by Justine Mamone, PT, DPT, and Michael Scarneo, PT, DPT, NCS
The World Health Organization (WHO) estimates that more than 1 billion people—about 15% of the world population—are living with some form of disability. The WHO has identified this as a global public health issue as it relates to barriers with accessing health services, education, and employment, and overall poorer health outcomes.1 Stroke has been identified as the leading cause of long-term disability in the United States, costing an estimated $34 billion each year per the Center for Disease Control and Prevention (CDC), with the prevalence only expected to increase as the aging population grows.
It has been shown that those who seek immediate medical care within 3 hours of identifying their first signs or symptoms of a stroke often demonstrate decreased disability 3 months post-stroke.2 Similarly, early rehabilitation for stroke survivors has been shown to improve functional outcomes and minimize the likelihood of long-term disability.2,3
Dynamic Stair Trainer and Body Weight Support
Technology’s Role in Recovery
Early rehabilitation is crucial in not only minimizing long-term disability, but also in persevering independence and optimizing quality of life. The optimal time frame to begin rehabilitation is unclear. However, research supports that there is a window after a stroke occurs when there is enhanced neuroplasticity and the brain is the most susceptible to change.4 During that time, intensive and dynamic therapeutic interventions are implemented in an acute rehabilitation setting to maximize an individual’s rehabilitation potential.
The WHO developed a model of care, The International Classification of Function (ICF), to streamline the terminology and provide a comprehensive framework in providing care for individuals with various diagnoses, including stroke.5,6 The ICF model is used to identify the needs of everyone seen in an acute rehabilitation facility, such as Kessler Institute for Rehabilitation in New Jersey. Within that plan of care a vast number of interventions are functional and goal-oriented to address the specific needs of each individual, including the use of advanced technology. Technology can be included in a plan of care not only to drive recovery through task-specific training, but to prevent secondary complications that arise and to preserve the mobility of those affected by a neurological insult.
Neuromuscular Electrical Stimulation
Many of the stroke survivors seen in acute rehabilitation have impaired walking ability resulting in the need for physical assistance, the use of bracing and assistive devices, and concerns regarding joint integrity and overall safety. As a result, much of the technology used in rehabilitation has been studied to improve quality of movement, overall function, and independence. Additionally, the use of technology allows for the opportunity for functional, high-intensity mass practice under safe, controlled conditions where compensatory strategies can be minimized. One of the most commonly used pieces of technology is neuromuscular electrical stimulation (NMES) specifically used to stimulate the ankle dorsiflexors to assist in foot clearance during the swing phase of gait.
The option of using NMES is to obtain a neuroprosthetic effect which provides the therapist the opportunity to facilitate and train patients in exhibiting a more normal gait pattern as compared to gait training with the use of an ankle-foot orthosis. In addition, the use of NMES may also yield a neuro-therapeutic effect in which there is carryover in gait quality and mechanics when no longer in use.7 The literature has identified a neuro-therapeutic effect as noted in lower extremity motor function, improved gait mechanics when use acutely as compared to several weeks post-CVA, significant improvements on the Berg Balance Scale, Timed Up and Go (TUG), and decreased spasticity and subsequent improvements in range of motion.7,8
The following companies offer technologies that can be used for the rehabilitation of gait and balance disorders:
Accelerated Care Plus
Allard USA Inc
Clarke Health Care Products
GAITRite/CIR Systems Inc
Gorbel Inc-Medical Division/SafeGait
Robotic-assisted gait training (RAGT) was researched and designed for utilization among the spinal cord injury population. In recent years, more and more studies have addressed the utilization of robotic exoskeletons with individuals post-stroke. This type of technology allows for increased training intensity and reduced demands on the therapists during locomotor training, allowing the therapist to address more specific impairments that would otherwise be difficult to complete in a safe and functional way.11 Additionally, RAGT provides the opportunity to minimize ineffective gait patterns, normalize gait speeds, and reduce the need for bracing in early gait training that would be difficult to control for with conventional interventions.
