Reaching for an orange, gripping a fork, holding a pen – all are everyday activities we take for granted. Yet for an individual with limited hand or arm control, they are challenging and frustrating endeavors. Occupational therapists at Helen Hayes Hospital have an innovative device to help their patients regain the arm and hand function needed to perform tasks such as these – the Armeo R – -developed by the Swiss company Hacoma Inc.
The Armeo was designed for patients with hemiparesis, or muscle weakness on one side of the body, including individuals with stroke, traumatic brain injury and other neurological and orthopedic disorders. Through intensive, repetitive and task-oriented therapy, the goal is to enable patients to regain functional use of their weakened arm and hand.
The Armeo works the shoulder, elbow, wrist and fingers simultaneously, or separately. It neutralizes limb weight, enabling the patient to use residual arm and hand control to complete functional exercises, thereby regaining use of their impaired arm.”
The patient sits in a chair or a wheelchair directly in front of the Armeo, while an occupational therapist places their affected arm into the spring-loaded, adjustable arm support. Therapists can select from a range of exercises, all virtual reality simulations of real-life activities. One exercise mimics a food shopping excursion, with the patient picking up fruits out of a display case. In another activity, the patient is collecting raindrops in a paper cup. In all exercises, the patient receives immediate feedback on how they are doing. The therapist can alter the level of difficulty based on the patient’s cognitive and physical condition and progress. The Armeo also stores the patient’s therapeutic and performance data, allowing the therapist to accurately track and document the patient’s progress.
Patients enjoy this new, virtual reality based therapy as they feel more like they are playing a game than performing therapy, motivating them to continue and have fun with it. It acts almost like a diversion from the hand-on therapy they also receive. Because patients enjoy working with the Armeo, they stick with it and complete the exercises. It is being used with both inpatients and outpatients and has been shown to improve limb function.
The Armeo is one more tool we have at our disposal to help patients regain their mobility. It is an adjunct to our comprehensive rehabilitation services.
The NESS H200TM is an addition to the many treatment modalities utilized by occupational therapists at Helen Hayes Hospital. A neuroprosthetic and rehabilitation system distributed by Bioness, Inc., the NESS H200 facilitates improved motor control and function for individuals with stroke, acquired brain or spinal cord injury or other disorders of the central nervous system resulting in impairments of the arm or hand. When there is little or no movement in a hand, this device can give survivors hope and potentially more function.
The device is a portable, custom-fit wrist/hand orthosis (splint). It is noninvasive and functions utilizing a microprocessor that activates the muscles of the forearm and hand. The H200 can be used in two different ways: as a therapeutic modality to assist in improving the motor recovery of a weak or paralyzed hand, or as a functional tool for performing activities of daily living. It can also provide other benefits, such as increased range of motion, reduced stiffness, increased local blood circulation, improved awareness of the limb, reduced spasticity and muscle re-education.
Use and training are initiated during either inpatient or outpatient therapy by certified occupational therapists. Ultimately, the goal is for patients to use the device in a therapy-directed home program. Progress will be monitored at regular intervals and the program will be revised to maximize continuing progress. A typical outpatient program would be 12-16 sessions with periodic follow-ups.
Patients may continue to use the H200 as long as they are showing improvements in function and those with chronic disabilities may use the device for the rest of their lives to manage or minimize their impairments. While many factors affect outcome, including the severity of the initial impairment, time since injury and the patient’s follow through with the program, the H200 is one more tool therapists can use to improve function.
Evaluating and treating swallowing disorders:
A New Approach
Speech-language pathologists at HHH now offer Flexible Fiberoptic Endoscopic Examination of Swallowing, or FEES. The non-radioactive examination allows for the direct visualization of the pharyngeal and laryngeal structures in order to assess an individual’s swallowing function.
FEES is a valuable tool that enables a trained speech-language pathologist to evaluate a patient’s swallowing impairment, determine the best intervention, measure the effects of treatment and identify appropriate dietary modifications. The procedure may also be used as a therapeutic tool by providing visual feedback to show patients the effects of utilizing different swallowing maneuvers.
Individuals who report trouble or pain while swallowing are candidates for FEES, including patients with stroke or traumatic brain injury or spinal cord injury. In addition, patients who experience persistent coughing or throat clearing during meals, patients with tracheotomy or patients with a history of swallowing difficulty related to progressive neurological disorders can also benefit.
FEES is a safe, reliable and effective tool for the management of swallowing disorders and is available at Helen Hayes Hospital for both inpatients and outpatients.
Functional Electrical Stimulation (FES)
State-of-the-art Functional Electric Stimulation (FES) equipment is currently helping many patients at Helen Hayes Hospital regain their strength and cardiovascular fitness. While FES technology has been around for more than thirty years, recent advances have made the equipment much more user-friendly. Physical therapists, who have received specialized training in the use of the equipment, including how to monitor the settings to ensure maximum benefit to the user, use the FES bicycle with inpatients and outpatients.
