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

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.

 

 

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

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

Buddist Biker Beats Cognitive Decline

The Dalai Lama, watched a brain operation during a visit to an American medical school in the early 1990s and asked the surgeons a startling question: Can the mind give shape to brain matter?

When you think about it, why is it that older people drive so slowly in the outside lane of the motorway?  You can picture how it is – cloth cap, sitting close to the wheel, a white-knuckle grip and oblivious to what is happening around them.  

Wouldn’t you think that being older they would be in more of a hurry to get somewhere – less time to live and all that?  Now whenever I have offended someone with ranting about this they usually say,  “This decline you see - Its natural – its about cognitive decline – reflexes, balance, eyes etc getting poor with age.” 

I have for a long time wondered how much ageing is a natural event and how much of it is based on a belief – albeit a deeply held unconsicous one -  that we have been conditioned to turn into reality.  It seems that science is starting to agree with me.

A few years I was presenting at a conference on the topic of "orthotic management of stroke". The presentation had a few controversial elements to it.  Leaving aside the orthotic element, I mentioned the emerging science of neuroplasticity and how potentially this could be an area to watch in terms of stroke rehab.   Whatever happens, this topic will be a “Hot” one in years to come. 

My thought was – would it be possible to increase the plasticity of our cognitive processes with some form of exercise to allow much faster recovery in the event of a stroke? Or would it be possible to create some form of after-the-event exercise that would enhance stroke recovery?

 Until recently my master plan for prevention of cognitive decline was to give everyone over 50 a high powered motorcycle.  There are some other techniques being developed that might be more palatable for the majority.

 In response to the Dalai Lama's question,  neuroscientists had explained to him that since the 1980's we know that mental experiences reflect chemical and electrical changes in the brain. When electrical impulses zip through our visual cortex, for instance, we see; when neurochemicals course through the limbic system we feel.

But something had always bothered him about this explanation.

The Dalai Lama asked “Could it work the other way around?”

That is, in addition to the brain giving rise to thoughts and hopes and beliefs and emotions that add up to this thing we call the mind, maybe the mind also acts back on the brain to cause physical changes in the very matter that created it.  If so, then pure thought would change the brain's activity, its circuits or even its structure.

 One brain surgeon hardly paused. Physical states give rise to mental states, he asserted; "downward" causation from the mental to the physical is not possible.  Despite this slap down ten years ago, the Dalai Lama had put his finger on an emerging revolution in brain research.

Neuroscientists have since overthrown the dogma that the adult brain can't change.

We now know, its structure and activity can morph in response to experience, an ability called neuroplasticity.  The discovery has led to promising new treatments for children with dyslexia and for stroke patients, among others.

But the brain changes that were discovered in the first rounds of the neuroplasticity revolution reflected input from the outside world. For instance, certain synthesized speech can alter the auditory cortex of dyslexic kids in a way that lets their brains hear previously garbled syllables; intensely practiced movements can alter the motor cortex of stroke patients and allow them to move once paralyzed arms or legs.

The kind of change the Dalai Lama asked about was different. It would come from inside.

Something as intangible and insubstantial as a thought would actually rewire the brain. To the mandarins of neuroscience, the very idea seemed as likely as the wings of a butterfly leaving a dent on an armored tank.

What I know for sure - and science is reinforcing - Is that visualisation of tasks helps an athlete reach higher levels of performance.  So why should it be a surprise that stroke survivors who can visualise correct movement of their arms using Tailwind will make faster progress.  Our spinal cord injured clients should visualise their legs pedalling their FES bike if they want to make faster progress. Thoughts are things.

 

The ELLIOTT™ orthosis - Early Lower Limb Intervention Orthosis for Therapeutic Treatment

Early intervention with an orthosis to assist standing and then start early walking training is a good thing for many patients recovering from a stroke.  The primary goals of early orthotic intervention are to prevent or minimize impairments and maximize functional recovery.

For a number of years we have advocated the use of an "evaluation orthosis" with such neurologically involved patients.  This is valuable when it is too soon for a therapist to know whether a custom-fit orthosis is required.   However to be valuable as an evaluation tool, such an orthosis needs to have many of the merits of a custom fit device but with the ability to be adjusted easily even when coming "off the shelf".

It is important to avoid poor, ill fitting, solutions that give the therapist no control.

In contrast, proper timing and use of an orthosis can facilitate gait training, increase overall safety, offset contractures, improve sensory feedback.

