Here’s a look at how the hand program works

Pre-surgery care plays important role

Whenever a health care provider is using expensive new technology, it’s important to make sure all the groundwork is laid so patients may achieve the best possible outcomes. That’s why Southern Indiana Rehab Hospital in New Albany, IN, established an extensive rehab program for quadriplegic patients receiving a new device that restores hand function.

Called the NeuroControl Freehand System and manufactured by NeuroControl in Cleveland, the computerized equipment allows C-5 or C-6 quadriplegics to write, hold a cup, brush teeth, and do other activities of daily living that involve their hands. In a special Freehand program, patients must work extensively with rehab staff to prepare and learn how to use the device.

Here’s how the rehab portion of the Freehand program works:

Pre-surgery preparation: Once the physician and a rehab team evaluate the patient and decide the person is ready both physically and emotionally for the Freehand System, they start the patient on an electrical stimulation program for four to 12 weeks prior to surgery.

The electrical stimulation program strengthens and increases muscle endurance, and it can be used while a person is sleeping. The patient follows a program established by the rehab therapist, and because the electrical stimulation device stores information about how long the patient used it each day, it’s easy to check on patients’ progress, says Linda Moore, OT, director of inpatient therapy services for Southern Indiana Rehab Hospital. "The device lets us know how motivated patients are," she adds. "If a patient’s not willing to do this electrical stimulation for six hours a day, then the patient probably is not going to be willing to do all the work involved in using the Freehand device."

A few Freehand candidates have demonstrated borderline motivation, Moore says. In those cases, the team establishes contracts with the patients and requires them to meet a certain level of preparation or they will not receive the Freehand system. Those who fail to meet the contract’s terms are told they are not ready for the system, and their surgery is not scheduled.

The typical stay in an acute care hospital following the Freehand implant is three days. Post-surgery rehabilitation begins three weeks later.

Post-surgery rehab: A therapist who has been trained specially to work with hands and with the Freehand System sets up the patient on a program that gradually will improve the patient’s ability to operate the device. Patients visit outpatient rehab for three to four hours, three times a week for three weeks, Moore says.

Also, patients continue practicing exercises at home, training at night for six to eight hours. That involves setting intensity for the nine electrodes that are implanted into various hand muscles, says Barb Ford, OT, who works with Freehand patients. "On the very first day, after I set the patient up on an exercise protocol, I check to see how well each muscle is reacting to the stimulator," she says. "I set the intensity, which may take very little to make the muscle contract, or it may take a lot of intensity."

Setting the intensity requires practice, testing, and precision. If the intensity is set too high, it may spill over to muscles that are not supposed to be moving, and if it’s too low, it will not provide enough power in the selected muscles, she explains.

Each patient has a laptop computer, which he or she carries to and from therapy. The laptop plugs into Ford’s master computer, and Ford can program the patient’s device. Patients are instructed to follow the exercise regimen she devised and return to see her in three to four weeks. "Most of the time, in three to four weeks I can see a lot of change in muscle strength," Ford says.

Ford assesses charts that demonstrate how the patient is using the system functionally. That helps her program the patient’s muscles into making various movements. For instance, a patient’s hand may make a lateral pinch, which is the movement required to start a car. Or the muscles could contract in a palmar pinch, which is used for picking up a cup or a pen.

By the next visit, patients may be able to grip a cup, but without much control. Ford begins to teach them and their muscles the finer elements of control. "Therapists have to be very observant because you’re watching the subtle muscle movements of tiny muscles," she notes. Changes in muscle strength determine the need for adjustment, she says. For instance, a patient’s thumb may be too strong, causing him to crush the paper cup. In that case, the thumb electrodes will need adjustment.

This trial and error period can be frustrating for patients, Moore says. "They’re so eager to get this system so they can pick up a can of Coke."

Now that the Freehand System has a number of graduates, some former patients have returned to the rehab facility to volunteer as coaches or supporters of current patients, Ford says. They talk with patients and offer tips on techniques they used that produced a good effect.

Discharge and reimbursement. Discharge planning varies according to a patient’s goals. Some patients may desire to eat and drink more easily, while others may want to perform handwriting skills, Ford says.

"We’ve had some very unique goals, like being able to apply makeup, and the one gentleman wanted to use power tools," Ford says. "So we may make the thumb muscle stronger for the patient who wants to use power tools, or provide more ulnar power grip and a stronger wrist."

Reimbursement for the rehab portion of the system has not been a problem, says John C. Shaw, MD, medical director of Southern Indiana Rehab Hospital. Shaw also performs the Freehand surgery.

"The actual therapy with an OT and hand therapist working with patients isn’t usually a problem," Shaw adds. "The biggest problem is the cost of the device, which is $60,000 to $80,000." The entire cost is about $125,000, he says.

"We’ve struggled with a lot of insurance companies not approving the device because the insurance company often considers these patients not able to return to work," Shaw says. "For one insurance company, we waited for over two years. The family was ready to sue the insurance company, and then it was approved."

As the patient who manages an apartment complex demonstrates, that is a short-sighted viewpoint. Some patients receiving the FreeHand System may be able to use a computer and a telephone, which are necessary for some occupations, and all patients may benefit from a better quality of life.

"This allows patients to feed themselves, write, and do things they could never do before," Shaw says. "So they’re making tremendous gains in their participation in life that give them self-esteem and hope."

Need More Information?

Barb Ford, OT, Occupational Therapy, Southern Indiana Rehab Hospital, 3104 Blackiston Blvd., New Albany, IN 47150. Phone: (812) 941-8300.

Linda Moore, OT, Director of Inpatient Therapy Services, Southern Indiana Rehab Hospital, 3104 Blackiston Blvd., New Albany, IN 47150. Phone: (812) 941-8300.

John C. Shaw, MD, Medical Director, Southern Indiana Rehab Hospital, 3104 Blackiston Blvd., New Albany, IN 47150. Phone: (812) 941-6156.