Therapists Kristin Myers, OTR/L, CBIS and Meredith Nichols, DPT, CBIS were invited to spend a week in China to share their experience of using a computer feedback system with Chinese therapists and physicians. During their time in China, they also demonstrated the concept of active and functional retraining following brain injury, and the seemingly novel idea of neuroplastic recovery, especially years after injury.
Myers and Nichols work in a post-acute brain injury program at CORE Healthcare outside of Austin, Texas. This program utilizes aspects of forced use theories and technology to improve functional outcomes for their clients. Their facility was initially one of only six in the United States to acquire and utilize this specific interactive biofeedback equipment. This computer-aided biofeedback system is one of many tools used at their program to facilitate neuroplasticity following traumatic brain injury.
They are currently collecting preliminary data to evaluate the clinical use of this technology to motivate their patients through mass practice. To reverse learned non-use after stroke, practice that has been clustered together (aka mass practice) has improved functional outcomes, such as seen in Edward Taub's clinical work using constraint induced therapy for stroke recovery.
The biofeedback computer system Nichols and Myers used combats the monotony of repetitive motions and encourages patients to work harder and move toward more complete recovery of function in less time. This work integrating mass practice and forced use theories using the computer system enabled them to be invited to spend a week in China earlier this year, where they shared their knowledge and expertise with Chinese physicians and therapists.
In a whirlwind tour, Myers and Nichols visited five hospitals, in five different major Chinese cities including Shanghai and Harbin, in five days. They had the honor of providing a picture of rehabilitation in America to over 500 Chinese therapists, doctors, administrators, and government officials.
New Concepts in Therapy
Though the concept of neuroplasticity was not new to some in the audience, the idea of active and functional retraining certainly was, and forced use seemed staggering. Nichols and Myers introduced and reinforced the idea that to regain lost ability, it is critical for the client to be active and involved in their rehabilitation. The Chinese approach to rehabilitation appears to focus on maintaining passive movement after injury, while not focusing on enforcing the active participation of the client. Repetitive practice in impaired areas facilitates the return of function, allowing for increased independence and ability. The assurance that healing and recovery are possible, even long after brain injury first occurs, appeared to startle many people in attendance, but also served to energize and excite the Chinese clinicians.
Culturally, the Chinese revere their elderly and are very caring toward their sick. They do not hesitate to anticipate their needs and physically assist them. The down side of this approach in rehab is that Chinese patients do not always get the benefit of practice in everyday movements. They are not always expected to do things for themselves and rely frequently on their family for their daily care.
While passive movement performed by therapists will maintain range of motion, the patient needs to make active movements to drive their recovery. Nichols and Meyers demonstrated the benefits of some of these concepts by using the biofeedback computer system with Chinese patients. Their work was well received, and they have been asked to return and share additional knowledge and expertise in the fall of 2013.
Evidenced by the new equipment already present in many of the clinics in China, the therapists and physicians are making advances in both physical and occupational therapy. Many clinics are on par technically with American systems, using the newest motorized Hi-Lo tables, balance systems, and exercise equipment with adjacent rooms devoted to massage, acupuncture, and herbal medicine.
Chinese physicians utilize a strong blend of both Western treatment options and Eastern medicine. These two American therapists got to see first-hand the effectiveness of traditional Chinese medicine, such as acupuncture, in use as a daily treatment for stroke. Similarities were also present as American and Chinese therapists discussed how best to prioritize treatment options within the restrictions of shortened lengths of stay in a rehabilitation setting.
It was noted, however, that bracing such as ankle-foot orthotics and hand splints, while present in the Chinese clinics, were not customized or utilized as part of their standard rehabilitation process as they are in the US. Bracing was used within the clinic as a treatment, but it was not evidenced to be issued to the patients for use after discharge from the rehabilitation setting. In addition to the clinical aspects, the Chinese were very interested in knowing about funding sources, therapist salaries, and numbers of rehabilitation facilities, as these reflected the importance of rehabilitation in the US.
As healthcare and technology evolves, it will be important for therapists to connect and network, not only in their fields of practice but across state, national, and international boundaries.
Erika L. Mountz MBA, OTR/L is director of rehabilitation at CORE Health Care, Dripping Springs, Texas. Meredith Nichols, DPT, CBIS is a graduate of University of Southern California. She has worked at CORE Healthcare in Dripping Springs, Texas since 2010. Kristin Myers OTR/L, CBIS is a graduate of University of Texas Medical Branch, Galveston. She has worked at CORE Healthcare for 3 years and in neurorehabilitation for 20 years. The technology referenced in this article is the Medi Tutor rehabilitation software from Meditouch Inc.