The International Functional Electrical Stimulation Society (IFESS): Highlights from the IFESS conference at Rehabweek 2023

The annual conference of the International Functional Electrical Stimulation Society (IFESS) was held in conjunction with the 7th RehabWeek Congress, from September 24 to 28, 2023 at the Resorts World Convention Centre on Sentosa Island, in Singapore. The Congress was a joint meeting of the International Consortium on Rehabilitation Technology (ICRT) together with 10 other societies in the field of assistive technology and rehabilitation engineering. The conference features comprehensive blend of technical and clinical context of FES, a sustained value the society has offered over many years. The cross- and inter- disciplinary approach of medicine, engineering, and science practiced in the FES community had enabled vibrant interaction, creation, and development of impactful and novel contributions to the field of FES, translating FES directly into highly relevant and sustainable solutions for the users.

Brain computer interface training with motor imagery and functional electrical stimulation for patients with severe upper limb paresis after stroke: a randomized controlled pilot trial

BACKGROUND

Restorative Brain-Computer Interfaces (BCI) that combine motor imagery with visual feedback and functional electrical stimulation (FES) may offer much-needed treatment alternatives for patients with severely impaired upper limb (UL) function after a stroke.

OBJECTIVES

This study aimed to examine if BCI-based training, combining motor imagery with FES targeting finger/wrist extensors, is more effective in improving severely impaired UL motor function than conventional therapy in the subacute phase after stroke, and if patients with preserved cortical-spinal tract (CST) integrity benefit more from BCI training.

METHODS

Forty patients with severe UL paresis (< 13 on Action Research Arm Test (ARAT) were randomized to either a 12-session BCI training as part of their rehabilitation or conventional UL rehabilitation. BCI sessions were conducted 3-4 times weekly for 3-4 weeks. At baseline, Transcranial Magnetic Stimulation (TMS) was performed to examine CST integrity. The main endpoint was the ARAT at 3 months post-stroke. A binominal logistic regression was conducted to examine the effect of treatment group and CST integrity on achieving meaningful improvement. In the BCI group, electroencephalographic (EEG) data were analyzed to investigate changes in event-related desynchronization (ERD) during the course of therapy.

RESULTS

Data from 35 patients (15 in the BCI group and 20 in the control group) were analyzed at 3-month follow-up. Few patients (10/35) improved above the minimally clinically important difference of 6 points on ARAT, 5/15 in the BCI group, 5/20 in control. An independent-samples Mann-Whitney U test revealed no differences between the two groups, p = 0.382. In the logistic regression only CST integrity was a significant predictor for improving UL motor function, p = 0.007. The EEG analysis showed significant changes in ERD of the affected hemisphere and its lateralization only during unaffected UL motor imagery at the end of the therapy.

CONCLUSION

This is the first RCT examining BCI training in the subacute phase where only patients with severe UL paresis were included. Though more patients in the BCI group improved relative to the group size, the difference between the groups was not significant. In the present study, preserved CTS integrity was much more vital for UL improvement than which type of intervention the patients received. Larger studies including only patients with some preserved CST integrity should be attempted.

Improving electrotactile communication with a multi-pad electrode under cognitive load

BACKGROUND

Electrotactile systems are compact interfaces that can be used to convey information through the skin by producing a range of haptic sensations. In many applications, however, the user needs to perceive and interpret haptic stimulation while being engaged in parallel activities. Developing methods that ensure reliable recognition of electrotactile messages despite additional cognitive load is, therefore, an important step for the practical application of electrotactile displays.

METHODS

This study investigated if a simple strategy of repeating electrotactile messages can improve message identification during multitasking. Ten participants identified 36 spatiotemporal electrotactile messages delivered through a 3 × 2 pad-matrix electrode placed on the torso while performing a concomitant cognitive task in three conditions: the messages were presented once (No-REP), and each message was repeated three (REP3) and five (REP5) times. The main outcome measure was the success rate (SR) of message identification.

RESULTS

During multitasking, in the No-REP condition, the SR (median (IQR)) dropped to 56.25% (22.62%), demonstrating that the cognitive task decreased performance. However, the SR significantly improved with message repetitions, reaching 72.92% (21.87%) and 81.25% (18.66%) in REP3 and REP5 conditions respectively, without a statistically significant difference between REP3 and REP5.

CONCLUSIONS

Multitasking affected the efficacy of haptic communication, but message repetition was shown to be an effective strategy for improving performance. Additionally, only three repetitions were enough, as an additional increase in the duration of message transmission (5 repetitions) did not lead to further improvement. This study is an important step toward delivering electrotactile communication that can cope with the demands of real-world applications.

