The 2006 National Rehabilitation Awareness Week, September 17 - 23, is an observance to recognize the determination of more than 50 million Americans with disabilities. In observance of this special week, Therapy Times
is featuring four inspirational case studies of creative therapy professionals improving rehabilitation techniques to help their patients overcome injuries or illnesses and live life to the fullest.
Physical Therapy – Overcoming Obstacles with a Dual Product Approach
Ten years, two children and half a dozen life-changing events later, Lisa Barkel is closer than ever to achieving her goal of walking again. Barkel was injured in a motor vehicle collision that left her a C-8 tetraplegic, ASIA A.
Barkel currently attends physical therapy three times a week, each session a lengthy three hours in which therapists help her regain strength below the level of injury utilizing the most current equipment and technology.
The most innovative tool Lisa Barkel uses is a combination of two products: a bilateral carbon fiber stance control knee ankle foot orthosis (KAFOs) fabricated at emBracing Designs, and a Second Step Gait Harness System. The two products work together to provide Barkel the opportunity to safely ambulate with a natural reciprocating gait pattern.
After Barkel’s injury, she was told she would never walk – or even stand – again. But with resilience and the opportunity to use the gait harness system in conjunction with the bilateral KAFOs, she is proving her physicians and therapists wrong.
When Barkel initially started her specialized intense physical therapy program two years ago, she used the KAFOs and the gait harness system with the goals of pre-gait activities, such as weight bearing while standing to increase passive range of motion at all her bilateral L/E joints and to learn how to shift her weight while increasing her balance and proprioception.
Today, Barkel continues working on these goals; she has added reciprocal ambulation within the Second Step system with the assistance of the KAFOs. She is not currently unlocking her braces at the knee joints, but the KAFOs have the ability to be unlocked when Barkel employs the help of two therapists to actively assist her extremities through terminal knee extension.
Since her accident, Barkel has regained some movement and sensation below the level of her injury, with much return occurring since she started in the specialized spinal cord injury (SCI) program. But Barkel’s goal is to continue her therapy on her off days and walk again. Therefore, her braces come home with her and the newly purchased Second Step gait harness system is used at home with her carbon fiber stance control braces.
Barkel currently requires physical assistance from her husband, who assists her with a sit to stand into the gait harness system. The braces are made from carbon fiber, the same material that makes racecars and airplanes lightweight and dynamic, reducing the force that Barkel has to move against to complete her pre-gait/gait training.
Recently, Barkel gained strength in both her quads thanks to the therapy, drive, personal determination and teamwork. The home therapy program includes: daily PROM/stretch of trunk/bilateral L/Es, neuromuscular electrical stimulation of all major muscle groups below the lesion level every other day, hand-cycling every other day and standing in the KAFOs and Second Step gait harness system to work on endurance, pre-gait and gait activities.
In addition, Barkel remains active by volunteering at her local chamber of commerce, hosting Pampered Chef parties – donating her proceeds to SCI programs – and keeping up with her two young boys’ school and recreational lives.
Source: Second Step Inc. and Messer Orthopedics
Respiratory Therapy – Breathing Easier with a Customized Rehabilitation Program
One of the biggest challenges that Roger Campbell, MS, MFT-C, faces when dealing with patients suffering from chronic obstructive pulmonary disease (COPD) is attitude and lack of education regarding their condition. Campbell, the cardiopulmonary program director for the Salt Lake City-based Mountain Land Rehabilitation (MLR), helps these patients realize that they can still have an active and full life.
In order to better serve their patients, MLR formed a partnership with Petersen Medical, a Salt Lake City-based company specializing in providing high-quality home medical equipment and dedicated professional service to patients with in-home respiratory needs. Petersen Medical uniquely screens its patients and then sends them to Campbell and the MLR team for their needed therapy. Although Petersen Medical receives no compensation for this service, it provides for the best-educated and most active patients with COPD.
“Patients often don’t realize that rehabilitation is even an option,” says Campbell. “This can lead to them becoming depressed and slowly slipping into an invalid state. Thus, education and attitude adjustment becomes a crucial step in the treatment process.”
Such was the case with patient Louise Routh of Ivins, Utah. Routh began to realize that if she did not stop the progression of her disease, then she would soon become an invalid. She began working with Campbell and his team as they implemented a customized rehabilitation program for her. MLR uniquely focuses on personalized treatment programs using a combination of specialized equipment and one-on-one intervention to bring each patient to the highest level of function and performance possible.