FES technology can help people with many levels of disability, including those with multiple sclerosis, spinal cord injury, brain injury, Parkinson’s Disease, stroke and other conditions. It is also being used to help children with cerebral palsy improve their motor skills.
This high-tech bicycle provides patterned electrical stimulation to the surface of muscles, enabling adults and children as young as four to work their muscles. Surface electrodes are placed on one or both sides of the patient’s upper or lower body by the therapists. The electrodes are then connected to the computerized brain of the machinery that controls speed and resistance. It also measures the amount of effort the cyclist is exerting and automatically measures each patient’s progress.
Even patients who have lost voluntary control over their muscles due to spinal cord injury are able to bicycle with the help of the FES system. Patients can even use the FES equipment without transferring from their wheelchairs. The exercise relaxes spasms, improve circulation, maintains or increases range of motion, and prevents muscle atrophy that often accompanies lack of use.
Once patients leave the hospital to return home, they can access FES as an outpatient, or even obtain the equipment for home use. With computerized connections, the patient’s safety can be monitored and through feedback, resistance and stimulation can be adjusted remotely. Medicare now covers FES therapy for patients with spinal cord injury.
For more information about the outpatient FES Program at Helen Hayes Hospital, call (845) 786-4799.
Advances in research suggest that functional neuro-recovery offers tremendous potential in rehabilitation medicine. The rewiring of neural pathways or the recruitment of new pathways to control movement offer hope for the restoration of function following traumatic injury.
To harness this potential, Helen Hayes Hospital offers locomotor training using the state-of-the-art TheraStride system. The training is available to both inpatients and outpatients with incomplete spinal cord injury, as well as to patients with traumatic brain injury and stroke.
We now know that the central nervous system is malleable and can still adjust and relearn post injury. Locomotor training is an activity-based rehabilitative strategy that provides the sensory experience of walking, with the goal of re-training neural pathways, ultimately resulting in ambulation.
The TheraStride combines a support harness system and a treadmill with computer software that measures and evaluates the patient’s progress. Trained physical therapists provide the necessary manual assistance, facilitating extension of the hip, knee and ankle. Following step training using body weight support on a treadmill (BWST), the patient then progresses to over-ground walking training and finally to community ambulation training.
Locomotor training helps to improve balance, motor control, weight-bearing ability and the re-creation of a natural gait. While it is extremely appropriate for certain spinal cord injury patients, it is also a viable rehabilitative tool for individuals with stroke and other neurological conditions.
For information on locomotor training, contact 845-786-4799
Occupational therapists have helped to restore functioning and independence to hundreds of stroke survivors. Depending on the location and the severity of the stroke, therapists have typically been able to provide treatment that has improved a clients’ shoulder and elbow movements, however, the hand has presented more of a challenge. When a client presents with a tight fisted hand, therapists have had limited treatment options and success with making the hand more functional – until now.
The development of the SaeboFlex orthosis has changed this picture. With the SaeboFlex, a client can grasp and release objects for the first time since their stroke, providing them with new hope for improved function in their arm. The device and treatment makes functional tasks, such as dressing and feeding oneself possible.
The SaeboFlex is a mechanical, dynamic hand orthosis that is utilized to enable a person to incorporate their involved hand into grasp and release activities. It works based on a spring release system that positions the hand in the open, extended position. During therapy, the client then utilizes his or her increased muscle tone to squeeze a ball. Once the client relaxes, the springs move the fingers back into an extended position, allowing the client to drop the ball in a designated location. The client then reaches for the next ball and completes high repetitions of grasp and release activities.
This high repetition helps to improve the strength throughout the arm and generates more cortical (brain) involvement. Over the course of therapy, the client learns to control the increased muscle tone in their hand so they can regain functional use of their involved hand. Clients are encouraged to use the device at home, reinforcing their therapy.
A unique and valuable aspect of SaeboFlex treatment is that it can help individuals who are up to 20 years post injury. The length of time since the onset of injury does not matter as long as the client meets certain criteria. The most appropriate clients are those who are unable to open their hand, but have some shoulder and elbow movement. The device is also helpful for individuals who have had a traumatic brain injury or other neurological condition. The device is primarily used on an outpatient basis.
A potential client is evaluated by one of Helen Hayes Hospital’s Saebo trained clinicians to determine their appropriateness for the SaeboFlex orthosis. Once determined appropriate, the device is ordered and therapy begins. The potential for improvement does depend on the follow through of the client. Clients who had a stroke several years ago are making progress and integrating their involved hand into every day activities once again.
Video games have been added to the hospital’s arsenal of equipment used to help patients recover from strokes and brain injuries. The games can help patients regain their balance and coordination.
The therapy team chooses the most appropriate games to help each patient recover from their deficits and regain motor skills. Game choices range from simple to complex. A camera, positioned on top of a TV monitor, focuses on the patient, so he or she instantly becomes part of the video game.