Designing Ecological Auditory Feedback on Lower Limb Kinematics for Hemiparetic Gait Training

Auditory feedback has earlier been explored as a tool to enhance patient awareness of gait kinematics during rehabilitation. In this study, we devised and tested a novel set of concurrent feedback paradigms on swing phase kinematics in hemiparetic gait training. We adopted a user-centered design approach, where kinematic data recorded from 15 hemiparetic patients was used to design three feedback algorithms (wading sounds, abstract, musical) based on filtered gyroscopic data from four inexpensive wireless inertial units. The algorithms were tested (hands-on) by a focus group of five physiotherapists. They recommended that the abstract and musical algorithms be discarded due to sound quality and informational ambiguity. After modifying the wading algorithm (as per their feedback), we conducted a feasibility test involving nine hemiparetic patients and seven physiotherapists, where variants of the algorithm were applied to a conventional overground training session. Most patients found the feedback meaningful, enjoyable to use, natural-sounding, and tolerable for the typical training duration. Three patients exhibited immediate improvements in gait quality when the feedback was applied. However, minor gait asymmetries were found to be difficult to perceive in the feedback, and there was variability in receptiveness and motor change among the patients. We believe that our findings can advance current research in inertial sensor-based auditory feedback for motor learning enhancement during neurorehabilitation.

Biomimetic Tendon-Based Mechanism for Finger Flexion and Extension in a Soft Hand Exoskeleton: Design and Experimental Assessment

This study proposes a bioinspired exotendon routing configuration for a tendon-based mechanism to provide finger flexion and extension that utilizes a single motor to reduce the complexity of the system. The configuration was primarily inspired by the extrinsic muscle-tendon units of the human musculoskeletal system. The function of the intrinsic muscle-tendon units was partially compensated by adding a minor modification to the configuration of the extrinsic units. The finger kinematics produced by this solution during flexion and extension were experimentally evaluated on an artificial finger and compared to that obtained using the traditional mechanism, where one exotendon was inserted at the distal phalanx. The experiments were conducted on nine healthy subjects who wore a soft exoskeleton glove equipped with the novel tendon mechanism. Contrary to the traditional approach, the proposed mechanism successfully prevented the hyperextension of the distal interphalangeal (DIP) and the metacarpophalangeal (MCP) joints. During flexion, the DIP joint angles produced by the novel mechanism were smaller than the angles generated by the traditional approach for the same proximal interphalangeal (PIP) joint angles. This provided a flexion trajectory closer to the voluntary flexion motion and avoided straining the interphalangeal coupling between the DIP and PIP joints. Finally, the proposed solution generated similar trajectories when applied to a stiff artificial finger (simulating spasticity). The results, therefore, demonstrate that the proposed approach is indeed an effective solution for the envisioned soft hand exoskeleton system.

A Novel Screen-Printed Textile Interface for High-Density Electromyography Recording

Recording electrical muscle activity using a dense matrix of detection points (high-density electromyography, EMG) is of interest in a range of different applications, from human-machine interfacing to rehabilitation and clinical assessment. The wider application of high-density EMG is, however, limited as the clinical interfaces are not convenient for practical use (e.g., require conductive gel/cream). In the present study, we describe a novel dry electrode (TEX) in which the matrix of sensing pads is screen printed on textile and then coated with a soft polymer to ensure good skin-electrode contact. To benchmark the novel solution, an identical electrode was produced using state-of-the-art technology (polyethylene terephthalate with hydrogel, PET) and a process that ensured a high-quality sample. The two electrodes were then compared in terms of signal quality as well as functional application. The tests showed that the signals collected using PET and TEX were characterised by similar spectra, magnitude, spatial distribution and signal-to-noise ratio. The electrodes were used by seven healthy subjects and an amputee participant to recognise seven hand gestures, leading to similar performance during offline analysis and online control. The comprehensive assessment, therefore, demonstrated that the proposed textile interface is an attractive solution for practical applications.

Electrotactile Communication via Matrix Electrode Placed on the Torso Using Fast Calibration, and Static vs. Dynamic Encoding

Electrotactile stimulation is a technology that reproducibly elicits tactile sensations and can be used as an alternative channel to communicate information to the user. The presented work is a part of an effort to develop this technology into an unobtrusive communication tool for first responders. In this study, the aim was to compare the success rate (SR) between discriminating stimulation at six spatial locations (static encoding) and recognizing six spatio-temporal patterns where pads are activated sequentially in a predetermined order (dynamic encoding). Additionally, a procedure for a fast amplitude calibration, that includes a semi-automated initialization and an optional manual adjustment, was employed and evaluated. Twenty subjects, including twelve first responders, participated in the study. The electrode comprising the 3 × 2 matrix of pads was placed on the lateral torso. The results showed that high SRs could be achieved for both types of message encoding after a short learning phase; however, the dynamic approach led to a statistically significant improvement in messages recognition (SR of 93.3%), compared to static stimulation (SR of 83.3%). The proposed calibration procedure was also effective since in 83.8% of the cases the subjects did not need to adjust the stimulation amplitude manually.

