Adaptive control of movement for neuromuscular stimulation-assisted therapy in a rodent model

Prevention of muscle atrophy in ICU patients without nerve injury by neuromuscular electrical stimulation: a randomized controlled study

Background

Extensive muscle atrophy is a common occurrence in orthopaedics patients who are bedridden or immobilized. The incidence is higher in intensive care unit (ICU) inpatients. There is still controversy about how to use neuromuscular electrical stimulation (NMES) in ICU patients. We aim to compare the effectiveness and safety of NMES to prevent muscle atrophy in intensive care unit (ICU) patients without nerve injury.

Methods

ICU patients without central and peripheral nerve injury were randomized into experimental group I (Exp I: active and passive activity training (APAT) + NMES treatment on the gastrocnemius and tibialis anterior muscle), experimental group II (Exp II: APAT + NMES treatment on gastrocnemius alone), and control group (Ctl: APAT alone). Changes in the strength of gastrocnemius, the ankle range of motion, and the muscle cross-section area of the lower leg were evaluated before and after the intervention. Also, changes in prothrombin time, lactic acid, and C-reactive protein were monitored during the treatment.

Results

The gastrocnemius muscle strength, ankle joint range of motion, and cross-sectional muscle area of the lower leg in the three groups showed a downward trend, indicating that the overall trend of muscle atrophy in ICU patients was irreversible. The decrease in gastrocnemius muscle strength in Exp I and Exp II was smaller than that in the control group (P < 0.05), but there was no difference between Exp I and Exp II. The decrease in active ankle range of motion and cross-sectional area of the lower leg Exp I and Exp II was smaller than that in the control group (P < 0.05), and the decrease in Exp I was smaller than that of Exp II (all P < 0.05). The curative effect in Exp I was better than in Exp II. There were no significant differences in the dynamic changes of prothrombin time, lactic acid, and C-reactive protein during the three groups (P > 0.05).

Conclusion

In addition to early exercise training, NMES should be applied to prevent muscle atrophy for patients without nerve injury in ICU. Also, simultaneous NMES treatment on agonist/antagonist muscle can enhance the effect of preventing muscle atrophy.

Trial registration

This study was prospectively registered in China Clinical Trial Registry (www.chictr.org.cn) on 16/05/2020 as ChiCTR2000032950.

Distribution Heterogeneity of Muscle Spindles Across Skeletal Muscles of Lower Extremities in C57BL/6 Mice

Muscle spindles, an important proprioceptor scattered in the skeletal muscle, participate in maintaining muscle tension and the fine regulation of random movement. Although muscle spindles exist in all skeletal muscles, explanations about the distribution and morphology of muscle spindles remain lacking for the indetermination of spindle location across muscles. In this study, traditional time-consuming histochemical technology was utilized to determine the muscle spindle anatomical and morphological characteristics in the lower extremity skeletal muscle in C57BL/6 mice. The relative distance from spindles to nerve-entry points varied from muscles in the ventral-dorsal direction, in which spindles in the lateral of gastrocnemius were not considered to be close to its nerve-entry point. In the longitudinal pattern, the domain with the highest abundance of spindles corresponded to the nerve-entry point, excluding the tibialis anterior. Spindles are mainly concentrated at the middle and rostral domain in all muscles. The results suggest a heterogeneity of the distribution of spindles in different muscles, but the distribution trend generally follows the location pattern of the nerve-entry point. Histochemical staining revealed that the spindle did not have a symmetrical structure along the equator, and this result does not agree with previous findings. Exploring the distribution and structural characteristics of muscle spindles in skeletal muscle can provide some anatomical basis for the study of muscle spindles at the molecular level and treatment of exercise-related diseases and provide a comprehensive understanding of muscle spindle morphology.

Shared Control of a Powered Exoskeleton and Functional Electrical Stimulation Using Iterative Learning

A hybrid exoskeleton comprising a powered exoskeleton and functional electrical stimulation (FES) is a promising technology for restoration of standing and walking functions after a neurological injury. Its shared control remains challenging due to the need to optimally distribute joint torques among FES and the powered exoskeleton while compensating for the FES-induced muscle fatigue and ensuring performance despite highly nonlinear and uncertain skeletal muscle behavior. This study develops a bi-level hierarchical control design for shared control of a powered exoskeleton and FES to overcome these challenges. A higher-level neural network–based iterative learning controller (NNILC) is derived to generate torques needed to drive the hybrid system. Then, a low-level model predictive control (MPC)-based allocation strategy optimally distributes the torque contributions between FES and the exoskeleton’s knee motors based on the muscle fatigue and recovery characteristics of a participant’s quadriceps muscles. A Lyapunov-like stability analysis proves global asymptotic tracking of state-dependent desired joint trajectories. The experimental results on four non-disabled participants validate the effectiveness of the proposed NNILC-MPC framework. The root mean square error (RMSE) of the knee joint and the hip joint was reduced by 71.96 and 74.57%, respectively, in the fourth iteration compared to the RMSE in the 1st sit-to-stand iteration.

