Since its beginning in 1936, Casa Colina Centers for Rehabilitation, Pomona, Calif, has helped thousands of patients recover from stroke and neurological damage. Despite access to a century's worth of rehabilitative therapies, Casa Colina's medical staff had not found a device that met the full spectrum of rehabilitative needs for treatment of foot drop, such as impaired dorsiflexion, stance limb stability, and muscle stimulation to avoid atrophy. This year, however, Casa Colina's medical staff found a breakthrough wireless functional electrical stimulation (FES) device that is designed to provide many of the benefits of traditional therapeutic devices, and in many cases has improved rehabilitation outcomes.

In early 2007, Casa Colina integrated the next generation in FES into its acute inpatient and outpatient rehabilitation programs. Called the NESS L300™, distributed by Bioness Inc, Valencia, Calif, it is a low-profile wireless device that sends electrical stimulation to the peroneal nerve; this nerve activates the ankle dorsiflexors that control the muscles that lift the foot up during ambulation for normal gait. The secondary effect of the L300—caused by activating the ankle dorsiflexors—is the movement of the ankle may simultaneously help with improving blood circulation, increasing range of motion, and reducing the workload on the body.

Before the NESS L300, traditional FES for functional training required patients to be wired by therapists with cumbersome electrodes. The NESS L300, however, is designed to be self-administered by the patient for daily functional use. It may allow close-to-natural gait among selected patients by activating muscles in a physiological pattern, enabling more freedom of movement compared with traditional systems. Additional possible benefits include: improved blood circulation in the peripheral vascular system, correction of compensatory patterns, improved coordination on uneven surfaces, and compatibility with everyday footwear.

Casa Colina adopted the NESS L300 after the medical director and rehabilitative staff observed the device at the headquarters of Bioness. Bioness was formed in 2004 by entrepreneur and philanthropist Alfred E. Mann, NESS Ltd (the Israeli manufacturer of the L300) and the Alfred E. Mann Foundation for Scientific Research, a pioneer of implantable bionic technologies. After reviewing the technology, Casa Colina implemented the NESS L300 into its inpatient and outpatient rehabilitation programs for patients in the acute and subacute phases of rehabilitation.

Patients with stroke, traumatic brain injury, incomplete spinal cord injuries, and other disorders of the central nervous system that result in functional deficits and impairments of the lower limb may be candidates for the NESS L300. In order to test its clinical scope, Casa Colina medical staff first administered the NESS L300 on a male patient in his 40s who suffered acute neurological damage with an incomplete SCI. This patient was selected to determine whether the L300 would be able to effectively control the patient's tendency to have excessive knee hyperextension, without causing instability of the patient's ankle and knee during stance phase. Therapists found that by adjusting the settings on the clinicians' programmer, the patient was able to better control the knee-extension thrust without causing instability to the ankle during stance phase. The end result was the patient ambulated with an improved gait speed without compromising stability.

THE NESS L300 VERSUS TRADITIONAL TREATMENTS

Traditionally, use of a rigid orthosis or ankle-foot orthosis (AFO) has been a common way to manage any dysfunction of the ankle or foot during ambulation. Even with a brace, however, it is challenging to walk on stairs and uneven surfaces, impacting everyday activities. In addition, AFOs may cause other problems, including ankle joint stiffness, skin breakdown around the orthosis, muscle atrophy in the ankle region, and degenerative joint problems in the hip due to a compensatory motion known as "hip hike."

Moreover, patients using AFOs often find them uncomfortable to wear and, because of the added bulk in shoes, patients may be required to purchase different-size shoes for each foot. As a result, AFOs have been reported to have poor user compliance. To date, the NESS L300 reduced or eliminated the need for most Casa Colina patients to use an AFO and offered even greater gait by improving walking pace and symmetry. Given a choice between the NESS L300 and the AFO for daily ambulation, most Casa Colina patients who had been prescribed the neuroprosthesis preferred the NESS L300.

Casa Colina PTs have found that most patients who have purchased the NESS L300 for home therapy use it regularly. A key feature of the NESS L300 is a built-in training mode that is designed to improve conditioning and control of the ankle dorsiflexors. This conditioning program completed daily with the initial patient group has been shown to improve the controlled strength in most patients by half a muscle grade. This improvement in strength was also noted in conjunction with improvements in gait velocity and improved symmetry of stance.

Mathu Hanson, PT, is an outpatient neurology department clinical coordinator at Casa Colina Centers for Rehabilitation in Pomona, Calif, and works with patients with balance and neurological disorders. Hanson also works at Casa Colina's Children's Services Center with patients who have suffered traumatic injuries.

David Patterson, MD, board certified in physical medicine and rehabilitation, is the medical director of Casa Colina Hospital, Pomona, Calif. He is a diplomate of the American Board of Physical Medicine. For more information, contact .