Recently, I had the opportunity to learn about several different technological enhancements for amputees and paraplegics. These devices seek to replace the functionality lost from catastrophic injury.
At the Rehabilitation Institute of Chicago (RIC), Todd Kuiken, MD, PhD, has been developing a bionic arm that has been featured in multiple science and technology magazines. The first patient to receive a bionic arm was a man who had both arms amputated because of an electrocution. At the Center for Bionic Medicine (CBM) at RIC, Dr. Kuiken pioneered the muscle reinnervation procedure which takes an amputee’s own nerves and connects them to healthy muscle. The “Bionic Arm,” or myoelectric arm, is operated through electrical signals from nerves transplanted from the affected limb into the pectoralis muscle of the amputated arm. The user activates the arms through a learned conditioning using his own thought-generated nerve impulses. These impulses are sensed, via surface electrodes, from the pectoral muscle and carried through to the mechanical arm, causing the arm to move.
The second bionic limb that I have seen is one that replaces the hand and fingers for people who have had their hands severed. ProDigits has developed several different devices that serve to replace lost fingers. These fingers can be powered by two types of control systems: myoelectric sensors that register muscle signals from the patient’s remaining finger or palm, or a pressure sensitive switch input (touch pad) that responds to the tissue surrounding the metacarpal bone to provide enough pressure to activate the digit. There are different built in features that sense the grasping around objects so that the fingers do not crush the object. This is part of the stall feature, which detects when digits close around an object, so users form different grip patterns. The particular person that I observed had his fingers severed on both hands and therefore lost all of his grasping function. Using the fingers, he was able to feed himself for the first time.
The third device was an exoskeleton known as eLEGS produced by Berkeley Bionics. eLEGS is a wearable, artificially intelligent, bionic device that enables people with paralysis to stand up and walk again. The exoskeleton is battery-powered and rechargeable, fitting comfortably and securely over your clothing. I observed one of their female test subjects, who has been paraplegic for almost two decades following a skiing accident, walk using the exoskeleton device. She wrapped herself into the exoskeleton and was able to balance herself and walk. The pace and control of walking could be enabled by devices that looked like ski poles/walking sticks that had an electronic connection to the exoskeleton.
Demonstration of eLEGS device.
Each of these devices are currently in the development and testing phases for use by injured people, and share similar features, including durability, self-contained power and specifically targeted functional replacement. Eventually, the hope is that they will return functionality to people who would have required additional support from caregivers or others. Currently, these devices are expensive. As the technology improves and the cost per unit decreases, they are likely to become more available to amputees and spinal cord injured patients.
The interesting thing for rehabilitation centers will be how these devices become part of the rehabilitation process. As an injured person is learning new routines for doing everything from feeding and combing their hair to walking, they go through a retraining process to compensate for the lost function from their injury. As these devices continue to evolve, they will likely become an early part of the rehabilitation process. I expect that over the next few years we will begin to see these devices incorporated into selected patients internationally. Within the next decade, we are likely to see some of the technologies more widely available.
As we have discussed, after significant and catastrophic injury, it is important to choose the path that will achieve the best recovery. The continuum of care that comprises the rehabilitation process is another key to successful outcomes.
Step 1: Acute Care Needs
The first step is stabilizing the acute injury, and it is critical to be treated at a center that is capable of managing acute needs. Trauma centers have designations which describe the complexity of services that are available. There are three primary trauma levels.
Level I trauma centers provide the highest level of surgical care to trauma patients. Given the multiple resources (both expert and technical) available at Level I trauma, a seriously injured patient’s chances of survival are increased by an estimated 20 to 25 percent. These centers have a full range of specialists and equipment available 24 hours a day, including surgeons, emergency physicians and anesthesiologists. There are specialty services available that include orthopedic surgery, neurosurgery, plastic surgery, radiology, internal medicine, oral and maxillofacial surgery, and critical care physicians. Finally, Level I trauma centers are usually involved in research, trauma education and injury prevention.
Level II trauma centers provide comprehensive trauma care with 24-hour availability of all essential specialties, personnel and equipment.
