in cancer. Good afternoon. Welcome to the talk about new technologies in cancer rehabilitation medicine. It's an honor speaking today at this event, and I'm joining the conference with Dr. Ekta Gupta and Dr. Amy Ng from MD Anderson. We're going to bring you up to date on all the new technologies that are being used in the cancer rehabilitation medicine and its research. We will have questions at the end of the or answer questions at the end of this session, but if you have questions throughout, please feel free to write them in the chat, and at the end, we'll dedicate a few minutes to answer all the questions, so you don't have to worry about remembering them, but you just write them in the chat, and we'll get to them at the end of the presentations. So first, I'm going to give you guys an introduction about all the things that have been happening in cancer rehabilitation medicine over the last few years in terms of new technologies and how these new technologies have been used. So only thing to disclose, I have a survivorship contract with the Florida Department of Health that is not interfering with the data in the presentation today. So when we talk about new technologies, it's very wide. There's a lot of things that are included in the new technology like TMS that Dr. Gupta is going to talk about later in the presentation or wearable trackers that Dr. Ng is going to also mention and provide data from this technology, but also we have other type of technologies that have been started with the use of video games during the rehabilitation sessions, including the Nintendo Wii and then some Xbox technology as well, but most revolutionary in the past few years have been the use of virtual reality or augmented reality with the goal of improving the rehabilitation outcomes of our cancer patients. So in the last few years, you can see here we have data from 1992 to 2019 and Young et al shows some of the information of how much publications and research has been increasing over the last few years, basically since the early 2000, exponential growth to now 2019-2020s, with the use of virtual reality in research in medicine. So this is true to all branches of medicine, not specific to cancer rehab, but these same numbers are translatable in terms of the amount of publications that have been come out in the last few years in cancer rehab and virtual reality. So the conditions that have been mentioned the most in these publications has been pain, stroke, cancer, so I just wanted to highlight how cancer is high up in the body of research that have been coming out about virtual reality and cancer rehab, mild cognitive impairment, which we can also see in our cancer patients, cerebral palsy, and traumatic brain injury. And this is another in the same publication that includes what areas specific has been researched about. So you can see that some of that has been in terms of simulation. So when they talk about simulation, it could be related to, for example, in the surgical world or how to perform a procedure using virtual reality, but the next one that you're going to see is the use of virtual reality in rehabilitation. You can see that these are the two main areas where virtual reality has been used in medicine in general. So rehabilitation, it's a big component of it. So why virtual reality is helpful? So it provides sensory input and also stimulates the frontal cortex and some other areas in the brain that at the end will result in an interaction that provides also feedback to the patient in the process of rehabilitation. So it's not always, it's not only doing the rehabilitation exercises or techniques, but it also provides an immediate feedback that helps with the plasticity of the brain in order to improve the outcomes of the rehabilitation process. So the patient can have a tailored interaction to the virtual environment. And that is very specific to each one of the patients. And the other one was the advantage that they have found utilizing virtual reality in rehab is that it requires less setup and less space because the patients have their equipment and they don't need additional large space or extra equipment to achieve this goal. So you can see here in this image how it's a stimulator for real learners versus virtual learners. And you can see that the areas and the mapping are very similar from one to another. So what it tells us is that basically using virtual reality as part of rehab, it is similar or it stimulates the same areas in the brain or similar areas in the brain as if you do it in a regular rehabilitation setting. This is a study that include X-Box where 40 women with cancer, breast cancer were studied. They had a unilateral mastectomy and also underwent axillary dissection with adjuvant therapy. And they use the virtual reality therapy through X-Box as a, and the standard of physical therapy. So basically they compare these two technologies or these two ways of doing rehabilitation during the six-week period. And they measure these outcomes at baseline and six weeks later. So basically they measure the pain level, grip strength, functional using the DASH questionnaire, muscle strength, range of motion, and fear of movement. So with the study, they show that it was significantly improved of all these functions from compared to baseline to six weeks later. So that is comparing the same group of women that underwent virtual reality or the regular treatment at the regular standard of rehabilitation. So all of them using virtual reality showing improvement in all the outcome measures and a significant improvement function. The important part also was that the women that had virtual reality had an improvement in the fear of movement. So that was statistically significant compared to the group that was doing rehabilitation physical therapy in the standard of care alone. So it's believed that because of the brain is distracted with the virtual reality and the images that are seen at that moment, that they are going to have less fear of moving or less fear of doing one activity versus another. So that outcome is statistically significant, greater than those undergoing regular or traditional rehabilitation efforts. The other ones, they showed that they were equally beneficial