Rehabilitation Matters

Open day at Physiofunction

Our partners, Physiofunction, are hosting an open day at Walnut Tree Physiotherapy Centre, The Orchard, Town St, Horsforth LS18 5BL on Saturday 18th February.  Physiofunction are neurological specialists.  We will be showing our RehaMove FES Cycling system including the new RehaStim 2 FES unit.  Click the poster below for full details.

Open publication - Free publishing - More open day

New RehaCom Price List

We published a new Price list and Order form for RehaCom software. RehaCom is Europe's leading software for cognitive rehabilitation having developed over more than 15 years in Germany.  The aim of the software is not to replace the skills of a therapist but rather to help guide and give structure to a rehabiltiation programme.  It's been slow to catch on in the UK but more and more therapists are seeing RehaCom as a valuable tool in their practice.

Open publication - Free publishing - More rehacom

Dan Eley's Ride Raises Funds for Spinal Research

Client Dan Eley broke his neck in a diving accident, whilst working in Colombia.  Dan was injured when he dived in to a deceptively shallow river in the Amazon, breaking his neck at the C4/C5 level.

I wrote before about Dan when I first met him during his stay in Stoke Mandeville at which point he became a client of our RehaMove FES Cycle.

At the point that I met him, Dan was recovering from his injuries.  Things were complicated by the fact that he was injured so far from civilisation and it took some time before he could get the benefit of essential (even adequate) health care. 

Despite the difficulties he had come through, I found Dan to be an irrepressable character - not to be detered in his ambition to make a difference in the lives of others.

Since leaving hospital Dan returned to Columbia and has shown he has lost non of his drive and ambition.

It was no suprise therefore to learn of his latest fundraising effort.

On 9th January 2012, Dan began his challenge to cycle 550 miles using his RehaMove FES bike, which uses electric stimulation to contract the major muscles groups in the legs, the quads, the hamstrings and the gluteus muscles - and stimulates these muscles in a sequence that creates a cycling motion.

Check out the link here at Spinal Research as he strives to raise £10,000 for Spinal Research

http://www.spinal-research.org/get-involved/events/dan-eleys-ride-for-research-2012/

RehaStim 2 unit enhances RehaMove FES Bike

I know I'm biased but the RehaMove FES Bike is the best value solution out there.  I have complained to the manufacturers about the looks (a bit retro 70's) but the performance has been as good as any other system.

Anyway, we at Anatomical Concepts are looking forward to the new RehaStim 2 unit which we hope to be able to supply from this month.  Colour graphics, improved useability through a large display and real-time performance monitoring are really nice further improvements to the benefits of RehaStim 1.  The tried and trusted Rehastim 1 will continue to be available.

With the RehaStim 2 - Via a rotary knob, the existing eight stimulation channels are assigned and defined with corresponding parameters. On the large color display the user can navigate easily.

Color-coded channels for each muscle make it even easier and faster to applicate the electrodes. In the extended memory, over 100 patients combined with their training settings can be stored and the respective course of therapy can be saved.

FDA Clearance has ben gained for the USA market

Electrotherapy with "mixed" paraplegia

We have recently had a couple of spinal cord injured clients with a "mixed" paraplegia.  I'll explain what this means in a second.  Let me explain a bit about one case in particular.  He has supposedly a T11/12 complete lesion following a spinal cord injury that he sustained in Nov 2008.

He is using an FES bike (RTI 300) which illicits good contractions in hamstrings and gluteals but he gets absolutely nothing from his quadriceps muscles.  It's really debatable whether he can benefit from a FES bike; probably I wouldn't have offered him our RehaMove FES bike system. 

We did use the Stimulette den2x (specifically designed for denervated muscles) to see if we could obtain a contraction from his quadriceps muscles.

I was able to get good twitch response from his quads using the den2x with some "spill over" into hamstrings and even gastrocnemius with less than 100 mA.  However, trying to illicit a tetanic contraction was less successful as the spill over (using large carbon electrodes/sponge bags) was quite large at even moderate levels of current.

