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A critical window for recovery after stroke | John Krakauer | TEDxJohnsHopkinsUniversity



okay thank you very much so yes I'm going to talk to you today about stroke it's the leading cause of disability in the United States somebody's having a stroke every 40 seconds it's about 800,000 people a year in the US and at the current time we don't really have a cure for the disability mainly weakness down one side of your body after stroke and I'm going to show you some new data on how maybe we can do something about this problem these are ten people who've all had strokes these are MRI images their particular kind of MRI they can actually detect the stroke within minutes if it's happening and for you to do all you need to know is that the intense white bright bit on those brain scans is the stroke and in all 10 of these patients they are completely paralyzed on one side and then the question is who is going to get better why don't they get better and can we make them get better even though we predicted that they would not now the problem is that after you have a stroke like that you go into a hospital and hospitals have become very luxurious and you can sit in a room alone and watch The Weather Channel like this patient here the problem is that in the first couple of weeks after a stroke you spend about 60 percent of your time alone and only about 15% of the time moving and it as I'm going to show you this is not the best kind of environment to try and get your brain rewired after the injury by the way sort of in the spirit of the day this drawing here was done by a Micah graduate who is a full-time animation artist in our lab now called cat and one of the themes that I hope you'll take away from us today and I'll be repeating is that you really need to do something creative by bringing artists and scientists together so this is just a tiny bit of science and math don't panic all this is basically saying is that after brain injury there seems to be a fairly predictable rule of recovery which we call proportional recovery and the idea is from patience you can get about 70% back of your maximal potential recovery but unfortunately there's a subset of patients particularly ones who are severely paralyzed who don't follow this rule so the reason why it's interesting to have this rule is it means there is some kind of process going on in the brain which is self repairing and we need to somehow piggyback on that process and make it even better and for those patients who don't even follow this process we have even more work to do and then this is a functional imaging scan where we were able to show that this rule of recovery that seems to be going on endogenously in the brain after injury can be captured by brain imaging suggesting once again there's something systematic about it and that we could potentially exploit it so one of the things that we did at Hopkins at other universities in Europe up in New York was to sort of take a closer look at this process of recovery after brain injury to get some mechanistic insight into it and then hopefully again be able to use what we've learned to come up with better treatments and essentially what this study did was track patients within a couple of weeks of their stroke over a whole year and then throw the kitchen sink at them in terms of available technologies to sort of see what's going on these included doing non-invasive brain stimulation functional imaging structural imaging behavioral analysis in the motion capture just to sort of get a sense of what the natural history of this process is and when I'm going to show you now sits a tiny piece of the data we gathered to sort of reinforce the idea that we don't have that much time to work in to try and piggyback on this repair process so one of the things we do is we have a kind of Inlet in the lab at blam brain learning and animation and movement lab and we have a setup where you sit at a chair and you have your arm on a sled and you can make out back arm movements rather like in that air hockey kind of thing the reason we do this is that you can't make these movements unless you or you have normal motor control in other words you're stuck in this chair your arms like this and you have to make these straight movements like you see there on the right and the point is that there's no way that you can cheat at this in other words you can't move your trunk back and forth there's no way to make these nice straight movements unless you can coordinate your elbow and shoulder together so it's basically our basic test of the quality of your ability to control your arm with your brain okay and we take this very much for granted and any of you were put in this apparatus would look just like you can see those trajectories on the right now there's a patient after a stroke a mild to moderate stroke so they're trying to do what the healthy subject is doing but they can't and the question is is can we get from the stroke level of motor control over to the healthy side now what happens when you go for rehabilitation after brain injury in 2015 is it there's not an attempt to try and make your movements normal again to actually repair the brain we just have to help you cope with what you have left so if you're that bad for example and that's your dominant arm you and perhaps will have to start learning how to use a fork and to write with your other arm okay so the idea is let's get you back into the world and deal with what you have left but we feel that that's a little bit pessimistic and what we really need to be trying to do is to actually truly normalize your movements again all right now if you take those trajectories that I showed you and you try and quantify them and then you