for their patients. So no one was superior than the other. So this is another one of the publications that have come out in the recent year. This is actually from this year, 2021, that evaluated the effects of exercise and physical function and quality of life of the breast cancer patients with lymphedema. So again, the outcomes included, similar to the other study, the visual analog scale and the dash range of motion and grip strength, but they also included the volume of the limb, which is specific to the lymphedema evaluation on this study. They also use virtual reality, like in the other project, and then they do the single blinded randomized clinical trial to evaluate that. Both groups receive complex decongestive physiotherapy. In the study, you can see here the results, but it shows that virtual reality training was superior to resistant exercise training in the treatment of breast cancer-related lymphedema. The findings are very small and not yet able to reproduce these and make it as a standard of practice. However, they are very encouraging in the use of these technologies as part of the rehabilitation care of the patients. But it's important also to highlight that both cases also receive aggressive decongestive therapy. So it's questionable what are all these results that are only secondary to virtual reality or also enhanced by the fact that they receive decongestive therapy. In an additional study, this was a little bit older. This is published in 2015. They also evaluate the use of virtual reality in upper extremity function, but this is now related to brain tumors. So as you can see before in the previous top two publications, most of the research in cancer rehab and virtual reality are in breast cancer, which is compatible with all the other trends in terms of how much publications are in terms of breast cancer as one of the most common diagnoses that we deal with in the cancer rehab world. But this one was related to brain tumor, and they tried to evaluate the function, the upper extremity function in those patients with weakness or impaired coordination as a result of brain tumor. So in the study, they do a virtual reality program for 30 minutes per session with nine sessions and conventional occupational therapy for 30 minutes per session for six sessions for three weeks. Occupational therapy alone was done 30 minutes per session for three weeks, and 40 patients each one in different in the groups, and they use all some different measures to see the outcomes of the patients. So these are like some of the videos of how they were using the virtual reality to do this, and you can see how the exercises are focusing on improvement of that upper extremity. So like you've seen image F, how they are trying to catch the ball playing soccer, or like if in figures see that they are trying to play music with the different drums, and all of the exercises were including the movement of the upper extremity. Important to highlight again that they also received some conventional therapy versus the other group that only received conventional therapy alone. So there was a variety of the type of tumor. There was metastatic tumors as well as some benign tumors like meningioma in the group, so that was a variety of diagnosis there, and they also received a different type of treatment. Some of them had resection, some of them resection plus radiation, and you can see that the interventional group had nearly in all of them significant improvement in the function of the upper extremity, especially the motor testing compared to the other group. The other group also received some improvement in the function. So again, it goes to speak that it's important to understand that both groups are receiving also traditional therapy, so probably one of the suggestions is in the future research to try to see them separate from each other without including traditional rehabilitation efforts to evaluate the outcomes of the patient. So these are the results of that study. First, the most important outcome that they wanted to highlight was that the reality is safe and well tolerated for all the patients that underwent that, and then when it's combined with traditional occupational therapy, there are significant functions recovered in the upper extremity that is affected. Another utilization of virtual reality in cancer rehab has been the use of new technologies for exercise interventions. So this is a meta-analysis that was performed to evaluate the different types of technologies that have been used to improve exercise, post-operative exercise, and you can see that they use the mobile applications, and Dr. Eng is going to talk a little bit more about that in a little bit. They also use mobile applications, not so much virtual reality in these cases, but they also utilize digital TV to do some of the exercises and planning of education for nutritional and protein-rich meals. In this meta-analysis was evaluating the effect of the virtual reality in the symptom, in the management of cancer-related symptoms, and it was very encouraging to see all these results as that you can see here. Most of them had benefit. However, the one that was the most significant and actually statistically significant benefit, it was the use of virtual reality for anxiety and for, excuse me, for cancer-related fatigue. So cancer-related fatigue you see at the bottom has the most improvement in terms of the research that had been published when compared to other symptoms related to cancer, such as depression and anxiety, although virtual reality also showed improvement in depression and anxiety. The one that they didn't see too much relief was in terms of pain and cognitive function, which is a little bit surprising. However, there was not, if you can see how much data was included for these evaluation of cognitive function, it was significantly less than, for example, other groups such as pain. And like in the previous one that we saw here, a lot of studies have been done in terms of anxiety, depression, some of them in cancer-related fatigue, but not so much on cognitive analysis. So this is another area of opportunity to include virtual reality in the management of these treatments. But then the other question is, are we