Toronto Rehab +10 Report on Rehabilitation Research
+10 Report on Rehabilitation Research Questions, answers, solutions.
Revolutionizing rehabilitation, maximizing life A message from Mark Rochon President and CEO One in two. It’s a statistic that always jumps out together a wide range of disciplines is the work We believe, and others agree, that these are at me—that one in two of us will be touched by we are leading in the use of artificial intelligence promising solutions to pressing problems. disability, either personally or through someone to help individuals with cognitive issues cope Our scientists work to quickly apply or in our immediate family circle. better at home. Imagine a house that can detect commercialize findings. As you will read, we However, one person in two is the reality in if someone has fallen and, someday soon, even are delivering new products to market, helping today’s society, with a rapidly aging population monitor a person’s nutritional intake, medication people who need them to maintain their and an increase in the incidence and prevalence use, heart rate and blood pressure. Toronto independence while creating good jobs and of people who live with multiple chronic Rehab’s fall-detection supporting a knowledge- conditions. As a result of medical advances, system was cited by The “As a result of medical advances, based economy. living with a disability is often a fact of life for Economist as one of several living with a disability is often You may have seen the growing number of people surviving heart advances in computer-vision Toronto Rehab’s latest disease, cancer, stroke and traumatic injury. software that are “begetting a fact of life for the growing public awareness As a consequence, more and more people will a host of new ways for number of people surviving campaign, launched in need rehabilitation in the years to come—and machines to view the world.” heart disease, cancer, stroke and 2010 to build awareness we will need new and more effective treatments, We believe that our about the hospital and and assistive devices and technologies to discoveries and innovations traumatic injury.” how rehabilitation saves support people, help them remain in their will enhance the efficacy and – Mark Rochon life. It describes our bold homes for as long and as safely as possible, and cost-effectiveness of health vision to revolutionize support their caring family members. services delivery. For example, our portable sleep rehabilitation—and maximize life. We do this Rehabilitation research—one of the most apnea device—much less expensive than an every day through quality and innovative important frontiers in healthcare today—is all overnight test in a sleep lab—provides an easier, clinical care and groundbreaking research. about meeting these needs. Toronto Rehab’s more convenient way to diagnose obstructive Making this research possible are the Ontario program of research is uniquely equipped to sleep apnea. Our new electronic hand hygiene Ministry of Health and Long-Term Care, and lead the charge. In just 10 years, we have built monitoring system prompts healthcare other ministries, agencies and foundations. one of the most comprehensive rehabilitation professionals to wash their hands. The goal: to These include the Ontario Ministry of Research research programs in the world. We’ve attracted prevent hospital-acquired infections that are and Innovation, the Ontario Innovation Trust, a remarkable team of scientists, clinician- so costly to patients and the healthcare system. the Canadian Institutes of Health Research, the scientists, students and postdoctoral fellows, Canada Foundation for Innovation, and the drawn by our first-rate facilities and the culture Ontario Neurotrauma Foundation. We are also of collaboration between researchers and deeply grateful to the generous individuals and clinicians across all our sites. We also value our corporations who support our research with their collaborations with our affiliate, the University contributions to the Toronto Rehab Foundation. of Toronto, and with other post-secondary We also thank the International Scientific institutions and private sector partners. Advisory Committee (ISAC), which provides an It’s remarkable how research filters throughout objective assessment of our research program Toronto Rehab, and the way that we’re integrating and advises on directions to accelerate future research and patient care. Featured in this report growth. are stories that illustrate how our research can With our tremendous research staff, we are help people recover more effectively, stay healthy producing solutions that will revolutionize and stay home. We also report on the important rehabilitation and maximize life for millions of work undertaken to assess and recommend Canadians, and millions more worldwide, living improvements to the delivery of health services. with disabling injury and illness or age-related An excellent example of research that knits conditions.
+10 Contents 2 3 4 Answering questions, offering solutions Scott Fraser: a timely answer to a devastating problem Research in the news 6 Retraining the brain 11 Matthew Linton: exploiting brain plasticity 12 Preventing falls on stairs 16 Dealing with dementia 20 Fighting disease with exercise 25 Wendy Angelo: an “amazing journey” 26 The scourge of sleep apnea 31 Mary Grzywna: breathing easier, getting on with life 32 Helping people hear better 36 Senior drivers: staying safe on the roads 40 The cold weather challenge 44 Taking care of caregivers 48 Rehab innovations 52 Open for business: the world’s most advanced rehabilitation research environmentOn the front cover 54 Eric Wan: helping a star to shineJennifer Hsu of the Winter Research Groupis studying how to prevent falls in winter. 55 GovernanceShe is one example of how Toronto Rehab 56 Who we areresearchers are dealing with issues oneveryone’s minds. On the pages of this 60 Acknowledgement of supportreport, you will meet other researcherswho are are working to revolutionizerehabilitation and maximize life forpeople everywhere affected by disabilitiesand age-related conditions. Top of mindfor all our researchers are the people whowill benefit from Toronto Rehab research,from patients to family caregivers.
