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A new study aims to assess the use of functional near-infrared spectroscopy (fNIRS), a type of imaging, to provide neurofeedback during stroke rehabilitation with a goal of eventually improving patient outcomes.

fNIRS is used to detect changes in brain oxygen levels using light. More recently it has also been used to develop brain-computer interfaces (BCIs), which allow patients with brain injuries to control devices like robotic arms with their thoughts.

Dr. Sue Peters, a Scientist at Lawson Health Research Institute and Director of the Neurorehabilitation Physiology Lab at St. Joseph Health Care London’s Parkwood Institute, was one of the recipients of the Spring 2022 Lawson Internal Research Fund (IRF) Awards. 

The funds will go towards a new study to assess whether fNIRS can be used to direct neurofeedback in stroke survivors – helping them with rehabilitation.

“Currently, there's no real measure of brain activity that is used in stroke rehabilitation to help make clinical decisions,” says Dr. Peters, who is also a Professor at Western University.

Over 400,000 Canadians live with the effects of a stroke, according to the Heart and Stroke Foundation, and there’s hope that fNIRS could make a big difference by eventually improving movement and independence.

“We're going to use the device in some common tasks that people might do with their arm and determine whether we can use this device reliably and accurately in a stroke-related context,” Dr. Peters explains. 

Participants in the study will imagine moving while remaining still. This activates very similar parts of the brain to when people actually move. If done correctly, patients will see a visual cue generated through measurement using fNIRS.

“We know from MRI studies that when I move my right hand, the left side of my brain is activated,” notes Dr. Peters. “We think we can use this concept in stroke rehab.”

Dr. Peters is recruiting 40 people from the community who are at least six months post stroke and 40 healthy adults of all ages. They will first participate in motor assessment with a physiotherapist and then wear an fNIRS cap while thinking about moving their wrist to measure brain activity.

Previously, there were a lack of methods to image the brain during real-life movement.

“The hope is to eventually conduct a clinical trial where we're testing motor interventions to see whether some things are more effective than others at activating the regions of the brain that were impacted by the stroke.”

Dr. Peters believes the study has the potential to have a big impact on the future of rehabilitation for stroke patients, leading to lasting changes in quality of life.

The following column was provided to Hospital News by Dr. David Hill, scientific director, Lawson Health Research Institute. 

Dedicated health researchers across the country are working every day to make discoveries that improve patient outcomes and support a higher quality of life. Our research hospitals have a mandate to develop and test new treatments, technologies and procedures that address our most pressing health challenges.

There is a cycle of health innovation that is supposed to happen – scientific discoveries are made, they transition to clinical trials and then are adopted as an improved standard of care. This is followed by evaluations of the new method and moving along to the next cycle of refinements and improvements. But the reality in Canada is that gaps, in some cases chasms, disrupt the creation and adoption of evidence-based health innovations.

This starts with discovery. The research funding climate in Canada continues to be extremely difficult. Despite the Federal Government outlining substantial new investments in discovery research in Budget 2018 much of that money will not be available to researchers until 2020 and beyond, and the Canadian Institutes of Health Research (CIHR) continues to be limited by a low funding rate of around 14 per cent. Funding for large, definitive clinical trials is especially difficult to support with public funds. Too many good ideas are left unfunded, and in that environment researchers can feel it’s wiser to propose incremental and ‘safe’ science that avoids controversy and the risk of losing support for experienced research teams built up over many years.

Yet researchers are persistent and manage to secure funding from a range of smaller agencies. Unfortunately, many of these do not fund the indirect costs of research necessary to cover administration, infrastructure, equipment maintenance and upgrades, and the investigator’s salaries. Indirect costs are estimated to be approximately 40 per cent on top of direct study costs. In research hospitals these costs generally fall on the institutions to find funding outside of the provincial government budget that covers the costs of hospital care. This is a negative spiral whereby the more successful a hospital becomes in attracting research funds, the bigger the gap in finding the resources to support that research.

When innovative solutions to health care problems are delivered, backed by solid evidence, adoption into our hospital-based care is often far from rapid. Currently, in most provinces, there is no funding mechanism to translate health innovation to the ‘real world’ setting of our front-line care. Yet, such a mechanism is crucial to the translation of science. Clinical trials are carefully designed with strict protocols and criteria for a highly specific population of patients. Innovations that work in a clinical trial do not always work in the real world where patient populations and settings are much more complex.

Following a clinical trial, innovation needs to be tested at the point of care. Without funding to do this, research innovation hits a roadblock. Scientists are left waiting and hoping that one day their provincial government might look to incorporating their innovations into the health system funding schedule. Meanwhile, their work may be used to inform health care improvements in other nations.