As expected, recent studies have shown that these devices have positive effects on gait recovery as compared to conventional gait training alone.12 Also, notably when utilized in a more acute phase of recovery, such as in an inpatient rehabilitation setting, there were more meaningful improvements.11 Improvements inclusive of increases in the individual’s self-selected walking speed and improvements in outcomes measures, such as the TUG and Functional Gait Assessment (FGA) when measured post-RAGT use.13There has also been evidence to improvements in spasticity management, bowel and bladder function, and bone density with varying populations in addition to improvements in balance, gait quality, and lower extremity strength.14
Functional Electrical Stimulation (FES) bicycle ergometers are utilized to improve aerobic capacity, neuromuscular recovery, and upper and/or lower extremity strength by increasing the intensity to a level not otherwise attainable and by stimulating plegic muscles, respectively. Safe and functional locomotor training requires the motor control, strength, and cardiovascular endurance to withstand the natural demands of walking, all of which can be addressed with the use of the aforementioned technology. Studies have identified that with the use of FES there is earlier onset of walking by 2 to 3 days, greater discharges to home as compared to conventional therapist, improvements in gait speed and walking distance tolerated, greater force production and limb symmetry.16-18
Breaking Down Barriers to Technology Acceptance
Advanced technologies have provided a greater number of options to physical therapists and increased possibilities of alternative interventions to provide to stroke survivors in an inpatient rehabilitation setting. The new and exciting interventions that the advent of technology has brought to the world of stroke rehabilitation continues to have increasing evidence to support utilization. An evidenced-based approach to identifying appropriate therapeutic interventions is the approach used when developing a physical therapy plan of care. Despite the amount of literature to support the use of advanced technology, there may be barriers and limitations to implementing some of these forms of technology.
For example, in a recent study, Auchstaetter et al found that barriers impacting the use of FES specifically included therapist preference for specific interventions, lack of knowledge/training/expertise, perception of intervention not being appropriate for specific patients, and lack of resources inclusive of time, equipment, and assistance.19 It can be inferred that, although these findings are specific to FES usage, that these may be barriers to utilization among many of the assistive technologies highlighted here. There are also patient-specific barriers that play a role in the utilization, including impaired cognition and communication limiting the individual’s ability to report pain and distress during use, behavioral issues, pre-morbid orthopedic issues, and hemodynamic instability which would result in poor tolerance.20
The limitations in knowledge and training may be directly related to the therapist’s ability to remain current with clinical advances and research which may prevent seamless integration of technology into daily practice. In a clinical setting, there may also be challenges with regard to access to these new technologies due to cost-effectiveness or benefits for populations served or with regard to clinical setting. Hughes et al stated that therapists take a pragmatic view when it comes to using assistive technologies and find these aspects of technology to be barriers to use. The Technology Acceptance Model developed by Hughes suggests that with any new technological advances several factors influence integration, including perceived usefulness and perceived ease of use.21 Taking these factors into consideration, stronger clinical evidence in various treatment environments, educational opportunities, and having a collaborative partnership with technology vendors will enhance knowledge transfer and increase usage of assistive technologies across all clinical settings.
Understanding the Path to Improved Outcomes
Greater understanding yielding greater clinician acceptance is critical to usage of assistive technologies. Additionally, the patient’s understanding of the benefit that technology can provide is crucial to enhance the individual’s engagement in usage of these interventions. As clinicians, we are limited in identifying the individual’s perception of their improvement or their adherence to interventions and with few outcome measures that address these areas.22 Psychology of the individual receiving the intervention, engagement and participation are key factors in rehabilitation performance, neuroplasticity, and ultimate recovery.23 Integration of technology has become standard in every daily life, and as the cultural gap between our treatment population and assistive technology usage closes, patients will be more eager in seeking out these interventions.23
It is anticipated that with greater understanding of the enhanced benefits that technology can provide by the entire therapy team inclusive of the patient, there will be improved patient outcomes. Despite the few barriers to use, technology has shown a great deal of promise with regard to functional outcomes and psycho-social benefits. Continued research and advances in technology will aid in providing our patients with a greater number of options and interventions to maximize function and minimize long-term disability. PTP
Justine Mamone, PT, DPT, is a board-certified clinical specialist in Neurologic Physical Therapy, and an inpatient clinical specialist physical therapist, at Kessler Institute for Rehabilitation.
Michael Scarneo, PT, DPT, NCS, is a senior physical therapist at Kessler Institute for Rehabilitation. For more information, contact PTPEditor@medqor.com.
- World Health Organization. Summary: World report on disability, 2011. Geneva, Switzerland: World Health Organization; 2011.
- Benjamin EJ, Blaha MJ, Chiuve SE, et al, on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017;135(10):e146-e603.
- Stroke Facts | cdc.gov. https://www.cdc.gov/stroke/facts.htm. Published 2018. Accessed May 24, 2018.
Lynch E, Hillier S, Cadilhac D. When should physical rehabilitation commence after stroke: a systematic review. Int J Stroke. 2014;9(4):468-478.