Routh’s rehabilitation started with an SF36 – a quality of life survey – and a functional capacity test, which allowed Campbell to know her current physical limitations. He then created a customized treatment program, which incorporated oxygen therapy, a tailored exercise program, wellness diet and copping skills and techniques to better manage her disease.
Oxygen Therapy
For Routh’s customized oxygen therapy program, Campbell teamed up with Jason Smith, RRT, from Petersen Medical and they selected the Inogen One oxygen concentrator for Routh’s therapy.
As a tank-free portable oxygen concentrator system, the Inogen One is designed to specifically help patients with limiting respiratory conditions breathe easier while enhancing their mobility and quality of life.
Previous oxygen devices fulfilled clinical requirements and therapeutic functions, but patients were limited in their ability to lead more active lifestyles. Conversely, the Inogen One system was designed to act as a stationary and a portable device, and also engineered to give patients an opportunity for a more spontaneous and active life at home.
Smith counseled Campbell on the best way to utilize the Inogen One for Routh. The new system performed quite effectively, allowing Routh to travel and perform daily tasks that were previously too difficult to complete.
“Studies show that patients suffering from COPD who use oxygen eight hours a day significantly increase their lifespan,” says Campbell. “The Inogen One has allowed Louise to undergo her needed oxygen therapy while giving her the freedom to conduct her life the way she’d like to.”
Exercise Program
While the damage done to Routh’s lung tissue is irreversible, the customized exercise program was designed to improve other systems in the body to make up for her lung’s lack of performance. She is now much more physically fit. The program drastically strengthened her diaphragm and cardiovascular system, which allows her to receive a better injection factor from her heart and the ability to utilize oxygen and overall energy much more efficiently.
Wellness Diet
Routh was issued a custom diet manual with an emphasis on whole body wellness. Often, COPD patients suffer from a lack of nutrition because gas caused by food results in abdominal swelling, thus affecting the diaphragm’s ability to work correctly. She was encouraged to eat whole-wheat grains, vegetables and multi-vitamins. She was also instructed to avoid gas-producing foods such as broccoli, beans and apples and to avoid white bread and other processed foods. In addition, she was told to avoid foods with high sodium because of complications of edema in her ankles and the effect of high sodium on the heart.
A Better Life
Along with these regimented programs, Campbell and his team worked with Routh to implement coping strategies and techniques for more efficient management of her disease, as well as stress management and panic control. She has decreased her oxygen requirement a significant 1.5 liters a minute since beginning therapy while increasing her workload by three times. She has also decreased her sensitivity to shortness of breath and ratings of perceived exertion.
Routh is now able to participate in the activities she enjoyed before her disease. For example, despite concern expressed from her siblings, she just recently traveled to North Carolina to visit her aging mother. Her siblings’ fears were put to ease when they saw the enormous progress she had made in managing her condition. Routh is an avid car enthusiast and collects Mustangs and T-Birds. She is now able to participate in car parades and shows, complete household chores and take an active role in her church.
Routh’s therapy, through Campbell’s expert guidance and Petersen Medical’s innovative oxygen products, is helping her regain the enjoyment of her former life and giving her hope for a better future.
Source: Tom Bradley, CEO of Petersen Medical.
Speech Therapy – Finding a Voice through a Mind/Body Balance
Dinaste Allen, a 12-year-old female, presented with voice loss at the time of her initial evaluation. Allen had been battling with this voice loss for two years. Her mother, Denise Allen, reported that the onset of the voice loss coincided with three consecutive asthma attacks associated with harsh coughing.
Dinaste was treated with antibiotics for her voice condition by her family physician without improvement of her vocal symptoms. She was subsequently referred to an otolaryngologist who diagnosed muscle tension dysphonia (MTD) and was therefore referred to a speech-language pathologist for voice therapy.
Muscle tension dysphonia creates a hoarse voice quality and sometimes even voice loss due to an inappropriate posturing of the many muscles in the voice box responsible for voice production. There are 13 muscles in the voice box that all must work together in a relative balance for a voice to be normal.
Occasionally, these muscles can be strained to the point where they become imbalanced and do not pull properly, resulting in various levels of hoarseness. When individuals continue talking during these events, the inappropriate muscular patterns become confirmed and persistent hoarseness or voice loss results.
Voice therapy continued over a 1.5-year period of time without any noticeable improvement in Dinaste’s voice quality. She was then referred to a psychiatrist without positive results. Concerned that her daughter would “never speak again,” Denise began searching for alternative treatments. She was referred to Joseph C. Stemple, PhD, CCC-SLP, ASHAF, who had recently left a 30-year clinical speech pathology practice in Ohio to begin a teaching and research career in the College of Health Sciences at the Lexington-based University of Kentucky.