Answering questions, offering solutions Introduction by Dr. Geoff Fernie VP, Research Not long ago, I was guiding a visitor through with advancing age. On these pages, you’ll accurately study and measure the difficulties one of our labs when he turned to me with a find surprising insights into why people fall. people encounter in the real world and produce personal question. His father had fallen down Innovations like insoles to help people keep their solutions that make a difference. the stairs at home and the family had no idea balance as they walk, are now on the market. Ten years ago, Toronto Rehab’s research how it had happened. “We’re all very worried,” he And we don’t only focus on the individual; program was created with a grant from the told me. “How can we prevent this kind of thing every day, we think about the wider Ontario Ministry of Health and Long-Term from happening?” environment, from the design of streets to winter Care (hence the title of this report, +10). Today, So many of us have questions relating to the apparel. The fact is that, during winter, mortality hundreds of projects are unfolding and showing challenges that come with older age, disability rates, injury rates and the incidence of acute and promise in all kinds of different directions. It’s and disease. In this report, you’ll find some of chronic illness all increase, making this season all so exciting that I can’t wait to get cracking in those questions, posed by people living in the particularly hazardous for older adults. Our the morning—and to tackle the questions on community, observations and practical recommendations everyone’s minds. And so, we present you with“So many of us have questions patients and will allow older people—and the general 10 of those questions and some of the answersrelating to the challenges that their families. Research at population—to stay safe and active in winter. Supporting family members is another big and solutions we’re producing.come with older age, disability Toronto Rehab focus. Incredibly, over one-quarter of Ontarioand disease.” is dealing with families have been providing constant care for – Dr. Geoff Fernie issues that are someone at home for more than two years. on everyone’s We’re determined to ease the burden on family minds. Our research is highly relevant to caregivers, and on professional caregivers such people’s lives. We’re producing practical as nurses, who experience high rates of back solutions to real-life challenges so we can injury. As you’ll read, Toronto Rehab scientists maximize life. are addressing these urgent needs through One of our goals is to help people recover some highly innovative projects. from injury or illness so that they can return And we’re having a real impact. Our research home as soon as possible and participate in is already producing new and more effective work or other activities. In the first section of treatments, assistive devices and technologies. this report, you’ll read about novel treatment We’re generating new knowledge and sharing approaches that involve stimulating the brain— our approaches—like our award-winning and harnessing its innate ability to recover after research-based cardiac rehab home program— injury. You’ll meet a young man who is back at with others. On top of that, we’re shaping work after taking part in a study investigating a practices and policies, such as building codes. new way of dealing with brain injury. The next few years will bring an explosion of Another goal is to support people safely in new ideas that can be developed and tested in their own homes so that they never need to our gleaming new research labs. We now occupy occupy a hospital bed or enter a nursing home. the most advanced rehabilitation research We do this by preventing injury and illness, and facility anywhere in the world. It’s a place helping people adjust to the limitations that can where researchers have the tools to recreate come with older age. Falls are a major concern real-life conditions. This allows us to safely and 2 ANSWERING QUESTIONS, OFFERING SOLUTIONS
Scott Fraser a timely answer to a devastating problem “Will I ever be able to eat normally again and to problems—a condition called dysphagia—were pneumonia, he had to tuck his chin to his chest enjoy meals at home with my wife and son?” devastating. “It was very, very depressing,” he every time he swallowed. For more than two years while hospitalized says of the time he was unable to drink liquids In the Toronto Rehab study, Fraser learned after a traumatic brain injury that left him and eat regular, solid food. a series of tongue-pressure exercises using unable to swallow, this question consumed It all began in November 2007 when Fraser’s his tongue to squeeze a bulb positioned in his Scott Fraser’s thoughts. The answer came in an family was involved in a car crash with an mouth. In 24 sessions, he mastered the exercises unexpected way: his wife Lorraine stumbled impaired driver. Fraser was left with many that Dr. Steele calls “boot camp for the tongue,” upon it in a copy of Toronto Rehab’s +8 Report challenges, including dysphagia. Tube feeding regained his swallow and moved a giant step on Rehabilitation Research that she found in a directly into his stomach deprived him of the closer to being able to go home from hospital. lounge a few doors down from her husband’s taste, texture and social aspects of eating, but it Dysphagia often occurs with conditions such room in a Toronto area hospital. kept him alive and nourished. as brain injury, stroke, Parkinson’s disease and A story about a man with a similar swallowing Eventually, he graduated to drinking multiple sclerosis. It also increases as people age problem led the couple to Dr. Catriona Steele, thickened liquids and eating puréed foods by (up to 80 per cent of people in nursing homes director of Toronto Rehab’s Swallowing mouth but he didn’t like the taste and texture. have swallowing problems). A major contributor Rehabilitation Research Laboratory. Fraser Every meal was a painfully slow process. Fraser is a loss of muscle strength in the head, neck enrolled in a research study, being conducted had to swallow twice for each mouthful of food and especially the tongue, which is composed by Dr. Steele, to test a new swallowing therapy and wash it down with a sip of thickened liquid. entirely of muscle. involving tongue-pressure exercises. He was To prevent food and liquid from going down “We want to be able “We want to be able more than willing to give it a try. His swallowing his airway and to his lungs, which can cause to train those muscles so to train those muscles that a person’s swallowing improves without needing so that a person’s to think about it every time swallowing improves they swallow,” says Dr. Steele. without needing to “After a brain injury, there’s enough to worry think about it every about,” says Lorraine Fraser. time they swallow.” “My husband has had to learn to walk again, his – Dr. Catriona Steele quality of speech has been affected and he has some cognitive challenges. So to have his swallowing resolved is a huge thing. Dr. Steele has no idea how our quality of life has improved. Her research has helped our family tremendously.” In the summer of 2010, after two-and-a-half years in hospital and treatment at Toronto Rehab, where he participated in the study, Fraser was discharged home. Every day, he enjoys meals with his family. He can safely drink liquids and eat the most challenging food including meat, popcorn and nuts. “I have the same food as Lorraine and my son Kyle, and I can eat my meal in half an hour. Scott and Lorraine Fraser: I enjoy these times with my family. It’s very “our quality of life has improved”. important to me.” n + 1 0 R E P O R T O N R E H A B I L I TAT I O N R E S E A R C H 3
