Thanks to a better understanding of brain plasticity, the approach to post-stroke therapy has changed dramatically in the past few years. Just 5 years ago, for example, it was widely held that patients had only 6 months to a year to make functional gains after a stroke.

"That's no longer true," says Kay Wing, PT, DPT, NCS, GCS, founder and president of SWAN Rehab in Phoenix. "There's just a plethora of information out there showing that the brain can and does change, but it takes the right interventions to make it change."

Driving brain plasticity for post-stroke patients means intense physical therapy that stresses thousands of repetitions. To give these patients the intense therapy they require, many neuro-rehabilitation specialists incorporate repetition-reinforcing equipment, such as partial-weight-bearing treadmill systems, into their treatment plans.

These machines and other products are designed to give patients immediate feedback on their progress, and are often instrumental in helping patients improve more quickly. This is vital in a health care system that does not generally reimburse well for stroke rehabilitation.

"We're really obligated to push people harder than we have in the past because services are becoming more and more limited," says Jeffrey M. Hoder, PT, DPT, NCS, assistant professor of rehabilitation medicine at Emory University School of Medicine in Atlanta. "So, if you have the equipment available to you, you are doing your patients a disservice by not utilizing it. We have to get people better faster."

IMPROVED GAIT TRAINING

Learning to walk again is often the first priority for the 590,000 Americans who survive a stroke each year.¹ Even more important is being able to stand from a sitting position and to transfer, which is why gait training encompasses these skills as well.

"It doesn't do you any good to be able to move one foot in front of the other if you can't get out of a chair," says Wing, who adds that not being able to stand from a sitting position is a leading reason why post-stroke patients are moved out of their homes and into care facilities.

Wing, who is also the president of the Arizona Physical Therapy Association, uses gait training to focus on walking speed for post-stroke patients as well. Recent research suggests that walking speed can be used to predict a patient's mortality.²

In the past, PTs often relied on their own two feet to help post-stroke patients walk over ground—a physically tiring process for therapists that often forced them to cut these exercises short. But the introduction of the partial-weight-bearing treadmill system changed all that.

"We found out that we could bring people through hundreds of gait cycles instead of dozens," Hoder says. "It allowed us to push people a lot harder than we ever could in the past."

It also gives PTs a better opportunity to observe patients during their training, make adjustments, and focus on the therapy itself—rather than on physically supporting the patient and the additional safety concerns that involves.

Partial-weight-bearing treadmill systems involve a portable frame from which a patient is suspended by a harness that goes around the pelvis and hips. Carol Wamsley, PT, who uses the LiteGait system from Mobility Research at Good Shepherd Penn Partners (GSPP) in Philadelphia, notes that either the patient's feet can be in contact with the ground, or a percentage of their body weight can be deweighted to facilitate movement.

"They may have some weaknesses—typically on one side of the body," she says. "By having the support of the harness, it may take some of the load off their limbs, so they can use their available strength to perform a walking pattern."

Wing, who also uses the LiteGait system, notes that these systems are successful not just for patients with low-level functionality.

"With higher-level patients, you can work on gait quality, gait speed, and higher-level gait patterns such as tandem walking and backward walking," she says. "You can also take the LiteGait off of the treadmill to work on over-ground training and balance training."

Hoder has used several partial-weight-bearing treadmill systems, including the Biodex model, and notes that they each have their pros and cons. "The Biodex allows more trunk mobility and allows the person to vertically displace up and down when they're walking, which is more like natural walking," he says.

Most patients adapt to using a treadmill system fairly well. To help patients make the adjustment, Hoder will sometimes walk with the patient over the ground using the treadmill's training harness as a gait belt before making the transition to the machine itself.

"I show them that, for unweighting, the machine becomes what I did," he says. "It gives me the freedom to work on the quality of their movement, or change the speeds to push their system to work harder."

Of course, there are other products to help with gait training as well. Wing swears by the Bioness NESS L300 as an effective intervention for foot drop. The unit, which consists of a cuff around the calf and a sensor in the patient's shoe, uses electrical stimulation to raise the foot during walking—eliminating the need for a plastic or metal brace.

"If somebody's in a brace, they don't get any motion in their ankle because they're just fixed in one position," Wing says. "When they're in an electrical stim unit, they get range of motion with each step; plus they get muscle contraction with each step." Bioness offers a similar product for the hand, the NESS H200, which Wing uses as well.

BETTER PATIENT FEEDBACK

Biofeedback displays are an essential element of today's stroke-rehabilitation equipment.

"I like the idea of giving patients biofeedback and being able to set goals for them," Hoder says. "It motivates people, but it also allows us to set objective goals about their improvements, which is really important."

It also gives patients a clearer understanding of their progress than relying on the PT's verbal feedback alone.

"If you say ‘good' enough, it loses its meaning," Hoder says. "So, it's nice to show people objectively how they're improving."

This is particularly true when it comes to balance, which is why Wamsley has been pleased with the biofeedback features of the Balance Master from NeuroCom. This computerized system features a pressure-sensitive platform that can detect how much a patient is weight-bearing on either leg and determine their limits of stability. It can also perform clinical tests for sensory integration of balance, in addition to a variety of other balance and functional mobility tests.

The device provides patients with sensory feedback, visual feedback, and numeric data that can be evaluated by the therapists as well as the patients themselves. Patients can see a graphical representation of a moving figure so that they can confirm whether or not they are swaying. When working on walking speed, they can set targets and find out how fast, far, and accurately they are moving.

"It's very hard to watch your own balance while you're balancing," says Wamsley, adding that she appreciates the foot positioning and consistency of the Balance Master system between one patient and the next. "So, this gives someone visual feedback."

