Search for tag: "rehabilitation"

Interviewer: For a patient who has experienced any sort of traumatic brain injury, recovery can be something that might seem a little scary. How long is it going to last? What can you expect, etc.?

So to answer some of these questions, we are here with Dr. John Speed. He is a professor in the division of Physical Medicine and Rehabilitation and practices at the University of Utah Health. Now, Dr. Speed, when we talk about a traumatic brain injury, that's a pretty big term. What kind of patients are we talking about here?

Dr. Speed: We're talking about a huge spectrum of people, from an individual that may have sustained a concussion heading a soccer ball all the way to someone that's been in a catastrophic car accident and sustained a brain injury that's left them in a coma for a prolonged period of time.

Interviewer: And what kind of patients do you see the most getting these types of injuries?

Dr. Speed: Well, the most common type of brain injury really is the concussion or mild brain injury that might be seen in the emergency room and sent home. But here at the Craig H. Neilsen Rehabilitation Hospital, we take care of patients in the hospital that have sustained more severe injuries that are perhaps comatose or have much more significant problems that last for a longer period of time.

Interviewer: So someone comes into say the hospital, the emergency room, this particular center with a brain injury, what's the first things that you guys are going to do to, you know, make sure that they're okay?

Dr. Speed: Well, that piece of it really falls to my neurosurgical and emergency room colleagues. They'll do any necessary surgical intervention to, say, remove a blood clot that may have formed. Possibly they'll do a procedure to remove a piece of skull to allow for brain swelling, which can be incredibly frightening for family members because obviously it looks very awful. But then once the person has recovered from a neurosurgical standpoint and they're ready for rehabilitation, they'll transfer over to the Craig H. Neilsen Rehabilitation Hospital and they'll have inpatient rehabilitation here working on all of the problems that they may have as a result of their brain injury.

Interviewer: And what are some of the problems that a patient like this might be experiencing?

Dr. Speed: Well, the brain is awfully complex and it does everything. So it could be emotional problems. It could be cognitive problems. It could be paralysis of one or both sides of the body, swallowing problems, speech problems, visual difficulties, you name it.

Interviewer: So when we talk about emotional or cognitive, what kind of things are we experiencing? Like a change in mood and behavior, lack of memory, what are some of those things?

Dr. Speed: Well, early on a person may still be in what we call post-traumatic amnesia. They have no idea where they are. They have no idea what's going on. They can't process information. They can't make sense of their environment. And I make the analogy that it's somewhat like living inside a kaleidoscope. They're just presented with all of the sensory input that they can't make any sense of. And so, of course, that's a very frightening experience, and oftentimes the reaction is one of thrashing around, being agitated, yelling, screaming, because it's a very frightening and disorienting experience. But as a person continues to recover, that orientation improves and the person can make sense of their environment again and that agitation will eventually settle down.

Interviewer: That sounds like a kind of situation that could cause some anxiety for both a patient and for, say, the loved ones that are looking on. What can, you know, doctors like you or someone at a center like the Craig H. Neilsen Center do to help relieve these kinds of symptoms and get the person, you know, closer to normal?

Dr. Speed: Well, the first thing we do is have the person in a low stimulation environment because the less sensory input coming in, the low light, low sound, the TV is off, blinds are down, etc., and minimize the stimulation. And then if necessary, we may use a person's music that they're familiar with, that they enjoy. That can be calming for lots of people. And interestingly, I had patient years ago, who was a young man who was into head banging heavy metal and that was something that was very calming for him. It was very disturbing for the staff, but it worked to help him feel more comfortable and relaxed.

Interviewer: So after a patient has gone through that post-traumatic amnesia, what are some of the steps that come next, and how long can a patient and their loved ones be expecting the recovery to take?

Dr. Speed: Well, of course, the recovery is incredibly variable, and it depends on the severity of the injury, it depends on the type of injury or injuries, and it also depends to some extent on what the person had in terms of life experience prior to the injury. But once the typical sort of sequence of events is the person will proceed out of post-traumatic amnesia. So they'll be oriented, they'll know where they are, they'll know what year it is, and so forth. They'll know that they're in the hospital and why they're in the hospital.

