The Rose Centre for Stroke Recovery and Research: Harnessing Biotechnology in Rehabilitation and Research

Stroke is the second most common cause of death worldwide and a common cause of disability in adults in developed countries.¹ The incidence of stroke in New Zealand is high compared to other developed countries, with over 6,000 new stroke events each year and over 2,000 deaths attributable to this condition. Only 50-70% of stroke patients regain functional independence, with 15-30% of stroke patients facing permanent disability.¹ At any point in time, there will be over 32,000 New Zealanders who have survived their initial event but are living with the disabilities arising from stroke.²

Not all strokes occur in the elderly. Approximately 25% of all first strokes occur in individuals under 65 years of age. Though the consequences of stroke are devastating for all ages, for younger patients this disability can cause long-term impairment in supporting a family, engaging in a career, and interacting effectively in a social context.^3,4 Studies have shown younger individuals experience not only the negative effects of disability following stroke, but worsened self-rated global health, with increased incidence of impairment in mobility, self-care, and depression.⁵ Health systems have developed comprehensive clinical rehabilitation services for individuals in the acute and post-acute phases; services are particularly well developed for elderly stroke patients. In New Zealand in particular, there are also well-developed services for young patients who have suffered disability due to accidental injury under the Accident Compensation Corporation program, which is a government-sponsored insurance provider. However, funding for and access to rehabilitation services are more restricted for stroke patients under the age of 65 years. This is compounded by a number of barriers in the accessibility of post-acute rehabilitation services at a personal, financial, and systematic level,⁶ and is in stark contrast to research indicating that younger patients may make the greatest functional gains following post-acute rehabilitation, despite severe disability.⁷ Swift discharge from acute care facilities necessitates patients and their families to rapidly coordinate post-acute care, made increasingly difficult by limited patient resources regarding how, when, and where to access ongoing rehabilitative services.⁸ Additionally, optimal treatment in the post-acute phase is time and labor intensive, with variable service delivery depending on provider, limiting the number of consistent treatment options available across the national health system.⁹ 

The UC Rose Centre for Stroke Recovery and Research 

A recent donation has provided the resources to formally address these gaps in service provision and rehabilitation research for chronic impairment. The University of Canterbury Rose Centre for Stroke Recovery and Research at St. Georges Medical Centre in Christchurch, New Zealand was established in 2014 due to the generosity of Mrs. Shirley Rose, who spent many of her final years tending to the disability created by stroke in her husband. This state-of-the-art facility was designed to blur the boundaries between clinic and research, providing the optimal environment for translational research activity. The centre builds on the successes of the current University of Canterbury Swallowing Rehabilitation Research Laboratory led by Assoc. Prof. Maggie-Lee Huckabee, first focusing on research and speciality clinics for swallowing impairment. This focus will very soon expand to encompass other areas of communication disorders, as well as physiotherapy, occupational therapy and nutrition, thus providing integrated treatment between disciplines, reducing the burden on patients who currently navigate multiple outpatient rehabilitation facilities. This aligns with a global focus to move from intradisciplinary provision of care toward a more comprehensive and integrated system of patient management.⁷

The Rose Centre specializes in the provision of intensive, specific, effective and innovative diagnostic and rehabilitative procedures that are driven by the latest research and the physiologic needs of the patients. Research into stroke recovery is clear that intensive rehabilitation maximizes neural plasticity and functional gains.¹⁰ In a recent survey, McNaughton et al revealed that only approximately one-half of rehabilitation units achieved 1 hour per weekday of direct therapist-patient contact time, and stated “few services … provide community or outpatient rehabilitation more than 2 or 3 days per week.”⁹ This is in stark contrast to evidence-based recommendations for rehabilitation to have a minimum intensity of 45 minutes per day, for each discipline.¹⁰ The uniqueness of the intensive services offered by the Rose Centre for Stroke Recovery and Research are already evidenced through a rapid increase in both national and international referrals.  

