Rehabilitation after Stroke

Rehabilitation after Stroke

Otto Bock HealthCare Rehabilitation after Stroke

Preface Dear Readers, One goal has remained unchanged since the beginning of our company history in 1919: To help people maintain or restore their mobility. Thanks to the continuous improvements in therapy and rehabilitation methods and the related progress in the medical technology field, many patients now have a much better chance of limiting or eliminating the effects of a physical handicap than they did just a few years ago. In this brochure, we would like to describe some new approaches that can make the return to an active, independent lifestyle easier after stroke. Prof. Hans Georg Näder CEO and President Otto Bock HealthCare GmbH Otto Bock HealthCare Rehabilitation after Stroke 1

Foreword In the developed, industrial nations, stroke is the most frequent cause of long-term disabilities. Each year, approximately 250,000 people in Germany suffer stroke; a dramatic increase is expected over the next few years due to current demographic developments and the aging of the socalled baby boomers. Type and Frequency of Problems 3 Months after stroke Loss of the ability to walk 25% 66% Restriction of the ability to walk The goal of modern stroke rehabilitation methods is to reintegrate our patients into their professional and social environments. In spite of improvements in acute treatment methods, there is still a huge need for better rehabilitation. Three months after the acute occurrence, one-quarter of all patients are still bound to a wheelchair; two thirds of all patients are walking so slowly that they cannot cross the street during a walk light and they need to stop and rest after a few hundred metres. Approximately one-third of all patients complain of a total loss of arm functionality, and everyday dexterity is significantly impaired in another 50% of all cases. Loss of arm functionality 33% 50% Impairment of dexterity 2 Otto Bock HealthCare Rehabilitation after Stroke

Over the last few years, there have been significant improvements in rehabilitation methods used after stroke. Interdisciplinary early rehabilitation and intensive early therapy have been proven to improve the patient mortality rate and rehabilitation results. Medical aids play an important part in the development of increasingly successful rehabilitation methods. They are no longer limited to merely compensating for a loss of functionality; in line with the principles identified above, they help the therapist to promote motor learning. Examples include early mobilization in an optimally adapted wheelchair which the patient can use to move about independently in the ward, fittings with intelligent orthoses that make repetitive gait training possible, and walking aids that reduce the risk of falling. New implantable electrostimulation technologies like the ActiGait system, which activates dorsiflexion in a timely manner in order to avoid dragging the foot during the swing phase, create entirely new treatment options both in regards to functionality and appearance. In the upper extremities, shoulder orthoses can be essential in order to make functional treatment in case of painful shoulder-hand disorders possible in the first place. Meanwhile, EMG-triggered electrostimulation of the paretic forearm extensors has also become accepted as a supplementary home therapy method. I am glad to see that Otto Bock wants to apply its extensive experience in fitting people with disabilities and illnesses in order to improve the rehabilitation of stroke patients. The initial developments have already been completed, additional projects have been initiated, and a strategy has been formulated in accordance with the modern state of knowledge regarding medical aids. In this context, Otto Bock sees itself as an active partner who wants to support physicians, physiotherapists, and patients with its globally recognized know-how. Prof. Dr. med. Stefan Hesse Otto Bock HealthCare Rehabilitation after Stroke 3

Modern Rehabilitation after stroke Recent insights regarding the functional plasticity of the brain have changed the way of thinking with regard to rehabilitation. Impaired functions can be assumed by other, undamaged areas of the brain and can therefore be fully or partially restored. This requires practicing these functions intensively as soon after stroke as possible. Therefore, physiotherapy and occupational therapy with a wide range of motor therapy methods that have been scientifically proven to be effective are the core components of neurological rehabilitation. A series of studies has shown that rehabilitation methods which focus on training can achieve impressive results in the improvement of motor functions and abilities not just in the acute phase, but also in the chronic phase after stroke. 4 Otto Bock HealthCare Rehabilitation after Stroke

