Rehabilitation interventions support people to lead productive socio-economic lives after brain injury. However, benefits shown in research studies are only partially transferred into clinical practice. Challenges include: providing a sufficient dose of repetitive task-specific practice (e.g. postural control exercises); re-training of everyday tasks (e.g. making a drink) in environments where people need to function; and predicting and monitoring response of individuals to tailored interventions to achieve maximal recovery.
Progress is promised by harnessing rehabilitation technology, including that enabled by ICT, for provision of evidenced-based interventions. For example, intervention delivered via robotic devices, exer-gaming and/or virtual reality can produce equivalent benefit to “hands-on” intervention from a specialist therapist. The promise is that technology-enabled therapy will: enable people to receive evidenced-based interventions in their own homes without a therapist physically present; receive feedback on their performance and progress; be empowered to take more control of their rehabilitation; and receive timely guidance from their specialist therapist either via tele- rehabilitation or a physical visit. However, not all technology may be suitable for people with brain injury as the sequelae are heterogeneous and disability is complex with combinations of problems including muscle weakness, attention deficit and/or memory disorder. In addition, as people are participating in rehabilitation in their own homes, space for specialized equipment is limited and they need to be able to use the technology on their own or with limited help from their informal caregiver/s.
Consequently, the next generation of technology needs to be designed iteratively with the users i.e. patients, their informal caregivers and therapists.
Another part of the required step-change in neurorehabilitation is to (a) enhance knowledge of the predictive markers of response to specific therapies and (b) develop objective measures of response to therapy that are more sensitive to change that those in routine use. In current clinical practice, most decisions about which intervention to provide for individuals are based on clinical experience rather than evidence, then judgement of whether the therapy is of benefit is made mostly via behavioural rather than physiological measures. It can be five or more days before it is clear whether a specific intervention is working. If three interventions are provided before the right one is found then three weeks of injury-induced, time-limited, neuroplasticity potential has been lost. Advances in neurorehabilitation need the development of predictive models for behavioural response and measures to detect its physiological mechanisms.
For advances in technology-aided interventions, predictive models of response and sensitive measures of response to be implemented into clinical practice policy makers, service managers and clinical therapists must be partners in neurorehabilitation research. Co-development and co-evaluation of proposed solutions for unmet need are crucial for the neurorehabilitation implementation framework. If rehabilitation technology or physiological measures of response cannot be used in clinical rehabilitation settings, mostly peoples’ homes, then they will not be implemented. Being user-friendly, user-pertinent, and effortless to maintain are vital.
Aims and specific short (1 year), medium (2-3 years) and long (4-5 years) objectives
Short term (1 year):
- complete evaluation of implementation of FestivApp and Viatherapy App into clinical practice
- develop objective protocols for delivery of peripheral nerve stimulation and neuro-navigated brain stimulation
- submit application to MRC Confidence in Concept for funding to develop UPED into a marketable product and finalize proof-of-concept investigation
- complete analysis of the FAST INdICATE Trial, if indicated, update the content of Viatherapy andFestivApp
- identify which visual representations of sensitive physiological measures are most meaningful to therapists and patients
- hold “sandpits” with stakeholders to identify solutions for unmet rehabilitation needs
Medium term (2-3 years):
- create service implementation manuals for FestivApp and Viatherapy App
- secure funding to conduct clinical trials of FestivApp and Viatherapy App
- develop novel technology-aided interventions in partnership with SMEs, patients and clinicians – following on from“sandpits”
- investigate the impact of sensitive physiological measures to enhance clinical decision-making
- secure funding to evaluate predictive models of response to well-characterised therapies
- have a test-bed network for innovation, in clinical and home settings, that has expanded beyond the East of England.
Long term (4-5 years):
- Have a suite of evidenced-based technology-aided interventions with service implementation models
- Have sensitive physiological measures in use in clinical practice
- Have predictive models in use by therapists to inform timely decisions about the most appropriate intervention for individuals
- Have a UK-wide network of SMEs, clinical practice, service provision, academia, service users and the public to continue technological development to meet rehabilitation need and is implemented into practice.