Level III trauma centers do not have the full availability of specialists, but do have resources for emergency resuscitation, surgery and intensive care of most trauma patients. These trauma centers usually have arrangements with Level I or II trauma centers for those patients that require extensive services and expertise.
Step 2: Acute Rehabilitation
There are a number of specific criteria required for a facility to be designated as an acute rehabilitation facility. A simplified way of thinking about this phase is that the facility must be prepared to deal with resolving both acute medical and surgical care issues (which essentially require round the clock nursing care and daily physician management). As such, it is an important transition phase in recovery where passive care is gradually replaced by active participation in therapies. As discussed in previous posts about the top ten considerations in choosing a rehabilitation center, it is important to choose a provider with significant experience in your case’s diagnosis. These centers should have patients who are similar to your injured person and focus on maximizing functional capabilities.
A pre-discharge step that is critical is to have training on managing inside the home and emergency safety procedures. This will enable the injured person to be functional and safe when returning home or entering a transitional center.
Step 3: Post Acute or Transitional Living Centers
An intermediary step that may be required between acute rehabilitation and outpatient rehabilitation is the post-acute or transitional living centers. These centers provide therapeutic supervision in a residential or community-like setting where skills can be practiced before returning home. These centers have been developed to provide for the needs of patients who are not independent enough to manage at home (even with family support) and would still benefit from intensive therapies. They generally do not have round the clock nursing capability but do have routine nursing supervision. They also do not have daily physician care provided; rather, doctors review the patients’ care and needs on a weekly to monthly basis.
Sometimes these centers provide for long-term placement if the injured person requires ongoing support. These types of patients would include those with acquired brain injury or spinal cord injury.
Step 4: Outpatient Rehabilitation (Residential Re-Integration)
As you plan the injured person’s return home, it is important to be able to continue the process of rehabilitation once he is re-integrated into his home and community. In many ways this is the ideal setting for rehabilitation to occur. It not only is most cost-efficient, but it is generally much more attractive for patients to be home than in an institution. Also, the unique and specific rehabilitation needs of each individual are highlighted by challenges faced in the daily tasks of their home environment. (Note: in many instances this concept of therapy in the site of daily living extends to the workplace or the school setting.)
In selecting centers for outpatient rehabilitation, you should identify therapists who are specialists in the specific diagnosis and who have provided services to a significant number of patients with the same diagnosis. In addition to selecting therapists to manage the physical and functional recovery, it is also important to consider psychological support services. This stage is marked by the realization of how impactful deficits will be and how life has changed.
Step 5: Check-Ins, Follow-Ups, Warnings and Staying on Track
Finally, it is critical to have follow-up plans, sometimes with the original center of excellence, so that improvement can continue to be made even 18 months following injury, and proper techniques and appropriate equipment can continue to be utilized to maximize function. For many of the serious injuries requiring rehabilitation there are a number of longer-term medical and functional risks that need monitored by specialist physicians, nurses and therapists.
Depending upon the type of injury, these multiple steps in the rehabilitation process can takes years, and even a lifetime, as the process itself becomes part of the injured person’s life.
After any significant and catastrophic injury, it is important to choose the path that will get you the best recovery. A large part in that decision is picking the correct rehabilitation center for your injury. This is the second half of our top ten list intended to help you get the best rehabilitation and recovery. To see the first part of the list, see last week’s post.
Many nationally recognized centers conduct clinical studies in collaboration with leading experts at other hospitals, research centers, medical schools and universities around the world. The best clinical centers will work to develop, refine and evaluate new treatments, including drugs, surgical techniques, diagnostic tools, and various therapy interventions that will improve the outcomes of patients.
7. Patient Satisfaction
Many centers will actively promote their patient and family satisfaction scores. You should ask if you can speak to some of those patients and families who were polled and would be willing to discuss their experiences.
Rehabilitation centers may be certified by the Joint Commission and the Commission on Accreditation of Rehabilitation Facilities. These accreditation authorities ensure local rehabilitation facilities meet basic standards for their services. Some facilities are included in the Model Systems of Care by the National Institutes of Disability and Rehabilitation Research (NIDRR) (part of the U.S. Department of Education). Model systems must conduct research of interest to NIDRR and collect data on the specific injury type (spinal cord, burn, etc.). In order to gain and maintain expertise, these designated systems provide care to a significant volume of people with the specific type of injury.
