The next chapter of rehab involves high-tech robotics, virtual reality and interactive gaming.

By Jonathan Bassett

What do Woodrow Wilson, Franklin Delano Roosevelt and Dwight Eisenhower have in common?

All are former U.S. presidents, of course. All steered the nation through times of widespread global conflict and left highly regarded legacies in U.S. history.

But they also share a less publicized link—each one sustained a stroke while serving in the country's highest office. What's more remarkable is how the repercussions, though largely downplayed at the time, may have changed the course of history.

Wilson was so incapacitated following a series of strokes that his wife Edith became his de facto representative, leading many to proclaim her "America's secret president." Roosevelt died of a massive stroke in April 1945, leaving the presidency to an unprepared Harry Truman just as World War II was winding down.

And Eisenhower's stroke, while only mildly debilitating, impaired his speech, concerned his advisors and prompted vice president Richard Nixon to take a more active role.

Given the current state of stroke rehabilitation, the consequences may have been different if these events happened today. Would the current options of 3-D brain imaging, clot-busting medications, microsurgery and rehabilitative robotics saved the lives of these presidents, and allowed them to return to office with full command of their faculties?

Until the middle of the last century, patients were discouraged from being active after a stroke. Today, researchers and engineers are busy writing the next chapter of stroke rehab. It's a high-tech world of robotics, virtual reality and interactive gaming, and it aims to push patients to reach higher levels of recovery.

MEETING OF THE MINDS

Allied Services Rehabilitation Hospital (ASRH) in Scranton, Pa., is where the "rubber meets the road" in stroke care. Up until a few years ago, this mountainous region of northeastern Pennsylvania ranked second only to Miami in highest median age among residents.

"We're a hardworking, family-oriented community," says Michael Wolk, MD, medical director of ASRH. "People remain in their homes, and we have to be prepared to serve their needs as they age."

A big part of this calling is stroke care. And even though ASRH doesn't boast university affiliation or have the resources associated with a large, multi-state care network, Dr. Wolk and his staff must stay attuned to the fast pace of engineering enhancements and make modern designs available to patients recovering from stroke.

When a new patient is admitted, the care team assembles to discuss the patient's impairments and map out a general rehab plan that encompasses traditional and modern techniques. And stroke care at ASRH is assuming a more contemporary look. Sophisticated gadgets are helping patients complete the longer, more intense therapy sessions that can restore damaged neural pathways and return function, sometimes years after the event.

What's happening in Scranton is indicative of a larger trend across the country, as high-tech rehab devices that used to carry hefty six-figure price tags and were available only in research institutions and university labs are sprouting up in mid-sized rehab hospitals and smaller outpatient clinics. Manufacturers are designing portable, accessible units, patients are requesting state-of-the-art treatments they see on television and the Internet, and the federal government is funding trials to determine the validity of these miracle machines.

SMOOTH MOVES

One of the most profound developments has been the move toward bodyweight-supported treadmill training, says Dr. Wolk. And that's good news for the 53 percent of stroke survivors who cite movement and mobility as their top rehab concern, according to a recent survey by the National Stroke Association.

By offloading a portion of the patient's weight by using a harness, patients can initiate walking therapy sooner, leading to more dramatic results.

A recent study at Baylor Institute for Rehabilitation (BIR) in Dallas found that initiating early treadmill training (less than 6 weeks post-stroke) before walking over ground produced results. This therapy improved gait by increasing knee flexion during swing, restored normal ankle kinematics at initial contact and terminal stance, assisted gait symmetry, and raised walking speed and distance as measured by the 6-minute walk test.

"In my 14 years as a physical therapist, I have not treated seven stroke patients that walk this well," says Karen McCain, DPT, NCS, a physical therapist at BIR and lead author of the study, referring to the group who received treadmill training. "We are definitely on to something."

The key, says Dr. McCain, is early intervention. "All of the patients started on the treadmill as soon as possible during the acute period of recovery after their stroke," she says. "We wanted to keep these abnormal gait patterns from developing in the first place."

New modifications to the treadmill theme are now being tested at facilities nationwide. An ongoing study at the University of Delaware (UD) in Newark is looking at a split-belt treadmill that can independently operate each side at different speeds and in alternate directions. Researchers feel that this treadmill can improve walking symmetry and stability by restoring coordination between the limbs.

"The preliminary results are very positive," says Darcy Reisman, PT, PhD, research assistant professor of physical therapy at UD. "This is the first study that has shown that we can influence asymmetry in post-stroke walking." Future phases of the study will attempt to determine if these results can be permanent.

