#91: Motor Learning in Neuro Rehab with Katie Riccio

[MUSIC] As occupational therapy professionals, many of us have witnessed the wonder of neuroplasticity in neurorehab. Yet despite years of research attempting to identify the most effective post stroke interventions, the reality is that our understanding of how to improve recovery of function remains incomplete. The article that we are reviewing today serves as an update on the state of the science in how new theories of motor control and learning can be incorporated into practice. The authors put particular emphasis on how technologies may be needed to truly meet the many principles of neuroplasticity. And in particular, they point to virtual, augmentative, and mixed reality technologies. After we review this article, we will welcome to the podcast in OT who works for one such virtual rehab solution as their manager of clinical services, Katie Ritchio, MSOTRL. Katie will share what she has learned about neurorehab in her role and orient us to the stroke rehab tools that are on the market. How they can intersect with your in-person practice and what to expect on the horizon. So let's dive in. Welcome to the OT potential podcast where we review new and influential OT journal articles that invite on an expert guest to help us pull out actionable takeaways that you can implement in your practice starting today. Welcome to the podcast. I'm your host Sarah Lyon and I am a licensed occupational therapist. Before we dive into this big topic of motor learning in neurorehab, I wanted to let you know that this podcast may qualify as continuing education for you. You are probably listening to this podcast on a free podcast platform. But to gain CEU credit, you will need to be a member of the OT potential club, our OT continuing education platform. So bearing in mind that this could count as a CEU course, I wanted to state our two learning objectives so you can be thinking about them throughout the podcast today. Our first learning objective is that you will be able to identify how virtual rehab can help meet the principles of neuroplasticity in OT treatment. And second, you will be able to recognize how virtual rehab can augment in person OT. So let's begin by looking at this journal article and then we will patch in Katie to discuss how this paper could play out in your practice. The article we are reviewing today is called Motor Learning and Neurological Rehabilitation. It comes to us from the Journal of Disability and Rehabilitation and it was published in 2021. We are reviewing this article today because it was found on our list of the 100 most influential OT related journal articles. This article was ranked 54th on this year's list. So the article begins with this introduction to motor learning in neurorehab. Over the years numerous studies have been conducted to identify the most effective rehab interventions for post stroke upper limb recovery. But our knowledge of this practice area remains incomplete. Upper limb sensory motor deficits continue to persist in a large portion up to 62% of stroke survivors for greater than six months. This means that the burden of upper limb impairment remains high. So what was the intent of this article? The authors of this article suggest that recovery potential may improve when upper limb training programs focus on remediating an individual specific motor impairment with the framework of a motor control theory. So to support this conjecture they review current theories of motor control and learning and describe how these theories can be leveraged in training programs. It is interesting to note that one author of this paper was trained as a PT and the other as an OT and are now research scientists. So this is about to get nerdy but please hang with me and please dig into the article for the full complexity presented. I am going to do quite a bit of simplifying for this one but we promise to bring it back to your practice. So let's begin with these theories of motor control and learning. There are two major approaches or theories to motor control and learning. The first is a computational or the physical approach which assumes that central processes directly control movement characteristics. The image I found to illustrate this computational motor control theory literally portrays the body as a machine. I will link to this in the OT potential club but you can imagine the brain as that central computer and the programming then that goes into motor control. So in line with this computational approach to motor control motor learning is then understood as a series of different systems that integrate information from the moving limtering task practice and then uses information to build a movement schema that can be stored and recalled when needed. So the way I understand it this theory really pushes us to practice the same movements over and over until this schema is built in our central processing. But there is a newer theory that probably better represents how we see motor learning occur in the real world. And this theory is going to feel very familiar to OT's even if you've never heard of it before it just so aligns with OT practice and that is the dynamical systems approach. In this approach motor learning is seen as a model of person environment and task related constraints that lead to movement. Literally the model is that picture of three intersecting circles the person the environment the task and at the center is motor development. So that really aligns with our OT way of thinking of integrating these different areas for the completion of an occupation. So in a dynamical systems approach to motor control the central nervous system is understood to govern rather than simply produce movement. There is a complex interaction between the neuromuscular system the biomechanics of the body and the object and environmental forces. Here's how the article describes skill learning under this approach. The mastery of degrees of freedom is achieved through a problem solving system that uses available constraints and possibilities to discover solutions to a movement problem. The approach emphasizes dynamic exploratory activity of their perceptual motor workspace to create optimal strategies for performing a task and give rise to adaptability based on demands and constraints. And quote, so I'm sure you can already see how adopting one of these two theories is going to impact your rehab approach. So from here let's look specifically at the general principles of exercise dependent neuroplasticity and how they intersect with the dynamical systems theory. So when a motor learning theory like the dynamical systems theory is combined with the 10 principles of neuroplasticity we really start to get some concrete guidance for rehab. In particular the authors highlight the importance of intensity repetition and salience. I think I'm going to make a handout of these 10 principles of neuroplasticity just to keep them fresh in our brains and I will link to that in our show notes. But focusing on these three ones that you're probably the most familiar with intensity repetition in salience, let's look