The Rehabilitation Renaissance
In October 2015, TIRR Memorial Hermann opened the doors to its long-awaited NeuroRecovery Research Center (NRRC), a partnership with the Department of Physical Medicine and Rehabilitation (PM&R) at The University of Texas Health Science Center at Houston McGovern Medical School. What once existed only on the pages of science fiction novels and comic books now finds its place within the walls of the rehabilitation hospital.
Housed on the third floor of TIRR Memorial Hermann’s 42,000-square-foot research building, the NRRC conducts innovative research and clinical trials using robotic technology geared toward rehabilitating people who have suffered brain injuries, spinal cord injuries, strokes and neurodegenerative diseases, such as multiple sclerosis. Equipped with four futuristic-looking exoskeleton suits, a robotic arm, various brain and spinal stimulators and a cap that detects brain signals and situated within a sleek, grayscale interior design that would make even Tony Stark feel at home, the ultramodern suite is a growing hub for collaboration between TIRR Memorial Hermann clinicians, UTHealth researchers and institutions across the Texas Medical Center.
“The Texas Medical Center has an embarrassing wealth of resources, and we’ve only tapped into a small portion of it,” said Gerard Francisco, M.D., chief medical officer at TIRR Memorial Hermann, director of the NRRC and professor and chairman of the PM&R at McGovern Medical School. “With the collaborations that we have with other hospitals and other institutions of higher learning, like the University of Houston and Rice University, it would be a sin not to take advantage of those resources and see how we can serve as a medium for collaboration so that the strengths of the different institutions can add up to something that will really enhance our patients’ recovery.”
Since Carl Josehart, senior vice president and chief executive officer of TIRR Memorial Hermann, assumed the mantle in 2006, the rehabilitation hospital jumped from being the fifth top rehabilitation center in the country to no. 2 on U.S. News and World Report’s List of Best Hospitals, on the heels of the Rehabilitation Institute of Chicago. But it’s the leadership team’s commitment and the clinical staff’s focus on their patients that galvanized the formation of the center and its eight independent laboratories: Neuromodulation, Neurorehabilitation, Neuro-Myo Engineering for Rehabilitation, Motor Recovery, Spinal Cord Medicine, Robotics and Rehabilitation Engineering, Human Machine Interface Systems and the Center for Wearable Exoskeletons.
“This building, this research center, was really part of the dream I had when I first arrived: to create a state-of-the-art facility to really launch our research initiatives to an even higher level,” Josehart said. “Part of what makes us a national leader in rehabilitation is not just doing rehabilitation effectively with the current knowledge that exists, but it’s creating new knowledge. Research is part of the investment in pushing the frontiers of clinical rehabilitation even further.”
With seven Ph.D. researchers and five physicians working under the same roof to combine academic research and clinical application, the NRRC is the epitome of what cross-collaboration between disciplines can achieve with a shared vision and goal. It’s a symbiotic relationship in which the physicians who are not trained in research work closely with researchers who have great ideas but need the physicians’ expertise in patient care.
“TIRR Memorial Hermann has a history of providing the best rehabilitation care and the quest for, ‘How do we make the best even better?’” Francisco said. “These are people who work at different levels—clinicians, physicians, therapists, nurses, administrators—and everyone has a common goal of giving our patients the best possible chance at recovery. When that passion comes together, there’s only one way to go, and that’s to be more creative and think of ways of how things that have been known to work successfully can [be applied to our patients].”
The NRRC is currently conducting about 20 independent and joint clinical trials and studies with that specific goal in mind, including a unique study out of the center’s Motor Recovery Laboratory that uses an array of wearable exoskeletons to evaluate how it could benefit people with multiple sclerosis and improve their quality of life.
According to the National Multiple Sclerosis Society, MS is a chronic and disabling immune-mediated disease that affects an estimated 2.3 million people worldwide. Because MS can present a variety of symptoms—including fatigue, muscle weakness, disorientation, vision impairments, spasticity and trouble walking—the disease can be difficult to diagnose. Although there is currently no known cure for the disease, the NRRC is conducting an ongoing clinical trial in an effort to help people with MS regain their mobility and strengthen their lower limbs.
For 45-year-old Pearland resident Kelly Davis, who was an avid dancer prior to her MS diagnosis in April 2005, participating in the clinical trial gives her the opportunity to do what she hasn’t been able to do since she was 34.
“When they hooked me all up the first day, I was terrified. He was kind of intimidating,” Davis said, referring to her “dance partner” Ekso, an exoskeleton developed by Richmond, California-based company Ekso Bionics. “The first time, it was very stressful, but then once I got the hang of it and we got more familiar with each other, if you will, we started learning how to dance.”
Davis spent 15 one-hour sessions “dancing” with Ekso, as well as the ponderous REX exoskeleton—created by Auckland, New Zealand-based robotics company Rex Bionics—under the guidance and supervision of trained physical therapists. The REX exoskeleton is programmed to independently perform the same walking, turning, reversing and climbing up and down stairs motions as humans to give people with MS a means of exercising their legs.
“My balance was so much better, and getting around was a lot easier. I was stronger, and my legs had definition again,” Davis said. “[Working with the exoskeleton] was a really great experience, and I see it helping so many people.”
In addition to the Ekso and REX suits, the NRRC also utilizes the ReWalk Rehabilitation System.
“I’m always interested in looking at how to help my patients with neurological conditions […] go back to their normal life and go back to what they love to do,” said human movement scientist Shuo-Hsiu “James” Chang, Ph.D., assistant professor of PM&R at McGovern Medical School and lead researcher of the MS clinical trial. “What I want to see is a smile on [our patients’] faces, saying that they feel good and they feel better after doing the study. They help us find the answers to our hypotheses, and we try to help them and provide the opportunity to recover their functions. I think that’s the most important part.”
