Dr EmilySplichalEmily Splichal, DPM
To attempt to address the issues of ambulatory symptoms like challenges in gait, posture, and balance, that many patients with multiple sclerosis experience, Emily Splichal, DPM, a podiatrist, and chief executive officer of Naboso Technology, has helped develop a textured insole and mat.

The textured insoles the first and only of their kind, feature 2-point discrimination that are placed across the entire insole as a way to target the mechanoreceptors, specifically the SA1-Merkel disc.

To find more about these insoles and the technology behind them, NeurologyLive® spoke with Splichal at the 2019 Annual Meeting of the Consortium of Multiple Sclerosis Centers in Seattle, Washington, May 28–June 1.

NeurologyLive®: What is Naboso Technology?

Emily Splichal, DPM: Naboso Technology is the first and only textured insole that is commercially available to help patients with chronic neurological conditions improve balance, posture, and gait. We have insoles and then we also have mats that are used in rehabilitation and at home for patient use.

How is this technology applied to patients with multiple sclerosis and how does it work?

A big belief around Naboso is that the more that we can connect to our foundation, which is our feet, it's the only contact point between the body and the ground, the overall improvement we can have in our balance, in our sense of movement, and in our coordination.

We use texture or what's called 2-point discrimination as a way to access the nerves in the bottom of the feet. All of our insoles have textures or 2 points that are across the entire insole. The height the shape, and the distance of each of those textures is very specific to stimulate a specific nerve in the bottom of the feet that is similar to Braille.

What do clinicians need to know about this and how they can potentially apply it to their clinical practice?

All of the Naboso insoles are very thin in design so they are low barrier to entry, they can fit into any shoes, seemingly a very simple product, simple intervention, but the effect is really profound. As I mentioned the specificity of the stimulation of the nerves helps the patient reconnect to their foundation. Many patients with multiple sclerosis start to feel a loss of that sensation, whether it's a true neuropathic presentation or they're just starting to get decreased sensation, and then you compound that with foot drop and now you start to see fear of falling, instability, maybe a history of falls, so by bringing in that reconnection to the feet, you're giving confidence back to that patient.

You can actually see changes in static balance and you can see changes in their gait, whether it's subjective from the patient saying I feel more confident when I'm walking, to an actual objective change of stride symmetry or decreased hesitation when they turn or decreased hesitation when they have to navigate an object, a lot of that is because you're simply reconnecting to their foundation which is the feet and again we're using a texture that the brain recognizes so it's very specific, it's intended to be specific, and that's really why we're getting the results of what we see.

From a more technical standpoint, what should the community know about the intricacies of how this works?

The skin on the bottom of the feet have nerves that are called mechanoreceptors, so it's a little bit different than proprioceptors, these mechanoreceptors are sensitive to 3 main stimuli, but there's 4 main mechanoreceptors. The one that we're going after is the SA1-Merkel disc which is sensitive to 2-point discrimination.

The spatial acuity of the SA1-Merkel disc is 1 mm, so again using Braille as an analogy, if you think of the shape and the distance of Braille, it's very similar to what you see on the Naboso products, the SA1 receptor is also the most superficial so it's the receptor in the feet or the hands that is the closest to the ground, and by having 2-point discrimination across the entire insole and stimulating the SA1 receptor we are giving a texture that the brain recognizes. If the stimuli was too far apart, meaning each texture was greater than 1 mm, we would probably not get the effects of what we see, also having that SA1 receptor really allows you to gauge how the patient is going to respond to it. We have 3 different levels of stimulus but all of them carry the same 2-point discrimination, 1 mm apart from each stimuli so you know exactly what you're trying to target with that patient.

Is there a specific subgroup within multiple sclerosis these insoles work best for?

With Naboso insoles don't think your patient has to have neuropathy or decreased sensation to benefit from the insoles, really every patient, every individual, needs to reconnect to their feet. Some of the neurologists that are using the Naboso insoles they'll start to think of them when they know their patient has decreased vibratory sensation or decreased plantar sensation through Semmes-Weinstein, so they'll do certain tests and then validate or confirm that a patient is starting to lose sensation. That is one application but I wouldn't limit it to that aspect of multiple sclerosis, I would say the earlier you bring stimulation to a patient or to the feet and to the nerves of the feet, thinking neuroplasticity, that they're just going to continuously adapt to that stimulus and stay connected to their feet, it may help them on the earlier side of things versus waiting until they're too far progressed to see any of those changes. This goes for every neurological condition, you don't have to have decreased sensation to benefit from it, reconnecting to your foundation overall for every single patient and every single foot type is important.

Where can these be purchased?

The Naboso insoles can be purchased on our website which is nabosotechnology.com and does not require a prescription. It is a Category 1 device under the FDA, so it's not restricted by certain regulations. We also do have reseller programs for doctors, physical therapists, and those who are within the healthcare industry, if they want to make it more easily accessible to patients.

Is there anything else you’d like to add?

Another important aspect is that a lot of patients with multiple sclerosis and other neurological disorders use orthotics, they might actually use ankle-foot orthosis (AFO) or something to help with foot drop, we have material that we work with orthotic labs and the orthotist can put it directly on to custom orthotics, they can put it onto the foot plates of an AFO, so you're getting the mechanical control of the orthotic or the AFO that a lot of patients need, but now we want to add this layer of sensory so that you can really combine both of those to help the patient stay solid in their foundation and reduce falls.

We are intentionally designed to be really thin and have absolutely no mechanical control which means it can be put into any shoe, any orthotic, any AFO, any prosthetic that the patient might be using with very minimal intervention because it's 2 mm and we tried to accommodate all foot types, foot widths, and foot shapes through the different sizes that we have and then the material can be easily cut to accommodate for that patient.

Transcript edited for clarity.

For more coverage of CMSC 2019, click here.