9. Family Support
If you will have a prolonged stay at a rehabilitation facility, you will likely appreciate the convenience of having your family and support nearby. In addition, they will likely want to learn more about your condition, rehabilitation and your eventual return home. You will want to see the facilities where family can stay (if available) and the resources for education and training that is available. You will also want to know the level that family is involved with and engaged in the process, not only at the beginning, but also throughout the stay and after the discharge to home.
Some things that are helpful for families include:
- Basic needs such as housing, meals and parking
- Coordination of medical resources from public and private insurers
- Support and education for families
If you will require a personal care attendant to help with your activities of daily living, it will be important for your family to understand how to find and hire personal care attendants when you are home. You will also have to think about how to balance the needs that you have with any family that will support you in addition to the attendant.
10. Discharge Planning and Coordination
Choosing the rehabilitation facility is a first and critically important step on the road to recovery. It needs to be part of an overall plan for the rest of your recovery and lifelong adjustment. Some rehab centers will have discharge planners who will help you along the way. Discharge planners will:
- work with others, including your case manager, to coordinate ongoing medical and therapy care needs, including providers such as local independent living centers;
- incorporate referrals into their discharge planning;
- establish follow up care (with the center that you have chosen for your acute rehabilitation or another local center if you have traveled);
- make arrangements for someone locally to evaluate the home for modifications;
- provide referral to an appropriate physician(s) and other medical specialists in the community;
- ensure scheduled equipment evaluations for appropriate fit and function when home;
- establish thorough vocational evaluation and referrals;
- make referrals to other services and resources in the community.
In Summary, choose a center that has:
- Experience and expertise in your type of injury
- A continuum of services available and partners for acute care services
- Facilities and expertise in tailoring equipment and assistive technologies for your needs
- Family support, services and housing as needed
- Collaboration with other providers in referring patients to and from facilities
If you are able, TAKE A TOUR and GET A FEEL FOR YOURSELF!
Remember, the relatively short stay at a specialized rehab facility (including those far from home) can make a world of difference in your near and long term course of recovery.
After any significant and catastrophic injury, it is important to choose the path that will get you the best recovery. A large part in that decision is picking the correct rehabilitation center for your injury. The following are the first five of ten tips to help you get the best rehabilitation and recovery. Come back next week for the rest of the list.
1. Specialty Care
Depending upon the rehabilitation needs, you may consider centers that specialize in the treatment of spinal cord injuries, brain injuries, multiple trauma, etc. It is important to understand the experience and expertise of the team that will be setting your rehabilitation plan.
Physiatrists (a.k.a. physical medicine and rehabilitation physicians) usually manage the overall care for rehabilitation patients. They should be part of an interdisciplinary team of professionals, and be board certified in PM&R. The physiatrist should facilitate the coordination of different medical specialties in your care. There should be physician coverage seven days a week, 24 hours a day.
Specialized rehabilitation nurses should be managing your daily care.
Experienced physical, occupational and speech therapists tailor a comprehensive treatment plan to your specific needs and provide therapy for a minimum of three hours a day, five or six days a week. The program should include recreational and other activities on the weekends and evenings.
Psychology and neuropsychology services should be available to help you cope with the many challenges you may face, including individual and group psychotherapy, couples, vocational and substance abuse counseling.
2. Associated Facilities
It is important that the rehabilitation facility have a direct connection to or direct affiliation with a medical center that is capable of more acute care services if the need arises. This usually lends itself to having consultations from those same subspecialists when needed. These services should include neurosurgery, neurology, urology, orthopedics, plastic surgery, neuropsychology, internal medicine, gynecology, speech pathology, pulmonary medicine, critical care medicine, general surgery and psychiatry.
Some facilities even have physical connections that will allow them on-site access to emergency services in case of serious illness or major complications.
For spinal cord injured patients who are on ventilators it is important to note that some facilities will manage this condition and others won’t. One must gain a full understanding of the resources and expertise in managing patients on mechanical ventilation, and the success in getting patients weaned from these devices.