SUBTHEME 1: Technology-aided rehabilitation interventions
Evaluation of novel rehabilitation technologies are underway. For example, UPED and ALLEX are nearing the end of their initial user-centred design phase. Proof-of- concept studies for their intended benefits for walking recovery are imminent. Other rehabilitation technologies are further advanced such as the App we have designed in partnership with a SME so that people receiving rehabilitation from Early Supported Discharge Services can participate in Functional Strength Training. With funding from the Health Foundation, we are investigating the service improvement following implementation of FestivApp into clinical practice. Another funded implementation project will start in early 2017 to evaluate the patient and service benefits of using Viatherapy App http://www.viatherapy.org in community-based neurorehabilitation
The purpose of Viatherapy, is to enhance the ability of clinicians to make evidenced-based decisions about the most appropriate upper limb therapy to provide for individuals. Future technologies are being planned in partnership with the Birmingham Trauma Centre. For example, peripheral nerve stimulation is a technology with potential to enhance neuromuscular function after both brain and bone trauma when used in different ways to address dysfunction from distinctive injury mechanisms and sequelae. Another promising intervention we are developing is neuro-navigated brain stimulation which promises increased precision over existing techniques. Interactive working between Brain Injury and Trauma researchers is also expected to make efficient use of resources to eliminate the challenges hampering widespread implementation of tele-rehabilitation (see subtheme 3). Any synergies with future MICs will be exploited to reflect this driver.
SUBTHEME 2: Predictive markers and measures of response to neurorehabilitation
As brain injury is markedly heterogeneous many factors must be considered in predictive models including: damage to brain networks; cognitive dysfunction, sensory impairment, muscle weakness, age and time after injury. Addressing these requires combining neuroimaging, neurophysiological and behavioural measures across sensori-motor and cognitive domains in sufficiently large groups of people. We will build on the findings of the FAST INdICATE Trial (now in analysis) to enhance Viatherapy (see subtheme 1) and inform the next set of research investigations into predictive models. We will continue to develop sensitive physiological measures of response to rehabilitation intervention suitable for both research and clinical practice. For example, (a) we are currently working to identify visual representation of neuro-biomechanical measures of the performance of functional activities such as standing up from a chair that convey physiological information immediately to both clinicians and patients and (b) we will develop the novel rapid collection of measures of brain-muscle connectivity towards routine use in research and clinical practice. Furthermore, we will work collaboratively with the WBIC to employ the 7T MR capability to develop new brain imaging measures directly relevant to neurorehabilitation. This will build on work already completed at UCL and currently underway for analysis of data from the FAST INdICATE Trial. These measures will also be employed to evaluate the technology-aided interventions developed within subtheme 1.
SUBTHEME 3: Implementation of rehabilitation technology into care pathway.
Here we will enhance our partnerships with: SMEs, clinical practice, service provision, academia, service users and the public (stakeholders) to ensure that user- centred design (working with the Cambridge Engineering Design Centre) is central to the development and implementation of rehabilitation technology e.g. development of a tele-rehabilitation toolkit (see subthemes 1 and 2). This activity will include facilitating multi-sectorial networking focussed around key themes e.g. holding “sandpits” with stakeholders to create innovative solutions for unmet needs. We have already established the ABIRA network that links research and clinical practice (http://www.abira.ac.uk) and within this have set-up a test-bed for technology with: (a) Association of Chartered Physiotherapists in Neurology, East of England branch (ACPIN-MoveTech); and (b) the Norwich Electronic Assistive Technology Centre (NEAT) at the University of East Anglia ( https://www.uea.ac.uk/health- sciences/enterprise/neat). The former are already involved in testing the implementation of Viatherapy (subtheme 1). The latter is an assistive technology resource for the community through provision of a home setting for exploring the usefulness of technology for everyday living. Both will enable the Accelerated Access review and translations of innovations rapidly into clinical practice. In addition, following active participation in an EPSRC think-tank on rehabilitation technology we have submitted an application to the EPSRC for funding for a Network Plus focused on neuroplasticity in December 2016. All this activity is cognisant of the need to adhere to regulations for medical devices including the need to adhere to upcoming legislation regarding apps including best practice for app design and accreditation. In addition, we recognise the need for integration into the digital health agenda. As technology is implemented into clinical practice we will ensure links to the rehabilitation prescription and dissemination of use to support ORIONetc.