by Cheryl Miller-Scott, DrOT
Technology continues to infiltrate every aspect of daily life, and modern healthcare has not escaped this trend. The average adult spends nearly 45% of their waking hours using technology. Ninety percent of American adults own a cell phone,1 64% own a smartphone,1 87% use the Internet,2 and 72% of Internet users have used the Internet to look up some form of health information.3 In the US, 69% of adults track at least one health indicator to maintain a healthy life, with 21% of that same group reporting they now track this information using some form of technology.4 The use of technology in the healthcare environment has become commonplace, and this trend is exemplified by the adoption of electronic health records, mobile health devices, remote health monitoring tools, wearable devices, and real-time locating services.
As the landscape of healthcare becomes based increasingly more in measures of quality and performance, the rehabilitation industry has likewise expanded the use of technologies that contribute to a patient’s experience, quality of care, outcomes, collection of measurable data, and an enriched environment. Healthcare providers are challenged to balance a steady stream of emerging technologies with evidence that supports the role of those technologies in providing direct patient care.
Historically, organizations that fail to innovate inhibit the experimentation and reflection that are vital to sustainable success in an unpredictable and evolving business environment.5 Future and sustained success for rehabilitation providers may be dependent on their ability to be innovative and to experiment with advances in the field. However, with the volume of new products being brought to market, it is increasingly difficult for rehabilitation managers to make well-informed decisions about which innovations or technologies are most appropriate to embed in their rehabilitation environment. Managers of rehabilitation environments should have a well-defined selection process to determine which technologies may prove safe and beneficial to their patient population and rehabilitation environment. Staff and physician engagement toward the use of specific technologies will also impact the success of adoption.
The use of advanced therapy technologies can be an integral part of a rehabilitation program and enhance an organization’s ability to provide quality, evidence-based rehabilitation services. Though research about the use of technology in the rehabilitation environment is often conflicting, significant evidence supports the idea that the use of advanced therapy technologies can impact the patient’s outcomes and experience, the health and safety of staff members, and the amount of staff required to provide care. Advanced therapy technologies also may offer a differentiating factor that can promote an increased volume of referrals derived from the added-value services hospitals can provide. Rehabilitation hospitals are often seeking programming opportunities to differentiate themselves from other providers in the eyes of a consumer. Patients and families seeking rehabilitation, or physicians referring patients to rehabilitation environments, often view these advanced technologies as an added value to the standard care that is provided. Those stakeholders therefore may choose one setting over another if some advanced technologies are available.
An Enriched Environment
An enriched environment impacts the patient’s experience and the outcomes of rehabilitation. It likewise offers many benefits to the recovery process. The brain has characteristics of plasticity, which is a natural ability to reorganize following an injury or structural changes.6,7 Stroke rehabilitation programs should include meaningful, repetitive, intensive, and task-specific movement therapy in an enriched environment to promote neural plasticity and motor recovery.8 An enriched environment enhances motor and cognitive function through the alteration of neuroplasticity.9
One of the most promising interventions with clinical feasibility is an enriched rehabilitation, which is a combination of environmental enrichment and task-specific therapy.10 Therapies used in combination with technology offer an enriched environment and may be much more effective than single interventions in improving stroke recovery. Advanced therapy technologies contribute to the enriched rehabilitation environment when used in combination with meaningful intensive therapies. This article offers a short summation of some available technologies that rehabilitation managers may want to consider when creating a more enriched patient experience.
• Is the technology FDA approved?
• Is the technology considered safe for patient use?
• What is overall patient opinion or experience with the technology?
• Does the technology meet the needs of the primary patient population served?
• Do evidence and outcomes support the usage?
• Was the cost for the technology budgeted?
• What is the projected return on investment?
• Are services offered with the technology reimbursable?
• What added value does the technology add to programs?
• What is the ease of use for clinicians?
• What is the willingness of clinicians to use the technology?
• What is the setup time required by the clinician?
• What are the clinicians’ training requirements?
• Is any stored health information protected?
• What are physicians’ opinions on the use of the technology?
• What are the reporting capabilities of the technology?
• What are the required disposables and maintenance?
Regaining functional ambulation is technically difficult since there are many requirements for walking, including balance disturbances, motor weakness, and endurance. Several technologies have been developed to help therapists improve walking requirements. One example is gait analysis and sensor-loaded walkways—also sometimes referred to as gait mats. These are valid tools that can assist therapists in measuring step parameters needed to effectively and efficiently treat gait disturbances.11 The devices are engineered to collect and analyze pressure, temporal, and spatial data that can be used to perform ongoing assessments. In turn, these assessments can help determine a treatment plan’s validity as well as offer key justifications regarding the continuation of care. Some gait mats are designed to allow patients to ambulate independently or provide the option of ambulating with an assistive device.