Encoding of spatial patterns using electrotactile stimulation via a multi-pad electrode placed on the torso

BACKGROUND

Tactile stimulation can be used to convey information to a user in different scenarios while avoiding overloading other senses. Tactile messages can be transmitted as spatial patterns, potentially allowing for a high information throughput. The aim of the present study was to design and test different encoding schemes to determine the best approach for conveying spatial patterns.

METHODS

Encoding schemes with simultaneous (SIM) and sequential pad activation (SEQ) were evaluated, including four SEQ variants designed to potentially facilitate the recognition. In SEQ-col and SEQ-row, the column and row of the activated pad were signified using different frequencies, while SEQ-all and SEQ-all-fast included the activation of all pads where those belonging to the pattern were indicated by changes in frequency (ON pads). The success rate (SR) of the pattern identification and the response time were quantified in 15 participants who recognized 20 patterns delivered through a 3 × 2 pad matrix placed on the lateral torso.

RESULTS

SIM was not a feasible method to present the patterns (median, 15%; IQR, 5%). The SR improved with SEQ (median, 60%; IQR, 20%) and further increased with additional cues, particularly with SEQ-row (median, 78.3%; IQR, 23.3%) and SEQ-all (median, 96.7%; IQR, 5%). Importantly, the stimulation time of SEQ-all could be decreased without a substantial drop in accuracy (SEQ-all-fast: median, 89.2%; IQR, 19.2%).

CONCLUSIONS

The spatiotemporal stimulation with sequential activation of all pads (SEQ-all) seems to be the method of choice when conveying tactile messages as spatial patterns. This is an important outcome for increasing the information bandwidth of communication through the tactile channel.

Reducing the number of EMG electrodes during online hand gesture classification with changing wrist positions

Background

Myoelectric control based on hand gesture classification can be used for effective, contactless human–machine interfacing in general applications (e.g., consumer market) as well as in the clinical context. However, the accuracy of hand gesture classification can be impacted by several factors including changing wrist position. The present study aimed at investigating how channel configuration (number and placement of electrode pads) affects performance in hand gesture recognition across wrist positions, with the overall goal of reducing the number of channels without the loss of performance with respect to the benchmark (all channels).

Methods

Matrix electrodes (256 channels) were used to record high-density EMG from the forearm of 13 healthy subjects performing a set of 8 gestures in 3 wrist positions and 2 force levels (low and moderate). A reduced set of channels was chosen by applying sequential forward selection (SFS) and simple circumferential placement (CIRC) and used for gesture classification with linear discriminant analysis. The classification success rate and task completion rate were the main outcome measures for offline analysis across the different number of channels and online control using 8 selected channels, respectively.

Results

The offline analysis demonstrated that good accuracy (> 90%) can be achieved with only a few channels. However, using data from all wrist positions required more channels to reach the same performance. Despite the targeted placement (SFS) performing similarly to CIRC in the offline analysis, the task completion rate [median (lower–upper quartile)] in the online control was significantly higher for SFS [71.4% (64.8–76.2%)] compared to CIRC [57.1% (51.8–64.8%), p < 0.01], especially for low contraction levels [76.2% (66.7–84.5%) for SFS vs. 57.1% (47.6–60.7%) for CIRC, p < 0.01]. For the reduced number of electrodes, the performance with SFS was comparable to that obtained when using the full matrix, while the selected electrodes were highly subject-specific.

Conclusions

The present study demonstrated that the number of channels required for gesture classification with changing wrist positions could be decreased substantially without loss of performance, if those channels are placed strategically along the forearm and individually for each subject. The results also emphasize the importance of online assessment and motivate the development of configurable matrix electrodes with integrated channel selection.

Increase and Decrease in Velocity and Force During Exercise with a Hybrid Robotic-FES Rehabilitation System

Early rehabilitation is beneficial for stroke patients, but it is often delayed since the patients are often bedbound due to their general condition. New robotic rehabilitation devices such as ROBERT® enable patients to exercise even while bedbound. During pilot testing of an automated FES-delivery system combined with ROBERT®, we observed both increased and decreased exerted velocity and interaction force during repetitive exercising with the system. The goal of the current study was thus to investigate the extent of both potentiation and fatigue, as assessed in the velocity and interaction force produced in response to repetitive robotic-FES exercising. Eight healthy subjects completed 50 repetitions of leg-press exercises using the hybrid robotic-FES system. For individual subjects, significant changes were found for both mean and maximal velocities and interaction forces exerted during the exercise. Roughly half of the subjects had an increase in maximal velocity and interaction force during the exercise, and half exhibited an increase in mean velocity, whereas three subjects had an increase in mean interaction force during the exercise. The changes in mean velocity were in the range of -40.6 to 30.9% and for the maximal velocity they were in the range of -21.9 to 22.0%. The changes for mean interaction force were in the range of -5.8 to 11.0%, while for the maximal interaction force, they were in the range of -7.8 to 14.4%. These changes might pose significant challenges for future developments of hybrid robotic-FES rehabilitation systems, as the system must be able to comply with the observed changes, and appropriately adapt to them in order to maintain efficacy and safety.