The fundamental tenets of intensive, integrated rehabilitation are supported by rehabilitation research, with, not surprisingly, reports positive clinical outcomes.¹¹ A systematic review complied by Langhorne & Duncan revealed “organized multidisciplinary rehabilitation was associated with a reduced odds of death (odds ratio, 0.66; P<.01), death or institutionalization (odds ratio, 0.70; P<.001), and death or dependency (odds ratio, 0.65; P<.001), which was consistent across a variety of trial subgroups.”¹³ In a meta-analysis investigating benefits of rehabilitative services as compared to medical care alone, Evans et al found patients who received multidisciplinary management had significantly better odds of survival and increased functional capacity, with improved likelihood of returning to work. Importantly, however, these gains were not maintained at 8-12 months after discharge from treatment, indicating a critical need for continued rehabilitation in the chronic phases to continue maintenance of gains, and development of further skills to promote recovery.¹⁴ It is paramount to continue rehabilitation in chronic patients; animal studies have shown neural plasticity can continue to occur via active practice, even after the spontaneous recovery process has been thought to end.¹⁵ From a patient perspective, Miyai et al found significant gains in chronic stroke patients when evaluating functional status even when multidisciplinary rehabilitation intervention was commenced after 90 days post stroke.¹⁶

Biotechnology in Rehabilitation Research 

In addition to this clinical work, the research profile of the Rose Centre will continue toward development of neurorehabilitation approaches and delineation of rehabilitative effects on neural, muscular, and behavioral function. In short, we want to answer the questions: When it is broken, how do we fix it? More specifically, when we fix it, what are we changing: muscle, nerve, brain, or behavior? Treatment approaches under investigation include neuromuscular exercise programs for swallowing impairment focusing heavily on the use of hierarchically presented sensory and neuromodulatory stimulation. A specific interest in the use of biofeedback modalities to enhance skill training are emphasized and enhanced by close collaboration with engineering colleagues to develop software and hardware platforms for this application. These techniques are focused on capturing cortical modulation of the complex brainstem-generated swallowing response.

Our research laboratories are well stocked with a broad range of instrumentation, focused currently on swallowing impairment. Our imaging laboratory can capture integrated swallowing biomechanics using videofluoroscopy, videoendoscopy, and ultrasound imaging. Using more specific instrumentation in the physiology lab such as high and low resolution oral and pharyngeal manometry, electromyography, respiratory airflow monitoring, and swallowing acoustics allow for clarification of specific physiologic effects of rehabilitation. Neural function is assessed using transcranial magnetic stimulation and, soon, near infrared spectroscopy. Electroencephalography and functional magnetic resonance imaging (fMRI) are available via affiliated labs. Our research is executed both in healthy research participants, to better understand mechanisms of rehabilitation, as well as patients following neurological impairment. 

While broadening this active rehabilitation and research profile to other allied health disciplines, it is clear that our focus on biomedical engineering is a critical collaborative feature, unique to the Rose Centre. Worldwide, biomedical engineering has seen tremendous growth over the past two decades.¹⁷ The development of this field has provided the application of a vast number of neurotechnological devices aimed at remediating damage caused by neurologic damage, like stroke. As explained by Berger et al, “engineered solutions to the problems of neural repair and/or replacement imply a substantial capability to model biological functions, and to translate those models into effective medical or experimental procedures.”¹⁷ This underscores the need for multidisciplinary collaboration to convert understanding of neural functioning, damage and subsequent rehabilitative targets to a technological tools, devices and software/hardware platforms. Further, as stroke rehabilitation moves towards the use of many non-invasive stimulation techniques and rehabilitation robotics, for example, collaboration is essential to effectively, safely, and ethically enhance neuro-recovery.¹⁸

