By Ben Van Houten
And while many of these wonder machines do indeed grace the halls and gyms of the 110-bed facility, physical therapists here have recently opted for a far simpler and much more portable tool to help patients learn tasks: a tiny kitchen egg timer. In fact, such a humble device was actually the backbone of a recent rehabilitation program for a patient with a brain disorder.
"We were working with a woman who was taking care of her husband," says Susan Sabadini, OTR/L. "She worked full-time and had to wait more than an hour each day for him to get dressed before she went to work. While he was a patient here, we actually used the egg timer to help keep him focused on the tasks of washing and dressing. By the end of his stay, he was able to get ready in less than 30 minutes."
This low-tech, yet practical routine is the perfect example of the hospital's unique and successful approach to rehab. The real-life approach to rehabilitation, coupled with the intensive assistance from physical and occupational therapists, defines the 30-year-old institution's gait-and-balance and movement-disorder programs. Braintree, which provides cutting-edge physical therapy to the greater Boston area, treats stroke victims and patients with spinal cord injuries, brain and neurological disorders like Parkinson's disease, arthritis, and many other problems via individual or group therapy. Physical therapists at Braintree specialize in "real world" scenarios designed to prepare patients for assimilation back into their homes and their communities.
The acute rehabilitation hospital provides patients with 3 to 4 hours per day of intensive therapy, 7 days per week, at its four on-site units and one off-site unit at MetroWest Medical Center in Natick, Mass.
Therapists at each unit conduct in-depth evaluations of each patient, formulating a customized treatment plan. "We use a lot of occupational therapy, with adaptive equipment and strengthening exercises," says Valerie Allen, PT. "But since every patient is different, we use a multidisciplinary approach that allows us to get them back to their optimal level of functioning, whether they're someone with Parkinson's or someone with cardiac problems."
Patients with gait and balance disorders admitted to Braintree, typically suffering from conditions such as spinal cord injuries, stroke, and brain injuries, and diseases like multiple sclerosis, are assigned a case manager who communicates with their insurance company and sets up the services each patient requires upon leaving the hospital. Rehabilitation costs are covered in full or in part by most health-insurance plans, including Medicare and Medicaid.
For example, the team of 25 physical therapists, 25 occupational therapists, and 10 speech pathologists can treat up to 110 patients in a given week. During that period, a therapist might work with a spinal cord patient for 3 hours or more each day on gait exercises, teaching them the best methods, helping them to develop their walking motions, and training them how to use assistive machines. "Medicare requires us to provide that amount of therapy, since we're an acute rehab facility," says Parkinson.
Once admitted, patients are assigned a team of physical, occupational, and speech therapists to provide focus on areas such as thinking skills, work capabilities, and emotional needs. After planning treatment for each patient, much of the work is left up to the individual therapist. "We really leave a lot of the decisions to the staff," says Parkinson. "They look at each patient's impairment and limitations and decide the plan of action to take." Typically, therapists at Braintree will pick the least-restrictive device or piece of equipment for a patient after evaluating the patient's level of mobility and balance. At that point, equipment such as a quad cane, roller walker, or other assistive device is picked, with patients being worked out either in individual rooms or in the larger main gym area.
TECHNOLOGY OF REHABILITATION The hospital's huge glassed-in gym features dozens of machines, a full kitchen, and a laundry area. Parallel bars, roller walkers, and gait trainers give patients and therapists a good range of options for daily workouts. Smaller, individualized therapeutic gyms are provided on each patient unit, for those patients needing a less-stimulating environment.
Therapists at Braintree are also involved in more than just rehab. Each gait and balance patient can receive vocational counseling, cognitive training, and patient/family education from a physical or occupational therapist. "Some therapists even hold weekly meetings with the patient and family, almost like a conference where progress is discussed and the therapists try to get feedback from everyone on likes and dislikes," says Parkinson.
Specific programs at the hospital include walking and mobility exercises, basic calisthenics, other workouts of varying intensities to increase mobility, and a wide range of targeted workout programs on one of two gait-training machines used by therapists. The first is a body weight support system for gait training that has a harness and strap positioned between a patient's legs to allow for a better gait pattern.
The second, which HealthSouth designed and began using in 2002, uses technology to assist patients with gait disorders and help them achieve better balance, coordination, and posture. Based on the principle that abnormal walking requires more energy and can result in decreased functional ability for simple daily activities, the treadmill device uses robotics to simulate normal walking motion while holding the move the legs across the treadmill while sensors track various functions, monitoring and adjusting power and speed. "It's really ideal for stroke and multiple sclerosis patients who can't coordinate their movements," says Parkinson. "Each therapist decides whether to use the machine, based on the level of rehabilitation required." That means patients must meet certain criteria after evaluation by the therapist.
