Rehabilitation Matters

Andy's New Venture - Prime Physio

For the last few years many of our clients for our RehaMove FES Cycling system have got to know Andy Galbraith (on the right in the picture shown working with an Ekso Bionics system).  He has provided assessments and home support for many of our clients in most parts of England whilst also working hard a few days a week at Standing Start (UK's well known unit offering active rehabilitation for spinal cord injury).

Andy has just branched out on his own and formed Prime Physio, a specialist sports injury and specialist therapy centre near his home in Melbourne, Cambridgeshire.  As many of you know, Andy has contributed a great deal to the development of Standing Start in the UK, but as expansion was on the cards the time was right for Andy to strike out on his own.

At first glance Prime Physio looks like one of many other therapy offerings.  However, he does have some interesting activities to offer that are not generally found elsewhere.

Not least is the Ekso Fit programme. 

As one of the few therapists trained to work with the Ekso Bionics Exoskeleton, Andy is offering a specialised therapy programme for people wishing to get the most out of using an Ekso "skeleton".

The gains made on this programme are transferable for day to day activities.  Many early adopters of the Ekso system are finding that some developed core strength is a real asset and many of the techniques used at Standing Start and Prime Physio (intense exercise based therapy) are invaluable for getting "fit to stand."

Of course Andy will also have available our FES fitness products the RehaMove FES Cycling system and Den2x for denervated muscle electrotherapy.  Having worked with countless cases now Andy has a lot of experience to offer. 

Of course he will have our support and best wishes in developing his business.  Anyone who has met Andy couldn't fail to be impressed with his knowledge and professional attitude. 

Im pleased that he will still continue to support Anatomical Concept (UK)'s clients and I think that his presence will do much to expand the opportunities for all the rehabilitation providers in this important area.

Im sure that Standing Start will miss him - but there is lots of room for growth for everyone and lots of work still to do. Prime Physio can be contacted at

Prime Physio Ltd, 5 Beech House, Melbourn Science Park, Cambridge Road, Melbourn SG8 6EE

T: +44(0)1763 264135 and email info@primephysio.co.uk

 

Ekso Bionics Launch Event in Leeds

I was pleased to be invited to Ekso Bionics's launch today in Leeds.

Ekso Bionics are teaming up with Technology in Motion to provide potential users in the area the chance to be assessed and then hopefully to walk in the exoskeletal system under supervision.

Luckily the day was kind because the numbers attending meant the active demo needed to be outside in the car park.

I think there was an element of risk in this as the terrain was maybe not perfect for demonstration purposes. 

At this stage the Ekso system is intended for rehabilitation use and the "pilots" showcasing the device today were in fairly early stages of walking in the system.

Physiotherapists Barry (Ekso) and Andy Galbraith (Prime Physio and Anatomical Concepts(UK)) were in charge of ensuring a safe experience for the users.  Used in "training mode" stepping motion was controlled by the therapists.

Everyone realises that there is a lot to learn about the absolute clinical benefits of these systems. Yet we already realise how great an experience these systems provide for their users.  With investment these devices may yet become a realistic proposition for many persons. Its an exciting prospect.

We at Anatomical Concepts are glad to be working with Prime Physio who will be offering Ekso assessments and walking trials near Cambridge. 

Andy Galbraith has worked with many of our spinal cord injured clients in recent years and supported their use of our RehaMove FES Cycling system from Hasomed, GmbH. Although Andy has now branched out from Standing Start to go his own way, he is rapidly developing his reputation as one of the leading lights in fitness development following spinal cord injury.

We are pleased that Andy will make use of the RehaMove system within his facility to work with clients - developing their fitness and expanding their potential to enjoy the Ekso experience. 

 

Client Dan Eley Rides for Research

Our RehaMove client, Dan Eley has reached the half way point on his virtual Ride for Research.

I wrote about Dan before in this article and this one.

Dan, who is paralysed from elbow level down, has been cycling for 2 months now using a RehaMove functional electrical stimulation (FES) bike and hand cycle.  He has now covered a staggering 275 miles.  As this is a virtual challenge, we have been plotting his progress on a map and he has now cycled the equivalent distance from Guildford to the city of York.

Dan must now cover another 275 miles to reach his final destination, The Queen Elizabeth Spinal Centre in Glasgow.

Find out here how taking part in this challenge is helping Dan as well as Spinal Research.

 

Mark Pollock stands up with Ekso

I wrote about client Mark Pollock in an earlier article.  An adventure athlete, entrepreneur and author, Mark has competed against professional explorers like Sir Ranulph Fiennes, Olympic gold medalists and special forces personnel.  And he's done so in a world of total darkness.  For the last decade, Mark Pollock has been blind.  After his last expedition to be the first blind man to walk to the South Pole he fell from a window and became spinal cord injured.