Therapy Approaches Motor Rehabilitation Established therapy methods: According to Bobath and Vojta Proprioceptive neuromuscular facilitation (PNF) Development kinesiology according to Hanke Treadmill therapy Classical gait training New therapy approaches: Gait training robot for locomotion therapy Functional electrostimulation* Robot-assisted rehabilitation Arm power training* Mental training Forced use of the paralyzed side (constraint-induced therapy)* Repetitive isolated movement exercises * can be performed with and without medical aid Explanation of the therapy approaches Motor rehabilitation of the arm and hand In addition to the long-established therapy methods according to Bobath and Vojta as well as proprioceptive neuromuscular facilitation (PNF), modern methods such as forced use of the paralyzed arm, repetitive isolated movement exercises, functional electrostimulation, robotassisted rehabilitation, arm power training, and mental training are also used to rehabilitate arm and hand functions. Constraint-induced therapy is based on the theory that patients rely on their non-affected arm after stroke and therefore lose the use of their paralyzed arm. With this method, the non-affected arm is immobilized, forcing regular use of the paralyzed arm not only during the therapy itself but also during normal everyday activities. Targeted use of medical aids in neuro-orthopaedics: Functional dorsiflexion-assist orthosis (Walk On) Functional shoulder orthosis (Omo Neurexa) Functional wrist orthosis (Manu ComforT) Dorsiflexion stimulator implant (ActiGait ) Special wheelchair (Start M3 Hemi) Functional positioning systems Quality for Life Mobility after stroke Treatment by means of neuro-orthopaedic technology is to enhance disturbed functions and optimally compensate for lost functions without impeding retained functions. Our products comply with these principles. Partners of motor rehabilitation Otto Bock HealthCare Rehabilitation after Stroke 5

In stroke patients, repetitive isolated movement exercises [1] during the acute phase led to signifi cant improvements in various arm and hand functionality parameters; the difference was still evident after fi ve years. Arm power training [2] was developed for patients suffering from mild to medium-severity arm paralysis; it involves targeted therapy after a precise analysis of the motor defi ciencies. The improvement in everyday functions following arm power training was still evident one year after therapy. 1 EMG-triggered functional electrostimulation [3] uses the residual activity of the paralyzed muscle being targeted for therapy. The patient is asked to deliberately contract the paralyzed muscle. As soon as the electrical muscle activity exceeds a predetermined threshold, the device applies an external electrical stimulus to the muscle; this in turn boosts or triggers the muscle contraction. This therapy method is used to assist the reorganization between damaged and sound areas of the brain and to promote learning processes. Numerous clinical studies have proven the effectiveness of this approach [4, 5]. 2 1. + 2. Proprioceptive Neuromuscular Facilitation (PNF) in combination with constraint-induced therapy 3. Functional electrostimulation of the upper extremity 4. Bolton, D. A., J. H. Cauraugh, H. A. Hausenblas (2004): Electromyogram-triggered neuromuscular stimulation and stroke motor recovery of arm/hand functions: a meta-analysis. J. Neurol. Sci. 223, 121-127. 5. de Kroon, J. R., J. H. van der Lee, M. J. Ijzerman, G. J. Lankhorst (2002): Therapeutic electrical stimulation to improve motor control and functional abilities of the upper extremity after stroke: a systematic review. Clin. Rehabil. 16, 350-360.

Severe shoulder pain and the development of a wrist flexion contracture often present severe obstacles in the rehabilitation of arm and hand motor functions. Partial dislocation of the shoulder joint due to paralysis so-called shoulder joint subluxation is one reason for shoulder pain after stroke. For this condition, Otto Bock has developed a shoulder orthosis that corrects the dislocation of the shoulder joint and therefore eliminates the cause of shoulder pain. Rehabilitation of the ability to walk When it comes to the rehabilitation of the ability to walk, the focus is clearly on intensive gait training. The principle Those who want to learn how to walk, have to walk! applies. Clinical studies have shown that treadmill therapy results in significantly greater improvements in the ability to walk than conventional therapy for wheelchairbound stroke patients in the chronic phase [6]. The guidelines of the Deutsche Gesellschaft 6. Hesse, S., M. Malezic, A. Schaffrin, K. H. Mauritz (1995): Restoration of gait by combined treadmill training and multichannel electrical stimulation in non-ambulatory hemiparetic patients. Scand. J. Rehabil. Med. 27, 199-204. Otto Bock HealthCare Rehabilitation after Stroke 7

für Neurologie (German Neurology Association) recommend the early use of medical aids for motor rehabilitation after stroke. Gait analysis studies have proven that dorsiflexion-assist orthoses improve the patient's gait stability. Functional shoulder-arm orthoses, consisting of a shoulder piece and a forearm cuff with adjustable connection straps, were most successful in a comperative study with regard to the reduction of shoulder dislocation, pain relief, and functional arm rehabilitation [7]. It has also been shown that the securing of the paretic arm improves gait stability. The purpose of knee orthoses is to prevent overextension of the knee caused by paralysis during gait training, which could otherwise damage the joint. Without an orthosis, the therapist has to support the patient s knee while the patient is walking. This requires a great deal of strength, which is why two therapists are frequently required for gait training for stroke patient. Not only can established and modern treatment methods combined with suitable medical aids and medical technology devices improve the rehabilitation results for the patient in this case; they can also make it easier for physiotherapists to provide their essential services. 7. Zorowitz et al, Arch Phys. Med Rehabil (1995): Use of devices to prevent subluxation of the shoulder after stroke Otto Bock HealthCare Rehabilitation after Stroke 9

