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The two leading institutions in the country, IIT Delhi and AIIMS New Delhi, have collaborated to establish the ‘Centre for Advanced Research and Excellence in Disability and Assistive Technology (CARE-DAT),’ a Centre of Excellence (CoE) established under the auspices of the Indian Council of Medical Research (ICMR).

The Centre’s objective is to promote thorough study on an identified topic with the goal of creating new information and enhancing the holistic understanding of neurological illnesses such as stroke, as well as providing assistive technology solutions for patient rehabilitation.

The AIIMS and IIT venture includes a gamut of things to cure stroke and bridge the gap between the numerous stroke patients and the limited number of neurologists across India. To discuss what it entails, Medically Speaking spoke to a panel of experts from the elite institutes: Dr Padma, Chief of Neurocentre, AIIMS; Dr Senthil Kumaran, Professor, Department of NMR, AIIMS; Dr YV Vishnu, Associate Professor, Neurology, AIIMS; Dr Amit Mehndiratta, Associate Professor, Biomedical Engineering Department, AIIMS, IIT Delhi.

Here are a few snippets from the interview:

What exactly does this collaboration between AIIMS and IIT Delhi entails? What is the purpose of the same?

Dr. Padma: Stroke statistics huge and just to put it in perspective as I speak with you, there’s a stroke happening every 20 seconds and a death happening every two minutes. Time is less and you need to unclog an artery. Besides the fact that there is this glamorous part of it that you need to unclog, go in and give an IV medication, even in the best of centers, you will have just a percentage who would get this. In fact, if you look at India, it’s not than 5% who are able to reach out and get this treatment. So what happens to even those who get this and what happens to those 95% who could not get this treatment? They are left with a disability and that’s the reason we say that stroke is life-altering, because besides mortality, it’s a morbidity, it’s a disability. So can we do something to disability to someone who has lost his speech, to someone who can’t use the handle like who can’t walk, who can’t balance who’s now in bed and is dependent on others for his activities of daily living and is not a useful member in the society? So for that we were looking at ways and means of going beyond the conventional aspects and in this we thought we can have the transdisciplinary Sciences which can come together which has been the focus across most areas of major public interest, whether it is pollution, whether it is climate change, whether it’s a major disease burden. In this, we partnered with IIT in the sense that can we go beyond exercises. So in this, the CARE-DAT program essentially is something to get the disability reduced and make a disable  person able to function, that’s a broad concept. And besides that we also have young entrepreneurship of our own research people, who come out with certain kind of apps. So we thought why not use this low-cost India centric venture where India is almost an IT capital in at least a developing world. So, in that can we use this science and reach out to people who are physicians, who are not neurologist and train them to treat stroke in a time-lock manner. Give them the Modus Operandi give the treatment in time.

What is the assistive technology that you have developed as far as the glove is concerned, or how is IIT Delhi partnering with AIIMS? What is the relationship between these two institutes and how are they using technology to assist the disabled?

Dr Amit Mehendiratta: IIT Delhi and AIIMS share a very unique mingle together. It’s a joint activity that is very unique to the Indian ecosystem, where a technological Institute pioneers in the technology or engineering world and another is a Medical Institute, who delivers real healthcare related, solutions to the society. CARE-DAT is a joint venture of both the Institute under the edges of ICMR, and we have been working together for a long time now, with the team of the clinical Partners at AIIMS. Sor far we have developed two products right now. One is a robotic exoskeleton, which is for the upper Limb, which is exactly for wrist and finger movement, which is very required for day-to-day activities.

Usually larger muscles rehabilitate faster whereas smaller ones take time. Patient undergoes physiotherapy for years and years it’s a very tedious process. Now the idea was to facilitate the recovery of these muscles better. There is a science behind it and there is a product which evaluates that science and comes out with a solution. So the idea is, if we enforce patients to do the movement repeatedly, the brain will learn skill, which we call technically call as neuro plasticity like child learns new activity as you enforce it again and again. We have developed this device in last four years and it is entering phase 3 clinical trials where we will evaluate it in large number of patients and then the product would be ready for market or commercialization.

In a country like India, of course, it’s the locals technology which is, of course, a low-hanging fruit, which we all really look forward to.When you say it’s a prototype and you have to test it on a large number of patients, how many patients have you tested it on? When you say low cost, how feasible it is when we speak of rural India also and have you got patents for it?

Dr Amit Mehendiratta: We have patented this technology in India, US, Europe and UK. By low-cost means that bill of materials, that is what we have spent to develop one prototype. Of course there is a cost, which goes in research. But if you ask me to develop one prototype again, the cost has been optimized and it is within few thousands. It is not a medicine or it’s not a process that it will be done for a week and the patient will be back to normal. It’s a long process that has to go for probably for months or maybe sometime years. Now, there are limitations in our society that if the patient has to go to a hospital to avail this facility, there is a cost of living for the patient and the care giver who is accompanying the patient. They have wages to earn which is affected if this process has to be done over a period of years. Now, the low cost solution is very portable. It is like a desktop and can be installed near panchayats where patients can come, do the activity for an hour a day and go back home and the device can be used by multiple patients.

Dr Vishnu if you could just tell us a little bit about what’s the app  entails? Since access to neurologist and physiotherapist is extremely restricted in rural areas, how do you think this app, how can it help?

Dr YV Vishnu: The idea of the app is based on the concept that we don’t have enough neurologist in this country. So this idea came from Dr Padma, when she used WhatsApp based technology to treat patients in Himachal Pradesh where have only a two or three neurologist. We tried to take inspiration from that and create an app which not only can help a physician in a remote area on how to treat stroke patients, but also provides them tele-rehab facility within the app. So we have developed the app and we are trying to test it out in a personalized trial along comparing with the stroke-physician model. The other model is just to train the physicians on how to manage the stroke patients and leave it to them. If this works out, it will be a great model to link the rural physicians to the neurologists across the country.

