2359 Recovery Machines
THOSE AMAZING MACHINES
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Many researchers, medical doctors, and bioengineers dedicate much of their careers and cash to the development and marketing of stroke recovery machines. Why do they spend so much time and money on stroke recovery? Because there are 50 million stroke survivors worldwide, and it’s a global economy. If an inventor brings one product to market and sells that product to just a small fraction of the 50 million, he stands to make a fortune. The tremendous potential for profit drives recovery machine development. This is promising news for stroke survivors. Many machines are already on the market, and more are on the way. It is wise for survivors to consider recovery machines now available, and keep an eye on emerging stroke-recovery technologies. It is also wise to keep an eye on people who make gizmos not to help but to profit from an often-vulnerable population.
Deciding which machines are appropriate for your recovery can be tricky. Much like picking and choosing other recovery options, picking machines is a matter of deciding what fits with!:
• Where you are in recovery
• What you need to accomplish
• How much you can afford
• What has independent evidence that it works
Stroke recovery technology can be expensive. On the other hand, some of these machines are designed to go home with you. This provides the opportunity for you to expand and magnify your at-home recovery effort without the ongoing aid of clinicians. In the long run, this can save time and money.
236Many machines can help jump start a new phase in recovery. Other machines lessen the humdrum of repetitive practice by turning repetitive movements into a game. Some machines build muscle, some teach spastic muscles to relax, some encourage improved coordination, some help develop cardiovascular strength, and so forth. From walking to swallowing, and from visual deficits to speech impairments, there are machines that attempt to treat every movement deficit caused by stroke.
One other note: Many of the following machines use electrical stimulation (e-stim). Electrical stimulation after stroke is the single most important modality there is for recovery. Part of the reason e-stim is so important is that it does so many different things.
E-stim can be used in a variety of ways to help survivors. E-stim can . . .
• Start the neuroplastic process—e-stim changes the brain!
• Build muscle
• Stretch muscles
• Decrease the time between Botox is injected into muscles and the time muscles relax
• Increase the strength of the effect of Botox
• Start the neuroplastic process
• Fatigue spastic muscles so their antagonists (the muscles that work in the opposite direction) can work
• Increase tactile (touch) sensation
• Increase proprioception (the feeling of where the body is in space)
Work with your healthcare providers to incorporate e-stim into your recovery plan.
How Is It Done?
The following list provides broad categories of stroke recovery technologies. Included are general explanations of what machines in those categories do.
• Cyclic electrical stimulation: Cyclic electrical stimulation (e-stim) machines send electrical stimulation through electrodes to the skin overlying the muscles you want to work. This sort of e-stim may jump start movement in paralyzed muscles. It may also build bulk and strength in paralyzed muscles. Also, e-stim may relax muscles that are spastic by stimulating the muscles antagonistic (opposite) to the spastic muscles.
• Electromyography (EMG)-based electrical stimulation (e-stim) with biofeedback: These are e-stim machines with another feature added: The machine senses the effort of your muscles. If you tighten the muscle enough, you reach a threshold. Once you reach the threshold, the machine helps you complete the movement you are attempting. This process, called biofeedback, turns the passive activity provided by cyclic e-stim into an active exercise. Brain rewiring (neuroplasticity) is believed to occur because mental and/or physical effort is required.
• E-stim orthotics: These orthotics are worn on the recovering limbs. They differ from other forms of e-stim because they do not just “turn on and turn off” muscles. Instead, these orthotics stimulate muscles in the right way to do some real-world tasks. For instance, some e-stim orthotics lift the foot for people with foot drop. There are arm/hand orthotics that will help you open and close your hand, so you can grasp and release objects. These orthotics have the advantage of working on two levels:
— They help you do some real-world tasks (e.g., grasping an object, walking). This task-specific training can promote recovery in that limb.
— They encourage you to use the joints around the orthotic. For instance, an orthotic worn on the forearm and hand will also promote movement in the shoulder and elbow. In the leg, an orthotic that helps lift the foot will encourage improved movement from the hip and knee.
— Unlike other forms of electrical stimulation, e-stim orthotics have the electrodes built in, eliminating or reducing the number of wires that tether the user to the machine.
