New Technologies for the lower extremity treatment of the neurologic patient

1. New Technologies for the lower extremity treatment of the neurologic patient

2. Bioness l300 Plus: Application to the neurologic Patient Adam M Hoyle, PT, DPT, MSPT Spalding Rehabilitation Hospital Aurora, CO

3. Objectives • Participants will be able to describe the main components of the L300 Plus system. • Participants will be able to describe the patient population for whom the L300 Plus system is indicated. • Participants will be able to describe how the L300 Plus system works and which anatomy and specific motor points are involved. • Participants will be able to describe types of treatments that can be implemented apart from gait training with the L300 Plus system.

4. Introduction • What is the L300 Plus System? • The Latest Technology to Help Patients Walk More Naturally. • The L300 Plus System builds on the success of the L300 Foot Drop System by adding a thigh cuff to give greater control over bending and straightening the knee, which may help normalize gait. • The L300 Plus System’s wireless components adapt to changes in walking speed and terrain, allowing patients to walk more easily on stairs, grass and carpet. Comfortably worn under most clothing, the system’s unique design may help eliminate the need for a rigid knee-ankle-foot orthosis (KAFO), or braces, and may reduce the risk of falls and injuries.

5. Indications • The NESS L300 Plus System is intended to provide ankle dorsiflexion and knee flexion or extension in individuals with foot drop and thigh muscle weakness following an upper motor neuron injury or disease. • During gait, the NESS L300 Plus System electrically stimulates muscles in the affected leg to provide dorsiflexion of the foot and knee flexion or extension; thus, it may improve the individual’s gait.

6. Indications • The NESS L300 Plus System may also: • Facilitate muscle re-education. • Prevent or retard disuse atrophy. • Maintain or increase joint range of motion. • Increase local blood flow.

7. Contraindications • Patients with a demand-type cardiac pacemaker, defibrillator, or any electrical or metallic implant should not use the NESS L300 Plus System. • The NESS L300 Plus System should not be used on a leg where a cancerous lesion is present or suspected. • The NESS L300 Plus System should not be used on a leg with a regional disorder, such as a fracture or dislocation, which could be adversely affected by motion from the stimulation.

8. The L300 Plus System May Help People Living With: • Multiple Sclerosis (MS) • Stroke (CVA) • Traumatic Brain Injury (TBI) • Spinal Cord Injury (Incomplete) • Cerebral Palsy (CP) • Many others are being trialed

9. The Equipment • Functional Stimulation Leg Cuff • Functional Stimulation Thigh Cuff • Intelli-Sense Gait Sensor • Wireless Control Unit

10. Applied Anatomy • Dorsiflexor • Anterior Tibialis • Quadricepts • Rectus Femoris • Vastusintermediuslateralis, and medialis • Hamstrings • Bicep femoris • Semitendinosus • Semimembranosus Anterior Tibialis

11. What are we stimulating During Gait? • Femoral Nerve and branches • Tibial portion of the Sciatic Nerve and common Fibular potion of the Sciatic Nerve • Deep peroneal nerve • Quadriceps • Hamstrings • Tibialis Anterior Nerve(s) Muscle(s)

12. Muscle Activity post CNS Injury • In Upper Motor Neuron Pathologies, muscle activity can: • Be absent • Display insufficient magnitude • Display excessive magnitude • Display incorrect timing • Delayed onset • Prolonged • Constant • Any combination of the above

13. Review of Gait Cycle

14. Neurologic GaitBasic Common Problem: Hamstrings vs Quadriceps • Why do we need the Hamstrings to be active during swing? • To control/decelerate the knee extension moment before Initial Contact • Why do we need the Hamstings to be active during stance? • To help control the knee position during Loading Response

15. Hamstrings vs Quadriceps • Why do we need the Quadriceps during swing? • To ensure full knee extension at the end of swing • Why are the Quadriceps needed during stance? • To control and stabilize the knee through Mid-Stance • Why do the Quadriceps go quiet during Mid-Stance? • Due to the ground reaction forces moving anterior to the knee joint.

16. And the answer is… • For stimulating the Quadriceps, think KAFO or weak stance force production. • For stimulating the Hamstrings, think Genu Recurvatum or poor timing and or poor stance control. • This is not all inclusive, but helps in the early assessment phase when learning to use the unit in practice.

17. Clinical applications besides gait training. • Forced use • Exercise equipment • Early start for proprioception and neuromuscular feedback • Using Clinician Mode

18. Programming • Select System Configuration. Select L300 Only, L300 and Thigh Hamstrings, or L300 and Thigh Quadriceps.

19. Programming • Program Stim Settings. Press Stim and the L300 tab. Adjust stim settings. Press Test to turn on stimulation. Press Stop to stop stimulation. • Program Gait Settings. Press Gait and the L300 tab. Adjust gait settings. Press Test to turn on stimulation in the L300 only. Press Stop to stop stimulation.

20. Programming • Program Stim Settings. Press Stim and the Thigh tab. Adjust stim settings. Press Test to turn on stimulation. Press Stop to stop stimulation. • Program Gait Settings. Press Gait and the Thigh tab. Adjust gait settings. Press Start to turn on stimulation in both FS Cuffs. Press Stop to stop stimulation.

21. Using the Training Program

22. Patient Case • 49 year old male. • Fairly healthy, only being treated medically for HTN prior to a severe Right Basal Ganglion hemorrhage back in 2011. • Acute hospital stay was complicated with hemorrhage extension and shift, which required craniotomy and intraventricular catheter and burr hole placement. • Subsequent respiratory failure with prolonged period of ventilation.

23. Patient Case • Once stabilized after a lengthy stay in Long Term Acute Care he presented for Acute Rehabilitation at Spalding Rehabilitation Hospital. • Prior to his stroke he was completely Independent and working fulltime as a Realtor. • Lives with his wife and two teenage daughters in a single story home with 4 steps to enter

24. Evaluation findings • Dependent for bed mobility, transfers, gait and stair mobility. • Dense L hemiparesis with impaired sensation and proprioception. • Midline deficit with L inattention • L flexion synergy both in upper and lower extremities. • Significant cognitive involvement with difficulty speaking and swallowing.

25. Plan of care • Neuromuscular reeducation utilizing an integrated approach of forced use, PNF, NDT and motor control/learning paradigms. • Primary focus was on midline reorientation and improved stance control on the LLE. • Pre-gait training in conjunction with the Bioness L300 plus was completed along with BID training sessions. • Followed by extensive progressive gait training with Bioness L300 • 60 days of acute rehabilitation

26. Outcomes

27. update • Patient went on to complete 20 more visits of both day treatment program and outpatient Physical Therapy over approximately 6 months. • Now with the Bioness L300+ he is able to ambulate up to 2500’ at a time with a quad cane and Supervision.

28. Summary • Efficacy • Cost ~$10,000.00 for whole system • In Colorado, per Bioness they are averaging about a 42% approval rating through private insurance. • Medicare will cover the L300 only for an incomplete SCI diagnosis. • The VA covers 100%. • Vocational Rehabilitation covers nicely as well.

29. Now on to dr. wang