Let's go back to the idea of "mixed paraplegia"

This means, that below the level of his injury there is some intact spinal cord left.  But - as his injury is located in an area in which the spinal nerves = 2nd motoneurons run parallel to the spinal cord for some centimetres - we also find lesions of the 2nd motoneurons of some segments. And because of anatomical reasons this results in denervation of quadriceps and the muscles of the front side of the lower leg and to a spastic paresis of the hamstrings and the calf.  This is a very challenging situation we find sometimes in patients with conus-cauda-lesions.

What we will attempt to do in that situation is stimulate the denervated muscles with the usual den2x programs and accept that there may be a co-contraction of the other muscles. The only thing is, that you have to take care, that the intensity of the stimulation is not too strong for the spastic muscles – their tendons also have to get used to the pulling of their (much stronger than the denervated) muscles!

Very often, after some time the denervated quadriceps gets strong enough for leg extension, but not always – sometimes the strength of the hamstrings stays higher than that of the quads and no leg extension becomes possible.

The “spill over” to the calf is the effect of the intact nerve of the spastic muscles, which “transports” the impulse to its muscles.

As the clients’ legs are very slim, we could try to use smaller electrodes, which should cover the whole quadriceps, but should not reach the dorsal half of the thighs. Sometimes we try to turn them through 90°, so that they lie on the leg longitudinally.

Exploring electrotherapy of denervated muscle

We recently had a vist from Dr Modlin from Vienna who was able to share her experience of using electrotherapy to restore denervated muscle.  She has some 15 years experience in this area which is probably pretty unique world wide.   We have now had a few months working with clients with the Stimulette den2x product, which can be used to restore muscle quality and bulk in denervated muscle. We wanted to short circuit the learning curve a bit and get to learn from a rare expert. 

One of the things that we learned pretty quickly is that the protocols described in the clinical papers are not exactly in line with those used in Dr Modlin's daily practice.  It's not that these are wrong - its just that useful nuggets of information are left out.  Sometimes these subtleties can make a big difference to results.

Lesions that cause denervation are those due to injury to the so called lower motor neuron. This might be due to a peripheral nerve lesion, brachial plexus injury or spinal cord injury at typically T12 or below. Such injuries cause rapid nerve degeneration followed by a cascade of other effects to the detriment of muscle tissue.

With spinal cord injuries, those with so called upper motor neuron lesions can, for example, use "conventional" FES systems.  In these cases, relatively small amounts of electrical energy can be used to trigger stimulation of a leg muscle via the intact nerve structures. 

Those with lower motor neuron damage find that such conventional FES techniques don't work.  The new Stimulette den2x actually aims to directly stimulate the muscle.  The levels and patterns of energy required are significantly different from those normally thought of with FES and protocols, electrodes and approches to use are all very different.

For many years, clinical and research work in Austria has focused on whether electrotherapy can be used to restore denervated muscle.  This idea has been controversial over the years but recent studies have been very positive - for example the RISE multicentre European trial was very successful in rescuing even long-term denervated muscles.  This is quite an important finding if it can promote improved tissue quality and circulation, as well as lower the risk of pressure sores.  Even when there is little or no expectation of reinnervation, preservation of muscle mass and improvement of the trophic situation is very important.

The RISE trial featured home-based training, 6 days per week and care needed to be taken during stimulation due to the energy levels used. 

Ideally with our clients we will work with quadriceps, hamstrings, gluteals and perhaps tibialis anterior and gastrocnemius/soleus, although the emphasis may change with the needs of the individual.

There are two dominant stimulation modes that we might use.  We are pretty much always using biphasic rectangular impulses. The pulse shape may on rare occasions be changed if a client has some sensation and it has been difficult to manage comfort levels.

