Alternative and Complementary Rehabilitation Therapies

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By Maria St. Louis-Sanchez

Around the country, experts have been searching for alternative ways to keep patients with limb loss engaged and excited about their recovery. From walking in swimming pools to virtual reality environments, patients have been working toward recovery in ways that take them outside therapists' clinics.

The premise for using alternative types of therapy in conjunction with traditional, proven therapeutic methods is simple: Even if an individual has access to the best therapies in the world, they will not be effective unless the patient has the motivation to improve and succeed.

Alternative therapies might motivate patients in ways that traditional therapies can't. For instance, patients may be able to gain confidence by walking in a pool after struggling to do so on land or may get more practice using their myoelectric arms if they are training to use them via a video game.


If a patient takes an interest in the therapy—whatever form of therapy it may be—that interest can help keep him or her motivated during recovery and provide an outlet beyond traditional post-amputation therapy, experts say.

"If patients are engaged in it, you see a change in their mood and attitude versus patients who don't engage…with their traditional recovery," says Alex Hetherington, CP, CFo, program director for the Amputee Comprehensive Training (ACT) Program within the Department of Orthopaedic Surgery at the University of California, San Francisco (UCSF).

That motivation can make all the difference in keeping patients working toward improvement.

"I think with therapy, a big component of it is motivation and patient compliance," says Susan D'Andrea, PhD, director of the Virtual Reality and Motion Analysis Rehabilitation Laboratory at the Providence VA Medical Center (PVMC). "If you are enjoying something, you are more motivated to do it."


Lyn A. Boulanger, a Naval Medical Center San Diego occupational therapist, assists Marine Corps Staff Sgt. Jesse A. Cottle, a bilateral amputee, while he practices swimming during endurance training.

U.S. Navy photo by Mass Communication Specialist 3rd Class Jake Berenguer/ Contributor: PJF Military Collection/Alamy Stock Photo.

Aquatic Therapy

One way to reduce the pressure of learning to walk with a new device is to literally take the pressure off through aquatic therapy.

Kelly Sacky, PTA, aquatic therapist at the Texas Orthopedic Hospital in Houston, helps her patients learn to live with their devices on land by conducting exercise training for prosthesis use in the water.

"If a patient is having a hard time due to contractures or if pain or overall weakness is an issue, and they are not tolerating land therapy really well, aquatic therapy can really help," she says. "It allows them to be successful in the pool and gain their confidence, so they can then increase their participation with land-based interventions," Sacky says.

"Maybe they don't have much endurance—get them started in the pool where it is not as difficult, and you can do 45 minutes of therapy where you can only do 20 minutes on land."

Along with helping build confidence and endurance, Sacky says aquatic therapy is a great way to help patients build the muscle strength they need. "I'm able to work with them in the water using buoyancy to force them to use the muscles they need to be successful in a prosthesis," she says. "It really increases their awareness of what muscles they need to engage. In the pool environment, even though their weight is unloaded, their body is constant-ly working to keep vertical."

That effort can help strengthen the body and core and give patients a greater range of motion of their residual limb, Sacky adds. While some therapeutic rehabilitation facilities or hospitals have pools, not all have therapists who are trained to work in the aquatic setting, which can make a difference. Her patients offer their own clarification; she says they tell her, "It's more than just little old ladies doing exercises in the pool."

There is one caveat to this kind of therapy, however. The patient must wait until his or her residual limb has fully healed, with no open areas or signs of infection before beginning aquatic therapy. Besides that, it's great exercise and a great confidence builder for patients with limb loss, Sacky says.

"It increases their awareness of what muscles they now have to use," she says. "So many of them still feel like they have a foot at the end of their limb down there. This helps them realize that this is the new normal and they figure out how to make it work."


The virtual reality system used in PVAMC's study allows subjects to view an avatar of themselves showing their gait while completing tasks in a simulated environment.

Photograph courtesy of PVMC.

Virtual Reality Gait Training

In a high-tech lab at PVMC, patients with transtibial amputations have used virtual reality as a training tool to help them walk better.

For a study in the PVMC Virtual Reality and Motion Analysis Rehabilitation Laboratory, researchers outfitted patients with motion sensor markers and instructed them to walk on a treadmill in front of a large screen. The markers captured the patients' movement on the treadmill that controlled an avatar on the screen. The treadmill is synchronized with the display and simulates walking up stairs or hills or going around curves. Patients are awarded points as they complete certain tasks in the simulator. While on the treadmill, the patients see their gait and are challenged to improve it. The hypothesis of the study was that patients who underwent virtual reality training would have better results than those who had conventional gait training.

D'Andrea, the lead researcher, says further testing is still needed, so she is writing a grant for a larger study. But she is encouraged by what she has seen so far.

"We found greater improvement after treadmill training in individuals with increased gait dysfunction," she says. "We need further research and clinical trials to establish the effectiveness of this type of therapy."

At the very least, it was a way to get patients walking when they otherwise might not have, D'Andrea says. "Instead of sitting down, participants came in to walk three times a week for six weeks," she says. "We got a lot of good feedback on how people thought it was helpful and a motivating way for them to get better at walking."

The exercises the patients did in the virtual reality training were not much different than what they would do with traditional gait training. The main difference was the visual display with the avatar and motivation for the patients to keep it up.

