Telerehabilitation to Make Treatment More Accessible for People with Stroke

Woman holding a tablet

After a stroke, more than 80% of patients experience impaired motor function including weakness and poor coordination. Unfortunately, these impairments commonly become chronic conditions that may reduce participation and quality of life for stroke survivors. Despite the benefits that rehabilitation can provide, barriers such as cost, lack of transportation, poor adherence, and other factors may prevent individuals with stroke from accessing sufficient amounts of therapy to maximize their recovery. Adding the ongoing COVID-19 pandemic to the list of potential barriers to therapy, investigations into the efficacy of remote rehabilitation treatments for stroke are critical.

The Human Motor Recovery Laboratory at Moss Rehabilitation Research Institute (MRRI) is dedicated to using technology to improve recovery in stroke and other neurological conditions. One line of research led by lab director Dylan Edwards, PhD, in conjunction with MossRehab (Alberto Esquenazi, MD) and California Rehabilitation Institute (Steven Cramer, MD), is focused on developing and evaluating home-based telerehabilitation therapies to improve motor recovery after stroke.

Telerehabilitation has become more widely available across the United States and around the world, and it may help people with stroke overcome barriers and achieve higher doses of therapy to improve outcomes. Dr. Edwards and collaborators recently published the results of a large-scale multi-site randomized noninferiority clinical trial comparing the efficacy of home-based telerehabilitation therapy to therapy delivered in the clinic for adults in the acute phase (4 to 36 weeks) post-stroke. The treatment targeted arm movement and included an education component as well. A total of 124 patients participated across eleven different sites in the United States. The intervention involved 36 sessions of motor therapy and stroke education delivered over six weeks, and each session was 70 minutes in duration.

Strengths of this particular study are that the intensity, duration, and frequency of therapy were matched across the home-based and in-clinic groups, and the interventions included stroke education to address gaps in knowledge that may impact recovery and prevent secondary stroke. The results showed that arm function, as measured by the Fugl-Meyer Assessment, improved significantly and with a clinically important change in both groups. The home-based telerehabilitation intervention was not inferior to the in-clinic intervention. In addition, the telerehabilitation intervention was found to be safe, it was well-received by participants, and adherence was excellent.

The study conducted by Dr. Edwards and colleagues was included in a recent Cochrane review examining telerehabilitation for people with stroke more broadly. The main goal of this review was to determine whether individuals with stroke are better able to perform activities of daily living following telerehabilitation compared to in-person rehabilitation or usual care. The review included 22 studies with a total of 1,937 participants. Of these 22 studies, the work by Dr. Edwards and colleagues was one of only three studies to be determined by the authors to have the highest methodological quality based on a low risk for all six potential types of bias assessed. However, overall evidence across studies was only low- to moderate-quality, and differences between studies in terms of interventions and outcomes made it difficult or not appropriate for the reviewers to pool data. Though preliminary evidence suggests that people who received telerehabilitation had similar outcomes for activities of daily living compared to those who received in-person rehabilitation or usual care, additional research is needed to draw more definitive conclusions.

Telerehabilitation for recovery post-stroke is an active and evolving field of research, and many questions remain to be answered. The recent clinical trial conducted by Dr. Edwards and colleagues focused on rehabilitation of arm movements in people with stroke, but further research is needed to understand the efficacy of home-based therapies for other aspects of movement as well as for language and memory. It will also be important to compare the costs of home-based versus in-clinic therapies. Dr. Edwards is honored to be making important contributions to this impactful area of rehabilitation research, and he looks forward to continuing to conduct exceptional, high-quality studies to further improve outcomes for individuals with stroke through technology such as telerehabilitation.


MRRI Postdoctoral Fellows Share Their Training Experience

Moss Rehabilitation Research Institute (MRRI) is dedicated to providing exceptional training and career development opportunities for postdoctoral fellows. In this video, MRRI postdocs discuss their experiences working at the Institute as well as how the resources and environment at MRRI are preparing them for the next stage of their research careers. 