How did the idea started a little bit of how the department gave it an asymmetry expose patients in Himachal Pradesh? How did you really zero in on the technology developed this app for the medical students and the gamut of things which are included in?

I have been collaborating with Dr. Padma for past 15 to 16 years and whenever the standard Of the neurologist and subsequent physiotherapist to try all possible methods that is going to augment the recovery of the patients is most important. So, mam has been trying to have other than conventional physiotherapy, constraint induced movement therapy and then using TMS- Transcranial magnetic stimulation and also Transcranial direct stimulation as therapeutic methods. She has also attempted stem cells using both mono-nuclear  stem cells. so all these methods have been tested to see how they are effectful in the benefit of the stroke patients and it has been done , both in acute as well as the chronic stage . Now, to evaluate the efficacy of the therapy, it is very essential . So, we have been using magnetic resonance imaging and functional magnetic resonance imaging to see the efficacy of the therapy and in all the therapy the standard care that is the physiotherapy was always free of cost. Now we have been seeing that physiotherapy is given for two weeks, 5 days a week and for 2 weeks. After that whether the patients are improving and we see that improvement is only up to 3^rd month and after that the care givers and he patients do not follow the physiotherapy so there is a small drop in the performance and the fine motor moments. We have to count the cash or holding a tea cup or anything like that is becoming a problem even putting the button of the shirt, etc. These small moments are really a problem and even after 2 years patients are not recovering. So, because of that as Dr. Amit has already mentioned that he has developed a exoskeleton device to assist. Now, our aim is that this moment can be further taken away, basically instead of going to the center every time it is possible to try something at home so we have patented the design and we have identified the company in Bangalore   to see if we can make it to the smart gloves . So basically in these smart gloves , we are using IMU sensors, Electric sensors and we are going to measure the torque , the movement , the angle and the intensity of the movement and we are going to give visual input to the patient to see if they are able to improve the performance on the mobile app. So, basically they are going to do the task as instructed using the gloves and the gloves will be continuously giving  visual feedback to the patient.

Tell us a little more about these tie ups which you have with Asha workers, primary health care centers, how do you plan to take and develop in the most remotest corners of the country?

Dr Padma: Actually the crux of the issue is that we do have the excellence in terms of science and also across discipline, whether it is engineering whether it is medicine, bench work which you have seen that in terms of how everything got together so covid is a perfect example for the same. The only problem here is that sitting in ivory towers and confined to an urban setting is not going to work for our country and if we are concerned about our country which is a prototype of a developing world we have a three tier system of health care delivery. We do have a primary secondary and tertiary , so primary health care delivery system is primarily 2 things, 1^st is prevention and 2^nd  is identification of a problem to be able to refer in time to the next level , because at a PHC level a lot of stuff can not be done . In terms, I cant have a CT-Scan positioned there and you really need a CT-Scan to identify a stroke and for managing a stroke and it is true across the world in PHC level the primary aim is prevention, like in prevention you have immunization , picking up blood pressure and you have the gynecological services say delivery , all these thing come in PHC , so prevention of an issue and identification of problems , the identifies strokes would be there. The 2^nd step would be , as to what situations are those, what are the red flags where they are getting referred to the district level. Now a secondary level will cater to  large section of the population. Almost 70% of the population are in this wheel where they can access the district level hospital and in that you can have this health care system both in terms of delivery in acute care that is app comes there , you can train the physician and that is what happened in Himachal and the first And managing an acute stroke patient , a brain attack patient was done by an orthopaedician  because he was the one who was managing the emergency section and this is an emergency. Brain attack , heart attack , trauma! These are all emergencies. So, that is feasible , we proved it, we published that. So, the district level, that is feasible and the second thing feasible is the low cost of assistive devises whether in terms of stimulating the brain or whether it is an exoskeleton which is a small little stuff which can be positioned into district level and trained. So, these are the things , it is possible to station them and deliver them and it also has a potential for scalability , sustainability and also upscaling it. So, I think that is a feasible option and of course the tertiary care centers will remain the main hubs and what I feel is that the future will depend upon networking, developing these wheels and having stroke maps ready , For example, someone in your neighborhood , god forbid got a brain or heart attack , the person should know which is the nearest stroke ready hospital that he can access . Not just rush into a normal clinic because then the most valuable time is lost. So, these are the networks that can be developed and I foresee in future that this is a feasible option. So, if we can demonstrate it by good scientific method then we can give the results to the policy makers and it can be then integrated into policy making and implementation system in the health care system and you know stroke is one of the identified and focused areas in non-convictable disorders and in PCDS in government of India.

The app which you have developed or any devises that you have developed, when can we see a ground implementation of the same on , if not a pan India level but a bigger level?

Dr.

Well certainly the objective is to get it out as soon as possible and that is the vision all of us share together and that is what we really want. Now , first the science and the product has been optimized and as ma’am has said, it is sustainable , scalable and the man power at the district level can be trained to execute that process then it is ready to launch. So, if you ask me the timelines, I am expecting that within 1 and a half year or 2 years we will be able to complete the third phase clinical trial of the robotic exoskeleton device. Parallelly we are communicating with couple of industries . At IIT an AIIMS we have a start-up ecosystem that is very strong so it might be possible with some startups or some other industries we are trying that it should be scalable and directly after that it will be developed parallel to the industry inputs , we don’t want to lack there. Regarding the app, I think the app is scalable , probably Vishnu will be able to tell better , but I am expecting that not in pan India but in a smaller area we should be ready to launch within 1 and a half year or 2 years .