Research in the news Toronto Rehab’s research program is constantly making news, whether it’s for our innovative new therapies and technologies, The Canadian Press The Toronto Star CBC News: The National CTV.ca Canadian researchers developing Creating a passion for elder care ‘Winter tire’ boot aims to Painkiller abuse sparks new specialized video games for thwart icy falls Canadian guidelines stroke treatment Seniors are the fastest growing population group in Canada, and Why do winter falls occur? It’s a Canada is the world’s third-largest per More than 50 per cent of stroke Dr. Kathy McGilton is a leading question that preoccupies Jennifer Hsu, capita consumer of opioid painkillers. survivors have speech and language advocate for their needs. The Toronto a Toronto Rehab student researcher These painkillers, such as morphine, impairments. Treatment and exercises Star profiled Dr. McGilton, a Toronto studying how well different types of codeine and oxycodone, help people for these disorders can be laborious Rehab senior scientist and University winter boots do on a variety of winter deal with chronic non-cancer pain. and repetitive. What if we could bring of Toronto professor who is pioneering surfaces. The CBC caught up with Hsu But there’s a growing misuse of these the excitement of gaming technology new approaches to senior care. at the hospital’s special ClimateLab, medications. CTV.ca reported on to speech therapy? As The Canadian Working with colleagues at Toronto which can simulate winter conditions new Canadian guidelines to help Press reported, Toronto Rehab Rehab, Dr. McGilton has developed as cold as -20C. Currently, Hsu is doctors when they are considering researchers are working with Algoma a new model of care for cognitively- focusing on postal workers, who are whether to prescribe opioids for their University in Sault Ste. Marie, Ontario, impaired hip fracture patients. Usually, particularly at risk of winter slips and patients. “We hope that one of the to do exactly that. The research team these patients move directly from falls because they work outdoors benefits of these guidelines will be is taking speech language techniques acute care to a nursing home, based in all types of weather on a wide to reduce the diversion and abuse currently used one-on-one in the clinic on a belief that they can’t benefit from variety of surfaces. Her goal: to make and addiction problems with these and turning them into a computerized, active rehabilitation. However, when recommendations on effective forms drugs, because these are really good game-like application. “The idea that Toronto Rehab offered a personally- of footwear against slips and falls on medications,” lead author Dr. Andrea we could take some of the therapies tailored form of rehabilitation, “they inclines and transitions, and to develop Furlan told CTV.ca. Dr. Furlan is an that we do that often have a repetitive were just as likely to walk out of the improved winter footwear design associate scientist at the Institute for component to them and make them hospital under their own steam and to criteria. Ultimately, the findings will Work and Health, a Toronto Rehab fun and alluring and keep people live in the community after discharge,” benefit everyone who spends time adjunct scientist and clinician, and an engaged was very attractive,” Toronto Dr. McGilton told The Star. It’s an outdoors, says Hsu, a PhD candidate assistant professor in the Faculty of Rehab senior scientist Dr. Elizabeth approach, she added, that can take in biomedical and mechanical Medicine’s division of physiatry at the Rochon told CP. It’s still early days in pressure off long-term care facilities engineering at the University of University of Toronto. The guidelines the technology’s development but, and acute care hospitals. Dr. McGilton Toronto. In the winter of 2005 to 2006 include 24 practice recommendations eventually, patients could play the is an associate professor at the alone, more than 21,000 Ontarians for doctors to use. video-game therapy on their own Lawrence S. Bloomberg Faculty of visited an emergency room because of time, in hospital or at home. Nursing. injuries related to falling on ice or snow. 4 RESEARCH IN THE NEWS
advances in knowledge, or expertise on disability, disease and aging. Some of the latest media coverage is listed below. Canadian Business Online Global News The Globe and Mail Most comprehensive study of its kind Sole support Rehab reprieve: games add a little fun shows impact of brain injury on women’s to recovery reproductive health It’s an all-too-common scenario: an elderly person falls, breaks a hip, has surgery and then, because Playing on a Nintendo Wii gaming system can help After a brain injury, women often ask how the injury of limited mobility, moves to a nursing home. And patients recover upper-arm function after stroke, will affect their fertility, pregnancy and postpartum there’s an even bleaker scenario: 20 per cent of new findings show. The Globe and Mail reported health. New findings, reported in Canadian Business people who break a hip die within a year. As Global on a study comparing 10 stroke patients who used Online, provide some much-needed answers. News reported, Toronto Rehab scientists have Wii gaming technology with 10 patients who did The insights come from a study which examined developed a simple footwear insole to improve standard recreational therapy, such as playing the health outcomes of 104 pre-menopausal balance and reduce the risk of falls and fractures. cards or bingo. After using the Wii for just eight women five to12 years after moderate to severe Sole Sensor™ enhances balance by heightening hours over two weeks, patients showed greater brain injury. It found that women with traumatic foot-sole sensation, explains Dr. Stephen Perry, arm speed and strength, compared to those in the brain injury (TBI) were more likely to experience a Toronto Rehab adjunct scientist and associate recreational therapy group. “Just having that variety menstrual disturbances, but did not appear to professor of kinesiology and physical education of different tools you can use that are adapted have significantly more problems with getting at Wilfrid Laurier University. The special insole has to the level of the individual and to their own pregnant when compared to women without a raised ridge that surrounds the perimeter of personal interest is where the field needs to go,” brain injury. However, women with TBI had fewer the foot, stopping just short of the large toe. The study co-author Dr. Mark Bayley, a Toronto Rehab children, reported lower levels of perceived health, ridge is designed to enhance the sole’s sensory scientist, told The Globe. Repetitive exercises are and experienced more postpartum difficulties. perception—something that declines with age— important for regaining upper-arm function, but “Our findings provide important information for by stimulating tiny sensors located in the outer they can get tedious, so making it more fun makes women who have experienced a traumatic brain edges of the sole. Published results show that sense, added Dr. Bayley, head of the hospital’s injury, and for health professionals working with Sole Sensor reduced the number of falls by half. Neuro Rehabilitation Program where the study these women,” says Dr. Angela Colantonio, a senior In Canada, fall-related injuries cost the economy was conducted. The findings were published in scientist at Toronto Rehab and lead author of the an estimated $2.8-billion a year. (For more on Sole the journal Stroke. A larger study is now underway, study, published in the Journal of Women’s Health. Sensor, see page 50.) headed by Dr. Gustavo Saposnik of the Stroke Dr. Colantonio holds the Saunderson Family Chair Outcomes Research Unit at Li Ka Shing Institute at in Acquired Brain Injury Research at Toronto Rehab St. Michael’s Hospital, to determine if Wii should be and is a professor of occupational science and widely used in stroke rehab. occupational therapy at the University of Toronto. + 1 0 R E P O R T O N R E H A B I L I TAT I O N R E S E A R C H 5
Q.1 Retraining the brain Last year, I had a bad fall from a ladder and fractured my skull. The brain injury has affected my ability to solve problems. I’m hoping to get back as much of this function as possible. I’ve read about the adult brain’s remarkable capacity to change. How can we – Roger in Toronto* retrain the human brain? 6 RETRAINING THE BRAIN *Some names have been changed for confidentiality.
Brenda Colella is a member of theCognitive Neurorehabilitation Sciences Lab. Researchers are working to improve recovery for brain injury survivors, like Sue Stewart (at right in inset picture). Stewart experienced a serious brain injury in 2005.