first at the definition of intensity in rehab. We know that rehab should be delivered at a high intensity i.e. dose frequency and duration and involve challenging practice. However, the definitive number of repetitions actually needed for motor learning post stroke is unknown. One thing that we do know is that compared to healthy individuals it takes more repetitions for individuals with a neurological insult to achieve improved motor outcomes. In one study which I'll link to healthy participants required around 20 repetitions to improve their performance for a reaching task. Individuals with neurological deficits required more than twice that number or 55 repetitions. So there's a lot out there about intensity in our neuro rehab but suffice it to say we probably need more than what we're doing even though we don't know that exact number of repetitions. Looking at training specificity, while intensity is an important piece of the puzzle, it is not on its own enough to improve function and neither is specificity. As the authors point out results of training programs for improving upper limb function have not demonstrated carry over to functional movement. These have been those kind of studies where one motion is done over and over and over again and maybe the person gets better at that one particular movement but that doesn't carry over to their functional movement to their daily life which is what we are going for as OT's. And this is where that theory becomes really important for us to understand because in the dynamical approach less emphasis is placed on reproducing an optimal movement pattern. Instead, this approach focuses on learning a set of movement patterns. that might be equally acceptable in light of the constraints presented by the environment, the specific task, and the learner's condition. Another principle of neuroplasticity is that the practice should be progressive and optimally adapted to the individual's capability environment. Thus to induce new learning practice should challenge the learner, progress over time, and engage the learner in active problem solving. The challenge level is also related to motivation, another key factor in motor learning. In clinical and healthy populations, it has been shown that surrogate markers for motivation, such as self-confidence, hope, autonomy, support, and social relatedness, may play important roles in promoting motor learning. So from here, the article talks about the type of task practice. Task practice that is organized according to the person, environment, and task constraints plays another important role. The two main practice paradigms are blocked practice and varied practice. More comprehensive studies are needed to determine the benefits of both practice types, but in terms of alignment with theory, varied practice just better lends itself to active problem solving. In the last component of rehab that they talk about in relation to theory is a type of feedback and delivery. So while not mentioned in the principles of neuroplasticity, we know that the frequency and type of feedback matter. Of note in this section, there is strong clinical evidence suggesting that individual's knowledge of performance post-stroke may lead to better motor learning outcomes and retention than knowledge of results. And that knowledge of performance is just that more ongoing in the moment feedback that happens during the movement versus knowledge of results, which for example would be, I move the cup, whereas knowledge of performance would be feedback on how that movement actually happened, which honestly is harder to give than just knowledge of results. So after going through a lot of detail on how this dynamical systems approach intersects with the different components of neuro rehab, the authors close with talking about the applications of motor control and motor learning principles in neuro rehab using VR. There are clearly so many considerations for motor learning post-stroke that is difficult to align theory with neuro rehab practice in our traditional rehab settings. Just looking at repetitions alone, the general consensus is that the number of repetitions performed in OT and PT session in both outpatient and inpatient rehab centers is inadequate. For example, in a study that I'll link to the average number of upper limb repetitions was only about 32, whereas we're ideally looking at repetitions that are in the hundreds. So the authors propose that rehab technology is poised to address not only the problem of practice intensity, but also practice structure and feedback. The authors spend quite a bit of time talking about what this could look like hypothetically, but thankfully I am just going to talk about this in detail with our guests who is coming onto the podcast to talk about what this can look like in real-world scenarios. Honestly, the technology here is developing faster than the researches, so I thought it would be most helpful to just talk to someone who is boots on the ground with this technology. So as we head into the authors' discussions and conclusions, they say that in summary, VR applications have the potential to provide high repetition, varied practice, and changing environments to engage learners in active problem solving. So while we need that intensity, we need specificity, we need very practice that active problem solving really is our goal in motor learning. These VR systems can also incorporate monitoring and NVivo performance tracking to continually assess whether the challenge is optimal while also providing real-time feedback. This paper has given an overview of the theory of motor control and learning principles that will help therapists evaluate VR options and ultimately move the field forward to improve the lives of people with disabilities following neurological injury. Okay, there was a lot to take in in this paper. I do think there are nuggets that could help you in your traditional OT practice, but really the heart of this paper is that we probably need technology to really be meeting all of these neuroplasticity principles to really be meeting the components of motor learning. And I left just like, curious, what does that logistically look like? And I'm so thankful because I found just a great person to talk to us about that. And that is Katie Ritchieo, MSOTRL. Katie has a BS in exercise physiology with a specialization in gerontology and an MS in occupational therapy. She has two decades of experience in adult rehabilitation across subacute and patient and outpatient settings, as well as experience in upper extremity robotics research. Katie's focus areas include upper extremity rehabilitation, driver evaluations, neurological rehabilitation, and rehab technology. Katie is currently working for neurofenix as the manager of clinical services, educating clinicians, caregivers, and clients on their upper extremity programs, utilizing their neuroball platform technology. And I do want to note that I thought long and hard about who to have on this podcast because we have actually talked about virtual rehab in the past on the podcast, but it was always pretty hypothetical. And