by Doug Glenn, PT, MPT
Many diverse treatment interventions are available to rehabilitation professionals working with patients who have suffered a stroke. Therapists who wish to focus on recovery of function in stroke patients have a wealth of resources available to them to maximize outcomes in a time- and cost-efficient manner. This article provides information and discussion about several technologies therapists may find beneficial to help their patients achieve maximum functional independence after suffering a stroke.
Body Weight Support Technology Equipment
An assortment of body weight support (BWS) resources are available to therapists as an early intervention to get a patient who has suffered a stroke in an upright posture to promote midline orientation and facilitate effective posture and alignment while addressing the patient’s fear of falling and emphasizing safety. One such device is a harness system that incorporates an overhead rope system and ceiling-mounted track. This height-adjustable system allows for a therapist-selected degree of movement based on the patient’s level of stability, can be used in both a patient-seated and patient-standing position, and can “free-up” the therapist’s hands for handling and facilitation of motor control. This device can be used early in treatment with a patient with poor postural stability or late in patients who have achieved return of motor control and wish to fine-tune balance and stability for higher-level functional tasks. The therapist can test the limits of stability of the stroke patient in a variety of conditions without risk of injury from a fall, and allow for progressive neuroplastic changes with repetitive mass practice of functional activities such as reaching for objects, stepping to targets, and eventually, gait.
Another BWS device available to therapists wishing to get their patient up and walking is a bodyweight-supported treadmill system. This device provides increased support for the patient and uses a harness attached to a hoist to suspend the patient over a treadmill for early-intervention gait training. The therapist can then facilitate the affected proper lower extremity musculature for effective gait technique, again, allowing for repetitive mass practice to invoke neuroplastic change for motor recovery. Some BWS treadmills incorporate robotics to attach to the patient’s lower extremities to assist in facilitation of effective gait pattern.
Gait re-training on a traditional treadmill is beneficial in that the therapist can emphasize repetition of steps in a controlled, obstacle-free environment with a preselected speed. The therapist can easily facilitate required musculature for each phase of the gait cycle by positioning themselves beside or behind the patient. With advances in technology, we now have “smart treadmills.” These treadmills utilize a force platform under the belt to detect step length and stance time on each limb. A computer collects data from a gait training session, and the therapist can print out reports to show objective information regarding a patient’s functional progress. If available, the therapist can utilize the BWS rope system attached to the ceiling track positioned over the treadmill in order to add an extra degree of safety and stability for a lower-functioning stroke patient.
Computerized Balance Systems
Multiple factors must be considered when working on retraining balance and stability with a stroke patient. First, one must consider motor control related to balance strategies used for fall prevention: ankle-righting strategy, hip-righting strategy, and stepping strategy. Second, a damaged vestibular system must be considered as a cause for balance deficits. With regard to motor control balance retraining, a computerized balance system can assist a stroke patient with ankle strengthening and sensorimotor retraining. This device utilizes a force platform that can detect minute changes in a patient’s postural sway and center of gravity. Some devices have the option to keep the force platform in a static position for the previously stated purpose as well as create a dynamic surface, allowing the platform to tilt in all directions, in order to increase difficulty of task. A display monitor allows the patient to use visual feedback to “re-calibrate” balance-righting systems and gain a better understanding of keeping the center of gravity over the base of support.
Another technology on the market designed to help recover walking are gait mats equipped with sensors that gather objective temporo-spatial measures of gait. Gait mats are available in various lengths that can be rolled out for use, and one model offers a snap together wi-fi walkway that permits a number of layouts including step-up and over elevations, turns, and circles. Measurements that can be computed include cadence, velocity, step length, stride length etc, as well as symmetry measures. Reports and displays can be tailored to measurements that apply to a specific clinical condition, and helpful for evaluating progress within a treatment protocol.
Technological advances have opened up a world of opportunity for therapists to improve outcomes. With this in mind, however, technology should be used as an adjunct and to assist the therapist’s role in creating an opportunity for the brain to make neuroplastic changes by way of repetitive mass practice for full motor recovery.
