TAG: "Physical medicine & rehabilitation"

Jacob’s story


Experimental gene therapy treatment for Duchenne muscular dystrophy offers hope for youth.

Jacob Rutt is a bright 11-year-old who likes to draw detailed maps in his spare time. But the budding geographer has a hard time with physical skills most children take for granted ― running and climbing trees are beyond him, and even walking can be difficult. He was diagnosed with a form of muscular dystrophy known as Duchenne when he was 2 years old.

The disease affects about 1 in 3,500 newborns ― mostly boys ― worldwide. It usually becomes apparent in early childhood, as weakened skeletal muscles cause delays in milestones such as sitting and walking. Children usually become wheelchair-dependent during their teens. As heart muscle is increasingly affected, the disease becomes life threatening and many patients die from heart failure in their 20s.

Today, Jacob is one of 51 children participating in a nationwide clinical trial for a new type treatment that could offer help to those suffering from devastating neuromuscular disease. Clinical researchers at UC Davis Medical Center and a handful other research centers around the nation are testing a high-tech drug designed to fix the underlying genetic defect causing the progressive muscular decline that is seen in children with Duchenne.

“This type of genetic therapy is the most exciting treatment approach I have witnessed in my career for Duchenne muscular dystrophy,” said Craig McDonald, professor and chair of the Department of Physical Medicine and Rehabilitation at UC Davis, as well as principal investigator of the national clinical trial that Jacob is participating in. “We are hopeful that it will delay many of the disease’s manifestations and ultimately improve life expectancy for patients.”

Duchenne muscular dystrophy is caused by genetic mutations in the gene for the muscle protein dystrophin. The protein is a stabilizer that protects muscle fibers; without enough functional dystrophin, muscles become damaged, causing them to weaken and deteriorate over time.

Functioning a bit like a bridge over a dangerous chasm, the experimental drug — known as drisapersen — is designed to effectively cover over the specific genetic mutation, allowing the problem area to be skipped and causing cells to produce a slightly shorter – but functional – dystrophin protein.

Because Duchenne muscular dystrophy is rare and the drug addresses only a small subset of the genetic variants responsible for the disease, recruiting qualified patients was not easy. Of the medical centers involved in the study, UC Davis, with its highly regarded neuromuscular disease and physical medicine and rehabilitation expertise, enrolled the largest group of patients in the nation. For more than a year, its eight young participants, including Jacob, have been to Sacramento from as far away as Colorado, Utah and Arizona. For each participant, the clinical trial involved weekly injections, which meant Jacob had to fly from Southern California to the UC Davis clinic every Friday for 24 weeks.

“I’ve never seen such a complicated study in terms of logistics,” said Erica Goude, who serves as the research coordinator at the UC Davis site. “We’re collaborating closely with departments of pediatrics, cardiology, radiology and several others, and their outstanding commitment to the project has made our tasks much easier and more efficient. This study is an amazing team effort that I see frequently reflected in the smiles of our patients and their families.”

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Muscular dystrophy group awards research grant to UC Davis team


Funding will expand Duchenne muscular dystrophy studies.

Craig McDonald, UC Davis

A New Jersey-based nonprofit organization, the Parent Project Muscular Dystrophy (PPMD), has awarded UC Davis physician Craig McDonald $175,000 to expand an ongoing international research effort aimed at better understanding the progression of Duchenne muscular dystrophy and determine the benefits of current standards of care that have been established by the national Centers for Disease Control and Prevention.

The PPMD funding enables investigators to recruit 100 additional subjects into an ongoing research project with the Cooperative International Neuromuscular Research Group. That investigation, chaired by McDonald and Erik Henricson, a UC Davis muscular dystrophy researcher, is the largest and most comprehensive assessment of boys and young men with the disease to date and is being conducted at 20 study sites around the world, including the UC Davis Sacramento campus. The grant helps extend the funding support the team has received from the National Institutes of Health, the National Institute for Disability and Rehabilitation Research and the U.S. Department of Defense.

Duchenne is the most common form of childhood muscular dystrophy, affecting about 1 in 3,500 newborns – mostly boys – worldwide. It is a progressive and fatal muscle disorder that usually becomes apparent in early childhood when it begins to cause the loss of muscle function, wheelchair dependency, and declines in respiratory and cardiac functions.

“Funding from PPMD will make a critical difference in the development of new outcome measures and the overall quality of the data we collect in this study,” said McDonald, who is chair of the UC Davis Department of Physical Medicine and Rehabilitation. “Our studies have already improved clinical trials for Duchenne, and this new funding now allows us to extend our research to younger boys, including those who have not yet started taking steroids.”

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UC Davis Chancellor emeritus Vanderhoef discharged from hospital


He was treated at UC Davis Medical Center after an ischemic stroke.

Larry Vanderhoef

UC Davis Chancellor emeritus Larry Vanderhoef was discharged from UC Davis Medical Center today (Dec. 27) after nearly four weeks of acute rehabilitation for a Dec. 1 ischemic stroke. He will continue to work with specialists as an outpatient to maintain and improve skills.

