Q&A: Balance tool improves neurorehabilitation evaluation in COVID-19, other illnesses

An update to the Bioness Integrated Therapy System, or BITS, called BITS Balance, will provide the medical community with another tool for evaluating patients in neurorehabilitation — including patients recovering from COVID-19.

Force plates are part of the traditional standard of care within neurorehabilitation, according to Suzanne Tinsley, PT, PhD, an assistant dean in the School of Allied Health Professions and an associate professor of physical therapy at LSU Health Shreveport in Louisiana, who specializes in neurologic rehabilitation. Typically, patients must either sit or stand on a force plate. The Balance component of Bioness’ Integrated Therapy System (BITS) expands on the capabilities of a force plate by tracking patient movement.

Healio Neurology spoke with Tinsley, who beta-tested the system, about the clinical implications of the BITS Balance component for neurological rehabilitation among so-called COVID-19 “long-haulers,” individuals who experience long-term COVID-19 symptoms.

Healio Neurology: What does the BITS Balance therapy system add to the world of neurologic rehabilitation?

Tinsley: In my opinion, it takes the world of neurorehabilitation around balance control to that next step. If you look at what we have now, most of the technology requires the patient to stand on some type of force plate. It is the augmentation of the weight through their feet that tells us what their balance capabilities are. The BITS system allows us to work with the patient on balance control in the real world, in tasks that are relevant or meaningful to them. It allows us to take that component of task-specific, environment-specific rehabilitation to the highest level of functioning. According to the theories of motor control and motor learning, you need to do tasks that are important to individuals in environments that are relevant to them, and this new technology allows us to do just that.

Healio Neurology: How could it improve neurological and overall functional outcomes among COVID-19 long haulers?

Tinsley: Here at LSU Health Shreveport, we have a COVID-19 recovery rehabilitation program. We found that there are about 8 to 10 areas of rehabilitation that would need to be addressed for any patient who survived COVID-19; that is the long hauler. The first is physical disability. For individuals who are extremely weak and have severe functional limitations, part of these functional limitations are going to be related to balancing activities. I see this system helping with that overall functional disability.

Then you look at the pulmonary function of individuals. We know that the pulmonary problem people have after recovery is that this severe inflammation almost makes the alveoli seem very sticky. Pulmonologists are finding that you have to force those alveoli open; much of that is going to be dependent on postural structure. Being able to work with somebody to promote thoracic extension will be extremely important; the BITS will help us do that.

The next area is ICU-acquired weakness, which goes along with the functional disability: The more patients are in bed, the weaker they become. One of the first things that happens when people become debilitated is that they lose their ability to balance in many tasks. This system will allow us to identify where a patient is having a problem and then assess and manage balance within that specific task, rather than having them stand on the foot force plate.

Healio Neurology: What else have we learned about the neurological aspects of COVID-19 rehabilitation?

Tinsley: In some of the other areas of rehabilitation associated with COVID-19 recovery, we are finding that many individuals develop peripheral neuropathy. This neuropathy is being described as Guillain-Barre-like, as a demyelination based on nerve conduction and amplitude tests. It looks clinically like the nerve is demyelinated. We know from experience that, if that is truly the case, it takes weeks or months for these peripheral nerves to remyelinate.

That said, when these individuals are treated with electrical stimulation and we force those nerves and muscles physiologically, recovery happens more quickly, so it does not seem to be true demyelination. What I think it is, and what a couple of our basic scientists here are looking at, is an extreme inflammation of the nerve — one nothing like we've seen before. Normally when you see neuritis, it involves mostly sensory problems. Very rarely is inflammation of a nerve the cause of motor problems, and certainly not to the significance that we're seeing with patients who are past the COVID-19 infection. We have found that the way to overcome that is to treat with functional electrical stimulation, stimulating that nerve as much as we can, and then putting the muscle that is innervated by that nerve back into activity. Most of the problems we are seeing are in the proximal hip musculature and in the ankles, primarily the peroneal nerve distribution. Every now and then, I see some ulnar nerve problems in the upper extremities, but it is primarily the distal components of the lower extremity, those muscles we know are important in balance.

References:

• PR Newswire (2020). Bioness, Inc. Announces Commercial Launch of Next Generation Bioness Integrated Therapy System (BITS) Balance System for Rehabilitation Facilities. Available at: https://www.prnewswire.com/news-releases/bioness-inc-announces-commercial-launch-of-next-generation-bioness-integrated-therapy-system-bits-balance-system-for-rehabilitation-facilities-301154839.html. Accessed Feb. 15, 2020.