Evaluation of the implementation of Armeo®Spring in a specialized neurorehabilitation center

Rehabilitation of the upper extremity (UE) is an essential part of the process following an acquired brain injury, where robot technologies have the potential of making the rehabilitation more intensive and effective. However, the implementation of robot technologies in a clinical setting can be complicated and not always successful. The aim of this study was to evaluate the implementation of the robot technology Armeo®Spring (Hocoma, Volketswil, Switzerland) at a specialized neurorehabilitation center, and to propose a list of actions for further implementation of the technology.The Study, Act and Plan phases of the Plan-Do-Study-Act (PDSA) model for structuring technology implementations was applied as the methodological framework in this study. In the Study-phase, nine semi-structured interviews with therapists, using Armeo®Spring, were conducted to evaluate the current implementation. In the Act-phase, a workshop was held with 13 participants to discuss the findings of the Study-phase and to find possible solutions to the identified problems. The results were incorporated into a list of actions (Plan-phase) for further implementation of Armeo®Spring.Facilitating and inhibiting factors for the implementation of Armeo®Spring were identified. Facilitating factors were the practical "hands-on" approach during training, support from the management, support and sparring with colleagues as well as a positive work culture. The inhibiting factors were related to the retention of the therapists' acquired competencies, the identification of the type of patient that can benefit from this form of training, challenges due to the technical use of Armeo®Spring, and prioritization of the rehabilitation needs of the patients.Several solutions were proposed in the Act-phase, which subsequently resulted in eight concrete actions to facilitate the further implementation of Armeo®Spring. It is expected that these actions will contribute to the further implementation of Armeo®Spring at the neurorehabilitation center. As a first step, an Armeo®Spring group with therapists from all relevant wards was established.

An Embodied Sonification Model for Sit-to-Stand Transfers

Interactive sonification of biomechanical quantities is gaining relevance as a motor learning aid in movement rehabilitation, as well as a monitoring tool. However, existing gaps in sonification research (issues related to meaning, aesthetics, and clinical effects) have prevented its widespread recognition and adoption in such applications. The incorporation of embodied principles and musical structures in sonification design has gradually become popular, particularly in applications related to human movement. In this study, we propose a general sonification model for the sit-to-stand (STS) transfer, an important activity of daily living. The model contains a fixed component independent of the use-case, which represents the rising motion of the body as an ascending melody using the physical model of a flute. In addition, a flexible component concurrently sonifies STS features of clinical interest in a particular rehabilitative/monitoring situation. Here, we chose to represent shank angular jerk and movement stoppages (freezes), through perceptually salient pitch modulations and bell sounds. We outline the details of our technical implementation of the model. We evaluated the model by means of a listening test experiment with 25 healthy participants, who were asked to identify six normal and simulated impaired STS patterns from sonified versions containing various combinations of the constituent mappings of the model. Overall, we found that the participants were able to classify the patterns accurately (86.67 ± 14.69% correct responses with the full model, 71.56% overall), confidently (64.95 ± 16.52% self-reported rating), and in a timely manner (response time: 4.28 ± 1.52 s). The amount of sonified kinematic information significantly impacted classification accuracy. The six STS patterns were also classified with significantly different accuracy depending on their kinematic characteristics. Learning effects were seen in the form of increased accuracy and confidence with repeated exposure to the sound sequences. We found no significant accuracy differences based on the participants' level of music training. Overall, we see our model as a concrete conceptual and technical starting point for STS sonification design catering to rehabilitative and clinical monitoring applications.

Does feedback based on FES-evoked nociceptive withdrawal reflex condition event-related desynchronization? An exploratory study with brain-computer interfaces

Introduction.Event-related desynchronization (ERD) is used in brain-computer interfaces (BCI) to detect the user's motor intention (MI) and convert it into a command for an actuator to provide sensory feedback or mobility, for example by means of functional electrical stimulation (FES). Recent studies have proposed to evoke the nociceptive withdrawal reflex (NWR) using FES, in order to evoke synergistic movements of the lower limb and to facilitate the gait rehabilitation of stroke patients. The use of NWR to provide sensorimotor feedback in ERD-based BCI is novel; thererfore, the conditioning effect that nociceptive stimuli might have on MI is still unknown.Objetive.To assess the ERD produced during the MI after FES-evoked NWR, in order to evaluate if nociceptive stimuli condition subsequent ERDs.Methods. Data from 528 electroencephalography trials of 8 healthy volunteers were recorded and analyzed. Volunteers used an ERD-based BCI, which provided two types of feedback: intrisic by the FES-evoked NWR and extrinsic by virtual reality. The electromyogram of the tibialis anterior muscle was also recorded. The main outcome variables were the normalized root mean square of the evoked electromyogram (RMS_norm), the average electroencephalogram amplitude at the ERD frequency during MI (A¯MI) and the percentage decrease ofA¯MIrelative to rest (ERD%) at the first MI subsequent to the activation of the BCI.Results.No evidence of changes of theRMS_normon both theA¯MI(p = 0.663) and theERD%(p = 0.252) of the subsequent MI was detected. A main effect of the type of feedback was found in the subsequentA¯MI(p < 0.001), with intrinsic feedback resulting in a largerA¯MI.Conclusions.No evidence of ERD conditioning was observed using BCI feedback based on FES-evoked NWR .Significance.FES-evoked NWR could constitute a potential feedback modality in an ERD-based BCI to facilitate motor recovery of stroke people.