MRRI Director’s New Year Message

With 2022 upon us, we welcome the new opportunities that may present over the coming months, the safe engagement with our research community, and continuing the momentum of MRRI’s remarkable scientific advancements of 2021. Please refer to the 2021 Annual Report for a list of our new and original research findings spanning the translational neurorehabilitation spectrum.

Through the significant challenges brought about by the waves of COVID-19 pandemic variants, our staff have found ways to find personal and professional balance, and they are to be commended for their perseverance and resilience. While MRRI may be robust and adaptable, we are not immune to prolonged effects of pandemic. Despite the ongoing stresses and uncertainty, we have done well to rely on each other, including finding opportunities for laughter, friendship, and support.

During the coming year, we anticipate MRRI scientists and staff will engage in activities to further integrate with Jefferson Health. In doing so, we will remain dedicated to our mission, as well as to promoting the professional growth of individuals and the evolution of the Institute as a whole.

I encourage you to stay informed about MRRI’s latest research findings and opportunities to participate in our cutting-edge basic and clinical research.

Best wishes for a prosperous, safe, and fulfilling 2022.

Sincerely,

Dylan J. Edwards, PhD

Director, Moss Rehabilitation Research Institute


MRRI Postdoc Dr. Cory Potts Discusses His Career and Research

Cory Potts, PhD joined the Cognition and Action Laboratory and the Neuroplasticity and Motor Behavior Laboratory at Moss Rehabilitation Research Institute (MRRI) in August of 2020. In this interview, he tells us more about his exciting research, his career, and his life outside the lab.

1) Can you tell us more about your academic background and training?

I began to consider pursuing an academic career during my junior year at Penn State while taking a class in cognitive psychology with Dr. David Rosenbaum. Dr. Rosenbaum directed a research lab investigating cognition and action, where I was invited to work as a research assistant and later as lab manager. My experiences during this time deepened my interest in psychological research and led me toward the decision to pursue my PhD in psychology from Penn State under the mentorship of Drs. David Rosenbaum and Rich Carlson. In my research, I have continued to examine interactions between cognition and action, focusing on how we plan and think about our movements.

2) What attracted you to science and the field of neurorehabilitation?

For as long as I can remember, I’ve been full of creative energy and have needed an outlet of some kind—for example, I’ve been an avid guitar player since I was twelve. Science is a deeply creative endeavor, and it has provided me with a creative outlet in my professional life. It can be profoundly invigorating to dream up new experiments or questions that might have never been asked before! But I also began studying psychology because I wanted to help people, and that desire has remained. The field of neurorehabilitation allows me to apply what I’ve learned about movement in neurotypical individuals to better understand, and ultimately improve, problems in movement occurring after stroke.

3) Why did you choose to work at MRRI?

MRRI has been on my radar since early in graduate school, as many former members of Dr. Rosenbaum’s lab have worked there. Because of this, I knew that MRRI was a top-tier research institute where I would be able to apply the principles I was learning in graduate school to individuals with disordered movement using cutting-edge techniques and technologies.

4) What are some of the research questions you are currently working to address?

I’m currently involved in a multi-component project examining “learned non-use” of the more affected arm in individuals with stroke, a puzzling and little-studied condition. Learned non-use refers to the disparity between the capacity and use of the more affected, weaker arm. In other words, the individual can effectively use the weaker arm to perform a task but chooses not to, instead defaulting to the use of the less affected, stronger arm. Learned non-use remains a challenge in stroke rehabilitation and prevents people with stroke from accomplishing activities of daily living, which are typically completed through the coordinated use of both arms. The broad aim of these projects is to better understand why this condition occurs and the variables that influence it. In one experiment, we’re using a virtual reality-based reaching task to examine whether non-use is affected by attentional demands, for example, by asking participants to simultaneously complete a secondary

task. For my independent project, I have developed a task to investigate the variables that shape the decision to use one or both arms to complete tasks in individuals with stroke.

5) What have been some of the key findings of your research thus far?

While this research is ongoing, the results suggest that arm non-use is worsened, meaning that the weaker arm is used less often, during more attention-demanding task conditions. We have also found that patients with stroke may differ from neurotypical individuals in the efficiency of their reaching movements, reaching far into the opposite-side workspace with the less affected arm. For the task examining use of one or both arms, we have found preliminary evidence suggesting that the spatial arrangement of objects is an important factor in decisions about whether to use one or both arms. Each of these projects contributes novel insight into changes in arm use following stroke.