plot how good and how close those trajectories get to the normal ones you can get a plot like you see up here and suffice to say these are just two different measures on the y-axis and all I want you to see is that you improve you go down over the first five weeks and then you hit flatline all right and just for you to see that that's not some sort of true bottom you can see healthy subjects in the Green Line underneath that's where you could get to in an age match control but you see the patients do well for the first month and then they do no better okay now that's concerning it means that of some reason whatever this endogenous repair process is it's over in a month alright and as I told you in the first two weeks after stroke you spend most of your time alone and most of your time not moving so I would make the point that we have this window and we're not using it alright so let's try another way of learning more about this kind of window by looking at animal models so in parallel with the human work that we're doing we're also looking at mouse models of stroke and I'm going to show you a little bit about mouse stroke and I would say that in 2015 if you do have a stroke you'll be better off of your mouse and this is just a slide to show that in fact rats and mice to a lesser degree how remarkably dexterous and can be used as a model of motor control and I'll show you this this is a mouse now mice don't really have table manners they would prefer just to pick up their food like that okay but you can train them over time to do what we call prehension and prehension is the term used for reach and then grasp so I'll just show you this this is a mouse at the beginning of training this is a normal Mouse this has not had a stroke look at that I know that you didn't know that nice gradual hands like that okay but now that you've all been warmed by the mouse will now give it a stroke alright so this is a mouse brain and what you can do is you can actually block an artery over its cortical surface but you can see there on the right and in an area of the brain dies has a stroke it's deprived of blood and oxygen and it dies and this is a cross-section and we're going to zoom in on it and there's the stroke okay so we've given it a stroke in its motor cortex which is the part of the brain that controls its contralateral reaching limb okay so you take a mouse and as I showed you in that video you train it to reach for pellet and get up to 60% efficacy meaning that on its first reach 60 percent of the time it successfully NAB's that food pellet so you get it up to about that level of performance you never get all the way up to a hundred percent because they're not really that good this kind of behavior and you know we want to do experiments in a you know realistic timeframe so then you give it a stroke like go ahead just showed you and of course it's performance plummets this is a group data and then you start giving it rehabilitation and in this case what you mean is you try and train it again on the same task and what you can see is that you can spend weeks doing it and you can never get back to where you were before it gets up a little bit okay but doesn't do very well and we waited a week okay so we put it back in its cage and then we started rehabilitative after a delay this is not that unlike what happens to you if you've had a stroke you go to acute stroke unit where I work at much of the time and you have to get the medical condition stabilized and then you go to rehabilitation okay but what if you don't wait a week what if you start right away so we give them a stroke and we go within a day back to normal so one day somehow for the same amount of training you can get a lot more back than if you wait fairly compelling now if it's true that there's something special about what strokes do that make the brain uniquely plastic and we feel like in a sense what happens after brain injury is you briefly go back to the kind of plasticity you see earlier in development then we should be able to prove that paradoxically by in fact making somebody better from their stroke by giving them another one now as you can imagine we're not going to be doing this at Johns Hopkins Hospital but we're doing it is a proof of principle that there's something special in the stroke environment that can actually aid recovery okay and this is exactly what we can show you here so you again you train the mice up you give them a stroke you wait a week you can't get them up to that level before and then you say let's give them another stroke right next door to where we gave the original one and it makes and you'll notice that they get worse and then they go all the way back to normal yeah so obviously there's something special about the period triggered by the ischemia that we need to exploit and I think this is fairly self-explanatory the question obviously at this point is how do we do this without giving people another stroke so just to summarize and you can read about this from our website and most importantly when it comes to our website you need to follow us on Twitter is that there seems to be unlike in the normal brain and unlike in the chronic brain when it may be a little too late a period very early after stroke where you have damage but you've also got this hyper plasticity that we may be able to do something with right so one idea is to try drugs now one potential one is prozac known as fluoxetine which is a serotonin reuptake inhibitor which has been shown to have some effect on brain plasticity I don't have enough time to go into details but suffice to say that we thought we give prozac ago in our mice I should point out that the effect it seems to be having does not relate to its effect on mood and you can see here that even