ready and are they ready, right? The patients are going to be the ones dealing with it, and it's important to understand how is their perception of using these technologies as part of the rehabilitation. So most of the studies have been coming from Denmark, and they actually evaluated this scale that is called the Readiness and Enablement Index for Healthy Technology, and it's a tool to measure individuals' health technology readiness in the use for cancer rehabilitation, in the cancer rehabilitation setting in particular. So what do they include in order to see if somebody's ready to do virtual reality or use of new technologies in general? So they want to understand the level of technology literacy, how much of them understand that, how much of them feel have the social support that is needed to complete some of these exercise routines or the use of these technologies. Also, they want to understand what is their ability to actively engage with digital services and understanding health concepts and language, so that they can engage in these activities on their own. So the combination of all these factors were utilized to come up with this scale. After they determined how to use it and the validity, they created four different profiles, and the profiles were using the information that was mentioned before about how ready they feel, how much social support they have, how understood and supported they were feeling, and also how much level of emotional distress and how that would affect their ability to participate on the new technology. So after that, they did a survey for cancer survivors and see how ready they were and which ones or those were more ready than others. So they realized that there is a group of people that regardless of being technological savvy and having all the support and being able to use different technologies, they were still not motivated to use new technologies in the rehabilitation outcomes. And it's believed that some of those information is more secondary to the fact that they are not are willing to engage on rehabilitation efforts rather than not willing to engage with the new technology as part of it, because they were otherwise very active on using the technology. However, it's also important to highlight that some people that were not users or that they didn't use cell phones or smartphones or tablet or computers, you can see here when it says technology ownership. And the ones that were not users that were less likely to be incorporating new technologies into the into the rehabilitation program or exercise routines. So, you know, once we evaluate the patients and we want to incorporate them in the studies or provide them with new technologies to motivate that part of the rehabilitation process, having a good understanding what is the level of familiarity with general technology that we use day-to-day, like smartphones, tablets, it's important for us to see how compliant they're going to be with these recommendations. So luckily enough, I think right now in this day and age, there's going to be a very minimum of people that are now familiar with the technologies and they're not using that in the day-to-day basis. So in the study, they included 216 applicants, this is also out of Denmark, and they tried to understand why the people that say that they are not able to use it or they will not be able to use it, why were the characteristics of this population? So they had 88 participants out of 216, which was 28.9% that responded that they could not imagine to supplement their rehabilitation with technology devices. So most of these people were older, so they were in the 65 and above. Some of them were having a lower proportion with long education, meaning that they were less educated in terms of higher educational level in terms of university and college. Higher proportion of them live alone, so not having somebody to support you at home and encourage you to do it was less likely that they felt that they could not imagine using the technology. As well, they were a higher proportion of them had other chronic conditions besides cancer. A lot of them were smokers, so that was also a negative factor, and they also have very low motivation because a smaller proportion of them wanted to be more active. And that just speaks, like I said before, to the fact that they are not ready to participate in rehabilitation efforts alone versus not just using the technology. A smaller portion of them already were using the technology, so again, those that are more active with a cell phone or smartphone or tablet were more likely to feel ready for it. Okay, thank you very much. This is a picture of Jackson, the Lean Rehabilitation Center, which is the rehabilitation care of University of Miami and Jackson Health System. Now we're going to have the presentation of Dr. Amy Ng that is going to present about wearable trackers and how to utilize them in the rehabilitation care of your cancer patients. Dr. Ng. Thank you, Dr. Molinares. I will share my screen now, and well, thank you, everybody, for attending another year of virtual talks, and I wish we could be in person to meet each other. We, of course, welcome any questions, and I forgot to provide my email address, but it is just ang.mdanderson.org if you needed to get in touch with me about any questions, additional questions you might have, or any other topics, and we want to thank AAPMRI for letting us talk about our new technologies this year. I have a disclosure slide. My own research was supported by the University Cancer Foundation via the Institutional Research Grant Program at the University of Texas MD Anderson Center. Well, everybody knows wearable technology is, you know, very, very cool, exciting. It's popular, and in the recent years, we've really seen a lot of it used in our research and in our own personal lives. A lot of it seen in research, I think, is because it's become so popular. It's relatively low cost to be able to afford one, and there are many brands. You know, some of these pictured are ones that we know, and some of them you could buy off of Amazon for like $30, and the most expensive ones, you know, can range anywhere from $400, $500, depending on if you get GPS, Wi-Fi, you know, your cell phone