Wedding Day Stimulation

The arrangements are all set, the invitations have been sent, everything will go off just as it’s been planned. Don’t forget the most important part of the day: walking down the aisle! Nobody, man or woman, wants this to be a stressful moment on this special day. For people with foot drop, however, it can be the least anticipated 30 or so feet they’ll ever have to walk.

When Carmela came to Aim2Walk in the fall of 2011, she informed me of the February wedding of someone close to her in which she would be a bride’s maid. She needed to be able to walk down the aisle without dragging the toes of her right foot, as she’s done the last several years.

Carmela, a mother of 2 young children, was diagnosed with Multiple Sclerosis in 2003. Other than undergoing CCSVI Liberation surgery in 2010, she had received no formal physiotherapy treatment for her MS symptoms.

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Foot Drop is a very common symptom of MS, and many other neurological conditions. Basically, the toes/ankle of the affected leg are unable to lift up far enough to clear the ground, so they drag while the leg is trying to swing forwards. The body is clever, though, and not all people with foot drop will actually drag their toes. There are three common presentations of foot drop: When the leg is trying to swing forward during walking, you will see 1) the toes drag along the ground, OR 2) an exaggerated knee bend, OR 3) the leg swing out to the side (circumduction). The last two symptoms allow the foot to clear the ground without dragging, thus reducing the likelihood of ‘tripping up’ and falling. It is possible to see all three presentations in one person.

There are several possible causes for foot drop:

- Neuromuscular Disease (Stroke, MS, Brain Injury)
– Peroneal Nerve Damage
– Sciatic Nerve Damage
– Spinal Cord Injury
– Cauda Equina Syndrome

When being assessed, it is important for the assessor to differentiate between a Central Nervous System cause (Stroke, MS, Brain Injury, Spinal Cord Injury) and a Peripheral Nervous System cause (Peroneal Nerve, Sciatic Nerve, or Cauda Equina Syndrome) because that may drastically change the treatment.

Treatment from a rehabilitation clinic will fall under one or two of the following categories: 1) Orthosis 2) Functional Electrical Stimulation (FES) 3) Exercise Therapy

Ankle Foot Orthosis

Not too long ago, an orthosis was really the only option for therapists trying to assist any patient with foot drop. An ankle-foot orthosis (AFO) can be worn to prevent the foot/toes from dragging during gait. This device will certainly preserve function, but if the goal is to retrain the muscles to perform the movement, the AFO will not do.

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Following a comprehensive neurological examination, we found that Carmela has no cognitive deficits, no fixed deformities, no severe spasticity, and no hypersensitivity. We decided to try both FES and exercise therapy in her treatment plan. The FES device we use is from Bioness – the NESS L300, and the exercise therapy included gait training on the Lokomat.

The Ness L300 stimulates the dorsiflexor muscles of the lower leg to lift the foot during the swing phase of gait. It is able to accomplish this with the aid of a heel sensor that triggers the electrical muscle stimulation once the foot is lifted from the ground. So while the functional goal of eliminating the foot drop is attained, the ultimate goal of retraining the muscle can also be realized with regular training. Carmela’s initial fitting with the L300 went very well and improved her gait immediately (see videos below). The time it took for her to get up from a chair and walk 3 metres before returning to the chair reduced from 25 seconds to 18 seconds on the same day. With the stimulation, her foot no longer drags, thus therapy can focus on other muscle issues higher up the kinetic chain (hip and core muscles).

The gait training on the Lokomat has also shown to help reduce foot drop. After her first session, Carmela’s foot drop disappeared for 30 minutes, and this number has and will gradually increase as therapy progresses. With the addition of the L300 to her Lokomat training (often used simultaneously), Carmela is experiencing physical recovery she had not experienced in her previous 8 years of living with MS.

With the help of the Ness L300 two weeks ago, Carmela achieved one of her treatment goals as she happily walked down the aisle as a bride’s maid. She did not have foot drop on this memorable day, and her party shoes survived un-scuffed.

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We would love to hear your stories. Please tell us your foot drop stories in the comments section.

If you or someone you know has foot drop, visit a Physiotherapist near you to find out the best treatment option available.

- Matt

Technology Review – Take that Gravity!

An engineer, physiotherapist and clinician walk into a bar…sounds like the beginnings of a bad joke, but indeed, it was the beginnings of ZeroG, “the most advanced gait and balance training system in the world.” Maybe they weren’t at a bar, but they definitely had their creative hats on for the next gait trainer in our gait technology review series. Aretech teamed up with Bioness for the ZeroG, the first non-exoskeleton gait trainer we will review. Let’s take a closer look…

ZeroG

Overview: An overground gait and balance trainer that utilizes a body-weight support system on an overhead trolley
Intended Use: Patients can practice a wide range of walking activities, balance tasks, and ADLs after a neurological injury. Patients must have some lower extremity function to initiate a walking or stepping motion. Also may benefit orthopaedic and cardiac patients with weightbearing restrictions.
Purpose: to provide gait and balance training in a safe, controlled environment at rehab facilities
Release date: Currently in use at rehabilitation hospitals and facilities across the United States, and will be implemented in Canadian facilities by 2012.
Cost: $150,000.

My Take: Let me start off by saying that the ZeroG name is a little deceiving. If this product really eliminated gravity, patients would just be floating instead of walking, like in this promo for a like-named company. They may want to think about naming it BelowNormalG, or LessThan9.81m/s2G.

Aside from its name, I was hard-pressed to find much to complain about with ZeroG. From a therapy perspective it provides most of what you want when gait training. The therapist, using an 18.5” touchscreen computer, can control the level of body-weight support, distance walked, fall settings and training duration. The system tracks everything about the gait training session, including the number of falls prevented by the system. The coolness doesn’t end there. If you don’t want to hang out by the main computer, you can take an Apple iPod Touch while you walk with your client.

As a therapist, the gait training allowed by the ZeroG is ideal. The client is always safe and will not fall to the ground, you have direct access to the client with no machinery in the way, and you can perform functional tasks, such as stair climbing and sit-to-stand training without risk.

ZeroG will not benefit spinal cord injured clients with no volitional movement in the lower extremities, and although allowing for weight-supported gait training, the biomechanics of gait are not assisted (as with the Lokomat or some other robotic exoskeletons). The user is restricted to walking in the rehab facility where the ZeroG is located, and unable to use this device outdoors.

As an aside – many of you know that we implement the Lokomat at our clinic, Aim2Walk, and the Lokomat allows for a similar body-weight supported gait training, just over a treadmill instead of the clinic floor.

Nonetheless, the ZeroG is currently the best option for over-ground gait training that I have come across. It is not a robotic exoskeleton, making it difficult to directly compare. As seen in previous reviews, exoskeletons allow for independent mobility and can be used in the community. The ZeroG, though, for gait, balance and functional training in the early stages of recovery, is currently floating high above other forms of over-ground gait training.