Muscle Synergy Constraints Do Not Improve Estimates of Muscle Activity From Static Optimization During Gait for Unimpaired Children or Children With Cerebral Palsy

Muscle synergy-informed neuromusculoskeletal modelling to estimate knee contact forces in children with cerebral palsy

Cerebral palsy (CP) includes a group of neurological conditions caused by damage to the developing brain, resulting in maladaptive alterations of muscle coordination and movement. Estimates of joint moments and contact forces during locomotion are important to establish the trajectory of disease progression and plan appropriate surgical interventions in children with CP. Joint moments and contact forces can be estimated using electromyogram (EMG)-informed neuromusculoskeletal models, but a reduced number of EMG sensors would facilitate translation of these computational methods to clinics. This study developed and evaluated a muscle synergy-informed neuromusculoskeletal modelling approach using EMG recordings from three to four muscles to estimate joint moments and knee contact forces of children with CP and typically developing (TD) children during walking. Using only three to four experimental EMG sensors attached to a single leg and leveraging an EMG database of walking data of TD children, the synergy-informed approach estimated total knee contact forces comparable to those estimated by EMG-assisted approaches that used 13 EMG sensors (children with CP, n = 3, R2 = 0.95 ± 0.01, RMSE = 0.40 ± 0.14 BW; TD controls, n = 3, R2 = 0.93 ± 0.07, RMSE = 0.19 ± 0.05 BW). The proposed synergy-informed neuromusculoskeletal modelling approach could enable rapid evaluation of joint biomechanics in children with unimpaired and impaired motor control within a clinical environment.

Clarify Sit-to-Stand Muscle Synergy and Tension Changes in Subacute Stroke Rehabilitation by Musculoskeletal Modeling

Post-stroke patients exhibit distinct muscle activation electromyography (EMG) features in sit-to-stand (STS) due to motor deficiency. Muscle activation amplitude, related to muscle tension and muscle synergy activation levels, is one of the defining EMG features that reflects post-stroke motor functioning and motor impairment. Although some qualitative findings are available, it is not clear if and how muscle activation amplitude-related biomechanical attributes may quantitatively reflect during subacute stroke rehabilitation. To better enable a longitudinal investigation into a patient's muscle activation changes during rehabilitation or an inter-subject comparison, EMG normalization is usually applied. However, current normalization methods using maximum voluntary contraction (MVC) or within-task peak/mean EMG may not be feasible when MVC cannot be obtained from stroke survivors due to motor paralysis and the subject of comparison is EMG amplitude. Here, focusing on the paretic side, we first propose a novel, joint torque-based normalization method that incorporates musculoskeletal modeling, forward dynamics simulation, and mathematical optimization. Next, upon method validation, we apply it to quantify changes in muscle tension and muscle synergy activation levels in STS motor control units for patients in subacute stroke rehabilitation. The novel method was validated against MVC-normalized EMG data from eight healthy participants, and it retained muscle activation amplitude differences for inter- and intra-subject comparisons. The proposed joint torque-based method was also compared with the common static optimization based on squared muscle activation and showed higher simulation accuracy overall. Serial STS measurements were conducted with four post-stroke patients during their subacute rehabilitation stay (137 ± 22 days) in the hospital. Quantitative results of patients suggest that maximum muscle tension and activation level of muscle synergy temporal patterns may reflect the effectiveness of subacute stroke rehabilitation. A quality comparison between muscle synergies computed with the conventional within-task peak/mean EMG normalization and our proposed method showed that the conventional was prone to activation amplitude overestimation and underestimation. The contributed method and findings help recapitulate and understand the post-stroke motor recovery process, which may facilitate developing more effective rehabilitation strategies for future stroke survivors.

A muscle synergy-based method to estimate muscle activation patterns of children with cerebral palsy using data collected from typically developing children

Preparing children with cerebral palsy prior to gait analysis may be a challenging and time-intensive task, especially when large number of sensors are involved. Collecting minimum number of electromyograms (EMG) and yet providing adequate information for clinical assessment might improve clinical workflow. The main goal of this study was to develop a method to estimate activation patterns of lower limb muscles from EMG measured from a small set of muscles in children with cerebral palsy. We developed and implemented a muscle synergy extrapolation method able to estimate the full set of lower limbs muscle activation patterns from only three experimentally measured EMG. Specifically, we extracted a set of hybrid muscle synergies from muscle activation patterns of children with cerebral palsy and their healthy counterparts. Next, those muscle synergies were used to estimate activation patterns of muscles, which were not initially measured in children with cerebral palsy. Two best combinations with three (medial gastrocnemius, semi membranous, and vastus lateralis) and four (lateral gastrocnemius, semi membranous, sartorius, and vastus medialis) experimental EMG were able to estimate the full set of 10 muscle activation patterns with mean (± standard deviation) variance accounted for of 79.93 (± 9.64)% and 79.15 (± 6.40)%, respectively, using only three muscle synergies. In conclusion, muscle activation patterns of unmeasured muscles in children with cerebral palsy can be estimated from EMG measured from three to four muscles using our muscle synergy extrapolation method. In the future, the proposed muscle synergy-based method could be employed in gait clinics to minimise the required preparation time.