A.Dr. Robin Green has simple advicefor her Toronto Rehab patients inthe months and years followingtreatment for traumatic braininjuries: “Use it or lose it.” For Dr. Green, ‘using it’ involves ongoing stimulation of the brain to maximize recovery. It begins while the patient is still in hospital. Dr. Green, a Toronto Rehab scientist and neuropsychologist, is currently leading a major study with brain injury patients to investigate the effects of doubling therapy on the brain’s ‘plasticity’—its ability to change and recover in response to stimulation. But Dr. Green is also looking at the impact of intensive brain stimulation when patients go home. She’s already shown that less cognitive atrophy of the brain after severe brain injury. On the positive side, this work suggests that engaging in stimulating activities—such as returning to work or school, or even meditating— preserves an important part of the brain and its functioning. It all relates to neuroplasticity. Brain cells communicate through chemical messengers at ‘synapses’, the junctions between neurons. Dr. Green says that it’s possible to change the strength of these connections and even grow new synapses through stimulation, thereby preserving stimulation is associated with greater chronic intact areas of the brain that would otherwise 8 RETRAINING THE BRAIN
can be tailored to a person’s abilities, environment and available resources. A recent review of the literature on meditation and the brain by Dr. Green suggests that meditation may be particularly effective for patients recovering from brain injury because it engages the brain, improves its structure and can be self- administered. Dr. Geoff Fernie, Toronto Rehab’s vice president, research, says that it’s important to keep the mind active, through everything from “We can push cells to playing electronic games to simply make new associations or being in a stimulating reconnect with old ones.” environment. “You need to exercise your – Dr. Robin Green brain the same way you exercise your heart,” he says, noting that this can make brain injury survivors more independent and productive, and less demanding on the A study being conducted at healthcare system. Toronto Rehab will show what The same may be true for people with other happens when therapy hours neurological disorders such as stroke and are doubled for patients with dementia, and also for the elderly, Dr. Green says. traumatic brain injury. Older people are especially prone to negative neuroplasticity, she says, because they are often removed from their previous professional and social situations, as well as experiencing hearing and vision problems and low self-esteem. “If we can stop the behavioural withdrawal from activities,” Dr. Green says, “we can minimizebe isolated when they are disconnected from the likelihood of healthy areas of the braindamaged ones. “We can push cells to make new Dr. Robin Green becoming understimulated and ultimatelyassociations or reconnect with old ones,” she says. losing their functional capacity.” Dr. Green and The findings of Lesley Miller, a student of Dr. colleagues recently expounded on this idea in aGreen’s who recently received her PhD at the paper published in the journal NeuropsychologicalUniversity of Toronto, revealed that patients who Rehabilitation.got more cognitive stimulation in the five to 12 Dr. Green holds a Tier 2 Canada Research Chairmonths after a brain injury maintained greater in Traumatic Brain Injury/Cognitive Rehabilitationvolume of the hippocampus, a part of the brain Neuroscience at the University of Toronto.that’s critical in functions such as memory, over An associate professor in the Department ofthat same time period and longer. Psychiatry, she leads the Social and Cognitive “Cells need input to remain viable,” Dr. Green Sciences field of the Graduate Department ofsays, adding that the level and type of stimulation Rehabilitation Sciences. n + 1 0 R E P O R T O N R E H A B I L I TAT I O N R E S E A R C H 9
Electrostimulation sparking brain changes When Dr. Milos R. Popovic dreams of brilliant The idea is that, after many repetitions, the In a landmark study published this year control systems, it’s not supercomputers or patient can perform the movement on his or in the journal Neurorehabilitation and NASA mission control he’s thinking of—it’s the her own—without the device. Neural Repair, Dr. Popovic and colleagues human brain. But how can this be? proved the power of FES therapy. Tested in “The brain is the most sophisticated control “The combination of the desire to move a randomized clinical trial, their approach system anywhere in existence,” says the and the sensory feedback flowing to the worked considerably better than conventional biomedical engineer and Toronto Rehab senior brain causes changes in the brain’s circuitry,” occupational therapy alone to increase spinal- scientist. Dr. Popovic says. “It forces the brain to adapt cord injured patients’ ability to pick up and hold Dr. Popovic marvels, in particular, at the and form new neural pathways to control objects. phenomenon known as ‘neuroplasticity’ —the movement. Neuronal cells are forced to take What’s more, the nine study participants brain’s remarkable ability to more responsibility.” who received stimulation therapy also saw adapt and perform new tasks, “The brain is the most It’s possible something else is big improvements in their independence and even after an injury. going on too. “The brain creates ability to perform everyday activities such as And he’s developed a way sophisticated control stem cells all the time. And those dressing and eating. to make use of this ‘plasticity’ system anywhere in new stem cells have to decide “This has real implications for people’s to help stroke and spinal cord existence.” whether they will become quality of life and independence, and for injury survivors who have lost neurons or supporting tissue in their caregivers,” says Dr. Popovic. “Even small key functions, like the ability to – Dr. Milos R. Popovic the brain. If there’s a lot of activity improvements in the ability to perform daily grasp, reach or walk. someplace, they will probably go activities can have a large impact on people’s “With these injuries, the brain is damaged there to assist.” Dr. Popovic hopes to prove this lives.” and some of its control mechanisms are gone,” hypothesis with brain-imaging studies. Dr. Popovic’s team is working hard to put he explains. “Motor or sensory commands It’s clear that patients are benefiting, and its approach into widespread use at hospitals, cannot be relayed from the brain to the significantly so, from Dr. Popovic’s novel use of physiotherapy clinics and in people’s homes. muscles, or from the muscles back to the brain. functional electrical stimulation (FES). The new The