linked to it, for example, and it's been relatively easy to use. You just slap that thing on your wrist, and you go, and unlike a cell phone or a smartphone, you don't have to like put it in your pocket, you know, once you wear it, you can sleep with it. Most of the time, you're not supposed to bathe with it or shower with it, but now the technology is there where we can even get it wet. You can go swimming. So really, it's been so easy to put on your wrist that people sometimes forget that it's there. So the other thing is how we use it. So, you know, it's been able, previously, we were just using it maybe just to track steps, but now we can track so much more, you know, sleep, your activity, how active you are, how many minutes was your heart rate in certain range, tracking your heart rate. And now the newer ones can even have a trace recording of your heart rate, ECGs. It can alert you if you are in a fib, atrial fibrillation. So the technology has really changed. And, you know, of course, the prices go up with the more function. And also, I wanted to mention that fashion is also, you know, catching up with the times, like even some of the more expensive brands, designers are getting into it and putting their logos and making exclusive, you know, wearable trackers for their own brands. So it's everywhere. And that's why I think that you see the research is also going up. So I just did this a couple of weeks or a month ago when I was doing my slide deck, you know, updating it. And I just typed in cancer rehab exercise tracker, you know, those words. And I saw this graph, amazing, 2015, you know, 2016, pretty low. And then starting to double 2017, exponential publications, 2018, 2019, 2020. And, you know, of course, we're not finished with 2021. So I think that's why we see that dip there. But definitely it is growing. And I wanted to go over today with you some of the published research that I was able to find and also go over my research and our own experiences using the wearable trackers and maybe give you guys some tips on how to do your own research. So one of the first studies that came up was Wu et al. Their team looked at breast cancer survivors and they used a jawbone up to activity tracker. And I had to Google this because I don't know which one jawbone up to was. So I put in a picture. It looks like a pretty basic exercise tracker. They did a very small study, 10 patients. And they were really, what they were really looking for was, you know, if this is giving them the motivation and help them to get out of their sedentary lifestyle. So what they found was that they, they seem to, of these 10 patients, they seem to say that the exercise tracker motivated these women to be more physically active and created more of an awareness of their sedentary lifestyle. So maybe it was buzzing, like if they weren't getting up and moving and but what they, what the what they didn't like was that the automatic generated advice was not really applicable to people's personal situations, such as having cancer. I'm very tired. I just had radiation. And they felt like it wasn't personable, like the automatic generated advice and feedback that were given. It only measured, this one was the basic tracker. So it only measured a step goal, which people felt was very one dimensional. You know, I don't get a heart rate. I don't get, you know, activity time. It's just telling me the steps is a basic one. And some people wanted, really wanted to do strength training. And they noted that the strength training, you know, time and, and you could log that in there as well. And the second study that I was able to find, and of course, there are many, many studies, and I only have a limited time here to go over some of these publications, recent publications. But if I had more time, you know, we would be able to go through a lot more because you could see that there was a lot of studies. But again, looking at breast cancer survivors preferences. So this study was really looking at whether or not they preferred, they're getting kind of a sense of how many people really want to use exercise trackers. And this study looked at 279 post-treatment survivors and looking, looking at their interests and their preferences, what they found was that fewer than half reported that they had an exercise or diet or some kind of diet app on their phone and, or owning an activity tracker. So less than half, about 40%. And these women were interested, however, they didn't have it, but they were interested in getting some information remotely delivered to them in exercise counseling, or even participating in a remote delivered exercise intervention, or using some kind of exercise app or a website. So over 70% to 80%. And they reported that they would find this technology be very good for them. If it was delivered in an activity tracker, about 90% said they would be open to using it and that they would want some kind of personalized feedback. So about 80% on how they were doing and also about how exercise influences or changes their physical or wellbeing or emotional wellbeing, such as mood or fatigue, et cetera. And McNeil et al and his team looked at activity trackers and how to prescribe different intensities. So again, breast cancer survivors, and this is going back. I wanted to make a note that supporting what Dr. Molinaro says, you know, majority of publications are really about breast cancer. A lot of it was about breast cancer survivors. And this publication looked at 45 breast cancer survivors and they were randomized into a home-based program. So 12 weeks of intensity, and they looked at different intensities. So a lower intensity or a high intensity and a control group. So the lower intensity got 300 minutes or asked, they were asked to do 300 minutes a week of about 40 to 59% of their heart rate reserve. And the higher intensity group were asked to do 150 minutes a week at about 60 to 80% of their heart rate reserve. And then the other group was no physical activity or control group. They used a polar A360 activity tracker. I Googled that, and this is a picture I came up with. And I, you know, it's, it's not something that it's readily available. So I think this, even this model is already outdated from