In business for almost 60 years, REHAB Hospital is proud of its legacy of providing rehabilitation with "aloha." Its 70-bed acute facility and three outpatient clinics serve more than 6,000 patients each year with strokes, traumatic brain injuries, spinal cord injuries, orthopedic and sports injuries and general rehabilitation needs.
In 2009, REHAB Hospital reorganized its outpatient clinics to meet escalating economic and regional competitive demands. One year later, its flagship Honolulu outpatient clinic underwent a metamorphosis with a precise business plan that identified necessary changes in facilities, services and marketing strategies with the ambitious goal of increasing revenues by 20 percent.
In addition to a complete facilities renovation designed around new clinical programs such as Clinical Pilates and an East West Rehabilitation Program, REHAB Hospital's new Innovation Center was instituted as a "think tank" to synergistically combine emerging technologies into clinical practice for maximal patient outcomes.
REHAB Hospital's Innovation Center has three goals: to seek breakthrough technologies, innovative methodologies and emerging trends; to inspire clinicians to implement the highest standards of care; and to advance program development to bring the most powerful treatment options to each patient.
To integrate high-tech into Hawaii's intense high-touch "island family" culture appears, on the surface, to be incompatible. But with technology comes the ability to engage a patient dynamically in the recovery process, creating a strong partnership between patient and therapist.
In Hawaiian, the word is "kokua," or cooperation; an integral part of Hawaii's high-touch culture.
Treating Stroke Survivors
In February of this year, at the recommendation of the Innovation Center's Advisory Council member Nancy Byl, PT, PhD, REHAB Hospital introduced a bionic leg into its outpatient stroke program. A few months later, it was implemented into the inpatient program.
The bionic leg is a wearable "intention based" robotic device that uses highly sensitive motors to provide assistance and "training" to the affected leg of a stroke survivor. A foot sensor inside the patient's shoe detects the patient's weightbearing status that is customized by the therapist to trigger the bionic leg's motors. Once the patient demonstrates the proper weight bearing status, the bionic leg's high-torque motor applies the predetermined percentage of "unweighing" necessary to equalize the strength of the affected leg with that of the unaffected leg. This equalization enables stroke patients to perform many high-level functional activities such as walking and climbing stairs with significantly reduced assistance.
A Paradigm Shift
Traditional rehabilitation protocols rely on compensatory strategies such as the use of a walker or quad cane after a stroke because of demand for functional outcomes as quickly as possible. This biomechanically changes the natural bipedal gait pattern and reinforces a pathological gait pattern during the critical initial recovery period, resulting in long-term balance vulnerabilities and secondary pain due to functional physical asymmetries.
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A therapist at Rehabilitation Hospital of the Pacific (REHAB) helps a patient with stroke use a bionic leg during gait training.
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With the bionic leg, its inherent design of using a customized weight-bearing sensor to activate motion addresses not only what therapists have been encouraging for years-"shift your weight"-it is encouraged through a dynamic sensory experience that becomes naturally intuitive to the patient. More importantly, with its very snug fit and strong hold around the knee joint, patients begins to "trust" the bionic leg once they acclimate to its "assistance." Patients feel safe using their affected leg much more aggressively then they would otherwise. This allows patients to actively engage in the intense, repetitive exercises necessary for neuroplasticity and true recovery of motor function.
Stair climbing is an excellent demonstration of the advantages of robotics for rehabilitation. The challenge of going down stairs or down curbs independently is heightened by the fear of tumbling forward. Eccentric muscle contractions, or the controlled lowering of the body, not only ignite tremendous apprehension, but require more stability.
On stairs, most patients are taught to use a step-to pattern versus a reciprocal pattern for safety reasons. However, this reinforces the asymmetrical strength and motor pattern of the affected versus non-affected leg.
With the bionic leg, most patients can immediately begin a reciprocal pattern on the stairs as the bionic leg provides a comforting "resistance" customized by the therapist to assist with the eccentric lowering of the body.
With the bionic leg on, patients often feel confident enough to practice aggressively, and over time, with a programmable decrease in assistance, the patient demonstrates strong carryover of functional recovery without the leg.
Optimizing functional alignment as soon as possible and consistently after a stroke becomes critical for the prevention of secondary and tertiary issues that can significantly impact a patient's outcome, both physically and emotionally. Once implemented and utilized as a functional pattern, compensatory and pathological patterns become increasingly difficult to change over time.
However, even with the chronic stroke survivor, the bionic leg is still able to provide that intuitive sensory experience to facilitate the normalizing of motor patterns to improve a patient's balance and dynamic function. Plasticity of the neurologic system requires both stress/challenge and repetition. Robotic equipment such as the bionic leg can do that.
Efficiency and Hope
Rehabilitation providers today face overwhelming challenges to providing optimal care, with rapid reductions from third-party payer systems. That pressure translates to the critical need to maximize efficiency with each treatment session.
New technologies like the bionic leg facilitate faster functional outcomes, and its design emphasizes optimal functional alignment to get a patient walking faster while allowing the patient to intuitively self correct.
Contrary to common methods used by therapists, physical rehabilitation is not a cognitive task taught through verbal instructions; rather, it is sensory-based learning that needs to be experienced repeatedly. The critical shift in which the patient becomes engaged in the intuitive sensory experience of what their body needs to do allows for real learning and motor recovery.
One of the most important things a therapist must do is provide hope during rehabilitation. This sets off a positive cascade including self-motivation, commitment and continued progress, even when formal therapy has concluded. Therefore, the high-touch element so integral to the Hawaiian culture becomes further enhanced with technology, as therapists facilitate motor recovery and a patient's confidence and sense of hope.
Teresa Wong is executive director of the REHAB Innovation Center, Honolulu, HI.