Cerebral vascular accidents, or strokes, often affect the strength of one side of the body, therefore impacting a survivor's ability to ambulate safely or use their arm for all activities throughout the day. The use of orthotics, especially paired with a functioning hand or mobility, can be critical in early intervention of stroke rehabilitation. For all joints, orthotics provide the following within rehabilitation:
Stability and alignment of the joints
Prevention of contractures
Assisting with movement
Promoting sensory feedback/input
Provide pain relief
Compensation for the loss of sensation in the affected limb
Swelling management
Increase safety during walking or use of the hand
Research surrounding stroke indicates the importance of early mobility and immediate integration for maximizing the chances of successful rehabilitation. The use of orthotics, in combination with assistive devices, can indeed play a role in facilitating early mobility and supporting early intervention in stroke rehabilitation.
However, it is important to note that the specific treatment approach may vary depending on the individual’s condition and the recommendation from the healthcare team. This article provides general information about the role of early mobility, integration of the affected arm, potential benefits of orthotics, and points of caution to consider in stroke recovery.
Understanding Orthoses
Webster’s dictionary defines orthotics as using “an artificial support or brace for the limb.” Orthotics are not only upper or lower extremity-specific but also joint-specific and use-specific. Static splints provide stability at the joint for support when weakness or spasticity is affecting positioning of the limb. Dynamic orthotics allow for slow progression in range of motion and use of the joint of the limb.
Both upper-extremity orthoses and lower-extremity orthosis are both used in stroke rehabilitation and recovery. Volar resting hand splints, wrist cock up splints, metacarpal blocking splints, and Oval-8 splints are some of the commonly used upper-extremity splints. Commonly used lower extremity orthotics include AFOs, KAFOs, shoe inserts, and knee braces.
Orthotists work closely with occupational or physical therapists to assess the patient’s condition and develop an individualized treatment plan. This plan may involve the use of custom-made orthotic devices that are specifically tailored to meet the patient’s needs. Alternatively, they may recommend off-the-shelf orthotic devices that can be integrated into mobility and daily tasks.
When considering the use of orthotic devices, an orthotist takes into account the patient’s condition, functional goals, and the specific requirements for rehabilitation. They ensure that the device fits properly and provides the necessary support and assistance. Orthotists are also familiar with insurance coverage and can guide patients through the process of obtaining financial assistance or reimbursement for the orthotic device.
In stroke rehabilitation, orthotic devices can play a valuable role in supporting the affected limb, promoting alignment, and facilitating movement. By providing stability and assistance, orthotics can help individuals regain function and participate more fully in their rehabilitation and daily activities. Working with an orthotist can ensure that the orthotic device is customized to their individual needs and contributes to their overall recovery and rehabilitation process.
Exploring Prosthetics
Prosthetics vary greatly from orthotics in both make and purpose. Webster’s dictionary defines prosthetics as an artificial device to replace or augment a missing or impaired part of the body, whereas, an orthotic supports a weak limb or joint and does not seek to replace. Prosthetics are not within a standard practice of care following stroke; however, some research shows that prosthetic devices can be used to improve weight bearing and motor learning very acutely after stroke. There are also myoelectric orthotic devices that use faint nerve signals to control motors on the device to move the limb in an active assisted motion. The Myomo is a prosthetic device which has been used with stroke survivors and other neurological deficits. Although it is not FDA-approved for post-stroke use, it works to assist upper arm movement. Using a prosthetic after a stroke is not a commonly used therapeutic route; therefore, if you are interested, please contact your trained occupational or physical therapist for guidance for assessment and connecting to the appropriate prosthetic companies.
Therapeutic Devices for Stroke Rehabilitation
Therapeutic devices include any device, appliance, or related accessories that aim to correct or treat a physical disability or human abnormality. There are many popular therapeutic devices on the market ranging from electronic stimulation, robotic-assisted devices, brain computer interface systems, and virtual reality and gaming systems. It is important to remember that all devices and technology are not created equal and it is important to evaluate each option for personal use. The following content is aimed to educated on the following areas:
Robotic-assisted devices
Robotic therapy can provide high-dose therapy: high-intensity, repetitive, and task-specific exercises that are necessary for motor recovery. Robotic therapy has matured and represents an embodiment of a paradigm shift in neurorehabilitation; this is the shift that is happening across all technologies. Instead of focusing on the compensation of the upper extremity, it allows the user to regain the function of the limb through the theory of neuroplasticity. There are two types of robotic classifications.
