The artist, the engineer and the scientist: a difficult equilibrium

Today I wanted to write about a balancing issue among science, engineering and entertainment. I face this dilemma over an over myself. We, people working in this field, are committed to find the perfect balance between those 3 factors in order to help “our” patients. We aim at developing systems that are novel and effective tools for motor rehabilitation. This point ideally requires a deep understanding of what actually motor rehabilitation is about. This is particularly difficult. Methods for motor rehabilitation are generally nothing else than those that have been (but not always) demonstrated to work. That means that there is a lot of knowledge derived from trial and error - guided by brilliant intuition - that has been shaped over centuries by medical and therapeutic praxis. In the particular case of stroke, it was not until recently that “some” of the brain mechanisms for motor functional recovery have been unveiled. That means that many times we do not yet fully understand why some therapies do work at all. This is what I consider the main challenge today in rehabilitation after a brain lesion. Given the new advances and understanding of how our brain works, we should fight to link medicine, therapeutic praxis and neuroscience - which is all but a trivial endeavor - in any novel rehabilitation strategy. We have to work on a closed loop approach in which rehabilitation strategies are always designed to exploit an existing or hypothetical brain mechanism for functional recovery. This approach needs to have this principle built into its core, and an interdisciplinary team to go through the “conception” of the working principle, the “building” of the novel tool, the “deployment” and the “validation” via clinical evaluation and brain imaging techniques. It is only by means of validating or falsifying an existing hypothesis that we can push further our understanding and pin-point what is it that makes our rehabilitation systems successful.

On the other hand, we know that there is so much that could be improved in rehabilitation methods just by making them more appealing... Imagine your motor training would be just like a game and you would enjoy doing it. Wouldn’t it be of great help? and the answer is “Sure it would. So, lets do it!”. We are in this period of human history that will provably be remembered by our huge technological boost. Technology has become so popular that we some times do not even realize what we have achieved. It is astonishing that with a couple of key strokes - or now screen taps - we can send any type of content or media from our phones to even from some photo cameras - not to speak about “ordinary” computing systems - and make it available to virtually every person in our planet in the prodigious internet. This progress has made it into the game industry as well, and we see it every day in devices such as the microsoft kinect, wii controllers or many others. These interfaces can be of great help for our purpose. They allow us to bridge between body and the machine. Our own body movements can be used in interactive media, and that, of course, has great potential in motor rehabilitation.

The main question here is whether we want to improve the rehabilitation method itself or its delivery and/or acceptance by patients, and what has the best return. If we go for the win-win situation we can improve the delivery of therapies by adding motivational aspects, extended feedback on performance, and other characteristics intrinsic of computer games. This, I’m convinced works in virtually any therapy. However, although results can be better than those of standard therapy programs, the knowledge created in this case is very limited since the therapy itself does not improve (the underlying principle of the exercise). Conversely, it is not necessary to build very fancy and cool looking games to make a breakthrough in treatments if there is an understanding of the underlying problem. A nice example is that of the mirror box therapy pioneered by Ramachandran et al. more than a decade ago. Ramachandran showed that a single mirror could be the best system to treat phantom limb pain in some patients. Phantom limb pain is a term used to define the syndrome of some patients that “feel” pain on a missing part of their body. The elegant solution of Ramachandran was that of presenting that missing limb by means of a mirror that reflected the remaining limb at the position of the missing one. The underlying hypothesis is that the brain of those patients undergoes a, so to speak, unbalance of the sensory input from the missing limb that results in what the brain interprets as pain. By the mere fact of reestablishing the visual input with a mirror, some patients stopped feeling the pain. Similar approaches have been used as well with stroke patients with good results. In this case, a very simple technology - a mirror - driven by our understanding of brain functioning turned out of extreme value to patients.

Hence, a difficult balance has to be achieved between the way therapies are delivered and their working principles, or what is the same, among the “engineer”, the “artist” and the “scientist”. The engineer pushes for the gadget, the artist for entertainment and the scientist, who has the most difficult bit, has to find the right working principle. It is very easy to be driven by the certitude of what the current technological means offer us, that is what the “engineer” and the “artist” can do, and loose sight (intentionally or not) of what the real problem is. Being able to separate those different aspects is very difficult as hybrid approaches using novel technologies are becoming more and more an essential part of the solution. Hence, it is necessary to keep in mind that more sophisticated approaches do not necessarily mean better treatments, that many times simple is best, and that approaches that may be very similar at the technological level may differ substantially in its core working principle. Therefore, it is necessary to critically examine them to understand what their real value is. In the next post I’ll write about the Rehabilitation Gaming System and describe how we balanced engineering, entertainment and science in its design.