for this episode, I just really wanted to talk just really specifically about the tools that are on the market and how they could augment your motor rehab. And there are multiple OTs who do work for rehab tech companies like this. But I landed on Katie because of her long background. Also working clinically, she really has that clinician brain that you'll get to hear. And the fact that she still does provide virtual rehab through neurofenix. So she just really actively is thinking about the role of the clinician and how these technologies can help us. So without further ado, I will patch Katie into this podcast. Katie, it's great to have you. Thank you, Sarah. Excited to be here. Oh, I am so thankful that you're here today to talk about this really big topic. I've kind of been thinking about it on two hands this morning. One, we just, we know stroke rehab is leading cause of disability worldwide. We know more people are surviving stroke. We know we're getting older. We just know the huge numbers of people who could use more stroke rehab probably than they're getting currently under our current systems. And then that's one hand. Just there's a lot of people who need it and probably more people will need it in the future. And two is a therapist stroke rehab is complicated. Like you think about all the points that this article touches on and all the things we need to hold in our mind is therapists. And it's pretty overwhelming. And with both of these things together, you're like, we need the support of technology both to get stroke rehab to all the people that need it and just to support us in our sessions because it is so complicated. So I'm so thankful that you are here today because you straddle technology and have this experience of being an OT, of providing an OT and can kind of talk to both sides of it. So you are the perfect person and I can't wait to dive in, but I want to start just with your story and how you got to where you are today at this really interesting stroke rehab company. Sure. Great. Thank you. And happy to share. I think my journey started like some other therapists, right? I got injured in high school. I tore my ACL and I went to physical therapy my senior year. So that is really what started to peak my interest into the therapy world. But I was always interested in fitness and sports sciences. And I went to Ohio University where I received a Bachelor of Science degree in exercise physiology as well as a certificate in gerontology. Because I really wanted to work with the adult population once I graduated. So after graduation, I did work in corporate fitness probably for about three months. But just I felt unfulfilled in my role, right? And so that's when I started to re-export the healthcare fields. And a friend of mine introduced me to occupational therapy. As I researched it further, I was immediately drawn right to the foundations and in this holistic care and the opportunity to really make a meaningful impact. Helping people return to function, right? Post injury and disability. So that's when I went to tells me university and got my Master of Science in occupational therapy. So from there, my career started and a skilled nursing facility. So I was working for about a year and got experience right with more patients in the subacute and the long term care populations. And then after about a year, I've experienced in subacute, I position opened up right at one of the top rehabilitation hospitals here in New York. So I transitioned over to a Burke rehabilitation hospital where I actually spent the next 18 years working with them. Yeah. So Burke was great. I was able to start at their inpatient rehab hospital. And you get to rotate around all of the different floors, right? really get experienced. working with patients, post orthopedic injuries, pulmonary and cardiac, diagnoses and injuries, as well as brain injury and spinal cord. But then I found my way up to the stroke unit, and the neurological unit. And that was it. I didn't want to rotate anywhere else. So this is where I really started to develop my passion for working with patients, post neurological injury and stroke, and started to really become intrigued with using technology to improve upper extremity function. So I did about a year after that with research where I was able to really see how using upper extremity and end-effector robot with patients with stroke, was helping them to really improve their function. And we were seeing patients two to three years post, two to three years post stroke, you know, up to 10 to 15 years post stroke, make changes, right? So they were provided with this high dosage, right? Which we'll talk about, right? Over a thousand repetitions, three times a week for six weeks. And we were seeing functional gains with our subacute and chronic strokes. So once that study ended, I moved over into the outpatient rehabilitation department, where I was able to just gain more experience working with rehab devices, right? So getting a more comprehensive understanding and training, I was fortunate to use electrical stimulation, right? Functional electrical stimulation bikes, robotics, different exoskeletons, you know, with or without EMG-based biofeedback. And then really was able to work with a lot of those sensory devices and wearable devices, as well as mobile apps, right? You see mobile apps, you see computer apps, and all of this is starting to incorporate this virtual reality and this augmented reality. And really it was here that I was introduced to neurofenix. So I was using their upper limb technology with my patients, and I was seeing great results, right? They were increasing their dosage and increasing their intensity, improved motor patterns, improved outcomes. And so after speaking with with the company and providing them feedback on the product, I just knew I wanted to be a part of this mission, right, to really help patients post neurological injury, increase what we're going to talk about, right? Dosage, intensity and frequency for your technology at home, right? So I initially I initially joined neurofenix as a senior clinical specialist, and now I am managing the clinical services department and leading the development and implementation of their virtual therapy programs. So we're really combining the use of technology with occupational therapy services, like merging those two together. That is just the best story because it feels so relatable. I also started in a SNF and SNF and then rotated around a trauma hospital, the different floors. And I think as you're doing that early in your career, it doesn't feel like you're preparing yourself for like a tech position, but I'm like, you totally are because you're really getting to know the patient experience and the therapist roles. I had one quick just follow-up question. Were you like trolling the website of neurofenix? Like I went to work there or like did you have a personal, no connection? Like that feels like a big leap. How did you land that job initially? It's a great question. So at Berk, I was the lead therapist for technology. So I was coordinating, bringing in all of the different, you