though we are waited a week now when you gave them the drug right after their stroke and then waited that week that beforehand didn't seem which led to a reduced responsive 'ti to training now you can get yourself back up to normal okay so on so that would be good news it means there are ways other than inducing another stroke where you can perhaps prolong and maintain this increased responsibility to training so what else well if you look in the animal literature unlike that hospital room with the patient watching The Weather Channel alone moving 15 percent of the time if you want to sort of induce improved recovery from brain injury and rodents the way to do it is to put them in enriched environments in other words you put them in with their friends you give them toys you give them multi levels you basically put them in this kind of fairground like environment and it's interesting that this kind of enriched environment that leads to motivation reward interaction enjoyment fun everything that we try and drain out of the hospital experience as quickly as possible they actually recover despite not receiving task specific training so in other words you can see there that we've got the task I showed you on the right then sort of spinning wheel in the middle and then just a general fun environment on the left ok and suffice to say that these kinds of environments that foster sort of enjoyment and play and exploration seem to actually make recovery better so the question we're going to finish with is how do we turn that hospital room more like an enriched wrap cage sort of translational medicine in the opposite direction right so the idea is is that you can create a kind of gaming virtual reality robotic environment in the hospital room ultimately and God forbid make it fun to be sick right if you're a child you in pediatric hospitals you're lucky some fairly scary clown might walk into your room but if you're an adult it's supposed to be bleak and austere and feel lonely and we have to do something about that seriously so I'm going to now tell you about a trial we're doing which is just about to begin where we're going to use exoskeletal robotics plus gaming plus brain stimulation to try and pounce on this period early after and create an adult version of an enriched environment in addition to that exoskeleton that I showed you we're also now working on 3d printed soft robotic hands to try and do the equivalent for your hand after Stroh and the idea is you could actually have this cool robotic hand on embed and self train so that's another direction we're going in so I'm going to show you the interface that patients are now seeing them and while they are in this exoskeletal robotic arm and i we've run about ten patients and i can tell you the kind of childlike delight and playfulness that it triggers it's really astonishing even to me so we're very hopeful that will actually bring fun and play back into the brain injury environment so let me just show you if we what people actually get to see in this trial i hope the sound is up and you are the dolphin you are controlling it this is the robot so this is the easy level we have to get fish and eat them and the patient's love it and then it gets hard this is when it becomes a sharp battle this happens in the oceans okay so and I have to tell you the patients absolutely do seem to love playing this but of course we can make no scientific claims as of yet as to its efficacy and whether it will work as an inner environment let me please point that out that this trial is about to start and these are pilot data but I have to say that even if and this is the provocative thing that this did not repair you for example if you were outside the window the ability to be in a controlling environment again is unbelievably pleasurable once you've lost movement and you could also dive into the ocean with a loved one and both of you go in okay be like going for a walk in the park without leaving the hospital room now I want to finish just by saying that and I think this speaks to the other talks you've heard which is to do this kind of work is really not about one person I'm talking about it but it requires an unbelievably talented group of people from unexpected disciplines to come together to do this so for example the carter team and that's the logo and just to tell you the kind of people this is omar catch permeat and kevin omar did his PhD in computer science he worked for Disney for awhile he's a computer scientist and programmer cat with the micro graduate who did the pictures I showed you before does all the rendering for these games as a micro graduate now a full time animation artist in a neuroscience lab at Hopkins I mean it's sort of unusual and then premier also did computer science at Hopkins and worked at Microsoft as a programmer and then kevin has just got his PhD in robotics here at Hopkins now these kind of super nerds right are working cheek by jowl with neuroscientists clinicians and therapists to do this and I will say that if we want to move forward in this space of brain injury and many other areas of Medicine you have to bring people together doing things that you may not at first blush think should be in the same room and what we really need to do is sort of Pixar up the healthcare and scientific space okay and so you know Omar cat permit and Kevin are working with you know teams this is the Columbia team for example and they're neuroscientist physiatrist rehab physicians and actually the guy with the least hair on the bottom row Steve Zoila is heading up the mouse data and so in other words you can imagine that all these people are working on what seem to be different parts of the same animal thank you very much he's our funders and I'll stop there you