Bio-inspired tendon driven mechanism for simultaneous finger joints flexion using a soft hand exoskeleton

A new tendon driven mechanism, embedded into a soft hand exoskeleton for rehabilitation and assistance, was proposed in this study. The proposed solution was a pulley flexion mechanism inspired by the human musculoskeletal system to enable a natural and comfortable finger flexion. A biomechanical constraint for the finger flexion motion states that the relation between the proximal interphalangeal joint angle of the finger should always be flexed around 1.5 times the distal interphalangeal joint angle. The study aimed to comply with this constraint, by simultaneously distributing the forces over the distal and middle finger phalanges. For evaluation, the voluntary and exoskeleton flexions were compared based on the relation between the proximal and distal interphalangeal joint angles. The results showed that during the exoskeleton flexion the relation between the interphalangeal joints complied with the biomechanical constraint, where the proximal interphalangeal joint angle was 1.5 times larger than the distal interphalangeal joint. This ensures that the mechanism flexes the finger comfortably. The proposed solution is therefore a promising design for a novel soft exoskeleton that will be used for training and assistance of patients with hand paralysis.

Toward Standardizing the Classification of Robotic Gait Rehabilitation Systems

With the existence of numerous rehabilitation systems, classification and comparison becomes difficult, especially due to the many factors involved. Moreover, most current reviews are descriptive and do not provide systematic methods for the visual comparison of systems. This review proposes a method for classifying systems and representing them graphically to easily visualize various characteristics of the different systems at the same time. This method could be an introduction for standardizing the evaluation of gait rehabilitation systems. It evaluates four main modules (body weight support, reciprocal stepping mechanism, pelvis mechanism, and environment module) of 27 different gait systems based on a set of characteristics. The combination of these modular evaluations provides a description of the system "in the space of rehabilitation." The evaluation of each robotic module, based on specific characteristics, showed diverse tendencies. While there is an augmented interest in developing more sophisticated reciprocal stepping mechanisms, few researchers are dedicated to enhance the properties of pelvis mechanisms.

Neurorehabilitation therapy of patients with severe stroke based on functional electrical stimulation commanded by a brain computer interface

Introduction

Brain computer interface is an emerging technology to treat the sequelae of stroke. The purpose of this study was to explore the motor imagery related desynchronization of sensorimotor rhythms of stroke patients and to assess the efficacy of an upper limb neurorehabilitation therapy based on functional electrical stimulation controlled by a brain computer interface.

Methods

Eight severe chronic stroke patients were recruited. The study consisted of two stages: screening and therapy. During screening, the ability of patients to desynchronize the contralateral oscillatory sensorimotor rhythms by motor imagery of the most affected hand was assessed. In the second stage, a therapeutic intervention was performed. It involved 20 sessions where an electrical stimulator was activated when the patient's cerebral activity related to motor imagery was detected. The upper limb was assessed, before and after the intervention, by the Fugl-Meyer score (primary outcome). Spasticity, motor activity, range of movement and quality of life were also evaluated (secondary outcomes).

Results

Desynchronization was identified in all screened patients. Significant post-treatment improvement (p < 0.05) was detected in the primary outcome measure and in the majority of secondary outcome scores.

Conclusions

The results suggest that the proposed therapy could be beneficial in the neurorehabilitation of stroke individuals.

A Novel Stimulation Paradigm to Limit the Habituation of the Nociceptive Withdrawal Reflex

In gait rehabilitation, combining gait therapy with functional electrical stimulation based on the nociceptive withdrawal reflex (NWR) improves walking velocity and gait symmetry of hemiparetic patients. However, habituation of the NWR can affect the efficacy of training. The current study aimed at identifying the stimulation parameters that would limit, in healthy participants, the habituation of the NWR. The NWR was elicited at every heel-off while the participants walked on a treadmill. Three stimulation paradigms were tested: deterministic paradigm (fixed parameters), stochastic pulse duration paradigm (varying the pulse duration of the stimuli), and stochastic frequency paradigm (varying the frequency of the stimuli). The charge delivered for the three paradigms was identical. The reflex response was quantified by the EMG activity of the tibialis anterior (TA) muscle and as ankle and hip joints angle changes. The ankle dorsiflexion and TA EMG responses were not significantly reduced with the stochastic pulse duration paradigm, in contrast to the two other paradigms. Hence, using a stochastic pulse duration stimulation paradigm seemed to be effective in limiting the habituation of the NWR in heathy individuals. This might be highly relevant for effective gait rehabilitation.