“Dr. Vanderhoef has responded well to rehabilitation and has regained much of the strength he lost on the right side of his body,” said Cassie Spalding-Dias, an assistant professor of physical medicine and rehabilitation and director of inpatient therapy at UC Davis. “Rehabilitation is an ongoing process, and we expect him to improve as his body continues to heal over the next year.”

A stroke, or “brain attack,” occurs when blood circulation to the brain fails, causing some brain cells to die from decreased blood flow and the resulting lack of oxygen. An ischemic stroke occurs when a blockage stops the flow of blood to the brain. It is the most frequent cause of stroke, responsible for about 80 percent of all strokes in the U.S. Rehabilitation helps individuals relearn skills that were lost when brain cells died. It includes a wide range of therapies that provide carefully directed, well-focused, repetitive practice — the same kind of practice used by all people when they learn a new skill such as playing the piano or pitching a baseball.

“I’m glad to be getting back home and am thankful for the excellent care that I received from the nurses and rehabilitation team at UC Davis,” Vanderhoef said. “I’m eager to pick up where I left off in the office and to be back in my seat at the Mondavi Center and at our men’s and women’s basketball games. I’m getting better, day by day and bit by piece. I am definitely on my way back!”

According to the Centers for Disease Control and Prevention, nearly 800,000 strokes occur in the United States each year. Recognizing the following signs of stroke and contacting 9-1-1 immediately can lower the risk of death and disability:

  • Numbness or weakness of the face, arm or leg, especially on one side of the body
  • Confusion, trouble speaking or difficulty understanding
  • Trouble seeing in one or both eyes
  • Trouble walking, dizziness or loss of balance and coordination
  • Severe headache with no known cause.

Spalding-Dias emphasizes that treatment options are available for stroke when symptoms are identified and treated early.

“Time is brain,” Spalding-Dias said. “Rapid, early treatment can prevent long-term damage and offers the best chance of recovery for acute ischemic stroke patients.”

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Q&A: Jacob Rosen


UC Santa Cruz researcher is developing robotics to aid patients, doctors.

Jacob Rosen, UC Santa Cruz

“There is really no end to the march of invention,” said Brevet Brigadier General John A.B.C. Smith, a character in Edgar Allan Poe’s 1839 short story “The Man That Was Used Up.”

This early science fiction tale of a military man remade of manufactured parts — a 19th-century bionic man — is more than an interesting side note to America’s conflicted relationship with technology. By expressing the fear that we may lose our natural selves, and the idea that the conquest of the frontier transforms us into pieces of military machinery, Poe prefigured the anxieties many Americans feel about technological advances.

If you dream of electric sheep — or androids with imperial ambitions — it’s reassuring to hear UC Santa Cruz robotics researcher Jacob Rosen describing the inspiration for his work. “I had an adviser back in Israel who told me that everything you do should at least help one person,” said Rosen, a professor in the Jack Baskin School of Engineering.

Rosen and his fellow researchers at the UC Santa Cruz Bionics Lab are developing robotic systems that will help far more than a single individual. Their main areas of research are “exoskeletons” that help stroke victims recover the ability to control arm movement, and remote surgical robotics that will allow doctors to operate without actually being on the scene, as well as to work with robotic “partners” to speed up surgeries.

Last spring, the Silicon Valley Business Journal honored Rosen with its “Health Care Hero Award” for his robotics research.

At the University of Washington, Rosen did postdoctoral research with pioneers in the field of remote surgery, including Richard Satava, a science fiction buff and professor who had served in Desert Storm. Satava envisioned a fully automated operating room called a trauma pod. This scenario is now close to becoming reality, thanks to collaboration between engineers like Rosen and surgeons like Satava. In a recent interview, Rosen explained why cross-disciplinary research is so crucial, but why it sometimes can be difficult.

Q: You’ve talked about conducting research collaboratively the way computer engineers develop open source software. Is this a new idea in the field of robotics?

A: It’s new, but it’s also a natural progression, if you think about the field, which is very multidisciplinary. My undergraduate degree is in mechanical engineering, my graduate studies were in biomedical engineering and my postdoc was electrical engineering. I moved across the engineering landscape. This is, in a sense, the story of robotics. There is no one sub-discipline in engineering that can claim it.

Q: You received a grant that will allow a half dozen institutions to experiment with Raven II, the remote surgical hardware and software you’ve developed. Was it hard to get your collaborators to accept this approach?

A: It was hard to get me to accept it. It was very suspicious. My colleague at the University of Washington, Blake Hannaford, came up with the idea: Let’s write a grant, duplicate the system, and give it to our “vicious enemies” (laughs) for free. The only reason I agreed to do it is that he had proved me wrong several times. And he was right.

There’s an honest effort to work together towards the common goal. Everyone can access the smallest screw to change and modify the system. On a more serious note, Raven itself was originally developed because industry wouldn’t allow academics full access to surgical robotics, and we didn’t want to hold the research back by adopting that approach.

Q: Your collaborators are a pretty impressive group.

A: They are impressive. We’re working with Harvard and Johns Hopkins, UCLA, UC Berkeley, University of Nebraska and the University of Washington. I feel that we’re taking the right stance. There are so many aspects of surgical robotics that a single researcher, and even multiple institutions, can’t address. Things get very intense and very complicated when you’re actually using the technology in the field.

Q: What closed the deal for you?

