By Lisa Edelstein, OT
In the United States, someone has a stroke every 40 seconds.1 With stroke mortality decreasing, and more people surviving the acute stroke event, stroke is a leading cause of long-term disability in this country.1,2 The resultant immobility and loss of independent functioning in daily activities speaks to the need for comprehensive and intensive stroke rehabilitation that address the often lasting effects of the stroke.
According to the American Heart Association/American Stroke Association, stroke is not just an acute event, but a chronic condition, with rehabilitation requiring “a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others.”3 These stroke rehabilitation guidelines call for programs to include individually designed plans, retraining to improve abilities to perform daily tasks and improve mobility, balance training to improve balance and decrease the risk of falls, and other key components that address impairments in speech, vision, and cognition, among others.3
In order to maximize the potential for recovery, stroke rehabilitation programs should include intensive, repetitive, meaningful, and task-specific therapies.3 These therapies address the devastating effects of stroke—loss of mobility, decreased ambulation, loss of upper extremity function—all of which impact overall and long-term health and quality of life. At Burke Rehabilitation Hospital, White Plains, NY, more than 500 patients who have suffered a stroke are admitted annually for comprehensive, acute inpatient rehabilitation. The large multidisciplinary team is focused on improving functional independence in preparation for discharge and return home. Individual care plans are developed and often utilize the latest technologies to ensure patient access to the most advanced equipment and evidence-based interventions. Investments in rehabilitation technologies have assisted in providing optimal, state-of-the-art rehab care for patients.
The following companies provide technologies for functional measurement and assessment:
GAITRite/CIR Systems Inc
Gait retraining is one of the primary goals of stroke rehabilitation. Patients often state their goal in rehab is “to walk again.” Many technologies are utilized to support the task-specific and impairment-focused interventions that facilitate pre-gait and ambulation tasks. Each offers unique features and benefits that assist patients and therapists with carrying out each individual’s treatment plan.
The ZeroG Lite from Aretech, Ashburn, Va, is a body-weight support treadmill system that allows patients to safely practice gait training tasks over a treadmill by altering the amount of body-weight support. The difficulty and challenge of the task can be adjusted for the patient’s ability to practice intensive gait and balance activities, and parameters can be changed to change the intensity and duration of the tasks. The treadmill can be inclined and the belt speed can be reversed to facilitate walking up and down slopes.
The Guldmann Active Trainer with Ceiling Mounted Track from Guldmann Inc, Tampa, Fla, is a ceiling track-mounted system that provides adjustable body weight support that is used to provide balance and gait training. Patients with lateropulsion (turning of gait to one side) can safety be brought to a supported upright position to assist with regaining midline orientation and improving posture and weight bearing. Patients who are ambulatory are able to use the trainer in therapy to decrease gait deviations and improve gait quality and speed. Other types of ceiling-mounted body weight support systems that can provide utility for rehabbing individuals affected by stroke include the ZeroG Gait and Balance Training System, also from Aretech. This system can help protect users from falls as well as facilitate functional activities such as walking, sit-to-stand, postural tasks, balance activities, and more. It is also built to accommodate users who weigh up to 400 pounds.
The Bioness Vector from Valencia, Calif-based Bioness is also a ceiling-mounted body-weight support system that can provide a safe environment for over-ground training. The system has an adjustable fall limit setting, and the overhead track designs can be built to a clinic’s specifications. The SafeGait 360° Balance and Mobility Trainer from Gorbel Inc-Medical Division, Fishers, NY, is another overhead track system built to provide dynamic body-weight support and fall protection for early rehab post-stroke.
Other technologies that provide body-weight support for rehab training include LiteGait from Mobility Research, Tempe, Ariz, a gait training device that controls weight bearing, posture, and balance over a treadmill or over ground. It allows individuals to comfortably walk in a secure environment free of falls, altering weight bearing capacity via a sling support. LiteGait provides proper posture, reduces weight bearing, eliminates concerns for balance, and facilitates the training of coordinated lower extremity movement. The device can retrain postural stability and upright posture.
The Lokomat is a robotic device from Hocoma USA, Norwell, Mass, designed to provide highly repetitive physiological gait training that can be useful to therapists treating patients affected by neurological impairment. The user is supported by a harness suspended overhead while using an individually adjustable exoskeleton. Speed, loading, and robotic support all can be adjusted.
The WalkAide System from Innovative Neurotronics, Reno, Nev, is a myo-orthotic device, which combines electrical stimulation with orthotic technology in the treatment of foot drop. It is used to improve independence, functional mobility, and safety.
Also utilized is the NESS L300 Plus Foot Drop System available from Bioness, a neuro-orthotic and rehabilitation system that provides electrical currents to stimulate nerves and muscles to assist with a more natural walking pattern, reduce muscle spasms, reduce muscle loss, maintain or improve range of motion, and increase local blood circulation. It, too, is used to improve independence, functional mobility, and safety in the treatment of foot drop.
The Up n’ Go, offered by Easy Walking, Maple Glen, Pa, is a support device with a suspension system that allows for gait training through partial weight bearing and assists with sit to stand transitions. The device is lightweight and adjustable, allowing use with individuals with a range of balance and strength capabilities.