• Electromyography-based gaming: These types of games work by sending information from muscles into a machine. These signals travel to the machine and guide a character or other game element on the screen. The machine uses your muscular effort to play a variety of video games, from solitaire to pinball.
• Virtual reality (VR) gaming (see the section You Are Game—Virtual Reality, in Chapter 4). There are now many virtual reality options for recovery from stroke. The two biggest are the Wii system by Nintendo and Microsoft’s Xbox Kinect. The Wii allows you to move images on a TV screen by moving a hand-held controller. The Xbox Kinect is controller-free, using motion sensors that can track up to 48 points on your body to put you “in the game.” Virtual reality gaming provides a safe, challenging, and fun environment in which to recover. Beyond the Wii and Xbox, many VR systems are inexpensive and plug directly into any TV with RCA type inputs. Therapists have even named this therapy: Wiihabilitation!
• Bilateral arm trainers: Bilateral training (BT) does not require equipment of any kind. For instance, walking is a form of BT. With every stride, the “good” leg provides guidance to the “bad” side about proper position and timing. There are machines that promote BT, however. Upper-extremity ergometers (stationary cycles used with arms or legs) are examples of simple bilateral trainers. Others include hand-crank upper-body ergometers, stationary bicycles, recumbent bilateral exercisers with arm components, and so forth.
• Body weight-supported treadmill trainers. A treadmill has many assets as a tool for relearning how to walk (see the section Train Well on a Treadmill in Chapter 2). One of the ways to safely use a treadmill, even for folks still unable to walk, is to support the weight of the body with a harness. These systems reduce the effect of gravity and also keep you safe if there is a loss of balance. Called partial weight-supported treadmill (PWST) training, this relatively low-tech safety apparatus is available at many rehabilitation hospitals. Some stroke survivors don’t yet have the coordination to bring the “bad” leg forward while involved in PWSW. The assistance needed to move the leg forward can be provided by therapists crouched at the side of the treadmill. They literally grab the foot and leg and lift them off the ground to push them into the next step. The newer version of this technology has replaced therapists’ hard work with a machine that moves the leg. An example of this sort of machine is the Lokomat®. Leg cuffs are attached to the hips, legs, ankles, and feet. The computer-driven leg cuffs progress the legs and feet in a way that promotes normal gait. This technology is quite expensive but is sometimes available at rehabilitation hospitals and other rehabilitation facilities. PWSW, when therapists assist leg movement, is much more low-tech. All that’s needed is a treadmill and a harness. It can, however, be labor intensive if a therapist is needed to progress the foot during stepping.
• Body weight-supported trainers without treadmills: These trainers are weight support systems that allow you to carry less of your own weight as you relearn walking. A rolling platform suspends you while you walk on the floor. The amount of weight supported can be increased or decreased so, as you develop greater balance, the machine takes less of your weight. These machines include the NeuroGym® Bungee Walker, the Biodex Unweighing System, and the KineAssist™.
• Cardiovascular machines: Cardiovascular strength (stamina) directly impacts the amount and speed of recovery. Machines that increase stamina include treadmills, the NuStep®, and BioStep® bilateral trainer. Cardiovascular exercise is vital to recovery from stroke.
With any technology you use, consider the following:
• Ease of use
• Cost
• If it needs a therapist or doctor to implement
• If it can be used at home
• If there is a substantial amount of clinical research that shows positive results
Stroke-Recovery Machines and What They Do
A list of stroke-recovery machines with descriptions and contact information follows. Note: The descriptions of these machines (in italics) were taken directly from the manufacturer and do not represent an endorsement by the author.
Contact information can always be found on the website. The website will be the quickest, easiest, and maybe even the best source of information on these machines. If you, your doctor, or your treating therapist have any questions about acquiring and/or using the machine, the manufacturer is the best resource. Generally speaking, the manufacturer will know the most about:
• Cost
• If there are available lease options
• If you can buy used machines
• Insurance coverage (if any)
• Where to find the machine
• What research has been done on the machine
• If the machine is appropriate for your deficits
• Which therapists in your area are trained to use the machine
This section has three parts:
• Machine names and website(s) (if available) are listed.
• What the machine does, in the words of the manufacturer (in italics).
• The Status section tells if the machines are commercially available and if the stroke survivor can use them without help, or if supervision from a clinician is required.