Dorsiflexion Paralysis (drop foot) Paralysis of the dorsiflexion musculature in the lower leg, resulting in so-called drop foot, is a frequent problem after stroke. Dorsiflexion-assist Orthoses Dynamic dorsiflexion-assist orthoses are a key part of gait rehabilitation in stroke patients. They compensate for the paralysis of the dorsiflexion musculature and raise the foot in the swing phase. This prevents the drop foot from getting caught on obstacles such as thresholds and carpets, significantly reducing the risk of falling. A dorsiflexion-assist orthosis also ensures that the patient does not step down on the tip of the drop foot but on the heel. This reduces the risk of twisting the ankle, which could otherwise result in ligament injuries. Studies show that stroke patients with a drop foot who are fitted with a dorsiflexion-assist orthosis feel safer, walk faster, and get caught on obstacles less frequently in the swing phase. Biomechanical studies have shown that patients fitted with an orthosis expend less energy while walking and develop greater force during the push-off phase while moving forward [8]. 28U9 Dorsiflexion-assist Orthosis With a dorsiflexion-assist orthosis, the anterior portion of the foot is raised and passive, flexible limitation of plantar flexion is provided in case of peroneal weakness and paralysis. The thin-walled construction of the dorsiflexionassist orthosis with a high-quality surface increases resilience. Thus it offers effective support at a pleasantly low weight. The long sole ensures exact guidance of the 8. Bestmann A., Sonntag D., Hesse S. (2000): Der Einfluß von Sprunggelenkorthesen und Stützen auf das Gehen hemiparetischer Patienten. Neurol. Rehabil. 6 (3), 117-120. 10 Otto Bock HealthCare Rehabilitation after Stroke

foot and good pressure distribution. Compensating movements such as increased raising of the shoulders and hip are reduced. The patient's gait pattern appears more harmonic. Subsequent problems are prevented. (Fig. 1) 28U11 Walk On Ankle-Foot Orthosis The Walk On ankle-foot orthosis is especially designed for use by active patients with weakness of dorsifl exion of the foot or paralysis. It supports dorsifl exion of the foot and limits plantar fl exion in a passive, fl exible manner. The foot is dynamically repositioned for secure heel impact. The orthosis is made of carbon and is therefore very stable with high energy return and simultaneously low weight. The fl exible elements in the anterior foot area and the heel make a dynamic physiological gait pattern possible, both on even and uneven surfaces. On the other hand, the middle portion of the foot and the calf band are held in place in order to actively support dorsifl exion of the foot. Gait analysis studies have shown that, compared to other carbon orthoses with frontal contact in the standing phase, the Walk On offers increased stability for the tient. pa- In addition, the Walk On with removable calf pad distinguishes itself through a high level of wearer comfort. The low weight and slim anatomical shape make a dynamic gait at higher speeds possible. (Fig. 2) Otto Bock HealthCare Rehabilitation after Stroke 11

Arm and Hand Paralysis musculature that raises the foot and turns it in or out. The swing phase is detected by a heel switch which sends a signal to a control unit attached at the waist when the heel leaves the ground. From there, the signal is transmitted to the implanted stimulator using an antenna attached to the thigh. The stimulator has four separate stimulation channels. This allows the foot position and dorsiflexion to be adjusted and customized to the patient s requirements very precisely. Scientific studies show that ActiGait significantly improves walking speed and steadiness of gait [9, 10]. After stroke, many patients suffer from arm paralysis and, in particular, the loss of gripping functions in the hand. FES Functional Electrostimulation Functional electrostimulation of the dorsiflexion musculature in the lower leg or the nerves that control this musculature can be used as an alternative or supplement to an orthosis. This type of treatment can be carried out using the surface stimulator STIWELL med4. Please see the chapter on arm and hand paralysis for more details regarding this device and information on functional electrostimulation treatment methods. Implanted Dorsiflexion Stimulator ActiGait is an implanted dorsiflexion stimulator for patients who fail to achieve satisfactory results with a dorsiflexion-assist orthosis. It stimulates the lateral popliteal nerve in the swing phase. This activates the lower leg Electrotherapy Targeted functional electrostimulation can be useful to support established physiotherapy and occupational therapy methods, also in combination with orthoses. The STI- WELL med4 is a surface stimulator with two measurement channels to record muscle signals (EMG) and four stimulation channels. It can be used to support or to even make possible the training of complex movement patterns such as opening and closing the hand or moving the hand to the mouth. So-called EMG-triggered electro stimulation uses the residual activity of paralyzed muscles in order to reestablish movement patterns that have been lost. It consists of a combination of functional electro stimulation and biofeedback training. Individual parameters within the various treatment programmes can be changed or adapted in order to custom- 9. Burridge J, Haugland M, Larsen B, Svaneborg N, Iversen H, Brogger Christensen P, Pickering R, Sinkjaer T: Long-term follow-up of patients using the ActiGait implanted drop-foot stimulator, presented at the 10th Annual Conference of the International FES Society, July 2005 10. Larsen B, Burridge J, Haugland M, Svaneborg N, Iversen HK, Christensen PB, Haase J, Brennum J, Sinkjaer T.: A preliminary non-randomized study to evaluate the safety and performance of the ActiGait implanted drop-foot stimulator in hemiplegia: patients perceptions International Symposium Evidence for stroke rehabilitation bridging into the future. Gøteborg, Sweden April 26-28, 2006. P22. 12 Otto Bock HealthCare Rehabilitation after Stroke