Design and test of a Microsoft Kinect-based system for delivering adaptive visual feedback to stroke patients during training of upper limb movement

The present paper describes the design and test of a low-cost Microsoft Kinect-based system for delivering adaptive visual feedback to stroke patients during the execution of an upper limb exercise. Eleven sub-acute stroke patients with varying degrees of upper limb function were recruited. Each subject participated in a control session (repeated twice) and a feedback session (repeated twice). In each session, the subjects were presented with a rectangular pattern displayed on a vertical mounted monitor embedded in the table in front of the patient. The subjects were asked to move a marker inside the rectangular pattern by using their most affected hand. During the feedback session, the thickness of the rectangular pattern was changed according to the performance of the subject, and the color of the marker changed according to its position, thereby guiding the subject's movements. In the control session, the thickness of the rectangular pattern and the color of the marker did not change. The results showed that the movement similarity and smoothness was higher in the feedback session than in the control session while the duration of the movement was longer. The present study showed that adaptive visual feedback delivered by use of the Kinect sensor can increase the similarity and smoothness of upper limb movement in stroke patients.

Feasibility of Using Lokomat Combined with Functional Electrical Stimulation for the Rehabilitation of Foot Drop

This study investigated the clinical feasibility of combining the electromechanical gait trainer Lokomat with functional electrical therapy (LokoFET), stimulating the common peroneal nerve during the swing phase of the gait cycle to correct foot drop as an integrated part of gait therapy. Five patients with different acquired brain injuries trained with LokoFET 2-3 times a week for 3-4 weeks. Pre- and post-intervention evaluations were performed to quantify neurophysiological changes related to the patients' foot drop impairment during the swing phase of the gait cycle. A semi-structured interview was used to investigate the therapists' acceptance of LokoFET in clinical practice. The patients showed a significant increase in the level of activation of the tibialis anterior muscle and the maximal dorsiflexion during the swing phase, when comparing the pre- and post-intervention evaluations. This showed an improvement of function related to the foot drop impairment. The interview revealed that the therapists perceived the combined system as a useful tool in the rehabilitation of gait. However, lack of muscle selectivity relating to the FES element of LokoFET was assessed to be critical for acceptance in clinical practice.

Spinal plasticity in robot-mediated therapy for the lower limbs

Robot-mediated therapy can help improve walking ability in patients following injuries to the central nervous system. However, the efficacy of this treatment varies between patients, and evidence for the mechanisms underlying functional improvements in humans is poor, particularly in terms of neural changes in the spinal cord. Here, we review the recent literature on spinal plasticity induced by robotic-based training in humans and propose recommendations for the measurement of spinal plasticity using robotic devices. Evidence for spinal plasticity in humans following robotic training is limited to the lower limbs. Body weight-supported (BWS) robotic-assisted step training of patients with spinal cord injury (SCI) or stroke patients has been shown to lead to changes in the amplitude and phase modulation of spinal reflex pathways elicited by electrical stimulation or joint rotations. Of particular importance is the finding that, among other changes to the spinal reflex circuitries, BWS robotic-assisted step training in SCI patients resulted in the re-emergence of a physiological phase modulation of the soleus H-reflex during walking. Stretch reflexes elicited by joint rotations constitute a tool of interest to probe spinal circuitry since the technology necessary to produce these perturbations could be integrated as a natural part of robotic devices. Presently, ad-hoc devices with an actuator capable of producing perturbations powerful enough to elicit the reflex are available but are not part of robotic devices used for training purposes. A further development of robotic devices that include the technology to elicit stretch reflexes would allow for the spinal circuitry to be routinely tested as a part of the training and evaluation protocols.

Characterization of gait pattern by 3D angular accelerations in hemiparetic and healthy gait

Characterization of gait pattern is of interest for clinical gait assessment. Past developments of ambulatory measurement systems have still limitations for daily usage in the clinical environment. This study investigated the potential of 3D angular accelerations of foot, shank, and thigh to characterize gait events and phases of ten healthy and ten hemiparetic subjects. The key feature of the system was the use of angular accelerations obtained by differential measurement. Further, the effect of sensor position and walking cadence on the signal was investigated. We found that gait phases are characterized as modulated amplitudes of angular accelerations of foot, shank, and thigh. Increasing the gait cadence from 70 steps/min to 100 steps/min caused an amplitude increase of the magnitude of the vector, summing all 3D angular accelerations on the sensor position (p<0.001). Comparison of healthy and hemiparetic gait showed a lower mean of the magnitude of the vector during the loading response in the hemiparetic gait (p<0.05), while during pre-swing and swing no significant differences between healthy and hemiparetic gait were observed. A comparison of the tangential acceleration component in the frontal plane showed no statistically significant difference between healthy and hemiparetic gait. Further, no statistically significant difference between the tangential components was found for both groups. This method demonstrated promising results for a possible use for gait assessment.