A: Robert Auman, an Israeli mathematician, won a Nobel prize in economics for his work on game theory. Basically, he discovered that collaboration isn’t necessarily effective if it’s a one-shot deal. But if a game is played multiple times, collaboration yields better results. I began to feel that collaboration is at the foundation of our existence. We used to collaborate to survive; now we have the luxury to choose whether we want to collaborate. But the benefits can be significant, across the board. For example, if two competing companies collaborate, they actually increase their revenue.

Q: You’d already collaborated with surgeons.

A: I found the confluence of engineering and medicine interesting. Most people were shying away from it because it’s a very elaborate and time-consuming process. These are two cultures and we don’t even speak the same language. They try to intimidate us with anatomical terms in Latin and you try to intimidate them with equations.

Q: How do you get everyone to agree?

A: It takes time. Once they learn our language and they learn about ours, things get better. A lot of it is setting expectations. Surgeons in particular are very hands-on. They want their tool to be in their hands tomorrow. Yesterday, actually. But as one of my colleagues put it, medicine is a problem-rich environment, and engineering is a solution-rich discipline.

Q: What do you see in the future for remote surgery?

A: I’m interested in collaborative surgery: two surgeons, two sets of arms. They could be next to each other, or in remote places, but either way, surgery would be accelerated. One of them could be a machine, so it would be a human collaborating with an algorithm. The U.S. military has a vision that 15 to 20 years from now, the entire military will be robotic. This includes medical services. So there will be movement in that direction.

Q: And after surgery, or stroke, comes rehabilitation. That’s where the exoskeleton comes in. What is it, exactly?

A: An exoskeleton is a device that you wear, like clothes. It’s supposed to interact with you physically, co-exist with you. It can amplify your strength, even if you’re healthy. For example, it can help you carry heavier loads. We sometimes call it a haptic device. Haptics in Greek is a sense of touch.

Q: How does it work?

A: I can put you in a virtual reality, and map the motion you make into an avatar. With most virtual reality set-ups, if you reach toward a ball, you can see the hand reaching the ball, and it might even penetrate the ball, but you don’t feel anything. Our exoskeleton stops once your reach the ball. You would not penetrate it, and you would feel it. You can move around in a virtual physical world and feel the force feedback.

Q: How does that help the disabled?

A: It’s neurological. The whole idea of treating these people is based on the brain’s plasticity. We have more neurons than we actually need, and if one part of the brain is damaged, other parts can take over and recover some of the motor control. But it takes time.

Insurance companies expect stroke victims to relearn in three months what took them 20 years to learn in the first place. It’s almost impossible. But you can amplify the learning. Now the learning is limited by how much time stroke victims have with a physical therapist, but people can tolerate far more therapy. That’s where the exoskeleton comes in.

Q: Will it replace physical therapists?

A: No. But it will allow therapists to treat more patients at the same time and offer patients the opportunity to do more therapy. We’re not removing people from the scene. What we’re planning to do is make it patient-centered, rather than therapist-centered.

Q: That sounds great. But the exoskeleton looks large and heavy. How do stroke victims use it?

A: Gravity is a very strong force on our body. About 95 percent of the energy we use goes to keeping our body in a certain posture, and only 5 percent to move in a certain direction. Some of these patients lose a lot of muscle control. This exoskeleton’s actuators, electrical motors, compensate for the gravitational load, and also for the patient’s weight. They feel as if they are in space. So they can concentrate on the motion itself.

Q: Is this similar to the devices we’ve seen on TV: those miraculous-appearing devices that allow paraplegics to walk?

A: That approach consists of connecting electrodes directly to the brain. There is a fundamental problem with it. The brain doesn’t like that you’re inserting electrodes in it, so it develops tissue that will isolate it from the electrodes. After three months, the brain will fully encapsulate the electrodes. Unless there’s a breakthrough in biocompatibility, the technology is viable but very short-lived.

With a stroke, the recovery continues indefinitely. You take someone in, you treat them for a while, you build the neurological connections, and you set them free. We looked at people 10 years past a stroke and the brain is still demonstrating the ability to recover. We think of our system as a “gym for the brain.” It’s a physical activity that’s changing neurological set-ups.

Q: Is this available yet?

A: We’re trying to make it commercially available through a company I founded called Exosense.

Q: You’ve only been at Santa Cruz for a few years, yet the lab seems to be moving quickly, both in the rehabilitation devices and the remote surgical effort.

A: Typically you find robotics distributed among many departments in engineering. Richard Hughey, who’s now the dean of undergraduate studies, decided to invest in robotics, and Santa Cruz offers both undergraduate and graduate degrees in robotics. The university is unusual in offering that degree for undergraduates.

Q: I’m getting the feeling that you’re intense about your work.

A: That’s possible. I used to play violin, and row competitively.

Q: How was the competitive rowing in Israel?

A: We were actually pretty good. We competed internationally, in three world championships. But it was 25 years ago. I’m still rowing, only now it’s in a reservoir a few miles from here.

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Saving dogs with spinal cord injuries


DoD funds UCSF, Texas A&M collaboration to test therapy that may help people.

