Rehabilitation after a stroke tends to focus on helping patients learn to get by with the physical function that they have left. But what if therapy could offer much more? In this episode of Mastering Innovation on SiriusXM Channel 132, Business Radio Powered by The Wharton School, John Krakauer, co-founder of Neuro Motor Innovations, describes how his company is testing specially designed video games to help stroke patients recover more fully.
Krakauer began by explaining the widespread problem of strokes in the United States and how his lab (the Brain, Learning, Animation, and Movement Lab) got started at the Johns Hopkins School of Medicine. He discussed how stroke rehabilitation has worked for the past few decades and the ways that new technologies can improve upon previous research. His idea to create a video game for recovering stroke patients is designed to engage patients in a rigorous yet enjoyable rehabilitation process. Finally, he explained the reasons for the founding of Neuro Motor Innovations and the work they do with MindMaze, their strategic partner.
An excerpt of the interview is transcribed below. Listen to more episodes here.
Nicolaj Siggelkow: How does rehabilitation currently work? What’s the current way of doing it?
John Krakauer: Rehabilitation has been, at least since the 80s and 90s, predicated in the idea that you should learn to use what you have left. In other words, it’s what we call a compensatory view, which says, “If you can’t use your right arm because you’ve had a stroke in it, learn to use your left arm better.” Given the amount of time that therapists have for you and the amount of time people tend to spend in the United States in the hospital for rehabilitation, it’s not feasible to try and reverse the deficit. Learning to cope is the basic idea. And that is due to the fact that people think any real return of function happens spontaneously, like a cut healing. That happens independently of what we’re doing as rehabilitation doctors. So you’ve got this healing process that is over fairly quickly, and then what you do is learn to cope with what you have left.
Siggelkow: That’s existing rehabilitation, “cope with what you have.” And if you’re lucky, your brain will heal itself to a certain extent. Now, you’ve done some exciting research and probably relied on other people’s exciting research on what happens in the brain in the first three months after a stroke. There seems to be some new knowledge coming out of that. Tell us about that.
Krakauer: We’ve known for quite a long time, going all the way back to Hippocrates, that most of the recovery happens early and spontaneously. We were wondering: could we find a way to piggyback on that, to amplify it or extend it? We began to embark on a series of studies, both in a mouse model of stroke and tracking humans to get some insight into this early spontaneous recovery. For example, if you give a mouse a stroke and you wait to start rehabilitating it for a week, then you don’t get a return back to its original reaching for pellet behavior.
But if you give that mouse a stroke and then start training again within 24 hours, you can get it back to the way it was before the stroke. If you give intense training early, it seems like in monkey models and mouse models, you can get a multiplication of the spontaneous healing process with the effects of training. But that’s not been done in humans. That’s because the doses and intensities required have not been attempted.
One surprising result made this case, in our view, is quite amazing: You take a mouse and wait too long to rehabilitate it after its first stroke. You then give it a second stroke. In other words, you make it worse. But now, you don’t delay. After this second stroke, if you start training right away, you can reverse the effect of both that second stroke and the first one. It does suggest there’s something special about the environment around the stroke early on, which makes you more susceptible to the effects of training.
Then we did a study that does suggest that humans are more receptive to training if you start early. But we’re still deciding what the best doses, intensities, and treatments are.
“There’s something special about the environment around the stroke early on, which makes you more susceptible to the effects of training.” – John Krakauer
Siggelkow: Tell us a little bit about this, because not everyone has seen the cool videos that I saw over the last couple of days about playing a video game and moving a dolphin around in the water. Explain to our listeners a little bit about the idea that you had to create a stimulating environment for people who want to move their arm early on.
Krakauer: Yes. You describe it well. We wanted to think, “How would we make it palatable for a human to do the huge amount of repetition and training that we’ve been able to do over the last century with the mouse and with the monkey?” We had a number of ideas that came together. One was finding a way to make them enjoyably babble, like children do motor babbling. You watch little babies, and they’re swinging their arms about all over the place. They’re exploratory and joyous, right? We wanted that.
We also knew that everyone is obsessed with movement. We know that half the planet watched the World Cup Final. People go and watch Pixar movies and Kung Fu movies and car chases. People love watching movement. They particularly like watching animation, and they particularly like watching animation of animals like Mickey Mouse and Donald Duck. We thought, “What about if you were not just watching animation, but you were the animation?” Maybe if you were the animation, it would be so much fun that you would move a lot.
That was the idea. We would make you a creature that swam about. It was so much fun that you didn’t realize you were doing an enormous amount of movement while you did it. It was a “star in your own Pixar movie” idea. That’s what we built. We spent many years at the National Aquarium here in Baltimore studying dolphins because they’re very joyous animals.
It’s interesting when people enjoy dolphins. Why do they enjoy dolphins? They enjoy dolphins because they can detect the playful intelligence in the animal as it swims. You can see it in the movement and in the intelligence injected into their movements. We wanted to allow people to control a dolphin. The team made a beautiful physics engine with a dolphin with real dynamics. The patients, with robotic support because they’re weak, could then swim by steering a dolphin in the ocean for several hours every day.
“What about if you were not just watching animation, but you were the animation?” – John Krakauer
Siggelkow: You mentioned the robotic arm that helps. That’s presumably part of the problem, right? When people have a stroke, to start them fairly early on on some hard regimen of movement might be quite difficult, right? One way to overcome this is to give them some help through this robotic arm?
Krakauer: That’s exactly right. One of the problems is, early on after stroke, you’re weak. Because you’re weak, you can’t practice skill because it’s masked by your weakness. It’s a little bit like flying into space and being weightless or doing therapy in a pool. You need to find some way that the strength requirements are reduced so that you then can start practicing skills. If you wait until your strength comes back, then that window we’ve been discussing is closed and you’ve lost the opportunity.
You need weight support that allows you to then practice your skill without the need for strength. Intuitively, you can imagine the difference, right? You could have a sumo wrestler and a young 12-year-old pianist. Just because the sumo wrestler is enormous and has enormous strength, it doesn’t mean they’re more dexterous than the 12-year-old pianist. Strength and dexterity are quite distinct when it comes to the nervous system.
About Our Guest
John Krakauer is a world-renowned neuroscientist, founder of the Kata Institute in the Department of Neurology at Johns Hopkins Medicine, Director of the Center for Motor Learning and Brain Repair at Johns Hopkins University, and Professor of Neurology and Neuroscience at Johns Hopkins Medicine. John is recognized in the United States and around the world as a preeminent thought leader on neuroscience, speaks around the world on brain function and repair, and has dozens of published works in the field. Previous work includes leadership roles in neuroscience at Columbia University. He leads all scientific discovery and validation for Neuro Motor Innovations.
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