Our USA based partners at Anatomical Concepts Inc have designed a new product that we will shortly bring to the UK market.  We will post details on anatomicalconcepts.com shortly

ELLIOTT™ (Early Lower Limb Intervention Orthosis for Therapeutic Treatment) is a prefabricated lower limb orthotic system that has been designed specifically for application in the acute, sub-acute and home health rehabilitation environments for management of the neurologically involved patient. 

This unique lower limb system consists of bilateral Knee Ankle Foot Orthoses (KAFO’s) referred to as ELLIOTT™ and ELLIOTT II™.

ELLIOTT™ consists of a KAFO (Knee Ankle Foot Orthosis) with three separate AFO (Ankle Foot Orthosis) variations that can be used either as part of a KAFO system or individually as AFO’s.

ELLIOTT II™ consists of a KAFO with three AFO’s that are part of the KAFO. The AFO segment can be quickly separated from the Knee Orthosis (KO) segment enabling the rehabilitation team member to use the KO independent of the AFO.

Utilizing either ELLIOTT™ product in the rehabilitation setting rectifies these concerns through the unique multipurpose design and multifunctional capabilities.

Having eight variations within the ELLIOTT™ system that are fully adjustable enables the rehabilitation team to intervene effectively and at the earliest point of the rehabilitation process.

ELLIOTT’s built in fully adjustable capabilities allows for accurate and effective joint positioning for gait and positioning augmentation to facilitate optimal outcomes. Single posterior upright minimizes bulk and impingement over bony prominences.   Secondary benefits consistent with early mobilization include; prevents DVT, skin breakdown, contracture formation, constipation and pneumonia.

Case Study - How RehaCom is used in practice.

This a case study focusing on RehaCom.  You probably haven't heard about RehaCom which is Europe's leading software for the professional therapist or neuropsychologist involved in dealing with cognitive impairments following an acquired brain injury (whether due to trauma, stroke or other condition).   Brain injury can have a devasting effect on the person - so essential is it to all aspects of life.  Even moderate injury can result in cognitive impairments such as lack of ability to concentrate, pay attention, remember and other aspect of daily life.

The software is very strong in Germany - the home of the manufacturer - Hasomed GmbH who have developed this software since the early 1990's.  This software has never been fashionable in the UK, but is finding favour now as it supports cost-effective therapy and lends itself to care in the community.

This article is more likely to be of interest to therapists who work in the area of cognitive rehabilitation and based on an interview made by Karen J Hewitt on our behalf.  As Anatomical Concepts now represents RehaCom in the UK we are interested in how we can learn from best practice elsewhere in the world.

Introduction
Frau Wartenberg is a (PTA) PT Assistentin, which is the German equivalent of a Doctor’s sister. She is an exception in terms of her training, in that she works as an Occupational Therapist (OT), but is qualified as a Psychologist.  Frau Wartenberg has been a PTA for 20 years at the NRZ Magdeburg (www.mediankliniken.de), Neurological Rehabilitation Centre. This rehabilitation centre is based at one of 22 Median state clinics (hospitals) all over Germany, and was founded by the late Professor Hans Regel. Frau Wartenberg, therefore, has known RehaCom for a very long time.

Clinic challenges
The main constraints and challenges within the NRZ Magdeburg Neurological Rehabilitation Centre are currently as follows:
1. Financial – The government budget available for cognitive rehabilitation insurance payouts is shrinking
2. Patient demand – the number of incidents of stroke and head injury are increasing all the time in Germany, indeed worldwide, and the clinic is required, therefore, to treat more patients than ever before.
3. Human resources – The therapist will always be essential to cognitive rehabilitation.  Currently there is a limit to the number of therapists allocated by the Government to the clinic.
4. Complexity – At the NRZ Magdeburg Neurological Rehabilitation Centre, the whole spectrum of brain injuries – from stroke to aneurism to head injuries and MS – is treated. Patients are also treated across the whole spectrum of cognitive disorder severity – from acute patients to levels B and C and also day patients. The therapist’s role is therefore varied, complex and demanding, including not just cognitive rehabilitation work, but also diagnostics and group work.

The implications
The implications of the above challenges at the NRZ Centre are as follows:-
1. Repeat visits - The financial constraints described above mean that patients often have to go back to work before they are ready.   Sometimes this leads to them becoming overstretched in their jobs and having to return to the clinic for a second phase of rehabilitation.

