Effective Arm Exercise for Stroke Survivors

Simple - safe and effective are good words in this context.

The picture above (courtesy of Encorepath Inc) shows this new product in use by a stroke survivor. The adjacent picture shows a close-up. In essence, the device guides the users arm movements - controlling the path and the range of motion in a precise way; based on the user's initial abilities. An audible cue is used to encourage rhythmic movement of each arm. Although science doesn't fully understand how it works, there are theories. The brain, encouraged by the rhythmic movement seems to recruit new nervous pathways over time to make improved ranges of arm motion possible.

"Tailwind", based on research conducted at the University of Maryland, has been shown to be effective in permanently improving arm movement affected by a stroke. The research is ongoing and enough is now known to allow the creation of Tailwind for use safely at home in an exercise programme. We will tell you more about this below.

Tailwind is going to be good news for many stroke survivors because 44% of them are likely to have been left with some arm disability.

How many people is that? Well statistics show that there are approximately 4 million stroke survivors in the USA. If that's not bad enough, this population is expected to grow as stroke affects more and more of us.

In the UK, where I live, every five minutes someone has a stroke; that's 150,000 people per year.

Almost one in four men and one in five women currently aged 45 can expect to have a stroke if they live to age 85.

We have set up a new website to offer the product and build a user community in the UK at armexerciser.com

Of course not everyone right now makes the time to pursue rehabilitation. In some countries, stroke survivors who are young are under pressure to return to work and simply dont have the time or money to spend in a rehabilitation clinic. Other individuals are depressed and are not in a frame of mind where rehab is an option. If arm movement is not restored, individuals learn to work around the problem but at quite a high individual and societal cost.

A study in the Journal Neurology, published in August 2006, reported that more than 50% of the future expenditure on stroke would be in the 45 to 65 years age group in decades to come. From the point of view of these individuals and the global economy, lack of rehabilitation, means that the most productive years of their lives are lost.

There are a number of robotic and other speciality devices on the market that are worn on the arm or hand. These devices often do currently require hours of therapy and may be expensive. Such robotic devices represent an area of intense research focus which is interesting. The challenge will be to produce devices that are inexpensive enough for clients to use effectively at home.

There is so much good information about stroke, you might feel comforted that the future is secure. Unfortunately we are better at describing the issues than preventing or treating stroke just now.

You know what - because stroke has reached epidemic proportions, both acute health and rehabilitation services are certainly gearing up to cope. We all should be aware of the signs and symptoms of a stroke and know how to take action - FAST.
Let's hope that early and prompt action limits the damage and enables many more people to enjoy close to full recovery.

Well that's all well and good - but what about the many people who have had a problem for years following their stroke? Will the health services be there for them?

We might find that the focus of health care is primarily on the new stroke victims - after all it looks like there will be a lot of them.

After many years working in and around heath care, I can see that increasingly care tends to be rationed. In the UK it's become a politically sensitive issue because sometimes treatment is denied to persons in one area and allowed in another. Nothing to do with effectiveness and a lot to do with resource constraints. As technologies emerge, there are new opportunities to alleviate disease and suffering but our national health care systems have the challenge of how to pay for all this stuff.

Health care professionals have to work with limited resources and when working with any individual recovering from a stroke they will have "a feel" for what might be realistic to achieve with a rehabilitation plan. Once that level of achievement is reached the stroke survivor is discharged and may find that further improvement becomes difficult. Of course what is judged to be realistic is based on clinical practice and evidence up to that point.

At the moment we are in a global recession and even optimistically speaking, health care expenditure will be squeezed. More and more of us will have to take responsibility for our own health. That's a fact, if we want to take advantage of the best there is.

Before we get to the good news, let me talk about another healthcare situation for a moment.
For the last few years I have been working with many spinal cord injured clients after they elected to work with new exercise technology to gain cardio-vascular fitness.

When someone is spinal cord injured, their whole life changes. The spinal injury units do wonderful work to stabilize their clients - adjustment of mind and body to the new situation is challenging - but life goes on.

