Young Joe Padova was big into radio-controlled airplanes, cars and robots. But he didn't put them together. Instead, he took them apart.

"I made little robotic hands," he told ADVANCE recently, "by using the servos that went inside a model airplane to power the fingers. I was really into robotics. I used other servos - from remote-controlled cars - to make arms and legs."

It was the early 1970s, and Lee Majors had brought his character Steve Austin, the bionic man, into everyone's living room. The television show The $6 Million Dollar Man featured Austin as an injured astronaut whose limbs had been saved with robotic implants, enabling him to do superhuman tasks.

But robotics was not to be his ticket to stardom. "I never even won a science fair," he confessed when we asked.

Maybe not. But last year he and his employer did win something: a patent on a brand-new hand splint that Padova, an occupational therapist, created; he believes it is the only one of its kind in the United States. The new splint, the RELEAS™, allows many stroke patients to make their affected hands useful even after years of disuse.

The science of robotics fascinated Padova, a young teen, and he worked at his hobby every chance he got.

At left, Moss Rehab patient Bonj Lee tries on his new Releas™ splint while Joe Padova, OTR/L, gives him instruction about how to use it. Lee, six years post stroke, has been able to use the splint to grasp certain items while his good hand manipulates them.

"Very frequently stroke patients can close their hands, tighten the grip and relax the grip," Padova explained. "They can't isolate the finger extensors to open the hand." The restive forces from a neoprene thumb spica and an outrigger on the new splint opens the hand just enough to allow the wearer to use it to grasp paper, a utensil, whatever will fit there. The wearer can use the splinted hand to grasp and hold objects while he manipulates it with his non-affected hand. But what makes this splint different from others of its kind is its size. Most outriggers are worn for treatment. You can actually use this one to do things.

"It's small and low profile," Padova explained. "That was the whole idea behind it. Outriggers have never been good for ADL because they are too big. You can't work buttons or zippers. It gets in the way if you are trying to dress."

In the past two years, more than 30 patients have been able to use the splint to promote integration of the affected hand during everyday activities after training.

The Site

For the past 23 years, Padova has been working at Moss Rehabilitation, based in Elkins Park, PA. A division of Albert Einstein Health Services, Moss was ranked the No. 1 rehab hospital in Pennsylvania in U.S. News and World Report's 2011-12 hospital survey; it is No. 9 in the United States. The hospital has been somewhere on the list for the past 18 years. The Moss Rehabilitation Research Institute sponsors interdisciplinary research aimed at improving human function and adaptation to disability. The institute's motor control analysis lab (MCAL) studies arm and muscle function and dexterity as part of paralysis research. Nathaniel H. Mayer, MD, a pioneer in the rehabilitation of people with TBI, directs the MCAL. He is internationally known for his functional approach to rehab.

Padova, OTR/L, who is outpatient clinical specialist for neurologic rehab and upper-extremity amputee specialist for both inpatients and outpatients, believes it is the ease of communication among all these entities that enables creativity at Moss.

"The OT and PT departments are together here," he said. "We share the same office. Dr. Mayer can walk right down the hall and talk to the therapists. And we can go up and talk to him. He shares information with us regularly."

A close-up of the splint, which Padova invented.

History

Padova, 52, graduated from Thomas Jefferson University's school of occupational therapy in 1986 after an 18-month stint to get his certificate in OT. He already had a degree in psychology and had been gearing up to go into optometry. But a mini-dissertation for his psych program set him on a project to design a training program to teach kids with amputations how to use prostheses before they actually received them.

"I went to some PTs for help," he said, "and they sent me to the OTs. I didn't even know what OT was. I said, 'They're kids. Why do they need a job?'"

But a visit to the occupational therapy department would change Padova's life.

"It (OT) had so many things I was interested in. It had the vision, the psych - it had everything. So I enrolled to become an OT."

He went to Einstein's acute care OT department for a level-II physical dysfunction affiliation, where Cindy Kwasniewski became his supervisor. She was his mentor and helped develop his early splinting skills. Today she is in charge of all hand therapy satellites for Einstein.

Earlier in his career Padova thought he might want to become a certified hand therapist. He spent three years at Mercy Catholic Medical Center's Fitzgerald Division in Upper Darby, where he did a lot of splinting for the inpatient acute care and rehab units as well as the outpatient center.But orthopedic splinting is much different than splinting for neurological issues. When he came to Moss, things were about to change in that area.

