FES cycling

OIDA: An optimal interval detection algorithm for automatized determination of stimulation patterns for FES-Cycling in individuals with SCI

Background

FES-Cycling is an exciting recreational activity, which allows certain individuals after spinal cord injury or stroke to exercise their paralyzed muscles. The key for a successful application is to activate the right muscles at the right time.

Methods

While a stimulation pattern is usually determined empirically, we propose an approach using the torque feedback provided by a commercially available crank power-meter installed on a standard trike modified for FES-Cycling. By analysing the difference between active (with stimulation) and passive (without stimulation) torques along a full pedalling cycle, it is possible to differentiate between contributing and resisting phases for a particular muscle group. In this article we present an algorithm for the detection of optimal stimulation intervals and demonstrate its functionality, bilaterally for the quadriceps and hamstring muscles, in one subject with complete SCI on a home trainer. Stimulation patterns were automatically determined for two sensor input modalities: the crank-angle and a normalized thigh-angle (i.e. cycling phase, measured via inertial measurement units). In contrast to previous studies detecting automatic stimulation intervals on motorised ergo-cycles, our approach does not rely on a constant angular velocity provided by a motor, thus being applicable to the domain of mobile FES-Cycling.

Results

The algorithm was successfully able to identify stimulation intervals, individually for the subject’s left and right quadriceps and hamstring muscles. Smooth cycling was achieved without further adaptation, for both input signals (i.e. crank-angle and normalized thigh-angle).

Conclusion

The automatic determination of stimulation patterns, on basis of the positive net-torque generated during electrical stimulation, can help to reduce the duration of the initial fitting phase and to improve the quality of pedalling during a FES-Cycling session. In contrast to previous works, the presented algorithm does not rely on a constant angular velocity and thus can be effectively implemented into mobile FES-Cycling systems. As each muscle or muscle group is assessed individually, our algorithm can be used to evaluate the efficiency of novel electrode configurations and thus could promote increased performances during FES-Cycling.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-022-01018-2.

FES Cycling and Closed-Loop Feedback Control for Rehabilitative Human–Robot Interaction

For individuals with movement impairments due to neurological injuries, rehabilitative therapies such as functional electrical stimulation (FES) and rehabilitation robots hold vast potential to improve their mobility and activities of daily living. Combining FES with rehabilitation robots results in intimately coordinated human–robot interaction. An example of such interaction is FES cycling, where motorized assistance can provide high-intensity and repetitive practice of coordinated limb motion, resulting in physiological and functional benefits. In this paper, the development of multiple FES cycling testbeds and safeguards is described, along with the switched nonlinear dynamics of the cycle–rider system. Closed-loop FES cycling control designs are described for cadence and torque tracking. For each tracking objective, the authors’ past work on robust and adaptive controllers used to compute muscle stimulation and motor current inputs is presented and discussed. Experimental results involving both able-bodied individuals and participants with neurological injuries are provided for each combination of controller and tracking objective. Trade-offs for the control algorithms are discussed based on the requirements for implementation, desired rehabilitation outcomes and resulting rider performance. Lastly, future works and the applicability of the developed methods to additional technologies including teleoperated robotics are outlined.

Electrical stimulator with mechanomyography-based real-time monitoring, muscle fatigue detection, and safety shut-off: a pilot study

Functional electrical stimulation (FES) has been used to produce force-related activities on the paralyzed muscle among spinal cord injury (SCI) individuals. Early muscle fatigue is an issue in all FES applications. If not properly monitored, overstimulation can occur, which can lead to muscle damage. A real-time mechanomyography (MMG)-based FES system was implemented on the quadriceps muscles of three individuals with SCI to generate an isometric force on both legs. Three threshold drop levels of MMG-root mean square (MMG-RMS) feature (thr50, thr60, and thr70; representing 50%, 60%, and 70% drop from initial MMG-RMS values, respectively) were used to terminate the stimulation session. The mean stimulation time increased when the MMG-RMS drop threshold increased (thr50: 22.7 s, thr60: 25.7 s, and thr70: 27.3 s), indicating longer sessions when lower performance drop was allowed. Moreover, at thr70, the torque dropped below 50% from the initial value in 14 trials, more than at thr50 and thr60. This is a clear indication of muscle fatigue detection using the MMG-RMS value. The stimulation time at thr70 was significantly longer (p = 0.013) than that at thr50. The results demonstrated that a real-time MMG-based FES monitoring system has the potential to prevent the onset of critical muscle fatigue in individuals with SCI in prolonged FES sessions.