Autonomous control of ventilation through closed-loop adaptive respiratory pacing

Mechanical ventilation is the standard treatment when volitional breathing is insufficient, but drawbacks include muscle atrophy, alveolar damage, and reduced mobility. Respiratory pacing is an alternative approach using electrical stimulation-induced diaphragm contraction to ventilate the lung. Oxygenation and acid-base homeostasis are maintained by matching ventilation to metabolic needs; however, current pacing technology requires manual tuning and does not respond to dynamic user-specific metabolic demand, thus requiring re-tuning of stimulation parameters as physiological changes occur. Here, we describe respiratory pacing using a closed-loop adaptive controller that can self-adjust in real-time to meet metabolic needs. The controller uses an adaptive Pattern Generator Pattern Shaper (PG/PS) architecture that autonomously generates a desired ventilatory pattern in response to dynamic changes in arterial CO₂ levels and, based on a learning algorithm, modulates stimulation intensity and respiratory cycle duration to evoke this ventilatory pattern. In vivo experiments in rats with respiratory depression and in those with a paralyzed hemidiaphragm confirmed that the controller can adapt and control ventilation to ameliorate hypoventilation and restore normocapnia regardless of the cause of respiratory dysfunction. This novel closed-loop bioelectronic controller advances the state-of-art in respiratory pacing by demonstrating the ability to automatically personalize stimulation patterns and adapt to achieve adequate ventilation.

Restoring Ventilatory Control Using an Adaptive Bioelectronic System

Ventilatory pacing by electrical stimulation of the phrenic nerve or of the diaphragm has been shown to enhance quality of life compared to mechanical ventilation. However, commercially available ventilatory pacing devices require initial manual specification of stimulation parameters and frequent adjustment to achieve and maintain suitable ventilation over long periods of time. Here, we have developed an adaptive, closed-loop, neuromorphic, pattern-shaping controller capable of automatically determining a suitable stimulation pattern and adapting it to maintain a desired breath-volume profile on a breath-by-breath basis. The system adapts the pattern of stimulation parameters based on the error between the measured volume sampled every 40 ms and a desired breath volume profile. In vivo studies in anesthetized male Sprague-Dawley rats without and with spinal cord injury by spinal hemisection at C2 indicated that the controller was capable of automatically adapting stimulation parameters to attain a desired volume profile. Despite diaphragm hemiparesis, the controller was able to achieve a desired volume in the injured animals that did not differ from the tidal volume observed before injury (p = 0.39). Closed-loop adaptive pacing partially mitigated hypoventilation as indicated by reduction of end-tidal CO₂ values during pacing. The closed-loop controller was developed and parametrized in a computational testbed before in vivo assessment. This bioelectronic technology could serve as an individualized and autonomous respiratory pacing approach for support or recovery from ventilatory deficiency.

Identification-Based Closed-Loop NMES Limb Tracking With Amplitude-Modulated Control Input

An upper motor neuron lesion (UMNL) can be caused by various neurological disorders or trauma and leads to disabilities. Neuromuscular electrical stimulation (NMES) is a technique that is widely used for rehabilitation and restoration of motor function for people suffering from UMNL. Typically, stability analysis for closed-loop NMES ignores the modulated implementation of NMES. However, electrical stimulation must be applied to muscle as a modulated series of pulses. In this paper, a muscle activation model with an amplitude modulated control input is developed to capture the discontinuous nature of muscle activation, and an identification-based closed-loop NMES controller is designed and analyzed for the uncertain amplitude modulated muscle activation model. Semi-global uniformly ultimately bounded tracking is guaranteed. The stability of the closed-loop system is analyzed with Lyapunov-based methods, and a pulse frequency related gain condition is obtained. Experiments are performed with five able-bodied subjects to demonstrate the interplay between the control gains and the pulse frequency, and results are provided which indicate that control gains should be increased to maintain stability if the stimulation pulse frequency is decreased to mitigate muscle fatigue. For the first time, this paper brings together an analysis of the controller and modulation scheme.

