(0:09) James: I'm talking with Val Pomeroy, who is the Theme Lead for Restoration and Rehabilitation in the HealthTech Research Centre for Brain Injury. So Val, we've got two bits, Restoration, Rehabilitation. Do you want to take one of those first? Tell me about Rehabilitation.

(0:24) Val: Rehabilitation, you can divide it up into two bits. So the key thing about Rehabilitation, especially early after a brain injury, is that we want to provide therapies that enhance the neuroplasticity, that is the inherent ability of the brain to repair itself.

(0:44) James: Okay, so the brain's going to mend itself and that means that if I couldn't talk, now I can, or if I couldn't walk very well, now I can.

(0:52) Val: I wish it was that easy, James, but unfortunately it's not that easy. For example, early after stroke there is a period of enhanced neuroplasticity, which is molecular and cellular changes that are induced by the injury itself, just in the same way as if you cut your skin, you get a period of inflammation, you get infiltration of more blood and you get a repair process.

(1:20) James: Yeah, okay, yeah, so I can heal quite quickly because the cells in that part of the body are going, hello, let's mend it.

(1:25) Val: Obviously the brain is a bit different, but the underlying mechanism of recovery from stroke, for example, is neuroplasticity, whether that be the injury-induced neuroplasticity, which happens up until probably about month three or four after the stroke, or the neuroplasticity that's going on in our brains now as we're listening to each other and learning things from each other, there is a normal, it's called Hebbian-type plasticity.

(1:52) James: So when we have rehabilitation therapy, is that something which is trying to enhance that neuroplasticity to make it last longer, to make it work harder, or is it just doing something different?

(2:02) Val: There needs to be more research, but the understanding at the moment is that you can provide therapies which are going to enhance the brain's neuroplastic mechanisms, and it's also thought the early period of neuroplasticity, which is the injury-induced neuroplasticity, it's very important to drive that with the right type of therapy for that individual.

(2:24) James: Okay, and how do we know what therapy is right? Is it as simple as identifying the impairment that somebody has and directing something at that, or is it a bit more nuanced than that?

(2:37) Val: I think it's about saying what can somebody do, what can't they do, where does it get difficult, and why? And then if we can focus in on the why, which tends to be the impairment, so for example, if I need to comb my hair and I can't lift my arm above the head, then why have I got that problem? Is it because I haven't got enough activation of particular muscles that are going to allow me to get my hand above my head? And then directing the therapy at that problem.

The evidence is that it's the practice of what you can't do, or practice of bits of what you can't do that are going to enable you to do the whole task, that is the most important thing in brain injury. It's called task-specific practice.

(3:30) James: Okay, that's interesting. And when we hear about rehabilitation, we think about physical things like raising your arm or walking, but what about cognitive impairments? People have problems with memory and speech and all sorts of things, don't they?

(3:45) Mood, for example. Depression is fairly common. Emotionalism, inability to control emotions, it just suddenly comes on and somebody could burst into tears and you say to them afterwards, what was the problem? There was no problem, I couldn't control it, I wasn't feeling sad.

(4:02) James: Just happened, yeah. So are there rehabilitation therapies that we can use for things like that? I can practice lifting my arm up and down, I can't practice not crying, can I?

(4:14) Val: It's very difficult. It's very difficult and there's lots of research that's going on into emotionalism at the moment.

(4:18) James: Yeah, interesting. And what about cognitive problems? So we find that lots of people have impairments in their cognition, their understanding and processing. Is there rehabilitation that they can do to practice and relearn those skills?

(4:34) Val: I'm not an expert in cognitive rehabilitation, but I understand that, yes, there is practice that you can actually do.

(4:44) James: So that's about rehabilitation then, about, I guess, essentially just practicing something so that the brain thinks, oh yeah, makes new connections so you can do those functions.

(4:55) Val: Yes and no, but what do you do if somebody can't walk, they're at home, they're receiving early supported discharge, they're not in a clinic and they can't walk, how can they practice walking? So there are limitations in the current evidence base, which is where the research is coming in. How can we give people who can't practice walking, what are the precursors of walking, what are the things they need to be able to do before then?

(5:30) James: And increasingly we know there's a move to try to get care and treatment at home rather than in hospitals. So are there sort of remote technologies that people can use? Can you do stuff on your telly or on the video to practice these sort of physical skills?

(5:44) Val: There are a number of apps available, there's a number of gamification of rehabilitation that is available. These have been shown to be of benefit. We have to be careful you can't be global about this. So when the research happens, the research needs to be on that specific game to make sure that there aren't any adverse events that would happen potentially.