now. I think they're on a new model already, but anyway, they were looking at increase at the different intensities. And what they found was that even in the low intensity group, they were able to see an increase in their moderate and vigorous intensity. And then they decreased the sedentary time, which is expected because they're being asked to do something. And this, this was significant over the control group at 12 weeks. And then in both interventions, meaning the low intensity and the high intensity groups at 12 weeks, they saw an increase in their VOT max. And that was significant. And this remained at 24 weeks, but then it did not become statistically significant, but they did see that they continued to have increase in their VOT max, but it just was not significant. So Van Blarghien and et al looked at using wearable trackers and the messages that was the tracker was giving back the feedback that it was giving back to the patients. This study looked at colorectal cancer, cancer survivors, and they were 42 patients or 42 survivors that were randomized into either an intervention group or the control group. And in this 12 week study, what they were looking at, patients were asked to wear their Fitbits. And they found that a median of 74 days, they wore it out of the study. So about 88% of the study period. And then the patients were, they responded to a median of about 34 out of the 46 text messages that they were asked to reply to. And 16 out of 21 or 76% reported that the intervention motivated them to exercise and they were satisfied with their experience. So in conclusion, what they found was that the Fitbit and text messages were feasible and were acceptable among colorectal cancer patients after their treatment. So finally, I wanted to share some of our findings with the use of wearable trackers. And in our study, we did use Fitbits and we saw what I wanted to do was to look at both inpatient and outpatients. And most of these studies that are published are outpatients. Most of them are breast cancer survivors. So I think that our patient population is a little bit different in our study because I was able to sample both the inpatient and the outpatient. And we also had a mix of cancer diagnosis. We had brain and CNS, breast cancer, GI cancers, GU, leukemia, lymphoma, melanomas, sarcomas, and others, which comprise of thoracic cancers, melanoma, gyne cancers, endocrine, and head and neck cancers. We also found that we had a pretty high adherence rate, 96% of the outpatients and 94% of the inpatients actually were reported wearing their trackers daily. And we checked this against the data to see that there was some heart rate measurement that they were using it and tracking it on themselves and not just like on a pet or something, you know, or your dog making them wear the Fitbit. And, you know, the other thing that we found was that our outpatients, patients were more likely than inpatients to report that they would continue to wear this exercise tracker. So our other survey results are shown in this figure, 84% of the outpatients and 67% of inpatients really perceived this wearable tracker as being useful, 64% of outpatient and 55% of inpatients perceived the wearable tracker as helping them to increase their physical activity and 92% in both the outpatient and in the inpatient found that the tracker was very comfortable to wear on a daily basis. And I think that's important because, you know, if it's uncomfortable and it's bothering you, you know, more likely you're not going to wear it. We're really not going to be able to use it and get that guidance that we're seeking. The other thing that we were able to find was that interestingly, the inpatients only had about 1,800 steps versus the outpatients had over 3,500 steps per day on average. What we know is that, you know, across cancer patients, we know that overall they are more likely to be less engaged in physical activity. They are more likely to be in more frail state or, you know, less muscle mass and really they've been put through a lot with their treatments. So on average, I was able to find that across ECOG performance status, you can find that the better off you are, the more likely that you are to get a higher number of steps. And that's common sense. Like you're not able to do much, get out of bed. You know, you're more likely not to log any steps or even break a thousand. So what we do know is that just for health reasons, if you can get up to 3,000 to 4,000 steps a day, that's all that's needed for good health. However, it has to be 3,000 to 4,000 steps that you are doing more than your usual. And it has to be at a vigorous activity level. And that's hard for some of our cancer patients to really achieve. And what this means, you know, for other patients is, you know, when they talk about wearable trackers, you know, is it like the 10,000 steps per day? You know, is that what I'm trying to reach? And, you know, what we found was that it's really hard for our cancer patients to get up to 10,000 steps a day. And if you're hospitalized, you know, you're more likely to be even less steps per day, maybe less than 2,000. And what this shows is that the 10,000 steps per day really has not been a validated target for cancer patients and may not be achievable for our advanced cancer patients. So in conclusion, you know, what we found was that patients were willing to use these wearable trackers. It's just one method really to increase your physical activity, increase their physical activity. And the patients really liked it. They liked the ability to get that real-time feedback. They like to look at their steps, how many steps, and the Fitbit was able to give them the heart rate, their sleep time. And they really found that helpful. And during the pandemic and post-pandemic, I think that the studies will continue as the patients will continue to use these devices on their own and exercise at home. Some of the, and I wanted to end with some of the lessons that we've learned and, you know, talk about the next steps. It was a very difficult study to get off, you know, off of the IRB scrutiny because there was a lot of technology involved. Cybersecurity team was involved. And now as, you know, this last two couple