An example can be found in medical imaging research. Canadian scientists, including those at Lawson Health Research Institute, are leaders in the development of positron emission tomography (PET) biomarkers to improve diagnosis and understanding of disease using PET scans.  PET biomarkers are successfully created and then validated in clinical trials across our nation, but there is little funding to translate them back in a timely fashion to patient care in our hospitals. While countries like the US and Europe readily adopt these innovations, Canada lags behind.

This gap was addressed in a report to the Federal government by the Advisory Panel on Healthcare Innovation entitled “Unleashing Innovation: Excellent Healthcare for Canada” and published in 2015. The panel recommended the formation of a Healthcare Innovation Agency of Canada open to hospitals and other care providers in order to evaluate health innovations in the real-world setting of our health system. Scientists would apply by putting forward evidence from their research, including that collected from clinical trials. They would then design a new translational study to test their innovation at the point of care, with the goal of building evidence for presentation to provincial government.

Will everything tested at the point of care succeed? No; some things will fail in the real world. This is why such a fund is so important. It will show whether or not an innovation truly benefits patients and if it’s ready for wider adoption. If successful, the evidence will highlight the right time to bring innovations into the mainstream standard of care. By bridging this gap in the system, we can improve patient care and ensure a timely return on the investment in science.

Dr. David Hill is scientific director at Lawson Health Research Institute, the research institute of London Health Sciences Centre and St. Joseph’s Health Care London.

For Wayne Kristoff, the possibility of getting off all medication for his type 2 diabetes was so intriguing he jumped at a chance to participate in an innovative trial in London. The REMIT study aims to induce remission of the condition – an exciting new concept being tested by researchers at Lawson Health Research Institute.

Kristoff was diagnosed in June 2014, which was difficult but not unexpected because there is a history of the illness in his family. He had to work his way up to taking four pills a day for his diabetes, which came with significant side effects. “If there was a way to get off medication, I wanted to be part of it,” says the 68 year-old. 

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He met the study criteria and was enrolled in February 2016. The results, so far, have been life changing for the Londoner. Since May 2016 Kristoff (right) has been off all medication, his blood sugar levels are good, and he has more energy and feels better than he has in years. He’s also lost 30 pounds thanks to the support offered by the research team.

“I remember well where I was and what I was doing when I received the call telling me that I could stop taking all of my diabetic medication,” adds Kristoff.

A second REMIT trial is now being launched, providing another opportunity for individuals with type 2 diabetes to take part. The trial challenges traditional type 2 diabetes treatment by testing an aggressive approach in recently diagnosed patients. St. Joseph’s Hospital in London is one of seven Canadian sites taking part in the landmark REMIT study. Being led by the Population Health Research Institute (PHRI), a joint institute of McMaster University and Hamilton Health Sciences, the trial follows a PHRI pilot study of early aggressive treatment that resulted in up to 40 per cent of 83 patients with type 2 diabetes going into remission and not needing any diabetes treatment for at least three months.

When Lawson launched the initial trial in December 2015, it generated a surge of interest with more than 200 people with type 2 diabetes asking to participate.

“The idea of remission in type 2 diabetes is obviously captivating to both patients and clinicians,” says Lawson researcher and endocrinologist Dr. Irene Hramiak, Chief of the Centre for Diabetes, Endocrinology and Metabolism at St. Joseph’s. “This overwhelming interest in the REMIT trial tells me that patients want solutions that will optimize care and reduce the complications associated with this disease.”

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Twenty-seven patients met the criteria and are enrolled in the first REMIT trial at St. Joseph’s, which is ongoing, says Dr. Hramiak (left). For the second trial, 20 to 25 patients are being sought who have been diagnosed with type 2 diabetes in the past five years. Some research participants who came forward for the first trial have been enrolled in the second. Each trial is testing a different combination of drugs. For both trials, patients are randomized to receive either the experimental treatment or the standard treatment. In addition, both groups are supported to make lifestyle changes to enhance control of their diabetes.  

The standard treatment for people diagnosed with type 2 diabetes is to start on a single medication, which is then followed by the addition of more drugs and insulin as the disease progresses, explains Dr. Hramiak. In the REMIT study, patients undergo an experimental intensive treatment - two diabetes oral medications plus insulin at bedtime - for three months to see if remission can be induced and how long patients can go without any medication.

“By being proactive with aggressive treatment early on, the theory is that we may slow the progression of the disease,” says Dr. Hramiak. “We are attempting to actually change the disease and induce remission, which is a significant departure from the current approach.”

Those who would like more information about the trial can call 519 646-6100 ext. 65373.