At the JFK-Johnson Rehabilitation Institute (JFK-JRI), physical therapists have a diverse mix of technologies available to assist with recovery of patients who have been affected by stroke. These devices support rehabilitation that can meet patients almost anywhere on the functional continuum, and support therapeutic activities that will help them meet their goals. Among the technologies available to PTs in both inpatient and outpatient settings are a body weight support treadmill, electrically powered mobile lift device, motorized elliptical trainers, computerized balance assessment system, neuromuscular electrical stimulation, functional electrical stimulation devices, and conventional lower extremity and upper extremity braces. This article explores the advantages these technologies provide especially when tailored to the needs of poststroke patients, and their varying levels of function.
GET WHAT YOU NEED
An “Advanced Technology Committee” at JFK-JRI guides the acquisition of every major piece of rehabilitative technology by researching the latest devices that are appropriate for poststroke patient care. As a discipline the committee is PT-specific, composed of interdepartmental personnel, and schedules meetings at quarterly intervals to review their findings. One of the committee’s most important functions is its continued investigation of assistive technologies for potential use by the facility. Among technologies currently under evaluation are sensory loading walkways, overhead track systems, and gravity-eliminated treadmills. If the committee determines a product provides adequate clinical benefit, vendors and/or manufacturers are contacted for presentation and trial of the product. Actual device purchase is handled by directors of the professional development department.
WHAT WORKS BEST
Rehabilitation of stroke patients can be a multifaceted pursuit. Patients may be medically complex and have comorbidities. They may enter the rehab continuum with a variety of functional deficits and exhibit a range of fitness levels. Attitudes, beliefs, and fears can all affect how a patient enters and prosecutes a rehabilitation program. Because of these multiple facets, therapists must understand which therapeutic technologies offer the most utility for a particular case. Following are notable advantages some of the latest technologies provide:
Body Weight Support Treadmill (BWST). This device stimulates the automatic pattern generators in the brain to activate reciprocal bilateral lower extremity movement. The strapping system eliminates the risk of patient falls. The device also allows for mechanical unloading of a specific percentage of the patient’s body weight that promotes ease of movement and increases patient confidence with ambulation. The device allows the PT to provide manual cues to the patient to facilitate greater muscle activation during the gait cycle. In addition, a mirror can be placed in front of the patient to provide the patient with visual feedback as to the sequencing and timing of reciprocal lower extremity movement. One or two PTs are required to assist the patient with weight shifting, advancing the hemiparetic lower extremity to achieve heel strike, symmetrical step length, and/or provide knee stability. A typical training session on the BWST is approximately 2 to 4 minutes at the fastest safe speed for each individual patient. A gait training trial over level ground surfaces should be conducted immediately following the treadmill session to assess for patient carryover.
Electronically powered mobile lift devices (EPMLDs) represent an additional type of body weight support technology used for gait training over level ground. This device, however, does not allow the PT to program a specific calculated unloading of a patient’s body weight. The lift pants, used with the EPMLD, facilitate safe and secure standing and gait training with patients who experience poor balance and hemiparesis. The PTs can devote their attention to the patient’s weight shifting, advancing the hemiparetic lower extremity, and/or providing knee stability. A second person is needed to maneuver the device to promote a reciprocal gait pattern.
Motorized elliptical trainers (METs) are another of the therapeutic technologies commonly used at JFK-JRI after stroke. Furthermore, METs have specific application for repetitive gait training. For example, the MET can be used with and without body weight support, and employs the same harness that is used for body weight support training. The unit has integrated sensors built to detect the level of assistance required by the patient and includes a motor that reacts to sensor input, providing the necessary amount of support to the patient. The particular MET chosen for JFK-JRI was selected because it most closely mimicked a normal walking pattern, as determined by electromagnetic studies. The device has a ramp and steps for easy access, as well as three different handles available for the upper extremities that provide varying levels of support and challenge. The MET includes a customizable unweighing system and offers the ability to customize patient stride length and strides per minute.
There are three possible modes in which the MET operates. The active assist mode allows the patient to move at a constant speed that is set by the therapist. This is the mode that offers the greatest level of assistance. The active mode is utilized when the integrated sensors detect that a patient’s speed is less than that speed set by the therapist. If the patient is able to move faster than the strides per minute set by the PT, then the motor will turn off. If the patient falls behind, the motor will turn back on to offer assistance. The last mode in which the MET can be used is the resistive mode. In this mode, the patient powers the elliptical independently and the therapist can add progressive resistance.
The advantages to using the MET during stroke rehabilitation include facilitation of weight shifting and weight bearing through the use of the harnesses and the ability to lock patient’s feet into place with straps, which decreases the risk of ankle injuries, especially with those patients who present with inversion tone. It also provides a safe environment for cardiovascular training by decreasing the risk of patient injury and falls.
A computerized balance assessment system (CBAS) is often used in stroke recovery at JFK-JRI. It can be used to improve balance, proprioception, and weight shifting for patients affected by hemiplegia. The balance system consists of a plate on which the patient stands, handles that may aid the patient in balance recovery, and an interactive touch screen. The plate can be static or dynamic, offering various levels of difficulty that further challenge patient balance.
There are two modes in which the CBAS can be operated. The first is testing mode. This mode consists of several tests to assess patient balance and fall risk. The therapist can objectively record the patient’s results and compare these values to the individual’s healthy age-related norms. It also may be used to document patient progress. The second mode is training mode. This consists of several games in which the patient practices both static and dynamic balance and weight shifting by following on-screen cues and scales. The screen is interactive and offers immediate visual feedback to improve patient performance.
