[00:11:44] Nele Handwerker: Yes, it makes perfect sense. I already had an episode on this, where I talked a bit about the primary, secondary and tertiary factors that cause fatigue. And it really has a lot to do with the fact that you simply use so much energy on body control processes because they no longer work well. So it makes sense to improve this. And it’s great that cognitive abilities are also improving.

In recent years, more and more people have discovered that this is really closely linked. And that it makes total sense for someone who is fitter, for example, to do sports training, perhaps with a little mental exercise. And then you improve all kinds of functions. The bladder is something new for me, but it’s great – it’s always good when neuroplasticity is stimulated.

Details on training with recoveriX

Can the training programme be adapted to the specific needs and progress of individual patients?
[00:12:48] Christoph Guger: Yes, that is a very interesting insight that we have gained. We started developing recoveriX about ten years ago. And back then we thought that we needed ultra-complex motion sequences. In other words, for every movement you want to make with your fingers and feet, you need to train it and use lots of stimulators.

We now know that if we perform a very primitive dorsiflexion of the hand and foot, this has an effect on the entire limb, i.e. fingers, wrist, elbow, upper arm, everything improves. Spasticity decreases in the whole arm and hand and fine and gross motor skills improve. It’s the same with the foot. And it’s actually quite interesting that we don’t have to train every single finger to achieve these results. And that also makes the whole thing practical to use, otherwise a therapy like this would simply take far too long.

You can now manage this with 30 therapy sessions. So you train effectively for about 24 hours and afterwards you are simply a lot better. I always say that if I learn English after 24 hours, I’m not much better. So it definitely pays off to take advantage of this therapy. We did a group study when patients did the therapy twice, and we saw that these improvements continue more or less linearly. So it doesn’t stop after these therapy sessions.

And what is also very important is that it is a long-term therapy success, so we carry out follow-up examinations one day after the therapy, one month later and six months later. Patients are usually better again six months later, because when they stop recoveriX therapy, the brain is healthier. And then the patients move their feet and hands more in everyday life, which trains the muscles. And finally, they go further and faster and feel better. So no more is lost. Unless there is some other medical event, but basically it stays that way.

[00:14:58] Nele Handwerker: Okay, that’s great. My tip is to make sure that you have a course-modifying therapy that keeps the MS under control, because then you can concentrate on rehabilitation. You briefly used the term dorsiflexion. I’m sure not all listeners are familiar with it. If you could just briefly explain again what kind of movement is meant by it.

[00:15:18] Christoph Guger: You simply raise your hand and all your fingers 90 degrees backwards. That’s what we mean by dorsiflexion. It’s almost the same with the foot, you pull the foot and the toes upwards as far as you can. And we produce this movement using this electrical stimulator, which is controlled by the brain-computer interface. In therapy, it is essential that this happens immediately, i.e. as soon as the patient thinks about the movement, this stimulator is switched on. And by repeating this 8,000 times, this neuroplasticity is stimulated and is as often as a child needs to learn to walk. And repetition is the decisive factor for the brain.

That’s why we also concentrate on these very simple movements, which the patient has to perform monotonously in principle and then the patients get better. That’s why we actually use the same therapy for all patients, because it simply works. In stroke patients, for example, we have also noticed that they can speak better and swallow better again. By activating the sensorimotor cortex through these hand movements, we have an effect on the speech network. You need the auditory cortex to speak. This is simply to understand speech. Then you need Wernicke’s area to simply recognise the words. Finally, you need Broca’s area to give the answer. And this still controls the mouth, tongue and lips to reproduce the words. This sensorimotor cortex, which is also responsible for the mouth and lips and so on, is stimulated by recoveriX. And this has an effect on the entire language network in the brain.

The same applies to pain; recoveriX is already being used in Finland, for example, to treat chronic pain in patients. So when medication and other therapies simply don’t help any more, they go and do recoveriX therapy, i.e. again just imagining movement and the pain subsides. And that is basically the same effect as with the speech network. We can also access the pain network by modulating the sensorimotor cortex through the therapy.

