CINDY SANDERS

The Armeo® virtual reality programming helps patients regain upper extremity functionality.

With a very small window of time to reverse the effects of ischemic stroke, the reality is many patients wind up with neurological deficits. The same is typically true for those who suffer trauma, hemorrhagic stroke or are victims of degenerative neurological disease.

For this population, traditional and newer therapies offer the best hope to retrain the brain and strengthen affected limbs in order to regain function. Following is a look at three area rehabilitation centers using a mix of modalities to positively impact outcomes.

Skyline Medical Center’s Rehabilitation Center: In late November 2007, Skyline was granted licensure to add nine additional inpatient rehabilitation beds to bring the total to 31. This increase, along with the expansion of the hospital’s neurological ICU (see sidebar), is a testament to the program’s growth over recent years.

In addition to JCAHO certification, Skyline’s Rehab Center is the only CARF (Commission on Accreditation of Rehabilitation Facilities)-accredited acute medical rehabilitation program in Middle Tennessee, according to Johnny Harrison, director of rehabilitation for the hospital. Skyline is one of only three in the entire state to also receive stroke accreditation from the independent, not-for-profit accrediting body, he added.

Dr. Robert Serro, medical director of rehabilitation services, said that while Skyline deals with many different diagnoses, stroke is certainly a major component of their care and an area for which the hospital is nationally recognized.

“Stroke is one of the things that sets Skyline Medical Center apart, and therefore the rehabilitation center,” he said. “We’re a comprehensive stroke center, and the first one in Tennessee to receive that accreditation.”

“We have state-of-the-art equipment to help with increased functional independence,” Harrison said of methods employed in the onsite gym.

Serro added that in addition to physical therapy, the staff focused on occupational therapy and simulated activities of home management to help patients put therapy into the context of daily living.

“As patients move towards the basic functioning skills of movement and transfer, we are also focusing on them being able to care for themselves. It’s an integrated approach,” Serro said.

He added that speech and language therapy are an integral part of the comprehensive program. “The majority of our patients have some deficits in speech, cognition, language or swallowing, and all of our patients are screened by speech and language pathologists.”

Taking the integrated approach even further, Serro said a neuropsychologist is available to help patients adjust to their new disability. Harrison added the team actually consists of nearly 50 professionals including seven certified rehabilitation nurses plus other RNs, LPNs, CNTs, speech and language therapists, physical therapists, occupational therapists, a case manager and master’s level social worker, among others.

Once patients are ready to move to an outpatient setting, Serro said the focus switches to ensuring continuity of care. The referring and primary care physician (if different) are sent copies of the patient history and follow-up appointments are set as part of the discharge plan.

Skyline also offers extensive outpatient and day services including Krueger Independence Square Village on the Madison Campus. Unlike any other facility in the area, Harrison said the model town truly mimics the different aspects seen in a community setting and helps patients learn to navigate different floor levels, uneven pavement and steps.

He noted Independence Square also provides patients with realistic settings including full-scale replicas of a bank, dentist’s office, gas station and café, plus a controlled environment in which to practice getting in and out of a car, maneuver through a grocery store and lift products off of shelves. There’s even a little marina with a small boat.

“I think sometimes it is easier for patients to understand when you are doing a real world activity,” Serro said. “It helps keep the motivation going.”

Vanderbilt Stallworth Rehabilitation Hospital: In addition to the traditional therapies used at the rehabilitation hospital, Vanderbilt Stallworth has recently invested in new equipment employing the latest in robotic and computerized technologies to help patients regain functionality.

“We’re about six months into a piece of equipment from a company called Bioness,” said Stewart Young, director of therapy operations. “The equipment we’re using is an upper extremity neuroprosthesis.”

The product, he continued, is a combination of a hand splint and electrical stimulation unit with the electrodes built into the splint.

“It allows a patient with a weak upper extremity affected by stroke … even to the point of paralysis … to regain some function,” noted Leslie Richerson, director of marketing operations and a physical therapist by training.

Young added that when someone has a stroke, the arm is often the last thing to come back. “They’ll lose range of motion, and the muscles will atrophy,” he said.

The Bioness hand rehabilitation system, which can be customized to fit virtually any patient, uses a combination of the electrical stimulation and support system to assist in neurological re-education. The computerized synchronicity allows for coordinated flexion and extension so that patients can complete tasks they wouldn’t be able to do by just placing electrodes on a major muscle group.

Young and Richerson explained that a patient, who might not be able to even move their fingers without the device, could actually extend an arm, grab a glass, bring it to the mouth, take a drink and return the glass to the table when wearing the splint.

Since the equipment is battery operated, there are no electrical cords to limit a patient wearing the device as part of their daily routine. Richerson and Young said several patients have purchased the Bioness Hand Rehabilitation System for use outside of therapy to make many tasks manageable again.

“Reimbursement via Medicare is currently pending,” said Richerson. Young added that Bioness has been good to work with patients who wish to purchase the device without full insurance coverage.

While the hand system is already in use, Richerson said Stallworth has also invested in a brand new piece of technology from Bioness, the L300 Foot Drop System.