Patients are tested for motivation, range of motion, and their ability to follow commands. "The therapists also determine the weight adjustment and speed, and then work with the patient for anywhere from 30 to 60 minutes at a time, with resting periods in-between." Patients usually work with a therapist for up to 15 sessions on the machine. "But it's a far cry from the old days, when our therapists would get really tired from being on their knees on the gym floor with these patients, literally moving their legs," adds Parkinson. "Even though that shows you how involved the therapists are here, the machines make it easier."
Walking speed is varied to each patient's tolerance and is increased to reproduce gait patterns that simulate normal walking. Patients with gait and balance problems use the machine alongside those with osteoporosis, multiple sclerosis, and brain and spine injuries, and those wearing prosthetics. "It also can reduce pain and muscle spasms for those patients in wheelchairs," says Parkinson.
HEART OF THE PRACTICAL But the heart of Braintree's program is its practical, everyday approach. "We like to measure our success based on if patients are able to wash and dress, or get out of bed, or get into their cars," says Christina Guarino, MS, CCC/SLP. "The gym features top-of-the-line equipment that really helps them work on their weaknesses. But we're most interested in getting them to practice realistic, daily activities like they'll deal with at home. We want to make sure that when they go home, they're able to maintain their mobility."
To that end, Braintree provides gait-disorder patients with scenarios such as a mock bedroom. "It's a very functional place," says Allen. "For example, our gym has a simulated car station with a car, curb, and ramp. It's one thing for patients to learn to walk on a flat gym surface, but quite another to walk outside on a bumpy sidewalk or grass."
Visual and auditory cues are also heavily used for real-world therapy for patients with gait and balance disorders at Braintree. A laser line is used as a tool to help teach nerve-damaged patients to step on a certain point in front of them, which helps them learn to step over objects in their way. Additionally, Braintree therapists use standard walkers with the laser shining on the floor as a training tool. "It's particularly effective for Parkinson's patients, who have a shuffling gait and need to look up and ahead of themselves to learn better walking," says Parkinson.
Music and rhythmic cues such as the egg timer also are effective for helping patients learn to take better care of themselves. "Using the timers works because it helps patients divide up their tasks, and makes things more orderly and organized for them," says Guarino. Another device, a metronome like those used by pianists to keep accurate time, assists patients with keeping specific beats. "When they have gait disorders, our use of the metronome is helpful in improving their shuffling gait pattern. It's very simple but very successful."
Other therapists use CD players to play patients' favorite songs during walking sessions. "Patients walk better to the beat of songs sometimes," says Parkinson. "The therapists help out by encouraging them and acting almost as a coach."
According to Allen, such down-home therapeutic techniques go a long way in preparing patients for life after rehab. "The most important part of rehabilitation is getting patients used to being back in their environment," she says. "Our physical therapy team here really focuses on getting these people active in their communities, going to the grocery store, the doctor, getting in and out of the car, or the bathtub. After they leave here, we don't want them to just sit and watch television. They need to continue working on their mobility."
To help patients achieve that goal, Braintree therapists often go out to patients' homes to assess the environment, making sure it is an optimal place in which to function. "We look at the stairs, furniture placement, where the rugs are," says Sabadini. "We want to make sure they have enough space to move in. We also give patients a list of things to do at home with someone, like a family member, supervising them and making sure they continue to have goals outside the hospital."
Allen mentions that physical therapy at Braintree is not just relegated to the gym or the patient's hospital room. "Our PTs often take the patients outside to walk around on the grass," she says. "They're very creative when it comes to utilizing the space. I've even seen therapists using the hallways to get people up and moving around."
SPECIALIZED SERVICE Working with Parkinson's patients is one of the hospital's specialties. "In the past, treating Parkinson's was all about prescribing medication," says Guarino. And indeed, physical therapists at Braintree work with on-staff neurologists to help manage patients' medications and get them onto appropriate therapy.
But physical therapy is an equal, if not more important, aspect of therapy. Gait and balance training on machines and through the various learning cues and tools helps these patients become much more able to face the world. "Parkinson's patients in various stages of functional decline have left our hospital in much better shape," says Guarino. "The movement-disorder program here has been very successful in helping them get back to baseline and into their environment again. And regardless of the patient's disorder, the importance of muscle toning and mobility cannot be overstated."
