Team helps brain adapt to damage

Program manipulates brain to achieve outcomes

Their success stories are heartwarming and at times just short of miraculous. A patient learns to walk 10 years after a stroke left him in a wheelchair. Another patient regains the use of his left arm and is able to enjoy boating again. The secret lies in neural plasticity, or tapping into the brain’s ability to adapt to damage and manipulating it to achieve improved outcomes, and the Emory Program in Restorative Neurology (PROREN) in Atlanta is pioneering new techniques that do just that.

While some of PROREN’s techniques are being used elsewhere, few, if any, centers bring them together under one roof and use them in quite the same way, say team members. Those techniques include:

Forced use. "We basically immobilize the good limb, and force the patient to use the involved limb," says Krish Sathian, MD, PhD, medical director of PROREN and assistant professor in the department of neurology at Emory University School of Medicine. "When the brain is first injured, it goes into a state of shock," explains Sathian. "Patients learn not to use the involved limb. The shock wears off and the brain’s circuits come back to normal, but in the meantime, the patient has learned not to use the involved limb."

Sometimes, forced use is combined with mirroring techniques, adds Arlene Greenspan, DrPH, PT, assistant professor in the depart - ments of neurology and rehabilitation medicine at Emory.

"We use the mirror to trick patients into thinking they are using their involved extremity when they are actually used their unaffected extremity," she explains. "Sometimes, we get patients who are sensory impaired. They can’t feel their arm. The mirror tricks them into believing they are using their involved arm."

Biofeedback. "Biofeedback has been around for a long time but not widely used in rehabilitation," notes Steven L. Wolf, PhD, FAPTA, PT, director of PROREN and a profes -sor in Emory’s department of rehabilitation medicine.

"We use computer visualization to show patients the amount of force their muscles are exerting," he explains. "Patients see a line moving across the screen. The line spikes higher with more activity. We can place targets on the screen for the patient to meet."

Balance retraining. The computer is also used to provide visual feedback of forces exerted through the body under stationary and moving standing platforms, says Wolf.

Careful selection

Fewer than 200 patients have completed PROREN since it opened its doors in 1996. That relatively small number is due in part to PROREN’s use as the program of last resort — the place patients go when they don’t achieve optimum outcomes in other rehabilitation programs, say team members. The other reason the numbers are so small is that the PROREN team carefully selects patients for participation. "We don’t take them if we don’t think we can help," Sathian says.

PROREN is designed for patients with neurological disorders that have a motor component. He notes that three groups of patients benefit most from PROREN’s unique approach:

• Patients with chronic neurologic conditions and movement disorders, such as Parkinson’s disease. "Many patients with chronic neurologic conditions never enter rehabilitation. There is not a lot of awareness among neurologists that rehabilitation could be helpful for these patients," Sathian says.

• Patients who suffered a brain injury some years ago, completed rehabilitation, and then recently experienced declines in function for no obvious reason.

• Patients who recently suffered a stroke and completed both inpatient and outpatient rehabilitation without achieving their rehabilitation goals.

Patients referred to the program undergo a comprehensive, multidisciplinary, objective evaluation, say team members. After patients have been evaluated by team members, the team holds a case conference to share findings and discuss the patient’s appropriateness for PROREN.

Team members use standardized evaluation tools that provide a quantifiable scores for muscle activity, range of motion, and joint function. Those scores are entered into the program’s database and referred to at each team conference to track the patient’s progress, Wolf adds. "The fact that we use so many objective, quantifiable measures of function sets us apart from other programs, he says.

The initial evaluation can cost as much as $1,500. The neurological evaluation costs roughly $350. The physical therapy evaluation costs about $150. If the patient needs a neuropsychological evaluation to assess cognitive or memory problems, it costs about $248 an hour with evaluations lasting an average of four hours.

According to Wolf, an excellent candidate for PROREN has the following characteristics:

• some ability to open the hands and move the fingers away from each other;

• some ability to straighten the elbows;

• ability to begin to bend the knees toward the rear end in standing position;

• some ability to raise the bottoms of the feet from the floor.

"We look for minimal motor criteria — something we can build on," says Wolf.

Send me in, coach

Patients with cognitive or memory problems are evaluated by Felicia C. Goldstein, PhD, associate professor in Emory’s department of neurology. "I probably see about 75% of the patients referred to the program," she notes. "The most important thing we have to determine is whether the patient will be able to understand and remember instructions. I am also able to detect conditions such as depression that may impact the progress of the patient’s rehabilitation."

Characteristics Goldstein looks for include the following:

• motivation;

• eagerness to participate;

• willingness to work hard;

• ability to comprehend, even if patient is unable to speak;

• ability to follow through with instructions.

"Patients can have memory problems, especially after stroke or head injury, and still participate in and benefit from the program," she notes. "I help identify cues that therapists can use to help patients remember what they learn. For example, a patient may need to have a note or diagram taped to his wheelchair to help him remember the steps involved in transferring from his wheelchair to his bed."

The patient evaluation sometimes identifies issues that members must address before effective therapy can begin, notes Greenspan. "I might note that the patient has a spasticity problem that is too great for me to have an impact. I might recommend holding off treatment and trying a neural block to control the spasticity before therapy begins."

Looking at outcomes

Once a patient is accepted into PROREN, the team develops a treatment plan and coordinates all of the patients appointments. "I coordinate all of the patient’s appointments, including appointments with outside specialists," says Alvatine Smith, PROREN coordinator. "For example, if the patient has some eye involve ment, the team may refer him to a neuro-ophthalmologist," she notes.

Team members meet frequently to discuss patient progress. "We have a philosophy that if a patient doesn’t improve over three or four consecutive treatments, we have to reevaluate the treatment plan," says Wolf. "If the patient is progressing well, we discuss the case every month to two months. If the patient does not progress as expected, we discuss the case after every three to four sessions."

Even when the PROREN team feels a patient is not suitable for the program, it makes recommendations to the referring physician. "We may recommend that the patient undergo standard gait and balance training at an outpatient rehabilitation center. We may recommend vocational support services or social programs to help enhance the patient’s life," says Sathian.

Greenspan works with the program’s database. "We’re tracking data to get a better sense of what is working. We’re using our outcomes to modify treatments and get a better feel for what works best for which patients," she says. "At this time, our numbers aren’t large enough to look at statistical significance, but we’re still using the data internally to improve our outcomes and also to report progress back to referring physicians."

In addition to functional measures, PROREN is tracking quality of life outcomes. "Quality of life is not measured enough in rehabilitation," Greenspan notes. "Our perception of a patient’s progress is not meaningful if the patient also does not feel his life has improved."