Implanted functional electrical stimulation system for mobility in paraplegia: a follow-up case report

Reconstruction of Quadriceps Function Using a Single Functional Gracilis Muscle Transfer With an Adductor Longus Nerve to Femoral Nerve Branch of the Rectus Femoris Nerve Transfer

BACKGROUND

A femoral nerve injury may result in cutaneous sensory disturbances of the anteromedial thigh and complete paralysis of the quadriceps femoris muscles resulting in an inability to extend the knee. The traditional mainstay of treatment for femoral neuropathy is early physiotherapy, knee support devices, and pain control. Case reports have used the anterior division of the obturator nerve as a donor nerve to innervate the quadriceps femoris muscles; however, a second nerve transfer or nerve grafting is often required for improved outcomes. We suggest a novel technique of combining an innervated, pedicled gracilis transfer with an adductor longus to rectus femoris nerve transfer to restore the strength and stability of the quadriceps muscles.

METHODS

This is a case series describing the use of a pedicled gracilis muscle transposed into the rectus femoris position with a concomitant nerve transfer from the adductor longus nerve branch into the rectus femoris nerve branch to restore quadriceps function after iatrogenic injury (hip arthroplasty) and trauma (gunshot wound).

RESULTS

With electrodiagnostic confirmation of severe denervation of the quadriceps muscles and no evidence of elicitable motor units, 2 patients (average age, 47 years) underwent a quadriceps muscle reconstruction with a pedicled, innervated gracilis muscle and an adductor longus to recuts femoris nerve transfer. At 1 year follow-up, the patients achieved 4.5/5 British Medical Research Council full knee extension, a stable knee, and the ability to ambulate without an assistive aid.

CONCLUSIONS

The required amount of quadriceps strength necessary to maintain quality of life has not been accurately established. In the case of femoral neuropathy, we assumed that a nerve transfer alone and a gracilis muscle transfer alone would not provide enough stability and strength to restore quadriceps function. We believe that the restoration of the quadriceps function after femoral nerve injury can be achieved by combining an innervated, pedicled gracilis transfer with an adductor longus to rectus femoris nerve transfer with low morbidity and no donor defects.

New Stimulation Device to Drive Multiple Transverse Intrafascicular Electrodes and Achieve Highly Selective and Rich Neural Responses

Peripheral Nerve Stimulation (PNS) is a promising approach in functional restoration following neural impairments. Although it proves to be advantageous in the number of implantation sites provided compared with intramuscular or epimysial stimulation and the fact that it does not require daily placement, as is the case with surface electrodes, the further advancement of PNS paradigms is hampered by the limitation of spatial selectivity due to the current spread and variations of nerve physiology. New electrode designs such as the Transverse Intrafascicular Multichannel Electrode (TIME) were proposed to resolve this issue, but their use was limited by a lack of innovative multichannel stimulation devices. In this study, we introduce a new portable multichannel stimulator—called STIMEP—and implement different stimulation protocols in rats to test its versatility and unveil the potential of its combined use with TIME electrodes in rehabilitation protocols. We developed and tested various stimulation paradigms in a single fascicle and thereafter implanted two TIMEs. We also tested its stimulation using two different waveforms. The results highlighted the versatility of this new stimulation device and advocated for the parameterizing of a hyperpolarizing phase before depolarization as well as the use of small pulse widths when stimulating with multiple electrodes.

A Muscle-First, Electromechanical Hybrid Gait Restoration System in People With Spinal Cord Injury

The development of a hybrid system for people with spinal cord injuries is described. The system includes implanted neural stimulation to activate the user's otherwise paralyzed muscles, an exoskeleton with electromechanical actuators at the hips and knees, and a sensory and control system that integrates both components. We are using a muscle-first approach: The person's muscles are the primary motivator for his/her joints and the motors provide power assistance. This design philosophy led to the development of high efficiency, low friction joint actuators, and feed-forward, burst-torque control. The system was tested with two participants with spinal cord injury (SCI) and unique implanted stimulation systems. Torque burst addition was found to increase gait speed. The system was found to satisfy the main design requirements as laid out at the outset.

A Sensor-Based Multichannel FES System to Control Knee Joint and Reduce Stance Phase Asymmetry in Post-Stroke Gait

Most of the studies using functional electrical stimulation (FES) in gait rehabilitation have been focused on correcting the drop foot syndrome. Using FES to control the knee joint in individuals with central nervous system (CNS) disorders could also play a key role in gait recovery: spasticity decrease, higher range of motion, positive effect on balance, limiting hyperextension and flexion in stance phase, reducing joint overload, etc. In stance phase, an accurate timing and a fine tuning of stimulation parameters are however required to provide a proper control of the knee stimulation while ensuring a safe and efficient support. In this study, 11 participants were equipped with inertial measurements units (IMU) and foot pressure insoles after supratentorial ischemic or hemorrhagic stroke, informing on knee angle and gait events used to online adapt FES during a 10 m walking protocol. Asymmetry of stance time and weight bearing were monitored as well as gait quality and physiological cost through a series of relevant markers. Vertical trunk motion has been significantly reduced during gait with FES (p-value = 0.038). Despite no significant improvement of stance phase asymmetry has been found, this preliminary work shows evidence of promising technical and rehabilitative potentials of a sensor-based multichannel FES system to control knee joint in post-stroke gait.

Walking after incomplete spinal cord injury with an implanted neuromuscular electrical stimulation system and a hinged knee replacement: a single-subject study

STUDY DESIGN

Single-subject repeated measures study.

OBJECTIVES

Neuromuscular electrical stimulation (NMES) can enhance walking for people with partial paralysis from incomplete spinal cord injury (iSCI). This single-subject study documents an individual's experience who both received an experimental implanted NMES system and underwent clinical bilateral hinged total knee arthroplasty (TKA). She walked in the community with knee pain prior to either intervention. Walking performance improved with an implanted NMES system. Knee pain and instability continued to worsen over time and eventually required TKA. This study evaluates the effects of these interventions.