[00:17:43] Nele Handwerker: Exciting, pain is definitely also an under-treated symptom of MS. That’s great, that will certainly be exciting for many people. Now you’ve explained it before, but I’d still like to go back.

Scientific principles and evidence

What happens in the body and brain during a recoveriX training session?
[00:18:14] Christoph Guger: The recoveriX system instructs the patient to visualise a right hand movement, for example, and this visualisation of the right hand movement activates the sensorimotor cortex. This is simply the area responsible for the right hand. This is usually in the left hemisphere of the brain. And this is exactly where we have attached EEG electrodes to measure this brain activity. In principle, these are voltages that are activated by the brain and we can simply measure them, which is quite normal electrical engineering.

This allows us to recognise as soon as the patient thinks of the right hand movement. And only then is the stimulator triggered and switched on, which then actually stimulates the right muscle. And this pairing effect, which is very important, means that the muscle is activated as soon as the brain thinks of it.
As a result, the neurones learn again that they belong together and the cognitive processes are coupled with the motor function.

Another interesting aspect of recoveriX is that many standard neuro-rehabilitation procedures can actually be carried out at once. This functional electrical stimulation, muscle stimulation, for example, is a standard therapy that we do. The motor concepts are used worldwide. The physiotherapist or occupational therapist simply says, imagine this movement. That’s what we do, with the difference that we do it 8,000 times.

We also do mirror neurone therapy. The patient sees this avatar on the screen and as soon as they think of the right hand movement, the avatar also moves the right hand. This in turn activates the sensorimotor cortex. Mirror neurons in the brain are responsible for copying behaviour. For example, my son learnt how to ski by simply watching other children do it. They talk back to the sensorimotor cortex and this is how you learn movement sequences.

There are also experiments that show that if a patient simply watches another person move their right hand, the right hand area in their brain is also activated because these mirror neurones produce this. This therapy is also included in the recoveriX system. Then there are a few other therapies that we combine, with the difference that we do everything at the same time. In the worst-case scenario, we have eight standard therapies at the same time. In addition, we also have this coupling of the mental and cognitive processes with the motor function via the brain-computer interface and this is actually what makes the therapy so effective.

[00:20:59] Nele Handwerker: Great, wonderful.

Are there specific studies or evidence that show the effectiveness of recoveriX for MS patients? And how comparable is the study data with stroke patients? Are the rehabilitation processes similar?

[00:21:20] Christoph Guger: The first study was with upper extremities in stroke patients. We trained right hand movements against left hand movements. Almost all stroke patients improved, there were only two exceptions. One patient, who unfortunately came from the same place as me and who I have known for a long time, had a second stroke during the time we were doing the therapy, i.e. in those two months. And that ultimately meant that she did not improve.

The second test subject, who did not improve, simply never paid attention. He was always looking around and chatting. And if you don’t join in, it’s no use. All the others got better. And that was even 10, 20 and 30 years after the stroke. And that is something that patients very often do not hear. They are told that after a year there is actually no improvement, sometimes after just six months. And that is simply not true. So the duration, how long ago the stroke happened, has nothing to do with the improvements. You just have to join in and then you improve.

We realized that the spasticity improves, fine and gross motor skills improve, temperature control, speech, swallowing, what was quite interesting was that speech also improves. Then we thought we should actually try it for the feet too and that was the second clinical study. We realized that the patients simply walk faster, can walk for longer, their balance improves, their coordination of movements improves and their gait is therefore much nicer.

Interestingly, the foot therapy also had an effect on the upper extremities. And even the hands and arms got better, even though we were actually treating the feet. Then the concentration and memory improved. And the foot therapy was simply much easier for the patient to understand how much they had improved. Because you need both feet to walk and it really stands out when the foot is better, that you are faster and can do more in everyday life.

With the upper extremities, you simply compensate for a lot and carry out activities with the healthy hand.
Then the patients often don’t even notice that this hand has improved. These videos were very important afterwards, so that we could compare before and after. And during this study, our neurologist, Tim von Oertzen, who was the head doctor, at the Kepler Clinic here in Linz, said, why don’t you try this for MS, it should work just as well.