If possible we want to stimulate a muscle group for approx 30 minutes per day - this is achieved gradually. For the first 3-4 weeks increasing the intensity and duration gradually is in order. The level of stimulation current is also carefully limited.

Stimulation is setup in programmes in the den2x so that the client can access them with a button press. Programmes are set for tetanic and twitch muscle contraction and both would typically be part of a programme.

If tetanic (smooth strong) contaction can be achieved this would be the primary focus of training with stimulation parameters something like this

40 ms impulse duration
20 ms impulse pause
3 secs surge duration (burst of pulses is on)
2 secs surge interval (burst of pulses is off)

With many clients, tetanic contraction is not easily achieved at the beginning and the stimulation is based on seeking "twitch" activation of the muscles.

120 ms impulse duration
400 ms impulse pause
5secs surge duration
2 secs surge interval

Once tetanic contraction is achievable, the aim is to develop muscle hypertrophy by working against a load.

This clearly requires a commitment from the client to work consitently with the programme and this has been one of my primary concerns about the techique. Would clients really be motivated to use the system especially if it took quite a while to see the benefits. So far early signs have been good.

According to research, there is a "window of opportunity" in using this technique.  Starting to use electrotherapy early is likely to preserve muscle tissue - a much better prospect than restoration in long standing denervated clients.

My feeling is that this technique has real value for certain clients with denervated muscles.  What would be ideal is if these persons could start to use electrotherapy early in their rehabilitation - in our case in the UK, whilst they are in the spinal units and then continue to use the system when they go hom

 

 

Arm rehabilitation post-stroke - Separating fact and fiction

Improving arm function post-stroke - Hemiparesis is by far the most common limiting symptom resulting from a stroke, affecting 80 percent of stroke survivors.  Unfortunately, many persons recovering from a stroke find that the health service doesn't really focus on helping them recover arm function.  When I first studied in this area (admittedly a while ago now) it used to be thought that it wasn't possible to recover much function anyway.  Now we know that functional recovery can take place given the right degree of support and the right tools.  Such a tool is the Tailwind product from Encore Path Inc.

We have been working with the Tailwind product in the UK for a couple of years now.  I was quite excited when I learned about it and keen that we should work with it - even if it meant working sometimes against the skeptics.  The Tailwind product was created by Kris Appel in the USA, based on research at the University of Maryland which focused on the concept of a Bilateral Arm Trainer with Rhythmic Auditory Cueing (BATRAC) device.

The investigators carried out controlled scientific studies that showed how their method significantly improved function in stroke patients suffering from the loss of function in one side of the body.  The BATRAC method is specifically aimed at the loss of function in one arm, and tackles the problem by literally retraining the brain. The BATRAC device requires the patient to use both arms to carry out the motion of reaching forward for an object and bringing it in toward the body. The movement is "cued" by a rhythmic auditory signal that apparently entrains the motor cortex of the brain.

In a study published in 2000, the developers of the BATRAC method reported significant improvement in the use of the affected arm with as little as one hour of training per week for six weeks.

This initial study showed improvement from 12 percent to 26 percent on two different motor improvement scales.  The study subjects were also asked to assess their ability for daily use of the affected arm in everyday tasks, and this self-assessment revealed an even higher rate of improvement, up to 43 percent after training.

The BATRAC investigators conducted further studies that compared BATRAC results to a more commonly used method of physical therapy — a technique referred to as dose-matched therapeutic exercises, or DMTE.

In a report published in the Journal of the American Medical Association, functional magnetic resonance imaging scans were gathered from subjects in a study that compared BATRAC and traditional training techniques.  Blood oxygenation-level dependent scans were made of the entire brain as the subjects moved the unaffected arm first, and then the paralyzed one.  The scans were taken before and after training with the two methods.

The investigators noted significant changes in brain activity in most members of the BATRAC group after training, but no changes in brain activity for the DMTE group. In addition, those members of the BATRAC group whose brains showed evidence for rewiring had improved function, while the control group showed significantly less improvement.

