A versatile drop foot stimulator for research applications

Advances in neuroprosthetic management of foot drop: a review

This paper reviews the technological advances and clinical results obtained in the neuroprosthetic management of foot drop. Functional electrical stimulation has been widely applied owing to its corrective abilities in patients suffering from a stroke, multiple sclerosis, or spinal cord injury among other pathologies. This review aims at identifying the progress made in this area over the last two decades, addressing two main questions: What is the status of neuroprosthetic technology in terms of architecture, sensorization, and control algorithms?. What is the current evidence on its functional and clinical efficacy? The results reveal the importance of systems capable of self-adjustment and the need for closed-loop control systems to adequately modulate assistance in individual conditions. Other advanced strategies, such as combining variable and constant frequency pulses, could also play an important role in reducing fatigue and obtaining better therapeutic results. The field not only would benefit from a deeper understanding of the kinematic, kinetic and neuromuscular implications and effects of more promising assistance strategies, but also there is a clear lack of long-term clinical studies addressing the therapeutic potential of these systems. This review paper provides an overview of current system design and control architectures choices with regard to their clinical effectiveness. Shortcomings and recommendations for future directions are identified.

Technical development of transcutaneous electrical nerve inhibition using medium-frequency alternating current

Background

Innovative technical approaches to controlling undesired sensory and motor activity, such as hyperalgesia or spasticity, may contribute to rehabilitation techniques for improving neural plasticity in patients with neurologic disorders. To date, transcutaneous electrical stimulation has used low frequency pulsed currents for sensory inhibition and muscle activation. Yet, few studies have attempted to achieve motor nerve inhibition using transcutaneous electrical stimulation. This study aimed to develop a technique for transcutaneous electrical nerve inhibition (TENI) using medium-frequency alternating current (MFAC) to suppress both sensory and motor nerve activity in humans.

Methods

Surface electrodes were affixed to the skin of eight young adults to stimulate the median nerve. Stimulation intensity was increased up to 50% and 100% of the pain threshold. To identify changes in sensory perception by transcutaneous MFAC (tMFAC) stimulation, we examined tactile and pressure pain thresholds in the index and middle fingers before and after stimulation at 10 kHz. To demonstrate the effect of tMFAC stimulation on motor inhibition, stimulation was applied while participants produced flexion forces with the index and middle fingers at target forces (50% and 90% of MVC, maximum voluntary contraction).

Results

tMFAC stimulation intensity significantly increased tactile and pressure pain thresholds, indicating decreased sensory perception. During the force production task, tMFAC stimulation with the maximum intensity immediately reduced finger forces by ~ 40%. Finger forces recovered immediately after stimulation cessation. The effect on motor inhibition was greater with the higher target force (90% MVC) than with the lower target (50% MVC). Also, higher tMFAC stimulation intensity provided a greater inhibition effect on both sensory and motor nerve activity.

Conclusion

We found that tMFAC stimulation immediately inhibits sensory and motor activity. This pre-clinical study demonstrates a novel technique for TENI using MFAC stimulation and showed that it can effectively inhibit both sensory perception and motor activity. The proposed technique can be combined with existing rehabilitation devices (e.g., a robotic exoskeleton) to inhibit undesired sensorimotor activities and to accelerate recovery after neurologic injury.

Flexible adaptation to an artificial recurrent connection from muscle to peripheral nerve in man

Controlling a neuroprosthesis requires learning a novel input-output transformation; however, how subjects incorporate this into limb control remains obscure. To elucidate the underling mechanisms, we investigated the motor adaptation process to a novel artificial recurrent connection (ARC) from a muscle to a peripheral nerve in healthy humans. In this paradigm, the ulnar nerve was electrically stimulated in proportion to the activation of the flexor carpi ulnaris (FCU), which is ulnar-innervated and monosynaptically innervated from Ia afferents of the FCU, defined as the "homonymous muscle," or the palmaris longus (PL), which is not innervated by the ulnar nerve and produces similar movement to the FCU, defined as the "synergist muscle." The ARC boosted the activity of the homonymous muscle and wrist joint movement during a visually guided reaching task. Participants could control muscle activity to utilize the ARC for the volitional control of wrist joint movement and then readapt to the absence of the ARC to either input muscle. Participants reduced homonymous muscle recruitment with practice, regardless of the input muscle. However, the adaptation process in the synergist muscle was dependent on the input muscle. The activity of the synergist muscle decreased when the input was the homonymous muscle, whereas it increased when it was the synergist muscle. This reorganization of the neuromotor map, which was maintained as an aftereffect of the ARC, was observed only when the input was the synergist muscle. These findings demonstrate that the ARC induced reorganization of neuromotor map in a targeted and sustainable manner.