Dogs with spinal cord injuries may soon benefit from an experimental drug being tested by researchers at the University of California, San Francisco, and Texas A&M College of Veterinary Medicine & Biomedical Sciences — work that they hope will one day help people with similar injuries.

Funded through a three-year, $750,000 grant from the U.S. Department of Defense, the drug to mitigate damage has already proven effective in mice at UCSF. Now the Texas team will test how it works in previously injured short-legged, long-torso breeds of dog like dachshunds, beagles and corgis, who often suffer injuries when a disk in their back spontaneously ruptures, damaging the underlying spinal cord.

About 120 dogs a year that develop sudden onset hind limb paralysis after such injuries are brought to the Small Animal Hospital of Texas A&M University, where they receive surgical and medical treatment similar to that for human spinal cord injury. Now, researchers will test whether the new treatment works on some of these dogs, with their owners’ consent.

“It would be phenomenal if it works,” said Linda J. Noble-Haeusslein, a professor in the UCSF departments of Neurological Surgery and Physical Therapy and Rehabilitation Science who designed the intervention. “We are in a unique position of being able to treat a dog population where there are simply no current therapies that could effectively improve their hind limb function.”

The new treatment does not seek to regrow injured pathways in the spinal cord. Instead, it aims to mitigate damage secondary to the spinal cord injury. Most spinal cord injuries trigger a cascade of chemical reactions in the spinal cord that collectively damage nearby cells and pathways, contributing to functional deficits including hind limb function.

A few years ago, Noble and her UCSF colleague Zena Werb showed how blocking the action of one protein found in the spinal cord of mammals can help mice recover from spinal cord injuries. This protein, called matrix metalloproteinase-9, can degrade pathways within the cord and cause local inflammation, leading to cell death.

Dog using a medical device to walk.

The injured dogs offer a great opportunity to take the next step on this treatment because their injuries more closely mimic spontaneous human spinal cord injury and, as is the case with humans, no existing treatment has substantially reduced paralysis.

Noble’s co-investigator on the new study, Jonathan Levine, D.V.M., an assistant professor in neurology at Texas A&M University, will treat the dogs through injections of a protein-blocking drug. He will then help the dogs through rehabilitation and assess their recovery. Ongoing studies at UCSF focus on further refining delivery of the drug so as to optimize recovery.

Other researchers have shown that movement can be preserved if as little as 18 percent to 20 percent of the nerve fiber tracts in the spinal cord remain intact.

If successful, the trials in injured dogs may lead to the development of similar treatments for people who suffer spinal cord injuries, Noble said. These are among the most expensive injuries: Every person with an injured spinal cord costs the health care system millions of dollars over his or her lifetime.

Such costs often are overshadowed by the tragic and devastating personal price of the injuries, which dramatically alter lives and most often occur in younger people, with long lives in front of them. According to the National Spinal Cord Injury Statistical Center, based at the University of Alabama, Birmingham, most of the 12,000 Americans who suffer spinal cord injuries are between the ages of 16 and 30.

As of this year, some 265,000 people in the United States are living with such injuries, according to the national center. This includes many wounded soldiers who have returned home from war zones.

UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.

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Can robots take over rehab?


At UC Irvine’s iMove center, machines help people regain use of damaged limbs.

UC Irvine professor David Reinkensmeyer (right) and Robert Sanchez demonstrate their Armeo robot (click image for larger view)

Visiting the iMove center at UC Irvine’s Gross Hall is like being on the set of a sci-fi movie. Here, the merging of machines and humans — the premise of such futuristic films as “Alien” and “The Terminator” — has become a reality.

Inside the lab, at Sue & Bill Gross Hall: A CIRM Institute, patients whose limbs have been impaired by a stroke or spinal cord injury don robotic arms, gloves with special sensors and other high-tech devices designed to help get them moving again.

For more than 20 years, iMove center director David Reinkensmeyer has sought to restore human mobility by developing new technologies for motion training, exercise and rehabilitation.

“I started in this field because I was interested in robotics and how the brain works. And I wanted to help people. You put those three things together, and you get this,” he says, gesturing to the assorted contraptions. “One of my close friends in graduate school had cerebral palsy, and I saw what it was like to live with a disability.”

A professor of mechanical & aerospace engineering, anatomy & neurobiology and biomedical engineering, Reinkensmeyer is like Q in the James Bond movies without the stuffy British attitude. Instead of weapons, though, he and his collaborators create exoskeletons that attach to patients’ limbs, facilitate their movement and relay progress to a computer.

“David is a leader in biomechatronics robotic systems that interact with something alive. But he’s so self-effacing that you’d never know it,” says Robert Sanchez, Ph.D. ’05, who worked with Reinkensmeyer while pursuing his doctorate in mechanical & aerospace engineering and now designs surgical eye equipment for Alcon Research Ltd. in Irvine.

On a fall afternoon, Reinkensmeyer and Sanchez demonstrate one of their favorite inventions: ArmeoSpring, a robotic arm that assists patients unable to perform rehab exercises on their own.

“When someone suffers a stroke, the nerve pathways to the brain that operate a limb are no longer viable. To repair them, patients need to practice moving the limb, but often they’re too weak. Gravity holds them back,” Sanchez says. “Armeo utilizes springs to counteract the weight, so they can move their arm and restore those neural connections.”