3. Specialized equipment
Part of the rehabilitation program usually includes getting the correct equipment. Assistive technology should be fitted correctly with the patient taught to use it while in rehab. You will want to have everything working properly by the time that you get home. It is important to establish whether your facility has the capability to provide, fit and modify any specialty devices such as manual wheelchairs, functional electronic stimulation bikes, as well as prosthetics and orthotics. While some centers have the latest and greatest equipment with all of the “bells and whistles” that you could imagine and more, the truly experienced facilities and staff understand that the best equipment for you is the one that you will use most proficiently in your daily life.
Some of the specialty equipment and training may need to include driver education, in addition to cooking and meal preparation in a modified setting.
4. Peer support
Peer support and contact with others who have similar injuries can be a critical part of the rehabilitation process. It can help you to adjust to your injury by learning from others who are going through and have gone through the same rehabilitation process. Some specialty centers have programs that bring alumni back to the centers to help in this process. This peer support is most helpful and accepted when people share similar problems and issues. You should ask about the age and gender mix of your injury for the peers at the facility may help you to identify places that have a peer group for you. This is an especially important consideration when choosing programs for women. For example, it is often difficult for women recovering from spinal cord injuries to find peer support because the incident rate among women is much lower than it is for men.
Some facilities offer specialized rehabilitation programs tailored to adolescents, patients on ventilators, low-level brain injuries, dual diagnoses (brain and spinal cord) and neuromuscular diseases, as well as advanced rehabilitation programs for patients who are several months or years post-injury or illness.
You will want to ensure that there are appropriate services if you or your families do not speak English.
5. National Ranking
You will want to understand how the facility compares to its peers on national and local levels.
Next week I’ll continue the list with tips 6-10, covering areas like accreditation, family support and more.
Traumatic brain injury (TBI) has been at the forefront of the news the past couple of weeks, specifically as it has related to the shooting of Congresswoman Gabrielle Giffords. Highly visible TBIs such as Congresswoman Giffords capture headlines, but millions more occur behind the scenes.
Consider that in the U.S. each year there are 5 million head injuries, 2 million with permanent damage, resulting in 235,000 hospitalizations and 50,000 deaths. Well over 300,000 of our U.S. troops in Iraq and Afghanistan have incurred TBIs during their service. TBI is the second most costly type of workers’ compensation injury.
It is important to remember that brain trauma is a process and not an event. These head injuries have both primary lesions related to the structural disruption and secondary lesions related to the sequence of molecular events that follow the injury. It is critical to recognize the changes as the result of traumatic events early so that the complicating sequelae can be prevented or reduced.
After someone sustains a head injury without visible external damage, yet begins to manifest cognitive changes such as headache, difficulty thinking, memory problems, attention deficits, mood swings or frustration, there should be a higher level of suspicion that TBI is present. This is the time to enlist further evaluation and testing. Some newer radiologic modalities, such as MR spectroscopy, FDG-PET scanning and HMPAO-SPECT are able to recognize injury earlier and with greater sensitivity.
Given that the external physical damage from TBI is not always reflective of the underlying processes that have and are occurring in the patients, we must recognize that mild to moderate cognitive impairment can still be incredibly debilitating and require intensive rehabilitation. The therapy with TBI patients requires practicing skills to function at home and work. This recovery process takes months to years and involves the transition to various care settings.
TBI rehabilitation centers such as TIRR (where the Congresswoman went), as well as Shepherd Center, Craig Hospital and others, recognize that intense specialized rehabilitation is the key to successful outcomes for people with TBI. TBI rehabilitation centers focus on extensive testing and intensive therapy that begins immediately. Studies have shown that intensive therapy is associated with earlier functional gains. In addition, TBI specialists recognize the complications that can result from these injuries and set up plans to avoid them.
What you should know:
- TBI is more prevalent than many people realize.
- Early intervention to prevent secondary injury, followed by immediate and aggressive rehabilitation are the keys to successful recovery from TBI.
- There are new modalities to screen for early evidence of traumatic brain injury.
- Even mild cognitive impairments can be debilitating.
- Recovery and rehabilitation is a long process.
I recommend these resources to learn more about TBI:
The Brain Injury Association of America
Next week: The key to finding a good rehab center