SETTING

Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland OH, USA.

METHODS

The differential and combined effects of NMES and hinged knee replacement were assessed in terms of walking speed, toe clearance, knee angle, and participant perceptions with and without stimulation assistance both before and after TKA.

RESULTS

The combined approach both reduced pain and restored walking ability to levels achieved prior to developing significant knee pain that prevented walking without NMES. There was an interaction effect between NMES and TKA on walking speed. Toe clearance consistently improved with stimulation assistance and TKA prevented significant knee hyperextension. The greatest impact was on endurance. Knee replacement re-enabled long distance walking with the addition of stimulation again more than doubling her maximum walking distance from 214 to 513 m.

CONCLUSIONS

These data support further research of combined implantable interventions that may benefit people with iSCI. Furthermore, joint laxity and pain may not necessarily be contraindications to NMES if addressed with conventional clinical treatments.

Wireless Electrical Stimulators and Sensors Network for Closed Loop Control in Rehabilitation

This paper presents a wireless distributed Functional Electrical Stimulation (FES) architecture. It is based on a set of, potentially heterogeneous, distributed stimulation and measurement units managed by a wearable controller. Through a proof-of-concept application, the characterization of the wireless network performances was assessed to check the adequacy of this solution with open-loop and closed-loop control requirements. We show the guaranteed time performances over the network through the control of quadriceps and hamstrings stimulation parameters based on the monitoring of the knee joint angle. Our solution intends to be a tool for researchers and therapists to develop closed-loop control algorithms and strategies for rehabilitation, allowing the design of wearable systems for a daily use context.

A speed-adaptive intraspinal microstimulation controller to restore weight-bearing stepping in a spinal cord hemisection model

OBJECTIVE

The goal of this study was to develop control strategies to produce alternating, weight-bearing stepping in a cat model of hemisection spinal cord injury (SCI) using intraspinal microstimulation (ISMS).

APPROACH

Six cats were anesthetized and the functional consequences of a hemisection SCI were simulated by manually moving one hind-limb through the gait cycle over a moving treadmill belt. ISMS activated the muscles in the other leg by stimulating motor networks in the lumbosacral enlargement using low levels of current (<110 µA). The control strategy used signals from ground reaction forces and angular velocity from the manually-moved limb to anticipate states of the gait cycle, and controlled ISMS to move the other hind-limb into the opposite state. Adaptive control strategies were developed to ensure weight-bearing at different stepping speeds. The step period was predicted using generalizations obtained through four supervised machine learning algorithms and used to adapt the control strategy for faster steps.

MAIN RESULTS

At a single speed, 100% of the steps had sufficient weight-bearing; at faster speeds without adaptation, 97.6% of steps were weight-bearing (significantly less than that for single speed; p  =  0.002). By adapting the control strategy for faster steps using the predicted step period, weight-bearing was achieved in more than 99% of the steps in three of four methods (significantly more than without adaptation p  <  0.04). Overall, a multivariate model tree increased the number of weight-bearing steps, restored step symmetry, and maintained alternation at faster stepping speeds.

SIGNIFICANCE

Through the adaptive control strategies guided by supervised machine learning, we were able to restore weight-bearing and maintain alternation and step symmetry at varying stepping speeds.

Accelerometer-based step initiation control for gait-assist neuroprostheses

Electrical activation of paralyzed musculature can generate or augment joint movements required for walking after central nervous system trauma. Proper timing of stimulation relative to residual volitional control is critical to usefully affecting ambulation. This study evaluates three-dimensional accelerometers and customized algorithms to detect the intent to step from voluntary movements to trigger stimulation during walking in individuals with significantly different etiologies, mobility limitations, manual dexterities, and walking aids. Three individuals with poststroke hemiplegia or partial spinal cord injury exhibiting varying gait deficits were implanted with multichannel pulse generators to provide joint motions at the hip, knee, and ankle. An accelerometer integrated into the external control unit was used to detect heel strike or walker movement, and wireless accelerometers were used to detect crutch strike. Algorithms were developed for each sensor location to detect intent to step to progress through individualized stimulation patterns. Testing these algorithms produced detection accuracies of at least 90% on both level ground and uneven terrain. All participants use their accelerometer-triggered implanted gait systems in the community; the validation/system testing was completed in the hospital. The results demonstrated that safe, reliable, and convenient accelerometer-based step initiation can be achieved regardless of specific gait deficits, manual dexterities, and walking aids.

Model-Based Dynamic Control Allocation in a Hybrid Neuroprosthesis

A hybrid neuroprosthesis that combines human muscle power, elicited through functional electrical stimulation (FES), with a powered orthosis may be advantageous over a sole FES or a powered exoskeleton-based rehabilitation system. The hybrid system can conceivably overcome torque reduction due to FES-induced muscle fatigue by complementarily using torque from the powered exoskeleton. The second advantage of the hybrid system is that the use of human muscle power can supplement the powered exoskeleton's power (motor torque) requirements; thus, potentially reducing the size and weight of a walking restoration system. To realize these advantages, however, it is unknown how to concurrently optimize desired control performance and allocation of control inputs between FES and electric motor. In this paper, a model predictive control-based dynamic control allocation (DCA) is used to allocate control between FES and the electric motor that simultaneously maintain a desired knee angle. The experimental results, depicting the performance of the DCA method while the muscle fatigues, are presented for an able-bodied participant and a participant with spinal cord injury. The experimental results showed that the motor torque recruited by the hybrid system was less than that recruited by the motor-only system, the algorithm can be easily used to allocate more control input to the electric motor as the muscle fatigues, and the muscle fatigue induced by the hybrid system was found to be less than the fatigue induced by sole FES. These results validate the aforementioned advantages of the hybrid system; thus implying the hybrid technology's potential use in walking rehabilitation.

