Rehabilitation Figure 2: The NESS H300® Foot Drop System Figure 3: Gait Cycle with Heel Switch On and Off
progression from a metal brace to a lightweight plastic brace was seen as a major accomplishment. However, the traditional ankle–foot orthosis (AFO) has many drawbacks. The patient is typically ‘fitted’ with an off-the-shelf AFO to use at the hospital, but then has to wait until discharge to be ‘fitted’ again with a custom AFO that can be placed inside their shoe. It is often necessary to have to buy two pairs of shoes because the AFO requires a half-size larger. The patient also walks in an unnatural, stiff manner, with a fixed ankle. FES once again solves the problem in the lower extremity. Another neuroprosthesis, the NESS L300® Foot Drop System, again from Bioness, is useful for individuals suffering from the effects of stroke as well as those with traumatic brain injury and multiple sclerosis. The NESS L300 includes an electronic orthosis, a control unit and a gait sensor (see Figure 2). A single, attractive unit wraps around the leg just below the knee, with stimulating electrodes over the peroneal nerve and the anterior tibialis muscle (see Figure 3). The gait sensor consists of a lightweight pad that is placed under the patient’s heel and is connected to a small sending unit. When the patient advances their leg and pressure comes off the heel switch, a signal is sent to the stimulating electrodes, causing dorsiflexion of the ankle. As the leg swings through the gait cycle and the heel strikes the ground, heel switch contact causes stimulation to cease, and the foot returns normally to the ground. Patients quickly develop a more normal gait pattern and, given the choice between the FES neuroprosthesis or a regular AFO, they consistently prefer the NESS L300. They have the ability to walk in similar-sized shoes, walk further and more frequently, and, most importantly, are more likely to avoid falls.10–12
There Is Always More to Do
goals of function, dose, and motivation. Even a patient with a flaccid hand can pick up an object and perform functional tasks with enough repetitions to drive neural repair. The positive reinforcement of successfully completing these tasks over and over again provides motivation that I have not seen before in my clinic; an increasing number of studies are also confirming these results.6–9
New technologies are only just beginning to scratch the surface of what can be achieved in rehabilitation. Robotics, mechanized ambulation, virtual reality, and mental practice all enable the patient to meet the criteria of task-specific therapy. Physicians and therapists consistently give up too soon on their patients, and leave them with a reservoir of untapped abilities. Remember the old commercial that stated “It is not your father’s Oldsmobile”? This is not your ‘father’s rehabilitation’, either. New technological advances offer patients opportunities that did not exist even five years ago. One must be certain that they get that opportunity. n
Patients are also
able to use the device at home, enabling them to increase their repetitions and incorporate treatment into their daily activities.
Technological Advances in Lower Extremity Rehabilitation
Orthotics and braces have been the mainstay for therapists and physicians in compensating for weakness in the lower extremity. The
1. Nudo RJ, Mol Psychiatry, 1997;2,188–91. 2. Nudo RJ, Curr Opin Neurobiol, 2006;16:638–44. 3. Kleim JA, et al., J Speech Lang Hear Res, 2008;51: S225–39.
4. Wolf SL, et al., JAMA, 2006;296:2095–104.
5. Wolf SL, et al., Lancet Neurol, 2008;7:33–40. 6. Alon G, et al., Neurorehabil Neural Repair, 2007;21: 207–15.
7. Hill-Hermann V, et al., Am J Occup Ther, 2008;61:466–72. 8. Meijer JWG, et al., J Rehabil Med, 2009;41:157–61.
Richard C Senelick, MD, is a Neurologist specializing in neurorehabilitation and Medical Director of the HealthSouth Rehabilitation Institute of San Antonio. He also serves as Editor-in-Chief of HealthSouth Press. He is a frequent lecturer on both a national and international level and has co-authored many books and publications. Dr Senelick completed his undergraduate and medical training at the University of Illinois and his neurology residency at the University of Utah.
9. Page SJ, et al., Neurorehabil Neural Repair, 2010;24: 195–203.
10. Ring H, et al., J Stroke Cerebrovasc Dis, 2009;18:41–7. 11. Dunning K, et al., Phys Ther, 2009;89:499–506. 12. Hausdorff JM, et al., Am J Phys Med Rehabil, 2008;87:4–13.
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