Spinal rehabilitation technology and therapy advances

The American Congress of Rehabilitation Medicine (ACRM) conference 2022 showcased many emerging technologies and trends in spinal cord rehabilitation. I review some of the recent innovations below and attempt to predict the extent to which any of these might individually or collectively alter the management of spinal cord injury (SCI) claims.

Neuromodulation (spinal cord stimulation)

Neuromodulation devices involve the application of electrodes to the brain, the spinal cord or peripheral nerves. It works by either actively stimulating nerves to produce a natural biological response or by applying targeted pharmaceutical agents in tiny doses directly to site of action. Recent evidence has demonstrated that over 50% of patients have reported improved pain management.

University College London has reported that neuromodulation can help to restore bladder control and that this technique is already being trialled as part of a clinical research programme at the Royal National Orthopaedic Hospital. At the ACRM conference, there was a particular focus on techniques and wearable tech that can be implemented in a community-based neurorehabilitation setting including transcranial direct current stimulation (tDCS); transcutaneous auricular vagus nerve stimulation (taVNS); evoked potential operant conditioning (EPOC), and a phantom neuromodulation training device (ERIK).

Dry needling

A seminar was held by occupational therapists to demonstrate manual therapy in managing the upper extremity of persons with SCI, with the goal of reducing pain, improving mobility, meeting functional goals, increasing independence and improving quality of life. In this session, there was also a demonstration of dry needling techniques for specific musculature of the upper extremities and discussion around the current evidence that dry needling can help to reduce spasticity in SCI patients.

Exoskeletons and advanced rehabilitation technology

Advanced rehabilitation technology (ART) is defined as the systematic application of technologies, engineering methodologies or scientific principles which includes technology devices and assistive technology. According to IISART, the med tech industry has grown year on year and in 2016, North America saw a 6.4% increase to $134 billion.

The benefits for deploying ART include the ability of upskilling therapists, standardisation of outcomes and efficiency of staff. Whilst the use of ART was reported to have grown from 22% of therapists using it with 51 to 75% patients in 2021 to 47.6% in 2022, barriers which include training, expectancy of results and continuity, are still holding full adoption back in practice. Various speakers commented on the benefits of tracking technology usage in order to determine whether ART is indeed improving patient outcomes and if so, how the use of dashboards to provide diagnostic and individual feedback could then lead to the development of prediction models.

The most advanced systems where technology is driving positive clinical outcomes for certain SCI patients include Re Walk, Idego, Ekso and the Keeogo. Nonetheless, these technologies are still in their infancy and the clinical practice guidelines from the American Physical Therapy Association suggest that interventions with exoskeletons should not be used within the first six months of acute injury or for individuals who are already ambulatory.

A study in 2016 by Miller et al has suggested that at least 67% of patients are able to walk independently following an exoskeleton training programme, with the most favourable outcomes when deployed in the earlier stages of rehabilitation.

Whether these devices offer greater benefits than traditional hands on physical therapy remains unclear. Studies by Swank 2020 and Nolan 2021 noted that outcomes are similar or favourable.

Qualitative outcomes indicate that SCI patients have less tolerability than stroke patients and a comment was made that, once the individual gains some trunk control and learns the general requirements to produce a reciprocal pattern, they should start transitioning out of the device where they can get a much higher response.

Spinal telecare

This session focused on being able to identify processes involved in the integration of virtual care in a rehabilitation setting. To maximise gains, it was noted that preparing patients and caregivers was important to provide choice. Benefits cited were a reduction in therapist time, reduced waiting lists, flexible admission, and reducing stigma.

In SCI it was highlighted that a negative mood presents as a barrier to self-management and individuals with comorbid depression are likely to experience increased hospital stays, need paid care, and suffer from increased mortality. Studies have shown that telecare CBT is a feasible and effective form of treatment for managing emotional wellbeing.

Comment

Technology should also be seen as one part of the rehabilitation journey, particularly as manual hands-on therapy continues to be an integral part of the management of spasms, upper limb movement, and bladder and bowel control.

Those handling SCI claims will often see huge amounts of equipment and technology introduced into the claim, sometimes seemingly without any evidence base. So whilst technology continues to develop with new products designed to be deployed into a community based setting, data from clinical trials could potentially be utilised to create prediction models for individual patients that help determine what technological equipment is most effective in that individual’s circumstances. This may assist claims professionals in the future when attempting to make funding decisions or value early reserves.

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