6) Can you tell us more about the impact or potential impact of your research?

This project adds a brand-new piece to our understanding of why non-use occurs after stroke. We all know from daily life that our attention is limited. That is why, for example, it can be difficult to hold a conversation while watching television. Our results suggest that these attentional limitations contribute to non-use of the more affected arm. Thus, it is possible that developing methods to reduce attentional demands during rehabilitation, or to equate the attentional demands of either arm, could be doors for new rehabilitative strategies.

7) What is one of the biggest challenges you face in your work?

I began my post-doctoral position during the COVID-19 pandemic, which has made it difficult to conduct in-person research. However, we have since adapted, and we have developed methods to continue to make progress with our work while keeping our participants safe.

8) What do you see as the next step in your career, and are there experiences or skills from your fellowship at MRRI that you think will be particularly useful going forward?

For my next position, I would like to work in a setting with a balance between teaching and research, ideally continuing to work with patients with stroke. I have learned a variety of new techniques in my fellowship at MRRI, such as motion tracking, that will remain at the core of my research program. However, I’m most excited about sharing the knowledge and experiences I’ve gained through this fellowship with my students in future classes, as I think they will find these topics interesting and engaging.

9) What is one of your favorite MRRI memories so far?

We had a socially distanced kayaking trip at the start of my post-doc that was a lot of fun and really helped me to get to know my colleagues! I’ve been kayaking since I was young, and I also worked as a whitewater rafting guide for many years, so that trip was right up my alley.

10) What are some of the things you like to do in your free time?

I like to spend my free time hiking, playing guitar, reading, kayaking, and hanging out with my partner, Felicity, and my dog, Willow, who is full of energy and keeps me busy!


MRRI’s Research Registry Helps Scientists Make Important Discoveries and Develop New Treatments

Founded in 2000, the Moss Rehabilitation Research Institute (MRRI) Research Registry is a computer database that allows MossRehab patients and members of the community to learn about research opportunities that may ultimately benefit them or others. The Registry is directed by Sharon M. Antonucci, PhD, CCC-SLP, and it is a unique and valuable resource for MRRI scientists and collaborators.  

MRRI scientists conduct cutting-edge research in cognitive neuroscience and cognitive rehabilitation, traumatic brain injury treatments and outcomes, and movement science and mobility rehabilitation. To answer important questions about the nervous system and how to advance neurorehabilitation treatments, MRRI scientists recruit volunteers to participate in a wide variety of research studies.  

The MRRI Research Registry allows researchers to identify individuals who are interested in volunteering for ongoing or future research studies. Individuals who join the Registry may have an opportunity to participate in one or more studies that assess speech and language (e.g. aphasia), attention, memory, movement, and/or emotional well-being. These studies include advanced techniques in neuroimaging, neurophysiology, neurostimulation, and robotics, as well as the evaluation of novel treatments and the development of new technology.  

Currently there are 2,021 members in the MRRI Research Registry, and it continues to grow. Registry members include adults aged 18 – 89 years old with stroke, traumatic brain injury (TBI), and Parkinson’s Disease or Parkinson-like symptoms, as well as individuals who do not have a neurological condition. As MRRI continues to expand and establish new research laboratories, the MRRI Research Registry may begin recruiting populations with other neurological diagnoses. Participation in each research opportunity is completely voluntary, and to date, members of the MRRI Research Registry have contributed to 157 different research studies.  

MRRI scientists are dedicated to improving the lives of individuals with neurological disabilities through research. The time, effort, and dedication of research participants has been critical in the success of MRRI scientists in advancing our knowledge in the fields of neuroscience and neurorehabilitation. For more information about the MRRI Research Registry and how to get involved, visit the Registry webpage or read the Registry brochure


MRRI Scientists and Collaborators Receive Chernowitz Medical Research Foundation Award

Carol Parlin Prushan, Vice President and Chief Development Officer, Einstein Healthcare Network; Jack Platt, Vice President and Trustee, The Chernowitz Medical Research Foundation; Dylan Edwards, PhD, Director, MRRI and Principal Investigator; and Shailesh Kantak, PhD, Institute Scientist, MRRI and Co-Principal Investigator.