2. Time – The financial constraints described above mean that patients cannot stay as long at the clinic as the therapists would like to be able to do their job effectively, and the latter are under pressure to deliver the same results in a shorter space of time.

3. Stress – The combined challenges of increased patient demand, reduced time to carry out therapy, the growing complexity of the therapist’s role and a limit to the number of extra therapists that can be taken on at the clinic inevitably mean that the therapist’s role is increasingly stressful.

The solution
Therapists are greatly in need of tools in general which make their jobs easier and less
stressful.

Now, more than ever, Cognitive Rehabilitation Centres and their therapists need an effective cognitive rehabilitation tool in particular which saves them time, allowing them to treat a growing volume and complexity of patients in an ever decreasing time period. Importantly, though, effective cognitive rehabilitation (effective = improved cognitive functions that are translated into everyday life) can only happen through a trained and experienced therapist. This means that any solution to the challenges described above can only ever be an “Enabler” used alongside an experienced therapist i.e. a tool which enables the therapist to carry out effective cognitive rehabilitation as quickly and easily as possible.

RehaCom the Enabler
RehaCom is not the ANSWER to cognitive rehabilitation it is THE ENABLER.

A good therapist already has the knowledge of how to work alongside the patient to improve their cognitive functions and develop strategies to translate these improvements into everyday life. What RehaCom does is provide the materials and tools for these improvements and strategies, and this makes the therapist’s life much easier.  Frau Wartenberg has known this for some time, and has found RehaCom to be a great enabler since it was first adopted back in the early 1990s. Now, more than ever, and in the face of the current challenges, a good therapist is required to use RehaCom to its full potential and realise all the benefits it is capable of.  A word of caution RehaCom has a vast capability covering more than 20 different cognitive procedures and many different difficulty levels for each. As such, it requires an experienced therapist to fully understand and exploit its capabilities.  But RehaCom is so intuitive as to be deceptively simple.

Stroke for Stroke

The Stroke Association have an annual fundraising initiative called "Stroke for Stroke" (Great name), Supported by Siemens, in which we are invited to row for a good cause.  The organisers say

"It is a fantastic way to help kick start your new year’s resolutions about becoming fitter and healthier in 2011, as well as raising money for The Stroke Association.
 
All you have to do is to row 10km in a week and get sponsored to do so.  You can do this by yourself in your local gym, or why not ask for a free pass for you and your friends to do the challenge together? The week in question is January 24th – 31st.
 
Stroke for Stroke is now in its fourth year and has so far raised over £120,000 for The Stroke Association. Not only that, but is has enabled us to get a lot of coverage for our messages, helping people to learn more about strokes and prevent a stroke through living a healthier lifestyle.
 
If you would like to sign up for this event, more details can be found at www.strokeforstroke.co.uk , alternatively please don’t hesitate to contact Joe Phillips (joe.phillips@stroke.org.uk) or Laura Golland (laura.golland@stroke.org.uk )."

Making the Glass Half Full

Do you intend to live a long and healthy life?  I read a nice blog from Brad Feld on the subject of "My life may be half over but the glass is half full". I'll leave you to read it - it's quite short - but also quite interesting as it points to a couple of life "trajectories" that probably reflect the prevailing belief about the inevitable decline from middle age to death.

This first model is certainly conventional wisdom - but much easier to swallow when you happen to be less than 45 years of age.

For most of my life I have felt pretty fit through an interest in wrestling, karate and most personally challenging sports.   And you know, it's amazing how your perspective changes with age.  When I was 17 I remember being at the weights gym and being impressed by a "senior" - all of 35 years of age - being able to do situps with a 20kg plate behind his head.

 I have always been interested in the power of attitude and belief and how it shapes our lives - and it seems to me we need to be very careful of the beliefs we choose.   So often our beliefs about health, age and fitness are shaped by societal conditioning.  Many of us didn't consciously choose our beliefs anyway.  After all "they" know so much more than we do and these influences are incredibly powerful.

Brad acknowledges that looking at this first graph was enough to motivate him to get back to the gym 6 times per week.

 

However, I was a bit puzzled by his reflection that this model (at left) would be a better one to live by.

Yes OK - it is somewhat better in the sense that the trajectory to death is quite shallow at first. 

 

But what about as you get closer to 85?

Doesn't look too appealing to me.  Funny how problems in the apparent distance don't seem so bad compared with those up close and personal.

When healthy people adopt belief's that are so limiting (ie. realistic) it's no wonder it's so hard to develop positive beliefs in those undergoing medical rehabilitation.