Technology: An Expanding Role in Rehabilitation Research
Dramatic advances in technology are being rapidly adopted into clinical rehabilitation practice. To ensure Baylor Scott & White Institute for Rehabilitation (BSW Rehab) safely and effectively integrates this technology into inpatient clinical care, researchers and clinicians have partnered to develop an evidence base. Under the direction of Chad Swank, PT, PhD, Research Scientist, BSW Rehab has begun to systematically investigate how and when to utilize Functional Electrical Stimulation – cycling ergometry (FES-CE) and Robotic Exoskeleton Gait Training (RGT) to maximize rehabilitation potential and promote return of function post neurologic injury.
Functional Electrical Stimulation Cycle
Despite the established benefits of habitual Functional Electrical Stimulation (FES) use in people with chronic spinal cord injury (SCI), there are no nationally recognized clinical protocols for implementing FES within inpatient rehabilitation settings. However, BSW Rehab clinicians and researchers have implemented a feasible and effective FES program for patients during inpatient rehabilitation. "We know FES use can improve limb function, decrease spasticity, and reduce risk of overuse injury in people with long-term SCI, but the benefits are unknown during the acute phase of recovery," says Dr. Swank. "We believe that a similar, if not greater, benefit can be harnessed during inpatient rehabilitation based on principles of neuroplasticity."
FES uses electrical current to stimulate peripheral motor units to partially innervate paralyzed musculature to perform a functional task. At the right dose FES has been shown to activate and re-educate the neuromuscular system below the injury level in people with chronic injury. The BSW Rehab team is collecting evidence on the effect of FES-CE programming during inpatient rehabilitation. To support implementation the team have successfully integrated the patient and family/caregiver into the therapeutic process by encouraging daily FES-CE participation.
"With no clinical practice guidelines or gold-standard program to use as a model, we combined existing scientific evidence with the requirements of inpatient rehabilitation to create a safe, feasible and therapeutically meaningful program," shares Christina Fazio, PT, ATP, Rehabilitation Therapy Manager.
"Utilization of our FES-CE program increased 264% from 2016 to 2017 after we established the protocol and implemented the staff and patient training."
The research team is now examining questions specific to the dosage of FES-CE and its impact on functional outcomes for our patients with SCI. "The evidence that we will gather will help us integrate FES-CE into the rehabilitation process at the right time and dose to maximize their recovery. We hope to create a model of use that can be implemented by programs across the country," notes Dr. Swank.
Robotic Exoskeleton Gait Training
An exciting application of robotic exoskeleton for gait training is using the technology during the acute recovery phase, when recovery is most likely to improve functional outcomes. The clinical and research team at BSW Rehab have been evaluating how to integrate robotic exoskeleton technology into clinical practice during inpatient rehabilitation for patients with mobility impairments.
Initial results from the team’s research suggests that integrating a Robotic Exoskeleton Gait Training (RGT) program into clinical practice is feasible, enjoyed by patients and did not increase their risk of injury. Over the past three years the therapists at BSW Rehab have worked with nearly 200 patients and completed over 700 RGT sessions with benefits noted as including lessened physical burden on therapists and enhanced patient motivation. Molly Trammell, Therapy Supervisor and lead RGT physical therapist, concluded, "Our therapists’ level of training and clinical knowledge have fostered RGT implementation during inpatient and outpatient rehabilitation, allowing for safe use with on-label and off-label patients." Dr. Swank echoed, "Use of RGT allowed the therapists to overcome barriers associated with traditional gait therapy and achieve early mobility even when faced with common clinical obstacles of increased muscle tone, incontinence, and difficult patient communication."
Initial data generated by the research and clinical team at BSW Rehab suggests that this technology may offer a better approach for gait training when compared with traditional approaches. While traditional gait training approaches such as body-weight supported treadmill training and over-ground gait training with braces can be burdensome to the therapists, patients who completed five or more RGT sessions spent more time each day in gait training and resulted in improved mobility. An interesting observation was that our patients with SCI responded differently to RGT sessions than our patients with stroke. "RGT is not a one size fits all approach. Because of unique patient characteristics, use of RGT requires diverse approaches for patients with differing diagnoses during inpatient rehabilitation," observed Dr. Seema Sikka, Director of Spinal Cord Injury Research and Quality.
The BSW Rehab research team is now exploring the difference in RGT ingredients based on clinical diagnosis to maximize the potential for walking recovery of patients with different types of neurologic injury. "We hope to efficiently utilize the brief time in inpatient rehabilitation to maximize outcomes for our patients. And based on our initial findings, we think RGT is helping us do so," summarized Dr. Swank.