Motion control of the ankle joint with a multiple contact nerve cuff electrode: a simulation study

The flat interface nerve electrode (FINE) has demonstrated significant capability for fascicular and subfascicular stimulation selectivity. However, due to the inherent complexity of the neuromuscular skeletal systems and nerve-electrode interface, a trajectory tracking motion control algorithm of musculoskeletal systems for functional electrical stimulation using a multiple contact nerve cuff electrode such as FINE has not yet been developed. In our previous study, a control system was developed for multiple-input multiple-output (MIMO) musculoskeletal systems with little prior knowledge of the system. In this study, more realistic computational ankle/subtalar joint model including a finite element model of the sciatic nerve was developed. The control system was tested to control the motion of ankle/subtalar joint angles by modulating the pulse amplitude of each contact of a FINE placed on the sciatic nerve. The simulation results showed that the control strategy based on the separation of steady state and dynamic properties of the system resulted in small output tracking errors for different reference trajectories such as sinusoidal and filtered random signals. The proposed control method also demonstrated robustness against external disturbances and system parameter variations such as muscle fatigue. These simulation results under various circumstances indicate that it is possible to take advantage of multiple contact nerve electrodes with spatial selectivity for the control of limb motion by peripheral nerve stimulation even with limited individual muscle selectivity. This technology could be useful to restore neural function in patients with paralysis.

Adaptive Inverse optimal neuromuscular electrical stimulation

Neuromuscular electrical stimulation (NMES) is a prescribed treatment for various neuromuscular disorders, where an electrical stimulus is provided to elicit a muscle contraction. Barriers to the development of NMES controllers exist because the muscle response to an electrical stimulation is nonlinear and the muscle model is uncertain. Efforts in this paper focus on the development of an adaptive inverse optimal NMES controller. The controller yields desired limb trajectory tracking while simultaneously minimizing a cost functional that is positive in the error states and stimulation input. The development of this framework allows tradeoffs to be made between tracking performance and control effort by putting different penalties on error states and control input, depending on the clinical goal or functional task. The controller is examined through a Lyapunov-based analysis. Experiments on able-bodied individuals are provided to demonstrate the performance of the developed controller.

Accelerating locomotor recovery after incomplete spinal injury

A traumatic spinal injury can destroy cells, irreparably damage axons, and trigger a cascade of biochemical responses that increase the extent of injury. Although damaged central nervous system axons do not regrow well naturally, the distributed nature of the nervous system and its capacity to adapt provide opportunities for recovery of function. It is apparent that activity-dependent plasticity plays a role in this recovery and that the endogenous response to injury heightens the capacity for recovery for at least several weeks postinjury. To restore locomotor function, researchers have investigated the use of treadmill-based training, robots, and electrical stimulation to tap into adaptive activity-dependent processes. The current challenge is to maximize the degree of functional recovery. This manuscript reviews the endogenous neural system response to injury, and reviews data and presents novel analyses of these from a rat model of contusion injury that demonstrates how a targeted intervention can accelerate recovery, presumably by engaging processes that underlie activity-dependent plasticity.

Fuzzy control with amplitude/pulse-width modulation of nerve electrical stimulation for muscle force control

The main goal of this study was to study the performance of fuzzy logic controllers combined with simplified hybrid amplitude/pulse-width (AM/PW) modulation to regulate muscle force via nerve electrical stimulation. The recruitment curves with AM/PW and AM modulations were constructed for the calf muscles of rabbits. Integrated with the modulation methods, a proportional-integral-derivative (PID) and three fuzzy logic controllers were designed and applied for the electrical stimulation of tibial nerves to control the ankle torque under isometric conditions. The performance of the two modulation methods combined with the four controllers was compared when the ankle was fixed at three positions for both in vivo experiments and model simulations using a nonlinear muscle model. For the animal experiments, AM/PW modulation performed better than AM modulation alone. The fuzzy PI controller performed marginally better and was resistant to external noises, though it tended to have a larger overshoot. The performance of the controllers had a similar trend in the three different joint positions, and the simulation results with the nonlinear model matched the experimental results well. In conclusion, AM/PW modulation improved controller performance, while the contribution of fuzzy logic was only marginal.