Balance, gait, and falls in spinal cord injury

This chapter covers balance, gait, and falls in individuals with spinal cord injury (SCI) from a clinical perspective. First, the consequences of an SCI on functioning are explained, including etiology, clinical presentation, classification, and epidemiologic data. Then, the specific aspects of balance disorders, gait disorders, and falls are discussed with respect to motor complete (cSCI) and incomplete (iSCI) SCI. Typically, these activities are affected by impaired afferent and efferent nerves, but not by central nervous processing. Performance of daily life activities in cSCI depends on the ability to control the interaction between the center of mass and the base of support or limits of stability. In iSCI, impaired proprioception and muscle strength are important factors for completing balancing tasks and for walking. Falls are common in patients with SCI. Subsequent sections describe therapy approaches aimed at modifying balance, gait, and the risk for falls by means of therapeutic exercises, assistive devices like robots or functional electric stimulation, and environmental adaptations. The last part covers recent developments and future directions. These encompass interventions for maximizing residual neural function and regeneration of axons, as well as technical solutions like epidural or intraspinal electric stimulation, powered exoskeletons, and brain computer interfaces.

"Long-term stability of stimulating spiral nerve cuff electrodes on human peripheral nerves"

Background

Electrical stimulation of the peripheral nerves has been shown to be effective in restoring sensory and motor functions in the lower and upper extremities. This neural stimulation can be applied via non-penetrating spiral nerve cuff electrodes, though minimal information has been published regarding their long-term performance for multiple years after implantation.

Methods

Since 2005, 14 human volunteers with cervical or thoracic spinal cord injuries, or upper limb amputation, were chronically implanted with a total of 50 spiral nerve cuff electrodes on 10 different nerves (mean time post-implant 6.7 ± 3.1 years). The primary outcome measures utilized in this study were muscle recruitment curves, charge thresholds, and percent overlap of recruited motor unit populations.

Results

In the eight recipients still actively involved in research studies, 44/45 of the spiral contacts were still functional. In four participants regularly studied over the course of 1 month to 10.4 years, the charge thresholds of the majority of individual contacts remained stable over time. The four participants with spiral cuffs on their femoral nerves were all able to generate sufficient moment to keep the knees locked during standing after 2–4.5 years. The dorsiflexion moment produced by all four fibular nerve cuffs in the active participants exceeded the value required to prevent foot drop, but no tibial nerve cuffs were able to meet the plantarflexion moment that occurs during push-off at a normal walking speed. The selectivity of two multi-contact spiral cuffs was examined and both were still highly selective for different motor unit populations for up to 6.3 years after implantation.

Conclusions

The spiral nerve cuffs examined remain functional in motor and sensory neuroprostheses for 2–11 years after implantation. They exhibit stable charge thresholds, clinically relevant recruitment properties, and functional muscle selectivity. Non-penetrating spiral nerve cuff electrodes appear to be a suitable option for long-term clinical use on human peripheral nerves in implanted neuroprostheses.

Restoring standing capabilities with feedback control of functional neuromuscular stimulation following spinal cord injury

This paper reviews the field of feedback control for neuroprosthesis systems that restore advanced standing function to individuals with spinal cord injury. Investigations into closed-loop control of standing by functional neuromuscular stimulation (FNS) have spanned three decades. The ultimate goal for FNS standing control systems is to facilitate hands free standing and enabling the user to perform manual functions at self-selected leaning positions. However, most clinical systems for home usage currently only provide basic upright standing using preprogrammed stimulation patterns. To date, online modulation of stimulation to produce advanced standing functions such as balance against postural disturbances or the ability to assume leaning postures have been limited to simulation and laboratory investigations. While great technological advances have been made in biomechanical sensing and interfaces for neuromuscular stimulation, further progress is still required for finer motor control by FNS. Another major challenge is the development of sophisticated control schemes that produce the necessary postural adjustments, adapt against accelerating muscle fatigue, and consider volitional actions of the intact upper-body of the user. Model-based development for novel control schemes are proven and sensible approaches to prototype and test the basic operating efficacy of potentially complex and multi-faceted control systems. The major considerations for further innovation of such systems are summarized in this paper prior to describing the evolution of closed-loop FNS control of standing from previous works. Finally, necessary emerging technologies to for implementing FNS feedback control systems for standing are identified. These technological advancements include novel electrodes that more completely and selectively activate paralyzed musculature and implantable sensors and stimulation modules for flexible neuroprosthesis system deployment.

Intraspinal microstimulation produces over-ground walking in anesthetized cats

OBJECTIVE

Spinal cord injury causes a drastic loss of motor, sensory and autonomic function. The goal of this project was to investigate the use of intraspinal microstimulation (ISMS) for producing long distances of walking over ground. ISMS is an electrical stimulation method developed for restoring motor function by activating spinal networks below the level of an injury. It produces movements of the legs by stimulating the ventral horn of the lumbar enlargement using fine penetrating electrodes (≤50 μm diameter).

APPROACH

In each of five adult cats (4.2-5.5 kg), ISMS was applied through 16 electrodes implanted with tips targeting lamina IX in the ventral horn bilaterally. A desktop system implemented a physiologically-based control strategy that delivered different stimulation patterns through groups of electrodes to evoke walking movements with appropriate limb kinematics and forces corresponding to swing and stance. Each cat walked over an instrumented 2.9 m walkway and limb kinematics and forces were recorded.

MAIN RESULTS

Both propulsive and supportive forces were required for over-ground walking. Cumulative walking distances ranging from 609 to 835 m (longest tested) were achieved in three animals. In these three cats, the mean peak supportive force was 3.5 ± 0.6 N corresponding to full-weight-support of the hind legs, while the angular range of the hip, knee, and ankle joints were 23.1 ± 2.0°, 29.1 ± 0.2°, and 60.3 ± 5.2°, respectively. To further demonstrate the viability of ISMS for future clinical use, a prototype implantable module was successfully implemented in a subset of trials and produced comparable walking performance.

