It’s impossible to overemphasize the importance of physical therapists (PTs) and occupational therapists (OTs) to a patient’s recovery from stroke, trauma or disease (including recovery from COVID-19). After a stroke, patients leave the hospital unable to walk or use their hands or arms, among other problems. Through the intensive training with PT and OT experts, patients relearn to walk, talk and regain some hand control. Building back body strength and regaining proper posture and movement are essential to restoring the functions of daily living. Those goals would be far more difficult to achieve without the expertise and dedication of these rehabilitation professionals.
“This job isn’t meant for everybody,” says Joe Kardine, a Jefferson Health outpatient occupational therapist and certified brain injury specialist. “You have to want to put yourself in that position to be multifaceted in your personality – coach, mentor, friend, confidant – because you need to tap into all those parts in order to relate to patients and to motivate them when they are at their most vulnerable. There can be challenging days, of course. But other days, when you see a patient make progress toward becoming self-sufficient again because of all the work you put in with them, are very rewarding.”
Therapist Joe Kardine uses functional electrical muscle stimulators to help relax the tension in Aaron’s stroke-affected arm.
Over the past year, Kardine and physical therapist Joseph McCoy were involved in the Cortimo clinical trial, an innovative study for a stroke patient that would test the boundaries of what’s possible with PT and OT therapy for stroke. They would help develop training protocols to help this one patient, after having a brain implant, use a motorized arm to restore his ability to move and function.
For extended periods, therapists see patients at their most challenged selves and, often, in great pain. Along the way, therapists may play a variety of roles to motivate patients, both physically and emotionally, to perform grueling exercises on the road to recovery. Working together through frustrations and triumphs alike, therapists and patients form a special bond that can make all the difference in achieving a successful outcome.
Courses of Action
For Kardine, occupational therapy was “something of a calling” – a career he knew in high school that he wanted to pursue because he was an athlete and able to discuss options with family members who work in health care. His interest grew as he did research, visited rehab facilities and realized that sports medicine was just one aspect of the profession. Following high school, he began an accelerated Master’s in OT that included three years of pre-professional coursework (e.g., sociology, anatomy and physiology, developmental and abnormal psychology), followed by a two-year (including summers) professional phase covering various domains of OT (musculoskeletal, neurological, pediatric, psychosocial, gerontological and emerging/specialty areas of practice) as well as fieldwork.
It wasn’t until after graduating college that Jefferson Health’s Joseph McCoy decided, based on his interest in sports and physical activity as well as the results of a career-determining personality test, to become a physical therapist. Among the courses in his Master’s curriculum at Thomas Jefferson University were pathophysiology, biophysical agents, therapeutic interventions and clinical decision making. McCoy is now a board-certified neurologic certified specialist working with outpatients.
“We get to spend a lot of time with patients compared with some of their other caregivers,” says McCoy. “This gives us the opportunity to persuade them that the work we do is going to help them. It’s incredibly fulfilling to get through to them, earn their trust and then see them get better.”
A Groundbreaking Opportunity
When Kardine and McCoy recently were asked by Mijail Serruya, MD, PhD, assistant professor of neurology at Sidney Kimmel Medical College at Thomas Jefferson University, to work on the Cortimo clinical trial, they both saw an exciting opportunity. They soon began to work with 42-year-old Aaron Ulland, who had suffered a stroke in January 2019. Although he regained his speech, ability to swallow and some mobility over several months of outpatient physical therapy near his home in southern New Jersey, Aaron had lost full use of his arm. The stroke had injured the portion of his brain controlling its movement.
Aaron Ulland runs through training protocol using a motorized brace.
In October 2020, Jefferson neurosurgeons, as part of a groundbreaking clinical trial, implanted electrodes in Aaron’s brain that would send signals to a motorized brace on his left arm, enabling him to move it again. The revolutionary Cortimo clinical trial marks the first time this was ever done in a patient with a common type of stroke and demonstrates what could be possible in the future for others with disability from strokes. As occupational and physical therapists, Kardine and McCoy became important parts of Aaron’s journey.