And our therapists are excellent at working with people to regain physical function, balance coordination, mobility. Our occupational therapists will work on what are called activities of daily living. How does a person get dressed? How do they bathe themselves? And those sound pretty basic, but, you know, if a person has had a brain injury, they may not be able to dress themselves. They may put their pants on and then put the underpants on outside because they just don't know the sequence of events that are necessary and they can't process that. So occupational therapists will work on those kinds of things. And then we also have speech therapists that will work on cognition, memory, and also address any language problems that might exist and also any swallowing difficulties that might result from the brain injury.

Interviewer: So what are the expected outcomes for the types of treatment regardless of what kind of brain injury this individual is having and comes to a center like the Craig H. Neilsen Rehab Center?

Dr. Speed: Well, outcomes, of course, are incredibly variable, but we're very proud of the outcomes that we do achieve here. And more than 80% of the people that we admit to the Craig H. Neilsen Rehab Hospital with brain injury are discharged to home. And that doesn't mean the rehab therapies are finished at that time, but people do go home and continue their therapies in some fashion after discharge to home.

Interviewer: And how long are they typically at a center like the Neilsen Center?

Dr. Speed: Well, our typical length of stay for someone with a brain injury that's admitted here is somewhere between two and three weeks.

Interviewer: Wow. So I guess one of the messages maybe that, you know, with the right help and the right medical assistance, there is hope for someone after a traumatic brain injury.

Dr. Speed: Oh, absolutely. For sure.

Interviewer: Technology can help individuals with disabilities live a full and rewarding life. That's next on The Scope.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope. The University of Utah Health Sciences Radio.

Interviewer: Dr. Richard Kendall is with the Rehabilitation Center of University of Utah Health Care and we're talking about the Americans with Disabilities Act 25 years later, which really kind of changed a lot of people's thinking about including people with disabilities in life. Tell me about some of the work that you do to include people with disabilities in recreation.

Dr. Kendall: Well, not just including people with disabilities in recreation, but people who have a disability, like everyone else, want to recreate, wants to socialize, wants to get out of their house and out of work and do things that are fun. Our program, here at the University of Utah and TRAILS does just that for people with spinal cord injuries.

Interviewer: And some of the equipment, the technology, and some of the things technology allows people with spinal injuries to do is amazing. Tell me about some of the things you have in your trailers. You have a whole bunch of trailers filled with lots of fun.

Dr. Kendall: Yes. Our program has three trailers full of equipment that are around the valley at any certain time. We have cart skis, we have robotic skis, kayaks that you can operate through sip and puff so really accessible to anyone with any level of any injury.

Interviewer: Let's take a little bit of a turn here and talk about technology and how technology has really changed the game for accessibility and socialization as well. There's something you have that I call robot legs, but you call it something else. Tell me a little bit about the robot legs.

Dr. Kendall: Yeah. The robot legs are exoskeletons, as they're called. They allow individuals with spinal cord injury, and soon strokes, to be able to stand and walk with the use of the robotic arms and crutches. This really is going to open a lot of opportunity for individuals with spinal cord injuries so they can stand, so they can walk, talk to their peers eye to eye. All of those are going to be very important. Technology, in general, is really opening the world and we have Bluetooth controlled prosthetic knees now. People can snowboard, people can walk in them. The technology of carbon fiber allows people to run pretty quickly if you think of Oscar Pistorius. So technology is changing and really is going to open up a lot of access for individuals with a disability.

Interviewer: I'm guessing you're about the same age as I am. When I grew up, I watched "The Six Million Dollar Man." At that point of your life, did you ever dream that that would become reality? I mean, as a physician that's pretty amazing to watch that.