SIGNIFICANCE

By activating inherent locomotor networks within the lumbosacral spinal cord, ISMS was capable of producing bilaterally coordinated and functional over-ground walking with current amplitudes <100 μA. These exciting results suggest that ISMS may be an effective intervention for restoring functional walking after spinal cord injury.

Functional electrical stimulation and spinal cord injury

Spinal cord injuries (SCI) can disrupt communications between the brain and the body, resulting in loss of control over otherwise intact neuromuscular systems. Functional electrical stimulation (FES) of the central and peripheral nervous system can use these intact neuromuscular systems to provide therapeutic exercise options to allow functional restoration and to manage medical complications following SCI. The use of FES for the restoration of muscular and organ functions may significantly decrease the morbidity and mortality following SCI. Many FES devices are commercially available and should be considered as part of the lifelong rehabilitation care plan for all eligible persons with SCI.

A preliminary comparison of myoelectric and cyclic control of an implanted neuroprosthesis to modulate gait speed in incomplete SCI

OBJECTIVE

Explore whether electromyography (EMG) control of electrical stimulation for walking after incomplete spinal cord injury (SCI) can affect ability to modulate speed and alter gait spatial-temporal parameters compared to cyclic repetition of pre-programmed stimulation.

DESIGN

Single case study with subject acting as own concurrent control. Setting Hospital-based biomechanics laboratory.

PARTICIPANTS

Single subject with C6 AIS D SCI using an implanted neuroprosthesis for walking. Interventions Lower extremity muscle activation via an implanted system with two different control methods: (1) pre-programmed pattern of stimulation, and (2) EMG-controlled stimulation based on signals from the gastrocnemius and quadriceps.

OUTCOME MEASURES

Gait speed, distance, and subjective rating of difficulty during 2-minute walks. Range of walking speeds and associated cadences, stride lengths, stride times, and double support times during quantitative gait analysis.

RESULTS

EMG control resulted in statistically significant increases in both walking speed and distance (P < 0.001) over cyclic stimulation during 2-minute walks. Maximum walking speed with EMG control (0.48 m/second) was significantly (P < 0.001) faster than the fastest automatic pattern (0.39 m/second), with increased cadence and decreased stride and double support times (P < 0.000) but no change in stride length (z = -0.085; P = 0.932). The slowest walking with EMG control (0.25 m/second) was virtually indistinguishable from the slowest with automatic cycling (z = -0.239; P = 0.811).

CONCLUSION

EMG control can increase the ability to modulate comfortable walking speed over pre-programmed cyclic stimulation. While control methods did not differ at the lowest speed, EMG-triggered stimulation allowed significantly faster walking than cyclic stimulation. The expanded range of available walking speeds could permit users to better avoid obstacles and naturally adapt to various environments. Further research is required to definitively determine the robustness, generalizability, and functional implications of these results.

Inverted Pendulum Standing Apparatus for Investigating Closed-Loop Control of Ankle Joint Muscle Contractions during Functional Electrical Stimulation

The restoration of arm-free standing in individuals with paraplegia can be facilitated via functional electrical stimulation (FES). In developing adequate control strategies for FES systems, it remains challenging to test the performance of a particular control scheme on human subjects. In this study, we propose a testing platform for developing effective control strategies for a closed-loop FES system for standing. The Inverted Pendulum Standing Apparatus (IPSA) is a mechanical inverted pendulum, whose angular position is determined by the subject's ankle joint angle as controlled by the FES system while having the subject's body fixed in a standing frame. This approach provides a setup that is safe, prevents falling, and enables a research and design team to rigorously test various closed-loop controlled FES systems applied to the ankle joints. To demonstrate the feasibility of using the IPSA, we conducted a case series that employed the device for studying FES closed-loop controllers for regulating ankle joint kinematics during standing. The utilized FES system stimulated, in able-bodied volunteers, the plantarflexors as they prevent toppling during standing. Four different conditions were compared, and we were able to show unique performance of each condition using the IPSA. We concluded that the IPSA is a useful tool for developing and testing closed-loop controlled FES systems for regulating ankle joint position during standing.

Implanted neuroprosthesis for restoring arm and hand function in people with high level tetraplegia

OBJECTIVE

To develop and apply an implanted neuroprosthesis to restore arm and hand function to individuals with high level tetraplegia.

DESIGN

Case study.

SETTING

Clinical research laboratory.

PARTICIPANTS

Individuals with spinal cord injuries (N=2) at or above the C4 motor level.

INTERVENTIONS

The individuals were each implanted with 2 stimulators (24 stimulation channels and 4 myoelectric recording channels total). Stimulating electrodes were placed in the shoulder and arm, being, to our knowledge, the first long-term application of spiral nerve cuff electrodes to activate a human limb. Myoelectric recording electrodes were placed in the head and neck areas.

MAIN OUTCOME MEASURES

Successful installation and operation of the neuroprosthesis and electrode performance, range of motion, grasp strength, joint moments, and performance in activities of daily living.

RESULTS

The neuroprosthesis system was successfully implanted in both individuals. Spiral nerve cuff electrodes were placed around upper extremity nerves and activated the intended muscles. In both individuals, the neuroprosthesis has functioned properly for at least 2.5 years postimplant. Hand, wrist, forearm, elbow, and shoulder movements were achieved. A mobile arm support was needed to support the mass of the arm during functional activities. One individual was able to perform several activities of daily living with some limitations as a result of spasticity. The second individual was able to partially complete 2 activities of daily living.