Design and test of a novel closed-loop system that exploits the nociceptive withdrawal reflex for swing-phase support of the hemiparetic gait

A novel closed-loop system for improving gait in hemiparetic patients by supporting the production of the swing phase using electrical stimulations evoking the nociceptive withdrawal reflex was designed. The system exploits the modular organization of the nociceptive withdrawal reflex and its stimulation site- and gait-phase modulation in order to evoke movements of the hip, knee, and ankle joints during the swing phase. A modified model-reference adaptive controller (MRAC) was designed to select the best stimulation parameters from a set of 12 combinations of four electrode locations on the sole of the foot and three different stimulation onset times between heel-off and toe-off. It was hypothesized that the MRAC system would result in a better walking pattern compared with an open-loop preprogrammed fixed pattern of stimulation (FPS) controller. Thirteen chronic or subacute hemiparetic subjects participated in a study to compare the performance of the two control schemes. Both control schemes resulted in a more functional gait compared to no stimulation (P < 0.05) with a weighted joint angle peak change of 4.0 ± 1.6 (mean ± Standard deviation) degrees and 3.1 ± 1.4 degrees for the MRAC and FPS schemes, respectively. This indicates that the MRAC scheme performed better than the FPS scheme (P < 0.001) in terms of reaching the control target.

Methods for gait event detection and analysis in ambulatory systems

After stroke, hemiparesis is a common problem resulting in very individual needs for walking assistance. Often patients suffer from foot drop, i.e. inability to lift the foot from the ground during the swing phase of walking. Functional electrical stimulation is commonly used to correct foot drop. For all supporting stimulation devices, it is vital to adequately detect the gait events, which is traditionally obtained by a foot switch placed under the heel. To investigate present methods of gait analysis and detection for use in ambulatory rehabilitation systems, we carried out a meta-analysis on research studies. We found various sensors and sensor combinations capable of analyzing gait in ambulatory settings, ranging form simple force based binary switches to complex setups involving multiple inertial sensors and advanced algorithms. However additional effort is needed to minimize donning/doffing efforts, to overcome cosmetical aspects, and to implement those systems into closed loop ambulatory devices.

Withdrawal reflexes examined during human gait by ground reaction forces: site and gait phase dependency

The objective of this study was to investigate the modulation of the nociceptive withdrawal reflex during gait measured using Force Sensitive Resistors (FSR). Electrical stimulation was delivered to four locations on the sole of the foot at three different time points between heel-off and toe-off. Peak force changes were measured by FSRs attached to the big toe, distal to the first and fourth metatarsophalangeal joints, and the medial process of the calcaneus on both feet. Force changes were assessed in five gait sub-phases. The painful stimulation led to increased ipsilateral unloading (10 +/- 1 N) and contralateral loading (12 +/- 1 N), which were dependent on stimulation site and phase. In contrast, the hallux of the ipsilateral foot plantar flexed, thus facilitating the push-off. The highest degree of plantar flexion (23 +/- 10 N; range, 8-44 N) was seen in the second double support phase following the stimulation. Site and phase modulation of the reflex were detected in the force signals from all selected anatomical landmarks. In the kinematic responses, both site and phase modulation were observed. For stimulations near toe-off, withdrawal was primarily accomplished by ankle dorsiflexion, while the strategy for stimulations at heel-off was flexion of the knee and hip joints.

Modulation of the withdrawal reflex during hemiplegic gait: effect of stimulation site and gait phase

OBJECTIVE

The objective of the study was to investigate the sensitivity of the nociceptive withdrawal reflex to stimulation of different locations on the sole of the foot during hemiplegic gait.

METHODS

Reflexes were evoked by cutaneous electrical stimulation of 4 locations on the sole of the foot of 7 hemiplegic and 6 age-matched healthy persons. The stimuli were delivered at heel-contact, during foot-flat, at heel-off, and during mid-swing. Reflexes were recorded from muscles of the stimulated and the contralateral leg. Ankle, knee, and hip joints angles were recorded using goniometers.

RESULTS

In the hemiplegic persons, the size of tibialis anterior reflexes, and the latency of soleus reflexes were site- and phase-modulated. In both groups, the tibialis anterior reflexes were significantly smaller with stimulation to the fifth metatarsophalangeal joint and the heel compared with the first metatarsophalangeal joint and the arch of the foot. The tibialis anterior reflexes evoked at heel-off and mid-swing were larger in hemiplegic persons than in healthy persons. Reflexes in the proximal and contralateral limb muscles were not site-modulated during hemiplegic gait. The kinematic response at the ankle joint was also different in the two groups during mid-swing.