Dr. Kendall: Yeah. It certainly is. While "The Six Million Dollar Man," if you think back in, I think that was the '70s, how much $6 million would have cost. If you think about it now we have neural interphases that people have an electrode put in their brain and can operate robot arms just with their thoughts. So yes, technology is coming to life and I think these are going to be things that as computer and softwares develop further, we're going to see really tremendous growth.

Interviewer: What's on the horizon? What's in the future? What next thing that we can imagine now is going to happen?

Dr. Kendall: Well, the exoskeletons are really in, what I would say is an infant stage at this point. I think that as the computer algorithms develop, you're going to be able these develop where you can stand and walk on their own. I mean, a number of companies have drones that can stand, walk, walk over rocky surfaces with no tethering devices for balance on their own. So I think you're going to see these develop into where somebody can put on the exoskeleton legs and walk even without the use of crutches, and balance, and not fall over.

Interviewer: Will that replace a wheelchair eventually?

Dr. Kendall: For many people, I think it will replace it for many things that they do and I don't think it'll be 100%, but certainly give them accessibility to be up and moving around.

Interviewer: That's incredible. I want to jump back quickly. What's a Bluetooth knee do, by the way?

Dr. Kendall: A Bluetooth knee, basically it's a knee that you can program through your smartphone and tell it to be more rigid or less rigid, depending on what activity you're doing. If you're using it for snowboarding, you can program it so it takes a real big hit and doesn't collapse easily, whereas if you're walking and you want a little more subtle joint play, then you can program for walk mode.

Interviewer: With your interaction with people that use this technology, your patients and what not, tell me the benefit. Tell me a story about how it affects their life.

Dr. Kendall: One of the things that when you see somebody stand and walk, who's been on a wheelchair for a number of years, just the look on their face and really their desire to be able to talk to you while they're standing up, it's really something that is hard to describe. It really brings a whole new phase into their life and gives them hope for the future and further access. Then there's the person who used the sip and puff kayak for the first time, had been living mostly in a nursing home or assisted living facility for many, many years. And he is a ventilator-dependent quadriplegic, can't use his arms or legs, but operated the sip and puff machine very well. The only problem was because he would laugh a number of times, couldn't use the sip and puff]to correctly steer.

Interviewer: Because he was so excited that he was laughing.

Dr. Kendall: He was so excited, he was laughing, being out on the lake in the kayak.

Interviewer: If somebody was interested in learning more about this type of technology to make their life better, what would they do? What would be the first step?

Dr. Kendall: Well, the first step is to go to our website here at the University of Utah Rehabilitation Center and look for theTRAILS program.

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Amy: This is Amy Steinbreck talking with Dr. Steven Edgely, the director of stroke rehabilitation at the University of Utah Health. What do you think is helpful to promote a helpful recovery with a stroke victim?

Dr. Edgley: A lot of recovery happens, initially, without the patient doing that much. We try to facilitate optimal recovery in the first couple of months. Those brain circuits come back to function.

Amy: So, the first couple of months are the most important, in a stroke victim's recovery, would you say Dr. Edgely?

Dr. Edgley: I would not say that.

Amy: Okay.

Dr. Edgley: Because stroke recovery can happen even years down the road. But the rate of improvement typically is fastest at the early months.

Amy: Okay.

Dr. Edgley: That's due to a number of factors, specific to what's going on in the brain and [retraining] the brain cells to function. After about three to six months, it becomes somewhat more difficult to see those marked improvements, but the potential for recovery is still present. It takes the patient to challenge him/herself to do things in a way that's comfortable for them, in a way that's still challenging to them. Simple tasks around the home, using their hands or arms for simple tasks. In time, the brain will change slowly to accommodate for those new tasks and ease of movement.

Amy: It's all part of the brain, reworking those connections and reforming those connections, I assume?

Dr. Edgley: Yes, that's exactly right, and, with time, the brain will be able to lay down new connections, new circuits, and be able to find an effective work around. The main point is the patient has to keep challenging themselves, to do more and go slightly beyond their comfort zone to facilitate those changes in the brain.

Amy: Do a lot of patients find that frustrating? I know, Dr. Edgley, that I sure found that frustrating.