“Wishi Washi” is a favorite with many patients because it is easy and reminds them of familiar tasks. The goal is to remove streaks from a glass door, as if you were washing windows at home. It can even be used with a prop, such as a sponge or a sock, to simulate the real-life experience of washing a window or mirror. The game helps with balance, eye-hand coordination and further improves the patient’s motor skills. For older patients, who may never have played video games, and who can be intimidated by this high-tech approach to therapy, “Wishi-Washi” is a good introduction.
“Kung Foo” helps improve the eye-hand coordination of patients whose visual fields may have been impaired as a result of a stroke. They learn to scan their entire visual field as they swat at video ninjas jumping at them. Patients’ response time and balance improves, and weakened arms get stronger as they practice fending off the ninjas’ attacks.
When patients play “Soccer Craze,” they’re having fun as they try to keep the soccer ball in the air, bouncing it visually off the top of their head. The rapid movements required to keep control of the soccer ball improves patients’ ability to move left and right, their balance, and response time.
The therapists work with each patient to get them comfortable with gaming. The games can be used sitting or standing, with one hand or both, so they are easily adaptable to each patient’s particular needs.
For young patients, who are often quite expert at video gaming, this new approach to therapy allows them to use familiar skills. Because the games are fun and challenging, the patients are usually eager to participate, and are able to make therapeutic gains quite effortlessly.
Individuals with neurological disorders, such as multiple sclerosis, stroke or spinal cord injury, often have difficulty walking. Specifically, they may have a condition called Foot Drop, which is characterized by weakness or paralysis of the muscles that control the foot. This may result in the foot or the toe of the shoe being dragged on the ground, making walking uncomfortable or even impossible.
A new Neuro Prosthetic device called the WalkAide is designed to restore a smoother, more natural gait, enabling users to walk faster, for longer distances with less fatigue. The device is now available through the hospital’s Prosthetic Orthotic Center, which became certified in fitting, customizing supplying the WalkAide for patient use.
The WalkAide utilizes functional electrical stimulation to restore the nerve-to-muscle signal in the leg and foot. Walking becomes a smoother, safer and more natural motion. Basically, the gentle electrical impulses activate the muscles to raise the foot at the appropriate time.
The small, easily operated device is battery operated, with two electrodes and electrode leads. It is applied directly to the leg with a cuff holding it comfortably in place. The WalkAide can be worn discreetly under clothing. It also permits walking barefoot, something that cannot be done with conventional bracing. The WalkAide may improve not only gait, but also circulation and joint range of motion.
For additional information, contact the Prosthetic Orthotic Center at 845-786-4122.
A swallowing disorder, more commonly referred to as dysphagia (dis-fah-jah), occurs when there is a problem with any part of the swallowing process from the mouth to the stomach. Some symptoms may include coughing and/or choking during or after swallowing, pain or a sensation of food getting stuck in the throat and shortness of breath while eating. Recent research has concluded that dysphagia effects as many as 15 million Americans, with 1 million being newly diagnosed each year.
Dysphagia can arise from a wide variety of causes including stroke, traumatic head or spinal cord injuries, head/neck/esophageal cancers, degenerative neurological conditions (Parkinson’s Disease, ALS, MS, Myasthenia Gravis), respiratory conditions (Chronic Obstructive Pulmonary Disease) and tracheotomies.
Dysphagia can have devastating side effects if not diagnosed and managed properly. The most severe is aspiration pneumonia, which is when saliva, food or liquid enters the airway and goes into the lungs. Aspiration pneumonia is a serious condition and has been cited for being one of the leading causes of death among the elderly. Other side effects of dysphagia may include choking, weight loss, chronic malnutrition, bronchospasm, physical de-conditioning and depression.
There are a wide variety of treatment methods utilized to treat swallowing disorders but one that is highly supported by clinical research is VitalStim Therapy (VST), which is a modified form of neuromuscular electrical stimulation (NMES) that has been designed to specifically treat dysphagia through muscle re-education. NMES is a type of therapy that has been used for many years by physical therapists to retrain the larger muscles in the body, such as the arms and legs. VitalStim Therapy is the only NMES device that is cleared by the FDA as a “safe and effective” treatment method for swallowing disorders.
So, how does VST work? VST uses non-evasive small electrical currents to stimulate and re-educate the inactive or atrophied muscles of swallowing. This treatment is conducted by a trained speech-language pathologist and should be used in conjunction with traditional therapeutic methods.
The validated contraindications for VitalStim Therapy are specific to patients suffering from dysphagia and are relevant to those who are severely demented, have significant reflux due to a feeding tube or for patients with dysphagia secondary to drug toxicity. The only side effect reported with VST is minor redness or irritation of the skin where the electrodes were placed.
VitalStim Therapy is a highly reputable treatment approach for the remediation of certain swallowing disorders. It is a safe, effective, painless and clinically proven treatment method that can improve a person’s quality of life.The specific goals and length of treatment are tailored to each individual patient and should be clearly outlined by a certified speech-language pathologist.