CONCLUSIONS

Functional electrical stimulation is a feasible intervention for restoring arm and hand functions to individuals with high tetraplegia. Forces and movements were generated at the hand, wrist, elbow, and shoulder that allowed the performance of activities of daily living, with some limitations requiring the use of a mobile arm support to assist the stimulated shoulder forces.

Voluntary EMG-to-force estimation with a multi-scale physiological muscle model

BACKGROUND

EMG-to-force estimation based on muscle models, for voluntary contraction has many applications in human motion analysis. The so-called Hill model is recognized as a standard model for this practical use. However, it is a phenomenological model whereby muscle activation, force-length and force-velocity properties are considered independently. Perreault reported Hill modeling errors were large for different firing frequencies, level of activation and speed of contraction. It may be due to the lack of coupling between activation and force-velocity properties. In this paper, we discuss EMG-force estimation with a multi-scale physiology based model, which has a link to underlying crossbridge dynamics. Differently from the Hill model, the proposed method provides dual dynamics of recruitment and calcium activation.

METHODS

The ankle torque was measured for the plantar flexion along with EMG measurements of the medial gastrocnemius (GAS) and soleus (SOL). In addition to Hill representation of the passive elements, three models of the contractile parts have been compared. Using common EMG signals during isometric contraction in four able-bodied subjects, torque was estimated by the linear Hill model, the nonlinear Hill model and the multi-scale physiological model that refers to Huxley theory. The comparison was made in normalized scale versus the case in maximum voluntary contraction.

RESULTS

The estimation results obtained with the multi-scale model showed the best performances both in fast-short and slow-long term contraction in randomized tests for all the four subjects. The RMS errors were improved with the nonlinear Hill model compared to linear Hill, however it showed limitations to account for the different speed of contractions. Average error was 16.9% with the linear Hill model, 9.3% with the modified Hill model. In contrast, the error in the multi-scale model was 6.1% while maintaining a uniform estimation performance in both fast and slow contractions schemes.

CONCLUSIONS

We introduced a novel approach that allows EMG-force estimation based on a multi-scale physiology model integrating Hill approach for the passive elements and microscopic cross-bridge representations for the contractile element. The experimental evaluation highlights estimation improvements especially a larger range of contraction conditions with integration of the neural activation frequency property and force-velocity relationship through cross-bridge dynamics consideration.

Stance controlled knee flexion improves stimulation driven walking after spinal cord injury

Background

Functional neuromuscular stimulation (FNS) restores walking function after paralysis from spinal cord injury via electrical activation of muscles in a coordinated fashion. Combining FNS with a controllable orthosis to create a hybrid neuroprosthesis (HNP) has the potential to extend walking distance and time by mechanically locking the knee joint during stance to allow knee extensor muscle to rest with stimulation turned off. Recent efforts have focused on creating advanced HNPs which couple joint motion (e.g., hip and knee or knee and ankle) to improve joint coordination during swing phase while maintaining a stiff-leg during stance phase.

Methods

The goal of this study was to investigate the effects of incorporating stance controlled knee flexion during loading response and pre-swing phases on restored gait. Knee control in the HNP was achieved by a specially designed variable impedance knee mechanism (VIKM). One subject with a T7 level spinal cord injury was enrolled and served as his own control in examining two techniques to restore level over-ground walking: FNS-only (which retained a stiff knee during stance) and VIKM-HNP (which allowed controlled knee motion during stance). The stimulation pattern driving the walking motion remained the same for both techniques; the only difference was that knee extensor stimulation was constant during stance with FNS-only and modulated together with the VIKM to control knee motion during stance with VIKM-HNP.

Results

Stance phase knee angle was more natural during VIKM-HNP gait while knee hyperextension persisted during stiff-legged FNS-only walking. During loading response phase, vertical ground reaction force was less impulsive and instantaneous gait speed was increased with VIKM-HNP, suggesting that knee flexion assisted in weight transfer to the leading limb. Enhanced knee flexion during pre-swing phase also aided flexion during swing, especially when response to stimulation was compromised.

Conclusions

These results show the potential advantages of incorporating stance controlled knee flexion into a hybrid neuroprosthesis for walking. The addition of such control to FNS driven walking could also enable non-level walking tasks such as uneven terrain, slope navigation and stair descent where controlled knee flexion during weight bearing is critical.

Brain-Computer Interface-FES Integration: Towards a Hands-free Neuroprosthesis Command System

This paper presents a critical review of brain-computer interfaces (BCIs) and their potential for neuroprosthetic applications. Summaries are provided for the command interface requirements of hand grasp, multijoint, and lower extremity neuroprostheses, and the characteristics of various BCIs are discussed in relation to these requirements. The review highlights the current limitations of BCIs and areas of research that need to be addressed to enhance BCI-FES integration.

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.

Radio frequency identification: the big role player in health care management

Purpose

This paper seeks to review the fundamental concepts of radio frequency identification (RFID) and to discuss the fact that the road to success for healthcare systems is the thorough management of patients, employees, equipment, medications, and records throughout the industry. Thereafter, it aims to prepare a deep review of the technology, study seven new cases on the topic of healthcare management and deliver a broad applications area thereof.

Design/methodology/approach

The paper identifies key elements of RFID through the review of healthcare management literature and case studies. For this purpose, seven cases from the healthcare industry are reviewed to demonstrate the extent of the applications of RFID in this area.

Findings

To make healthcare management systems functional and successfully operational, RFID solutions can be used to reduce operating costs through management of patients, employees, equipment, medications, and records to improve tracking and tracing, and preventing the lost of resources under any circumstances.

Originality/value

This paper delivers a review of RFID on the healthcare industry. For this reason, the basic and key point on RFID technology is discussed and seven cases from the literature are reviewed.