researchers have almost completed a But the fact is that some of the neuronal cells treatment approach has already helped some prototype of a stimulator for clinicians to use can be retrained to do new tricks.” stroke and spinal cord injury survivors to reach (See Rehab innovations on page 50). Here’s how Dr. Popovic and Toronto Rehab’s and grasp again—in some cases, years after At Toronto Rehab, Dr. Anthony Burns, Neural Engineering and Therapeutics Team are injury. medical director of the hospital’s Spinal Cord teaching injured brains to perform new tasks— Rehabilitation Program, says he will work with with extraordinary results: Dr. Popovic “to make this intervention available First, the patient is asked to imagine a to our patients, and to answer important movement that he or she wants to do but questions such as the duration of the effect.” cannot, such as grasping a glass. “This engages Dr. Popovic holds the Toronto Rehabilitation the brain in creating signals. But the signals Dr. Milos R. Institute Chair in Spinal Cord Injury Research. cannot go anywhere due to the injury.” Popovic He is an associate professor in the Institute of At the same time, an external device is used Biomaterials and Biomedical Engineering at the to stimulate the person’s muscles with tiny University of Toronto. n bursts of electricity. This causes the desired movement to actually happen. “As the hand moves, the patient gets sensory Go to www.torontorehab.com to watch lab video feedback from the movement, plus visual from our recent study in which patients with spinal feedback from seeing his or her hand move.” cord injury received stimulation therapy. The whole process is repeated many times. 10 RETRAINING THE BRAIN
Matthew Linton exploiting brain plasticity everything I could possibly do to get better,” he says. For eight weeks, Linton’s physical, occupational and speech therapies were doubled to six hours a day. The treatment was exhausting, he says. “It was the most difficult thing I’ve ever done in my life.” But there was constant improvement, against all odds. Since leaving Toronto Rehab, Linton has maintained a “managed lifestyle” of exercise, a strict diet, lots of rest and constant stimulation, such as listening to audio books. He continues to cope with fatigue, headaches, balance problems, memory lapses and blind spots in his eyes. Yet a positive attitude, strong support from those around him and a determination to “never stop trying” have allowed him to return to a near-normal life. The 31-year-old has resumed his career part- time in venture capital and corporate finance,Matthew and Stefanie Linton (at right) watch the and recently startedSuper Bowl with friends. his own consultancy “There was no expectation in the field. He’s that I would survive, or Matthew Linton believes in the capacity of survive, or that I would ever have a functional mindful that his the brain to regenerate itself with intensive life,” says Linton. He attributes his recovery “truly exceptional” that I would ever have a therapy. He’s living it. to enrolling in a research program at Toronto improvement is functional life.” On Victoria Day weekend in 2009, while Rehab that capitalizes on the ‘plasticity’ of the not shared by all of staying at a Collingwood chalet, Linton fell brain to repair and recover functions that might those with injuries as – Matthew Linton from a deck and hit his head on a concrete otherwise have been lost. severe as his. slab below. Friends found him unconscious Specifically, the research project is “We’ve got a long way to go before we have and roused him, but he later fell into a coma. examining the value of intensifying treatment a solid understanding of how the brain works.” Flown by air ambulance to a Toronto by doubling the amount of therapy. Results will His recovery to date has been “a miraculous hospital, doctors found massive internal show whether recovery is greater or faster, and surprise,” Linton adds. With his unflinching bleeding and damage in his brain. They whether the ‘intensity’ is tolerated or too tiring. commitment to achieving the best possible operated to relieve the pressure, but told When Linton arrived at Toronto Rehab two quality of life and the support of family, the his wife Stefanie, family and friends to say weeks after regaining consciousness, he was rehabilitation and research community, he goodbye. paralyzed on his left side and had little short- hopes this progress will continue well into the “There was no expectation that I would term memory or ability to read. “I signed up for future. n + 1 0 R E P O R T O N R E H A B I L I TAT I O N R E S E A R C H 11
Q.2 Preventing falls on stairs My 82-year-old mother recently came to stay. One day, she decided to take a shower. After gathering her toiletries, she started down the stairs to our basement bathroom. I was in another room when I heard an awful noise—the sound of my mother falling. I found her at the bottom of the stairs. She had What can we broken her arm. But we do to prevent both knew it could have been a whole lot worse. people from – Alex in Toronto falling on stairs? 12 P R E V E N T I N G FA L L S O N S TA I R S
Dr. William McIlroy is producingastounding insights into howpeople act on stairs. The aim: togenerate new knowledge thatcan help prevent falls, which area very common cause of injuryamong older people.
In a study with University of Waterloo colleagues, Dr. William McIlroy (right) foundA. that people rarely look at the handrail even while using it. “In Canada, we suspect it’s even worse. So this is a were surprising. People tended to look only at theIt’s incredible to think that every big problem,” says Dr. Geoff Fernie, vice president, first step or two and the last, ignoring the ones inyear in North America more research, at Toronto Rehab. “Stairs can be very dangerous places, and yet between. And they rarely looked at the handrail even while using it.than a million people are sent to we don’t always treat them with appropriate The brain, it seems, relies on an internal map of respect,” says Dr. William McIlroy, a senior scientist what a staircase looks like. “This can get you intohospital because of falls on stairs. and Mobility Team leader at Toronto Rehab and professor in the Department of Kinesiology at the University of Waterloo. Many of those injuries are extremely serious. Dr. McIlroy’s career in balance research was In fact, falls on steps and stairs account for initially inspired by his grandmother, who tripped about 60 per cent of hip fractures, which can have on a curb and broke her hip. “She never recovered disastrous, even fatal, consequences. In addition, from the fracture,” he recalls, “which is all too Dr. Brian Maki devastating head injuries are much more likely to common in older people.” occur when falling on stairs, compared to falls on Dr. McIlroy’s studies are yielding astounding level surfaces. insights into how people act on stairs. In a newly And the numbers are only getting more completed study, he put ‘eye trackers’ on people worrying. In the United States, deaths from falls to determine where they look while climbing or on stairs are increasing at six per cent per year. descending a laboratory staircase. The findings 14 P R E V E N T I N G FA L L S O N S TA I R S