Repetetive hindlimb movement using intermittent adaptive neuromuscular electrical stimulation in an incomplete spinal cord injury rodent model

The long-term objective of this work is to understand the mechanisms by which electrical stimulation based movement therapies may harness neural plasticity to accelerate and enhance sensorimotor recovery after incomplete spinal cord injury (iSCI). An adaptive neuromuscular electrical stimulation (aNMES) paradigm was implemented in adult Long Evans rats with thoracic contusion injury (T8 vertebral level, 155+/-2 Kdyne). In lengthy sessions with lightly anesthetized animals, hip flexor and extensor muscles were stimulated using an aNMES control system in order to generate desired hip movements. The aNMES control system, which used a pattern generator/pattern shaper structure, adjusted pulse amplitude to modulate muscle force in order to control hip movement. An intermittent stimulation paradigm was used (5-cycles/set; 20-second rest between sets; 100 sets). In each cycle, hip rotation caused the foot plantar surface to contact a stationary brush for appropriately timed cutaneous input. Sessions were repeated over several days while the animals recovered from injury. Results indicated that aNMES automatically and reliably tracked the desired hip trajectory with low error and maintained range of motion with only gradual increase in stimulation during the long sessions. Intermittent aNMES thus accounted for the numerous factors that can influence the response to NMES: electrode stability, excitability of spinal neural circuitry, non-linear muscle recruitment, fatigue, spinal reflexes due to cutaneous input, and the endogenous recovery of the animals. This novel aNMES application in the iSCI rodent model can thus be used in chronic stimulation studies to investigate the mechanisms of neuroplasticity targeted by NMES-based repetitive movement therapy.

Neuromuscular stimulation therapy after incomplete spinal cord injury promotes recovery of interlimb coordination during locomotion

The mechanisms underlying the effects of neuromuscular electrical stimulation (NMES) induced repetitive limb movement therapy after incomplete spinal cord injury (iSCI) are unknown. This study establishes the capability of using therapeutic NMES in rodents with iSCI and evaluates its ability to promote recovery of interlimb control during locomotion. Ten adult female Long Evans rats received thoracic spinal contusion injuries (T9; 156 +/- 9.52 Kdyne). 7 days post-recovery, 6/10 animals received NMES therapy for 15 min/day for 5 days, via electrodes implanted bilaterally into hip flexors and extensors. Six intact animals served as controls. Motor function was evaluated using the BBB locomotor scale for the first 6 days and on 14th day post-injury. 3D kinematic analysis of treadmill walking was performed on day 14 post-injury. Rodents receiving NMES therapy exhibited improved interlimb coordination in control of the hip joint, which was the specific NMES target. Symmetry indices improved significantly in the therapy group. Additionally, injured rodents receiving therapy more consistently displayed a high percentage of 1:1 coordinated steps, and more consistently achieved proper hindlimb touchdown timing. These results suggest that NMES techniques could provide an effective therapeutic tool for neuromotor treatment following iSCI.

Chronic neuromuscular electrical stimulation of paralyzed hindlimbs in a rodent model

Neuromuscular electrical stimulation (NMES) can be used to activate paralyzed or paretic muscles to generate functional or therapeutic movements. The goal of this research was to develop a rodent model of NMES-assisted movement therapy after spinal cord injury (SCI) that will enable investigation of mechanisms of NMES-induced plasticity, from the molecular to systems level. Development of the model requires accurate mapping of electrode and muscle stimulation sites, the capability to selectively activate muscles to produce graded contractions of sufficient strength, stable anchoring of the implanted electrode within the muscles and stable performance with functional reliability over several weeks of the therapy window. Custom designed electrodes were implanted chronically in hindlimb muscles of spinal cord transected rats. Mechanical and electrical stability of electrodes and the ability to achieve appropriate muscle recruitment and joint angle excursion were assessed by characterizing the strength duration curves, isometric torque recruitment curves and kinematics of joint angle excursion over 6-8 weeks post implantation. Results indicate that the custom designed electrodes and implantation techniques provided sufficient anchoring and produced stable and reliable recruitment of muscles both in the absence of daily NMES (for 8 weeks) as well as with daily NMES that is initiated 3 weeks post implantation (for 6 weeks). The completed work establishes a rodent model that can be used to investigate mechanisms of neuroplasticity that underlie NMES-based movement therapy after spinal cord injury and to optimize the timing of its delivery.