More than 200,000 people have a stroke each year, and millions more have multiple sclerosis, traumatic brain injury and other conditions that impact the nervous system. The effect of these conditions on the nervous system is profound and often leaves individuals struggling with physical disability and deficits of the hand, arm and leg.

Individuals with neurological impairments are typically prescribed a course of physical and occupational therapy to assist with motor recovery and functional gains. However, therapy time is often limited and focused on teaching patients how to accommodate their limitations, rather than regaining function in their affected limb(s).

Treatment strategies are shifting to target recovery of function combined with therapeutic modalities. Over the past decade, researchers have gained more knowledge about how both the nervous system and brain function in the aftermath of a neurologic impairment. A recent advance in the field of neurostimulation offers hope for those who have mobility issues, specifically from gait dysfunction. By combining functional electrical stimulation (FES) and repetitive, task-specific, functional movement patterns, therapists now are able to quickly create the optimal treatment session and obtain immediate results.

Targeting the Nervous System

FES is a rehabilitation technique that uses sequential electrical stimulation of the peripheral nerve to achieve sensory and motor activation for purposeful movement and function. By directly stimulating both sensory and motor nerve fibers as well as providing joint movement for proprioceptive feedback, individuals may feel and see improvements in just one treatment session.

FES allows therapists to help patients move their arms or legs through a normal, patterned physical activity that otherwise is not possible to perform on their own. Additionally, the technology addresses musculoskeletal limitations by relaxing muscle spasms, increasing muscle strength and mass, and increasing joint range of motion. Most importantly, it provides valuable and necessary input to the nervous system. Research has shown that FES can influence cortical reorganization and facilitate neuroplastic changes in the brain.

Traditionally, FES technology with cumbersome wires required a therapist to treat patients, which was not only time consuming, but alsocould not be easily administered outside of a rehabilitation facility.

The next generation of FES devices, such as the NESS L300™Foot Drop System and the NESS H200™Hand Rehabilitation System, are designed to be self-administered by a patient for daily use. The innovative wireless design allows ease of placement both in the clinic and at home, as well as accurate electrode placement with each use.

The NESS L300 Foot Drop System™helps patients walk smoother and faster, and allows them to participate in activities that were previously impossible.1The FDA-approved device consists of two components, a small transmitter in the shoe and device fitted below the knee. During ambulation, the L300 sends electronic signals to stimulate the peroneal nerve, activating the ankle dorsiflexors, the muscles that lift the foot during swing phase.

H200 Hand Rehabilitation System®uses electrical stimulation to improve hand function in certain patients, helping patients perform daily activities and reeducate muscles over time. The device consists of a light-weight orthosis and a hand-held control unit and is designed to provide both functional and therapeutic benefit for individuals with neurological disorders affecting the function of the arm and hand.

This medical advance has allowed therapists to combine both FES interventions and traditional treatment approaches, offering excellent measured functional gains. Total Rehab Care credits these advances in FES technology, as well as a focused interdisciplinary team approach for the success of their patients' motor recovery.

One Case Example

In May 2009, 13-year-old Cameron Beckner was participating in his middle school track meet and collapsed just after he completed the 800-meter race. Three hours later, he was diagnosed with a stroke due to a congenital malformation of his internal carotid artery. The ischemic attack caused complete paralysis of his left side, slurred speech and mild cognitive deficits.

After completing three weeks of inpatient therapy, Cameron was referred for outpatient rehab services at Total Rehab Care, where he was evaluated by physical, occupational and speech therapy services. A team approach and an intense five-day per week rehab program enabled Cameron to participate in therapy for five hours each day for a total of 12 weeks. Cameron's intense therapy started in June 2009; at his initial evaluation, he was walking with a single Loftstrand crutch and AFO (ankle-foot-orthosis) to assist with clearance of his left lower extremity during swing phase.

When Cameron arrived at Total Rehab Care, he had no functional use of his left upper extremity and limited tolerance for activity due to muscle fatigue. Therapists determined that he could benefit from FES technology, and he was properly fitted for the NESS L300 to re-educate the muscles in his left leg and improve his safety and balance during all dynamic tasks.

From the first treatment session, Cameron loved watching the movement in his foot and walking without his rigid AFO on all surfaces. Daily, he would request to use the NESS L300 and would often say "this is cool." Likewise, his family was overjoyed to watch him walk without his brace and achieve a normal walking pattern with ease and consistency.

Within two weeks, Cameron went from wearing the device for 20 minutes in therapy to being a community ambulator with decreased effort and improved walking speed across level ground. After four weeks, he was no longer reliant on an assistive device for walking.

The FES foot drop system enhanced the clinical treatment sessions with Cameron, providing him with a good foundation and control at the ankle. His therapists were able to focus on the quality of movement and stability of his hip and knee, and qualities of his gait that were never in reach while he was wearing his rigid AFO.

Over the next several weeks, Cameron demonstrated improved gait symmetry, consistent heel strike, and increased walking speed over ground and on the treadmill while using an overhead harness support system. Cameron also demonstrated immediate improvements in his balance. His family noted that he completely eliminated any falls once he started using the NESS L300 at home.

The FES foot drop system helps patients complete normal movement patterns without wearing rigid AFOs and using compensatory strategies to advance the leg during swing phase. We perform balance exercises, repetitive step ups, walking on uneven terrain in addition to treadmill walking with patients.

Community Re-Entry

Today, Cameron continues to use the NESS L300 during all walking hours. This is a huge asset to his daily routine of school and attending sporting and community events. He continues to use the training mode for 20 minutes of repetitive movement into dorsiflexion daily.

In addition to the NESS L300, Cameron's therapy regimen includes fun therapeutic activities such as Wii exercises, resistive training, weight training, Total Gym, dynamic balance exercises, aquatic therapy, kick boxing, golf and his favorite activity, kick ball.

During Cameron's recovery he did experience an increased flexor tone pattern of his fingers. He received small dose injections of Botox followed by intense use of the NESS H200 Hand Rehabilitation System both in the clinic and at home.

Community re-entry is a central feature of Total Rehab Care's therapeutic approach. His therapists met with Cameron's family, teachers and counselors to assure a successful transition back to school.

With very few accommodations, Cameron returned to school successfully and continues outpatient therapy services three times per week. In addition, he participates in a home program, H200 Hand Protocol, weight training, and aquatics to continue his motor recovery.

Cameron is a very active athlete. Despite not being able to physically play football this year, his team members appointed him co-captain. With the assistance of the FES foot drop system, he is able to walk out onto the football field and help during practices-even on uneven field surfaces.

Unable to play contact sports at this time, Cameron has picked up the game of golf. With the help of the NESS L300, Cameron recently went golfing with his occupational therapist.

The advances in FES technology have greatly improved Total Rehab Care's functional outcome gains. Patients can take charge of their recovery and lives again. Many patients no longer need to rely on a rigid AFO and can regain confidence with a normal, coordinated walking pattern. In addition, patients leave our program more confident and satisfied with their overall motor recovery.

Reference

1. Hausdorff, J., & Ring, H. (2006). The Effect of the NESS L300 Neuroprosthesis on Gait Stability and Symmetry (abstract). Journal of Neurological Physical Therapy, (4), 195-200 (included in CSM 2007 Platform Presentations).

Judy Peck is a physical therapist assistant at Total Rehab Care of Washington County Hospital, Hagerstown, MD.