“Stairs can be very dangerous places, and yet we don’ttrouble if you are on stairs with always treat them with using Toronto Rehab’s new In June 2011, Toronto Rehab will host a specialany variation. If even one stair appropriate respect.” state-of-the-art stair laboratory. international symposium bringing together moreis slightly higher, it creates a The new lab, opening in 2011, than 30 experts in the field. Together, saystremendous fall risk.” – Dr. William McIlroy will launch a new generation Dr. Fernie, they will develop a coordinated Carrying things on the stairs of research. It features eight strategy on how best to use the new stair lab tois also risky. Amazingly, Dr. McIlroy has found that steps fixed to a sophisticated motion platform that answer crucial research questions that will helppeople tend to cling to an object like a coffee moves on cue to cause a stumble or fall. A harness prevent falls on stairs. ncup rather than grab for the handrail when losing system attached to the ceiling keeps researchbalance. “For some reason, the central nervous subjects safe while sensors in the stairs and LED Born in the Russian city of Salsk, not far from thesystem has difficulty letting go of objects. This markers on the body collect key data. Black Sea, Dr. Dimitry Sayenko used to work withis true even if people are holding something “We will know exactly how you move on the cosmonauts. Now, he’s helping people with spinalinconsequential like a plastic tube.” stairs, how close you come to tripping and we can cord injuries to stand and balance. Understanding stair behaviour will allow watch what happens when you do fall,” Dr. Fernie Find out more at www.torontorehab.comresearchers to develop personalized therapy explains.programs that improve strength and balance,and change behaviours (discouraging holdingof objects on stairs, for example). These are notcurrently a regular component of rehabilitationprograms. Computer vision Improving handrail design can also helpprevent falls. Research by Dr. Brian Maki, a Toronto keeping an eye on mobilityRehab senior scientist, shows that older peoplerely more on arm movements for balance and are When patients go home person could then be advised on how to minimize risk.twice as likely to use handrails as younger adults. after rehabilitation, Dr. Allin has a personal connection to her research.But they are also much less likely to look at the rail there’s something Her 70-year-old father suffers from a condition calledand more likely to make errors such as missing the potentially dangerous foot drop (difficulty raising the foot at the ankle) that waiting for them: stairs. causes him to stumble. “I do worry that he might fall onrail, or hitting it with the back of the hand. Ongoing research the stairs in his house,” she says. One of Dr. Maki’s solutions is a cueing system by Dr. Sonya Allin, a She hopes to start testing the system in 2011 in thedesigned to improve ability to grab the rail Toronto Rehab adjunct homes of people recovering from hip replacementeffectively in response to sudden loss of balance. scientist, will provide surgery.It can also prompt people to grab the rail before vital information to Meanwhile, Dr. Alex Mihailidis and PhD studentlosing balance. As someone approaches a decrease the danger of Jasper Snoek are using similar technology for acustom-built handrail, a row of LED lights flashes a fall on stairs. Dr. Allin different goal—saving researchers time and money.and a voice recording is triggered, attracting the is developing low- Their computer-vision technology sifts through videoperson’s attention. cost computer vision footage collected in public settings and automatically technology to monitor identifies unusual stair behaviours like slips, trips and A study testing the system on 120 older adults people’s mobility, misuse of handrails.has just been completed. “We’re still analyzing Dr. Sonya Allin including their stair use, “Right now, researchers who study falls have tothe data but it looks like the verbal cueing in in the home. manually review each video, perhaps watching hundredsparticular is effective in getting people to use “The goal is to develop a system that determines of hours of tape just to find one fall,” says Dr. Mihailidis,the handrail,” says Dr. Maki, a senior scientist at when a person is at risk, delivers information to a a senior scientist at Toronto Rehab and associateSunnybrook Research Institute and director of the therapist and prompts the person to take corrective professor in the Department of Occupational ScienceCentre for Studies in Aging at Sunnybrook, as well action,” says Dr. Allin, a postdoctoral fellow in the and Occupational Therapy at the University of Toronto.as a professor at the University of Toronto. Department of Occupational Therapy at the University “These are great examples of how we can apply Other studies by Dr. Maki have led to changes of Toronto. artificial intelligence to collect much larger volumesto building-code requirements for handrail height, For instance, the system might indicate that of data in real-life settings,” says Dr. Mihailidis, who someone is going down the stairs too quickly or failing holds the Barbara G. Stymiest Chair in Rehabilitationshape and size, to help ensure that people are able to lift their feet enough to safely clear the stairs. The Technology Research at Toronto Rehab.to use the rails effectively to maintain balance. Drs. Maki and McIlroy are also eager to start + 1 0 R E P O R T O N R E H A B I L I TAT I O N R E S E A R C H 15
Q.3 Dealing with dementia A few months ago, I learned that my mother has dementia. She is still living at home but getting increasingly forgetful. Things go missing and turn up in odd places. The other day, the TV remote vanished. It was in the bathroom. Sometimes, my mother sits down for a meal, forgetting that she has already How can we eaten. She is happy in help people her home and wants to live there for as long as with dementia possible. My siblings and who are living I want that too, but we worry about her. at home? – Sylvie in Toronto 16 DEALING WITH DEMENTIA
Student Yulia Eskin is with a Toronto Rehab-University of Toronto team developing ‘intelligent’ assistive technologies to support seniors, those with disabilities and their caring family members—like these ones—in daily living.