Denise contacted Stemple and explained her daughter’s situation. Suspecting that the diagnosis of MTD was correct, Stemple asked that an otolaryngologist at the University of Kentucky department of Otolaryngology Ear, Nose and Throat Clinic evaluate Dinaste and confirm the diagnosis. When this was confirmed, a voice evaluation involving Dinaste, her mother, Stemple and Bridget E. Williams M.S., CCC-SLP, speech-language pathologist at the UK Communication Disorders Clinic, was conducted.
Dinaste presented for this evaluation with a severe breathy hoarseness. With great effort, she struggled to produce voice but was able to only speak in a harsh whisper. It was evident to Stemple and Williams that the inappropriate muscle patterns that Dinaste was using to produce voice had been well confirmed over the two-year period since the asthma attacks.
During the initial evaluation, she was educated as to how normal voice was produced, and perhaps more importantly, was reassured that the problem was not “all in your head.” Many different vocal exercises were probed in an attempt to modify the inappropriate muscular patterns. Dinaste left that day with a different voice; not normal, but different. It was characterized by a high-pitched effortful phonation.
When dealing with MTD, the goal is to change or break the inappropriate muscular pattern. Therefore, the different voice was a step in the right direction to returning the voice to normal. Dinaste and her mother were assured that normal voice was, indeed, the goal.
Over the next two sessions, progress was slow, as the old muscle patterns remained difficult to modify. Stemple and Williams continued to try to change the patterns by modifying pitch, loudness and sound placement in the resonators as well as laryngeal massage techniques. All of these techniques were met with effortful phonation as the old patterns of muscle activation dominated.
It was determined that the muscle tension in the larynx and the base of the tongue needed to be modified before the normal voice patterns could emerge. Consequently, it was recommended that Dinaste follow a voice rest program for one week while Denise massaged the laryngeal area two times per day.
Upon her return, it was noted that while massaging her neck, Dinaste presented with a significant decrease in tension. To capitalize on this improvement, it was decided not to directly challenge the old voicing patterns, but rather to try a technique that would reintroduce voice without tension. This technique was to produce voice while inhaling, rather than exhaling. Normal voice production is accomplished by air from the lungs passing between the vocal cords and setting the cords into vibration.
For Dinaste, the inappropriate muscle tension was not permitting the air to flow out normally. The vocal cords are also able to vibrate if they are approximated while inhaling. Inhalation phonation significantly reduces the inappropriate tension of many of the muscles involved in phonation.
Initially, Dinaste found it difficult to posture her vocal cords to vibrate on inhalation of air. With practice, she was able to coordinate by following the steps: breath out, inhale and say “EEE” while inhaling.
By the end of the session she was able to expand her “breathing in” voice productions to other vowels, words and two word phrases with some pitch modifications without tension. Indeed, the inhalation voice quality was the most normal voice she had produced in two years. Home practice was given using inhalation phonation with all of the above as well as simple songs and nursery rhymes.
Upon her return to therapy the next week, Denise reported that Dinaste had produced some intermittent, spontaneous normal voice. She was able to produce inhalation phonation on many vowels for an average length of five seconds. It was then determined that it was time to reverse the inhalation phonation to exhalation or normal phonation. Initially, this reversal was a challenge, as the old pattern of tension tried to reassert itself. This was quickly modified with tactile feedback as Dinaste was asked to feel her neck with her hand during both inhalation and exhalation phonation. With this feedback, she was able to reduce the tension and more consistent normal phonation resulted.
She was then given home exercises involving inhaling and exhaling a series of words and short phrases. Dinaste returned in two weeks with a clear and confirmed normal voice. The final stage of therapy involved a series of exercises to confirm the appropriate voice patterns so that the occurrence of MTD would be less likely to ever occur again.
This was a difficult case because of the long time period that this child used the inappropriate muscle patterns. Many patients are seen with MTD of shorter duration and the patterns are often modified during one session through voice manipulation or manual massage.
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Source: University of Kentucky College of Health Sciences
Occupational Therapy – Taking Baby Steps Toward Independence
Margi Williams, RN, staff nurse in the Children’s Healthcare of Atlanta Comprehensive Intensive Rehabilitation Unit (CIRU), works daily with children needing extensive physical and occupational therapy. In addition to her nursing duties, she’s also spearheading a research study, funded by the Dudley L. Moore Nursing and Allied Health Research Fund and the Rehabilitation Nursing Foundation, where she designed and is testing a new infant Adaptive Crawler™ device to help CIRU’s infants suffering from spina bifida become independently mobile.