Machines That Help Arm and Hand Movement and Function
• H200™ (www.bionessinc.com): The H200 is a noninvasive device, worn on the forearm and hand that enables patients to perform everyday activities that were previously impossible. The NESS H200 can help the hand open and close, reduce stiffness, increase range of motion and strength, improve circulation, and assist in regaining awareness of an impaired limb. In addition to the amazing therapeutic benefits of the H200, patients have also embraced the comfort and ease of use of the system. Unlike other systems, the H200 orthosis incorporates a self-adjusting fit, to hold the wrist and hand in a functional position. This superior fit, coupled with the H200 electrode placement, allows patients to remove and replace the device without compromising therapy effectiveness. Also, the patented technology behind the H200 provides six different stimulation patterns to enable patients to perform a variety of tasks and use it for therapeutic activities, as well. The system is also versatile enough to be used in varied settings, including the home, with little technical expertise needed.
— STATUS: Commercially available. A therapist or physician should always supervise this treatment at the beginning. However, with training, this treatment can be done at home by the stroke survivor.
• MyoPro: This is a portable, lightweight functional arm brace that restores movement to a weakened arm as a result of neuromuscular damage. The product incorporates a noninvasive myoelectric platform technology in a wearable device that enables a person to initiate and control his or her own motion. The portable arm brace has been proven effective in facilitating functional repetitive task practices during therapy and assist people in their daily living activities in the home. MyoPro technology does not use electrical impulses or stimulation. It reads weak muscle signals and sends them to the device’s computer, which allows a person to move the affected arm.
— STATUS: The Myomo MyoPro is a myoelectric limb orthosis available with a prescription from a Myomo-certified clinician. It may be reimbursed depending on medical necessity and the individual’s insurance coverage.
• Armeo® (hocoma.com): The Armeo facilitates intensive task-oriented upper extremity therapy after stroke, traumatic brain injury, or other neurological diseases and injuries. It combines an adjustable arm support, with augmented feedback and a large 3-D workspace that allows functional therapy exercises in a virtual reality environment.
— STATUS: Not yet available in the United States.
• Hand Mentor™ (kineticmuscles.com): The Hand Mentor™ is the first Active Repetitive Motion™ hand therapy device designed for use in therapy clinics to improve outcomes in stroke rehabilitation. The Hand Mentor™ actively involves the patient in his or her rehabilitation by encouraging self-initiated motion in the wrist and fingers, and assisting movement only when necessary.
— STATUS: The “Pro” version, for treatment by therapists, is clinically available. The manufacturer is in the process of engineering an at-home version of the Hand Mentor™.
• SaeboFlex® (SaeboFlex.com): The SaeboFlex™ positions the wrist and fingers into extension in preparation for functional activities. The user is able to grasp an object by voluntarily flexing his or her fingers. The extension spring system assists in re-opening the hand to release the object. Saebo equipment, especially the SaeboFlex™ orthosis, is specialized patented technology. Occupational and physical therapists attend specific education classes offered by Saebo, Inc. to become trained in the SaeboFlex®.
— STATUS: Commercially available. A therapist or physician always supervises this treatment in the beginning. However, with training, there is potential for this treatment to be done by the stroke survivor, at home.
• Reo™ Go (motorika.com): The Reo™ Go is a portable, easy-to-use system for delivering Reo Therapy. Combining streamlined ergonomic design and advanced software, the Reo™ Go provides a robust platform for highly effective robot-assisted upper extremity therapy.
— STATUS: Commercially available. A therapist or physician should always supervise this treatment. This machine is expensive. However, treatment on this machine may not cost any more than typical physical-therapy treatments.
Machines That Help the Leg and Foot and Help Walking
• NESS L300™ (bionessinc.com): The NESS L300™ utilizes proprietary technology that not only lets you walk smoother, but faster, as well. And, only the NESS L300™ has a built-in sensor that recognizes the surface you are walking on and adjusts accordingly. It is also a much more streamlined device compared to other available options. There are no bulky wires to deal with and the compact design even allows patients to wear their normal footwear. It’s also easy for patients to use. Unlike some systems that can’t easily be taken off and on, the NESS L300™ is surprisingly simple—making it ideal for inpatient or outpatient use.