Adds Reinkensmeyer: “If they didn’t have the device, their arm would just drop. It’s exciting to see patients move in ways they haven’t since their illness or injury.”

Working out with Armeo feels more like playing a computer game. The patient’s movements are tracked on software that guides them through simple challenges, such as loading virtual apples into a cart.

“It’s like a three-dimensional mouse,” Reinkensmeyer says of the robotic arm. “The tasks mimic activities in daily life.”

People using Armeo have shown greater improvement than those who underwent conventional therapy. The device is now sold by Hocoma and employed in more than 200 clinics worldwide.

“Patients like training with Armeo more than table top exercises because it’s a game against themselves. So the hope is that they’ll spend more time training,” Sanchez says.

Reinkensmeyer’s lab, in collaboration with UCI mechanical & aerospace engineering professor James Bobrow, has developed another exoskeleton called PAM/POGO (Pelvic Assist Manipulator/Pneumatically Operated Gait Orthosis) that gives patients full range of motion in their legs and pelvis while training on a treadmill. “It helps you stand and start moving,” Reinkensmeyer says.

Sophisticated software enables the robot to adapt to people’s different strides, instead of leading them astray “like the ‘wrong trousers’ in that Wallace & Gromit movie,” he says.

PAM/POGO even caught the attention of rapper Dr. Dre, who borrowed it for the “I Need a Doctor” (5:54) video, in which his character undergoes rehabilitation after a car accident.

“At first I wasn’t sure if we should do the video, ” Reinkensmeyer says. “I worried that it wouldn’t treat people with disabilities with respect. But — although some of the language is objectionable — the video does portray the hope and hard work of rehabilitation.

“It’s had more than 73 million hits on YouTube. Young people see robotic rehabilitation and think, ‘This is really cool.’ It might inspire them to want to help others with technology.”

Another cool invention, the Music Glove, fosters finger dexterity. Doctoral student Nizan Friedman, electrical engineering assistant professor Mark Bachman and Reinkensmeyer attached sensors to ordinary leather sports gloves, then hooked them up to a computer. Patients play songs on Guitar Hero by tapping their fingers together.

“It’s a low-cost way to do a lot of hand exercises,” Reinkensmeyer says. “If we asked people to move their fingers 1,000 times like that without playing the game, they’d say, ‘No way.’”

Because these devices can precisely gauge a patient’s progress in rehab, they’re valuable tools for stem cell researchers, which is why iMove is located in the Sue & Bill Gross Stem Cell Research Center.

“We hope to give stem cell scientists the gadgets to better measure if stem cell therapy is working and to enhance regeneration through intense exercise,” Reinkensmeyer says.

In 2010, Reinkensmeyer received a $1.5 million grant from the National Institutes of Health to study how effective robots are in restoring motor skills.

“Right now, we’re limited by making these devices strong yet lightweight enough for people to wear them but it’s becoming increasingly possible,” he says.

Reinkensmeyer hopes that robotic devices, coupled with the kind of stem cell therapies being developed at UCI, will someday help patients live better, more active lives.

“To see a person who’s been injured recover completely may seem like science fiction, but that’s what we all dream about,” he says.

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Merging robotic rehab & stem cell research


UC Irvine’s Gross Hall hosts robust effort to accelerate stroke and spinal cord injury recovery.

Stroke patient Dorothy Williams uses Dr. Steven Cramer’s hand/wrist-assisting robotic device to improve function in her left hand, as occupational therapist Lucy Der-Yeghiaian monitors her progress.

Computer games and stem cell research may seem unrelated, but at the Sue & Bill Gross Stem Cell Research Center, they fit together like hand and glove — a Music Glove, to be exact.

The device, used in stroke rehabilitation studies at the bustling UC Irvine research facility, features sensors attaching the glove to a computer and allows patients to play songs on Guitar Hero by tapping their fingers together.

Several cutting-edge rehab programs at the center similarly utilize robotics and computer software that someday could be combined with stem cell-based therapies to accelerate recovery from strokes and spinal cord injuries.

With support from the state’s stem cell research funding agency — the California Institute for Regenerative Medicine — neurologist Dr. Steven Cramer and biomedical engineer David Reinkensmeyer last year moved their existing rehab programs into the first-floor clinical lab space at Sue & Bill Gross Hall: A CIRM Institute and have since become integral to the stem cell research center’s mission.

Besides Music Glove, Reinkensmeyer and his collaborators have developed several other technologies to help restore limb movement after a stroke or spinal cord injury, while Cramer employs a robotic device with video games to improve hand and arm function in stroke patients.

“When the day comes that people can be treated with stem cell therapies, we believe these types of rehab programs will boost their effectiveness,” Cramer says. “The therapies will have maximum impact when paired with behavioral training that aids brain cell regeneration.”

On their own, the rehab programs are producing notable results. In one, Cramer is studying a hand/wrist-assisting robotic device that helps patients grasp and release common objects. It wraps around the hand and is coupled with software that directs people through a physical therapy program including video games. HWARD users initiate hand movement, and the robot monitors and supplements motor activity to meet therapeutic goals.

When Dorothy Williams entered the HWARD study earlier this year, she was recovering from a stroke that had severely weakened the left side of her body. She could grip nothing with her left hand.