Supporting front crawl swimming in paraplegics using electrical stimulation: a feasibility study

Background

Participation in physical and therapeutic activities is usually severely restricted after a spinal cord injury (SCI). Reasons for this are the associated loss of voluntary motor function, inefficient temperature regulation of the affected extremities, and early muscle fatigue. Hydrotherapy or swim training offer an inherent weight relief, reduce spasticity and improve coordination, muscle strength and fitness.

Methods

We present a new hybrid exercise modality that combines functional electrical stimulation (FES) of the knee extensors and transcutaneous spinal cord stimulation (tSCS) with paraplegic front crawl swimming. tSCS is used to stimulate the afferent fibers of the L2–S2 posterior roots for spasticity reduction. By activating the tSCS, the trunk musculature is recruited at a motor level. This shall improve trunk stability and straighten the upper body. Within this feasibility study, two complete SCI subjects (both ASIA scale A, lesion level Th5/6), who have been proficient front crawl swimmers, conducted a 10-week swim training with stimulation support. In an additional assessment swim session nine months after the training, the knee extension, hip extension, and trunk roll angles where measured using waterproof inertial measurement units (IMUs) and compared for different swimming conditions (no stimulation, tSCS, FES, FES plus tSCS).

Results

For both subjects, a training effect over the 10-week swim training was observed in terms of measured lap times (16 m pool) for all swimming conditions. Swimming supported by FES reduced lap times by 15.4% and 8.7% on average for Subject A and Subject B, respectively. Adding tSCS support yielded even greater mean decreases of 19.3% and 20.9% for Subjects A and B, respectively. Additionally, both subjects individually reported that swimming with tSCS for 30–45 minutes eliminated spasticity in the lower extremities for up to 4 hours beyond the duration of the session. Comparing the median as well as the interquartile range of all different settings, the IMU-based motion analysis revealed that FES as well as FES+tSCS improve knee extension in both subjects, while hip extension was only increased in one subject. Trunk roll angles were similar for all swimming conditions. tSCS had no influence on the knee and hip joint angles. Both subjects reported that stimulation-assisted swimming is comfortable, enjoyable, and they would like to use such a device for recreational training and rehabilitation in the future.

Conclusions

Stimulation-assisted swimming seems to be a promising new form of hybrid exercise for SCI people. It is safe to use with reusable silicone electrodes and can be performed independently by experienced paraplegic swimmers except for transfer to water. The study results indicate that swimming speed can be increased by the proposed methods and spasticity can be reduced by prolonged swim sessions with tSCS and FES. The combination of stimulation with hydrotherapy might be a promising therapy for neurologic rehabilitation in incomplete SCI, stroke or multiples sclerosis patients. Therefore, further studies shall incorporate other neurologic disorders and investigate the potential benefits of FES and tSCS therapy in the water for gait and balance.

Stimulation of paralysed quadriceps muscles with sequentially and spatially distributed electrodes during dynamic knee extension

BACKGROUND

During functional electrical stimulation (FES) tasks with able-bodied (AB) participants, spatially distributed sequential stimulation (SDSS) has demonstrated substantial improvements in power output and fatigue properties compared to conventional single electrode stimulation (SES). The aim of this study was to compare the properties of SDSS and SES in participants with spinal cord injury (SCI) in a dynamic isokinetic knee extension task simulating knee movement during recumbent cycling.

METHOD

Using a case-series design, m. vastus lateralis and medialis of four participants with motor and sensory complete SCI (AIS A) were stimulated for 6 min on both legs with both electrode setups. With SES, target muscles were stimulated by a pair of electrodes. In SDSS, the distal electrodes were replaced by four small electrodes giving the same overall stimulation frequency and having the same total surface area. Torque was measured during knee extension by a dynamometer at an angular velocity of 110 deg/s. Mean power of the left and right sides (P_meanL,R) was calculated from all stimulated extensions for initial, final and all extensions. Fatigue is presented as an index value with respect to initial power from 1 to 0, whereby 1 means no fatigue.

RESULTS

SDSS showed higher P_meanL,R values for all four participants for all extensions (increases of 132% in participant P1, 100% in P2, 36% in P3 and 18% in P4 compared to SES) and for the initial phase (increases of 84%, 59%, 66%, and 16%, respectively). Fatigue resistance was better with SDSS for P1, P2 and P4 but worse for P3 (0.47 vs 0.35, 0.63 vs 0.49, 0.90 vs 0.82 and 0.59 vs 0.77, respectively).