Other trials are looking at the addition of robotic attachments that automatically place patients' feet on the treadmill—a task that used to require several therapists. At Moss Rehab in Philadelphia, patients complete robot-aided walking while sensors track movement functions and alter speed and intensity to match a user's ability.

"We don't rely on the machine exclusively, but it's an effective way to introduce early walking in acute patients without the need for multiple therapists," says Lisa Werner, PT, an inpatient therapist at Moss. The robotics allow her to focus on guiding posture, gait mechanics and foot strike as the patient walks.

MIRACLE MACHINES

While walking impairments are the leading cause of stroke-induced disability, upper extremity function is another common barrier between patients and independent living. Contemporary devices are being designed to return function to paralyzed arms and hands through repetitive, intense practice, which allows the brain to circumvent damaged neural pathways.

Melissa Morris, a PhD student at The Technion-Israel Institute of Technology in Haifa, Israel, has been interested in health-oriented technology since learning about surgical robotics in high school. As an engineering graduate student at Florida Atlantic University in Boca Raton, Morris conceived the idea for a robotic cable-driven device to aid stroke patients during recovery.

Working with adviser Oren Masory, PhD, Morris built a device comprised of motors, cables and spools, and enclosed it in an acrylic case with a joystick handle that's indirectly connected to the system through magnetic attraction. The device challenges a patient to follow a preprogrammed path that corresponds to traditional physical therapy repetitions, adding assistance or resistance as needed.

"The benefits of using a robot are that it can perform the repetitions with almost perfect accuracy, it can go as long as the patient is willing, and it works on the patient's schedule," says Morris. "The quantitative judgments rendered by the device give a clear picture to the therapy team of progress made and persistent problem areas to be addressed."

This therapy capitalizes on the concept of haptics, which uses the perception of touch to help patients see and feel daily tasks and improve specific fine motor skills and hand-eye coordination. By repeating a single task, patients learn to control objects in a smooth, precise manner.

Manufacturers are building on this concept by designing PC-based systems that use joysticks to move objects on a computer screen. Robotics engineers at Rice University have teamed with doctors at Memorial Hermann/TIRR in Houston on a 2-year study of a prototype system that uses a joystick outfitted with motors to help patients practice hand-eye coordination.

"The computer can precisely measure how a patient responds to every single exercise," says Marcia O'Malley, director of Rice's mechatronics and haptic interfaces laboratory. "This precise, measurable feedback provides a great advantage over the subjective evaluations currently in use."

Robotic technology is also taking the form of external, electrode-equipped prosthetic arms that stimulate and activate hand muscles that have been affected by a stroke, and sophisticated EMG-controlled systems that use electrodes, biofeedback and e-stim to re-educate compromised arm and leg muscles. Patients complete repetitive grasping and releasing motions, and can practice activities of daily living to increase functional hand use.

"This therapy accelerates the traditional steps in therapy to improve upper limb function," says Dr. Wolk. "It can move certain patients further along the rehabilitation curve more quickly." In addition, functional electrical stimulation (FES) can also be fitted to a patient's legs to help complete walking motions, he says.

THE FINAL FRONTIER?

One of the newest—and somewhat controversial—directions in modern-day stroke rehab involves computer gaming and virtual reality. Video manufacturers are offering therapy-specific games to rehab markets, and patients are responding.

But video gaming poses an intriguing quandary in health care. While detractors claim that video games are the antithesis of all things movement, proponents look for ways to exploit their inevitable popularity by bridging the chasm between exercise and computers.

"We believe there's a huge opportunity to improve health through gaming," says Chinwe Onyekere, MPH, program officer at the Robert Wood Johnson Foundation (RWJF), which recently launched an initiative to fund research into video gaming for health applications. The program shares its findings with game developers to steer future games toward healthier ends.

One RWJF-funded grant was recently awarded to the University of South Carolina Research Foundation to compare the effects of two popular video game systems on patients' mobility, balance and fear of falling after a stroke.

Gaming "involves a challenge to reach a goal," says Debra Lieberman, PhD, director of the RWJF initiative and a communication researcher at the Institute for Social, Behavioral and Economic Research at the University of California at Santa Barbara. "Patients work harder and reach further in their rehab when they have a game environment. They stop thinking about 'it hurts' or 'I can't do it.' "

Video gaming also translates to home use. Allowing discharged patients the opportunity to continue rehab at home is assuming greater importance, in light of insurance restrictions.

