Saturday, January 15, 2011

Tools, Techniques and Technology

I do a lot of seminars on driving cortical neuroplastic change, the unequivocal bedrock of recovery, in stroke survivors. I've done talks in some of the best rehab hospitals in this country. I've also done talks in rural areas where the nearest rehab hospital is hundreds of miles away. Some of the attendees have access to a smorgasbord of leading-edge technologies. Some home care therapists have access to very little technology. And whatever technology they do have has to fit in the car. Some have immediate access to neurologists and physiatrists. Other's laugh when I say "Kick it upstairs to physiatry." "We rarely see any doctors,” they say. Rehab settings run the gamut; feast or famine or somewhere in between.

When I do talks I always remind myself of a particular touchstone that reminds me of why I, again and again, get up in front of therapists in the first place. It goes something like this: "If I was a stroke survivor knowing what I know about stroke recovery, what would I want therapist to know?" This question has served me well. I challenge clinicians as an informed advocate.

There are people, facilities and technologies that are essential to achieving the highest level of recovery. It is unfortunate that many facilities and therapists don’t have accesses to these tools. Stroke is the leading cause of long term disability. Recovery deserves the best tools. The clinical expertise is there. Clinicians spend a tremendous amount of time, energy and money being trained to be the best they can be. But just like every other profession from astronaut to auto mechanic, the right tools and access to the right people are essential.

During seminars I’ll ask, who has access to XYZ technology? Who has the availability of a physiatrist? Who has access to somebody who can do serial casting? Who has access to e-stim orthotics, or a particular splint or a partial weight supported trainer, etc.? Usually the same one or two or three people raise their hands. If the talk is in a hospital setting where all the clinicians are from that hospital they may all raise their hands. If it's a rural area where many are involved in skilled nursing or home health care, very few raise their hands.

Having access to and an understanding of a handful of technologies is essential to standard of care for stroke survivors. Also essential is access to clinicians with the right skill set. So what and who is essential? If I were to start "Pete's Center for Stroke Recovery" I would have access to the following before the doors ever opened.

Treadmills. Treadmills are never ending parallel bars. They expand the size of the gym with a very small footprint. Put a mirror in front of them and they become instantaneous feedback machines. They also provide an essential bit of quantifiable data: speed of gait.

Recumbent, 4-limb bilateral trainer. Recumbent trainers do not have to break the bank. Inexpensive ones can be found for $2500 or so. These are essential not only as a pre-ambulation device, but also because they develop cardiovascular and muscular strength; "banking" both are essential to doing the hard work of recovery.

Some sort of harnessing system for gait training. Stroke recovery works best with over-challenge. Challenge drives neuroplasticity and neuroplasticity drives recovery. It's impossible to over challenge with standard gait training (a gait belt and guarding). The fear of falling on the part of the survivor and the therapist runs headlong into the challenge that needs to be realized. If the survivor is harnessed, falls are impossible and challenge flourishes. Partial weight sported walking is but one option that requires harnessing. Speed intensive treadmill training (also known as speed dependant treadmill training) has shown stellar efficacy in increasing speed of gait (please see my previous article in Advance entitled "Using Gait Speed as a Marker for Progress" for description of the importance of gait speed in recovery, and as an outcome measure). The usual suspect in this category is the LiteGait. But that's not the only option. Google "parachute harness" and you'll find a ton of inexpensive options. Of course you need something to hang the harness from, but this could be more of an issue of your facility's maintenance department, and less an issue of buying an expensive piece of equipment. Over ground systems may be a better option for some gyms. NeuroGym, Biodex and other companies make over ground systems that provide an inexpensive harnessing option.

Cyclic electrical stimulation. The problem with e-stim generally is that the machines tend to intimidate most clinicians. But there are so many good things that e-stim dies that it is no longer optional. From reestablishing sensation to keeping soft tissue shortening at bay, e-stim is essential a certain points in the arc of recovery.

EMG based electrical stimulation (EMG-e-stim). This “next generation” of e-stim is important once a minute amount of movement is possible. It is believed that EMG-e-stim drives cortical changes which leads to small increases in movement. And small increases in movement are important in the early stages of repetitive practice paradigms.

Access to serial casting. Essential to fighting the good fight against soft tissue shortening. There are no splints that have shown clinical efficacy in increasing soft tissue length. Serial casting is the only nonsurgical treatment option to increase PROM of joints that have established contracture.

Access to neurologists, and especially physiatrists. Without them it's very difficult to deal with issues that range from spasticity to pain.

A constraint induced therapy (CIT) program. Although usually only benefiting higher-level stroke survivors, CIT is essential to the stroke recovery endgame.


oc1dean said...

Pete, good article, the latest saying I got from another blog is quite applicable for stroke recovery. Something that is well diagnosed can be cured well. This is one of my pet peeves, our PMR docs, physiatrists, etc. are not diagnosing us other than looking at the deficits presented. This would be the first item on 'Dean's Center for stroke recovery',after that would be the breakdown between penumbra recovery vs. dead brain recovery. Oh well, I can dream. You are working within the existing constraint of stroke rehab, I think a brainstrorming session could blow open many other out-of-the-box possibilities.

Michael said...

Can you please show a picture of a "Recumbent, 4-limb bilateral trainer" or show a link to a picture of one? I did a google search using the phrase above and got a number of images returned. I didn't know which was the correct one. Thank you. Great book, by the way. -- Michael

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