Silva S, Corrêa F, Faria C, Buchalla C, Silva P, Corrêa J. Evaluation of post-stroke functionality based on the International Classification of Functioning, Disability, and Health: a proposal for use of assessment tools. J Phys Ther Sci. 2015;27(6):1665-1670.
Brewer L, Horgan F, Hickey A, Williams D. Stroke rehabilitation: recent advances and future therapies. QJM. 2012;106(1):11-25.
Knutson JS, Fu MJ, Sheffler LR, Chae J. Neuromuscular electrical stimulation for motor restoration in hemiplegia. Phys Med Rehabil Clin N Am. 2015;26(4):729-745.
Howlett OA, Lannin NA, Ada L, McKinstry C. Functional electrical stimulation improves activity after stroke: a systematic review with meta-analysis. Arch Phys Med Rehabil. 2015:96(5):934-943.
Louie DR, Eng JJ. Powered robotic exoskeletons in post-stroke rehabilitation of gait: a scoping review. J Neuroeng Rehabil. 2016;13(1):53.
Nilsson A, Vreede KS, Häglund V, Kawamoto H, Sankai Y, Borg J. Gait training early after stroke with a new exoskeleton – the hybrid assistive limb: a study of safety and feasibility. J Neuroeng Rehabil. 2014;11:92.
Srivastava S, Kao PC, Reisman DS, Scholz JP, Agrawal SK, Higginson JS. Robotic assist-as-needed as an alternative to therapist-assisted gait rehabilitation. Int J Phys Med Rehabil. 2016;4(5):370.
Bruni MF, Melegari C, De Cola MC, Bramanti A, Bramanti P, Calabrò RS. What does best evidence tell us about robotic gait rehabilitation in stroke patients: A systematic review and meta-analysis. J Clin Neurosci. 2018;48:11-17.
Chang WH, Kim Y-H. Robot-assisted therapy in stroke rehabilitation. J Stroke. 2013;15(3):174-181.
Ambrosini E, Ferrante S, Ferrigno G, Molteni F, Pedrocchi A. Cycling induced by electrical stimulation improves muscle activation and symmetry during pedaling in hemiparetic patients. IEEE Trans Neural Syst Rehabil Eng. 2012;20(3):320-330.
Aaron SE, Vanderwerker CJ, Embry AE, Newton JH, Lee SCK, Gregory CM. FES-assisted cycling improves aerobic xapacity and locomotor function postcerebrovascular accident. Med Sci Sports Exerc. 2018;50(3):400-406.
Yan T, Hui-Chan CW, Li LS. Functional electrical stimulation improves motor recovery of the lower extremity and walking ability of subjects with first acute stroke: a randomized placebo-controlled trial. Stroke. 2005;36(1):80-85.
Auchstaetter N, Luc J, Lukye S, Lynd K, Schemenauer S, Whittaker M, Musselman KE. Physical therapists’ use of functional electrical stimulation for clients with stroke: frequency, barriers, and facilitators. Phys Ther. 2016:96(7):995-1005.
Chua KSG, Kuah CWK. Innovating with rehabilitation technology in the real world. Am J Phys Med Rehabil. 2017;96(10 Suppl 1):S150-S156.
Hughes AM, Burridge JH, Demain SH, et al. Translation of evidence-based assistive technologies into stroke rehabilitation: users’ perceptions of the barriers and opportunities. BMC Health Serv Res. 2014;14:124.
Meadmore KL, Hughes AM, Freeman CT, Benson V, Burridge JH. Participant feedback in the evaluation of novel stroke rehabilitation technologies. J Rehab Robotics. 2013;1:82-92.
Morone G, Paolucci S, Cherubini A, et al. Robot-assisted gait training for stroke patients: current state of the art and perspectives of robotics. Neuropsychiatr Dis Treat. 2017;13:1303-1311.
Objective Data for Evaluating Gait & Balance
An expanding category of tech-enabled devices is helping gait evaluation stay on the straight and narrow.
Compiled by Physical Therapy Products staff
Once restricted to observational analysis, today’s clinicians now have access to technologies that provide objective data for developing an accurate picture of a patient’s recovery. To spotlight the latest features and benefits of systems that collect objective gait measurements, Physical Therapy Products profiles four solutions that provide data-driven insight into patients who are affected by a movement impairment.
Vista Medical / BodiTrak
Vista Medical, Winnipeg, Manitoba, Canada, introduces the BodiTrak Balance Mat, which is designed to assess steadiness, symmetry, and dynamic stability as an aid for fall prevention, concussion evaluation and recovery, athlete rehabilitation, and general postural/sway.