Beyond the MS study, the NRRC is also conducting a clinical trial out of its Neuromodulation Laboratory to evaluate the efficacy of vagus nerve stimulation for improving upper limb motor functions in patients who have suffered a stroke. Although vagus nerve stimulation has been shown to effectively treat chronic depression and epilepsy, this is the first time researchers are implementing the technique to study its effects on stroke recovery.
According to the Centers for Disease Control and Prevention, stroke is one of the leading causes of disability in the country. More than 795,000 Americans suffer strokes and 130,000 die from strokes each year, averaging one death every four minutes. For those who survive, recovery can take anywhere from weeks or months to years; however, regaining full function of the body is not always guaranteed. Long-term physical disabilities from stroke include muscle weakness, pain in the hands and feet, and paralysis on both or one side of the body, but researchers are optimistic that the vagus nerve stimulation clinical trial could improve patients’ chances of recovering upper limb motor functions.
Sponsored by Texas-based medical device company MicroTransponder, which first ran the vagus nerve stimulation clinical trial in January 2013 at the University of Glasgow in the United Kingdom, the NRRC is one of only three locations in the United States, along with Dallas and Minneapolis, testing the effects of the technique on stroke survivors.
The vagus nerve is the 10th and longest of the 12 cranial nerves responsible for conducting electrical impulses between the brain and neural system. Patients involved in the clinical trial undergo a surgical procedure in which an electrode is attached to the vagus nerve at the neck and a battery is placed in the chest beneath the skin. Using a remote to activate the battery from the outside, the system sends electrical pulses to the entire neural system to help the brain rebuild neural circuits that control upper limb functions.
“In other forms of neuromodulation, the non-invasive brain stimulation focused on the motor cortex, the part of the brain that is directly responsible for movement, planning and movement execution,” said the study’s lead researcher Nuray Yozbatiran, Ph.D., assistant professor in the department of physical medicine and rehabilitation at UTHealth. “But with the vagus nerve, we are not directly stimulating the motor cortex but stimulate parts of the brain (basal forebrain and locus coeruleus) that release neurotransmitters such as acetylcholine and norepinephrine that are known to facilitate reorganization of cortical networks.”
A critical component in the clinical trial, Yozbatiran said, is combining the technique with simple, activity-based training and exercises that reteach the portion of the brain responsible for motor function how to do certain movements, such as reaching, grabbing and turning objects of various sizes. Each time a movement is attempted, the patient receives small electrical pulses to activate the vagus nerve and rebuild neural connections affected by stroke.
For retired Richmond, Virginia-based business consultant and investor Paul Kelly, 56, that possibility of regaining function in his left arm was enough for him to move to Houston for two months to participate in the trial. After he suffered a stroke in January 2013 while working out at his home, Kelly became paralyzed from the neck down on his left side, and he was determined to regain full function of his body. Eventually, he was able to use his left leg again, but his tenacity, coupled with his business savvy, drove him to experiment with a variety of therapies—including stem cell treatments and an upper limb exoskeleton—to see what else could be done for his left arm.
At the encouragement of one of his doctors in Virginia, Kelly decided that one of the best ways to improve, while also helping others, was to participate in the vagus nerve stimulation clinical trial at TIRR Memorial Hermann. To him, the decision was clear and recovering from a stroke was no different than solving complex tax situations in China.
“I’d pull together a team of experts—accounting experts, tax experts—and we would go through in detail everything we needed to do to solve that problem,” Kelly said. “I told my wife many times, ‘I don’t know why we can’t have a team like that to address stroke?’ […] But when I had lunch with Drs. Francisco, Yozbatiran and their team, I told her, ‘That’s my dream team right there. That’s it.’”
Starting in August 2015, Kelly committed each week to working with Yozbatiran and her team to perform different exercises, such as moving small blocks and turning cards. The two months of hard work eventually paid off: By the end of the clinical trial, Kelly, a self-proclaimed outdoorsman, was able to cast a fishing rod. For many, this was a simple task, but for Kelly, this was a major, meaningful milestone.
“My greatest accomplishment has been that I have not allowed [the stroke] to ruin my life,” said Kelly, who recently returned from a hiking trip to Machu Picchu in Peru. “I loved the life I had before, but probably the most important lesson I’ve learned in the three and a half years is to not let what you cannot do keep you from enjoying the things you can do.”
While the NRRC already has a cutting-edge setup, the team’s hope is to further develop their program and continue providing the clinical rehabilitation version of precision medicine for their patients by using and finding new neurorehabilitation applications for the most advanced technology available.
“What I want to see in the future for this center is to develop very novel and effective treatments in physical rehabilitation and neurorehabilitation to help patients,” Chang said. “My hope is that we can push this to the clinical phase to help the public. That is my vision of what is next for the NRRC.”
In the process of the NRRC’s ongoing evolution, and in keeping with the center’s mission of finding novel and creative ways to rehabilitate people, the team is currently preparing for the addition of three new harness support devices, including one from NASA that runs on pre-installed ceiling tracks to provide over-ground gait training to help people develop the strength to walk again.
“The first time I see a patient moving around the facility, either walking, through a power chair or some assisted device, being able to take back control and feel like they’re in charge of their life again, there’s just nothing better than that,” Josehart said. “We really don’t think that good is good enough, so we’re always tweaking, always looking for that next level of function. We’re always trying to push the boundaries [because] it’s our goal that people not just recover medically, but they recover emotionally and that they get back to life.”
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