The completely wireless system, which looks similar to a small athletic brace, can be completely concealed underneath clothing. The lightweight leg cuff fits just below the knee and uses electrical stimulation where needed. A gait sensor attaches to the shoe to “tell” the cuff when to activate the muscles to pull up a user’s toes during the gait cycle. The technology allows patients to get rid of their plastic orthotic and achieve a much more normal-looking gait.

“Discreet is always the word that comes to my mind,” said Richerson of the device. “This allows them to walk normally, and no one would even know it’s there.”

Additionally, she said, there are important therapeutic reasons for correcting the gait. Dragging a foot, she noted, causes a person to compensate, which often leads to future problems with the knees and hips.

Another new addition to the therapy family, said Young, is the Reo™ Go system. He described the look of the new equipment, which arrived last December, as being similar to a flight simulator with a large robotic arm and video screen.

“The purpose is to train functional mobility for the upper extremity … not just the hand and wrist … but the hand, wrist, elbow, shoulder – all movements together,” he explained. “You have pre-designed programs with functional movement patterns, but you also have patterns that simulate real world activities,” he continued. “They (patients) will go through repetitive movements that are patterned and reinforced on the screen.”

Young said the machine initially guides a patient through the exercises. As a patient is able to do more of the work, the machine does less. “If you get to a point where you can handle resistance, the machine pushes back against you,” he noted.

Richerson added the new equipment and devices are adjuncts to the extensive therapy used at Stallworth but said these new technologies give therapists even more tools to help patients achieve their goals.

Ware Centre: Opening in Cool Springs this month, Ware Centre is a collaborative effort between exercise physiologist Dick Storie, registered nurse Susan Stoner and Nashville fiber optics salesman Scot Ware.

Ware, who suffered a massive stroke a little more than two years ago, received inpatient rehabilitation at the Shepherd Center in Atlanta. When he awoke from a coma after 23 days, he was completely paralyzed except for one cheek muscle. Today, after months of inpatient and outpatient therapy, he speaks clearly and walks with the assistance of a cane. He credits his ability to ambulate to the Swiss-developed Lokomat® system, which he and his partners are bringing to Middle Tennessee.

Storie said the new 8,200-square-foot facility, located on Mallory Station Lane, includes direct van access so that wheelchair-bound clients can actually drive into the gym and unload in close proximity to the therapy equipment.

The Lokomat by Hocoma was FDA approved in 2002. The equipment, which costs close to $300,000, is used for those who have suffered strokes, spinal cord injuries, traumatic brain injury or who have been diagnosed with neurodegenerative diseases.

Storie explained the foundation begins with a specialized treadmill that runs across a platform with individual slats rather than a flat belt. Therapists can set the speed for as little as 0.1 mile per hour up to 12 miles per hour in 0.1 mph increments for a smooth transition. The robotic Lokomat harness system is built around the base and can unload up to 85 percent of a person’s body weight. The machine progressively increases the body weight carried by the user as they re-acquire walking skills.

“It can take someone who has been wheelchair-bound for several years … or someone paralyzed such as with a severed spinal cord and no movement … and walk them in what would be, for them, a normal gait,” said Storie.

For those with a completely severed cord, the equipment cannot, of course, help them walk again, but it can help mitigate ancillary issues. For the others, it helps reprogram parts of the brain and spinal cord to control the gait and allow them to regain ability.

Typically, Storie said, even a patient who has been wheelchair bound will see improvement to the point of being able to ambulate with assistance from a therapist, cane or other device within a six-week period, assuming a minimum of three sessions a week lasting from 30 minutes to an hour.

Although there are a number of Lokomats in the United States in a university setting, the Franklin center is only the third in the nation to be open to the public. However, there are more than 150 of the systems being used worldwide.

The plus of the system, said Storie, is the repetition … the ability to get in many more steps than would be possible using parallel bars and therapists … and a more natural gait than having a therapist physically move one or both legs.

“The whole thing is about repetition so the more signals we send up to the brain, the more improvement we get,” he noted.

Storie and Stoner, who have both received Lokomat certification, hope to soon purchase a system for children.

“On the pediatric Lokomat, we actually have virtual reality programs,” Storie said. In one program, a child is walking through the woods looking for specific animals. For the child, he pointed out, it’s engaging and fun. For the clinician, it’s highly useful, high-tech feedback.

“Without even realizing it, their eyes and head are tracking what’s on the screen. It helps their vestibular system, their balance, and it makes it fun. The Lokomat also shows us the child is trying to turn their feet to go through the forest. Next time they come in, we make adjustments and build upon that progress.”

In addition to the Lokomat, the new facility will also feature the nation’s first Armeo® rehabilitation system.

“It’s a robotic system based on the principals utilized in the Lokomat but for the upper extremities,” Storie explained.

Both technologies have a biofeedback mechanism so the user can see on a large screen if they are making progress and performing their tasks correctly. For clinicians, Storie said, the data helps therapists measure outcomes and provide progress information to insurers.

An onsite physical therapist will also utilize other equipment including vibration units, a functional suspension system, Biodex Balance System, weights and more to enhance performance.

“The traditional physical therapy model is geared towards allowing people to function within their limitations,” Storie concluded. “Our goal is to eliminate the limitations.”



April 2008