Uyen Nguyen (PT, Executive Director), Jill Truman (PT)
Synaptic Spinal Cord Injury and Neuro Rehabilitation Centre, Calgary, CANADA
We would like to share our experience in the use of hunova as a tool for balance treatment and assessment in a rare neurological condition. Our patient presented a cavernous malformation and hypertrophic olivary degeneration, resulting in ataxia, decreased balance, impaired gait and additional deficits focalized in the left side. He underwent a training on hunova as part of our PoNS program. Hunova intervention was focused on static and dynamic balance, sensory integration, motor dual task and weight shifting exercises. Balance and motor abilities were evaluated with hunova as well with clinical tests. In this case study we will show how robotic balance therapy with hunova in conjunction with innovative PoNS therapy led to significant improvement in our patient in balance and gait abilities as well as in performance of activities of daily living. hunova also allowed for precise and objective evaluation of balance improvements.
As we increase our understanding of neuroplasticity, it becomes paramount to be able to quantify functional deficits in order to treat them. In conjunction with physical therapy treatment methods, innovative technologies are making their way to clinical practice to better rehabilitative outcomes. Along with other neuro technology, hunova, a robotic device for balance and core stability evaluation and training, was used in the treatment and assessment of a rare neurological condition that resulted in significant functional challenges. As part of a comprehensive treatment plan, hunova was invaluable in quantifying and addressing balance, coordination, and gait deficits.
Murray is a 59 year old male from Minneapolis, Minnesota who was a former professional hockey player. He had a Cavernous malformation that was surgically extracted from his brainstem/pons in August 2015. He was also diagnosed with hypertrophic olivary degeneration in November 2015. His symptoms included left sided weakness and ataxia, decreased balance and impaired gait. Murray also experienced nystagmus, vertigo/dizziness and a feeling of heaviness/tightness in his left foot. He also has ear sensitivity and a tremor in his palate. Murray has completed several different rehab therapies in the past including 12 month outpatient therapy at the Courage Kenney Rehab institute, vestibular PT at the Mayo clinic, functional neurology chiropractor (GyroStim) and NeuroPT gait and balance program in Florida. Prior to the PoNS program Murray was using a 4 wheeled walker for indoor/household ambulation and was unable to walk outdoors without assistance. He avoided all activities outside of the home that he used to enjoy including going out to eat at restaurants, going on vacations and attending sporting events (football and hockey). He had difficulty with ADL’s including dressing and showering and also had difficulty managing stairs using a handrail. He had not skated since February 2016 and has been unable to work for about 4 years. He was also unable to drive and was unable to work out (both at home and doing crossfit).
Overall treatment goals:
- Improve gait and increase confidence walking in a variety of environments including outdoors + public places
- Return to work as a strength and conditioning coach at a hockey prep school (Shattuck)
- Return to skating (hockey)
- To be able to go out for dinner with his wife and family
- Be able to pick up and play with his grandkids
- To ascend and descend a full flight of stairs without requiring use of a handrail
- Return to working out (both cardio + strength training) using home gym
On October 17, 2019 Murray underwent an initial assessment as part of the PoNS treatment program. Part of the initial assessment included robotic balance evaluation using the Hunova. Other clinical evaluation included:
- Functional Gait Assessment (FGA) -measures the client’s postural stability during various functional walking tasks
- Balance Error Scoring System (BESS) – test’s the client’s ability to maintain posture during 6 different balance conditions. The conditions vary between firm surface and foam surface to provide a range of challenge. A true test is performed with the eyes closed.
- 6 minute walk test- assessment of walking speed by measuring total distance covered in 6 minutes
- Cognitive: Neurocatch Platform Scan – measurement of brain vital signs using surface EEG technology
- Range of motion – assessed using inclinometer
- Strength – using manual muscle testing
- Self-reported outcome measures – Pittsburgh Sleep Quality Index, Headache disability Index, Neuro quality of life (select subscales), Patient health questionnaire (PHQ-9), Fatigue severity scale, Activities specific balance confidence scale (ABC)
- COPM – used to set goals for intervention planning The assessment revealed left sided weakness & ataxia, and gait & balance impairments.