Patient is a 47-year-old male with history of hypertension who suffered a right brain middle cerebral artery stroke. He was admitted to inpatient rehabilitation after a 2-day acute care stay. Upon physical therapy evaluation, the patient presents with flaccid left upper extremity and 1-2+/5 strength left lower extremity with proximal musculature stronger than distal. Lower extremity sensation equal bilaterally, diminished reflexes on left. Functional status as follows: bed mobility: moderate assist, bed to chair transfer: moderate to maximal assist with compensation noted, standing balance: poor, gait: dependent to maximal assist with no assistive device and left AFO three steps. Five times sit-to-stand test: 32 seconds (moderate assist required from physical therapist). Goals are set for supervision to modified independent with all functional mobility. Five times sit-to-stand goal: <20 seconds. Patient’s goal is to return home with spouse who works during the day and teenage daughter with an eventual goal of returning to work as a truck driver. Patient owns no DME and has five steps to enter a single-story home. His treatment plan consists of neuromuscular re-education interventions to focus on repetitive mass practice for regaining function to progress to ADLs, IADLs, and eventually return to work. Length of stay in inpatient rehabilitation facility is 10 days.
Day 1: Evaluation, five times sit-to-stand test, assess functional mobility, goals discussion, educate patient about repetition of functional tasks for neuroplasticity and recovery
Day 2: Practice seated static and dynamic balance activities on edge of bed and mat with emphasis on posture and alignment; bed mobility and transfer training with repetition. Functional status: minimal assist with bed mobility and level transfers, patient requiring verbal and tactile cues to decrease compensation
Day 3: Continued work on sitting balance, progressing dynamic balance activities to reaching beyond base of support with right upper extremity, weight bearing on left upper extremity, weight shifting within and beyond base of support: work on forward lean in preparation for sit-to-stand progression; sit-to-stand training with moderate to maximal assist, and cueing to maintain midline and promote symmetry
Day 4: Sit-to-stand progression from high surface with minimal to moderate assist, continue emphasis on symmetry and inhibiting compensation, static standing balance work with minimal to moderate assist with increasing time. BWS treadmill training with maximal manual assist to advance left lower extremity. .4 meters per second, 15 minutes duration. Sit-to-sit transfer now minimal assist
Day 5: BWS treadmill training .8 meters per second, 20 minutes duration BID with moderate to maximal assist to advance left lower extremity; minimal assist for sit-to-stand from standard wheelchair height, decreased cueing for symmetry, posture, and alignment; balance activities/gait training over ground in harness and rope/pulley device in ceiling track system with bilateral platform walker, emphasis on pre-gait: stance on left lower extremity, stepping to varying height targets with right lower extremity—moderate to maximal assist for balance and stabilizing left lower extremity. Five times sit-to-stand test: 27 seconds, minimal assist
Day 6: BWS treadmill 1.0 meters per second, 20 minutes, moderate manual assist to advance left lower extremity; continued gait training in harness and ceiling track system with bilateral platform walker and left AFO 50 feet—moderate assist for stabilizing and advancing left lower extremity. Stairs training minimal to moderate assist for six steps using one handrail; sit-to-sit transfer now supervision to modified independent, stand pivot transfer now minimal assist. Five times sit-to-stand test: 22 seconds, supervision to minimal assist
Day 7: Computerized balance system training in harness and ceiling track system to work on balance recovery with small perturbations; weight shifting in stance within and outside of base of support—minimal assist for left lower extremity stabilization. Repetitions with sit to stands from progressively lowering height; stand-pivot transfer training minimal assist to supervision; smart treadmill training 1.0 meters per second 3×5 minute bouts in harness and ceiling track system using left hinged AFO; gait training in harness and ceiling track system with bilateral platform walker and left AFO 100, 150 feet minimal assist
Day 8: Smart treadmill training 1.0 meters per second 5×5 minute bouts in harness and ceiling track system using left hinged AFO; over-ground gait training with rolling walker with left walker splint, left hinged AFO, minimal assist 100, 150, 150 feet; computerized balance system dynamic balance training on compliant surface with bilateral upper extremity support. Basic transfer status: supervision to modified independent. Twelve stairs minimal assist with one handrail; five times sit-to-stand test: 20 seconds supervision
Day 9: Computerized balance system training with progressive difficulty weight shifting outside base of support; gait training over ground with rolling walker and left walker splint and left hinged AFO supervision 300 feet x 2, 12 stairs supervision with one handrail, transfers modified independent, five times sit-to-stand: 19 seconds
Day 10: Discharge home with family, patient to return for daily outpatient therapy RM
Doug Glenn, PT, MPT, received a Master’s in Physical Therapy from The University of Mississippi Medical Center. He has been employed by HealthSouth for 15 years with concentration in the management of patients that have suffered CVA and brain injury in the acute rehab setting. Glenn serves as a mentor in the neuroresidency at the Medical University of South Carolina. NDT and Neuro-IFRAH trained. Currently, he is Director of Therapy Operations and member of the Stroke team at Anmed Health Rehabilitation Hospital in Anderson, SC—a JCAHO Disease Specific Certified hospital for stroke rehab. For more information, contact [email protected].