The rehabilitation and research programs of the Rose Centre extend outside the laboratory to hospital-based settings with close supporting collaborations in several New Zealand District Health Boards, several overseas hospitals, and many other research and academic programs. This provides mutual benefit, as the expertise of personnel and sophistication of the instrumentation in the laboratory offer valuable resources to individuals in the region pursuing intensive stroke rehabilitation. Stroke is a global health issue that will continue to escalate with an aging population.¹⁹ The prevalence of survivors of stroke is estimated to reach up to 77 million by the year 2030.^19,20 As patients follow the continuum of care in stroke rehabilitation, streamlined, evidenced-based options for recovery are key, especially in the chronic stages. Currently, many patients encounter fragmented pathways for stroke care, each unit with a specific purpose and individual accountability.⁸ It is our hope that the Rose Centre for Stroke Recovery and Research will provide a new model for intensive, integrated care with a commitment to implementation of biomedical technology in an evidenced-based manner. This is a critical step forward in the comprehensive rehabilitation of patients living with disability following stroke, and not a moment too soon. 

References

1. Carod-Artal FJ, Egido JA. Quality of life after stroke: the importance of a good recovery. Cerebrovascular Dis. 2009;27(Suppl 1):204-214. 
2. Stroke Foundation of New Zealand. National acute stroke services audit 2009. Wellington, New Zealand: Stroke Foundation of New Zealand/2010.
3. Desrosiers J, Noreau L, Rochette A, Bravo G, Boutin C. Predictors of handicap situations following post-stroke rehabilitation. Disabil Rehabil. 2002;24:774-785.
4. Dijkerman HC, Wood VA, Hewer RL. Long-term outcome after discharge from a stroke rehabilitation unit. J R Coll Physicians Lond. 1996;30:538-546.
5. Palmcrantz S, Widén Holmqvist L, Sommerfeld DK. Young individuals with stroke: a cross sectional study of long-term disability associated with self-rated global health. BMC Neurol. 2014;14:29-34.
6. Ottenbacher KJ, Graham JE. The state-of-the-science: access to postacute care rehabilitation services. A review. Arch Phys Med Rehabil. 2007;88(11):1513-1521. 
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10. Intercollegiate Stroke Working Party. National clinical guideline for stroke, 4th edition. London: Royal College of Physicians, 2012.
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13. Langhorne P, Duncan P. Does the organization of postacute stroke care really matter? Stroke. 2001;32:268-274. 
14. Evans RL, Connis RT, Hendricks RD, Haselkorn JK. Multidisciplinary rehabilitation versus medical care: a meta-analysis. Soc Sci Med. 1995;40:1699-1706. 
15. Whitall J, McCombe WS, Silver KH, Macko RF. Repetitive bilateral arm training with rhythmic auditory cueing improves motor function in chronic hemiparetic stroke. Stroke. 2000;31:2390-2395. 
16. Miyai I, Suzuki T, Kii K, Kang J, Kajiura I. Functional outcome of multidisciplinary rehabilitation in chronic stroke. J Neuro Rehabil. 1998;12:95-99.
17. Berger T, Gerhardt G, Liker MA, Soussou W. The impact of neurotechnology on rehabilitation. IEEE Rev Biomed Eng. 2008;1:157-197. 
18. Krebs H. Rehabilitation robotics: an academic engineer perspective. 33rd Annual International Conference of the IEEE EMBS, Boston, Massachusetts, USA, August 30 - September 3, 2011, 6709-6712. 
19. Donnan GA, Fisher M, Macleod M, Davis SM. Stroke. Lancet. 2008;371:1612-1623.
20. Strong K, Mathers C, Bonita R. Preventing stroke: saving lives around the world. Lancet Neurol. 2007;6:182-187.
21. Wissel J, Olver J, Sunnerhagen KS. Navigating the poststroke continuum of care. J Stroke Cerebrovasc Dis. 2013;22:1-8. 

Acknowledgements. The authors are grateful for financial support from Mrs. Shirley Rose, The Canterbury Medical Research Foundation, and The University of Canterbury.

Disclosure: The authors declare they have no conflicts of interest.