Over three weeks of rehab sessions, Williams’ strength and range of motion grew steadily, and she excelled at the video games. “My scores broke a lot of records,” says the 86-year-old Westminster resident. “I’m really excited about that.”

Williams can now carry 8 pounds in her left hand and perform such functions as dressing, according to her son Michael. “Her therapists are thrilled by her improvement,” he says. “HWARD really helped restore her strength and coordination. It’s a godsend.”

“We’re showing that robotic therapy is beneficial,” says Cramer, adding that his team is building a laptop version of HWARD for home use. “But combined with stem cell treatments, the results could be amazing.”

UCI researchers are doing their part. The world’s first two clinical trials of stem cells for the repair of spinal cord injuries are based on therapies developed by Sue & Bill Gross Stem Cell Research Center scientists.

“It’s a nice setup here in Gross Hall,” Cramer says. “We’re working on the human and behavioral sides of it, and — upstairs — they’re creating the stem cell candidates for treatments. Someday the two groups will collude, which will bring the best outcomes for patients.”

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The bridge to recovery


Home health: The bridge between the hospital and a full recovery.

Physical therapist Charlotte Norton helps post-surgery patient Steve Caruso navigate his stairs.

Steve Caruso had a difficult adjustment following hip replacement surgery at UC Davis Medical Center. He wasn’t prepared for the pain following his procedure or for the emotional strain of being homebound. The UC Davis home-health team is helping him regain his mobility – and more.

“I felt for a while like I was never going to get any better. It was frustrating because I had no similar experiences as a patient to compare it to,” said Caruso, who has been visited regularly at home by physical therapist Charlotte Norton and nurse Marianne Ciavarella since being discharged in September. “They have been very helpful in reassuring me that I am coming along fine, pushing me to go further with my therapy and never letting me think of myself as an invalid.”

UC Davis Home Health is a team of experienced nurses, social workers, physical therapists and home-health aides who, under the leadership of family and community medicine physician Don Zacharias, support patients like Caruso who are well enough to leave the hospital but not yet able to independently manage all of their medical needs. Home health fills those gaps in the healing process. The services are typically less expensive, more convenient and as effective as in-hospital care. They also help prevent rehospitalizations.

The department’s hard work was rewarded this year with a 5-Star Patient Perception Award from Professional Research Consultants (PRC), an independent market research firm specializing in patient-satisfaction measurement. For 2010, 75 percent of patients surveyed rated the overall quality of care as “excellent,” placing the home health department in the 98th percentile relative to other home-health agencies in PRC’s database. Home health was one of four UC Davis Medical Center departments that received such high marks.

“We know we have a ‘dream team’ in terms of experience and commitment. However, it was great to get this external validation that our patients appreciate what we do,” said Glenda Reckner, administrator of the home-health team.

Always interested in improving patient satisfaction, even when the scores are already high, home-health managers check in with patients and caregivers regularly to discuss their experiences and potential improvements.

“It’s our version of doing rounds,” Reckner said.

An important part of the dream team is Ciavarella, an R.N. case manager who helped establish UC Davis’ home-health program 16 years ago and has seen vast changes during that time.

“In general, we are more highly regulated and patient-outcome management is now the driving factor,” she said.

As a result, the team works together to develop specific care plans based on each patient’s particular needs and challenges. One patient, for instance, was an elderly man with a history of diabetes, cancer and chronic pain. His wife, also elderly, was experiencing challenges providing her husband’s care.

His plan included Ciavarella, who educated the couple about diet, medications and getting the patient’s blood sugars under control, and then worked with his physician to help with pain management. Vanessa Brown, a social worker, linked them with community resources for additional in-home support. Norton helped him improve his strength and abilities with a walker so he would need less assistance with bathing and transfers. She also recommended a ramp that would enable him to more easily leave home for medical appointments and enjoy his garden. As he began to do things for himself, it freed his wife from some of her responsibilities and stress.

Most important, this patient was able to recover at home, where he wanted to be.

“We help in ways that can’t be supported in the hospital,” Reckner said. “Once patients’ immediate medical needs are resolved, they tend to heal faster in familiar surroundings.”

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Computer games help people with Parkinson’s


Computer-based physical therapy games helped patients improve both gait and balance.

Released jointly by Red Hill Studios and UC San Francisco

Glenna Dowling, UC San Francisco

>>View video on the therapy games

Playing computer-based physical therapy games can help people with Parkinson’s disease improve their gait and balance, according to a new pilot study led by the UC San Francisco School of Nursing and Red Hill Studios, a California serious games developer.

More than half the subjects in the three-month research project showed small improvements in walking speed, balance and stride length.

UCSF and Red Hill were the first research team in the United States to receive federal funding in the burgeoning field of low-cost computerized physical therapy games. Unlike off-the-shelf computer games, these specialized games encourage scientifically tested specific physical movements to help people with functional impairments and diseases.

Teams at Red Hill and UCSF collaborated to produce nine “clinically inspired’’ games that were designed to improve coordination in people with Parkinson’s disease, a chronic, progressive neuromuscular disease characterized by shaking, slowness of movement, limb and trunk rigidity. The clinical team members at UCSF focused on specific body movements and gestures that their previous research had shown to be beneficial for staving off the physical declines of Parkinson’s.