Then we recruited the first 5 MS patients for the next clinical study. Then 5 out of 5 got better, which is always a good indication, and then we just had to prove in a group study that this applies to basically everyone. And with MS it actually works even better than with stroke, so the patients just get a little better. And this can be explained by the fact that the lesions in the brain are simply much smaller than in most stroke patients, where really large areas are affected.

With MS it is sometimes not really possible to see where the lesions are in the magnetic resonance image. This may simply make it easier for the healthy neurons to bypass the damaged neurons and increase movement. With MS the challenge was that MS is bilateral. So both sides of the body are affected, whereas with a stroke only one side of the body is affected. And we solved this by treating MS patients with the left foot against the right hand in one therapy session and then the other foot against the other hand in the next session. We always alternate in this way and can actually activate all four extremities.

The impressive thing with MS patients was… we expected the improvement in motor skills and spasticity anyway, because we simply knew from stroke patients that it helps. But the impressive thing was actually how much they improved in terms of fatigue and bladder control. And these are two very important points, because they are extremely helpful in everyday life.

[00:25:46] Nele Handwerker: Yes, absolutely. Now I have to ask again out of curiosity, bladder control will probably improve if I do the feet too. So is it also possible that you only stimulate the hands and arms of MS patients?

[00:26:00] Christoph Guger: We haven’t tried that because we wanted to treat all four extremities. That could of course be investigated in the next clinical study. But we have now focused on a follow-up treatment, this clinical study is currently running. And that should answer the question, what actually happens if I carry out the therapy 60 times instead of 30 times? How much better will I be then? We know from stroke patients that the results are fantastic. We have had patients six months after the stroke, and their fine motor skills have improved significantly. We measure this by having them stick small rods in something and we simply measure how long it takes. And after 25 treatments, they are already much better, even though they have actually exhausted all the treatment options with the neurorehabilitation that we offer, but they still get better.

And if we add another 25 sessions afterwards, they get even better. We have had some patients whose motor skills look like they did before they were healthy. So without a test, I would not be able to determine whether the hand had ever had any impairment. With these fine tests, you can see it because we can simply quantify very precisely whether something is getting better and how much it is getting better. And it is exactly the same with MS patients, they get significantly better.

User experience and availability of recoveriX

What short-term and long-term improvements have MS sufferers made through neurorehabilitation with recoveriX and how does this affect everyday life?
[00:27:29] Nele Handwerker: Yes, I think most of us know these tests. I do them regularly too. This 25-foot walk, 25-foot walk and the 9-hole peck test, where I have to put sticks into a template, left and right. But just briefly again, someone who is obviously severely impaired will probably not be healthy after 30 or 25 sessions. It is probably always from the point where I come from, I improve by a certain factor, you said it, for example three times faster. So that no false expectations are raised.

[00:28:07] Christoph Guger: No, that is not it. That’s why we did the group studies. On average, we know exactly how much a patient improves. There are different scores, i.e. how much you walk further, how much you walk faster. With foot therapy, for example, our patients walk 0.19 meters per second faster after they have had this therapy. That’s a bit difficult to imagine. But if you want to register a medical product in Europe, you have to carry out a clinical evaluation.

So we have now looked at all the other existing rehabilitation options and the most effective other device manages 0.11 meters per second. We manage 0.19 meters per second and recoveriX is simply much easier to use. The patient sits in a chair, carries out the therapy, a therapist can treat several patients in parallel. So it’s much easier and we actually achieve a much greater increase in speed than any other technology. If you walk normally, you walk about one meter per second. We achieve an improvement of 0.19, so you can get an idea of ​​how much faster you can walk. The greater the impairment, the more you notice how much faster you can walk.

[00:31:30] Christoph Guger: If you give Botox or something like that for the spasticity, it lasts for three months and then you have to go back. At recoveriX we have some patients who simply never needed Botox again because the spasticity was gone or the pain and cramping were no longer so dramatic that they simply didn’t need it anymore. That is of course extremely useful. The improvement is that it either starts right at the beginning and continues continuously. It can be a lot right at the beginning. But nothing can happen for a while and then suddenly it starts.