of years, Indiana has even gotten more strict with cybersecurity. So it's been, you know, my experience was that it was hard to get through IRB, hard to get the devices, you know, to be safe and given to our patients, worry about HIPAA compliance. And, you know, they really wanted to know a lot of things to make sure that, you know, people weren't hacking into MD Anderson or weren't stealing proprietary information, but more importantly, that we were keeping our patients safe too. We did give iPods to our patients because at that time, I felt that not everybody had smartphones. Perhaps they could afford a $30 wearable tracker, but they might not be able to afford, I don't know how much smartphones cost, but mine was over a thousand dollars, you know? So most people might not have smartphones. So at the time, you know, how do we get over that hump? And if you didn't have a smartphone, you know, do you need to pair it with this exercise tracker, wearable tracker, or can you just use the wearable tracker? So those are things that we thought about. We polled the patients as well, whether or not the iPods was helpful. In the end, I think that the feedback given was just that the wearable tracker itself was great. And we also, another thing was interesting thing was that the patients knew when they signed up for the study, that they really needed to have internet access. And we had patients that signed up and then would let us know that they could not enroll because, or they couldn't log on because they didn't have internet. So the data wasn't transferring from their wearable trackers to the database that was keeping track of how many steps, what was their heart rate, was their sleep. And you know, the wearable trackers would only keep the data that you're logging for a finite amount of time. So in this case, I think it was somewhere like 14 days and then it would rewrite and then you would just lose all the data. So that's something to keep in mind. And like, how would you get these patients to get them to be able to transfer the data to your research team? The research in itself does cost a lot of money. You have to, not only for the equipment, for the fitness trackers, somewhere cheaper than others, of course, but on average about 10 to, I'm sorry, a hundred to $150 for a wearable tracker on average. That's if you're not going fancy with the fancy name brands. And the more that you were asking to track, the more money it's going to cost. So you got to pay your research staff. You got to pay somebody to call these patients if they're not using the tracker or somebody is available to answer. So that's also time and money. And then lastly, I really didn't think about this, but where does the data go? It's in a cloud somewhere, but where is it? And there's data mining companies that actually will pull the data from these wearable trackers. And Fitbit itself does have a company that works with them or a couple of companies, but they're not cheap. And they will start with a pilot grant and just give you the basics. But if you're asking for more parameters, it's definitely going to cost you money. And this is such an interesting topic. The trackers themselves are rapidly changing. And I wanted to also talk a little bit about what Dr. Molinares had said earlier in her talk about the people that in that study that weren't ready for the technology and our patients were in rehabilitation already. So we did have kind of a held and captive audience. There were already seeing physicians, physiatrists, they were already engaging in some form of rehabilitation or sent to us because they needed rehabilitation. So they knew that this was something that they needed to do. So in other studies, I think that it can be varied how people will take to new technology. But we were seeing very interesting research in these past few years. And perhaps, you know, even using the new technology and bring down the cost, you know, having patients already having technology, you can just enroll those people already with the technology so you don't have to pay for the technologies or the devices. So that is it for me today. I would like to introduce my colleague, Dr. Ekta Gupta from MD Anderson, who is going to talk with us about transcranial magnetic stimulation. Thank you. Okay. Thank you, Dr. Ng and Dr. Molinares. Those were both great talks. I am learning a little bit each time I hear them as well. So as we get closer to the end of the talk, I will try to hurry a little bit. I will be speaking today about cancer rehabilitation with transcranial magnetic stimulation. I also have no disclosures. I wish I had a few, but unfortunately none right now. So this is my outline. I'll be reviewing the literature related to transcranial magnetic stimulation. Then we'll focus a little bit on brain tumor rehabilitation, talk about a study that we're in the process of doing at MD Anderson, and maybe some goals for the future. And just for fun, I've included some trips for my, sorry, some pictures from my trip to Argentina a couple of years ago. So what is transcranial magnetic stimulation? Dr. Molinares had mentioned it in her talk. Specifically for my talk in my study, we used the Nexstim machine, but there are several different machines out there. So basically transcranial magnetic stimulation is a technique for non-invasive transference of an electrical field using a pulsatile magnetic field. So you can see in this picture where there's a figure of eight coil, and generally this coil can reach at least three to four centimeters below the scalp. Now there are other machines that we use that are called deep transcranial magnetic stimulation, and those can reach past four centimeters, but they are not covered in our talk today. So there's minimal side effects with this machine. Usually headaches are most common. Sometimes we hear about chopping, occasionally auditory difficulties, and then one that we worry the most about are seizures, which is relatively rare. There are definite contraindications to using the machine too, and we'll talk a little bit more about those later. So basically the idea is that it depolarizes motor neurons, and every single person's cortical susceptibility is different and unique. So using EMG surface