4/9/2003 by Pamela Rust

[Photo: Russ Nieland, owner of Northern Arm & Hand.]

Learning how to re-use an injured hand can be traumatic and painful. But what if your injury could be treated, and strength regained, through playing a customized video soccer game or dodging trees in a fast-paced downhill skiing game?

Northern Arm & Hand Center, located in the Lakewalk Building at 1420 London Road in Duluth, is an upper extremity trauma and rehabilitation center that offers 10 different computer games as physical therapy.

“We have patients who over-exercise because they enjoy the games so much,” says Russ Nieland, owner, physical therapist and certified hand therapist. He says the clinic’s state-of-the-art software offers the best way to regain use of an injured limb.

“Therapy has the reputation of not being fun,” he says. “Our center is relaxed and family-oriented.”

Other services include wound care, splinting, home programs and job-site ergonomic evaluations.

Nieland, who’s practiced physical therapy for 31 years, started the clinic in May 1999 using personal savings and a bank line of credit. After stints at St. Luke’s, St. Mary’s/Duluth Clinic Health System (SMDC) and other large clinics, he felt he could provide better treatment at a lower price on his own.

“The problem with big physical therapy clinics is that money is the bottom line, not patient concerns and quality. That’s not the way PT should be,” he says.

With annual revenues averaging around $450,000, Nieland says the business has operated profitably since its second year. Starting with two and a half employees, it grew to 14 employees within 18 months. It’s now “right-sized” to a staff of 10, he says. He links the staff reduction to “politics” and competition with larger clinics, declining to elaborate.

Part of the “right-sizing” included the departure of co-founder and partner Norm Radke, who recently started his own clinic, Lake Superior Physical Therapy, in Duluth at 1131 E. Superior St.

While the clinic’s business manager handles some administrative tasks, Nieland is overall director and juggles a full patient caseload.

Therapy and testing equipment

Nieland embraced new technology at the onset, feeling it offered greater objectivity and exact measurements, both critical to gauging a patient’s improvement. The software saves therapist’s time and effort and provides better accuracy for employers concerned about an injured employee’s progress.

Part of his initial investment included $100,000 for two computerized physical therapy systems, from Dexter and Biometrics.

• Dexter® Evaluation Software and Workstation, manufactured by Cedaron Medical, Inc. of Davis, CA. The system measures dexterity in shoulders, elbows, fingers and the hand, using evaluation, therapeutic exercise, testing and rehabilitation components. The workstation, which uses screen-touch software, gauges strength through devices and gadgets, taking age and gender into consideration.

For example, through measuring the strength of a hand squeeze, it can graph average force, determine torque rates and swiftly print out graphs and charts of findings.

Most clinics use a hand-held dynometer that typically has a 20 percent error rate, Nieland says. The Dexter’s error rate is .01 percent, he says.

No other clinic in a five-state area has this machine, Nieland says.

Measurements are tracked in a database, while the screen provides a visual display of the injured area. As therapy renews strength, the display reflects the progress. Patient history can be entered, and exercises built around specific work or hobby needs.

• Biometrics video game software, manufactured by Biometrics, Ltd. (Gwent, United Kingdom). The laptop-based rehabilitation game therapy is popular in Europe.

Nieland says it’s a motivational tool that encourages competitiveness, simulating tasks that require needed exercise. Patients typically play games for 60 to 90 minutes several times weekly for complicated or difficult injuries. The software tracks progress and displays a graph indicating the range of movement. It even issues a challenge for improvement in the next session, contributing to the potential for patients overexercising.

Just a handful of U.S. physical therapy clinics use this technology. Nieland says five therapists from China spent a week at his clinic in 2001 learning to use the Dexter system. He’s given in-service training to other therapists and lectured in Japan.

Business climate

The clinic is not affiliated with a health care system. While SMDC and St. Luke’s Orthopedic and Internal Medicine refer some patients, most referrals to Northern Arm & Hand come from independent physicians. Nieland says William Cooney, MD, a top hand surgeon at the Mayo Clinic in Rochester, and surgeons at Fairview University Medical Center in Minneapolis, often refer their Duluth patients to Northern Arm & Hand.

The center treats about 150 patients weekly. Nieland says he gets more complicated cases that need specialized rehabilitation. The most common wounds are “hand crush” injuries, table saw injuries, industrial and commercial injuries. About 80 percent are post-surgery patients.

Novacare Physical Rehabilitation, at 925 E. Superior St. in Duluth, has provided physical therapy since 1991. Part of a national chain, it also has no formal affiliation with local health systems.

Physical therapist Sara Chmielewski, Novacare’s manager, says her business profile differs from Northern Arm & Hand’s because her operation provides whole body therapy.

Novacare also uses computerized equipment, including an isokinetic exercise work station that helps patients to lengthen their muscles and strengthen most body parts through variable resistance. Made by Biodex Medical Systems in Shirley, NY, it can simulate steering to help repair injuries that interfere with driving. The equipment is used as part of an overall rehabilitation program that includes home exercises, she says.

Chmielewski says Novacare also uses software developed by Isernhagen Work Systems , a division of WorkWell Systems in San Juan Capistrano, CA, to help evaluate functional capacity. Therapists manually test a patient’s strength, then enter the measurements into a secure Internet system that scores results.

Administered over two days, the six-hour test used to require hours of handwriting and calculator time, she says.

Duluth physical therapist Susan Isernhagen founded Isernhagen Work Systems, which developed the proprietary therapy assistance programs that are used internationally for work injury prevention and management.

New technology is spurring other innovative rehabilitation methods as well. Therapists typically provide home care instructions in paper form.

A new company based in Superior, iTherapies, has developed a set of CD-ROMs that allow clinicians to prescribe and manage home programs with individualized, digital video content.

“We believe we are the first in the world to offer this. We hope to drive the market,” says physical therapist Mike Carey, iTherapies CEO. Carey says the first CD offers the Mulligan Home Exercise treatment, a regimen of full-body rehabilitation techniques.

Nieland also is moving beyond the arm and hand therapy business. In 2001 he started NorthStar Rehab & Sports Medicine in an adjacent office to address upper and lower body sports injuries. He set up the center with Biodex equipment that measures injury severity, including range of movement and strength of up/down and side-to-side movements. The equipment also provides therapy and strength training on sports injuries to ankles, knees, back, hips and neck.

Nieland plans to hire another sports physical therapist.

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