Probabilistic modeling of selective stimulation of the human sciatic nerve with a flat interface nerve electrode

Ankle control is critical to both standing balance and efficient walking. The hypothesis presented in this paper is that a Flat Interface Nerve Electrode (FINE) placed around the sciatic nerve with a fixed number of contacts at predetermined locations and without a priori knowledge of the nerve's underlying neuroanatomy can selectively control each ankle motion. Models of the human sciatic nerve surrounded by a FINE of varying size were created and used to calculate the probability of selective activation of axons within any arbitrarily designated, contiguous group of fascicles. Simulations support the hypothesis and suggest that currently available implantable technology cannot selectively recruit each target plantar flexor individually but can restore plantar flexion or dorsiflexion from a site on the sciatic nerve without spillover to antagonists. Successful activation of individual ankle muscles in 90% of the population can be achieved by utilizing bipolar stimulation and/or by using a cuff with at least 20 contacts.

Autogenic EMG-controlled functional electrical stimulation for ankle dorsiflexion control

Our objectives were to develop and test a new system for the potential for stable, real-time cancellation of residual stimulation artefacts (RSA) using surface electrode autogenic electromyography-controlled functional electrical stimulator (aEMGcFES). This type of closed-loop FES could be used to provide more natural, continuous control of lower extremity paretic muscles. We built upon work that has been done in the field of FES with one major technological innovation, an adaptive Gram-Schmidt filtering algorithm, which allowed us to digitally cancel RSA in real-time. This filtering algorithm resulted in a stable real-time estimation of the volitional intent of the stimulated muscle, which then acted as the direct signal for continuously controlling homonymous muscle stimulation. As a first step toward clinical application, we tested the viability of our aEMGcFES system to continuously control ankle dorsiflexion in a healthy subject. Our results indicate positively that an aEMGcFES device with adaptive filtering can respond proportionally to voluntary EMG and activate forceful movements to assist dorsiflexion during controlled isometric activation at the ankle. We also verified that normal ankle joint range of movement could be maintained while using the aEMGcFES system. We suggest that real-time cancellation of both primary and RSA is possible with surface electrode aEMGcFES in healthy subjects and shows promising potential for future clinical application to gait pathologies such as drop foot related to hemiparetic stroke.

A wearable pelvic sensor design for drop foot treatment in post-stroke patients

A novel wearable pelvic sensor design for gait analysis was developed and evaluated in both normal and pathological gait. The device is a hip worn fusion of gyroscopes and accelerometers which allows for monitoring of the periodic vertical rotation of the pelvis during the walking cycle and uses this information as a predictor of gait events such as Heel-Strike (HS) and Toe-Off (TO). The gait pattern of two age and gender-matched groups (40-65 years) of 10 healthy subjects (5 male, 5 female) and 10 subjects with hemiplegic drop foot were examined. The pelvic sensor method was correlated against an optical motion system and footswitches, to evaluate the technique's efficacy at detecting foot contact events in walking and hip pattern. Data analysis showed the device was able to predict foot contact events from recorded maximum and minimum pelvic angle (TO: Healthy - 130ms Hemiplegic - 95ms; HS: Healthy - 127ms, Hemiplegic - 96ms). This ability to detect gait events would allow this sensor design to be used in simplifying drop foot stimulation systems. The proposed method also records the relative range of motion of the pelvis from which useful information on gait symmetry can be obtained and used in ambulatory monitoring or treatment intervention analysis.

A microcontroller system for investigating the catch effect: functional electrical stimulation of the common peroneal nerve

Correction of drop foot in hemiplegic gait is achieved by electrical stimulation of the common peroneal nerve with a series of pulses at a fixed frequency. However, during normal gait, the electromyographic signals from the tibialis anterior muscle indicate that muscle force is not constant but varies during the swing phase. The application of double pulses for the correction of drop foot may enhance the gait by generating greater torque at the ankle and thereby increase the efficiency of the stimulation with reduced fatigue. A flexible controller has been designed around the Odstock Drop Foot Stimulator to deliver different profiles of pulses implementing doublets and optimum series. A peripheral interface controller (PIC) microcontroller with some external circuits has been designed and tested to accommodate six profiles. Preliminary results of the measurements from a normal subject seated in a multi-moment chair (an isometric torque measurement device) indicate that profiles containing doublets and optimum spaced pulses look favourable for clinical use.