Number of synergies impacts sensitivity of gait to weakness and contracture

Muscle activity during gait can be described by a small set of synergies, weighted groups of muscles, that are theorized to reflect underlying neural control. For people with neurologic injuries, like cerebral palsy or stroke, even fewer synergies are required to explain muscle activity during gait. This reduction in synergies is thought to reflect altered control and is associated with impairment severity and treatment outcomes. Individuals with neurologic injuries also develop secondary musculoskeletal impairments, like weakness or contracture, that can impact gait. Yet, the combined impacts of altered control and musculoskeletal impairments on gait remains unclear. In this study, we use a two-dimensional musculoskeletal model constrained to synergy control to simulate unimpaired gait. We vary the number of synergies, while simulating muscle weakness and contracture to examine how altered control impacts sensitivity to musculoskeletal impairment while tracking unimpaired gait. Results demonstrate that reducing the number of synergies increases sensitivity to weakness and contracture for specific muscle groups. For example, simulations using five-synergy control tolerated 40% and 51% more knee extensor weakness than those using four- or three-synergy control, respectively. Furthermore, when constrained to four- or three-synergy control, the model was increasingly sensitive to contracture and weakness of proximal muscles, such as the hamstring and hip flexors. Contrastingly, neither the amount of generalized nor plantarflexor weakness tolerated was affected by the number of synergies. These findings highlight the interactions between altered control and musculoskeletal impairments, emphasizing the importance of measuring and incorporating both in future simulation and experimental studies.

Clinical Relevance of State-of-the-Art Analysis of Surface Electromyography in Cerebral Palsy

Surface electromyography (sEMG) can be used to assess the integrity of the neuromuscular system and its impairment in neurological disorders. Here we will consider several issues related to the current clinical applications, difficulties and limited usage of sEMG for the assessment and rehabilitation of children with cerebral palsy. The uniqueness of this methodology is that it can determine hyperactivity or inactivity of selected muscles, which cannot be assessed by other methods. In addition, it can assist for intervention or muscle/tendon surgery acts, and it can evaluate integrated functioning of the nervous system based on multi-muscle sEMG recordings and assess motor pool activation. The latter aspect is especially important for understanding impairments of the mechanisms of neural controllers rather than malfunction of individual muscles. Although sEMG study is an important tool in both clinical research and neurorehabilitation, the results of a survey on the clinical relevance of sEMG in a typical department of pediatric rehabilitation highlighted its limited clinical usage. We believe that this is due to limited knowledge of the sEMG and its neuromuscular underpinnings by many physiotherapists, as a result of lack of emphasis on this important methodology in the courses taught in physical therapy schools. The lack of reference databases or benchmarking software for sEMG analysis may also contribute to the limited clinical usage. Despite the existence of educational and technical barriers to a widespread use of, sEMG does provide important tools for planning and assessment of rehabilitation treatments for children with cerebral palsy.

Maturation of the Locomotor Circuitry in Children With Cerebral Palsy

The first years of life represent an important phase of maturation of the central nervous system, processing of sensory information, posture control and acquisition of the locomotor function. Cerebral palsy (CP) is the most common group of motor disorders in childhood attributed to disturbances in the fetal or infant brain, frequently resulting in impaired gait. Here we will consider various findings about functional maturation of the locomotor output in early infancy, and how much the dysfunction of gait in children with CP can be related to spinal neuronal networks vs. supraspinal dysfunction. A better knowledge about pattern generation circuitries in infancy may improve our understanding of developmental motor disorders, highlighting the necessity for regulating the functional properties of abnormally developed neuronal locomotor networks as a target for early sensorimotor rehabilitation. Various clinical approaches and advances in biotechnology are also considered that might promote acquisition of the locomotor function in infants at risk for locomotor delays.

Locomotor patterns during obstacle avoidance in children with cerebral palsy

Previous studies mainly evaluated the neuromuscular pattern generation in cerebral palsy (CP) during unobstructed gait. Here we characterized impairments in the obstacle task performance associated with a limited adaptation of the task-relevant muscle module timed to the foot lift during obstacle crossing. Impaired task performance in children with CP may reflect basic developmental deficits in the adaptable control of gait when the locomotor task is superimposed with the voluntary movement.