know, the vendors, right? And so I got, I had a close relationship with someone who worked at neurofenix and we did a follow-up, right? So you always do a follow-up with these, but these companies and they want to know how you use the product and the clinic and what results you saw. And honestly, Sarah, after I got off the phone call with with him, I wrote him an email and said, "I want to work for your company." That's awesome. Connection happened. Good for you. That's amazing. We're going to be talking about rehab tech, kind of generally in broad buckets today, but I do want to be oriented to like neurofenix in your job there specifically. Can you tell us just a little bit about the product and how it fits in this larger stroke rehab ecosystem and maybe what made you write that email? Like what made it stand out to you? Sure. Yeah. So in general, neurofenix is a rehabilitation technology company and a virtual service provider, right? So we're combining the use of our cutting-edge technology with personalized therapy services, virtual therapy services to help patients who are recovering from neurological injuries and particularly post stroke. So the combination really allows the therapist to facilitate high repetition training through the use of the platform, but in return, it's also a welling us as therapists, right, to monitor our patients' progress and adherence and wheel time. So we're able to really provide continuous support, track their progress and adjust their programs as needed. With neurofenix, they have a patented device called the neuroball and that was developed for patients to use at home, right, post neurological injury to regain upper limb movement, you know, range of motion, strength, coordination, but with the focus on providing high repetition and high intensity to induce neuroplasticity, right, and maximize recovery. And so that's really what kind of pulled me over because I thought how do we fill in the gaps, right? You know, our patients have two to three days of therapy in the outpatient clinic, but what are they doing for the rest of those days and how can we really increase this intensity for our patients because we know they need it, right? And so that's really what, you know, maybe make that phone call or send that email to the company. So with the neuroball, it is a sensor-based device, obviously it's shaped like a ball. It keeps the hand in an open functional position and it uses IMU sensors, right? So it's really detecting that rotational movement of all the pivots in your upper extremity. And then it connects to a tablet via Wi-Fi, right, a Bluetooth connection, and that's what really helps to keep the patients engaged because they're using therapeutic games and activities, right, with the hardware. And so that gamification provides a continuous challenge to the patient while providing feedback, right, and external cues to keep them motivated. So again, thinking about increasing intensity and dosage and how that fits into like the overall larger ecosystem into virtual reality is that it's a non-immersive VR device, right? So the patient's not fully immersed into that virtual world. Virtual reality, right, or they call it virtual rehabilitation in the article, involves the use of computer-generated environments, right, to simulate real world scenarios. And we're using this in rehab, right, because it's providing those task-specific scenarios that can be adapted to the patient's needs, right? So we're really targeting motor learning. And with VR, right, you can work on increasing the challenge, the specificity, the intensity, the salience, you know, all of those that we know are the foundations for neuroplasticity. There are different types of VR, right, devices on the market. So as mentioned, we have a non-immersive virtual reality device where the user interacts with the environment and it's usually through a screen or a tablet, right, a computer, a smartphone, but you're not fully immersed. It often involves the use of a controller or a wearable, right, and they have pressure sensors or IAMU sensors to detect movements. And sometimes it's just an app on a tablet, right, where you're working on visual therapy or cognitive therapy. There's also fully immersive virtual reality, right, where the patient's completely immersed and surrounded by a 3D environment, right? So it's creating that sense of being present in the virtual world. And this typically involves, you know, like a VR headset helps to block out the real world and puts you into this virtual one where you can really focus on task-specific training. And then there's also augmented reality, right? So these are where digital elements are super imposed into the world, right? Kind of blending that virtual component with the user's real environment. So you'll see this through smartphones or tablets with motion tracking software or like video capture tracking systems and that helps to blend the two together. A lot, you'll see now that there are companies that use glasses that allow you to interact with the real world with the digital overlay. So in general, that's how we fit into the whole scheme of VR there. It feels like where we're at in StrogreHab right now is we know we need technology to help us meet the complexity of StrogreHab to get those high levels of intensity. But there's not really a gold standard of like this is the exact way to do it. There's still a lot of the therapist still has a lot of discernment to find the right fit for their particular client. And like you said, there's a lot of different options out there that might be the right fit for your particular client. And turning to this research or to this specific paper, it was to me, it was a lot to take in to take in like the theories presented, but the more Before I read it, the more I was starting to feel like this is almost like a checklist of questions that we should be asking these technologies. Is it helping us meet these different components of Strogree-Hab, the principles of neuroplasticity and the components of the dynamic systems approach? And also just to be asking of our own in-person Strogree-Hab too, are we trying to pull these elements together as much as we can in our in-person sessions as well? And the part that really stood out to me, I love that dynamic systems approach in the heart of it being problem-solving. That to me was like the key check mark. Like, are you actively problem-solving in your tasks? Like if you're just doing cones, there's no active problem-solving. And you could be on a sweet fancy VR thing, but if you're not problem-solving and it's just a row of movements over and over, you're probably not getting the full benefits. That was my takeaway from this big article. What were your takeaways? You're so much more immersed in it. Yeah. No, that's a great outlook from a night-re because we have to problem-solve in our everyday life. And task is not always going to be the same, reaching for a glass in the kitchen versus in the bathroom, depending on the environment. And so I think from the research, I thought it was a great overview of the different theories. And I liked