— STATUS: Commercially available. A medical doctor or physical therapist supervises this treatment. However, the stroke survivor can also use this treatment at home during everyday walking.
• WalkAide (walkaide.com): WalkAide uses advanced sensor technology to actually analyze the movement of your leg and foot. The system sends electrical signals to your peroneal nerve, which controls movement in your ankle and foot. These gentle electrical impulses activate the muscles to raise your foot at the appropriate time during the step cycle.
— STATUS: Commercially available. This treatment is supervised by a medical doctor or physical therapist. However, the stroke survivor can also use this treatment at home during everyday walking.
• LiteGait® (litegait.com): LiteGait® is a therapy device used to promote the generation of normal walking patterns by controlling weight bearing, balance, and posture during walking therapy.
— STATUS: Commercially available. A therapist or physician always supervises this treatment.
• NeuroGym® Bungee Walker (neurogymtech.com): The NeuroGym® Bungee Walker is a versatile body weight support mechanism enabling safe, intensive motor retraining. The unique patented design enables the re-training of gait and natural protective reactions by counteracting loss of stability as naturally as possible. Comparable to a pool environment in terms of support, the Bungee Walker allows graduated weight bearing while normal protective reactions such as sidestepping are re-developed.
— STATUS: Commercially available. A therapist or physician always supervises this treatment in the beginning. However, with training, there is potential for this treatment to be done by the stroke survivor at home.
• NxStep™ (biodex.com/rehab): The Biodex NxStep Unweighing System enables partial weight-bearing therapy to be conducted with the assurance of patient comfort and safety, and with convenient access to the patient for manual assistance and observation.
— STATUS: Commercially available. A therapist or physician always supervises this treatment in the beginning. However, with training, there is potential for this treatment to be done by the stroke survivor at home.
• Gait Trainer 3™ (biodex.com/rehab): The Gait Trainer 3™ has an instrumented deck that monitors and records step length, step speed, and right-to-left time distribution (step symmetry). Patients are motivated by the real-time audio and visual biofeedback. They are prompted into proper gait patterns, step length, step speed, and step symmetry.
— STATUS: Commercially available. A therapist or physician always supervises this treatment in the beginning. However, with training, there is potential for this treatment to be done by the stroke survivor at home.
• Lokomat® (hocoma.com/products/lokomat): Locomotion therapy supported by an automated gait orthosis on a treadmill has established itself as an effective intervention for improving over-ground walking function caused by neurological diseases and injuries. The Lokomat is the first driven gait orthosis that assists walking movements of gait-impaired patients and is used to improve mobility in individuals following stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, or other neurological diseases and injuries.
— STATUS: Commercially available. A therapist or physician always supervises this treatment. This machine is very expensive. However, treatment on this machine may not cost any more than typical physical therapy treatments.
• Reo Ambulator (motorika.com): Reo Ambulator is an innovative robotic gait training device that integrates body weight support treadmill training (BWSTT) with advanced robotics to help rehabilitate patients who experience neuromuscular dysfunction to address problems with ambulation, balance, coordination, posture, and stamina.
— STATUS: Commercially available. A therapist or physician always supervises this treatment. This machine is very expensive. However, treatment on this machine may not cost any more than typical physical therapy treatments.
• KineAssist™ (kineadesign.com): KineAssist™ technology will allow therapists to safely challenge patients in functional environments with reduced concern about falls, record objective measures, and integrate with existing practice settings.
— STATUS: Commercially available. A therapist or physician always supervises this treatment.
Machines That Can Be Used for the Upper or Lower Extremities
• NeuroMove™ (neuromove.com): The NeuroMove™ works by detecting the attempts to move a muscle group sent from the brain. These attempts are shown in the display as significant increases in the signal over regular muscle activity. The built-in microprocessor intelligently distinguishes between regular muscle activity, muscle tone, noise, and real attempts. When a real attempt is detected, the unit “rewards” the patient with a few seconds of muscle contraction, where the visual and sensory feedback serve as an important element in relearning the movement.
— STATUS: Commercially available. A therapist or physician always supervises this treatment in the beginning. However, with training, there is potential for this treatment to be done by the stroke survivor at home.