Exoskeletons, otherwise known as “Exos”: These systems allow for accurate determination of human joints. Well-known examples of these are the ArmeoSpring and the ArmeoPower.
End-effector robots, otherwise known as EE: These robotics use forces exerted only in the most distal part of the limb to help the arm with assisted movement. Two well-known examples of this are the InMotion2 manufactured by BiopNik and the REAplan manufactured by Axinesis. Overall, EE robotics provide better feedback on performance and evaluation and research has found that improvement in stroke survivors were significantly better in the EE user group compared to Exo users.
Robotics tends to provide high repetition which is necessary for positive stroke rehabilitation, and is generally safe, allowing a wide range of users with aphasia or stroke-related neglect to use them without contraindications. The cons of robotics are the high associated price (average between $75,000.00-350,000.00), there being no true specific guidelines for use in the stroke population, and the use of this technology is unable to promote neural plasticity in the same way that other technology does, such as brain-computer interface or virtual reality.
Brain-Computer Interface
Brain-computer interfaces (BCIs) is a neural system that acquires brain signals through sensors, analyzes those signals, and translates them to output devices that carry out desired actions. BCIs do not use normal neuromuscular output pathways. The main goal of a BCI is to facilitate motor recovery or restore useful function to people disabled by neuromuscular disorders such as amyotrophic lateral sclerosis, cerebral palsy, stroke, or spinal cord injury.
BCIs are devices that augment an injured neural pathway, facilitate motor function, and increase the independence of ADL’s and subsequent quality of life. There is clinical evidence that in non-invasive BCI studies in the chronic stroke population proved clinically significant motor improvement in the upper extremity. There is growing evidence in minimally-invasive BCIs solidifying the theory that you can augment a neural pathway to improve functional independence in persons with severe paralysis.
It is predicted that as BCIs refine their use in the clinical population, there will be a growing number of applications to assist individuals with physical and/or functional limitations. There are two approaches to BCI.
Invasive
An implanted device is implanted in a vein or in a subcutaneous pocket within the motor cortex to generate signals related to movement, which then relays neural signals to an external computer. Then, an external processor transplants brain signals to external devices to improve functional independence.
Non-invasive
A non-invasive headset is used to detect the intention to move an impaired link or the injured part of the brain. When the user is thinking about wanting to move the limb, the external devices respond by moving as their thoughts intend.
Since the use of BCIs is on the newer side of technology, the Neurolutions IpsiHand is leading the path in upper-extremity rehabilitation following a stroke. One hundred percent of all users of the IpsiHand BCI technology have shown some sort of upper extremity recovery following a stroke. Additionally, 67% of users have had statically significant recovery of the arm in functional movement and have shown improvement in aspects of recovery such as tone, sensation, subluxation, and even possible improvements in language and cognition. What is also unique about BCI, specifically the Neurolutions IpsiHand system, is that stroke survivors without any movement, no matter how long it has been since their stroke, can use it. The use of BCI is a new horizon of stroke rehabilitation that should not be missed.
Electrical stimulation devices (E-Stim)
For electrical stimulation, the voluntary movement relies on an intact connection between the brain’s upper motor neurons. During physical activity, muscle contractions increase muscle mass and strength, and lead to a variety of important life-sustaining health benefits. When using functional electrical stimulation, this technology activates intact motor neurons in the muscles, inducing neurotransmitter release at the neuromuscular junction and causing muscle contraction. This way, electrical stimulation can bypass nervous system dysfunction and help restore the pathway to the health benefits provided by muscles that actively contract. Commonly used electrical simulation technologies include Bioness products and Restorative Therapies.