George and Edith Chernowitz were pioneers in the development of quality control in scientific and industrial applications. Respected and influential service providers and technology leaders in the space program, they combined their analytical interests into developing statistical and engineering analyses of military weapons systems and related aspects of flight-related testing. Their work lives on today in applications used by all branches of the military and NASA.

Together, they created the The Chernowitz Medical Research Foundation as their legacy to enhance human health and well-being by supporting innovative research in the areas of circulatory disorders and mental health. 

The Moss Rehabilitation Research Institute (MRRI) has been awarded funding to further develop treatments for patients who have experienced a stroke. Over $400,000 from The Chernowitz Medical Research Foundation will support this MRRI-led study and conducted in collaboration with the Athinoula A. Martinos Center for Biomedical Imaging at Massachusetts General Hospital, Harvard Medical School, and Massachusetts Institute of Technology.

Led by Principal Investigator, Dylan Edwards, PhD, Director of MRRI and Director of the Human Motor Recovery Laboratory, the study titled “Precision Targeting for Transcranial Magnetic Stimulation (TMS) Treatment in Stroke Patients” will validate advanced computational TMS mapping methods for clinical and research applications including depression, neurosurgery, and stroke.

Co-Principal Investigators include Shailesh Kantak, PhD, Institute Scientist and Director of the Neuroplasticity and Motor Behavior Laboratory at MRRI and Aapo Nummenmaa, PhD, Assistant Professor of Radiology at Harvard Medical School, Assistant in Neuroscience at Massachusetts General Hospital, and Director of the TMS Core at the Martinos Center. Co-Investigators are Sergey N. Makarov, PhD, and Mohammad Daneshzand, PhD.


New Podcast Episode Discusses the Importance of Integrating Research and Clinical Care

Over the years, MossRehab has been consistently recognized as one of the nation’s top ten Best Hospitals for Rehabilitation by US News and World Report. Communication and collaboration between researchers and clinicians allows MossRehab to provide cutting-edge, evidence-based treatment to patients and ensures that scientists at the Moss Rehabilitation Research Institute (MRRI) are pursuing research topics that address critical needs in rehabilitation assessment and treatment.  

MRRI Director and Director of the Human Motor Recovery Laboratory Dylan Edwards, PhD, joins Alberto Esquenazi, MD, to discuss the importance of integrating research with clinical care in the latest episode of the MossRehab Conversations podcast. Dr. Esquenazi is the John Otto Haas Chair of Physical Medicine and Rehabilitation and Chief Medical Officer at MossRehab.  

In this episode, Drs. Edwards and Esquenazi describe the collaborative environment and other factors that drew them to Moss and have kept them here. They also share examples of programs and initiatives that MossRehab and MRRI have developed to foster interactions between scientists and clinicians, and they explain some of the impacts these efforts have on both research and clinical practice.  

You can listen to the full podcast episode or read the transcript on the MossRehab website.  


Dr. Buxbaum Receives Prestigious Freda Newcombe Prize

Moss Rehabilitation Research Institute (MRRI) is honored to announce that Laurel Buxbaum, PsyD, has recently been selected to receive the 2021 Freda Newcombe Prize from the British Neuropsychological Society (BNS). The BNS was formed in 1989 to build relationships between cognitive neuroscience and clinical investigations of patients with neuropsychological impairments. This Prize is named after Freda Newcombe, PhD, a British scientist who played a pivotal role in developing the discipline of cognitive neuropsychology. The Executive Committee of the BNS chooses one distinguished scientist annually to receive The Freda Newcombe Prize for their excellence in research. Dr. Buxbaum is now one of only fifteen scientists to have the distinction of receiving this highly competitive award. Previous recipients include renowned cognitive neuropsychologists Karalyn Patterson, PhD, Glyn Humphreys, PhD, Tim Shallice, PhD, Michael Kopelman, PhD, and Matt Lambon-Ralph, PhD.