CONCLUSION

Consistently higher P_meanL,R was observed for all four participants for initial and overall contractions using SDSS. This supports findings from previous studies with AB participants. Fatigue properties were better in three of the four participants. The lower fatigue resistance with SDSS in one participant may be explained by a very low muscle activation level in this case. Further investigation in a larger cohort is warranted.

Development of practical functional electrical stimulation cycling systems based on an electromyography study of the Cybathlon 2016

The purpose of this study was to develop a functional electrical stimulation (FES) system based on the motor driving concept for use by spinal cord injury patients participating in the FES Cycling competition at the Cybathlon 2016. The proposed FES system consists of a low-power control system, a precise processor unit, and a 4-channel stimulation unit. Self-adhesive carbon conductive electrodes were utilized for stimulation. A 26-year-old SCI patient was qualified to participate in the competition. The pilot patient underwent training for 16 months, which included experience with FES stimulation, performing FES cycling, and reducing spasticity, to practice using the FES system. In addition, using surface electromyography (EMG) during cycling, the muscle activation pattern for generating the stimulation profile was applied and resulted in good performance. The best FES cycling performance the pilot achieved was 1000 meters translation with the cycling system during twelve minutes of using the FES system. The pilot achieved an 1000 meters translation mobility within an average of 16 minutes of cycling. Nevertheless, the system must be further investigated regarding muscle fatigue and other factors that may affect the stimulation conditions.

Participation to the first Cybathlon: an overview of the FREEWHEELS team FES-cycling solution

This article is a contribution to a special issue aiming at collecting data and documenting the different specificities of the teams which participated into Cybathlon 2016 FES-bike discipline. Our team prepared one paraplegic pilot over one year and developed a FES-cycling device based on existing commercial products. Our pilot (47 y.o, spinal cord lesion T3 AIS A since year 1995) was qualified for the final race and finished in 6th position over 12 participants in the discipline, covering a total distance of 750m at an average speed of 5.71km/h, propelled by his own quadriceps and hamstrings muscles.

Power output and fatigue properties using spatially distributed sequential stimulation in a dynamic knee extension task

PURPOSE

The low power output and fatigue resistance during functional electrical stimulation (FES) limits its use for functional applications. The aim of this study was to compare the power output and fatigue properties of spatially distributed sequential stimulation (SDSS) against conventional single electrode stimulation (SES) in an isokinetic knee extension task simulating knee movement during recumbent cycling.

METHODS

M. vastus lateralis and m. vastus medialis of eight able-bodied subjects were stimulated for 6 min on both legs with both setups. In the SES setup, target muscles were each stimulated by a pair of electrodes. In SDSS, four small electrodes replaced the SES active electrodes, but reference electrodes were the same. Torque was measured during knee extension movement by a dynamometer at an angular velocity of 110°/s. Mean power (P mean) was calculated from stimulated extensions for the first 10 extensions, the final 20 extensions and overall. Fatigue is presented as an index, calculated as the decrease with respect to initial power.

RESULTS

P mean was significantly higher for SDSS than for SES in the final phase (9.9 ± 4.0 vs. 7.4 ± 4.3 W, p = 0.035) and overall (11.5 ± 4.0 vs. 9.2 ± 4.5 W, p =  0.037). With SDSS, the reduction in P mean was significantly smaller compared to SES (from 14.9 to 9.9 vs. 14.6 to 7.4 W, p = 0.024). The absolute mean pulse width was substantially lower with SDSS (62.5 vs. 90.0 µs).

CONCLUSION

Although less stimulation was applied, SDSS showed a significantly higher mean power output than SES. SDSS also had improved fatigue resistance when compared to conventional stimulation. The SDSS approach may provide substantial performance benefits for cyclical FES applications.

Towards Parameters and Protocols to Recommend FES-Cycling in Cases of Paraplegia: A Preliminary Report

Functional Electrical Stimulation assisted cycling (FES-Cycling) is increasingly becoming an alternative option recommended to people with spinal cord injury struggling with paraplegia and interested in practicing sports. In order to propose preconditions to guide FES-Cycling recommendation, we aimed to investigate some features and their potential relationships with responsiveness to Neuromuscular Electrical Stimulation (NMES). Fourteen volunteers attended a public recruitment forum to be assessed about their responsiveness through the 16-sessions of NMES. Volunteers were separated in two groups (responsive and non-responsive to NMES) which were investigated in the light of some personal, clinical, structural and functional features. Fifty seven percent of the initial sample responded to electrical stimulation with a visual contraction. This responsive group was predominantly composed by subjects presenting traumatic spinal cord injuries above T12 vertebral level. Only two subjects became responsive at the 3rd and 16th sessions. Among the observed features, the etiology and level of injuries seems to be more associated to responsiveness. Our observations seem to indicate that subjects with traumatic spinal cord injury above T12 level were the best potential candidates for FES-cycling.

