Rehabilitation Matters

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

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.

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

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.

 

 

Help for Clients - and Helping Ourselves

We have set up a new support site for the business using Zendesk.  It seems quite simple to use so Im hoping that it will be a very useful tool for us on a few levels and become vital to customer support in the long term. 

As our business has grown - more products - more clients - more locations - its become really important to have a way of capturing some of the knowledge and problem solving expertise we have and put this in a central location.  It's also vital that we have a way of tracking and dealing effectively with any issues that clients have. 

Once upon a time my partners and I would be totally "hands-on" but after a few years of weekend and holiday "emergency" calls, the novelty of that approach starts to wear off.  And you know what, these days with Smart Phones we are never far away from that email or voice mail.  Just a week ago I was in the Cairngorm mountains on holiday-  and still trying to email a client and fix an issue.  I don't find it all that stressful but I cant say it's nice for family harmony.

There is another issue too.  One day we will wish to exit from the business and hopefully someone will want to carry on.  How much easier that will be if we have robust and useful support processes in place.

http://acuk.zendesk.com/home

New RehaCom version

RehaCom is Europe's leading software for cognitive rehabilitation.  It's pedigree is well established in the management of cognitive disorders following brain injury or stroke and it's used by therapists and neuropsychologists as well as clients training at home.  And now RehaCom Version 6.0 is ready.  Beside a new improved appearance it also offers several new functions.

BRAND NEW ARE:

• Functions: Shopping in a Do-it-Yourself-Shop, Divided Attention in 3D and many more,
• User interface & attractive design,
• additional and reworked languages,
• higher resolution and colour depth.

You can request a demo version via our contact page

The problems of a product focused manufacturer

All product manufacturers tend to love their products - and that's a good thing because if they dont... well who will.  But any of us that are client-facing and trying to offer products know that clients dont really "buy" a product.  They instead buy a "feeling".  The total service and support package, feelings of confidence with the supplier and many subtle things often make the difference. 

Disruptive forces mean that it is harder and harder to compete with product innovation alone.  Henry Chesbrough has talked in his books about the commodity trap that recognised:-

1. Manufacturing and business process knowledge and know-how is widely distributed - so its hard to differentiate your business on that basis
2. Manufacturing of products is moving to areas of the world with the lowest costs.
3. Shrinking product lifetimes - means its harder to get a return on investment based on maintaining a competitive advantage with any product.

It's imperative that manufacturers become much more client and service focused in their innovation stategies. Leveraging services innovation effectively is a challenging task that requires nothing less than a new approach to doing business.

In rehabilitation enginerring, service and support is absolutely critical.  A few years ago, the Clinical Director of a Spinal Injuries Unit said to me, "We rely on you guys so that WE don't have to get the phone calls from clients on a Sunday morning".  Thank goodness as technology for effective support is imporving I have to take fewer of these Sunday calls these days.  It's just holidays still.

Motor Neuron Lesions - Influence on FES following Spinal Cord Injury

One very popular and effective way for spinal cord injured persons to exercise their legs is through using Functional Electrical Stimulation (FES) - sometimes in combination with a FES bike (FES Cycle).  This taps into a knowledge of neurology to usefully activate paralysed muscle.

But not every individual can take advantage of this technology.  Let's see why.

In very basic terms, there are two groups of spinal cord injured persons.

One group has innervated and paralysed muscles (so called upper motor neuron lesions) and the Second group has denervated and paralysed muscles (so called lower motor neuron lesions).

There are formal explanations of  lower motor neuron and upper motor neuron lesions that you can read if you are interested.  Injuries around the lower thoracic level are likely to affect the lower motor neurons.

From the point of electrical stimulation and rehabilitation strategies these groups have to be treated differently.

FES, as we commonly see it, uses quite small levels of electrical energy applied to the surface of a leg muscle for example.  When a pulse of energy is applied in a "suitable" form to a person with an upper motor neuron lesion, the lower motor neuron is intact and the energy causes the intact nerve structure to "fire" propogate through the nerve structures and make the muscle contract. 