• Biomove 3000 (biomove.com/biomove-home): The system is able to detect the extremely small electrical EMG signals still measurable in paralyzed muscles after a stroke. These tiny signals are used to initiate an electrical stimulation impulse to the same muscles, resulting in actual muscle movement!
— STATUS: Commercially available. A therapist or physician always supervises this treatment in the beginning. However, with training, there is potential for this treatment to be done by the stroke survivor at home.
• Interactive Metronome (IM) and Gait Mate (interactivemetronome.com): The Interactive Metronome is an advanced brain-based treatment program designed to promote and enhance brain performance and recovery. This is accomplished by using innovative neurosensory and neuromotor exercises. IM also makes the Gait Mate, which is described like this: The therapist inserts a wireless insole into the patient’s shoe that detects when the patient performs a heel strike. The patient hears a beat through wireless headphones or speakers and is asked to match the cadence provided. The Gait Mate provides the patient with auditory feedback as he or she walks, with instruction to speed up if walking too slowly or to slow down if shuffling or dropping his or her foot too quickly. The patient receives no positive feedback if his or her heel doesn’t strike the ground.
— STATUS: Commercially available. A therapist or physician always supervises this treatment in the beginning. However, with training, there is potential for this treatment to be done by the stroke survivor at home.
Machines for Other Aspects of Stroke Recovery
• VitalStim Therapy (vitalstimtherapy.com): VitalStim Therapy uses small electrical currents to stimulate the muscles responsible for swallowing. At the same time, trained specialists help patients “re-educate” their muscles through rehabilitation therapy.
— STATUS: Commercially available. A therapist or physician always supervises this treatment.
• NovaVision VRT™ Vision Restoration Therapy™ (novavision.com): VRT is a clinically proven, FDA-cleared technology designed to improve the quality of life of stroke and brain injury patients by restoring some of their lost vision. The therapy does not require surgery or medication of any kind.
— STATUS: Commercially available. A therapist or physician always supervises this treatment. This machine is expensive. However, treatment on this machine may not cost any more than typical physical therapy treatments.
• This list of machines is not complete, nor can it be. The rapid development of these new technologies means that new products become available every day.
Future Machines
The best way to stay abreast of the latest and greatest recovery machines is to “keep your ear to the ground.” Check the Internet, TV, and print for new ideas. The best outlet for information on cutting-edge machines for stroke 246rehabilitation is a website called Medgadget (medgadget.com/rehab). The free magazines, Stroke Smart (strokesmart.org) and Stroke Connection (strokeassociation.org), have great suggestions for new machines. The advertisements in these magazines provide a wealth of information, photographs, and contact information on commercially available stroke recovery machines. There are also articles that review the latest stroke recovery technology.
As time goes on, stroke recovery will rely more and more on machines. The most difficult part of this new machine-driven world of recovery is figuring out how to use these machines. Using some machines is as simple as placing a couple of electrodes and flipping a switch. Other machines are so complex that without a highly trained person, the machine is virtually useless. Some rehabilitation hospitals spend tens of thousands of dollars on machines that end up collecting dust. If the machine takes too long to learn, therapists won’t use it. Also, if setting up the machine for a patient to use takes too long, then the machine will not be used. My hope, as we move forward, is that the folks who make these machines understand that simplicity of use is essential. If a machine is simple and effective, survivors will be inclined to buy it and use it at home. Or, if a therapist is needed, the machine needs to be simple enough to not burn available treatment time with a protracted set-up.
What Precautions Should Be Taken?
Make sure your doctor knows if you decide to add a machine to your recovery efforts. Some machines require a doctor’s prescription. Contact individual manufacturers to determine if the machine needs a doctor’s prescription. These machines may or may not be covered by insurance, depending on a number of factors. Again, the manufacturers will know if their machine is covered. They are in business to serve you, so you will find them helpful and informative as you consider their machine.
Recovery options that involve electrical stimulation have precautions and contraindications. Discuss these with your medical doctor prior to using any electrical stimulation options. Here is a partial list of contraindications and precautions for recovery options that use electrical stimulation:
• Pregnancy
• Skin irritation
• Epilepsy/seizures
• Sensitive skin
• Compromised sensation
• Heart disease
• Pacemakers or defibrillators
• Recent surgery if muscle contraction may disrupt healing
• Electrode placement over the carotid sinus in the neck
• Existing thrombosis