I first met Mark in Stoke Mandeville and was pleased to work with him using FES to strengthen leg muscles - first with our RehaStim unit and eventually with a full RehaMove FES cycling system.

Mark is an inspirational guy who has impressed many people with his determination to push back the barriers of what we currently believe is possible.

On Mark's blog he recently posted a video of his adventures with the Ekso Bionics exoskeleton system.

The Ekso Bionics system is evolving rapidly from an original development project in Berkeley California aimed at "soldier enhancement".  This ground breaking technology is finding application in the world of rehabilitation and one day soon may become a practical choice for many persons with a physical disability.

Knowing personally some of the people working with Ekso Bionics, I have no doubt that this system will be the one to emerge as the acknowledged leader. 

Of course the technology is only part of what will make this a success - this development and its introduction must be made with a sensitivity to the expectations of potential users. 

Those of us who have worked in this field for decades can point to times when expectations were unfortunately far ahead of what could be achieved in practice.

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

 

 

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.

Young Transverse Myelitis Client Responds Well to FES Cycling

These notes refer to very pleasing progress with an FES Cycling Client - a 4 year old little boy with a neurological condition affecting motor function in his lower limbs.  It has a similar aetiology as transverse myelitis (TM). TM is a rare disease of the central nervous system involving inflammation of the spinal cord. This inflammation causes swelling which can block the nerve impulses that travel along the spinal cord.  It can also cause damage to the myelin sheath surrounding the axons in the spinal cord.

With this client not all muscle groups are affected and the weakest measles are his glutes and hamstrings.  He is able to mobilise independently holding onto furniture or walls for support. He has some spasms in his quads but are not problematic, sensory function is preserved.  The Client was supplied a RehaMove FES Cycling system, based on the Gracile model which is appropriately sized for children. The text here was originally produced by Andy Galbraith and edited by me.

Initial Setup visit
Starting Parameters: for RehaMove Gracile (Paediatric version of the RehaMove FES Cycling System)

• Motomed bike set to “direct” from “motivation”
• Initial gear start-up set to 1
• Passive cycling speed - default set at 20rpm
• Torque power set to 10

Stimulation Parameters:
All programmes set at 5mins warm up - 20mins stimulation - 5mins cool down
As client has preserved sensory function we set the stimulation to constant.

Programme 1 Ramp 5 Freq 20Hz Pulse width 150us (increased to 160us)
Involving quads and hamstrings of both legs
Ch1 - 35mA, Ch2 - 35mA, Ch5 - 35mA, Ch6 - 35mA

Programme 2 Ramp 5 Freq 20Hz Pulse width 150us (decreased to 130us)
Involving quads, hamstrings and gluteal muscles of both legs
Ch1 - 35mA, Ch2 - 35mA, Ch3 - 30mA, Ch5 - 35mA, Ch6 - 35mA, Ch7 - 30mA

Programme 3 Ramp 5 Freq 20Hz Pulse width 150us (decreased to 130us)
Involving quads, hamstrings, pretibial muscles and gastrocs of both legs
Ch1 - 35mA, Ch2 - 35mA, Ch3 - 25mA, Ch4 - 25mA, Ch5 - 35mA, Ch6 - 35mA, Ch7 - 20mA, Ch8 - 20mA

On muscle testing: all muscles reacted to stimulation, strongest contractions being felt in the quads, Client gave very good feedback for his age on the testing and we were also able to see contractions in the glutes, pre tibial and calf muscles, we reduced the current levels in response to his feedback being careful not to associate any discomfort with the stimulation.

Of course client attention span was limited, a diversionary video was playing which helped. When the client was paying attention and trying he was actively cycling well, this was limited to short bursts of approx. 15 to 20 seconds before "finding nemo" would be more important.

We belived that client will respond really well to the stimulation providing it is kept at low levels given his preserved sensation.  Reviewing in 6 weeks time, quick start with web support and fitness principles literature was left with mother.

Notes at FES Cycling 6 week follow up
Clients mother advised that Client has been using the FES Gracile system fairly regularly.  Apart from a family holiday for two weeks in August they have used the system for 20mins every other day, mostly on programmes 2 and 3. Client enjoys the sessions (providing he can watch TV) and remains motivated to use it.  It is believed the client has full sensation in his lower limbs and he has said the stimulation has been too painful from time to time, Mother has been reducing the Pulse width (down to 130us) to accommodate this, but this is not every time. At present the client does not tolerate any other physio intervention.

Checked Starting Parameters:

• Initial gear start-up 1
• Passive cycling speed - default at 20rpm
• Torque power at 10

Stimulation Parameters: at 6 weeks
All programmes set at 5mins warm up - 20mins stimulation - 5mins cool down, Mother feels 20mins is probably the maximum length of time the Client will tolerate the sessions at present.

