Regardless of the type of injury or disease of the nervous system, one treatment strategy has been revealed again and again to improve a disabled person’s ability to reach and grasp with a weakened arm and hand, improve balance, walk faster and more safely, and become less physically dependent on others: a patient needs to simply exercise and practice the tasks that they wish to better accomplish after a brain disease. It seems so obvious, but is remarkably complex. Exercise and repetitive practice are the same formulas that everyone uses to improve motor control to handle a chef’s knife, play an instrument, ride a bicycle, hit a ball, or push to get more fit. An adequate dose of repetitive practice at increasingly challenging tasks improves motor skills; but how? That practice, as well as fitness exercise, stimulates molecules, genes, and the connections between neural cells, as well as growth in the pathways that encode the performance of every action. Practice and exercise turn on innate mechanisms for learning and remodeling the nervous system. However, in a nervous system that has been degraded by stroke, brain, or spinal cord trauma; degenerative diseases like Parkinson’s; multiple sclerosis; peripheral neuropathies; and muscle diseases, practice is more difficult and may need to be guided by a rehabilitation therapist to recover what was once done with little effort. While performance may not recover as much as desired, there is much to be gained; but practice usually falters after the time of formal inpatient or outpatient rehabilitation concludes.
A commitment to practicing and exercising waivers when a person is well—let alone when unexpectedly disabled. Excuses abound. Even more troubling for the neurological patient is how to best practice outside of a physical therapy session, both safely and progressively, in terms of duration, speed, force, and types and quality of movements, when movement has become unnatural. Patients need more personal help to continue to try to improve in areas that are important to them.
To meet this need, Dr. Bruce Dobkin, Director of the Neuro-Rehabilitation Program in the Department of Neurology, collaborated with UCLA faculty in electrical engineering in the UCLA Henry Samueli School of Engineering and Applied Science to create devices that allow clinicians to monitor practice and exercise in the home. Most commercial sensors, such as the Fitbit, are quite inaccurate when walking is slow (less than 1.5 mph) and irregular, which characterizes the gait of many disabled persons. To get around this inaccuracy, motion signals from accelerometers and gyroscopes in easy-to-wear bands above each ankle are sent over the Internet to clinicians in the UCLA Department of Neurology, and interpreted by machine learning algorithms to record the duration, speed, and quality of every walking session throughout the day. An infrared sensor is placed in a laptop box that allows the team to see every arm and hand practice session as patients lift a glass or move objects across the transparent surface. In addition, Dr. Dobkin and his team can monitor how often and how well patients stretch against the resistance of an elastic band for strengthening. With this community-based data, the team is able to modify behavior to enable better motivation and knowledge for self-management. Indeed, we consider our inexpensive monitoring and practice devices to be behavioral intervention technologies (BITs, if you will). Participants are contacted weekly with feedback about the past week’s performance, goal setting is emphasized, and instructiongiven on ways to meet personal goals. The team discusses with the patients adherence to convenient practice schedules and tries to detect and overcome barriers to daily activity.
The Neuro-Rehabilitation team calls the sum of the BITs that monitor the type, quantity, and quality of practice and exercise a Rehabilitation Internet-of-Things, or RIoT. The components of this system and those that are evolving from other investigators enable remote supervision and tailored counseling, a new form of telerehabilitation, to increase practice and exercise. Especially important during clinical trials of new medications and biological interventions to enhance recovery, participants can for the first time be encouraged, via smartphone or tablet, to practice key tasks intensively enough to enable those strategies to have a chance to improve the patients’ function. It is a RIoT.
Join the conversation…Dr. Dobkin will answer questions about this piece and his work in Neuro-Rehabilitation on Twitter, Tuesday November 28th, 9-4pm (Pacific Time) @UCLANeurology. Please note: Dr. Dobkin can not answer patient-specific questions.