how they compared the computational approach to the dynamical systems approach, but more as if the dynamical systems approach expands on the computational. So for example, with computational, we know motor learning occurs right through a series of different systems. So our attention, our perception, the forces, the velocity of movement, all of those are going to help us to develop a scheme and a generalized motor program. So as you mentioned, if you're just reaching for a cup, 400 times in the same direction, yes, you're going to develop a generalized plan. But then using that dynamic systems approach, we take that scheme. And now we want to see how are we interacting with the individual and the environment. So how heavy is the cup? Is it plastic, is it glass? Are you standing, are you sitting, are you weight shifting? Is there an obstacle in the way while you're reaching? So I think that that dynamic system approach really focuses on that variability and how it affects our motor planning as we problem solve and as we discover new solutions. So that reaching pattern will never be the same depending on our individual restraints and environment. So I did like that and I did like that both models really stress the importance of task relevant training and that we need to incorporate that into our sessions. Obviously we're doing that as OT's, but it's always good to have reinforcement from the evidence as well. I also liked that they went over general principles of neuroplasticity in the article and it helps reinforce our strategies that we're using with our patients, post neurological injury, looking at salience, repetition and intensity as being key drivers to neuroplasticity and recovery. And I thought it was great, right? Just again, reinforces that we need to deliver this high intensity, progressive levels of change to our patients. And as you mentioned, they have to be an active learner in this problem solving, right? And we also have to motivate and provide rewards so that we can reinforce that learning. Yeah, so I agree. I thought it was a great article, a lot to unpack, but once I've read through it a few times, like you mentioned, it just really makes sense and helps reinforce what we should be doing with our patients and therapy. Yeah, and really reinforcing of that OT approach, like considering the dynamic systems approach, just looked like an OT approach and really lent itself to our way of thinking. I went to get into like the practical therapist side of your brain and ask, I guess starting just with like the theories presented, were there like practical takeaways that you had as a therapist that either reinforce or would like push you to do things a little bit differently in your sessions? Yes, and I think there was three theories I really pulled out. Obviously, we keep talking about this dynamical model of motor learning, right? So as OT's, we're always looking at the interaction of the body, the environment, the test, right? And that's the three words that kept coming up through this article. But I did find it interesting that they kept using the word constraints, right? What are the constraints that we're encountering from our environment versus what are the constraints that we're encountering from the person's impairment versus what are the constraints from the task itself, right? And so really, you know, really reinforce that we have to analyze the environment, right, in the situation in which our patients are completing the tasks. And they have a really great picture in the article of a person reaching for a messy desk, right? So it's a great illustration of how your motor control will change based on the environment and how the task is set up. I also really liked that they discussed the concept of kinematic abundance, right? So it just basically means that our body has many different ways to move and complete a task, right? There's no single correct way to do something. There's always multiple solutions. And so I, you know, the brain doesn't just find one way to perform a movement. It can find multiple solutions. So I think, again, just reinforcing that, look at the environment, right? How you're positioned or where you're reaching versus what you're interacting with, right? Is it soft? Is it firm? Is it lightweight? Is it heavy? You know, that will help your body discover different ways to achieve the same task. So again, variability is really important for learning, especially in rehab. And it's also allowing us to explore different ways to challenge our patients, right? And then, the last thing that I really enjoyed reading about too was that practice should be challenging, right? To induce learning. So the challenge point theory, learnings that improve the most when the difficulty of the task is matched to the patient's skill level, right? And the last theory that I really enjoyed reading about too was that practice should be challenging, right? To induce learning. And the complexity of the task. So we just need to make sure that we're pushing our patients enough, right? So that they'll get better, but not so much that they're going to get frustrated, you know? So just finding that just right challenge for our patients, you know, which is what we're always doing through grading our tasks, right? Up and down. Yeah. So just finding the ways to challenge our patients to help them improve and learn new skills. Those theories are so helpful. I feel like they are what we try to do in OT currently. But they also highlight how technology can be a support for us. We know it's just so hard to get the number of repetitions we need. We know it's so hard to keep grading that challenge by ourselves. Like there's ways technologies can help with that. And there's ways that technology can help give that real time feedback. Either when we are there or when we're not there, technology can also be helping with that. Can you help me understand the interplay between our traditional in person rehab. And these virtual rehab options. And I guess maybe paint a picture of the ways they can be weave together. Like I assume there's you can be incorporating virtual rehab into your in person's segment or into your in person treatment or it can be something that's done remotely in your monitoring and how do you see that interplay and how it can be most helpful for our patients. Sure. Yeah, I say with virtual technology. I see it as a complimentary system, right. Each approach can enhance each other. But I can I definitely see that we can use it in multiple different scenarios, right. So for in person rehab rate and especially when I was in an outpatient rehab rate using that technology during your sessions helps to increase repetition and intensity. So for example, when I was working in the outpatient clinic, I had a patient and we were working on an upper extremity task and I was able to help her get 100 repetitions. But then I added in virtual technology and she completed 400 repetitions right in the same period of time. So it really works to help us get a higher dosage with our patients. So utilizing it in the clinic with your patients for sure will increase intensity. So