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Pearls From: David Putrino, PhD

Pearls From: David Putrino, PhD

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The field of neurorehabilitation is burgeoning, explained David Putrino, PhD, director of rehabilitation innovation at the Mount Sinai Health System in New York, during an exclusive interview with MedPage Today.

He breaks down — from active-engagement to neuromodulation and robotics — everything providers should know when working with patients recovering from neurological damage, and research gaps that still need filling.

The following is a transcript of his remarks:

The lowest-cost thing that I think that we need to remember in terms of clinicians working with people recovering from neurological damage is that neurorehabilitation should be all about active engagement, getting people very involved in their rehabilitation. What we have seen in the latest studies is that that improves participation, which actually modulates neuroplasticity. So you get better outcomes when your patients are highly engaged in what they’re doing and very, very motivated. That is super low-cost, new to the field of neurorehab, shouldn’t really be new, but it is, and it’s something that everyone can do to improve their patients’ outcomes.

The next sort of tier is there’s an entire new field of neuromodulation that is sort of exploding, whereby we have new devices that can perform non-invasive brain stimulation, things like transcranial direct current stimulation, which haven’t yet been proven to improve neurorehab, but there’s some exciting studies that are happening. Then there are interventions like transcranial magnetic stimulation that actually have good evidence behind them. They’re a little bit more expensive, the devices, and you need specific expertise to make them work, but they’re starting to show good evidence that if you combine these with conventional neurorehabilitation, they can enhance or augment the effect of neurorehab.

Finally, the thing that we should all be aware of, which the highest cost (the highest tier of expense) is robotics. We’re starting to see an exponential growth in the rehab robotics industry, and we’re starting to see really good results. Because what rehab robotics does effectively is it takes the dosage of therapy from a physical therapist or an occupational therapist sitting with a patient and performing 20-30 repetitions of a movement in a session, right up to thousands of repetitions with the same level of supervision and engagement from the occupational therapist and physical therapist. It becomes a much more cost-effective way of delivering a much higher intensity dose of physical therapy to the patient.

I think that some of the big gaps that are currently present in the field center around — I’m going to break that down into two parts: the first is combination therapies. We really tend to, in neurorehabilitation, fall into camps. We should be doing this, or we should be doing that. Very few people are actually actively investigating combinations of therapies. Let’s look at robotics, neuromodulation, and a drug like memantine, which has had promising effects in neurorehabilitation. Ideas like that are not being investigated as much as pure concepts. Let’s just look at robotics or let’s just look at a drug.

Where the people who are leading the field in neurorehabilitation all seem to have a consensus is that you kind of want to throw everything at the wall. You want to excite the nervous system as much as you can and get people as engaged as they can, and then throw as many neurorehabilitation strategies at them as possible to give the best chances of a good outcome.

The other thing, the other gap that I think we really need to address is our ability to quantify impairment. Currently, we’re still using the same old clinical scales, incredibly insensitive to change. They’re incredibly variable between the different clinicians that administer them. These give us very muddy endpoints to determine whether or not someone is actually improving following their neurorehabilitation.

There’s a brave new world of wearables, of motion-capture devices, of force platforms, of things that don’t actually cost all that much money, but can quantify someone’s function in a very precise way and actually let us know if we’re having an influence on whether or not they’re getting better and what their level of function is, and maybe even what level of function they can expect down the track. Those are the two big areas that I think we can really improve on — combination therapies and assessing our patients with better granularity and better sensitivity.


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