A.As an engineering graduate in1996, Dr. Alex Mihailidis waslooking for a challenging areaof research that would have ameaningful impact in his field—and on people’s lives. washing, dressing and meal preparation. Today, Dr. Mihailidis is on the leading edge of research in the use of artificial intelligence, computer visioning and voice- recognition to support older in daily living. The internationally recognized senior scientist, who leads Toronto Rehab’s Artificial A nutritional detection system, now under development, uses computer vision to monitor what a person eats and drinks to guard against malnutrition and dehydration. a number that will double in the next generation. Providing greater assistance in the home can enhance quality of life and independence, reduce caregiver burden and lower Dementia affects 20 healthcare costs, Dr. Mihailidis says. people and those with disabilities per cent of people by Intelligence and Robotics Team, is cent by the age of 90. developing a range of ‘intelligent’ devices to allow people to live longer and more For his master’s, he created The the time they are 80, COACH, which ‘prompts’ users to carry out the different steps involved and more than 40 per in hand washing. Through his PhD He found it in a chance encounter at a conference safely at home. with a fellow engineer whose wife had early-onset “People want to remain in their communities Alzheimer’s disease. and they do better in their own homes,” says There was little available in terms of Dr. Mihailidis, holder of the hospital’s Barbara technologies to help his wife cope in the home, G. Stymiest Chair in Rehabilitation Technology the man said. For Dr. Mihailidis, who had started Research and an associate professor of Dr. Alex Mihailidis a master’s in biomedical engineering, the story occupational science and occupational therapy struck a chord—and charted a lifelong career at the University of Toronto. “We have to have path. To assist people with dementia and their concrete ways of supporting them there.” caregivers, he thought, a computer could model, Dementia affects 20 per cent of people by the monitor and then offer prompts for the various time they are 80, and more than 40 per cent by the steps involved in routine tasks such as hand age of 90, amounting to 500,000 Canadians today, 18 DEALING WITH DEMENTIA
Powered mobilityand beyond, he adapted and took on more complexaspects of the technology, applying artificial helping people to get aroundintelligence and advanced theoretical computertechniques. His hand washing system is today beingtested at an Alzheimer’s clinic. The team is adapting It’s a cruel To see how the prototype worked in a long-termit for tooth brushing and other activities. paradox. Many care environment, Dr. Wang recruited six residents nursing home with different degrees of cognitive impairment There’s also a system, under development, that residents with and asked them to “test drive” the prototype, withmonitors what—and how often—a person eats dementia some residents testing it for up to several months.and drinks, to guard against dehydration and need powered The results were unexpected.malnutrition. wheelchairs and “We thought users would warm to this device,” “Because an intelligent home learns and adapts scooters to get says Dr. Fernie. “In fact, they were embarrassedto the habits of its occupants, it can interact with around—but to be seen trundling around slowly in somethinga person if his or her behaviour does not fit with aren’t allowed to that looked like a tank.”typical patterns and, if necessary, alert caregivers,” use them because Adds Dr. Wang: “Users felt a certain social of the risks to stigma because of the chair’s speed andDr. Mihailidis explains. themselves and appearance. They felt ‘different’ because their Different devices could stand alone or be fellow residents. wheelchairs were obviously different—slow andincorporated into the very architecture of a “If they bump cumbersome—and this perception was reinforcedhome—a concept he calls “brick computing”. into another by well-meaning remarks by staff and residents.” Dr. Rosalie WangSensors embedded in floor tiles, for example, resident, the result There were even surprising reactions to thewould monitor and record someone’s blood could be serious injury or even fatal,” explains idea itself. Some residents said they actuallypressure, respiration, heart rate and body Dr. Rosalie Wang, a member of Toronto Rehab’s enjoyed having other people push them intemperature through the soles of the feet. Technology Team and postdoctoral fellow with manual wheelchairs because it gave them more the Intelligent Assistive Technology and Systems opportunity to socialize. Of course, the power Dr. Mihailidis has also developed a device that Lab at the University of Toronto (U of T). wheelchair—once perfected—should offerdetects if someone has fallen. It ‘learns’ and tracks But a high proportion of people in long-term residents new opportunities to link up with othersthe actions of the user—and can interact with the care can’t walk or use a manual wheelchair and socialize.person and call for help. because of a physical disability, Dr. Wang points Lessons learned from on-site research are now Fifteen years ago, says Dr. Mihailidis, people out. “So our challenge is to develop technology being incorporated into the next prototype, whichin his field saw little need for such technologies. that will allow nursing home residents with is being developed by Tuck-Voon How, a formerToday it’s a different picture, with collaborators dementia to use powered wheelchairs safely.” It’s U of T graduate student and now researcharound the world focused on various aspects of estimated that at least half of residents in long- developer at the Intelligent Assistive Technology term care are cognitively impaired. and Systems Lab. The wheelchair uses computerthe ‘intelligent’ home. “You can’t go to a conference Developing a powered wheelchair that’s safe for vision and has improved sensor capabilities andwhere someone isn’t presenting on this topic.” this population is harder than it might seem. For faster processing speeds to avoid obstacles. Dr. Mihailidis envisages a practical and starters, the system must be absolutely reliable; Meanwhile, Dr. Wang is field-testing ancommercially viable product that incorporates even a single collision is unacceptable. upgraded interface that helps users navigate byprompts for a range of tasks and can be tailored The Toronto Rehab-U of T team initially giving audio and visual prompts, as well as touch-to individuals. Now 36, he’s optimistic such experimented with collision-avoidance systems based feedback from the joystick, which will nottechnology is “totally doable” in his lifetime, based on infrared and ultrasound sensors, but move in any direction where the system ‘senses’adding that he sees a day when he himself will rejected them as too unreliable. Ultimately, the an obstacle. Users are responding positively. researchers came up with a completely different “These trials remind us that technology is onlybenefit from his research. “I’ve got to make sure I design. part of the solution,” says Dr. Wang. “To helpget the technology perfect.” n “The prototype looked a bit like a bumper people with cognitive impairments become more car, with a wide bumper or ‘skirt’ at the bottom mobile by using power wheelchairs, we have to containing an array of micro-sensors,” says pay close attention to what they tell us, as well as Semantic dementia is a rare kind of dementia Dr. Geoff Fernie, vice president, research, at to social and organizational issues.” that tends to strike people in their 50s and 60s Toronto Rehab. “If the chair hit something, the Dr. Wang’s new research in this area is partially who are otherwise quite functional. ‘skirt’ would collapse without applying any force supported by CanWheel, a cross-Canada research Dr. Elizabeth Rochon is working on a language to the obstacle and the chair would stop. It was collaboration formed to enhance the mobility of therapy that is showing promising results. ugly but effective.” older wheelchair users. Read the article at www.torontorehab.com + 1 0 R E P O R T O N R E H A B I L I TAT I O N R E S E A R C H 19
Q.4 Fighting disease with exercise I was diagnosed with Type 2 diabetes several years ago. I take medication to control my diabetes and I keep a close eye on my blood glucose levels. I also try to follow a healthy diet and have taken off some weight. But I do not get much physical activity. I’m considering joining Does exercise an exercise program for really pay off seniors. for people with – Maria in Windsor diabetes? 20 FIGHTING DISEASE WITH EXERCISE
Dr. Pearl Yang is tracking the progress of people with diabetes as they complete Toronto Rehab’sDiabetes, Exercise and Healthy Lifestyle program.Suzanne Parsons (at left in inset picture, sharing a laugh with family) participated in the program.