The National Institutes of Health recently funded the development of a compact, portable in-home exercise device to help activate new brain pathways to improve arm function. The device relies on bilateral arm training with rhythmic auditory cueing. Researchers observed that it helped stroke survivors improve the ability to control movements and compensate for damaged parts of the brain more than 6 months after a stroke, according to a 2004 study in The Journal of the American Medical Association.

"There seems to be some benefit of improved motor function in a significant portion of the people we have tested some years after their stroke," says Jill Whitall, PhD, professor in the department of physical therapy and rehabilitation science at the University of Maryland School of Medicine.

Morris also designed her cable-driven device with an eye on home use and patients without insurance, and sees potential for a safe and marketable product for long-term home rehab. "Therapists can even observe a patient's progress from a remote location," says Morris, who crafted the device with the capacity to be pre-programmed for long-term sessions.

KEEPING IT REAL

While 21^stcentury rehabilitative robotics has inspired quantum leaps in applications for stroke sufferers, some question the overall value of robotic technology in a hands-on medium. Relying on technology too heavily, they feel, places patients in a passive role. Instead, active therapy is the true goal.

A study in Stroke found that therapist-assisted walking therapy was "significantly more effective" than robot-assisted training among 48 patients who'd suffered strokes at least 6 months prior.

"Stroke patients improved their walking whether they had the robotic device or the therapist helping them," says T. George Hornby, PhD, MPT, assistant professor in the physical therapy department at the University of Illinois-Chicago and the study's lead author. "However, the amount of improvement was greater in the therapist-assisted group."

Dr. Hornby hypothesizes that the lower improvement among the robotic group could be because the machine didn't account for human error, and placed patients into a passive, restricted role. "When learning to walk again, if people can make mistakes and realize their errors and change their behavior based on those errors, they may learn better," says Dr. Hornby. He feels that robotic devices may be better for acute stroke patients who have little or no ability to walk on their own.

At Moss Rehab, bodyweight-supported treadmill training and robotic-assisted upper extremity training is always used as an adjunct, rather than the central part of care, says Matthew Vnenchak, MS, PT, NCS, an outpatient therapist at Moss.

"There's always the concern that robotic-assisted therapies are too passive for the patient, and that therapists can become too dependent on them," says Vnenchak. "We find we achieve better results with the patient assuming an active role in the recovery." n

Jonathan Bassett is senior associate editor of ADVANCE, and can be reached at jbassett@advanceweb.com

High-tech devices: At what cost?

There's no debate regarding the potential for motor recovery using the latest advances in stroke technology. However, one area of concern is affordability. Many high-tech devices are being offered at top rehab hospitals across the country. But that's often where the high-tech road ends.

Because of high costs and limited insurance reimbursement, many patients can't use these devices at home to carry out an ongoing rehab program. As a result, their access to daily therapy is limited.

Many recent neurological advances are affordable and covered by insurance carriers, including Medicare. For example, functional dynamic orthoses have become more popular over the last 5 years. These custom-fabricated orthoses are spring-loaded and allow neurological patients to perform volitional grasp and release activities. An extensor spring mechanism assists with opening the fingers and thumb following functional grasp.

These orthoses don't contain electrical parts, and patients learn to actively grasp and release without machine assistance. Insurance coverage allows patients to acquire the devices for treatment and home use. The most appropriate patient populations for this therapy have impaired arm and hand function.

Functional orthoses continue to be a major component to neurological rehab. As new, high-tech stroke devices emerge into the rehab sector, affordability and overall efficacy are challenges that must be addressed. Effective, less-expensive alternatives should be considered.

Henry Hoffman, MS, OTR/L, is a clinician in Charlotte, N.C.

Tracking the causes of foot drop

Older patients are at risk for many problems, including foot drop. Foot drop is the inability to actively dorsiflex a foot during the swing phase of gait. Testing may classify the dysfunction as a weak anterior tibialis muscle. This situation can be due to a central nerve problem from a cerebral vascular accident, traumatic brain injury or multiple sclerosis. Other patients may experience the same problem due to peripheral nerve pathologies, demyelinating disorders or peripheral neuropathy. These peripheral causes often accompany other medical concerns, such as neuropathies induced by chemotherapy or cauda equina syndrome. Traditional treatment of foot drop often includes a multidisciplinary approach among therapists, doctors and orthotists.