An innovative neurofeedback company in Auckland is bringing together a diverse set of experts to teach people to control parts of their brain that are normally invisible. In doing so, they’re hoping to address a condition that plagues modern society: chronic pain.
This content was created in paid partnership with Exsurgo.
Exsurgo’s Albany office initially looks unremarkable, like any number of tech companies – white desks, dual screens, a cramped tea room. That’s until you spy the human-sized robotic exoskeleton in the corner of a boardroom. More body parts perch on long benches behind a chest-height room divider; mannequin heads fitted with contraptions that look like long-fingered hands wrapping around the models’ skulls. 3D-printed joystick prototypes sit in front of their detailed blueprints. In a garage workshop connected to the office, machines noisily automate rehab tools through movement repetitions, testing durability. On an upper floor, engineers and account managers work on computers, while psychologists and physiotherapists sketch neural pathways on whiteboards.
The rehabilitation company is a modern merging of specialties: engineers designing tools to address problems defined by physiotherapists and neuroscientists, with computer scientists integrating rehabilitation devices with online games and extracting streams of data. The team has tackled issues as wide ranging as multiple sclerosis, concussion and PTSD, but they’re currently focused on a condition that’s more prevalent than diabetes, heart disease and cancer put together: chronic pain.
Exsurgo have created “Axon”, a lean, wearable electro-encephalogram (EEG) machine, which allows them to present chronic pain sufferers with an on-screen representation of their own brain activity. They believe that with practice, those people will be able to learn to increase their “good” brain activity, and decrease the “bad”. It’s an area that’s been investigated by a number of labs, and shown promise, but no one knows yet exactly how effective it could be. Exsurgo are starting to open the door for chronic pain sufferers to learn to adapt their own brain’s activity at home, by playing games. It could even be fun.
Founder Richard Little, a Scottish immigrant and “Kiwi by choice” of over 30 years, is firmly grounded in the practical. He wears a Leatherman bracelet with attached screwdriver bits – Phillips on the underside of his wrist, square recess further round. In introducing his inventions, he caveats his explanations with “but I’m just a dumb engineer”. He might be underselling himself; that robotic exoskeleton in Exsurgo’s office was an invention Little tasked himself with after his friend Robbie Irving was diagnosed with multiple sclerosis. The pair had grown up together, and Little had seen Irving’s mum, who’d also had MS, use a wheelchair for most of Robbie’s life. “So we expected that for Rob,” Little says. “We can’t fix MS, we’re not clinicians, so it just seemed obvious to us to build Robbie a set of robotic legs.”
What Little did have was a long career in engineering. An ex-marine engineer and commercial diver, he’d been involved in testing high-tech solutions to underwater problems. While working on oil rigs, he’d trained as a paramedic, dipping a toe into medical sciences, where he’d eventually devote his attention.
A few months after Irving’s diagnosis, and the robotics conversation, the two met up in a pub in Newmarket, and sketched out ideas for Irving’s new legs on the back of cardboard beer coasters. They worked on the legs for about four years in Little’s garage. Irving, also an engineer, took on the mechanics, and Little worked on the electronics and computer software needed to control the legs. By the time they first talked to investors, Little and Irving had a functioning prototype, in which Irving could harness himself, and jerk slowly around the room, controlling the robot legs with a joystick.
Those robot legs became “the Rex”, and the foundation of a company called Rex Bionics. It was a success, but you still won’t yet see anyone stomping down the street in a pair of Transformer-style lower limbs. After many visits to rehab facilities, Rex Bionics became focused on addressing issues that accompany paralysis, like bladder and bowel issues and bone density problems, induced by long periods of sitting.
“Being up walking and standing is the opposite of that,” says Little. “Walking is good for you, who knew?”
Rather than an everyday walking aide, the Rex is now being used in clinics, helping people with spinal issues and mobility impairments across the world stand and move in an upright position, helping them stay healthy throughout their lifetime.
When Rex Bionics went public in 2014, Little extracted himself from the company. He was proud of what they’d achieved, but a close personal tragedy had presented him with new problems to solve.