“When I first started working with Aaron a month before his surgery,” recalls Kardine, “his range-of-motion in his left shoulder and elbow were limited. The joints and muscles were much tighter than they should have been. This condition is call ‘spasticity’ and is typical of what we would see in a patient with this type of stroke. He couldn’t control movement of his left wrist or fingers. During the next few weeks, we made a lot of progress in improving these issues to prepare him to use the robotic device on his left arm after the surgery.”
Following surgery, Kardine met with Aaron twice a week, two hours at a time, for nine weeks at an apartment maintained close to Thomas Jefferson University Hospital for patients receiving extended outpatient therapy. Aaron’s OT during this period included exercises that correlated with practical, everyday tasks, such as holding a pen and cutting his own food, and then, when he’d made sufficient progress, attempting the tasks themselves. As he typically does with his patients, Kardine carefully adjusted the therapy as necessary, making specific repetitions either more difficult or less, as Aaron’s progress dictated.
Let the Games Begin
McCoy’s PT work with Aaron was entirely post-surgery and lasted for 10 weeks. “The first thing I did was to establish an aerobic exercise program for Aaron,” he says. “That involved exercising on a recumbent bike and a step machine in the gym. I worked with Aaron for an hour a week, and graduate assistants did so between our visits. They also took him for walks around the neighborhood.
“We also came up with games to encourage engagement on Aaron’s part to improve control of his left arm,” recalls McCoy. “These games included batting practice with a Wiffle ball bat and tossing a ball in a basket. In addition, we got him more comfortable standing in various positions from which he would have better control of the robotic arm brace.”
An Amazing Experience for Students Too
Providing invaluable assistance during the several weeks of Aaron’s post-surgery therapy were two Thomas Jefferson University graduate students: Ashly Parekh, a first-year OT student at the College of Rehabilitation Sciences, and Joely Mass, a fourth-year student at Sidney Kimmel Medical College. They each spent several hours a week coaching Aaron through his exercises and games, accompanying him on his walks and providing good company and conversation.
“My grandfather was paralyzed from the neck down for over 20 years,” says Parekh. “I always imagined there could be some type of medical device that could basically un-paralyze him and help him regain his mobility and part of his brain function. Then I learned about occupational therapy at the nursing facility that he was at, and that motivated me to one day become an OT and to work in neuro rehabilitation.”
Several months ago, Parekh was fascinated by a webcast in which entrepreneur Elon Musk demonstrated an implantable wireless brain-computer interface that aimed to help cure neurological conditions like Alzheimer’s, dementia and spinal cord injuries. So when she found out about the Cortimo trial, she immediately volunteered to help. Working with Kardine, Parekh learned how repetition of exercises and tasks could enable new neural pathways, enabled by the electrodes implanted in Aaron’s brain, to gain function in his arm and better control his robotic arm brace. So would strengthening his muscles and improving his posture.
“This was an amazing experience – especially so early in my education,” Parekh says. “It definitely confirmed what I want to accomplish within the field. I want to learn more about how brain implants can assist with patient rehabilitation.”
Mass was recruited as a volunteer by Dr. Serruya, with whom she had worked on a prior research project as a first-year student.
“When I first heard about the idea behind the trial, it was really surprising to me that something of this nature could be done at Jefferson,” says Mass. “It was a really cool opportunity to become involved and to spend time providing Aaron with some social interaction for more than two months while he was living away from home. Like his physical and occupational therapy, I think the social engagement he received from me and from other volunteers was very therapeutic.”
Mass found observing Aaron’s physical therapy and occupational therapy sessions very enlightening for her as a medical student: “I didn’t realize how much creativity rehabilitation therapists put into the different exercises and games developed for patients, or how difficult and exhausting it can be for patients to maintain progress. The experience has enhanced my appreciation for the work that therapists do and further increased my empathy for patients, which will be valuable in my future career as a pediatrician.”
Aaron has since completed his three-month journey as a clinical trial participant. The results are encouraging and the research will serve as a bridge to inform additional studies into the ways brain implants can help restore mobility in stroke patients. Throughout Aaron’s pioneering journey were OT and PT specialists like Kardine and McCoy, and students like Parekh and Mass, who played important roles in his recovery, rehabilitation and mental well-being to drive his unwavering commitment to help other stroke survivors.