Dr. Edgley: It's frustrating at times, but I like to promote people training for a triathlon. Not necessarily frustrated, just challenged. Training need not be frustrating. Frustrating things are mostly a product of their own emotions. The patients are less frustrated when they see progress towards goals that are meaningful to them.

Amy: I remember in the hospital when I was just learning to walk and they had me in the wheelchair, with the railing, you know, the guided walking path.

Dr. Edgley: Yep.

Amy: I found that very frustrating. But eventually, I was able to walk with a cane, then a gait belt, and now look at me, you know?

Dr. Edgley: Yeah.

Amy: Twenty-four months later.

Dr. Edgley: Yes.

Amy: Yeah.

Dr. Edgley: Yeah so, your situation was not unique.

Amy: So, Dr. Edgley, what factors do you think in the young stroke patient, are optimal influencers on promoting a strong prognosis for a recovery?

Dr. Edgley: Setting long term goals, and those goals should be something that the patient has to reach a great deal for, like 6 to 12 months, or beyond. Then teaming up with a group of people that can help you on the process.

Amy: I would say from a personal experience, a strong support network of family and friends to push you to your limit is important.

Dr. Edgley: Yes, so, pushing people to their limits is good to a point. Sometimes people, all people just need a break in knowing what your limits are, is also important. One of the unique things about changes in the brain, in improvements is, for example, if you played the piano and worked for hundreds of hours to perfect a piece, you don't sense necessarily the brain changing to make it easier to perform the task of being able to play that piece perfectly. You may perceive the completion of that perfect piece, but the brain does not have this building, built in system to signal when you're improving. So, you actually have to look at milestones, recognize the milestones, because it's not natural to do so and give yourself credit.

Amy: The self recognition, and giving yourself a pat on the back.

Dr. Edgley: Yes.

Amy: Is often important.

Dr. Edgley: Yep.

Amy: And recognizing that the milestones and the path people will take are all different. There is different milestones and different paths.

Dr. Edgley: Absolutely. Absolutely.

updated: November 3, 2021
originally published: May 6, 2015

Interviewer: Amputees move prosthetic hands with their thoughts. Up next, on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Interviewer: I'm talking with Dr. Greg Clark, Associate Professor of Bioengineering at the University of Utah. Dr. Clark, I love you work because you're turning what sounds like science fiction into reality. Tell us what you're doing.

Dr. Clark: One example of what we're trying to do is to restore sensory function and motor function back to people who may have lost their hands and long term amputations. So one of the limitations with present prostheses is having enough control over them. The limitation isn't simply in making a hand. That's an engineering challenge for sure, and a very real one. But even if you have that hand, the problem is how does the user control it? Especially if they've lost a lot of their limb, they don't have very many muscles left. So what do they use?
And one idea is to plug that hand right into the user's own nervous system. The brain thinks about moving, just as it normally does with a normal hand. The signals come flying down the nerve, just as they normally would. And if we could wiretap into that nerve, and capture those signals, and translate them, and send them into the artificial hand, the hand would move just as it always did. So one of the beautiful aspects of that approach is that the person doesn't have to learn anything new. They don't have to learn anything counter intuitive.

Interviewer: Well, and I think one of the amazing things is that this has gone beyond the planning stages. I mean, you've actually been able to try parts of this with people, correct?

Dr. Clark: Yes, and we're not the only ones. This actually builds on a pioneering technology and set of studies here done a long time ago, or a decade ago at the University of Utah, by one of my present colleagues Dr. Douglas Hutchinson and Ken Horchin, and others. And they showed that, perhaps surprisingly, the nerves that used to be attached to the hand still work after the hand is lost. And that opens up lots of possibilities both for capturing motor signals, but also talking back to the user and providing sensory experiences.

Interviewer: And that's another interesting aspect of it. Is that the user will not only be able to just move their hand, like you said, they can also feel the hand. What will they be able to feel? Just pressure, or pain, or...?