we can see that we can use it in between sessions, right. So if a patient can access technology in between sessions through a virtual app or a virtual device. Then this helps to provide an extension of their care outside of the clinic, right. And in between visits. So this could happen in an in patient setting where patients take the technology back to their room. Right and can work on it in between visits or this could happen in an outpatient setting, right where they can use the technology at home in between sessions. And then the third way that I see virtual technology being used is at home, right. So certain patients can't access in person rehab due to gee grade. Graphical constraints, you know, they live too far away from a neurological center or they have no transportation right to get to a clinic So virtual therapy can really help to increase their access to care and then just you know building on that as well If they're using the therapy at home, right certain therapies you can use on your own But then you can also pair that with a virtual therapist Right to really increase Personalized treatment, progressive challenge and intensity so you can use it across the continuum up here You know, I also know of certain Hospital systems using it more on the acute side as well again because that's when you're really focused on ADLs But we also want to make sure that we're addressing upper extremity earlier on as well too If I'm a therapist and I'm evaluating the different options for my patients I'm going to be thinking like Are the tech options I'm looking at are they meeting this checklist of like These neuroplasticity principles that we talked about about the dynamic systems theory is their problem solving What's my ideal vision of how this could interact with in person rehab? But all this is going to lead me to the question of How do we pay for this? What are the different payment models out there that we as therapists should be aware of as we're thinking of trying to match The right technology with the right patient. What's on the market for us as far as getting these paid for? Yeah, that's a great question and there are definitely different answers Right, so certain technologies are paid for out raid, but it's not usually the case right we're finding that you know Insurance isn't always covering these technologies, unfortunately, and some can be rather expensive As we know we also have therapists again utilizing this technology during their sessions right so that they can build through insurance using the appropriate CPT codes But oftentimes patients are paying out of pocket for the devices Some companies do an outright purchase, but other companies also have subscription models right where patients can pay a month to month fee Or they can pay a rental fee right if they're renting the device for a certain period of time So I think there's lots of options also There are grants right in private funding so sometimes certain organizations will help to pay for a virtual rehabilitation device and so I think it's a tough answer because there's so many different options But you know best to reach out to the company that supplies the device for the service and then they can really Really help guide you, but yeah, I think that's one of the barriers to the virtual rehab is that sometimes It's not covered by insurance or it can be too expensive and yeah, so that's That's my long short answer. Yes Yeah, it's hard because we see these technologies Making stroke rehab more accessible. That's like part of the promise of them but figuring out the payment models and reimbursement is One of the challenges that we have to layer on to an already really Challenging list of things to take into account for stroke rehab and I'll just be curious to see how that develops as the cost of these things I anticipate will come down But yeah, that will definitely definitely be something for us to follow as therapists and that we Just have to be aware of you have been immersed in this technology. I imagine you now have just so many like personal stories that you've racked up over the years getting to interface with the technology and patients and I'm just curious like What you have learned from seeing these patients get these higher intensity levels in their rehab and I guess I kind of want to put you like back at Like if you were still in a hospital or an outpatient or even in that SNF What would you do differently now seeing what you've seen? Yeah, what have you learned that you can share with the rest of us? Yeah That's a great question. My my short answer is I would start earlier and provide more intensity Right and I think with all of the evidence coming out now is that we know we can start earlier with a higher intensity program You know, I think we're all aware right that the research shows we're not doing enough Repetitions in the clinic grade Observational studies show we're doing 32 reps, you know as an average But we know we need to push our patients, right? You know 300 to 400 repetitions and even up to a thousand to induce neuroplasticity So what I've learned is that we need to do more right and how can we get there and can we use technology right to help us get there? For me, yes, it's been exciting to see in real time That patients are completing 1600 to 2000 reps in a 45 minute session, right? So that's fantastic, right? I could barely get to 100 with my one patient and then helping with technology Right, we can push up into the hundreds and the thousands and so I've seen that intensity is definitely Increasing especially as more therapists are aware of what's out there, right and technology is becoming more accessible Right, but I think we're seeing more commercialized products And so we're able to push our patients with the use of intensity. I also see that The intensity and the repetitions are getting more task-specific right and more challenging So back at my initial research with Robonix You know, I we were having our patients do those 1200 repetitions, but it was the same movement pattern, right? So we were they were just making a circle But now technology is progressed. We're seeing gamification so you can facilitate the environment the challenge, right? You can give this feedback that's helping patients do a larger range of motion, right? Move in different directions work more pivots of the upper extremity and you task specific training So I think in general, yes that intensity is increasing and it's getting Better with the quality and then I think also Utilizing apps for patients, right? Can't we give them something to look at that's going to count their repetitions, right? That's going to count the change to push them further, right? So like in our program we pushed the patient we put a little number up at the top of our App and we want them to do 400 repetitions, right? So this is helping right to increase that intensity and get them to that point And then just the opposite with technology clinicians can see the data, right? So we can push our patients more Yeah, so overall, yes, I would start earlier do more repetitions and utilize whatever you have low