Various devices and technologies provide targeted, repetitive, and often, task-based activities to improve impairments in strength, range of motion, tone, pain, and functional use. Technologies offered at Burke include the MOTOmed with Functional Electrical Stimulation from Betzenweiler, Germany-based Reck. The MOTOmed can be used for arm or leg training. In conjunction with the cycling motion, this system provides functional electrical stimulation that compensates for the missing impulses from the brain. This technology provides an active training option despite paralysis.
The RT300 Functional Electrical Stimulation (FES) Cycle Ergometry System from Restorative Therapies, Baltimore, provides electrical current stimulates nerves to evoke muscle contractions in the arms and legs, enabling muscles to work and perform active cycling even if voluntary control of muscles has been lost.
The NESS H200 Hand Rehabilitation System from Bioness is a neuro-orthotic and rehabilitation system that provides electrical currents to stimulate nerves and muscles to increase hand function, prevent muscle loss, re-educate muscles, increase blood circulation, reduce muscle spasms, and increase or maintain hand range of motion.
Electric stimulators, which are available from various manufacturers, are used to relax muscle spasms, increase local blood circulation, maintain or increase range of motion, and slow or prevent muscle disuse atrophy. For patients with painful subluxations, electrical stimulation may be used as an effective modality.
A variety of technologies and devices offered by Saebo Inc, Charlotte, NC, are utilized in Burke’s rehabilitation program. All are designed to facilitate and assist post-stroke impaired mobility and function. These include the SaeboMas, a mobile arm support designed to support and allow movement for patients with proximal weakness; SaeboFlex, a mechanical wrist and hand orthosis which assists digit extension to allow for object release and improved hand function and use; SaeboStretch, a dynamic resting hand splint that helps to decrease spasticity; SaeboGlove, a low-profile, tension-based glove that provides digit and thumb extension assist; SaeboStim Micro, a sleeve and glove-based system, which provides sensory electrical stimulation to the arm and hand; and the Saebo Myo Trac Infiniti, a portable, biofeedback triggered electrical stimulation device, which delivers targeted electrical stimulation to specific muscles.
The Bioness Integrated Therapy System, BITS, available from Bioness, is a computer and large screen-based therapy system which offers programs targeting visual motor skills, visual perceptual skills, visual processing skills, cognition, as well as coordination, limb use, and endurance. Computer programs have adjustable and varying levels of difficulty, which can be customized to meet each individual’s specific treatment needs.
Recumbent exercisers, such as the NuStep Recumbent Cross Trainer from NuStep, Ann Arbor, Mich, are used to help patients with overall strengthening and accommodate specific patient needs.
Mainstream products, not originally developed for therapy use, such as the Nintendo Wii Fit, manufactured by Nintendo of America Inc, Redmond, Wash, are utilized in therapy programs to enhance balance, strength, and endurance with various games.
Capturing Data for Gait Analysis
The ability to collect and analyze specific measures relative to the gait of a recovering patient has been useful at rehab facilities and research centers throughout the country. One manufacturer that provides technology for this purpose is ProtoKinetics, Havertown, Pa, which offers the Zeno Walkway. The device has a 3-layer framework that reduces sensor damage and includes a pressure carpet with up to 46,080 sensors to capture movement with high spatial resolution. The Zeno Walkway can collect and analyze temporal, spatial, and pressure data provides a Symmetry of Propulsion metric. The PKMAS software outputs measures for static and dynamic
Another technology that can be used for temporo-spatial gait analysis is the GAITRite Portable Walkway, from Franklin, NJ-headquartered CIR Systems Inc. The GAITRite is a portable gait analysis device designed to use proprietary software to provide exportable footfall, gait cycle, walk and test level measurement. The mats, which are a single layer and offered as single units that roll out, can be set up for use in a hallway and used on flat ground or an incline. The CIRFace model features individual squares that can snap together as a system in a variety of configurations.
Objective measures of gait can be valuable in making treatment decisions that may otherwise rely solely on visual assessment.
Technology Enhances Capability
The variety of technologies used in inpatient stroke rehabilitation is vast. Studies have shown that intensive, repetitive task training leads to better outcomes for mobility training, including gait, gait-related activities, and activities of daily living.3 The ability to incorporate technologies and devices to enhance therapists’ capabilities to deliver activity-specific, functional, task practice positively impacts post-stroke recovery for many individuals, and is consistent with current guidelines and recommendations for adult stroke rehabilitation and recovery. PTP
Lisa Edelstein, OT, is director of the Stroke Program at Burke Rehabilitation Hospital, White Plains, NY. For more information, contact PTPEditor@allied360.com.
1. Centers for Disease Control and Prevention. Stroke facts. Available at: https://www.cdc.gov/stroke/facts.htm. Accessed February 1, 2017.
2. Lackland DT, Roccella EJ, Deutsch AF, et al, on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Quality of Care and Outcomes Research, and Council on Functional Genomics and Translational Biology. Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association. Stroke. 2013. Available at: http://stroke.ahajournals.org/content/early/2013/12/05/01.str.0000437068.30550.cf.full.pdf+html. Accessed February 1, 2017.
3. Winstein CJ, Stein J, Arena R, et al, on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Guidelines for adult stroke rehabilitation and recovery, a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Available at: http://stroke.ahajournals.org/content/strokeaha/early/2016/05/04/STR.0000000000000098.full.pdf. Accessed February 1, 2017.