electrodes, we then map muscles of interest and calculate motor thresholds for each person. An example with repetitive transcranial magnetic stimulation for depression is that 120% of the resting motor potential, while cortical mapping is done at 110% of the resting motor threshold. The idea with this machine and what we're using it for is for neuroplasticity, but it does differ based off of the diagnosis that the machine is being used for. So currently what are we seeing TMS practice with? Well, it's FDA approved for depression, pre-procedural localization of the primary motor cortex when we're talking about mapping with brain tumors, also localization of cortical areas that do not contain essential speech function. It's also FDA approved for abortive treatment for migraines with auras, obsessive compulsive disorder, and then promoting smoking cessation. Things are always changing. So in the U.S., we look at the FDA approvals. However, in Europe, the machine is actually approved for use in other areas of medicine as well. It is being practiced with anxiety, epilepsy, stroke, chronic neuropathic pain, PTSD, Asperger's, and autism. So there's a lot of new literature coming out with transcranial magnetic stimulation. So my talk is a little bit more focused on navigated repetitive transcranial magnetic stimulation or RTMS. So basically we're looking at how the repetitive transcranial magnetic stimulation regulates the excitability of the cerebral cortex. It's, um, there's different ways to use the navigated repetitive transcranial magnetic stimulation as well. So a low frequency NRTMS of the non-lesion hemisphere is conducive to an inhibitory effect to help restore equilibrium and hopefully promote neuroplasticity. And I mentioned neuroplasticity a couple of times now. So we know that the patient's brain activity is modified by these electrical impulses that are carried by magnetic fields into the brain. And this can then invoke a shift in the way that the brain's electrical currents are transmitted. At a neuronal level, this reorganization strengthens or changes existing pathways to accommodate new processing. When, when I'm discussing neurotransmit, um, navigated repetitive transcranial magnetic stimulation, once again, I'm focused on this low frequency stimulation. Um, but there are several studies looking at other aspects of that, um, navigated repetitive transcranial stimulation, and I'll talk a little bit more about, um, the differences in the next slide. So if we have low frequency stimulation on the hemisphere, contralateral to the lesion that allows us to indirectly stimulate neural activity in the affected hemisphere. And what do I mean by that? Um, so if you look at this picture, basically it shows you that in part A, you have low frequency, repetitive neurotransmit, transcranial magnetic stimulation that's being applied, and that's actually decreasing the MEPs on the affected side. And if we did high frequency, repetitive transcranial magnetic stimulation, that would be increasing the MEPs on that side. So, um, and, um, we're going to the next step, which is specifically focused on brain tumor rehabilitation. So what do we know about brain tumor rehabilitation in general? It incorporates principles, not only from brain tumor rehabilitation studies, but we also are looking at traumatic brain injury and stroke. Um, we know that brain, brain injury, traumatic brain injury and stroke, while they're different mechanisms of injury, we see some, we see some similar neurological effects. This specifically includes weakness, such as hemiparesis and hemiplegia, cognitive deficits, visual perceptive deficits, and then 75% of patients have three or more impairments that can include spasticity, aphasia, dysphasia, depression or adjustment disorders, and neurogenic mal and bladder. We know that brain tumor rehabilitation is really focused on symptom management and quality of life as is honestly rehabilitation focused on traumatic brain injury and stroke. When we talk about rehabilitation options for brain tumor rehabilitation, we know that we have, um, an inpatient setting and then an outpatient setting. Honestly, there's very few studies with the outpatient setting, mostly because, um, in general in academic device, we do focus on inpatient setting. We have more control over the studies, and then we're also looking at different measures of function. We do know that the studies in the outpatient rehabilitation setting for brain tumor rehabilitation, um, did show improved functional gains. So when we look at the inpatient setting, we're seeing that inpatient brain tumor rehabilitation patients make comparable functional gains to stroke and TBI patients. They also have a shorter length of stay, but they can have a comparable discharge rate to the community. We know that the outcomes between malignant and benign brain tumors, as well as primary versus metastatic brain tumors for their first rehabilitation state are very similar. We do know that there is a slightly longer length of stay for high-grade estrocytomas versus low-grade estrocytomas. There's also a higher rate of transfer back to the acute service for medical issues in brain tumor rehabilitation compared to stroke and traumatic brain injury rehabilitation. In addition, there are limited randomized or case controlled studies when we're talking about brain tumor rehabilitation. Um, so what do we know about transcranial magnetic stimulation and brain tumor rehabilitation? Honestly, there's very minimal literature. Um, there's, um, some literature, um, actually quite a bit of literature on transcranial magnetic stimulation for preoperative mapping by neurosurgery. Um, and these studies have shown that the use of navigated TMS can identify motor areas and possibly predict upper extremity motor function recovery by mapping motor evoked potential. But once again, the idea when the FDA approval here is for mapping prior to neurosurgical intervention. Um, there is a case report of a depressed patient who was undergoing repetitive transcranial magnetic stimulation at higher frequencies. So these were greater than five Hertz who was found to have an incidental penile mass. And this patient tolerated TMS well with no seizure activity. So