Dr. Clark: We're hoping to not activate pain, if that's your question. So there's really two important aspects of this, and the best way to think about this is to imagine yourself picking up an object. So imagine picking up, say, a Styrofoam cup filled with water. Close your eyes, reach out, grab that cup. Pick it up, and you know what it is. That's almost self-evident, but think about what it means.
So in our brains, without our even being consciously aware of it, we take all of this type of sensory information and build this mental image. So, although we call it a sense of touch, it's actually conveys lots of information about pressure. That's one example. About vibration when we first hit it. About where our hand is in space. The shape of our hand, both from stretch receptors in our skin, and also from joint receptors that tell us what our joint angle is, and also from muscle receptors that tell us how we're contracting our muscles.

So the two basic types of sensory experience we want to be able to restore are the sense of touch, and the sense of movement so that the person can move his or her own hand through space and know where it is, without having to watch it, but actually feel it. And in the end, we hope that this very rich sensory experience will allow the person to integrate the hand into their own body image, and so the hand will feel like part of themselves.

Interviewer: So you're really sort of the technology behind this ability to move things with their thoughts, and to feel, and...

Dr. Clark: There's many aspects to that technology, and one is actually developing the electrodes, the actually interface that will plug into the nervous system. But if you think about it just a moment more, there's other aspects about that that are very challenging and extraordinarily important. And one reason this is a huge multidisciplinary project is that all of these have to work in order for it to work together.
So for example, suppose I had the perfect electrode technology and I could record the neural signals coming down the nerve, I still have to know how to interpret those, and then send them to the muscle.

So a big part of our project is doing what's called the decode. That is the interpretation of the signals. Another aspect of it is talking back to the nervous system so that the user can understand that the hand has just touched something, or that it's moving through space. And that's called the encode problem. That is sending information into the brain in such a way that the user understands what's out there in the real world. And then there's the whole clinical aspect of it, and then we also have testing the user's ability to use a real physical hand. And so the real benchmark is how well does this prosthetic hand compare with a real biological hand?

Interviewer: This must have an incredible kind of emotional, or psychological impact on the person who's using it.

Dr. Clark: Indeed it does. Today we've done four human subjects. They've been able to control an advanced prosthetic hand on, in virtual realities. That is on a computer screen, and they've also been able to get a sense of touch and movement back from that virtual hand. And it truly is as emotional as you say. One user describes it as, "The loss of hand is like losing a family member, except you're reminded of it every day of your life." And so, as he sat there using it for the first time, it turned out that we provided movement back to him 21 years to the day after he lost his hand, and he could watch it and see it move again.
And one time we began to also provide sensory feedback to it. He could feel his hand, and he described what he had been through. He had been through some 10 surgeries, and after his hand was first damaged they tried to save his thumb, and it didn't quite work. And he went back again, over and over again, 10 times, to try to save his hand. And ultimately it didn't work, and he said, "Just please it out. Take it away." And that day it woke up again for the first time and he could feel it and he could move it, and it was truly overwhelming experience for him. And that's we hope to be able to do. To restore a sense of touch and motion back to individuals, included wounded warriors who have given their, literally their arms for our country, but also we hope this technology to disseminate into the larger community.

Interviewer: What was your reaction when you saw this technology work with a real person?

Dr. Clark: One of the truly poignant aspects is that you do get to know them. We work together with them, and they become truly a part of the team. They tell us what it's like, and what they like and what they don't like, and we try to incorporate that into present work and future designs. And, to be honest, they win your heart as well as your mind. And when you begin to restore some of that sensation and motion back to them, and see how important it is to them, you share a little bit in that joy.

Announcer: Interesting, informative, and all in the name of better health. This is the Scope Health Science Radio.

Amy: This is Amy Steinbrech talking with Dr. Steven Edgley, the director of stroke rehabilitation at the University of Utah Health Care.

Dr. Edgley, thank you for joining me so much in studio for a podcast on stroke recovery.

Dr. Edgley: My pleasure.