Back when Little was fleshing out his plans to build new legs with Robbie, his 72-year-old mother suffered a stroke. She lived in Fort William, a town in the Scottish Highlands that sits at the bottom of Ben Nevis, the UK’s highest peak.
“I was shocked,” Little says. “She was a very fit woman who walked with the dog every day. And she was relatively young.”
When Little’s mother came home from the hospital in a wheelchair, he realised that paralysis in her right arm was causing the biggest impact on her quality of life. She couldn’t perform two-handed tasks like holding her tube of toothpaste in order to unscrew the lid, and simple things like eating had become a big challenge.
While Little was home supporting his mother, he realised how hard it was to address those problems using the traditional rehabilitation that she, and millions of other stroke patients around the globe, received.
“When you talk to clinicians about it, they’d say you’d get an average of 30-40 movements in a session. I liken it to trying to play guitar. You can’t just do 30-40 movements and hope that you’re going to be Stevie Ray Vaughn.” Additional problems, like cognitive issues or the impracticality of driving to a rehab medical centre compound the difficulty with rehabilitation. “For my mum, her ability to engage was vastly reduced after the stroke, because she had a cognitive deficit that she didn’t have before.” Little was struck by these complications, and wondered how different his mum’s rehabilitation could have been if she’d been engaged more creatively.
While he was working on the Rex, Little visited a number of rehabilitation clinics. The staff there would be interested in his engineering skills, and many approached him with suggestions of rehab equipment they wanted built. The rehab industry was teeming with ideas about how to do things better, but was lacking collaboration with the right industries. Moreover, Little was inspired by what could be changed by focussing on upper limb rehab. “There’s a really good body of science that says you can get a lot more recovery in those areas.”
Faisal Almesfer was a mechatronics student in his third year at Auckland University when he took an internship with Rex Bionics. Ten years later, when Little left Rex to set up a new upper limb rehab venture, Almesfer went with him, and the pair set up Exsurgo. The company experimented with a suite of rehabilitation tools, including joysticks for simple computer games that can be adapted for client’s specific needs. Two joysticks can be attached together by a plastic bar, so that a stroke survivor’s good hand can guide their bad, or attached to a round bottom and placed on a desk, so players have to balance the joysticks during the game.
Then they designed games to play with these set-ups, like flying a dragon through hoops above a fantasy landscape. It feels like a flight simulator pared back to the absolute basics; a meditative activity you can lose yourself in. “Gamification” had always been part of the Exsurgo strategy. “If you’re playing a game, you will tend to do thousands, or tens of thousands more movements than if you weren’t,” says Little. There’s a social side to these games as well. “We’ve seen older people who have their grandkids log on to the game and play on their rehabilitation device. Then there are conversations about who’s better.”
At the same time, Almesfer and Little were developing brain-computer interfaces that are able to control devices by thought. An effective brain-computer interface involves recording the brain activity associated with someone’s intention to make a movement, then using that activity to signal a device to make that movement. If the brain activity is reliable and repeatable, just imagining the movement would make the device move. Brain computer interfaces (BCI) have long been a goal of the neuroscience industry, but require a level of computer processing power that’s only been available in the last decade. Just three labs were working on brain computer interfaces in the early 2000s, and now over a hundred BCI projects are underway across the world.
In the 18 years since Little started tinkering with the Rex in his garage, and the 14 years since Almesfer met Little at Rex Bionics, the pair have amassed a range of expertise, including mechatronics, game creation, brain computer interfaces, and on-the-ground rehabilitation experience. Then at a neuroscience conference in 2019, Little met Christine Ozolins, a psychologist and neuroscientist who had done award-winning research in neurofeedback: a discipline that uses electro-encephalograms to record brain activity, visualises it on a screen, allowing people to see what their brain is doing, and learn to control things that are usually automatic. Little had previously consulted on some neurofeedback work at Glasgow University, that was tackling chronic pain, and was fascinated by what he saw. He convinced Ozolins to join Exsurgo to work on a project that Little and Almesfer had been developing for a few years, an EEG headset they call ‘Axon’.