However, when the lower motor neuron is damaged, applying the same level of energy to a muscle seems to create no effect.  The nerve does not fire. In fact the nerve and muscle fibres may have regressed and the tissue quality deteriorated over time; especially when the injury is more than a couple of years old.

Whilst of course each person is unique to some extent, persons with upper motor neuron lesions can use a bike such as the RehaMove FES Cycle and in practical terms persons with denervated muscles cannot.

There is a caveat though.  I have clients who, during their time in early rehab, were classified as denervated and they didnt respond to stimulation.  However, they persisted using conventional FES and after a number of months had recovered enough to be able to use a full FES Cycle.  The problem with trying to draw conclusions from this is that we dont know whether this recovery was due to the bodies natural processes (and would have occured anyway) - or whether they were not completely denervated and the use of stimulation had strengthened the innervated component. (Hope this is clear!)

Anyway, we now have an innovative new product that uses direct muscle stimulation.  The Stimulette den2x is especially designed to rescue denervated muscles.  The stimulation parameters are quite different from those used with intact lower motor neurons.  Such stimulation has been a subject of interest for quite a considerable period and after many years of research - particularly in Austria - an effective technique has ben found. 

Clients with denervated muscles can now restore the tissue bulk and quality of thir limbs to reduce the risk of pressure sores, enhance circulation and ultimately develop improved fitness.

Biofeedback Methods to Assist Recovery After Spinal Cord Injury

I had a brief conversation with a client today on the topic of Biofeedback methods that could be used to assist in muscle functional recovery folowing a spinal cord injury.  Im going share some of my observations in this blog. 

In particular, I refer to the Brucker method and IMF (Intention Controlled Myofeedback) methods of so-called "operant conditioning". 

The basic idea has been around a long time and attributed to psychologist BF Skinner who experimented with the notion that

A behavior followed by a reinforcing stimulus results in an increased probability of that behavior occurring in the future.

His "Operant Conditioning" approach and its related methods has two elements -

The first is the detection of some useful event (the behaviour) - the second is to provide feedback to the observed entity with positive stimulus to reinforce the useful behaviour. 

 The classic studies were performed with Rats who were rewarded for succesfully pressing a lever. The stimulus used to reinforce the behaviour was the delivery of a tasty treat.  One of the issues that limits practicality is that the biofeedback tends to become less effective over time.  (In other words a hungry rat quickly learns to press the lever to get the treat but soon stops once the hunger is satisfied)

The field of Biofeedback developed and refined these ideas and applied them to a broad range of applications including a number in rehabilitation.

 So what's this got to do with spinal cord injury?

Well suppose that you have an "incomplete" spinal cord injury.  It may be the case that the muscles are partially denervated and yet a weakened inervated component remains.

Suppose it were possible to detect the faint traces of nerve activity deep in the muscle and then immediately provide a stimulus to the muscle to increase the likelyhood of that muscle activity becoming stronger?  Well that's the idea at work here.

EMG sensors "listen" for activity in the muscles of interest.  The client consciously imagines moving the legs or the muscles of interest and if an EMG signal is detected above a specific threshold, then muscle stimulation is provided through surface electrodes to make the muscles contract

These "therapies" are well known as complementary measures that have apprarently given support to many patients in the past.  They capitalise in natural recovery and training of any residual nerve function but may well recruit additional neural activity as well. 

They are relatively expensive and do not confer any additional benefit such as cardiovascular fitness as in FES Cycling or Rowing. The maximum benefit is within the first year but they certainly do no harm.  As always with these therapies and approaches - dont swallow claims whole - research carefully and balance hope with practical demonstrations of utility.

I tried the IMF method with one client who had denervated muscles in her thighs due to a low thoracic spinal cord injury.  The IMF method did not demonstrate to have any useful function for her.

You can also read this at the Institute of Spinal Cord Injury