Williams says outpatients of the Myleodysplasia Clinic at Children’s Healthcare of Atlanta are using the Adaptive Crawler in the home environment. “Several therapists have interacted with infants on the Adaptive Crawler and given feedback,” she adds. “I know [occupational therapists (OTs)] working with infants on the Adaptive Crawler have used it as an opportunity to encourage play in the prone position, to encourage upper extremity weight bearing and extension and to encourage the infant to open (his or her) hand.”
Williams’ infant Adaptive Crawler device is being tested at CIRU, while Georgia Tech’s Center for Assistive Technology and Environmental Access (CATEA) is designing and making the device according to her specifications and modifications. So far, the infants that have been tested with the crawler have experienced dramatic results. The most noticeable benefits include an increase in upper body strength and dexterity, and an increased interest in interaction with family, including pets, and their environment.
One of those patients experiencing dramatic results is Amarion, a little boy with thoracic level spina bifida.
He started on the Adaptive Crawler™ at the age of seven months. “On the first day, he was able to move it forward and backward,” says Williams. By eight months, the infant could travel across a room – taking 15-20 minutes to do so. Lisa, Amarion’s mother, would sit at one end of the room and call to him and he would go to her.
She would also put him on the Adaptive Crawler while she was working in the kitchen. “She figured that if he wanted her, he would figure out how to get to her, and he did,” says Williams. “By 10 months, he could rock back and forth with the Adaptive Crawler, similar to a typical infant who rocks back and forth prior to crawling onset.”
He also liked to hear the sound the Adaptive Crawler made when he backed into a wall. It’s a good thing the Adaptive Crawler was longer than he was, because he would repeat the motion over and over to feel the bump and hear the sound. “[The length] was on purpose to protect his sensory impaired lower extremities,” says Williams.
By 12 months, in addition to the previous skills (lifting head and neck, going forward, going backward, going to the left, going to the right, rocking back and forth, moving forward the length of his body and moving across a room), he was also able to pivot in circles and, if he was stuck against an obstruction, such as a corner, he was able to back up and change his direction.
According to Lisa, prior to the Adaptive Crawler, Amarion would lie in one spot and just cry. But, that changed with the Adaptive Crawler. Because the device promotes the feeling of weight bearing in the upper extremities by putting weight on the hands and facilitates neck extension, Lisa noted increased upper body strength.
She also noted the increased independence. “Previously, she had to constantly entertain Amarion,” says Williams. “With the Adaptive Crawler, she could put him on it and get other things done as he entertained himself.”
This is important for developing physically and mentally, especially in social settings. Lisa cares for another infant, who crawls and is just a few months younger. With Amarion on the Adaptive Crawler, and the other crawling, they play together like two typical babies. Wherever she crawls, he follows on the Adaptive Crawler, says Williams. Even more impressive, when she pushes him on the crawler, he puts his arms down when he doesn’t want to move.
Williams notes that this improved upper body strength will be useful, when the infant is older, for performing transfers and using a wheelchair.
“With the Adaptive Crawler, infants experience vestibular, proprioceptive and tactile input. They learn what stimuli are coming from within their body and what stimuli are coming from an external source,” says Williams. This device helps an infant accommodate to a prone position and to have hands flat on the floor while lower extremities are in extension. On the Adaptive Crawler, infants reach out for toys in a prone position and perform weight shifting, which is a precursor to commando crawling. “Being prone on the Adaptive Crawler is a great position for play and interaction with other infants,” says Williams. “They can move around independently without pinching their fingers.”
Williams says the Adaptive Crawler will revolutionize OT techniques in the future, especially those who often used scooter boards in therapy. But what is new about the Adaptive Crawler is that it is sized smaller for an infant, yet it is longer to protect the sensory impaired lower extremities.
“A goal of OT is to build dynamic movement and ability on stability,” says Williams. “So, as a child develops strength in the shoulder from movement on the Adaptive Crawler, the child’s overall ability is enhanced to play, reach out and manipulate tools such as a cup or spoon, which leads to other skills (both functional and ADL) such as writing.”
According to Williams, the Adaptive Crawler will be marketed to younger children, infants, with limited movement choices. It allows a child to use his or her upper extremities, create mobility supports and strengthen the whole upper extremity complex while enhancing exploration and play skills.
While the product was primarily tested on children with spina bifida, as they tend to have upper extremity weakness and lack of dexterity, the Adaptive Crawler may also be useful for infants with hypotonic disorders such as hypotonic cerebral palsy and Down syndrome.
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Source: Children’s Healthcare of Atlanta