Posture shifting after spinal cord injury using functional neuromuscular stimulation--a computer simulation study

The ability for individuals with spinal cord injury (SCI) to affect changes in standing posture with functional neuromuscular stimulation (FNS) was explored using an anatomically inspired musculoskeletal model of the trunk, pelvis and lower extremities (LE). The model tracked trajectories for anteriorly and laterally shifting movements away from erect stance. Forces were applied to both shoulders to represent upper extremity (UE) interaction with an assistive device (e.g., a walker). The muscle excitations required to execute shifting maneuvers with UE forces <10% body-weight (BW) were determined via dynamic optimization. Nine muscle sets were examined to maximize control of shifting posture. Inclusion of the Psoas and External Obliques bilaterally resulted in the least relative UE effort (0.119, mean UE effort = 45.3N ≡ 5.4% BW) for anterior shifting. For lateral shifting, the set including the Psoas and Latissimus Dorsi bilaterally yielded the best performance (0.025, mean UE effort = 27.8 N ≡ 3.3% BW). However, adding the Psoas alone bilaterally competed favorably in overall best performance across both maneuvers. This study suggests suitable activation to specific muscles of the trunk and LE can enable individuals with SCI to alter their standing postures with minimal upper-body effort and subsequently increase reach and standing work volume.

Multiscale modeling of skeletal muscle properties and experimental validations in isometric conditions

In this article, we describe an approach to model the electromechanical behavior of the skeletal muscle based on the Huxley formulation. We propose a model that complies with a well established macroscopic behavior of striated muscles where force-length, force-velocity, and Mirsky-Parmley properties are taken into account. These properties are introduced at the microscopic scale and related to a tentative explanation of the phenomena. The method used integrates behavior ranging from the microscopic to the macroscopic scale, and allows the computation of the dynamics of the output force and stiffness controlled by EMG or stimulation parameters. The model can thus be used to simulate and carry out research to develop control strategies using electrical stimulation in the context of rehabilitation. Finally, through animal experiments, we estimated model parameters using a Sigma Point Kalman Filtering technique and dedicated experimental protocols in isometric conditions and demonstrated that the model can accurately simulate individual variations and thus take into account subject dependent behavior.

Walking after partial paralysis assisted with EMG-triggered or switch-triggered functional electrical stimulation--two case studies

Functional Electrical Stimulation (FES) facilitates walking after paralysis by activating the muscles of the lower extremities. The FES-assisted stepping triggered either by a manual switch (switch-trigger), or by an electromyogram-based gait event detector (EMG-trigger) were presented in random order to two subjects with incomplete spinal cord injuries (iSCI) during ten trials over two alternate days. Subject iSCI-1 (C6 ASIA C) was non-ambulatory without the assistance of FES and could stand but not initiate a step volitionally. Subject iSCI-2 (T1 ASIA D) could walk only short distances with great difficulty without FES. Gait kinematics and kinetics were captured during FES-assisted over-ground walking with a rolling walker under laboratory conditions. Gait parameters including speed, left and right step length, left and right double support duration, left and right swing phase durations were extracted from the kinematic data. Mean, standard deviation, coefficient of variation, and 95% confidence interval were computed for each gait parameter under each triggering condition. The ground reaction forces were recorded for both the subjects while upper body support provided by the instrumented walker was recorded for iSCI-2. One way analysis of variance (ANOVA) was performed to determine whether significant differences existed in gait parameters between command sources. The left and right double support duration were significantly lower (p<0.05) during EMG-triggered gait than switch-triggered for iSCI-1. The average normal ground reaction force was significantly (p<0.05) higher during EMG-triggered gait than switch-triggered for iSCI-1 and iSCI-2. The average body weight support on the walker was significantly lower for EMG-triggered gait than switch-triggered one for iSCI-2. The results suggest that less user effort was needed when walking with EMG-triggered stepping than with manual switch trigger.

Design and testing of an advanced implantable neuroprosthesis with myoelectric control

An implantable stimulator-telemeter (IST-12) was developed for applications in neuroprosthetic restoration of limb function in paralyzed individuals. The IST-12 provides 12 stimulation channels and two myoelectric signal (MES) channels. The MES circuitry includes a two-channel multiplexer, preamplifier, variable gain amplifier/bandpass filter, full-wave rectifier, and bin integrator. Power and control signals are transmitted from an external control unit to the IST-12 through an inductive link. Recorded MES signals are telemetered back to the external control unit through the same inductive link. Following bench testing, one device was implanted chronically in a dog for 15 months and evaluated. Conditions were identified in which MES could be recorded with minimal stimulus artifact. The ability to record MES in the presence of stimulation was verified, confirming the potential of the IST-12 to be used as a myoelectric controlled neuroprosthesis.

Fascicular anatomy of human femoral nerve: implications for neural prostheses using nerve cuff electrodes

Clinical interventions to restore standing or stepping by using nerve cuff stimulation require a detailed knowledge of femoral nerve neuroanatomy. We harvested eight femoral nerves with all distal branches and characterized the branching patterns and diameters. The fascicular representation of each distal nerve was identified and traced proximally to create fascicle maps of the compound femoral nerve in four cadaver specimens. Distal nerves were consistently represented as individual fascicles or distinct groups of fascicles in the compound femoral nerve. Branch-free length of the compound femoral nerve was 1.50 +/- 0.47 cm (mean +/- standard deviation). Compound femoral nerve cross sections were noncircular with major and minor diameters of 10.50 +/- 1.52 mm and 2.30 +/- 0.63 mm, respectively. In vivo intraoperative measurements in six subjects were consistent with cadaver results. Selective stimulation of individual muscles innervated by the femoral nerve may therefore be possible with a single neural prosthesis able to selectively stimulate individual groups of fascicles.