For example, we had a patient who thought after the first seven treatments, I’m just wasting my time, it’s no use and he could actually go to a coffee shop. After the eighth treatment, the spasticity in his foot suddenly went away and he was able to move his foot again. For the first time in years. So it was a very brief moment when the spasticity went away and the motor skills were back. We see these immediate improvements quite often. Suddenly, something is moving.

How accessible is recoveriX for MS patients? Where can you find providers for this type of neurorehabilitation? And are there specific requirements?
[00:32:53] Christoph Guger: I think we are currently represented in 18 countries. That is of course Switzerland, Germany, Austria, but also South Korea and Honolulu. The number of countries is actually increasing every week. In Austria, for example, we work with a physiotherapist who has already set up recoveriX centers in Vienna, Graz, Linz, Klagenfurt, Schladming, Innsbruck and, together with a partner in Waidhofen an der Ypps, she will actually cover the whole of Austria. Ultimately, we want to ensure that no one has to come for more than 30 minutes for therapy, because it is of course a logistical effort. At the moment, some people drive two or three hours to get therapy.

[00:34:09] Nele Handwerker: Okay, great. Is there an address or an email you can send to ask where the nearest recoveriX provider is and always get the latest information, no matter when you listen to or read the episode?

[00:34:31] Christoph Guger: The best thing is to go to recoveriX.com. All franchise partners and recoveriX centers are listed there and you just enter your address in Google Maps and the nearest recoveriX center will appear. We also have a newsletter, of course, where we inform people when a new center is opened. You can simply sign up.

Of course, you also want to get it into rehabilitation clinics and hospitals. Then you can simply get a referral there for normal rehabilitation. In Austria, for example, there is a center like this in Bad Hall, where a patient goes for a month and can simply be treated there. This also has the advantage that the costs are covered. With these other franchise partners, you simply have to pay for it yourself. In Austria, the health insurance company already co-finances a large part.

In Switzerland, someone will soon start in Zurich and will then cover the whole of German-speaking Switzerland. In Germany, we already have centers, for example in Lindau and Leipzig, in Passau and in Freiburg. And in February, Munich will be added with two locations, Frankfurt and Hamburg. And in two years we will have around 50 centers in Germany.

How much does treatment with recoveriX cost and are there any options for getting partial or full reimbursement from the health insurance company?

[00:35:44] Christoph Guger: That depends a bit on the country. In Finland, for example, 80 euros are reimbursed per session, in Austria 48 euros are reimbursed per session. And the costs vary a bit depending on the country. In German-speaking countries, i.e. Germany and Austria, the cost per therapy is around 130 euros. 48 euros are reimbursed in Austria and the rest can be deducted from your taxes afterwards. Then there isn’t really that much left that you have to pay yourself. But what is much more important is that there is the option of simply getting better. When patients come to us, money isn’t really the issue. The big question is more when will I get my recoveriX appointment.

[00:36:31] Nele Handwerker: You said that you can also do the recoveriX therapy as part of a rehabilitation program. If I’m there for a month, I’ll train 50 times, so much more often. Or will I then have fewer sessions?

[00:36:44] Christoph Guger: You usually have fewer sessions. The rehabilitation centers do one therapy session per day, but they only work from Monday to Friday. And if I’m there for a month, I manage about 20 therapy sessions. Of course, it also depends on how quickly they start, because at the beginning there are often examinations of patients and only then is the therapy plan drawn up. But you can expect about 15 to 20 therapies. Although we already know from the group study that it is absolutely essential to do these 25 therapies for stroke and 30 therapies for MS. We have patients who haven’t really improved after 10 or 20 sessions. After 25 or 30 sessions, almost everyone is better. So you have to do a certain number of repetitions to be able to achieve success. There can be a lot that gets better, or it can be just a little bit, but on average patients still get a lot better.

[00:37:51] Nele Handwerker: Okay. And that means, if I had the opportunity to do that as part of my rehabilitation, then it would make total sense to see that I continue training afterwards with a local provider who is outside the rehabilitation facility in order to get my 30 units, right?