In chatting to many of these individuals they relate their experience in going through the treatment process. They point out that the medical system takes them to a point at which a "reasonable level of independence" is reached and then they are discharged. They are on their own. They didn't decide they had reached their potential, it was decided for them. You see,conventional medicine has only so much resource to invest in any one person - and then it must focus on someone else.

Of course health professionals always try to work with clinically effective methods - those proven statistically through research to be "effective." And that's a good thing, except that judging effectiveness is extraordinarily difficult, especially when it comes to rehabilitation.

What many of my spinal cord injured clients have realised is that they can, with help, take responsibility for improvement. Even intensive physiotherapy, directed the right way can make massive difference to quality of life. We are not talking cure here - we are just talking about going further than the health service can afford to take things to get worthwhile improvement.

The difference between success and failure in life is often as thin as a razors edge. For ourselves and our family we will naturally want the best. The good news is that, just sometimes, we need to question the status quo. We need to carry out our own research and challenge our clinicians to "go the extra mile." Few of them are Gods. They don't know everything and they probably trust most what they already know and are comfortable with - rather than that new idea. It's human nature.

Tailwind is a product that you should look at if you or a family member has lost arm movement following a stroke. Look carefully at the evidence and see for yourself. It's based on sound research. There never has been a perfect research study but see if you can get a feel for whether it could work for you.

Tailwind emerged from research using a technique with the un-promising acroynm BATRAC or Bilateral Arm training with Rhythmic Auditory Cueing.

Tailwind consists of two handles that move along independent resistance-free tracks. The patient moves the handles along each track at different starting marks and has auditory cues while moving his or her arms. It is a "sound-to-brain" neural pathway retraining approach that is theorized to help patients with mild stroke symptoms achieve life-altering results.

An article in the October 2004 Journal of American Medical Association, "Repetitive Bilateral Arm Training and Motor Cortex Activation in Chronic Stroke - A Randomized Controlled Trial," reported the results of the clinical study that examined the association between brain re-organization and improved arm function.

After several training sessions over a six-week period working with the device, stroke patients showed marked improvement in movement and function.

These changes were also noticeable in patients who had their stroke as many as 20 years ago.

Study investigators Drs. Jill Whitall and Sandy McCombe Waller, from the University of Maryland, Baltimore Department of Physical Therapy and Rehabilitation Science, invented and developed the BATRAC device. This has evolved in the product, Tailwind, available today.

The Tailwind is an exercise device for stroke survivors who want to improve the arm function and range of motion they have lost. But just like any other approach, it doesn't work for everyone and so how do you know if it will work for you. We have found that the most important question to ask is:

* Do you have some movement at your shoulder?
* Starting with your affected (weaker) arm at your side, can you swing your arm forward 3 inches from the shoulder?

If you can answer "yes" to this question, Tailwind could help you improve your arm movement.

As with any exercise program, ask your healthcare professional to make sure that you are ready for a home exercise program.

If you have a frozen shoulder or have pain in your shoulder, your healthcare professional can show you some simple stretches to do before using Tailwind. Most people will use Tailwind seated at a table, so be sure you can sit upright for 30 minutes a day without losing balance. And since it will take several weeks to start seeing results, make sure you're ready to commit to the Tailwind exercise program.

If you are prepared to focus on improving your arm movement, you are ready for Tailwind!

Working on a therapy program at home, especially if you are on your own, IS a challenge for some people!

Sometimes getting transportation to a therapy session in a hospital is difficult too - and so potentially working on a program at home is very appealing. But you do have to stay motivated. Here are a few suggestions that we have heard from other stroke survivors:

Involve your friends or family to encourage you. Make them aware of your program - maybe they can help you set it up or ask you about your progress regularly.

When you work with Tailwind, it should have your total concentration so that you can see that you are making the moves along the track correctly. Proper posture and positioning are critical for maximum results.

Included with your Tailwind is a progress report. Fill in your treatment schedule and see how you are improving week to week.