Gait initiation with electromyographically triggered electrical stimulation in people with partial paralysis

Functional electrical stimulation (FES) facilitates ambulatory function after paralysis by activating the muscles of the lower extremities. Individuals with incomplete spinal cord injury (iSCI) retain partial volitional control of muscles below the level of injury, necessitating careful integration of FES with intact voluntary motor function for efficient walking. The FES-assisted stepping can be triggered automatically at a fixed rate (autotrigger), by a manual switch (switch-trigger), or by an electromyogram-based gait-event-detector (EMG-trigger). It has been postulated that EMG may be a more natural command source than manual switches, and therefore will enable better coordination of stimulated and volitional motor functions necessary during gait. In this study, the above stated hypothesis was investigated in two volunteers with iSCI during the over-ground FES-assisted gait initiation. Four able-bodied volunteers provided the normative data for comparison. The EMG-triggered FES-assisted gait initiation was found to be more coordinated and dynamically more stable than autotriggered and switch-triggered cases. This highlighted the potential of surface EMG as a natural command interface to better coordinate stimulated and volitional muscle activities during gait.

Single channel hybrid FES gait system using an energy storing orthosis: preliminary design

A new system for paraplegic gait by electrical stimulation is presented. The system combines electrical stimulation of the paralyzed quadriceps muscle with a hip-knee orthosis. The orthosis is spring-loaded and contains pneumatic components that store and transfer the energy from knee extension caused by quadriceps stimulation to a pneumatic actuator that drives hip motion. In this manner, cyclic hip and knee motion with arbitrary timing can be achieved using a single channel of surface stimulation. Previous work developed a dynamic model and bench top prototype of the energy storing system. Simulation and design prototypes are presented with the eventual goal of developing a wearable version of the complete gait system.

Development of an implanted intramuscular EMG-triggered FES system for ambulation after incomplete spinal cord injury

Ambulation after spinal cord injury is possible with the aid of neuroprosthesis employing functional electrical stimulation (FES). Individuals with incomplete spinal cord injury (iSCI) retain partial volitional control of muscles below the level of injury, necessitating careful integration of FES with intact voluntary motor function for efficient walking. In this study, the intramuscular electromyogram (iEMG) was used to detect the intent to step and trigger FES-assisted walking in a volunteer with iSCI via an implanted neuroprosthesis consisting of two channels of bipolar iEMG signal acquisition and 12 independent channels of stimulation. The detection was performed with two types of classifiers- a threshold-based classifier that compared the running mean of the iEMG with a discrimination threshold to generate the trigger and a pattern recognition classifier that compared the time-history of the iEMG with a specified template of activity to generate the trigger whenever the cross-correlation coefficient exceeded a discrimination threshold. The pattern recognition classifier generally outperformed the threshold-based classifier, particularly with respect to minimizing False Positive triggers. The overall True Positive rates for the threshold-based classifier were 61.6% and 87.2% for the right and left steps with overall False Positive rates of 38.4% and 33.3%. The overall True Positive rates for the left and right step with the pattern recognition classifier were 57.2% and 93.3% and the overall False Positive rates were 11.9% and 24.4%. The subject showed no preference for either the threshold or pattern recognition-based classifier as determined by the Usability Rating Scale (URS) score collected after each trial and both the classifiers were perceived as moderately easy to use.

Alternative foot placements for individuals with spinal cord injuries standing with the assistance of functional neuromuscular stimulation

This study investigated the effects of altering foot placement for two individuals with spinal cord injuries (SCI) that stood using functional neuromuscular stimulation (FNS) as compared to an able-bodied subject group. FNS-assisted standers used parallel bars as needed for support, while the able-bodied group stood hands-free. Three different foot placements were tested: side-by-side, wide, and modified tandem. For SCI subjects, the percentage of body weight loaded on the feet was not greatly affected by foot placement, which potentially could be altered to provide postural benefits during functional tasks. Anterior/posterior (A/P) center of pressure (COP) origins tended to be located more anterior in the base of support for SCI subjects as compared to able-bodied subjects. SCI subjects also tended to have medial/lateral (M/L) COP excursions that were larger than able-bodied subjects. The sacrum appeared to hold some promise as a sensor location for monitoring A/P postural sway, but movements in the M/L direction were inconsistent and will require additional study. General guidelines such as positioning the A/P COP more posterior in the base of support and feedback concerning excessive M/L COP displacements may be useful to improve standing performance for SCI subjects. In addition, the modified tandem placement was an effective alternative for making postural adjustments in one SCI subject who experienced excessive right knee flexion with other foot placements.

Functional electrical stimulation after spinal cord injury: current use, therapeutic effects and future directions

Repair of the injured spinal cord by regeneration therapy remains an elusive goal. In contrast, progress in medical care and rehabilitation has resulted in improved health and function of persons with spinal cord injury (SCI). In the absence of a cure, raising the level of achievable function in mobility and self-care will first and foremost depend on creative use of the rapidly advancing technology that has been so widely applied in our society. Building on achievements in microelectronics, microprocessing and neuroscience, rehabilitation medicine scientists have succeeded in developing functional electrical stimulation (FES) systems that enable certain individuals with SCI to use their paralyzed hands, arms, trunk, legs and diaphragm for functional purposes and gain a degree of control over bladder and bowel evacuation. This review presents an overview of the progress made, describes the current challenges and suggests ways to improve further FES systems and make these more widely available.

Neuromuscular electrical stimulation induced forelimb movement in a rodent model

Upper extremity neuromuscular electrical stimulation (FNS) has long been utilized as a neuroprosthesis to restore hand-grasp function in individuals with neurological disorders and injuries. More recently, electrical stimulation is being used as a rehabilitative therapy to tap into central nervous system plasticity. Here, we present initial development of a rodent model for neuromuscular stimulation induced forelimb movement that can be used as a platform to investigate stimulation-induced plasticity. The motor points for flexors and extensors of the shoulder, elbow, and digits were identified and implanted with custom-built stimulation electrodes. The strength-duration curves were determined and from these curves the appropriate stimulation parameters required to produce consistent isolated contraction of each muscle with adequate joint movement were determined. Using these parameters and previous locomotor EMG data, stimulation was performed on each joint muscle pair to produce reciprocal flexion/extension movements in the shoulder, elbow, and digits, while 3D joint kinematics were assessed. Additionally, co-stimulation of multiple muscles across multiple forelimb joints was performed to produce stable multi-joint movements similar to those observed during reach-grasp-release movements. Future work will utilize this model to investigate the efficacy and underlying mechanisms of forelimb neuromuscular stimulation therapy to promote recovery and plasticity after neural injury in rodents.