GSPP also uses the Biodex Balance System SD, which comes equipped with handrails that are helpful for those who are just beginning to work on their balance. The clinic invested in the basic Balance Master model that features a fixed platform, so PTs use the Biodex model's tilting platform to train patients on varied surfaces.

	ON THE WEB: For additional information and articles on post-stroke therapy, visit our online archives and search for “stroke therapy.”
PTProductsOnline.com

"The Biodex Balance System and the Balance Master both provide some visual feedback to the individual," Wamsley says. "So, they have some similarities, and there are pros and cons for why you would select one device over another."

MORE ENGAGING EXERCISES

While thousands of repetitions are crucial to driving brain plasticity, that doesn't mean the exercises have to be boring.

Wing uses the Hand Mentor from Kinetic Muscles to help engage patients in hand exercises. Patients use a computer controller to play a variety of games that help improve their hand function.

"They can set goals and beat their goals," she says. "And it works on finger opening and closing and wrist flexion/extension."

The Foot Mentor product by the same company allows patients to practice the same games, such as "Pong," with their feet.

Wing also uses the SaeboFlex by Saebo to help strengthen the arm and hand and to improve spasticity. This mechanical orthotic is spring-loaded to help patients voluntarily open and close their hand to perform tasks such as grabbing and releasing a ball.

"It also helps with shoulder function and strength because they have to grab the ball, and then they have to move it to someplace else," Wing says.

NEURO-SPECIFIC THERAPY

Products for stroke rehab aren't always high-tech. For example, having the correct walking aid—a quad cane versus a single-point cane—is critical for patients who need assistance walking. For patients who use wheelchairs, finding the right fit with the correct cushion is also important. Lift devices are also important to help transfer patients, especially during acute rehab.

Often, stroke rehab specialists use the same types of equipment that orthopedic rehab professionals use.

"It's the same equipment, just a different utilization of the equipment," Wing says." You just treat patients with neurological disabilities different than you do those with orthopedic disabilities."

For example, therapy balls are often used for core strengthening on the orthopedic side—while in a neurological clinic, they might be used more for balance or training patients to hold an object bilaterally. Mat tables are also used in both disciplines.

"The mat tables would be used for neuromuscular reeducation with rolling and bridging and scooting and transfers, as opposed to in an orthopedic clinic, where they might be used for short-arc quads, knee rehab, and straight-leg raises," Wing says.

No matter what type of equipment is used in stroke rehab therapy, however, giving patients the opportunity to perform thousands of repetitions is the key to success.

"We know the brain is plastic, but to drive the system to change requires intense intervention and a lot of practice," Hoder says.

Ann H. Carlson is a contributing writer for Physical Therapy Products. For more information, contact .

REFERENCES

1. Complete Guide to Stroke. The National Stroke Association, 2003. hwww.stroke.org/site/DocServer/NSA_complete_guide.pdf?docID=341. Accessed December 10, 2009.
2. Nainggolan L. Walking speed predicts CV mortality in older people. Heartwire. WebMD; November 10, 2009. www.theheart.org/article/1020311.do. Accessed December 10, 2009.

A Team Approach

Providing treatment for acute stroke patients is a team effort at Good Shepherd Penn Partners (GSPP), a joint venture between the Good Shepherd Rehabilitation Network in Allentown, Pa, and the University of Penn Health System in Philadelphia. Specialists from a variety of disciplines come together to direct and supervise the patient's treatment to ensure the best possible care.

The core of the team is made up of a physiatrist, a physiatry resident, a full complement of therapists—physical, occupational, and speech—and nurses, as well as a social service worker. Often a neuropsychologist and a psychologist are also involved.

"Any number of other professionals may be a component of the team," says Carol Wamsley, PT, of GSPP. For example, if a patient also had a lung transplant, a member of the transplant team may be involved. Specialists such as neurologists or cardiologists may also be part of the team.

Three times a week, representatives from each discipline convene for morning rounds to go over the patient's progress as well as hindering factors, such as accessibility issues in the patient's home. The team also holds weekly conferences to discuss the care plan, and the results of these meetings are recorded in written reports.

The idea is to facilitate communication so that everyone is on the same page as far as the patient's goals, progress, and treatment are concerned.

"We're all coordinating what we're doing to be able to provide the best care to the patient," Wamsley says.

Wamsley notes that the patient and the patient's family members are also vital members of the team. Special team meetings are held with the patient and his or her family members to discuss progress and address any questions they may have.

"We involve them from the beginning," Wamsley says. "We don't work on the discharge on the last day. That process is started with the team, the patients, and families at the point of admission."

Patients receive a total of 3 hours of therapy per day for 5 to 7 days per week, and family members are encouraged to observe and participate in these sessions early on. Physical therapists educate family members about stroke, stroke prevention, and the effects of the stroke on their loved one. They also show family members how to assist the patient with walking, standing, and performing exercises.

When working with family members, Wamsley notes that it is important to remember that they will need to be eased into the role of caregiver—a responsibility that many of them have never had to take on before.

"For some family members, it can be a total change in lifestyle, not just for the individual who's recovering from the stroke," Wamsley says.

Thus, she recommends being welcoming to family members and making sure they know that they are a valuable part of the team. She also encourages patience, as it takes time for family members to bridge the gap between their own goals and expectations and the reality of how the patient is functioning.

"That's not an overnight process," Wamsley says. "The families need time to evolve and develop recovery from this, as well as the patient."

—Ann H. Carlson

Product Resources

Physical Therapy Products has compiled a brief list of companies that offer products for the stroke/neurological rehabilitation list. For a complete list, visit our Online Buyer's Guide.