Set a few realistic goals that you personally want to achieve - do you want to be able to hold up a newspaper or push a grocery cart? Watch for those improvements week to week. Focus on what you wish to achieve to find that motivation.

Share your experiences with us.

In 1998, I had a severe stroke that severely limited my right side. I couldn't move my right arm or right hand as I wanted, and couldn't seem to control my movements.

I was retired at the time, and didn't have the pressure of needing to do certain motions for my work, so I just learned to compensate. Like many stroke survivors, I would use my "good" arm and hand to do "double duty" for all the many small movements that are done in a typical day. Because my left side was fully-functioning, I could drive again 10 months after my stroke.

I was very motivated to try to regain the use of my right arm, and I'd go to my local gym and try to lift weights, working on my own. But I found that the gym was not set up for someone who had experienced a stroke and even the lightest weights were too heavy for me to work with and I wasn't comfortable trying to explain myself to the staff there.

For the most part, I thought that I had as much muscle recovery as I would be able to get.

But, in 2005, physicians at Kernan Hospital, a hospital renowned for its rehabilitation programs, referred me to a series of clinical trials testing new rehab equipment at the University of Maryland School of Medicine. There, two physical therapists had developed an innovative new device - the BATRAC or the bilateral arm training with rhythmic auditory cueing.

The trials were working with patients who had experienced their stroke at least a year earlier, and even a few others were like me, with a stroke many years before the study. The BATRAC uses recorded sounds to cue patients to push two T-bar handles back and forth on a track. The repeated movements help the brain of stroke patients to re-learn arm and hand movements. These researchers showed that the brain can rewire itself after a stroke.

I was a very determined volunteer. First, I was in a control group but then I became part of the BATRAC clinical trial. I continued participating three times a week, for over a year. Within a short period of time, I started to regain gross right arm movements, then later, with the finer motor skills of my right hand.

The improvements came quickly, but then I'd hit a plateau. I had to work to keep up with the exercises, and then I'd make more improvements.

I use my arms constantly, so when I suddenly couldn't move my left arm in 2001, it was particularly disturbing. That was a very stressful period in my life, and my doctor was convinced that I had multiple sclerosis. When I went to physical therapy, the PTs kept telling me that I was presenting like someone who had a stroke. With occupational therapy, regular massage & acupuncture, and vitamin supplements, I regained full use of my arm. I was only in my 40's then.

But then, in July 2005, I was in Georgia at an outdoor festival. It was hot and I was dancing out in the sun. I was dehydrated, and suddenly, my left arm felt numb, just like it did in 2001. I just collapsed, right there. I kept thinking it was MS, so I didn't know there was urgency for medical care. My brother came to Georgia to get me home and I waited to go the hospital until I got to Maryland. I wanted individual attention from a hospital with my medical records, where they knew what I'd experienced in 2001.

By the time I arrived at the same hospital, I could not walk, I didn't have balance or any strength in my left leg and I still couldn't use my left arm. They did many tests and finally, went back to the MRI films on file from 2001. Then, they realized I'd had a stroke in 2001 and had a stroke again that summer in 2005.

I had excellent rehab and within three weeks, I was walking with a cane and left the hospital. At home, I continued with OT and PT. I could walk, but I could not use my arm or control my movements, and here I was, trained as a massage therapist! I didn't work for six months and it was awful.

It never occurred to me that I would have any permanent damage or that I wouldn't be able to resume what I had been doing before the stroke. I kept starting questions for my therapists and doctors with the phrase, "when will I be able to.." There were so many activities I wanted to resume. What was shocking to me is that the doctors and therapists were using phrases like, "you may never be able to." and that was just devastating.

I was so determined to improve; I tried lots of different options. About two years after my stroke, I was told about the BATRAC (brand name "Tailwind") clinical trial. I could extend my fingers and arm and I could reach my arm over my head, but I could not open door knobs or put a key in the lock, so I was a good candidate for the clinical trial. The researchers wanted people in the trial who had not regained their arm and hand movements, even years after their strokes.