Axon slips onto a person’s head like a scalp massager, fingers fitting snug around the forehead, temples, under the ears and around the back of the neck. Each finger has an electrode, and these electrodes, in concert, measure three different types of brain waves; theta, alpha and beta. Theta waves dominate when you’re in a drowsy state, and beta waves dominate when your brain is humming with activity. Alpha waves dominate when you’re relaxed but alert, and people with chronic pain often produce an abnormally low level of alpha wave activity. In theory, training a specific area of your brain to favour alpha wave activity should reduce pain. “I think of these brain waves as two being pain, and one being anti-pain,” says Little. “So if you can reduce the pain brainwaves, and increase the anti-pain brainwaves, then you reduce pain.”
Typically, EEG involves applying more than 30 electrodes to the scalp, lined with conductive gel, and using amplifiers to pick up brain waves, and software to extract the useful signals and separate those from all the other noise being produced by the brain. The process can take hours, but produces robust reliable signals that are useful to scientists. But it’s impractical for everyday use.
EEG can typically only be used by trained specialists such as neurologists and neuroscientists, and leaves the user with gel all through their hair, and often with a headache from the tightly fit electrodes. In an early usability study on brain computer interfaces, Little saw a big issue with that. “One of the ladies who’d had a stroke said ‘I don’t care how good it is, you’re not putting that stuff in my hair.’ That might sound ridiculous, but that’s what was important to her. It would be the same for my mum – she would get her hair done, it’s one of those things where she could treat herself and feel good.”
For someone who’s had a stroke, showering, washing the gel out and drying their hair can be a long, difficult process. With Axon, the Exsurgo team has broken away from the long, messy set up, and created a device that people can use at home, by themselves, without disrupting the rest of their day.
In the Exsurgo offices, Almesfer removes the Axon device from a mannequin head, wets the electrodes, and eases it onto his head. For 30 seconds he sits still, eyes open, with Axon recording baseline brain activity measurements. He does the same with his eyes closed, a simple change that produces a different kind of brain activity. Little asks him to demonstrate the simplest game: three bars, each of which represent each of the types of brain wave. Almesfer sits still, focuses, and quickly raises the first bar (representing the “anti-pain” brain wave) above a marked threshold. The other two bars (representing the “pain” brainwaves), fall. The bars jump around constantly, Almesfer continually trying to rein them in. “It takes people two to four sessions to learn to control them,” says Little. “Everyone gets better over time.”
I try, and automatically attempt something that feels like trying to drag a 3D picture out of a Magic Eye book. The waves jump around, and I immediately want to sit there for as long as it takes for me to learn to control them. The motivational aspect of neurofeedback is immediately obvious.
Almesfer takes the headset back and switches to what he explains is his favourite game, a hot air balloon rising above a mountainous landscape. He falls silent, focuses on the screen, and the hot air balloon gradually rises and falls, as Almesfer increases his alpha, or “anti-pain” brain waves, and decreases the others. At times it falls, but over time, he manages to float the hot air balloon into the sky.
Exsurgo has just published their first peer-reviewed study of Axon, a proof-of-concept trial involving 16 people suffering from chronic pain. They used Axon for half an hour, four to six times per week, for eight weeks. At the end of the eight weeks, 11 out of the 16 patients reported an improvement in their pain, and 9 out of 16 reduced their pain from “severe” to “mild”. Exsurgo has just started a new trial, involving more than a hundred patients, where some patients will have “sham”, or fake neurofeedback. This will help the team detect any placebo effects, something that is common in any clinical practice.
The team believe they’ve found an application for Axon beyond working with stroke rehab, which affected Little’s mother, and multiple sclerosis, which his friend Irving still has. We find Irving in the workshop attached to Exsurgo’s office, an expanded echo of the garage in which the two worked on his original robotic legs. He’s standing, unaided, preparing some metal parts for welding. Irving, now Exsurgo’s production manager, is living evidence of what Little’s work can achieve since he dedicated his efforts to rehabilitation; that the human body is malleable, powerful, but most of all, unpredictable.