[00:38:10] Christoph Guger: Exactly, that’s what we recommend and that’s what we ultimately want to achieve, that recoveriX is available in hospitals and rehabilitation facilities. Then you get therapy in the acute or sub-acute stage and you can also just come to the recoveriX centers as an outpatient. That has the advantage that you can just go home straight away and lead a normal life and not be stuck somewhere for the month where you just can’t get out. So the combination makes sense. And we’ve also seen that it doesn’t stop after 25 or 30 sessions, so it goes on like that. And with very serious impairments, it goes on for a long time. We had a patient who did it 100 times and he started really badly and I told you before that at the end he started talking again and left.

[00:39:00] Nele Handwerker: And apparently a higher quality of life because he was able to communicate with his wife again. The topic of quality of life is really important.

Future plans for recoveriX

Are there plans for the further development of recoveriX or other offers in the field of neurorehabilitation for MS patients?

[00:39:29] Christoph Guger: Yes, we… well, technically speaking, we are constantly getting approvals in various countries. We are in Canada, Australia, New Zealand, soon in China and Japan, USA and so on, all of Europe and Israel, we have had that for a long time anyway. So geographically we are expanding. And of course MS is in almost every country in the world, funnily enough not in Hong Kong, or thank God not. Technically speaking, we are also trying this for other diseases, such as Parkinson’s. The first patients have already been with us and they are also getting significantly better. Our first patient, for example, walked twice as fast in this Timed-Up-and-Go test, which is an indicator of fine and gross motor skills, coordination of movements and balance, that all of this has improved. We are also conducting the current clinical study.

Because of the fatigue, we also invited patients with long Covid. The fatigue of long Covid patients who have now been with us has also improved significantly. But we are still missing the group study. These are just a few patients who have been with us so far. We have also included a few people with incomplete paraplegia in the recoveriX therapy. Our first patient was also able to complete this Timed-Up-and-Go test more than twice as fast after completing 25 recoveriX therapies.

So in principle we can carry out clinical studies for a wide range of neurological diseases. It’s just that every clinical study is very time-consuming and requires a lot of effort. But it works for a wide range of brain impairments. And as you can see, even in the spine, i.e. in the case of an incomplete cross-section, the lesion is not in the brain, but deeper. And the mechanism probably works in such a way that the brain is reorganized through neuroplasticity, that the brain simply uses the pathways that are still present in the spinal cord better so that the patient can walk better.

[00:41:47] Nele Handwerker: Really exciting.

Farewell

Where can interested listeners find further information on neurorehabilitation with recoveriX?

[00:42:00] Christoph Guger: The results of the clinical studies for stroke and multiple sclerosis can be found on recoveriX.com. You can read about it, of course it is also explained in scientific publications in detail, what improves, how much improves and how it works, anyone can read about it. We also have a publication in Frontiers for Kids. This is basically a scientific publication that is written for children, you can even give it to children, it is also reviewed by children. It is quite interesting. And this article, for example, is much easier to read than a scientific paper. And you understand really quickly how recoveriX actually works and what it does.

And we also have lots of videos online. Firstly, these are patient interviews where patients simply report what has improved. It is very interesting to listen to them because you can then weigh up a little whether you have a similar impairment and whether it will be of any benefit to you. Then we have lots of pre- and post-examination videos online where you can simply compare in one video how the patient moved before and how he moved afterwards and you can see very clearly what has improved.

That is always the decisive factor for the patient and for the family and for the doctors, that they see a video like this, because all these tests, 9-hole peg and whatever they are called, even if it is twice as fast, you can’t really imagine what that means in everyday life. With the videos you can see very clearly what they are doing.

[00:43:38] Nele Handwerker: Wonderful. Thank you very much for the development and to your team, with whom you are of course working on it, sounds like a really great thing. Thank you very much for being my guest and I wish you continued success so that as many patients as possible can benefit from it. It is probably suitable for all kinds of illnesses where neuroplasticity is needed and needs to be improved. It doesn’t stop with MS or stroke. Super exciting. Thank you very much, best wishes to Austria. Bye.

[00:44:17] Christoph Guger: Thank you for the invitation. Ciao.

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