you have ever had anybody who’s been in a VR and a vestibular and an immersive type of environment, it has to be set up in a very particular way. An immersive environment for somebody that just has a true central, like any sort of vestibular issues that are going on is not very favorable. But what we’ve started to see with some of the patients we’ve trialed it on is augmented reality has been helping quite a bit because now you’re actually putting the patient not in an immersive sensory deprivation type of an area they can still fix on certain areas. And then in one of the games that we have made at this point, we actually go through and we have a focal point that we’re able to get the patient to focus on and add blinders to them. We can add different things that can make the environment better, but we haven’t gotten to the point yet of gathering data on those applications. We’re still developing those piece specifically for VR.

Mark Bowden:

There’s one case study that we haven’t published yet where we’re in a process of writing it up and it was somebody that had an impairment of what vertical was, and so they were maybe 20 degrees off. And they worked with the programmer for the virtual reality in an immersive system. And it was super interesting. Instead of correcting it, they made it worse. So you had to compensate back to vertical and had an amazing, amazing outcomes, in of one. But that’s where these concepts start.

Robert McIver:

It’s going to be really interesting to see really where the world goes with that. Because with all of the, you now have on the new Oculus Rift systems and other ones where you can do eye tracking in real time, so you have cameras on the eyes so you can see everything. So as you’re doing your Dix-Hallpike tests and you’re doing everything in these environments, you can give people things where you actually can start seeing stuff, not having to have, I don’t really know how expensive they are, the frames with the lenses and stuff.

Mark Bowden:

Hey Bob, we’re, we’re getting down to our last minute. So before we run out of time, tell everybody how they can access the Center for Innovation.

Robert McIver:

So it’s through our website brooksrehab.org or brooksrehab.com. And you go to our Center for Innovation page, and on that page there is tabs to be able to submit. If you have an idea and you just want to get a consult and I get some ideas how we can build for it, or is it a research question or is it just a clinical consult? So through there, there’s a form fill that then connects you directly to us and we can go through and help you out from there.

Mark Bowden:

Awesome. Well, thank you so much for joining us. We’re live at the Association for Academic Physiatrist conference in Phoenix for the Brooks Rehabilitation Podcast. For more information about Brooks and to connect with us, please visit brooksrehab.org.