In addition, JFK-JRI recently installed an overhead track system that provides a fall-free gait training environment over level ground. The overhead track system is mounted to the ceiling in H configuration allowing for multidirectional movements. The patient is supported by a harness that allows the PT to coordinate multiple body parts without creating a fall risk for the patient.
EYE ON EVALUATION
A technology currently available that aims to assist PTs in assessing the gait of patients post-stroke is a sensory loading walkway. These mat-like devices record both static and dynamic pressure as the patient ambulates across the walkway; patients may ambulate independently or use an assistive device, such as a cane or walker. Using this technology, PTs can measure and assess a patient’s step/stride length or determine the width of their base of support, cadence/velocity, or efficiency of the gait pathway. In addition, swing/stance times and toe in and toe out may be measured. This device allows for PTs to objectively identify areas of gait dysfunction and allows therapists to reassess gait after PT intervention.
BRACES AND ASSISTIVE DEVICES STILL EFFECTIVE
Patients also may require bracing of the hemiparetic leg to provide greater stability and patient safety. The PTs at JFK-JRI have a plethora of trial hip-knee-ankle-foot orthoses (HKAFOs), knee-ankle-foot orthoses (KAFOs), and ankle foot orthoses (AFOs) available to them. If conventional bracing is not required, but patients require assistance with foot clearance and/or medial-lateral support, an ankle brace can be utilized. At JFK-JRI, the PTs have the advantage of an in-house prosthetic and orthotic clinic and lab that utilizes an interdisciplinary team approach when recommending and fabricating braces. Therapists recognize the importance of providing support to the hemiparetic upper extremity (UE) during upright mobility. A unique UE sling allows the upper extremity to be supported in a functional position while minimizing the potential for worsening subluxation.
Another mature technology that may aid recovery for some post-stroke patients is the adult supportive walker. These devices can help users learn and strengthen normal gait patterns and associated muscle groups, while providing a level of secure mobility. These types of walkers are designed to allow the pelvis to drop down into the heel strike and toe-off portion of gait, and assist with elevation in a way that allows for a proper swing-through phase.
The use of electrical stimulation in stroke has many clinical advantages, such as muscle strengthening and re-education, spasticity management, improving or maintaining joint range of motion, promoting awareness to the hemiplegic side, and improving overall functional mobility. The most common use of neuromuscular electrical stimulation (NMES) and functional electrical stimulation (FES) after stroke is to stimulate the peroneal nerve to improve foot drop and walking ability. This can be done with the use of a cyclic device with a heel switch or with any of the neuroprosthetic devices previously described. An advantage of using a neuroprosthesis versus a cyclic device is that neuroprostheses are wireless. They are controlled either by a heel switch or by a tibial angle sensor and a control unit. Parameters are set by the PT and can be adjusted during the gait cycle. Therapists may control foot drop during the swing phase of gait and also knee hyperextension or buckling during the stance phase. Electrical stimulation units also improve sensory awareness and facilitate improved patient weight shift and gait velocity. Furthermore, they can be used in conjunction with other technology such as body-weight support systems to best facilitate motor relearning. Research has shown that FES improves hemiplegic gait in the areas of velocity, symmetry and knee and ankle mechanics. These devices decrease spasticity and the risk for patient falls. Furthermore, research demonstrates an increased ability to move out of synergy, increased patient balance, and improved patient quality of life after stroke.
Another way to treat foot drop in patients after stroke is through the use of NMES and FES. NMES is electrical stimulation of the lower motor neurons that evoke a muscle contraction. FES is electrical stimulation used to directly accomplish functional tasks, such as standing and walking. One of the advantages of using NMES and FES is that these modalities may help facilitate motor learning through goal-oriented repetitive movement therapy. In addition, they have been shown to influence physiological changes in the primary sensory and motor areas of the brain. FES is used dynamically, allowing patients to ambulate over elevations and uneven surfaces more efficiently than if a patient were to use a more conventional AFO. In addition, FES is also more aesthetically pleasing, as FES devices typically have smaller profiles and can easily be concealed under clothing. They can be worn with any variety of shoes (depending on the type of FES device chosen), so patients have the ability to change footwear as needed to accommodate different types of social situations. The two types of NMES most commonly used in outpatient JFK-JRI are cyclic devices and neuroprostheses. A neuroprosthesis is a device that can be worn to facilitate, substitute, or replace functions lost by injury and disease.
Prior to the development of these advanced technologies, the PT would be limited to focus on facilitating one area of the body. The use of assistive technology opens the PT to work on addressing the multiple impairments of the patient during one treatment session as well as increase the number of repetitions the patient completes. The PTs at JFK-JRI are very fortunate to have access to advanced technology that improves patient safety and clinical outcomes after stroke. Through the facility’s “Advance Technology Committee,” members of the clinical staff are continually exposed and have the opportunity to trial new products on the market to utilize with this patient population.
Alyson T. Dutkiewicz, PT, MSPT, is a staff physical therapist at JFK JRI Inpatient Rehabilitation. She has been with JFK JRI for three and one-half years and previously worked in an acute care and acute rehabilitation setting. Alyson earned her Masters of Science in Physical Therapy from Misericordia University in 2007. Her areas of interest include orthopedic and stroke patients in an inpatient rehabilitation setting.
Dana Abel, DPT, is a clinical consultant at JFK JRI Outpatient Rehabilitation. She has been with JFK JRI for 4 years and previouslyu worked in Delaware as a physical therapist in an inpatient rehabilitation setting. Dana earned her DPT from Widener University in 2007. She is certified in Bioness for the lower extremity, LSVT BIG therapy, and is also a PWR! (Parkinson’s Wellness Recovery) trained clinician.