To illustrate the program's effectiveness, Braintree was recently the site of a study of rehabilitation efforts on Parkinson's patients, with 44 patients followed from January 2004 to March 2005. Therapists at the hospital provided specialized training in movement disorders and pharmacological adjustments during weekly movement-disorders rounds. The therapists worked on patients' functional independence measure total, motor and cognitive sections, 2-minute walk, timed up and go, and finger-tapping skills. Differences between admission scores and discharge scores were significant for all motor and cognitive scores. In fact, according to the data, improvements were seen in patients whether or not medication adjustments were made. "The study really proved that there's a benefit for Parkinson's patients from a specialized inpatient movement-disorders rehabilitation program," says Allen.
One of the additional ways that therapists at the hospital help such patients is through family interaction. "We encourage family members to come to the initial consultation and to be an active part of the rehabilitation," she says. Ongoing education is also provided to help family members understand Parkinson's patient diagnoses and to help adapt therapy to the home.
Ultimately, Allen notes, the success of physical therapy at Braintree comes not only from how patients perform and function during their stay at the hospital, but more important, how they themselves feel about their progress. "We use a data graph that clearly plots their progress from day 1 until they're released," she says. "It shows their movement patterns when they were admitted, and how these improved. Every patient that leaves here is really proud of that graph and of the gains they made. It clearly shows them that they reached their goals. To us, that says they're willing to continue to build on that when they're out in the world. And that's really what we're all about."
Ben van Houten is a contributing writer for Rehab Management.
Gait training has come a long way since the days when several therapists assisted a patient by moving their legs for them as they were carried down a hospital corridor. Technology has transformed this once-arduous method of gait training, allowing the therapist to facilitate the treatment while the patient safely learns to walk in a normal way again.
A variety of gait trainers are available, giving the patient a safe, supported environment for moving across indoor and outdoor terrain. For therapists, however, one of the most useful and technologically advanced tools available today is the body weight support (BWS) system. This device, which features a treadmill, allows the patient to access it using either a gait trainer that can fit over it or a harness that is suspended over it, allowing the patient to walk naturally—building and retraining weakened or damaged muscle without the fear of falling.
Though all the various BWS systems on the market are designed to control weight-bearing and use a variable-speed treadmill, there are several differences between them, including their harness design and how it impacts the trunk and posture. "Some harness systems have one primary point of control; others have two," explains Terry Breisinger, PT, CBIS, brain injury rehabilitation team leader at the University of Pittsburgh Medical Center Institute for Rehabilitation and Research's Centers for Rehab Services. "The result of this variation is that certain gait trainers work better for certain diagnoses. For example, one gait trainer may be a little better for a stroke patient with hemiparesis, and another for a patient with spinal cord injury. The comfort of the harness itself may also be variable."
Not every BWS system may be the best fit for every patient population. However, for most departments, budgetary realities will influence purchasing decisions based on what is best for the largest patient population. But that does not mean that departments will not eventually end up with a variety of systems. "Usually, [departments] purchase one system to begin with and possibly add more as use, effectiveness, and satisfaction are experienced," says Cindy Flom-Meland, PT, PhD, NCS, an instructor in the Department of Physical Therapy at the University of North Dakota School of Medicine and Health Sciences, Grand Forks. Her ability to access the patient while they are using the treadmill influenced her to purchase the system.
The use of BWS systems, like most interventions, is dependent on the health of the patient. Only those who are medically stable are prescribed treatment on a BWS system. BWS gait training can be recommended at any time during the treatment process, though there is a trend for later in the treatment cycle. This trend could also reflect the type of research that is currently being done on the effectiveness of BWS gait training. "A majority of the research conducted in this area has been in the chronic stages, with more up and coming in the subacute and acute stages of recovery," says Flom-Meland. BWS gait training is typically used in conjunction with other treatments.
Ongoing research is being conducted to examine the duration and frequency of BWS treatment. "What we do know at this point is that speed and repetitions are needed," says Flom-Meland.
But as effective as the equipment appears to be with its ability to eliminate fall risks, offer variable treadmill speed, and allow for therapist access, there is one wild card that can negatively affect progress—the patient. "The patient's diagnosis, any comorbidities, motivation, etc, will also play a role in the recovery of locomotion," says Flom-Meland.
The future of BWS systems is tied to advancing technological sophistication, with robotics likely to play an increasing role. The trend toward evidence-based practice will also continue to impact gait training as protocols are researched and developed, says Breisinger.
—Chris Wolski