Strategies for generating prolonged functional standing using intramuscular stimulation or intraspinal microstimulation

Spinal cord injury (SCI) often results in the loss of the ability to stand. The goal of this study was to implement a functional electrical stimulation (FES) system for restoring prolonged periods of standing after SCI. For this purpose, we tested two control strategies: open-loop and closed-loop control, and two stimulation paradigms: non-interleaved intramuscular stimulation (IM-S) and interleaved intraspinal microstimulation (ISMS). The experiments were conducted in anesthetized cats. Stimulation was applied to the muscles through IM-S electrodes implanted in the main knee and ankle extensor muscles, or to the spinal cord through ultra-fine ISMS wires implanted within the ventral horn of the lumbosacral enlargement. The cats were partially supported over parallel force plates and accelerometers were secured to the hindlimbs above and below the ankle joint. Ground reaction forces and knee and ankle joint angles were measured by the force plates and accelerometers, respectively. The closed-loop controller used these feedback signals to modulate the amplitude of stimulation applied to the extensor muscles. The open-loop controller applied constant levels of stimulation which were determined before the onset of each trial. The duration of standing achieved using closed-loop control of IM-S was significantly longer than that achieved with open-loop control (approximately 2 times longer). The increase in the duration of standing corresponded with a decrease in the rate of force decay and a lower average injected current during closed-loop control. Standing was further improved with the use of ISMS. Closed-loop control of interleaved ISMS resulted in a period of standing > 3 times longer than the best trial generated using non-interleaved IM-S. There was also a significant improvement in the balance of force between the two hindlimbs. The results suggest that a system which uses closed-loop control in conjunction with interleaved ISMS could achieve prolonged FES standing in people with SCI.

Benefits of FES gait in a spinal cord injured population

STUDY DESIGN

Review.

OBJECTIVES

This review article investigated the objective evidence of benefits derived from functional electrical stimulation (FES)-assisted gait for people with spinal cord injury (SCI). Both FES and gait have been proposed to promote not only augmented health and fitness, but specific ambulatory outcomes for individuals with neurological disabilities. However, due to small sample sizes and the lack of functionality of the intervention, it has not been widely used in clinical practice. This review assessed whether there is sufficient evidence to encourage a more widespread deployment of FES gait within the rehabilitation community.

METHODS

Hand searches and online data collection were performed in Medline and Science Direct. Specific search terms used included SCI/paralysis/paraplegia and tetraplegia with electrical stimulation/FES, gait and walking.

RESULTS

The searches generated 532 papers. Of these papers, 496 were excluded and 36 papers were included in the review. Many reported benefits were not carefully investigated, and small sample sizes or different methodologies resulted in insufficient evidence to draw definitive conclusions.

CONCLUSIONS

FES gait can enhance gait, muscle strength and cardiorespiratory fitness for people with SCI. However, these benefits are dependent on the nature of the injury and further research is required to generalize these results to the widespread population of SCI individuals. Proof of the functionality and further evidence of the benefits of FES gait will assist in FES gait gaining clinical acceptance.

The feasibility of a functional neuromuscular stimulation powered mechanical gait orthosis with coordinated joint locking

The purpose of this study was to examine the feasibility of a hybrid orthosis for walking after spinal cord injury (SCI) that coordinates the locking and unlocking of knee and ankle joints of a reciprocating gait orthosis (RGO), while injecting propulsive forces and controlling unlocked joints with functional neuromuscular stimulation (FNS). The effectiveness of the hybrid system relative to gait stability and posture were determined in this simulation study. A three-dimensional computer model of a hybrid orthosis system (HOS) combining FNS with a RGO incorporating feedback control of muscle activation and coordinated joint locking was developed in Working Model 3D. The simulated hybrid orthosis system achieved gait speeds, stride lengths, and cadences of 0.51 +/- 0.03 m/s, 0.85 +/- 0.04 m, and 72 +/- 4 steps/min respectively, exceeding the performance of other hybrid systems. Forward trunk tilt was found to be necessary during initial step from standing and pro-swing, but posture and stability were significantly improved over FNS-only systems. The results of the model shows that a HOS that coordinates knee and ankle joint locking with electrical stimulation to the paralyzed muscles holds significant advantages over brace- and FNS-only walking systems in terms of enhanced trunk stability and posture.

Neuromuscular electrical stimulation in neurorehabilitation

This review provides a comprehensive overview of the clinical uses of neuromuscular electrical stimulation (NMES) for functional and therapeutic applications in subjects with spinal cord injury or stroke. Functional applications refer to the use of NMES to activate paralyzed muscles in precise sequence and magnitude to directly accomplish functional tasks. In therapeutic applications, NMES may lead to a specific effect that enhances function, but does not directly provide function. The specific neuroprosthetic or "functional" applications reviewed in this article include upper- and lower-limb motor movement for self-care tasks and mobility, respectively, bladder function, and respiratory control. Specific therapeutic applications include motor relearning, reduction of hemiplegic shoulder pain, muscle strengthening, prevention of muscle atrophy, prophylaxis of deep venous thrombosis, improvement of tissue oxygenation and peripheral hemodynamic functioning, and cardiopulmonary conditioning. Perspectives on future developments and clinical applications of NMES are presented.