ize the therapy to each patient. These modified programmes can then be saved and locked for the patient. The STIWELL med4 is suitable for stationary use in a hospital as well as home therapy by the patient. Treatment data for past therapy sessions can be accessed on the STIWELL med4 or on a PC for documentation purposes. 5065 Omo Neurexa Functional Shoulder-Arm Orthosis The functional Omo Neurexa shoulder orthosis provides pain relief for patients who suffer from shoulder pain after stroke and injuries to the central or peripheral nervous system by correcting the dislocation of the shoulder joint. Repositioning of the humerus head achieved by the Omo Neurexa, pain relief, and positioning of the upper extremity to counteract spasticity facilitate the free functional treatment and activity of the pectoral girdle and arm. A combination with functional electrostimulation is possible. Thanks to increased sensorimotor control, the body posture and gait pattern are improved. The Omo Neurexa is notable for particularly high wearer comfort and easy individual adjustability. 4055 Manu ComforT The Manu ComforT can primarily be used in the first, flaccid phase after stroke for stabilizing support of the affected wrist. Soft tissue injuries caused by overstretched capsules and ligaments of the affected wrist can be counteracted, thus making safe beginning of targeted rehabilitation of the hand function possible. Moreover, the orthosis is notable for a high level of wearer comfort, temperature-regulating PCM material, and easy handling. Otto Bock HealthCare Rehabilitation after Stroke 13

People are the Standard Loss of the ability to walk Stroke can lead to hemiparesis (partial paralysis on one side of the body) or hemiplegia (total paralysis on one side of the body). Many patients initially lose the ability to walk and therefore need to use a wheelchair for a period of time. Approximately one-quarter of stroke patients never regain the ability to walk. Standard adaptive wheelchair for stroke patients The Start M3 Hemi standard adaptive wheelchair, which can be customized to the patient s requirements, is suitable for stroke patients who are unable to walk. The patient usually moves the wheelchair with the sound arm and by toddling with the sound foot. The one-arm propulsion system, low anterior seat height, wider foot well, and individual footrests facilitate this type of locomotion. The lightweight aluminium construction of the Start M3 Hemi accounts for the fact that the amount of strength the patient is able to expend in order to move around is signifi cantly reduced. In case of arm paralysis, the Start M3 Hemi can be equipped with height-adjustable arm rests and adjustable channel forearm pads in order to comfortably position the arm. Thoracic supports and head support systems can be used to stabilize the patient s seating position in order to reduce posture problems caused by sitting asymmetrically. High-quality seat cushions reduce the risk of pressure sores. 14 Otto Bock HealthCare Rehabilitation after Stroke

Quality for Life We profess that the vision of our company is to provide people with the highest possible level of mobility and independence. Otto Bock products are subject to a high quality standard we want to be able to offer the solution that optimally meets individual requirements in every single case. The pace of development has accelerated rapidly due to new technologies. At the same time, each new Otto Bock product is based on decades of experience. From our company history, which began in 1919, we have learned that the following principle also applies to our future research and development activities: People are the standard. Otto Bock HealthCare Rehabilitation after Stroke 15

Für weitere Fragen und Informationen stehen wir Ihnen gern zur Verfügung. Otto Bock HealthCare GmbH Max-Näder-Straße 15 37115 Duderstadt/Germany Phone +49 5527 848-0 Fax +49 5527 848-1414 healthcare@ottobock.de www.ottobock.com Otto Bock 646B37=GB 05.08 Technical changes reserved.