Dr. Buxbaum is Associate Director of MRRI and Director of the Cognition and Action Laboratory at MRRI. She will be presenting her prize lecture titled “The way(s) you do the things you do: left hemisphere representation and selection of tool knowledge“ at the BNS Autumn Online meeting on Thursday November 11, 2021


MRRI Contributes to New Research Exploring How to Improve Memory in Traumatic Brain Injury and Depression

Dr. Umesh Venkatesan

Umi Venkatesan, PhD, who directs the Brain Trauma and Behavior Laboratory at Moss Rehabilitation Research Institute (MRRI), is Site Principal Investigator of a new study that will examine learning and memory in individuals living with traumatic brain injury (TBI) and depression. Amanda Rabinowitz, PhD, Director of MRRI’s Brain Injury Neuropsychology Laboratory, will also contribute to this effort. The project represents a collaboration between scientists at Kessler Foundation (lead site; East Hanover, NJ), Montclair State University (Montclair, NJ), the University of Pennsylvania, and MRRI. The work is funded by the National Institute of Neurologic Disorders and Stroke, National Institutes of Health.

Symptoms of depression are commonly experienced by individuals with TBI and can present significant functional challenges beyond cognitive or mobility impairment. However, many research studies on cognition after TBI do not examine depression symptoms, or exclude individuals with depression, rather than understanding the impact of depression on cognitive outcomes. This new study aims to fill that gap by examining how individuals learn and remember information when they are living with either TBI or clinical depression, and also how having both conditions at the same time impacts memory. It will incorporate both paper-and-pencil testing of cognitive abilities as well as advanced, non-invasive neuroimaging (MRI) methods. Using specialized tasks, the research team hopes to study new ways in which we can improve memory performance when people are simultaneously experiencing the effects of TBI and depression. Ultimately, the goal is to find support for new memory treatments that could positively impact patients’ quality of life.

Study planning is well underway, and recruitment at MRRI will begin within the next month. Research participation consists of an MRI scan and computerized testing at the University of Pennsylvania, followed by a research visit at MRRI for further assessment of cognitive abilities and psychological functioning. The study will run through Spring 2026, and findings will provide important insights into the mechanisms underlying memory impairment in TBI. A better understanding of these mechanisms will inform development of future treatments, particularly in individuals living with both TBI and depression. This study is just the latest in MRRI’s long history of productive scientific collaboration and commitment to work that matters to patients, families, and healthcare providers.


The Achievements and Significance of the Moss TBI Model System

The National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) awards Traumatic Brain Injury (TBI) Model Systems grants to institutions that are national leaders in medical research and patient care. Launched in 1997, the Moss TBI Model System is a world class center of excellence providing state-of-the-art research, innovative treatment, and valuable programs for people with Traumatic Brain Injury. Each TBI Model System contributes to the Traumatic Brain Injury Model Systems National Data and Statistical Center, participates in independent and collaborative research, and provides information and resources to individuals with TBI; their families, caregivers, and friends; health care professionals; and the general public. 

Moss and MRRI are very proud to be recognized as a TBI Model System. This prestigious designation was recently added as an element of the US News and World Report ranking methodology for Best Hospitals for Rehabilitation, and it contributed to Moss’s Top 10 ranking in 2021. In this new data-driven ranking system, rehabilitation facilities receive points for measures of resources related to patient care (structure), clinicians’ decisions and actions toward patients (process), and patient outcomes (outcomes). Facilities receive credit in the structure category if they have one or more model systems designations awarded by NIDILRR (designations are available in the areas of Spinal Cord Injury, Burn, and Traumatic Brain Injury), and the model systems designation accounts for 2% of the overall ranking.

Over the past 24 years, the Moss TBI Model System has followed 1,390 participants and conducted over 4,500 interviews out to 20 years post-injury. Our efforts and collaborations have resulted in 112 peer-reviewed research publications and 16 research grants, as well as the development of novel clinical programs and products. Moss clinicians and researchers look forward to continuing to serve as leaders in the field of rehabilitation for people with traumatic brain injury as they work to advance innovative research projects and deliver exceptional clinical care through the Moss TBI Model System.