"It wasn't better than other therapies—it was different," D'Andrea says. "The advantage with virtual reality is that it is engaging. We keep score with how many things they do correctly. It's engaging and fun, and you are playing a fun game while you are doing therapy."

Clinics might not have the resources for the same virtual reality setup as the VA, but there are other options that may also work well for patients, D'Andrea says. Video game systems like the Nintendo Wii or Xbox Kinect or Dance Dance Revolution have been shown to have a positive impact on many different types of patient populations by encouraging physical activity and improving rehabilitation outcomes, she says.

The key, D'Andrea says, is to find something that patients enjoy enough to keep working at it.

"Virtual reality really has a component that engages people in what they are doing," she says. "It's a component of playing a game instead of thinking you just have to go to therapy."


Game Training for Upper-limb Prostheses Users

Mastering the use of an upper-limb myoelectric prosthesis is so challenging that many patients give up before they get to the point where they can use their devices to their full potential.

Design Interactive hopes that its game system ADAPT-MP will keep patients engaged long enough to make full use of their devices.

"What we're seeing are issues with compliance," says Brent Winslow, PhD, chief scientist at Design Interactive. "Many amputees, once prescribed a myoelectric device, don't use it. Most prosthesis training is focused on increasing range of motion but not as much on whether the candidate can successfully control their device once it arrives."

The myoelectric prosthesis, which is operated by using the muscles of the residual limb, requires months of intensive training to master. The hope is that the training games will keep patients engaged long enough to make good use of their devices.

"It takes a lot of time to become an expert," Winslow says. "These devices do a lot more than a basic prosthetic hand does, and it doesn't control as quickly or as easily as a biological hand before amputation. The most common reason for giving up is poor training, which is exactly what we are trying to fix."

The series of games is designed to begin before a patient receives his or her device, so the patient can begin engaging the muscles necessary to control the prosthesis.

The four training games increase in difficulty throughout and all involve dinosaurs.

"A lot of upper-limb amputees are young adult males; also, our development team was really into Jurassic Park," he says.

To play, the patients put on a wearable band called the Myo Gesture Control Armband, Thalmic Labs, Waterloo Ontario, Canada. The patient then activates and deactivates muscles to control the game. The four games help the patient progress from beginning to advanced user and range from basic control to training on how to use proportionate strength for the device.

"The activities are very similar to the daily living activities that amputees perform once their device arrives," Winslow says.

The game also includes an online dashboard with performance data, so members of the patient's medical team can track progress and ensure that the patient is continuing work.

"They can see all of the ways the patient is doing well and where they might need improvement," Winslow says. "They can then make adjustments that speak to that need. The patient doesn't necessarily have to come on-site to be tracked. It can reduce cost and save time."

So far, the games have been through two phases of research development initial trials and the system will soon undergo full clinical trials.


Recreational Therapy

Sometimes the best therapy for patients is not a new exercise or sport but getting back into the life and activities they once enjoyed, says Hetherington.

Through the ACT Program, the Department of Orthopaedic Surgery helps patients get back to the sports and activities they participated in before their amputations. Some of the programs are small classes, such as a ballroom dance class taught by a patient who loved to dance. Others are huge events, like an annual basketball clinic that teams up with the Golden State Warriors. Patients young and old practice shooting and passing drills, he says.

"It's not just about basketball, but also a mobility clinic," Hetherington says. "Everyone loves it but especially the kids."

Participants in the ACT Progam take advantage of orthopedic training in Bakar Fitness Center.

Photograph courtesy of  the ACT Program.

Other activities include art therapy and rock climbing. The programs let the patients have fun and help them to socialize and meet others who have the same interests. "It's a great resource that rounds out our care," Hetherington says. "The patient will take that next step in their recovery when they are re-engaging in what they enjoy. They are not just concerned about walking, and they think, ‘Hey, I can get back to riding a horse or [making] pottery.'"

If a patient has an interest and there isn't a specific class, ACT helps them find a way. "If it's one patient who has this goal, we set them up with a coach to get them there," he says.

Among other benefits, the program helps patients stay fit and active even after they may be done with traditional physical therapy. "It refocuses their energy and rehabilitation on the next goal," he says.

By focusing on these recreational therapies, it also helps prosthetists give their patients the best device for those activities.

"It sets very specific goals of what we are trying to achieve with the device," Hetherington says. "We can narrow down and fine tune where they want to get to—beyond just wanting to walk 400 meters or work or exercise."

He acknowledges that most clinics do not have the same kind of training resources that UCSF has but says that there are always ways to reach out. Clinics should keep community resources on hand for classes or for coaches or therapists who are willing to help train patients. Or perhaps it's just taking patients to the beach to practice walking on sand or going to the track to attempt some running.

"The patients appreciate it, and it might be outside of the normal of what we get paid to do, but I think it goes a long way of not only connecting with the patients but also helping them achieve their goals," he says.

Helping them reach those goals is the point of his job, Hetherington says.

"I feel like it's my goal—beyond just building a good prosthesis—to coach them to the finish line, which is getting them back into the activities they enjoyed before their injury."


Maria St. Louis-Sanchez can be contacted at