The UCSF team was led by Glenna Dowling, R.N., Ph.D., professor and chair of the UCSF Department of Physiological Nursing, and Marsha Melnick, PT, Ph.D., a clinical professor in the UCSF School of Medicine’s Department of Physical Therapy and Rehabilitation Science and professor emerita of the Department of Physical Therapy at San Francisco State University.

The Red Hill team then designed physical games, similar to Wii and Kinect games, in which subjects win points by moving their bodies in certain ways. Each game has multiple difficulty levels so that the clinical team could customize the therapeutic games for each subject’s particular abilities.

“Each subject found his or her own gaming ‘sweet spot’ — the spot where the physical challenge was not too hard, not too easy, just right,’’ said Bob Hone, creative director of Red Hill Studios and the lead principal investigator of the study. “And when subjects mastered one game level, they often moved on to harder levels for more beneficial effect. The subjects improved their games scores while improving their gait and balance.’’

Red Hill developed a custom sensor suit with nine tracking sensors to analyze subjects’ movements with higher resolution and accuracy than is possible with consumer gaming platforms. The PC-based system sent encrypted data to a secure database allowing the research teams to track the subjects’ performance daily.

“From the data tracking we could see that there were some subjects who were playing the games more than the specified three times a week,’’ Hone said. “Because this was a highly structured research study, we actually had to ask them to play less than they wanted.’’

The trial involved 20 participants in Northern California with moderate levels of Parkinson’s disease. After playing the games for 12 weeks, 65 percent of game players demonstrated longer stride length, 55 percent increased gait velocity, and 55 percent reported improved balance confidence.

“These initial studies show the promise of custom-designed physical therapy games promoting specific movements and gestures that can help patients get better,’’ Dowling said. “Now that we have this preliminary positive result, we want to conduct a longer term clinical trial with more subjects to confirm these initial findings.’’

The study was funded by two Small Business Innovative Research grants totaling $1.1 million from the National Institute of Neurological Disorders and Stroke — part of the National Institutes of Health.

UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.

Red Hill Studios is an award winning serious games developer that creates interactive games for health, online science games, and immersive museum exhibitions. It also conducts research into new educational and health gaming paradigms. Red Hill is based in San Rafael.

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UC Davis named neuroscience clinical trials site


One of only two sites in California.

Craig McDonald, UC Davis

The National Institute of Neurological Disorders and Stroke (NINDS) has selected UC Davis Health System to be one of 25 clinical sites in the United States, and one of just four on the West Coast, in its newly created NeuroNEXT Network for Excellence in Neuroscience Clinical Trials.

The network is designed to support high-quality clinical trials over the next seven years for neurological disorders ranging from brain injury, multiple sclerosis and stroke to dementias, neuromuscular diseases, movement disorders and autism. The new network also will leverage the health system’s major research and clinical care strengths in neurosciences and make new treatment protocols available in the region.

“This prestigious designation enables us to greatly enhance the important collaborations taking place between experienced clinicians and clinical investigators in our neurology, neurosurgery, pediatrics and physical medicine and rehabilitation services,” said Craig McDonald, professor and chair of the UC Davis Department of Physical Medicine and Rehabilitation, and principal investigator for the new project. “What’s truly exciting about being part of a national network is that it offers great hope for a diverse community of patients and families who face incredible challenges from devastating neurological disorders and injuries.”

As one of just two network sites in California – the other being at UCLA – UC Davis’ Sacramento campus will be the state’s only NeuroNEXT clinical trials site north of Los Angeles. The capital city location comprises a number of core research and care facilities, including the UC Davis MIND Institute, UC Davis Center for Neuroscience, the UC Davis Center for Mind and Brain, and the UC Davis Imaging Research Center, as well as the health system’s Department of Physical Medicine and Rehabilitation, which is highly regarded for its research and clinical care support to patients with neuromuscular and neurodevelopmental disorders.

“The road from ‘bench to bedside’ is a long one,” said McDonald. “Combining the health system’s great interdisciplinary team-oriented care, superior clinical neurosciences services, and physical medicine and rehabilitation expertise with our experience in clinical trials offers a spectacular opportunity to advance care for patients.”

McDonald added that the new NeuroNEXT program will benefit from its proximity to UC Davis’ Clinical and Translational Science Center, which is part of a national consortium working to transform how American biomedical research is conducted. It, too, is designed to speed the translation of laboratory findings into treatments for patients.

“Investigating potential therapies for neurological disorders and injuries requires careful planning, partnerships and collaborations so that the most promising treatments can be successfully tested and evaluated,” he said. “All of the elements for success are in place right here in Sacramento.”

UC Davis Health System is advancing the health of patients everywhere by providing excellent patient care, conducting groundbreaking research, fostering innovative, interprofessional education, and creating dynamic, productive partnerships with the community. The academic health system includes one of the country’s best medical schools, a 645-bed acute-care teaching hospital, an 800-member physician’s practice group and the new Betty Irene Moore School of Nursing. It is home to a National Cancer Institute-designated cancer center, an international neurodevelopmental institute, a stem cell institute and a comprehensive children’s hospital. Other nationally prominent centers focus on advancing telemedicine, improving vascular care, eliminating health disparities and translating research findings into new treatments for patients. Together, they make UC Davis a hub of innovation that is transforming health for all. For more information, visit healthsystem.ucdavis.edu.