As the Client has preserved sensory function we set the stimulation to constant and discussed with Mother the possibility of changing to adaptive stimulation protocols at a later stage. We have reduced the Frequency by 5Hz and planned to slightly increase the current and pulse widths to make the stimulation more tolerable.  The majority of the session was teaching Mother how to make the changes to the stimulator and reviewed position advice.

Programme 1 Ramp 5 Freq 15Hz Pulse width 150us
Ch1 - 35mA, Ch2 - 35mA, Ch5 - 35mA, Ch6 - 35mA

Programme 2 Ramp 5 Freq 15Hz Pulse width 150us
Ch1 - 35mA, Ch2 - 35mA, Ch3 - 30mA, Ch5 - 35mA, Ch6 - 35mA, Ch7 - 30mA

Programme 3 Ramp 5 Freq 15Hz Pulse width 150us
Ch1 - 35mA, Ch2 - 35mA, Ch3 - 25mA, Ch4 - 25mA, Ch5 - 35mA, Ch6 - 35mA, Ch7 - 20mA, Ch8 - 20mA

Good seating position was easily achieved with the use of a small wooden chair this time with a small cushion supporting Clients hips and lower back.  Much improved from the video clip viewed last week. As they had recently had a 2 week break from the set up procedure I think it was just down to them being a bit rusty and a bit of coaching was required with positioning.

Client's quadriceps muscle are his strongest muscles, he also has strong gastrocnemius muscles that spasm when he is excited or generally rushing (quite a lot of the time for a (now) 5year old) causing him to walk on his toes.  At present the client prefers to do this as he feels taller when he is doing it and should be able to modify this as he gets older which will have a positive impact on his gait . Mother informs me he can walk with his heels down when he is less excited. I did not see this when I was there but did note planter grade being achieved when using the bike.

Have constructed the following programme to accommodate Glutes, Hamstings pretibial and gastroc muscles.

Programme 4 Ramp 5 Freq 15Hz Pulse width 150us

Ch1 - 30mA Right Gluteus Maximus Start Angle 120 Stop Angle 210
Ch2 - 35mA Right Hamstring Start Angle 220 Stop Angle 360
Ch3 - 25mA Right Tibialis Anterior Start Angle 330 Stop Angle 90
Ch4 - 25mA Right Gastrocnemius Start Angle 180 Stop Angle 280
Ch5 - 30mA Left Gluteus Maximus Start Angle 300 Stop Angle 30
Ch6 - 40mA Left Hamstring Start Angle 40 Stop Angle 180
Ch7 - 25mA Left Tibialis Anterior Start Angle 150 Stop Angle 270
Ch8 - 25mA Left Gastrocnemius Start Angle 0 Stop Angle 100

On muscle testing: all muscles reacted to stimulation Client gave very good feedback again and we were also able to see good contractions in the glutes and hamstrings with slightly reduced, softer contractions in the pre tibial and calf muscles.  Client was able to actively cycle and with the reduced frequency level did not report any discomfort.  Mother is now happy to change current and pulsewidth and will adjust over the coming weeks to get the optimum levels for the Client.

I have discussed with Mother the importance of not neglecting the quads and to monitor their strength in relation to his other muscles.  Client can actively cycle (20reps) in gear 1 using predominantly quads, Mother is constantly working on his exercise tolerance with this activity.

Since he has started using the Gracile and stimulator Client can now independently cycle his regular push bike with stabilisers to the park (approx. 400m) and back. He used to get very frustrated at not being able push over the top of the pedals. He proudly showed me his cycling today with no assistance, Mother did not think she would ever hear herself shout “that’s enough - not too far ahead” it was very impressive. Mother feels the Client has made great progress in a short period of time.

Sequence mode was successfully loaded onto the stimulator, demonstrated with Mother and explained set up. Not sure if the Client will tolerated the sequence mode at present as he needs the distraction of the bike or TV or even both when stimulation is on. I do feel Clients’s Gluteus medius will benefit most from sequence mode and have discussed this with Mother today.

Mother's Update at 10 Weeks
Client is continuing to make good progress with FES cycling. When we started, he could barely pedal it at all without the motor assistance.  The last 3 sessions, he has managed 8 minutes without the motor.  Speed  continues to be his aim so he is managing to get further each time. He was managing 0.7km last week in his 8 mins without the motor but over the weekend, it was 1.5 km without the motor in the same time period.  And I am quietly increasing the resistance levels too. We are up to level 6.

His legs are slowly starting to plump up, particularly at the tops. And his standing balance is much improved from 8 weeks ago. Walking is still poor but it's early days.
 All in all, a big success so far from our point of view. So thanks to you and Andy for your assistance.