tech high tech It doesn't matter. There are so many therapists sharing ideas to now Through social media and through different platforms and so There's so many options on how we can provide that intensity to our patients earlier Yeah, just to get visions of what's possible like When I started I went to thought 400 reps was possible. I just went to thought that but now we know it is And yeah, and we also those earlier the earliest versions of this where it was just like one motion over and over and over And then that was great. I came back at that one motion, but it didn't generalize and now we're able to do repetitions with more variation and like you said task specificity I guess thinking so again back in your like Taking your brain now and putting it back into That outpatient acute care therapist Thinking not only of intensity, but what you've learned about creating that progressive level of challenge And then like this paper said I love the little part on knowledge of performance not just knowledge of results How would you take what you've learned about those two things What would you have done differently in those more traditional roles now knowing what you have seen and what you know now Yes, right so knowledge of results is our end result that we're seeing versus that knowledge of Performance we're really looking at What's happening right while we're completing that termist? Yeah, which is harder. Yeah to give that feedback That's challenging to me as a therapist How do I do that was that actually look like Exactly, but that's really where the changes happening right and so how do we progressively push our patients Because we know that that's what's needed to drive neuroplasticity right that's what's gonna help us improve motor recovery So you know always just gradually increasing the task To keep our patients progressing And we want to make sure that we are using feedback right to help them to progress and so you know we discussed this a little bit but You know How far is the patient moving through through their range of motion to reach the target? Okay, they were able to reach the target So let's push that cup a little bit farther down right and so we have to just progressively change What they're doing and challenge them And so they'll get better right instead of like we said reaching for that cup straight out in front of you Let's go out into scaption into abduction right and so really start to you know push the patient into different environments and so I think that this you know the gamification helps to offer the the progressive challenge with our patients And it helps them to advance to higher levels right so As they improve within our function So if they're improving their motor control and they're improving by moving faster, that's where you have technology then will progress the patient to the next level. So I think that's what we're seeing too with technology is that the technology is able to progress the levels of challenge, but then we're also providing the rewards to keep the patient motivated. So what I've also learned to extrinsic feedback is extremely helpful, right? And I air base learning, right? We want to make sure that our patient is refining their skills and improving their movements throughout time. And so when we're using virtual rehab, there's many ways to do this, right? We can provide visual feedback to our patients, right? So for example, having to move the spaceship side to side, did I increase my range enough far enough to get around the obstacle, right? Did I squeeze my hand hard enough to pop the balloon or, you know, to make the person jump, right? And so providing this feedback is going to help that patient to get stronger, right? Because maybe they weren't able to pop the balloon that those first five squeezes. But as they're working harder, right? Intensity is increasing, then they're able to pop that balloon. Yeah. And I think the other feedback that's really important from this virtual rehab too is that we can give sensory feedback and vibration, right? Like, haptic feedback, which is also another piece of the puzzle. And that's going to help, you know, provide patients with more sensory stimulation, as well as auditory feedback, right? So we can use a variety of ways to help progress our patients through feedback. I actually did a past podcast on virtual reality and OT. And if I'm remembering correctly, we ended with kind of like, I can't wait till the haptic feedback comes. Like, this was a couple of years ago and it was come, it was like, just barely on the horizon. And I'm like, now we're, we're already there. And I think my question is, we've seen the earlier versions of this kind of stroke tech support where like the robotic where you do this, you do the same motion over and over and it helps with that one motion, but it doesn't generalize. And now we're at a better and more exciting phase of virtual read rehab where we have haptic feedback, we have more differences in the movements being performed. It's a game of fight. But my question is, what's missing from where we're at currently and where do you think we're going on the near horizon? Like, I think there is exciting technologies. Like, I don't think we've fully arrived yet. Like, I think we're still learning learning and getting a little better. What's what do you see on the horizon for us? Yeah, I agree. Well, first, what remains missing, I think is access, right? I think there's just so many patients are unable to access those technology. And we know virtual re-up tools will help us. I also think what's missing is that therapists are not always exposed, right? Two virtual technology and the options. So they're not able to use it in the clinic, right? And it's underused. I think therapists also have a limited understanding of what options are out there. So what I see on the horizon, yes, I see that we're going to continue to improve with the tools that we're developing. I think, again, through education and social media, we're seeing more treatment options. And so I think the awareness is growing, right, with therapists. And so my hope is that right, all of this evidence is going to get into the clinic faster, right? So by collecting all these metrics and all this evidence, we're going to get rehab technology into the clinic faster, which then, yes, I think will improve what we're using and provide new options for patients. Definitely. And again, I also see on the horizon virtual programs, right? So now that we have more accessible technology, right, that patients can use at home. I think we'll see more of a combination of therapy partnered with rehab technology so we can really improve access, you know, for our patients. Definitely. By that, you mean someone seen a virtual therapist and that therapist is using rehab tech. Yeah, the patient has it at home. And then they have the therapist guiding them virtually, right? Mm-hmm. Yeah, you can see that opening access up for so many patients. And I always think about that chronic phase of stroke two and how many patients I discharged, who would have been motivated to keep going. They just didn't fit in my