(6:12) James: Yes and there's a big fad for these sort of brain exercises, brain games and playing things. And I think what happened is that you got really good at doing that thing, but nothing else. And is that the same of rehabilitation? You can target specific things, but it's really only that?

(6:28) Val: Yes and no is the answer to that. So if I go back to my example of somebody who can't walk, one of the precursors, one of the prerequisites of being able to walk is that you can control your ankle. So if the goal is to get somebody to stand up from a chair and to be able to take a few steps across their living room and they can't control their ankle, then putting that in the context of a walking rehabilitation program, ankle exercises, would be a beneficial activity that you can then build on. But if you're just doing something in isolation and it's not part of an end goal, it's not a component of the end goal, it's much more difficult to generalise it.

(7:23) James: Okay, so rehabilitation. What about restoration? Is that a different thing entirely or is it just a way of applying the rehabilitation?

(7:30) Val: Right, two different approaches to rehabilitation. There's the driving of the neuroplasticity, i.e. the ability that the brain has to adapt, to repair, to regenerate to a certain extent, which needs to go in very early after stroke. As that neuroplasticity mechanism changes over time, then we would turn more to a learning, this is how you have to learn to do this activity. There will be people for whom the brain damage is such that there's always going to be some residual disability and in that case we move to teaching compensatory behaviours or use of an aid, because the whole goal of rehabilitation is to get people as independent as possible and able to do the activities on a daily basis that they actually want to do. Sometimes you have to adapt those goals because it would just not be possible, but it's very difficult to tell very early after the brain injury just how that's going to be.

(8:43) James: So they'll find different accommodations, different ways of working, so restore some function.

(8:48) Val: Different ways of behaving, so it's the same if I take an example of I've broken my leg, I've got a broken shank bone, tibial bone, I will have it pinned, initially I can't take any weight on it, but I'm still walking and then I gradually can take more weight on it as the bone heals. Sometimes it doesn't heal altogether and people have to use walking aids.

(9:14) James: Yeah, so you find those different ways and I guess alongside these things it's the psychological therapy as well and people getting used to understanding that they're probably always going to have some kind of impairment, won't quite be back to the person they were before.

(9:34) Val: Yes, brain damage is brain damage. I mean even people with so-called mild, a mild stroke or a mild brain injury, there are consequences.

(9:45) James: So HealthTech Research Centre, is their tech looming? In five years time, is the world going to look different because of new innovations, new technologies or are we going to be actually wrestling the same problems in much the same way?

(9:58) Val: Oh, you're asking me to be a soothsayer now? (James: Oh yes.)

I would like to hope that there would be neurotech out there that's going to allow us to monitor people better. We've already got the beginnings of some of that, so you know everyone has a smartphone now, can we use smartphones to actually record some of these symptoms and the answer is yes we can with the right apps. So we can get a better picture in clinic of how people are actually experiencing things and how they're improving.

Recovery after any brain injury is a very slow process and I know I said earlier that you've got this rapid period of recovery but there's evidence in the literature that recovery after stroke can happen 25 years later. It's very difficult to predict so from a psychological point of view, people after injury want to know what am I going to be like in three months time, it's very difficult.

(11:04) James: Yeah and families as well, if you're caring for somebody you want to have some idea about what's going to happen.

(11:09) Val: You want to have some idea about what the long-term effects are going to be, what the long-term impacts on your lives are going to be. It's very difficult to tell.

(11:17) James: And do you think there'll be diagnostic technologies coming on which might help us with those kind of predictions?

(11:21) Val: I would hope so, there's a big interest now in biomarkers of neuroplasticity after stroke. These can be picked up from blood samples, the researchers at a very early stage but if we can have a better understanding of what's actually happening in the brain, because not everyone can get into hospital to have a MRI scan you know, and then people have contraindications to some of these magnetic fields. So we need to explore some of these potential biomarkers that are available through private companies, the biomarkers of neuroplasticity and how can we use those.

(12:02) James: I guess we should come and talk again in five years time and see if things have changed.

(12:08) Val: I'm not in the prediction.

(12:11) James: No we can't know, but I guess the focus of this stuff and this theme really is how do we give people the best recovery that they can get

(12:22) Val: We've got to make sure that we get more people doing activities of their own choosing than we can now and that's through employing science, employing neurotech to take advantage of that new knowledge and then implementing that into everyday routine practice.

(12:38) James: Great what a lovely way to end this conversation, Thanks ever so much for your time Val.

(12:43) Val: Ok, Thank you very much