Robotic evaluation was performed at baseline, 8 weeks, 14 weeks and at the completion of PoNS training (additional 8 weeks).
Balance test on static base (eyes open and eyes closed) – the client must maintain their balance on a static surface in a standing position. With this test subject’s ability to maintain balance in a static condition is tested; with the closed eyes condition, the proprioceptive and vestibular components in maintaining balance are tested by evaluating the subjects balance performance without the support of the vision.
- Balance test on elastic base (eyes open and eyes closed) – the client must maintain their balance on a dynamic/unstable surface in a standing position. The aim of this test is to evaluate the capability of the subject to maintain balance in a dynamic situation: the platform is unstable and can move following subject’s instability and oscillations. Indeed, in this configuration, the platform angular displacement is induced by the Center of Pressure (CoP) displacement.
- Limits of stability – the client is standing on a static platform and must move the load as a pendulum as far as they can in the indicated directions (right, left, forwards and backwards). This test evaluates subjects’ ability to move the center of pressure (CoP) in anteroposterior or mediolateral directions, giving an objective indication of the subject’s perception of his stability limits.
- Five times sit to stand – the aim of this test is to measure the time taken by the patient to reach a standing position from a seated position repeated 5 times. It measures functional lower extremity strength, transitional movements, balance and fall risk.
Monopodalic – modified into tandem stance
Balance on static base (right foot forward + left foot forward, eyes open and eyes closed)
7 customized hunova training sessions were completed as part of the 20 minute balance training component of the PoNS program. The hunova training sessions were focused on:
- Static balance
- Dynamic balance
- Sensory integration
- Dual motor tasks with movements of the upper limbs Weight shifting
Sway parameters improved across training showing better results in the final evaluation. At the end of the training CoP sway area and sway path were decreased showing a better balance control with a lower energy expenditure in maintaining balance. Trunk control parameters were also improved after training, reaching values closer to normality. Results were obtained both in the closed eyes and open eyes conditions; however, the obtained improvement was greater for the closed eyes conditions. Indeed, while at the beginning of the training, in this condition, the subject performed much worse with respect to the open eyes condition, after training he showed for some parameters better performance with respect to the open eyes situation (final evaluation, CoP sway area: open eyes 11,3 [cm^2]; closed eyes: 8,72 cm^2). These results confirmed the improvements showed in clinical tests performed with closed eyes.
In the balance test on the unstable platform the subject showed improved performance at the end of the treatment, especially in the open eyes condition, in which he showed decreased sway area, sway path and RMS. Even the trunk control during the open eyes test was improved after treatment, indicating that better balance performance was not due to trunk compensatory strategies. With closed eyes, in the final evaluation the subject showed an increased sway area and RMS, with a greater trunk displacement in the mediolateral direction; however, in this condition, the sway path, trunk variability and trunk oscillations in the anteroposterior direction were decreased.
Limits of stability.
At the end of the treatment the CoP limits of stability were decreased. However, looking at the trunk behavior during the task, we can notice that the subject changed the strategy to reach his limits of stability, especially for the forward and backward directions. Indeed, in these directions, in the first session subject’s CoP limits were very high, but coupled with high trunk displacements, highlighting a compensatory strategy involving the trunk, i.e. during the test the subject inclined the trunk to shift the CoP farther. In the last session, the CoP shifts were lower, but also the trunk displacements were lower: the ratio between trunk and CoP displacements decreased, indicating less trunk compensation to accomplish the task.
Sit to stand.
At the end of the treatment the subject improved the five times sit to stand total duration, improving both sitting and standing mean times, reaching values beyond normality ranges.
Monopodalic balance test (tandem test). Right leg forward.