In the early 1990s, particularly with the advent of Botox™, neuroblocks were beginning to prove effective in controlling spasticity, often a complication of stroke. The botulism neurotoxin, used in a controlled way, kept injected muscles paralyzed for a limited amount of time, unable to tighten. Today, Botox is part of Einstein's very effective treatment protocol for stroke patients attempting to regain control of their limb function.

But splinting in stroke care is a controversial issue, and right now a special-interest group at Einstein is doing a literature search on it.

"There are a lot of contradictory articles," Padova explained. "It looks as though the majority say that there's no purpose in splinting for spasticity and suggest it doesn't change contraction."

But in Einstein's motion control lab, Mayer can use chemodenervation with botoxin to lessen spasticity. Once the muscular over activity is managed then they do a very intensive serial casting program to stretch the affected limb over time.

"You can't just stretch out an arm when there is spasticity; it will just go back into contraction," Padova said. "Once you have the muscle stretched out and you have the over activity more under control, you can see if the patient can activate the opposite muscle group. Can they do some weak elbow extension? If so then it leaves a window of opportunity to work on improving elbow extension. Well, sometimes you can do the same thing with the hand."

Mayer uses the Modified Ashworth Scale as an outcome tool to measure the intensity of spasticity. Botox can often bring an individual down a level. "The RELEAS works best when they're at a Modified Ashworth level of 2 or less," Padova said. "If a patient comes to the motor control lab with a level of 3, then the lab can use the Botox to decrease the intensity of the spasticity. The patient can be referred to the outpatient center if he has a level of 2 or less spasticity in the hand after the botoxin; but as treatment continues, if we see he is not developing the ability to actively open the hand, then we can use the RELEAS."

Moss is finding that the new splint sometimes works better for those who are not brand-new stroke patients. It seems that patients accept using a functional orthotic more after other attempts to open the hand have failed. "We are getting very good about defining our goals," Padova said. "We are bringing patients back in three to six months after previous outpatient rehab stays to see if they warrant getting back on therapy. Many of them can. But you have to keep communication open with the physician and explain what you are doing and why, and what you're looking for in terms of improvement. Without well communicated goals it's easy for the doctor or insurer to just to say no." The option of improving hand use through functional splinting can make restarting therapy intervention more likely.

The Splint

When Padova first created his model, he used very thin Orthoplast. The first patient he tried it on went into the bathroom and was able to hold up his pants well enough to get the belt around them. He took the splint home with him, and his OT had no idea where it had gone. The patient called a few days later to ask if he could keep the splint.

But the material was not strong enough. The plastic eventually broke, and Padova tried a stronger plastic of the kind that is used to make fishing rods.

Today the splint, which is really a kind of prosthetic, is a neoprene thumb spica with a low-profile dynamic steel spring-loaded outrigger between the index and long fingers. "We try to keep it less than a quarter-inch above the fingers," Padova said. "By relaxing the grip force the extension forces of the splint opens the thumb index and long fingers. By tightening the hand the patient over powers the extension forces of the splint and closes the hand to hold an object. By modulating the grip forces on an object some patients have been able to use gravity to mimic manipulation by letting the object slide to different positions in the splinted hand".

One of Padova's patients, a Korean man, Bonj Lee, had plateaued with upper-arm function. But four months later he went back to the motor control lab and tried the Botox treatment.

"It worked," Padova said, "Now he's holding paper and cutting it (his non-dominant hand was affected).

Other RELEAS users have been able to open jars, use staplers, grip mixing bowls, open sugar packets, hold bottles and cut their own food.

Padova is pleased with his invention, which will be manufactured by Tiburon Medical Enterprises and come in an initial splint kit for $225. The initial kit consists of the splint, three different tension outriggers a fitting guide and training guide for therapist to train teach the patients. It provides the basic samples of the outrigger tension so that therapists can trial it on patients. Therapists can then order individual components to make up a RELEAS for the patient. The cost for a completed splint by ordering the components is $75. This was an important idea to keep the splint affordable to stroke patients who may have limited incomes.

But Padova wanted to make clear that his is not the only thing out there that is important.

"No single splint will apply to every person," he said. "So you don't want to block out anything. Something might be appropriate for someone at one time, but at another time it would not be. He'd have to use something else.

"My splint is only one tool for neurorehab. You don't want to stifle creativity."

E.J. Brown is ADVANCE editor.