Virtual reality and gaming systems (VR)
VR programs for stroke neurorehabilitation are based on the potential for brain neuroplasticity to recover motor function or that of the UE, LE or balance/posture after a neurological injury by acquisition and retention of new motor skills. The goal of VR therapy in stroke is to apply these motor learning principles for stroke neurorehabilitation by providing the following: repetition, graded intensity, and task-specific training to provide feedback on motor movements in real time. Therefore, VR systems are designed to enhance conventional therapy by providing a tool to deliver more specific, intensive, and enjoyable therapy with real performance feedback and ultimately helping with rehabilitation. There are two kinds of gaming systems.
Immersive: run through use of goggles to integrate movement into the entire immersive VR world. Common examples of immersive VR systems are the REAL System by Penumbra, MindMotion, and the VR-MIll.
Non-immersive: run a 2D hardware system in which movements are stimulated via an accessory device such as a joystick, mouse or sensor. Common examples of non immersive VR systems are The Neofect Smart Glove, Saebo VR, Motus Mova Hand, and Flint Rehab FitMi.
Research shows that virtual reality paired with traditional therapy may be beneficial as it may enhance neural plasticity. However, it is important to be aware that commercially available systems such as the Nintendo Wii may not be effective for stroke rehabilitation due to difficulty, the decreased ability to adjust to personal needs, and that it doesn't allow for grading of motor impairments. Therefore, it is important to work with a medical professional of a virtual reality company for guidance on programs and use if interested in this technology for your rehabilitation.
Getting Stroke Rehabilitation Devices
When purchasing a therapeutic device, there are many considerations to take in. When purchasing medical device, it is important to keep the following in mind prior to making the final decision:
Evaluating individual needs and goals.
Does it fit your budget?
Does it help achieve your functional or mobility goals?
Have you consulted your healthcare provider or a clinician from the medical device company?
Is there customer support within the company to help you use your device through the purchasing process?
Make sure you understand if it is meant to be used right after a stroke or for long-term survivors.
Will you need help when using it? If so, do you have a family member, friend, or caregiver who can assist with set up and use?
Does it need Wi-Fi to use successfully?
Do you have to use it daily?
Does it need to be used with a therapist or medical guidance?
Is it covered by insurance, and/or can you use FSA/HSA when purchasing?
Can you rent or lease it if you’re not able to purchase?
Are you able to return it?
Conclusion
As a stroke survivor, it’s essential to explore all available options throughout your rehabilitation journey based on your individual needs. Initially, orthotics or assistive devices can provide stability and support weakened limbs, helping you regain some functionality. These devices can assist with mobility, balance, and coordination.
However, as you progress and regain strength, it may be beneficial to incorporate more advanced therapeutic devices and technology into your rehabilitation. The Neurolutions IpsiHand System, for example, is a device that uses brain-computer interface technology to help stroke survivors regain hand and arm function. These devices can assist with mobility, balance, and coordination.
Virtual reality (VR) and electrical stimulation (Estim) are also emerging technologies that can be used in stroke rehabilitation. VR provides an immersive and interactive environment where stroke survivors can engage in therapeutic exercises and simulations to improve motor skills, coordination, and cognitive function. Estim involves the use of electrical currents to stimulate muscles, promoting muscular re-education and facilitating movement.
It is important to work closely with your healthcare team, including physician therapists, occupational therapists, and physicians to determine the most suitable options for your specific needs and stage of recovery. Rehabilitation plans should be personalized and regularly reassessed to ensure they align with your progress and goals. Empower yourself by being the best advocate for yourself or your loved ones during your recovery!
References:
Hase K, Fujiwara T, Tsuji T, Liu M. Effects of prosthetic gait training for stroke patients to induce use of the paretic leg: a report of three cases. Keio J Med. 2008 Sep;57(3):162-7. doi: 10.2302/kjm.57.162. PMID: 18854669.
Lang CE et al. Dose-response of task-specific upper limb training at least 6 months post stroke: a phase II, single-blind, randomized, controlled trial. Ann Neurol. (2016) 80:342–54. doi: 10.1002/ana.24734
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Advanced Technologies for Upper Extremity Neurorehabilitation (Part 1). [URL]. PowerPoint Presentation.
Advanced Technologies for Upper Extremity Neurorehabilitation (Part 2). [URL]. PowerPoint Presentation.