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Grant to boost muscular dystrophy rehab training


Five-year grant also will train research specialists in neurodevelopmental disorders.

Craig McDonald, UC Davis

After a highly competitive selection process, UC Davis has been awarded a five-year, $750,000 federal grant to train 10 specialists in research related to the rehabilitation of patients with neuromuscular and neurodevelopmental disorders.

The grant from the National Institute of Disability and Rehabilitation Research, an agency within the U.S. Department of Education, underscores UC Davis’ reputation as an international leader in the study of conditions such as muscular dystrophy and autism.

“This critical funding will help us address the severe shortage of experienced, qualified rehabilitation researchers in the areas of neuromuscular and neurodevelopmental disorders,” said Craig McDonald, chair of the Department of Physical Medicine and Rehabilitation and an internationally recognized expert in the clinical management and rehabilitation of muscular dystrophies. “While the subspecialties of neuromuscular and neurodevelopmental disorders have historically attracted clinicians, the training of clinical scientists in these disciplines has been neglected, creating a profound shortage of qualified researchers.”

Neurodevelopmental and neuromuscular disorders are highly complex diseases that can have a tremendous impact on health, quality of life and life expectancy. Because of their unrelenting, progressive nature, many of the disorders create enormous psychological, emotional and financial burdens for patients, families and caregivers.

More than 5 percent of the population suffers from genetic and acquired neuromuscular disorders such as muscular dystrophy, Lou Gehrig’s disease (ALS) and peripheral neuropathy, which represent major causes of mortality and morbidity in American children and adults. Similarly, neurodevelopmental disorders such as autism and fragile X syndrome also have a significant impact on human health, altering both the developing and mature nervous system, and affecting emotion, learning ability, cognition, social interactions and communication. Once considered rare, autism-spectrum disorders are now known to affect more than 1 in 150 persons — and possibly as many as 1 in 91.

While McDonald is the principal investigator of the grant, he said the training program will be a collaboration leveraging stellar resources within UC Davis’ Clinical and Translational Science Center, together with training programs directed by Jay Han, associate professor of physical medicine and rehabilitation, and Robin Hansen, professor of pediatrics and director of clinical programs at the UC Davis MIND Institute.

“This project is a real example of collaborative, interdisciplinary research at UC Davis and one reason why this institution has been able to excel in team science and clinical translational research,” McDonald said.

Under the grant, each trainee will complete a two-year comprehensive program to develop specialized and interdisciplinary research skills in the field. Trainees will be either physicians, postdoctoral fellows or allied health professionals and will follow a “hands-on,” individualized research training plan, supervised by an experienced group of mentors.

Over time, McDonald said, the training will help UC Davis “accelerate the translation of new knowledge acquired through basic science into clinical therapeutics and rehabilitation interventions that will enhance the health, function and quality of life for those with these disabling disorders.”

In addition to the training grant, the Department of Physical Medicine and Rehabilitation recently received two additional NIH grants related to muscular dystrophy research, totaling almost $2 million over four years. One grant will fund ancillary studies linked to a multi-center natural history study of Duchenne muscular dystrophy currently led by UC Davis. The second grant will help researchers generate much-needed data on novel biomarkers as outcome measures for future clinical trials.

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Cutting-edge facility for physical therapy


New UCSF facility offers advancements in treatment and patient care.


uch_ucsf_treadmill_tMore than 100 faculty members, students and staff celebrated the UCSF Department of Physical Therapy and Rehabilitation Science’s new home on the Mission Bay campus on March 15 as part of an open house to highlight the innovative services available in the cutting-edge facility.

Located just upstairs from the UCSF Orthopaedic Institute at 1500 Owens St., the new space offers several advancements in treatment and patient care. Physical therapists can now treat patients almost immediately following orthopedic surgery, a welcomed change from when the program was previously housed across town at the Mount Zion campus.

“Before we were split at Mount Zion across Divisadero Street,” said Kimberly Topp, PT, PhD, professor and chair of the Department of Physical Therapy and Rehabilitation Science. “With this new space it’s so much easier to take care of problems and be creative.”

Additionally, the UCSF Physical Therapy Health and Wellness Center – where patients receive individualized exercise instruction designed by physical therapists – is also located at Mission Bay, further shrinking the distance and increasing continuity of care.

“The patient can now go from the operating room downstairs to rehab in our new physical therapy facility upstairs and then to the Health and Wellness Center across the street to get up and running in no time,” said Topp. “It’s also the first time we’ve had contiguous academic and clinical space.”

The new facility consists of a large main room, dubbed “the gym,” which is lined with physical therapy tools such as an anti-gravity treadmill that “unweights” up to 80 percent of the user’s body weight, offering personalized precision benefits to those recovering from injury or surgery without the pain and risk associated with full-weight impact on joints, bones, tendons and muscles. Cameras attached to the ceiling work in conjunction with a force plate in the floor to conduct running and gate analysis, measuring how much force is exerted through the foot and whether the patient is off balance.

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