Amy: Every year, more than 795,000 people in the United States suffer a stroke. Strokes are becoming more common among young adults in the prime of their life. I'm wondering if you could tell me a little bit about stroke recovery process in the young stroke survivor.

Dr. Edgley: It's true that about 10% of stroke patients are under the age of 50. This population represents a special population in terms of the unique challenges they face that are generally in the crux of their career and raising families, and this life event is very hard for most people. I find that all stroke patients who have a loss of function, they go through certain stages of mourning or loss.
We talk about the Kubler-Ross stages of mourning, which entails denial, bargaining, things like anger, and, ultimately, acceptance. I find that especially in the young stroke patient, meaning younger than, say, 50, these patients need to be guided towards things that will improve their chances for recovery before they reach the level of acceptance. Oftentimes stroke patients don't fully realize their own potential.

Amy: So this is somewhat pushing the stroke patient to their potential and making them realize their potential?

Dr. Edgley: Exactly. It takes a lot of guidance and someone actually, a whole team of people to guide them through the barriers that they encounter, medical, physical, emotional, everything.

Amy: Right. So I guess one way to look at a stroke is it's a process from beginning to end. Stroke recovery is truly a process.

Dr. Edgley: That's exactly right. A process that takes a lot of support. For many people that are young, they have the potential to get back to high level things like driving, or returning to work. They just need a little guidance and the resources and a team of people to help them along.

Amy: Young adults are often faced with this different set of circumstances than elderly stroke patients. They have a long life expectancy in front of them.

Dr. Edgley: I think it's critical to set the patient on the right course for their next future decades. And getting them set up with the things that will truly provide quality of life, like being able to access the community, like being able to recreate and like being able to form meaningful relationships with friends and family. And for some people, like being able to return to their former employment, or at least do some service, activities, which is helpful to their overall quality of life.

Amy: Remaining engaged with community and family I'm sure is a big part of that.

Dr. Edgley: Yes. Yes.

Amy: How do young patients sell themselves short oftentimes?

Dr. Edgley: You know, when patients have a stroke, it's a really traumatic life event. They probably don't see their friends and family going through and succeeding without the process of recovery. They don't know what to expect. They don't know how to get themselves out of this black pit. I think many patients come to a certain level of comfort and realize that things will be okay in their life in terms of their basic needs, but don't really have an idea what to reach for. Many times the limits of people are limits that they put on themselves.

Amy: Self imposed. Yeah.

Dr. Edgley: Now, that's not to say that every stroke patient has the potential to get that back to 100%, the way their life was in the past. Certainly reaching and striving to get as much quality of life, and be as independent in the community is really important.

Amy: Recognizing your potential.

Dr. Edgley: Yes.

Amy: Have you experienced other people putting limits on stroke patients?

Dr. Edgley: I do see occasionally some people around the stroke patient who, based on misinformation, have some assumptions what the stroke patient's potential is. We commonly deal with this in therapy. For example, the patient's family member tries to do everything for the patient without giving them the chance to learn how to do the activities themselves. That's a common occurrence, and a simple matter of just educating the family members to let's try to promote as much independence as possible. And the way to do that is you learn by doing.

Amy: Right. Most often finding that balance, that perfect balance between independence and dependence.

Dr. Edgley: Yes.

Amy: What are some of the barriers, Dr. Edgley, do young stroke patients face in recognizing their potential?

Dr. Edgley: I would say, again, a stroke is a major life event and it requires a major life adjustment. Some people are able to adjust better than others on their own.

Amy: Right.

Dr. Edgley: Most people are able to adjust more effectively with a broad network of support, including family, friends, and rehab specialists. With time we like to promote higher level goals, like return to work if possible. For that to occur, you have generally got to have a supportive employer who is willing to take a chance. Stroke patients have the potential to be superb employees.

Amy: Dr. Edgley, what advice or tips do you have for the young stroke patient?

Dr. Edgley: Accept yourself and where you are. But don't accept the limitations that you perceive or that other people put on you.

updated: April 7, 2021
originally published: December 10, 2014