David Putrino, Ph.D., P.T., is setting up his new lab in the basement of the Burke Medical Rehabilitation Institute and it looks like something out of the future. In place of lab benches and fume hoods, the space will boast an assortment of high-tech toys—motion capture systems, EEG and EMG equipment, computers with powerful graphics cards—all in the service of telemedicine. BMRI has long been a pioneer of rehabilitation research and Dr. Putrino, who joined the faculty in February, is studying ways to harness the latest technology to improve rehabilitation and physical therapy. “Burke is putting in enough resources so that in a couple of years we’ll be a real leader in telemedicine,” he says.
Dr. Putrino started his career as a physical therapist in Perth, Australia, helping patients with a variety of neuromuscular problems, from cystic fibrosis to hip replacement and abdominal surgery. He noticed that patients often did not follow the prescribed exercises. “The truth is that physical therapists have so many patients to treat that individual patients aren’t going to get the care they need, especially once they leave the hospital and have no one to push them,” he says. Moreover, he became dissatisfied with the lack of science in the way therapy was practiced. There wasn’t a rigorous understanding of what therapies led to the best outcomes for patients. Optimal therapy for stroke patients, for example, was essentially a “black box.”
Dr. Putrino wanted to peer into that black box and gain a scientific understanding of how therapy leads to recovery. He went on to graduate school at the University of Western Australia to study the neurophysiology of motor control, which, he soon found, brought up more questions than it answered. His Ph.D. work looked at the neurophysiology of target reaching in cats (surprisingly trainable, he says), specifically, how individual and pairs of neurons behaved as the animal planned a movement or learned a skill. Then as a post-doc at Harvard and MIT, working with Emery Brown, M.D., Ph.D., he built upon this work to analyze large sets of neural data. For normal movement, he explains, “You need large numbers of neurons firing in synchrony with very specific timing.” Aberrant firing patterns among the neurons can cause motor dysfunction.
Two years later, Dr. Putrino moved to a post-doc position at NYU, where he worked on a DARPA-funded project involving monkeys controlling robotic limbs. His first task was to build a prosthetic limb. With his background as a physical therapist and knowledge of joints and biomechanics, he considered the options. “I can make the prosthetic 27 dimensional to emulate all the movements of a human arm and it would cost 2 to 3 million dollars,” he told Bijan Pesaran, his PI at the time. “Or I can build you a virtual prosthetic that uses kinematic models and works and behaves like a real limb for a fraction of the cost.” The lab went with the second option. A virtual prosthetic has the added advantage of being highly customizable, easily made to resemble a monkey, a robot, or a weird blob. Using the virtual limbs, the lab was able to study embodiment—the feeling that your arm is your arm—and how to diminish or boost that feeling, or transfer it to a prosthetic.
“In the virtual world you can do more,” says Dr. Putrino. By tapping into the virtual world, his new lab at BMRI aims to make therapy more scientific, more fun, and ultimately more effective. Virtual games that integrate therapy can engage and motivate patients to complete exercises that may otherwise seem onerous. Motion capture technology offers, for the first time, a way to precisely assess small changes in motor abilities. The goal is to clarify exactly how specific exercises correlate with improvement in function. “If someone says, ‘The main thing I want to do is rub my hair in the shower,’ I’ll know what exercises to give them,” says Dr. Putrino.
New technology has made finding these answers possible, and increasingly affordable. “Up to five years ago, if you wanted to track everything the patient is doing, you’d have to put the patient in a motion capture system that cost $200,000. Now I can do this with a Microsoft Kinect that retails for a couple hundred dollars,” he says.
Dr. Putrino’s enthusiasm for bringing low-cost, innovative solutions to people in need extends beyond BMRI. He has worked with Not Impossible Labs, a California-based non-profit technology company, on several projects. He was part of the team that designed the prototype for Project Daniel, which uses 3-D printers to build simple prosthetic arms (about $100) for people injured in war-torn Sudan. Another venture was inspired by a graffiti artist paralyzed by ALS. Known as the Brainwriter (about $300), it’s a device that uses brain waves to control a cursor on a computer screen, helping those with limited motor function to communicate and to create.
“The work that I do with Not Impossible Labs is important to me because it shows that implementing innovative technology into the practice of medicine is making things better, not worse,” says Dr. Putrino. One of the main challenges for those on the forefront of telemedicine is the perception that the merging of technology with rehabilitation will result in a lower and less personal standard of care. Dr. Putrino is determined to prove the very opposite. “I am passionate about showing the world that telemedicine and virtual rehabilitation are going to result in better standards of care and outcome for millions of patients worldwide,” he says. “There is no limit to the impact we can have.”