The BodiTrak Balance Mat measures weight-bearing, like a force plate, but also pressure-maps each foot individually, including heel/toe segmentation. Additionally, the BodiTrak Balance Mat tracks center-of-pressure (COP) total distance moved, maximum COP displacement, and velocity of COP movement.
The Mat brings quantification and objectivity to balance tests such as mCTSIB, which have historically been observational and subjective. By displaying and reporting detailed data about various balance-related metrics, it is designed to enable the detection of even slight improvements in outcomes over time—thereby enhancing the quality and value of reports for both physicians and insurers.
GAITRite / CIR Systems Inc
GAITRite from CIR Systems Inc, Franklin, NJ, a leader in temporo-spatial gait analysis for the past 26 years, is engineered to capture with unsurpassed accuracy the objective data necessary to reliably document patient condition and progression. Measurement of stride-to-stride variability has shown to be an invaluable tool in evaluating or monitoring interventions aimed at improving balance and gait with numerous patient conditions. Built to be durable, GAITRite walkways may be left in place permanently or can be moved easily and set up in less than 75 seconds.
Robust reporting options allow for tailorable reports with multiple export functions available. The software identifies, through a multitude of specific spatial-temporal gait parameters, asymmetries and deviations from normal time and distance values. These objective numbers allow for an informed assessment of targeted interventions such as gait training or use of assistive devices or sensory aids.
The company reports that GAITRite walkways and modular systems have been cited in many peer-reviewed publications worldwide, across multiple disciplines that include geriatrics, neurology, orthopedics, orthotics, prosthetics, pediatrics, physiotherapy, and rehabilitation, from educational and research institutes to hospital and other clinical settings. GAITRite walkways and modular systems are reported to have been widely used in 54 countries for the past 26 years.
The Strideway is a modular system from Tekscan, South Boston, Mass, that calculates spatial, temporal, and kinetic parameters essential for a comprehensive gait analysis. The system is engineered so that data is presented in easy-to-understand tables and graphs for quick comparison of patient progress between visits. Symmetry tables can provide quick insights into differences between left and right sides, a key indicator in the rehabilitation process. The pressure data provided by the Strideway is useful to identify asymmetries, potential problem areas, pain points, or areas of ulceration.
With a smooth, flush surface, the Strideway is designed to be ideal for patients of all ages, and its width can easily accommodate individuals who use walking aids. The Strideway is a tile-based system, built to be quickly assembled and disassembled for greater mobility. It is available in multiple lengths and provides flexibility to add or subtract length at any time. This design allows for reduction or expansion based on need, and greater capabilities with a longer walkway.
With a quick set-up time, full data collection can be completed in minutes. A downloadable data sheet on the company’s website shares extensive details about platform dimensions and technical specifications.
Michael Rowling, COO of ProtoKinetics LLC, Havertown, Pa, reportedly is credited by some in the rehab industry with putting gaitmat technology on the map. According to Jacquelyn Perry, MD, one of Rowling’s mentors described as a “pillar of clinical gait analysis”: “the wide range of initial disability following an acute stroke and the seeming inconsistency of recovery, …, continue to challenge therapeutic planning.”1
Clinical scales have predictive value in assessment of walking potential at an early recovery state. However, the sensitivity of these clinical measures is questioned for more advanced stages of recovery.2 More valid and reliable measures are essential to evaluate the many walking and balance strategies acquired by patients.
The Zeno Walkway from ProtoKinetics has a wide surface that allows for the capture of assistive device performance in addition to the loading patterns of the patient’s footsteps. PKMAS software automatically eliminates walker tracks, while expertly identifying overlapping steps, which is crucial for implementation in clinical care.
ProtoKinetics is reported to consistently review updates in the literature for valuable measures and protocols that will improve data output and interpretability. Recent implementation of the enhanced GVI3 and automated Four Square Step Test are just two examples of rehabilitation-related outcomes which may assist in clinical decisions about balance control to plan therapy and discharge from the hospital.
- Perry J, Burnfield J. Gait Analysis: Normal and Pathological Function. 2nd ed. Thorofare: Slack Incorporated; 2010.
Gouelle A, Rennie L, Clark DJ, Mégrot F, Balasubramanian CK. Addressing limitations of the Gait Variability Index to enhance its applicability: The enhanced GVI (EGVI). PLoS ONE. 2018;13(6):e0198267.