My goal was to get more fine motor skills, more accuracy with my arm, and have less tremors and more strength in my arms.

I worked on the BATRAC for six weeks, three times per week, and I did see improvement very quickly. I had much more awareness of my left arm. I have more body awareness, more strength, and my range of motion improved.

I can also use my fingers more accurately and can control my smaller motor motions more. My arm has become much more accurate - my control, too. If I reach out to touch something, I'm likely to be able to touch it. For example, if I'm trying to get my laundry and reach out to take it from the washer into the dryer, now I can grab the right clothes. Working with the BATRAC helped me accomplish the goals that I wanted to reach with my gross motor skills.

I believe strongly that my health is my responsibility. I was determined to improve. There is no magic pill to help you recover. Some treatments take a lot of effort and cost. I've gone to stroke survivor support groups and told people about the BATRAC. I tell people about my experiences because I want others to be able to learn or benefit from what has happened to me.

Since my own experience, I now am adept at massage therapy for stroke survivors. I know exactly where to put emphasis and how to help others feel better through massage. But often, people will say to me, "massage isn't covered by insurance" or "I don't get reimbursed for that."

My feeling is that is the wrong approach. I was out of work for six months and wiped out my savings, but I knew that I had to invest in my own health and my own treatments.I was determined to improve. My health is my responsibility.

The medical specialists - doctors and therapists - were telling me that I might have severe setbacks and to be prepared that there were movements that I might never be able to do again. But I decided I'd work harder and keep trying different options. I don't put limits on myself. I don't know what will help me improve, unless I try it.

Try everything you possibly can - that would be my advice to any other stroke patient - and you have to trust that you'll get better. Our potential for health & healing is unlimited when we believe it is. The only limits are the ones we impose on ourselves.

Optimal health is a necessity, not a luxury. Don't put limits on yourself.

If you would like to know more about the research you can follow the links here

http://www.encorepath.com - Encorepath Inc, USA

http://armexerciser.com - UK Distributor, Anatomical Concepts (UK) Ltd

The following abstract is from an article by McCombe Waller S; Whitall J, in the journal NeuroRehabilitation. 2008;23(1):29-41.

Bilateral arm training has emerged as an approach that leads to positive outcomes in addressing upper extremity paresis after stroke. However, studies have not demonstrated improvements in all patients using current outcome measures. Furthermore, the rationale for using this type of training has been incompletely explained. The purpose of this article was to first review the theoretical justifications for the use of bilateral arm training by examining motor control and neural mechanisms underlying arm function and neural recovery, and second, to discuss examples of clinical studies using a variety of bilateral training strategies to identify who may benefit most from this approach.

We argue that bilateral arm training is a necessary adjunct to unilateral training because bilateral re-training is important and best served through bilateral not unilateral training, and also, that bilateral training may help unilateral skill recovery through alternative putative mechanisms. Our review of the empirical evidence suggests that individuals at all levels of severity can benefit in some manner from bilateral training, but that not all approaches are effective for all severity levels.

In addition to requesting more randomized controlled trials and studies of neurophysiological mechanisms we conclude the following:

1) Bilateral training can improve unilateral paretic limb functions of the upper extremity after stroke, however, specific training approaches need to be matched to baseline characteristics of the patients;

2) Given the importance of bilateral activities in daily life, there is a need to recognize, train and assess the important contribution of supportive role functions of the paretic arm used on its own and as part of complementary bilateral functional skills;

3) An assessment of bilateral and unilateral functioning which includes bilateral task analysis, as well as, evaluations of interlimb coordination should be included in all studies that include bilateral training; 4) Studies with thoughtful sequencing or combining of bilateral approaches or sequencing of bilateral and unilateral approaches are needed to assess if there are improved outcomes in paretic and bilateral limb function.

University of Maryland, School of Medicine, Department of Physical Therapy and Rehabilitation Science, Baltimore, MD 21201, USA. smccombewaller@som.umaryland.edu