traditional outpatient system. And maybe I wasn't being creative enough as a therapist, but I know if there was like that virtual option, they would have kept going. They had that motivation. I agree. And that's, yeah, that is what we're seeing too, right? Patients are looking for options. And you know, what can they do at home on their own to right to continue with the therapy? Because yeah, as you know, there are certain limitations in outpatient, right? They get so much time with that in person therapist and then discharge tone, whether it's from insurance options, whether they're not making enough progress, right? And so I think having these options is great for patients to continue with their rehab because we know it's a lifelong rehab for them. As I hear you talking, I feel, I want to say like burdened as a continuing education provider, because I'm still focused on like, here's the new research that is coming out. But on the other hand, there's all these technologies coming out. And how do we stay educated on them? And I guess I'm interweaving this even with like thinking about the AI clinical decision support that's going to come to us in our documentation. Like does that need to be suggesting different technologies to us in ways for it to get paid? My question is that in that is how do we how in the world, Katie, are we going to keep up? And how do we as OT's position us ourselves as a leaders in that like you've been such a role model? What's your advice to the rest of us because I'm excited, but I'm honestly overwhelmed by it. Yeah, it's a lot. Yeah, I could tell you right two years ago, right, kind of jumping into the into the health tech world. And I have learned a tremendous amount in the last two years. And I really, I really appreciate it. But right, it's you guys got to stay up to date, right with the latest technologies and the research. But we have so much access for going to conferences, you know, attending to webinars listening to podcasts. You know, there's so much information to ingest, but I do think there's just so much sharing now within the industries, you know, network. I think we all say this right network and collaborate with others in the field. There are so many therapists are that are involved with technology right now. And whether it's the user experience role, a clinical specialist role, right medical device sales product development. But network collaborate, right and learn about this technology for sure. And then if you're in it, once you're in it, you know, measure your outcomes, share your key studies. There's so much data that's been collected that it's important right to to share what we're learning to help push the field forward. But, you know, and then I would say, you know, join the team, right. We have such knowledge and task analysis and body mechanics and functional movement patterns. So, you know, OTs can really help develop these virtual tools. Yeah. So just bringing bringing our knowledge of patient centered care to help. Yeah, with developing features and providing a successful user experience, right. So there's so much that OTs can do. But yes, you know, getting involved. It's hard to know. Yeah, it's always evolving, right. As you said, so it's hard to know everything. But I think yeah, having, you know, updated webinars about, you know, new technology that's on the market is a great way to start. I've loved getting this glimpse into your career. And I think you've just done you as an individual like showcase to us as OTs what's possible. One, your trajectory from that first SNF to being in this tech company, like on this right that I would guess you would never have projected because where you're working to exist when you started. You show us what's possible from just a career trajectory, but also then what's possible for our patients like you're saying these higher levels of reps, like really meeting these principles of neuroplasticity that the article laid out for us and all in this technical systems approach where there's problem solving at the heart of it. We've talked about so many things we've talked about theory we've talked about tech we've talked about career trajectory in this episode. What's the closing thought that you want to leave us on? Yeah, I agree a lot of buzzwords today. I mean, high intensity progressive challenges, you know, but I think it all came back to write the interaction of the person environment and the task right. And so really the take home is that evidence based theories and principles right are being utilized right and we're able to utilize these through virtual rehab and technology. And so, you know, it's working. Our patients are getting better. I'll, you know, my take home is to continue learning, right? Keep exploring options and let's just keep moving our field forward. Yeah. Because like you said, you're right. I would have never imagined I would be in this role 20 years ago, you know, because it didn't exist. And so I think that's what we're going to see on the horizon. There's other roles that don't exist yet, but they will. And so, you know, and follow your heart and your passion. What really brings you joy, you know? That's when that's what I did. And that's what kind of landed me here. Yeah. Oh, well, Katie, thank you so much for being here today for sharing about yourself and about your work and this vision for what's possible. And like you said, I just hope the access continues to increase. And we as OTs can be part of that and part of those teams. And I just thank you for that push in this conversation today. Yeah. Thank you, Sarah. It was such a pleasure. Thank you for having me. And, you know, I've been part of OTs potential now for a few years. And I really appreciate all the work you're doing and helping to, you know, advance evidence and our practice and really being a thought leader. So thank you for inviting me. While you all this is such a complex topic, we tackled a lot. We dove into how theory should drive neurorehab and how technology is needed to bridge our current gaps in neurorehab. Luckily, Katie's story made this complex intersection just feel full of possibilities. And I hope you are leaving feeling just full of hope and possibility for your patients and also for your OT career. And as always, we want to hear what your thoughts are on this episode. If you are a casual listener, we would just love a review from you. You can review us on our homepage or we always appreciate your comments on our YouTube video. But the best place to really discuss the implications of this is in the OT potential club. And I'll be watching for your comments in our forum. The OT potential club is also where you will go to earn a CEU certificate for your time today. So what you are going to do next is head to otpotential.com and either sign in or sign up for the OT potential club. Once you are in there, you can take a five question test. And when you pass, we will generate a certificate for your time today. OK, I want to thank you so much for joining us. I hope this podcast helps keep you informed and inspired as an OT professional. Take care and we'll talk next time.