In the final evaluation the subject showed in the open eyes condition better results in trunk oscillation, with a decreased sway area and similar or slightly increased sway path and RMS. The OC condition showed similar or slightly increased sway parameters values (sway area, sway path, rms ) but with a worst trunk control during the task.
Monopodalic balance test (tandem test). Left leg forward.
In the final evaluation the subject showed a better balance control with open eyes (CoP parameters and trunk control parameters were improved at the end of the treatment). With the eyes closed, sway path and sway area were increased at the end of the training but trunk control parameters were improved.
The Functional Gait assessment score increased from 11/30 at initial assessment to 22/30 at final assessment. His BESS score improved from 51/60 total errors to 28/60 errors. Murray demonstrated significant improvement in double leg stance with eyes closed on foam, tandem stance with eyes closed (both on floor and on foam) and single leg stance eyes closed on floor. His 6 minute walk test distance also increased from 921 feet to 1627 feet. Murray demonstrated improvements in range of motion and left upper extremity + lower extremity strength. He also showed decreased ataxia on his left side and increased overall confidence.
The results obtained shows the effectiveness of robotic balance therapy in conjunction with innovative PoNS therapy. The client expressed satisfaction with the use of hunova and the progressive challenge to training that it presented. The hunova also allowed for precise and objective evaluation of balance improvements. Murray was able to reach his goals with the PONS treatment program in combination with use of the hunova robotic balance platform. The improvements obtained in the robotic tests showed increased balance in static and dynamic situations, with a decrease of trunk compensatory strategies. In particular, the improvements obtained in the static balance test with eyes closed (mean improvement 55%) and in the elastic balance test with eyes open (mean improvement 47%) highlight an improved proprioception after training. These results were in line with the improvements obtained in the clinical tests performed with the eyes closed. Moreover, the improvements reached in the balance test in dynamic condition can be related to the improvement reached in gait evaluations. The decrease of trunk movements during dynamic balance task (elastic balance test with eyes open, and limits of stability test) and tandem tests suggest a decrease of trunk compensatory strategies, and improved strength and control in lower limbs. This was confirmed by the improvements in the five times sit to stand test (mean improvement 46%). His gait pattern, speed and endurance also improved significantly, and he now has confidence walking in a variety of different settings without using a gait aid (including outdoors and in a rink). Murray has also been able to walk in shopping malls, go to the grocery store and go out to restaurants to eat with family. He is now able to ascend and descend a flight of stairs without using a handrail. Murray had an opportunity to try on ice balance training and skating as part of the PoNS treatment program but will need further sessions in the future to increase confidence and left foot stability. Murray’s functional improvements will lead to enhanced performance in his daily life and ability to perform work demands. He is in the process of creating a return to work plan.
hunova with PoNS:
hunova has been an invaluable addition in the assessment of balance and coordination for our PoNS clients. It has given us another tool to objectively quantify a client’s function at baseline testing and it allowed us to systematically measure and track changes in function.
hunova also provided novel treatment activities for a lengthy and intensive program where we were constantly seeking new ways to challenge our clients. With its ability to adapt to all levels of function, it was universal in its application and comprehensive in its integration of mental and physical tasking. Clients were always motivated when they could objectively see their improvement, and it contributed to the affirmation that therapy was effective.
hunova in conjunction with PoNs:
- Increased clients body awareness
- Integrated variety into balance training
- Increased client buy in into balance training
- Integrated visual, vestibular, and musculoskeletal systems
Synaptic is an integrated neuro rehabilitation center in Canada that provides progressive treatment options for people with neurological conditions such as MS, Parkinson’s, stroke, Cerebral Palsy, Traumatic Brain Injury, and spinal cord injury. Applying innovative technology with leading methodologies, Synaptic aims to promote neuroprotection, neurorecovery and neuroplasticity to improve function and quality of life. Synaptic is excited by the opportunity to work with Movendo in changing the paradigm behind neuro rehabilitation.