Stroke: neuromodulation and virtual reality (FS-11)

Focused symposium

Levin MF1,2Liebermann DG3Solomon JM4Frenkel-Toledo S5,6 
1McGill University, School of Physical and Occupational Therapy, Montreal, Canada, 2Center for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montreal, Canada, 3Tel Aviv University, Physical Therapy, Tel Aviv, Israel, 4Manipal Academy of Higher Education, Department of Physiotherapy, Manipal, India, 5Ariel University, Department of Physiotherapy, Ariel, Israel, 6Loewenstein Rehabilitation Hospital, Physical Therapy, Ra'anana, Israel

Learning objective 1: To be able to discuss the principles of motor learning based on concepts of neuroplasticity and motor control
Learning objective 2: To identify and discuss possible mechanisms of action of non-invasive brain stimulation for motor learning and critically assess its advantages and pitfalls
Learning objective 3: To identify different virtual reality approaches and how VR can be combined with other technologies in a study conducted in different countries.
Description: This symposium will review how technology can be used to address principles of motor learning and motor control, and how they can be combined to deliver personalized upper limb impairment-based rehabilitation interventions. 
Recent advances in technology have the potential to enhance sensorimotor recovery after acquired brain injury such as stroke. Motor learning can be optimized using non-invasive brain stimulation of sensorimotor, cognitive, attentional and motivational networks combined with movement training in enhanced environments. Thus, technologies such as non-invasive brain stimulation combined with intensive training of functionally-relevant movements using virtual reality technology are thought to tap into the brain's capacity for neuroplasticity and reduce motor impairment, such as spasticity, in the paretic upper limb. In addition, for better sensorimotor recovery to occur, it is also important that training be matched to the individual's level of motor impairment and based on the principles underlying the production of smooth, stable and skilled movement. In particular, training may be more effective if the tasks practiced are done within an area of peri-personal space in which the patient is able to produce controlled movements compared to one in which the task is possible only with abnormal or compensatory movements. Technology can be used to enhance the training experience. For example, training in virtual reality environments allows therapist to manipulate principles that enhance motor learning such as task difficulty and feedback. 
The Symposium will begin with an overview of how a tri-national (Canada-Israel-India) randomized control trial was conducted and discuss its advantages and pitfalls (5 mins - Levin). The first speaker will provide an overview of non-invasive brain stimulation and recovery after stroke (15 mins - Liebermann). The second speaker will review motor control and motor learning principles and describe how these can be translated to design more effective training paradigms for upper limb motor recovery (15 mins - Levin). The third speaker will present a demonstration of a training approach combining anodal-tDCS, personalized arm motor training in a virtual reality environment in a patient with stroke (15 mins - Frenkel-Toledo). The final speaker will discuss patient perception and acceptance of using tDCS and virtual reality technologies in a lower income country (15 mins - Solomon). A 15 minute question and answer session with the audience will ensue followed by a 10 minute summary by the panel highlighting the implications, applicability and relevant take-home messages.
Implications / Conclusions: It is important for physiotherapists to keep up to date with current advances in technology and their potential for use in the rehabilitation of patients. This symposium will provide an overview of non-invasive brain stimulation (tDCS) and virtual reality technologies for sensorimotor retraining and demonstrate how they can be combined with personalized impairment-based training in patients with sub-acute stroke. Physiotherapists will also be able to assess the feasibility of applying treatments combining these technologies and principles in different countries with different socio-economic structures. 
Key-words: 1. motor learning 2. stroke 3. technology
Funding acknowledgements: Canada-Israel Health Research Program, jointly funded by Canadian Institutes of Health Research (CIHR) and International Development Research Center (IDRC) #108186-001, Azrieli Foundation and Israel Science Foundation (ISF) #239215
Relevance to physical therapy globally: This symposium will describe how an international collaboration was established between physiotherapy researchers and physiotherapists working in rehabilitation centers in three countries – Canada, Israel. India. We will describe steps to overcome sociocultural/health system differences between countries in order to deliver the same level of care across centers. We will also discuss how differences in health care delivery across countries was taken into account to design a rehabilitation program incorporating the highest standards of care.
Target audience: Physiotherapists, kinesiologists, physical therapy assistants and researchers interested in developing training programs to enhance motor learning and motor recovery in patients with acquired brain injury.