Hand technology could bring rehabs new business

Patients need pre-surgery and post-surgery rehab

Quadriplegic patients who can do no more then bend their elbows now have a technological option that could enable them to type, eat, or even operate a power tool. Rehab facilities, working with surgeons who implant the new system, provide the training and education patients need to operate the device.

The NeuroControl Freehand System, manufactured by NeuroControl Co. in Cleveland and approved in 1997 by the Food and Drug Administration, gives new hope to C-5 and C-6 quadriplegics, who could not be helped by tendon transfers or other hand reconstruction procedures.

"The Freehand allows us to work with patients who have higher levels of injury," says John C. Shaw, MD, medical director of Southern Indiana Rehab Hospital in New Albany, IN. "Patients must be able to bend their elbow and control their shoulder to benefit."

Shaw also is a surgeon at Clark Memorial Hospital of Jefferson, IN, which, along with the 60-bed Southern Indiana Rehab Hospital, is a member of the Jewish Hospital Health Network based in Louisville, KY. Shaw has been performing hand surgery on quadriplegic patients for nearly 20 years and is among the first physicians to implant the Freehand System.

The system involves implanting a pacemaker-like stimulator in the patient’s chest. The device is connected to electrodes by tiny wires under the skin. The patient is taught to move an external sensor that translates small movements of the shoulder into control signals, which are converted to radio waves that activate the Freehand System.

"By using a control mechanism, the patient can activate the computer hand, which allows them to open and close the hand, power the wrist, and bring the thumb into position for a palmer pinch, where the thumb comes into contact with two fingers, and another position called the key grip," Shaw explains.

One of the most attractive features of the system is that the benefit is not limited by length of time since injury. However, patients may have to undergo rehabilitation to make the joints supple before the implant, Shaw says. "We must stimulate the selected muscles to allow them to develop strength because once the implant is done, these people may use the device eight to 10 hours a day."

Southern Indiana’s program for implanting the device now requires patients to be at least one year post-surgery, so the patient is stable and mentally prepared to use the system, says Linda Moore, OT, director of inpatient therapy services.

"Patients have to want independence and be willing to do a lot of hard work," Moore says.

While the device offers patients hope, not all quadriplegic patients who are physically capable of using the device are emotionally ready. That’s another reason the preparation needs to be conducted in a rehab setting, Shaw says.

"We’ve recently had two surgical candidates commit suicide, including one patient who was waiting for the Freehand," Shaw says. "It’s very important that these people are evaluated psychologically and have good family support, and that’s the major reason to wait a year post-injury."

Support from families needed

Family support is very important for success in using the system. The patient’s motivation to stick to a therapy regimen in preparation and afterward needs to be evaluated before a physician recommends the operation. "There is some risk for a surgeon to evaluate the patient physically and say, We can do an operation,’ when the surgeon’s not involved with that patient," Shaw says.

Shaw and the rehab facility learned that partly from their experience early on with the system. The first patient was an ideal candidate physically: He was only 17, and it was less than a year after his injury, so his muscles were still strong.

But what Shaw and the other providers evaluating the teen-ager had failed to take into consideration was the boy’s dependency on his parents. "They do everything for him, and he’d rather let them wait on him than use the device," Shaw says.

Eventually, as the boy matures and becomes more independent, he may begin to work at using the Freehand device, but his motivation thus far has been poor, he adds.

By contrast, another Freehand patient was a man in his 30s who had become a quadriplegic after a diving accident more than 10 years earlier. This patient knew what it was like to live without the ability to do many small tasks for himself, and he was highly motivated to increase his independence. The man has pushed the limits of the system and now is an apartment complex manager who does woodworking and uses electrical drills and power saws.

Those examples show how personal motivation plays a big role in the system’s success, which is why the rehab facility has instituted a methodical pre-surgery and post-surgery program. (See story, below.)

Most of the first people to receive the Freehand system through the rehab facility’s program have successfully adjusted to the device and are doing quite well, Moore says.