It's quite interesting that in the USA few therapists question the validity of the technique whilst we still have many in the UK who are skeptical.  We belive that Tailwind has shown itself to be an effective tool for stroke rehabilitation - what we need now in the UK is the correct, timely input from therapists

The Truth of the Quiet Box

A few weeks ago a friend was fund raising for charity by paticipating in the Iron Man Wales event.  My wife and I went to see him off - from a safe distance.  It's quite a challenge starting with a 3.8 km swim, followed by a 180k bike ride and finished off with a 42.1 km run. Not exactly something to take casually. 

Andy had just finished the bike section and was starting the run when he heard the PA system announce ".. And here comes the oldest competitor!" 

Just for a second Andy thought the announcer was referring to him but then as he looked back he saw right behind him was indeed the oldest competitor - a 75 year old man. 

I think most of us would think that a 75 year old doing Iron Man Wales was beyond belief.  After all we have evidence all around us that suggests such a feat would be impossible.

Isn't that the trouble with beliefs. We all hold them - and yet they have an often silent and unconscious grip on our lives.  My one time mentor, Michael Breen used to say something like, "If you are going to have beliefs - make sure you choose useful ones".  Sadly most of us don't.  We don't even know how strongly our lives are shaped by the beliefs we hold.  Our beliefs can be like stealthy parasites that steal our lives and infect those around us.

Working in rehabilitation I am very interested in my client's beliefs about what they can achieve in their lives as they recover from their injuries.  I meet many spinal cord injured people who would like to believe that they might walk again some day.  The challenge is that all around these people are others that want them to stay "realistic" - to accept that they will never walk again.  So often well meaning observers manage to "kill hope" rather than nurture realism.  Certainly this world requires that we take action in the moment; we can't neglect that.  However, the purpose with which we act shapes the way our world becomes.  Without mankind stretching what is possible and believable we would still be living in caves.

Here is a nice story from Kensho Furuya (Kodo - Ancient Ways)

The Master said, "Think about this.  I have here two small wooden boxes of the same size."  Holding up the boxes one at a time he told his students, "Listen. When I knock on this one, a loud sound resonates around the room.  When I knock on this other one, there is hardly any sound at all."

"Now tell me, from our experience of such things, what do we already know about the loud-sounding box?" asked the Master.  The students understood that the box was empty.

"And what do you make of the quiet box?" asked the Master again.  The students recognised that this box was full of something.

So the Master posed a question.  "Tell me, with human enterprise in mind, do we use the lessons of the wooden boxes?"

A student answered at once, "We certainly do not, Master.  We only take notice of who makes the loudest noise.  We don't pay attention to the quiet one."

A second student spoke up.  "I can see what you are suggesting but in our democracy the majority rules.  What the majority believes is desireable is supported and will grow in influence as a result."

"I agree," replied the Master.  "But keep in mind that the value of an idea or of a belief is is not determined by how many people believe it or choose to follow it."

In times gone by the majority may have believed that the world were flat or that the sun moved around the Earth.  The majority idea it didn't make it a fact.

There may be a deeper truth that is separate from the ideas of majority and minority.  If this truth exists it will lie within each of us awaiting cultivation.

Using Tailwind when the User has Limited Arm Movement post-Stroke

Tailwind is an arm rehabilitation training device that stroke survivors can use at home to recover gross arm function.  I've wrote about this product before as we have been enthusiastic about working with it in the UK.  Despite the product having an excellent evidence base, we still do come across clinicians who are skeptical.  All too often, rather than study the evidence, clinicians speak from their past experience and manage to kill the hope and belief of patients before they even get started.

Tailwind is not a silver bullet of course. It needs to be set up and used correctly and with consistency.  In the USA where the device is manufactured, their experience is that every single user can report positive gains after using Tailind for two weeks. This  is entirely consistent – in two weeks, users will see changes—such as being able to lift the arm overhead which they never did before, putting a coat on, being able to swing the arm at the side naturally while walking.