A.With a disease like diabetes,it’s all too tempting to just takemedication and hope for betterhealth. But there’s anotherapproach with a big payoff—and Toronto Rehab researchshows how and why it works. “Exercise works as well as medication in reducing blood sugar levels and it has only positive side effects. You lose weight, you gain muscle strength and you feel better,” says Dr. Paul Oh, a scientist and medical director of Toronto Rehab’s Cardiac Rehabilitation and Secondary Prevention Program. The new research quantifies those benefits. Researchers tracked the progress of 62 people with Type 2 diabetes, the most common kind, as they completed Toronto Rehab’s Diabetes, Exercise and Healthy Lifestyle program. Participants work out in a weekly class, and four times a week at research-based exercise and education programs for people with diabetes in Canada. • • • • And the results are remarkable. After completing the program, participants showed significant improvement on several key measures: • blood sugar levels dropped 9.5 per cent on average aerobic capacity improved 17 per cent on average average weight loss was 3.4 pounds body fat dropped from an average 32 to 31per cent questionnaires showed lower depression scores and higher quality-of-life scores. home using a personalized program of walking and resistance training. It’s one of the largest The lowered blood sugar levels can mean people 22 FIGHTING DISEASE WITH EXERCISE
Explaining how a glucometer works: blood sugar levels were one of the key areas that showed significant improvement in a study of people with diabetes. did less exercise. “Knowing this, we can start to tailor the program to meet their needs and help them stick with it,” says Dr. Pearl Yang, the Toronto Rehab researcher who led the study. The program is continually being fine-tuned to improve outcomes with each new research result. Scientists want to know how much exercise is required, at what intensity and duration. Dr. Yang’s research has found that resistance “Exercise preserves all training can control blood sugar levels whether at the systems of the body, high or low intensity. from muscles and bones “What’s most important is to heart and brain.” to find the protocol that’s right for each person,” she – Dr. Paul Oh says. “Adherence is key.” Dr. Oh, meanwhile, is reaching out to family doctors to spread the message about diabetes and exercise. Working with the Canadian Diabetes Association, he’s developing a tool kit of posters, prescription pads and information sheets for national distribution. In his eight years at Toronto Rehab, Dr. Oh has seen thousands of cardiac and stroke patients benefit from structured exercise programs. The evidence is irrefutable, he says. Exercise works. Now he’s developed a similar program forneed less medication or, in the case of pre- women with breast cancer, supported by a one-diabetics, none at all. year grant from Pfizer Canada. The program has “It’s easier to give a pill but lifestyle changes been modified to meet the specific needs ofcan work just as well,” says Dr. Oh. “People just this group ensuring, for example, that they canneed the right support to stay with it and make it exercise safely during chemotherapy or radiationsuccessful.” treatments. “The research has just begun but Dr. Paul Oh anecdotally it works and people love it.” The improvements in aerobic capacity, weightand body fat can be ultimately lifesaving because In fact, says Dr. Oh, exercise is good for virtuallythey lower the risk of heart disease. Diabetes is every disease and disability, as well as healthyone of the greatest risk factors for coronary heart aging. “Past the age of 40 we’re all unfortunatelydisease. “But regular exercise can cut your risk in on a downward path. Exercise preserves all thehalf,” Dr. Oh explains. systems of the body from muscles and bones to Another key finding: people who started the heart and brain. There is good evidence that itprogram with higher depression scores typically helps with almost everything.” n + 1 0 R E P O R T O N R E H A B I L I TAT I O N R E S E A R C H 23
Changing unhealthy behaviours The behaviours of today are tomorrow’s that showed obese people have medical costs used by 70 to 80 per cent of U.S. employers. It diseases, says Toronto Rehab senior scientist that are about 30 per cent greater than their identifies a person’s individual risk and provides and cardiologist Dr. David Alter. normal weight peers. educational materials and telephone coaching The most obvious warning sign: “the rising Governments can change behaviours in healthy behaviours such as diet, exercise, tide of obesity.” Almost 24 per cent of Canadians through policies, such as banning public stress management and smoking cessation. are now obese, up from 11.1 per cent in 1976. smoking and taxing cigarettes. Another way is In the healthcare setting, hospitals need to Obesity causes numerous health conditions and through workplace programs better understand a person’s is a leading cause of preventable death. that target people who are “When we visit the doctor, readiness to change behaviour “The root causes of obesity are not all still healthy and productive. we tend to go because of and to stick with lifestyle that complicated,” says Dr. Alter, pointing to Unfortunately, Canadian programs, says Dr. Alter. He is sedentary behaviour and unhealthy diets. employers lag behind their complaints and symptoms devising patient surveys and But the solutions are more complicated. Our U.S. counterparts in this —not for a two-hour other tools to help hospitals healthcare system, for instance, is primarily set area, according to Dr. Alter’s lifestyle coaching lesson.” do this. up to deal with disease. research. Another way hospitals “We tend to go to hospitals for things like “In Canada, we have yet – Dr. David Alter can change behaviour and angioplasty, bypasses and stents. When we to really develop workplace increase adherence is through visit the doctor, we tend to go because of programs that target lifestyle and behaviours; outreach programs, Dr. Alter stresses. “On-site complaints and symptoms—not for a two-hour whereas, in the U.S., as a solution to rising costs, services are not the be-all and end-all, mostly lifestyle coaching lesson.” employers have implemented many more self- because they rely on patients to proactively As research director of Toronto Rehab’s care programs, laced with incentives for their come in to seek care.” Cardiac Rehabilitation and Secondary employees to become more active and healthy.” Toronto Rehab, for instance, is sharing its Prevention Program, Dr. Alter says there’s a huge Dr. Alter cites a phone-based, lifestyle successful cardiac rehab home program with opportunity to save lives and reduce the burden modification program, which he says is now distant providers to further extend the reach. on our healthcare system—if we act now. Last year, the hospital guided a Cambridge, “What’s at stake is our health, our productivity Ontario ambulatory specialty clinic through the in the workplace and our healthcare system. steps of setting up a cardiac home program. There is a sustainability crisis. Our population is “We are still learning what makes people becoming more sedentary, and getting more change their habits, but tailoring programs obese. The burden of disease is growing, and it’s to the individual certainly maximizes the getting more costly to our system.” possibility for change,” adds Dr. Alter, who is The costs of obesity alone are staggering. also a senior scientist at the Institute for Clinical Dr. Alter co-authored a study last year with Evaluative Sciences (ICES) and an associate Queen’s University researcher Diana Withrow professor at the University of Toronto. n Dr. David Alter 24 FIGHTING DISEASE WITH EXERCISE