A biomechanical cause of low power production during FES cycling of subjects with SCI

BACKGROUND

The goal of Functional Electrical Stimulation (FES) cycling is to provide the health benefits of exercise to persons with paralysis. To achieve the greatest health advantages, patients should produce the highest possible mechanical power. However, the mechanical power output (PO) produced during FES cycling is very low. Unfavorable biomechanics is one of the important factors reducing PO. The purpose of this study was to investigate the primary joints and muscles responsible for power generation and the role of antagonistic co-contraction in FES cycling.

METHODS

Sixteen subjects with complete spinal cord injury (SCI) pedaled a stationary recumbent FES tricycle at 60 rpm and a workload of 15 W per leg, while pedal forces and crank angle were recorded. The joint muscle moments, power and work were calculated using inverse dynamics equations.

RESULTS

Two characteristic patterns were found; in 12 subjects most work was generated by the knee extensors in the propulsion phase (83% of total work), while in 4 subjects most work was shared between by the knee extensors (42%) and flexors (44%), respectively during propulsive and recovery phases. Hip extensors produced only low net work (12 & 7%). For both patterns, extra concentric work was necessary to overcome considerable eccentric work (-82 & -96%).

CONCLUSIONS

The primary power sources were the knee extensors of the quadriceps and the knee flexors of the hamstrings. The antagonistic activity was generally low in subjects with SCI because of the weakness of the hamstrings (compared to quadriceps) and the superficial and insufficient hamstring mass activation with FES.

Functional electrical stimulation cycling in youth with spinal cord injury: A review of intervention studies

CONTEXT

Preliminary research suggests that functional electrical stimulation cycling (FESC) might be a promising intervention for youth with spinal cord injury (SCI).

OBJECTIVE

To review the evidence on FESC intervention in youth with SCI.

METHODS

Systematic literature searches were conducted during December 2012. Two reviewers independently selected titles, abstracts, and full-text articles. Of 40 titles retrieved, six intervention studies met inclusion criteria and were assessed using American Academy for Cerebral Palsy and Developmental Medicine Levels of Evidence and Conduct Questions for Group Design.

RESULTS

The study results were tabulated based on levels of evidence, with outcomes categorized according to the International Classification of Functioning, Disability, and Health framework. Evidence from the six included studies suggests that FESC is safe for youth with SCI, with no increase in knee/hip injury or hip displacement. Results from one level II randomized controlled trial suggest that a thrice weekly, 6-month FESC program can positively influence VO2 levels when compared with passive cycling, as well as quadriceps strength when compared with electrical stimulation and passive cycling.

CONCLUSIONS

FESC demonstrates limited yet encouraging results as a safe modality to mitigate effects of inactivity in youth with SCI. More rigorous research involving a greater number of participants is needed before clinicians can be confident of its effectiveness.

Evaluation of functional electrical stimulation to assist cycling in four adolescents with spastic cerebral palsy

Introduction. Adolescents with cerebral palsy (CP) often have difficulty participating in exercise at intensities necessary to improve cardiovascular fitness. Functional electrical stimulation- (FES-) assisted cycling is proposed as a form of exercise for adolescents with CP. The aims of this paper were to adapt methods and assess the feasibility of applying FES cycling technology in adolescents with CP, determine methods of performing cycling tests in adolescents with CP, and evaluate the immediate effects of FES assistance on cycling performance. Materials/Methods. Four participants (12–14 years old; GMFCS levels III-IV) participated in a case-based pilot study of FES-assisted cycling in which bilateral quadriceps muscles were activated using surface electrodes. Cycling cadence, power output, and heart rate were collected. Results. FES-assisted cycling was well tolerated (n = 4) and cases are presented demonstrating increased cadence (2–43 rpm), power output (19–70%), and heart rates (4-5%) and decreased variability (8–13%) in cycling performance when FES was applied, compared to volitional cycling without FES assistance. Some participants (n = 2) required the use of an auxiliary hub motor for assistance. Conclusions. FES-assisted cycling is feasible for individuals with CP and may lead to immediate improvements in cycling performance. Future work will examine the potential for long-term fitness gains using this intervention.