Body weight support gait technologies provide partial body weight support to the patient during ambulation, thereby facilitating walking in rehabilitation for patients who cannot support full weight on their lower extremities. Body weight support technologies comprise a wide scope of options. Among them are the following: 1) mobile devices that can be used while walking throughout the environment; 2) overhead track systems that offer support over a predetermined path for therapy, including equipment such as curbs and stairs; and 3) treadmill devices, with or without robotics. The use of body weight support gait technologies enables early initiation of gait training and integration of weight bearing, stepping, and balance activities. It has many advantages over the conventional method of therapy, including less effort for the physiotherapists, longer session duration, more physiological and reproducible gait patterns, and the possibility of measuring a patient’s performances.12 Evidence is conflicting regarding the use of these devices. However, it suggests that the use of body-weight support can improve gait ability in stroke patients,13 and may facilitate adaptive processes related to motor control of walking in Parkinson’s disease patients.14
Electrical Stimulation Technologies
The use of electrical stimulation has long been used in rehabilitation settings for pain management and motor recovery, but new uses for electrical stimulation have recently emerged. Rehabilitation of the multifaceted factors of gait may benefit from a wide range of interventions and approaches in an enriched environment, such as functional electrical stimulation (FES).15 Gait training combined with cyclic neuromuscular electrical stimulation (NMES) reduces lower-extremity impairment and increases functional ambulation.16 The acute application of FES can change the ankle and knee kinematics and increase walking speed over a short distance in people with multiple sclerosis who experience foot drop.17 Also, FES may facilitate functional improvement of the hemiparetic upper extremity18 and enhance the upper-extremity motor and functional recovery of stroke survivors.19
Technologies that treat the upper extremities in rehabilitation have been embraced by many rehabilitation professionals who have incorporated the concepts of neuroplasticity, neuromuscular facilitation, electrical stimulation, functional arm training, and robotics. Upper-extremity repetitive, task-oriented activities can improve upper-extremity motor and functional performance20 and reduce muscle tone.21
Robotic devices may be used in rehabilitation environments as devices to enhance the therapeutic treatment provided or as assistive devices designed to support people with disabilities to perform activities of daily living.22 Robotic interactive technologies may improve upper-extremity motor recovery of stroke-related hemiparesis.23 Robotic devices also seem to have a beneficial effect on final functional gait outcomes24 and have been shown to enhance motor outcomes in patients with stroke, and the effects have been maintained for more than 3 years.25 Robotic therapies induce neuroplasticity, eventually leading to motor recovery. Intensive rehabilitation training results in neuroplasticity, which suggests that the brain is adaptable to rehabilitation even in chronic stroke. People who receive robotic electromechanical-assisted gait training in combination with physical therapy after stroke are more likely to achieve independent walking, as opposed to people who receive gait training without these devices.26
Extending the Possibilities
Each day, rehabilitation managers are faced with decisions that impact the care their therapists provide to patients. As technology becomes smaller, less expensive, more available, and more reliable, its use in rehabilitation will continue to evolve. Additional evidence is needed to substantiate the most effective technologies, optimal dosage, and best procedures that rehabilitation managers should adopt in their settings. Leaders in rehabilitation should be looking to the future for opportunities to extend the use of technologies to provide long-term rehabilitation in the home and community through the use of telerehabilitation and possible bundled care models. RM
Cheryl Miller-Scott, DrOT, is a licensed occupational therapist and the national director of therapy operations for HealthSouth Corporation’s more than 120 inpatient rehabilitation hospitals. She is a licensed occupational therapist in the state of Florida, with more than 30 years of experience working with physically impaired adults and children. Miller-Scott also serves on the Board of Trustees for the American Occupational Therapy Foundation. For more information, contact RehabEditor@allied360.com.
- PEW Research Center. Mobile Technology Fact Sheet; 2014: Retrieved from http://www.pewinternet.org/fact-sheets/mobile-technology-fact-sheet/
- PEW Research Center. Internet User Demographics; 2014: Retrieved from http://www.pewinternet.org/data-trend/internet-use/latest-stats/
- Fox S, Duggan M. Health Online 2013; 2013: Retrieved from http://www.pewinternet.org/2013/01/15/health-online-2013/
- Fox S, Duggan M. Tracking for Health; 2013: Retrieved from http://www.pewinternet.org/2013/01/28/tracking-for-health/
- Edmondson AC. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. San Francisco, CA: Josey-Bass; 2012.
- Bach-y-Rita P. Brain plasticity as a basis of the development of rehabilitation procedures for hemiplegia. Scand J Rehabil Med. 1981;13:73-83.
- Bach-y-Rita P. Central nervous system lesions: sprouting and unmasking in rehabilitation. Arch Phys Med Rehabil. 1981;62:413-417.
- Takeuchi N, Izumi S. Rehabilitation with poststroke motor recovery: A review with a focus on neural plasticity. Stroke Res Treat. 2013;2013:128641. doi: 10.1155/2013/128641. Epub 2013 Apr 30. PubMed PMID: 23738231; PubMed Central PMCID: PMC3659508.