It's important to get off to a good start using Tailwind and for many users this means dealing with a weak wrist that can prevent many users initially from using Tailwind effectively.

Here are some some guidelines for this situation

1. Hand/wrist support. Most of these users will require at least the hand strap in order to hold onto the handle, and some may also require a soft splint in order to keep their wrists from buckling. A soft wrist splint is suggested, and the user should be reminded not to become dependent on it. It should only be used for a short time.  Avoid moderate and firm wrist supports. Use the soft to mild support to make the wrist align with forward movement, but not to weaken overall wrist muscles.

2. Elbow support. It may be necessary for the therapist or caregiver to gently guide the elbow of the user for the first few weeks of exercise, until the user can do the movement on their own. Gently supporting the wrist by placing the caregiver’s hand under the wrist may also be necessary, at first.

3. Length of movement along the track. Some individuals may only be able to move the handle ½“ to 1" along the track. Do not be discouraged by this – the goal is to learn the exercise and practice it repeatedly.  Start low and go slow.  It may be best to start off with this small movement only, with just the affected arm.  After the user is comfortable with this movement, then the other arm may be added, then the metronome.  Trying to do the complete movement in the beginning may be very challenging for some users – just focus on the affected arm, then add the other arm, and build up to using the metronome. Proper posture and movement is important.

4. Other suggestions
• Make sure the user’s chair is high enough so that the arms and wrists clear the pod
• Make sure the user is not too high which can cause downward weight on tracks
• Have users do mild arm stretching for a few minutes prior to using the device
• Have the user change their grip from the top of the T-bar to the side of the handles. This will
allow a lower grip to extend arms outward

After a few sessions, the user should be able to move farther along the track, and eventually do the
exercise without the wrist support. Users with even a small amount of movement can be helped by the Tailwind.

 

 

Visit to Pace Rehab - An Excellent UK Prosthetic Rehab Centre

Too often I see that we do not give rehabilitation the attention it deserves in the UK.  Most of us have no idea of what such services could or should do for us until we have a personal need.  Even then, when we have the need we do not truly know what is possible.  We trust our clinicians to guide us but what are the beliefs that underly that guidance?  As we recover from amputation, stroke or other condition we are likely to have many years of life ahead of us; we would all prefer these years to deliver a decent quality of life but too often that's not the case. 

The fact is that NHS can't live up to our expectations for rehabilitation - the resources are not there - and increasingly clients who are able will find alternative ways of not only meeting their needs but exceeding their expectations.

Im just back from spending the day with PACE Rehabilitation in Cheadle near Manchester.  Their ethos in delivering prosthetic rehabilitation is about providing benefits to clients rather than just meeting their needs.  There is a vast difference between simply meeting peoples needs and equiping them for a full and happy life.  They work with clients to understand their hopes and dreams and work with them mentally, physically and technically to bring about great results.

PACE was started by an old friend and prosthetist Toby Carlsson along with Consultant in Rehabilitation Medicine, Earnest Van Ross.  They are very passionate about what they do and it shows.  Toby describes the work they do as "a priviledge".

At yesterday's referrers meeting we saw demonstrations and presentations to showcase the work done by PACE.  In addition to hearing from Toby and Earnest, we had presentations from Sue Turner on the counselling and the "buddy scheme" aspects of their work.  Howard Wolley demonstrated prosthetic cast taking and limb alignment whilst physiotherapist Carolyn Hirons involved us all in demonstrations of physiotherapy techniques for gait and improved function.

Colin Lynch, Paracycling World Champion, gave a very interesting presenation and demonstration that described how PACE had worked with him to imporve his cycling prosthesis. Taking him from top 10 to number one in the world.  Alan Roberts, a bilateral amputee following military trauma shared his rehab experiences with us to complete the day.

I have no vested interest in PACE - and I highly recommend them.