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Reported January 26, 2010

Stroke Rehab At Home -- In-Depth Doctor's Interview

Sandy McCombe Waller, Ph.D., Associate Professor in the Department of Physical Therapy and Rehabilitation Science at the University of Maryland, talks about using a device called Tailwind for stroke rehab months after it happens. What do you think makes Tailwind different than other devices out there for stroke rehabilitation?

Dr. Sandy McCombe Waller: I think that one of the advantages of the Tailwind is it’s portable, and it’s something that in terms of expense, it’s reasonable – not only for clinics to purchase, but even individual clients and patients to purchase – therefore, it makes the treatment accessible to people. There are some very similar principles with Tailwind and robotics to some extent, at least a lot of the robotics that are out there, but the accessibility is not there. They may be able to access it in certain large, teaching centers, but they can’t take it home, and it won’t be in the smaller centers where you may see a vast majority of patients post-stroke. That’s one of the major advantages, I think – that it provides a mechanism to train that can be done in a wide variety of clinics and settings, as well as in the home setting.

What are the mechanics behind the device, and what makes it successful?

Dr. Waller: It’s based off of motor learning principles, where we have kind of the major features of when you’re looking at learning a skill that it’s goal directed – it’s repetition, there’s a focus and attention to the task, and it’s a novel task. You may think that reaching out and back is not so novel, but in a patient where there’s stroke, where their attempt to reach with the paretic arm is kind of in an abnormal synergistic pattern, this is encouraging a reach outward which is novel and challenging for them to carry out. They have task practice goals with the auditory cuing – to match the cuing, to hit the targets, and to keep up with the speed. We can actually also make it more challenging by increasing the resistance with which they move against, and even the direction in which they move, so the adjustability of it allows for training in variations of a reaching task, which are important for functional re-training.

What kind of reasonable range should patients expect to have?

Dr. Waller: I can honestly say that’s not yet been determined. In our studies, we have tried to look at a training paradigm that would fit into a typical outpatient stay or even an inpatient stay where somebody would be seen three times a day for approximately six weeks. In that window, we have seen people who have responded, and we’ve seen people who have not responded. Some folks get the pattern of the motion down within a week or two weeks, but then they continue to improve in terms of moving against resistance or speed of movement or the directions that they can take the arm out, but it’s challenging. I would say, we need much more practice than what is allowed with typical health care stays for outpatient care, which is why the portability of going home is so important, because they can get more daily practice, which is what I would think is more beneficial for folks.

What are some of the daily tasks this will help them do around the house?

Dr. Waller: It’s bilateral training, first off, so the first thing we have to think of is bilateral movements. We have in-phase and anti-phase, so think about the times where we have to move our arms together, or when we may be stabilizing with one and the other arm is reaching out or doing an activity. The examples of what patients are telling us they’re improving in are pushing up from their chair, reaching back to assist sitting down, pulling something out, pulling drawers out, carrying bags, lifting the different things in the house that may be of a larger size that they can’t do with a single arm, or holding something with one arm and opening the door with the other, as opposed to taking their cane, putting it on their paretic arm and opening the door with their non-paretic arm, so again, returning to use of the arm in more supportive roles, but it’s actually engaged in the task again. From a more ADL perspective, people who can support their plate while

eating, that can stabilize with one hand while they’re cutting food or putting butter on bread, or putting toothpaste, washing with both hands, so that they can actually clean both sides of their body, because both hands can now participate in the task.

Even though it’s in a supportive role, does using the arm that was impacted make a huge difference in daily life?

Dr. Waller: It makes a huge difference in independence because in many cases, if they can’t dress themselves or they can’t bathe themselves with just the single arm, somebody has to assist. If they now can use that arm to stabilize and somebody else doesn’t have to walk in to help them, that’s increased their independence, and that’s huge for patients.

How much hope is there for patients after a certain period of time, in terms of their rehab?

Dr. Waller: In all of our studies with the exception of the newest one, people have been entered in that are at least six months post-stroke – actually most are years post-stroke – and I think that it’s very important for people to realize there’s still tremendous potential and to kind of change how we’re thinking, at least in terms of arm function. I think that a lot of people counted on functionality because they weren’t writing with the arm, they weren’t doing primary manipulative skills with the arm, and they lost a whole realm of the arm use which is its supportive roles that are very important for daily activities and make a difference in daily activities. Even things like transfer and bed mobility, to have your arm participate in that task again, to suddenly take something that required the assistance of another person to independence, so there’s tremendous potential to improve and regain use of the arm and see functional changes that are meaningful to patient’s lives.

How does it make you feel starting 15 years ago with this idea and seeing it come to fruition like this?

Dr. Waller: It’s exciting to find that there is now an option for people who thought they were counted out, that there was no possibility for them, and now there is something they can work towards and they can begin to see meaningful changes. It’s always been near and dear to our hearts to work on treatment approaches for patients with more paralysis, and that’s where our research has really been focused because those are the folks that we struggle with in the clinic, and it’s nice to see that people are beginning to recognize that these folks can change and they do warrant care and ongoing follow up.

With more severe paralysis, have you seen people go from absolutely no function to just some function?

Dr. Waller: It’s limited a bit because they need to have some function to qualify for our studies, but that is minimal function – just barely moving their arm, a lot of abnormal synergies that they’re kind of bound by. We have heard stories of people who stuff it in their pockets – it gets in their way so they don’t use it at all – to having their arm back again, even if it’s just stabilizing their supporting arm or swinging a bit when they’re walking. That’s been very rewarding to hear about people, surprising in some cases, like wow, that was really important to them and meaningful to them to just feel their arm, to move their arm. There are not drastic changes that they go from no function to writing and drinking and doing a lot of manipulative skills, but realizing that they actually can do tasks again more independently because they are using that arm in a different way, but they are using it.

How much does it cost to have one of these in your home?

Dr. Waller: I think it’s about two thousand dollars. When you look at robotics, you’re in the hundreds of thousands of dollars range, so it is definitely exceedingly reasonable for clinics, and I think with payment plans relative, it is in the reasonable realm for patients and clients.

How big of an advance is the Tailwind?

Dr. Waller: To be perfectly honest, I want to make sure that people can realize what it can do – that it’s a start and it’s not the end. I think that people should realize that the Tailwind may be a stepping stone to increasing function to then be eligible to do other types of training that will then move them along. We think it’s a valuable device and we think it has a defined purpose, but there may be additional approaches that people could then progress to after use of this device, or we’re looking at combining treatments with the use of this device – using the Tailwind prior to a training device with an orthosis to see if we can kind of augment the nervous system’s response or potential to respond to treatments that people at this level typically failed to respond to.

END OF INTERVIEW

This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.

If you would like more information, please contact:

Jill Whitall, PhD Dept. of Physical Therapy and Rehabilitation Science

University of Maryland (410) 706-0764 (410) 706-0764 http://www.tailwindtherapy.com