Glenn Chapman

18 Comments

  1. You have my support a million percent. Genius idea!!!!!!!!

  2. My rehab was MountSinai in Hartford aconnecticut inUnited States.. Every nurseCVNA doctor and therapists loved me through my childlikeness almost healed my wounded inner child. I went through so much abuseand trauma as s young child I am almost sure that is why I finally stroked out. My blood pressure has been perfect and my pulse and resting pulse since my stroke. Every therapist and nurse who were coming to my house discharged me immediately because they said I was doing so good and that was immediately after discharge fffo rehab at Mount Sinai.When I could not open and close my left hand it finally happened like s robotic hand and that how I described it to other patients there also.They gave us Bruner balls and putty to play with in bed. I never turned my tv on in there I wanted to be busy!!!

  3. how sad that no computer aided technology has been introduced yet instead of animal testing so we don't have to hear some cold scientist talking nonchalantly about torturing animals again and again….

  4. When I get better I plan on helping out other stroke victims my arm and leg are getting better my sight is still mess up I call it drunk vision hope everyone severing stroke a swift recovery

  5. This guy talking about strokes doesn't know what he's talking about I hate when all these people have pie in the sky ideas . I have been paralyzed for 5 plus years from a massive stroke when you are taken right after a stroke all they work on is walking and math no qrm or upper extremities. I felt the therapists just had a job clock out at the end of the day I was carried around from one tharapist to another one would see me and say good I could get you in early especially on Fridays thinking they get off early for the wekend. Others just say do this and come back after a week of doing it at home

  6. I was moving from day one. So were other patients. physio and OT was intensive.

  7. I'm hopping when I try to take a step my leg seems to be holding weight fine except my knee starts to hurt. What do I need to do? Also I don't have any use of my arm and hand on the left side I'm having a hard time getting it to do anything.

  8. I had a stroke April 3, 2016 I didn't know that I had had a stroke until just over a week after I had the stroke. The ER Dr, thought it was just the flu, but when does the flu mess up your walking and equilibrium completely to the point of barely walking and having to have a hand against the wall to get to where your going? That was the only symptom of a stroke that I had, at least I think that's true, nobody ever said that something was wrong with me to give me a clue that I was having a stroke. Your life is different forever when you have a stroke, the life you knew before your stroke is dead and gone, you will never be the same, you can get back almost everything from your stroke that you could do before your stroke, but you will be different. Every stroke is different, every stroke recovery is different, every stroke victim is different. You can't put someone who's had a stroke into a box and tell them what they can and can't do as a result of their stroke, no doctor can possibly know that or tell a patient who's had a stroke what they will or won't be able to do in their recovery. You can tell someone what they can and can't do after a stroke and then sit back and watch them prove you wrong. Or they can work as hard at their recovery as hard as they can every day the rest of their lives and yet still only improve a very small amount. But you don't know which one is which. When someone works hard at their rehab and recovery you never know which group they would be in or closer too. When you have a stroke you can't take the chance to take it easy and not work very hard on your recovery, because you might very well get back alot of your abilities that you had before your stroke, if you saw me walking then you would never guess that I had a stroke just over 2 years ago and how I could barely walk and needed alot of help to walk anywhere i was going too. The 1st few weeks I was in the VA hospital I was wheeled everywhere I was going. I worked as hard as I possibly could work in my rehab and recovery from my stroke.

  9. I realize the window of opportunity but if a person cant see or talk then what ??? anyone please

  10. which video games and how often did you play would love to try, please PM me the details

  11. I can vouch for video gaming helping me in my Thalamic/PLIC stroke recovery.

    Regular PT is about strengthening muscle groups and ROM at set intervals a week and a major pain. Video games you can not only work at home using your shoulder/arm/hand again, but also helps in spatial awareness some strokes cause, everyday and for hours a day, too.

    It just depends on the type and how extensive your stroke is, that video gaming is a good additional means to keep a patient motivated to get better (a big concern, as strokes shock the system badly).

    A year later I'm back to about 90% norm in functioning on the left side. Still have other setbacks with the vision, but motor skills have mostly returned to normal. Just some ataxia and numbness and vision issues remain.

  12. Note findings of the AVERT trial. Patients in the very early mobilization group had poorer outcomes (poorer modified ranking scale score and more deaths) than the usual care group. So it is possible to do rehab (particularly mobilization) too early.

  13. I'm almost 7 years out from hemorrhagic stroke and I'm still making gains, it just takes longer to reach each one

  14. I trying to follow you, but there is NO LIMIT to relearning and make better our MINDS, this brain CAN Keep doing. I hate when people Limit us, LIMIT YOU, No us Stroke SURVIVORS. Geez

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