- Lee SS, Kim C, Jin YS, et al. Effects of home-based pulmonary rehabilitation with a metronome-guided walking pace in chronic obstructive pulmonary disease. J Korean Med Sci. 2013 May;28(5):738-43. doi: 10.3346/jkms.2013.28.5.738. Epub 2013 May 2. PubMed PMID: 23678266; PubMed Central PMCID: PMC3653087.
- Corbett D, Jeffers M, Nguemeni C, Gomez-Smith M, Livingston-Thomas J. Lost in translation: rethinking approaches to stroke recovery. Prog Brain Res. 2015;218:413-34. doi: 10.1016/bs.pbr.2014.12.002. PubMed PMID: 25890148.
- Websterm KE, Wittwer JE, Feller JA. Validity of the GAITRite walkway system for the measurement of averaged and individual step parameters of gait. Gait Posture. 2005;22(4);317-321.
- Schwartz I, Meiner Z. The influence of locomotor treatment using robotic body-weight-supported treadmill training on rehabilitation outcome of patients suffering from neurological disorders. Harefuah. 2013 Mar;152(3):166-71,182,181. Review. Hebrew. PubMed PMID: 23713378.
- Visintin M, Barbeau H. The effects of body weight support on the locomotor pattern of spastic paretic patients. Canad J Neurol Sci. 1989;16:315Y25
- Rose MH, Løkkegaard A, Sonne-Holm S, Jensen BR. Effects of training and weight support on muscle activation in Parkinson’s disease. J Electromyogr Kinesiol. 2013 Dec;23(6):1499-504. doi: 10.1016/j.jelekin.2013.07.012. Epub 2013 Aug 13. PubMed PMID: 23953762.
- Zackowski KM, Cameron M, Wagner JM. 2nd International Symposium on Gait and Balance in Multiple Sclerosis: interventions for gait and balance in MS. Disability Rehabilitation. 2014;36(13):1128-32. doi: 10.3109/09638288.2013.833306. Epub 2013 Sept 16. PubMed PMID: 24041009.
- Knutson JS, Chae J, Hart RL, et al. Implanted neuroprosthesis for assisting arm and hand function after stroke: a case study. J Rehabil Res Dev. 2012;49(10):1505-16. PubMed PMID: 23516054; PubMed Central PMCID: PMC3605749.
- Scott SM, van der Linden ML, Hooper JE, Cowan P, Mercer TH. Quantification of gait kinematics and walking ability of people with multiple sclerosis who are new users of functional electrical stimulation. J Rehabil Med. 2013 Apr;45(4):364-9. doi: 10.2340/16501977-1109. PubMed PMID: 23407855.
- Hara Y, Obayashi S, Tsujiuchi K, Muraoka Y. The effects of electromyography-controlled functional electrical stimulation on upper extremity function and cortical perfusion in stroke patients. Clin Neurophysiol. 2013 Oct;124(10):2008-15. doi: 10.1016/j.clinph.2013.03.030. Epub 2013 May 22. PubMed PMID: 23706813.
- Boyaci A, Topuz O, Alkan H, et al. Comparison of the effectiveness of active and passive neuromuscular electrical stimulation of hemiplegic upper extremities: a randomized, controlled trial. Int J Rehabil Res. 2013 Dec;36(4):315-22. doi: 10.1097/MRR.0b013e328360e541. PubMed PMID: 23579106.
- Rosenstein L, Ridgel AL, Thota A, Samame B, Alberts JL. Effects of combined robotic therapy and repetitive-task practice on upper-extremity function in a patient with chronic stroke. Am J Occup Ther. 2008 Jan-Feb;62(1):28-35. PubMed PMID: 18254428.
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- Abdollahi F, Case Lazarro ED, Listenberger M, et al. Error augmentation enhancing arm recovery in individuals with chronic stroke: a randomized crossover design. Neurorehabil Neural Repair. 2014 Feb;28(2):120-8. doi: 10.1177/1545968313498649. Epub 2013 Aug 8. PubMed PMID: 23929692.
- Schwartz I, Meiner Z. Robotic-assisted gait training in neurological patients: who may benefit? Ann Biomed Eng. 2015 Feb 28. [Epub ahead of print] PubMed PMID: 25724733.
- Volpe BT, Ferraro M, Lynch D, et al. Robotics and other devices in the treatment of patients recovering from stroke. Curr Neurol Neurosci Rep. 2005;5:465 470.
- Mehrholz J, Elsner B, Werner C, Kugler J, Pohl M. Electromechanical-assisted training for walking after stroke. Cochrane Database Syst Rev. 2013 Jul 25;7:CD006185. doi: 10.1002/14651858.CD006185.pub3. Review. PubMed PMID: 23888479.