there's some literature also with the pre-op mapping that showed that, um, TMS is also safe with patients that do not have a bone flap in place. And then there are studies going on right now in Germany and at UCSF that are looking at TMS and brain tumor rehabilitation as well. But in terms of the literature that's out there, it's very minimal. So, so, um, what do we want to look at when we're talking about TMS and brain tumor rehabilitation? Well, basically we want to focus on how the brain changes, um, with TMS therapy to augment rehabilitation. And then we want to see what changes are needed within the brain in order to increase the efficacy of rehabilitation. This has not really been studied, um, as I mentioned previously, and we would like to see whether or not we can see some of the same effects that we're seeing in stroke rehabilitation, especially. Um, so our study that I'll go over pretty briefly, I know we're running short on time here, um, was looking at navigated repetitive transcranial magnetic stimulation and improving motor rehabilitation and participants with grade two through four brain tumors. Um, so this is a feasibility study that I have done with some colleagues in the neurosurgical department, as well as our integrated medicine department, um, and then our biostat department as well. So the data for this study is still being analyzed and pending publishing, um, but we did use the, um, NextGen machine for treatments in our study. Um, given that this is still preliminary data, I just wanted to briefly bring it up. Um, we did basically, um, 10 sessions of neuro repetitive navigated repetitive transcranial magnetic stimulation during the post-surgical rehabilitation time period. And so the, the objective of the study was to determine whether or not this is feasible. Um, we then explored secondary objectives, which were really looking at how the TMS affected motor recovery. And we also wanted to explore changes in cortical activity, looking at EEG activity, event-related potentials, motor potentials as well from the baseline to end of treatment. Um, our study, um, basically included patients with brain tumors within or associated with the more motor cortex. Um, we had specific criteria partially because we wanted to make sure that we could, um, avoid any adverse events. So we, we, um, did not include any patients that were taking antipsychotic medications diagnosed with bipolar disorders, schizophrenia, because there has been literature with TMS and it's shown that it can induce mania. Um, and then we also specifically excluded patients with a history of stroke because we do know that patients with the post, in the post-acute stroke phase, um, actually can improve with TMS. So we didn't want to have that as a confounding variable. Um, so basically our intervention was navigated repetitive transcranial transcranial magnetic stimulation delivered over the primary motor cortex using this figure eight, um, head quote. So in our studies specifically, we did low frequency stimulation on the hemisphere contralateral lateral to the lesion, um, to indirect, indirectly stimulate neuronal activity in the affected hemisphere. We looked at 110% intensity of the resting motor threshold. Um, basically we were using 100, uh, for 10 seconds with 10 trains with an, with an inter train interval of 30 seconds. So basically the duration of stimulation time for the session was about 20 minutes, um, for a total number of about 200 pulses. And these patients underwent 10 sessions post brain surgery. Um, we did have functional measures. And once again, as I mentioned, the data is still pending from, um, analysis of these measures. Um, we evaluated these functional measures at different time points. We did use patient reported outcomes as well as objective measures to look at function. Um, and then we're also looking at, um, different modalities. We'd like to see how EEGs changed, um, during the TMS session as well as the event related potentials, as I mentioned. Um, and then we looked at motor hope potentials as well. Um, so future goals for our TMS, um, is definitely doing more randomized control trials. Um, I think across the nation and across the world, that will be important in order to say whether or not TMS actually have an effect for our brain tumor rehabilitation patients. Um, we also would like to look more into EMG motor evoked potentials. And then I think one big thing, especially looking at the stroke literature is evaluating the acute versus the subacute versus the chronic, so that we can see the effects of TMS over different time periods. Um, definitely we need to be looking at biomarkers. There's expansion to, um, involvement with speech language pathology for more than just mapping and then looking at connectomes. Um, and so I know I kind of rushed through this in order to try to make it towards the end. If you have any questions, please feel free to post them in the chat or communicate with us later. Um, thank you to everyone for joining us for this talk about immunopathologies and sensory rehabilitation, specifically looking at virtual reality, verbal trackers, and then transcranial magnetic stimulation. Um, I think this is a growing field and we hope to continue to enhance patient care with these technologies. Um, we have 30 seconds left. Um, if we can open it up to questions. Okay. There's a question on the chat. Is there evidence of electromagnetic stimulation causing cancer spreading? Um, so there is no evidence that we know of right now. Um, in our study, specifically, um, the reason we chose to do transcranial magnetic stimulation to the unaffected hemisphere was to avoid any concern with that, but we do not, um, know of any know of any information showing that. Um, what is the carryover from these therapies? I answered the question for them in the chat, uh, due to the short amount of time, but thank you everybody for joining us. Thank you everybody. Thank you.

cancer rehabilitation medicine

virtual reality

wearable trackers

transcranial magnetic stimulation

VR in cancer rehabilitation

wearable trackers benefits

TMS in neurosurgery

neuroplasticity in brain tumor rehabilitation

ongoing studies in TMS

impact of new technologies in cancer rehabilitation