CONCLUSIONS

Hemiplegic and healthy middle-aged people presented different phase-modulation of the kinematic and muscle nociceptive reflex responses evoked by stimulation delivered on the sole of the foot.

SIGNIFICANCE

The results have potential application in programs to rehabilitate hemiplegic gait.

Gradual enlargement of human withdrawal reflex receptive fields following repetitive painful stimulation

Dynamic changes in the topography of the human withdrawal reflex receptive fields (RRF) were assessed by repetitive painful stimuli in 15 healthy subjects. A train of five electrical stimuli was delivered at a frequency of 3 Hz (total train duration 1.33 s). The train was delivered in random order to 10 electrode sites on the sole of the foot. Reflexes were recorded from tibialis anterior, soleus, vastus lateralis, biceps femoris, and iliopsoas (IL). The RRF changes during the stimulus train were assessed during standing with even support on both legs and while seated. The degree of temporal summation was depending on stimulation site. At the most sensitive part of the RRF, a statistically significant increase in reflex size was seen after two stimuli while four stimuli were needed to observe reflex facilitation at less sensitive electrode sites. Hence, the region from which reflexes could be evoked using the same stimulus intensity became larger through the train, that is, the RRF was gradually expanding. Reflexes evoked by stimuli four and five were of the same size. No reflex facilitation was seen at other stimulus sites outside the RRF. In all muscles except in IL, the largest reflexes were evoked when the subjects were standing. In the ankle joint, the main withdrawal pattern consisted of plantar flexion and inversion when the subjects were standing while dorsi-flexion was prevalent in the sitting position. Up to 35 degrees of knee and hip flexion were evoked often leading to a lift of the foot from the floor during standing. In conclusion, a gradual expansion of the RRF was seen in all muscles during the stimulus train. Furthermore, the motor programme task controls the reflex sensitivity within the reflex receptive field and, hence, the sensitivity of the temporal summation mechanism.

Repetitive Painful Stimulation Produces an Expansion of Withdrawal Reflex Receptive Fields in Humans

The aims of the present study were to investigate whether temporal summation of the nociceptive withdrawal reflex depends on the stimulation site on the sole of the human foot, and to characterize the reflex receptive fields (RRF) of lower limb muscles to repetitive stimulation. The cutaneous RRFs were assessed in 15 subjects in sitting position by recording the EMG from five lower leg muscles and the kinematic responses (ankle, knee, and hip joints) to repetitive painful electrical stimulation. The stimulus consisted of a series of five stimuli (frequency: 3 Hz) delivered randomly at 10 different sites on the sole of the foot. The size of the reflexes increased generally between the first and the second stimulus, however, the increment depended on the stimulation site. In tibialis anterior, the RRF covered the distal sole of the foot and gradually expanded during the stimulus train. No expansion toward the heel area was detected. In soleus, the reflexes were facilitated after the second stimulus at all sites and remained in this state until the last stimulus. In vastus lateralis, biceps femoris, and iliopsoas a gradual expansion of the RRF was seen, resulting in RRFs covering the lateral, distal foot, and part of the proximal foot (iliopsoas). Knee and hip flexion were evoked at all sites. Ankle dorsiflexion was evoked at the distal foot, while ankle plantarflexion was evoked at the heel. The enlargement of the RRF reflects spinal temporal summation leading to gradually stronger reflex responses. The degree of temporal summation was dependent on stimulation site. The facilitation of the withdrawal reflex responses due to repetitive stimulation might have potential applications in the rehabilitation engineering field, where these reflexes could be used to assist gait of patients with central nervous system injuries.

Expansion of nociceptive withdrawal reflex receptive fields in spinal cord injured humans

OBJECTIVE

In spinal cord injured (SCI) subjects, exaggerated withdrawal reflexes associated with a dominant flexor pattern irrespective of stimulation site have been reported. In the present study, withdrawal reflex receptive field (RRF) was determined in complete SCI subjects (N=9).

METHODS

Distributed electrical stimulation was applied to the sole of the foot, and reflexes in tibialis anterior, soleus, biceps femoris, and vastus lateralis muscles were recorded together with knee and ankle movement trajectories. A group of spinally intact subjects (N=10) were included as controls. With the subjects in supine position, stimulation was applied to 10 different sites on the foot sole. Based on the tibialis anterior reflex threshold for stimulation on the mid foot sole, two stimulus intensities (1.1 times the reflex threshold and 1.4 times the reflex threshold) were used for all 10 sites.

RESULTS

In SCI subjects, dorsi-flexion dominated independent of stimulus site and the tibialis anterior RRF covered the entire foot sole in contrast to a well-defined tibialis anterior receptive field at the medial, distal foot sole in the spinally intact subjects. Further, the soleus RRF also covered the entire sole in the SCI subjects. The reflexes in biceps femoris and vastus lateralis muscles were small and associated with weak knee flexion at all 10 sites in the SCI subjects and in the controls.

CONCLUSIONS

The RRF of the ankle flexor and the ankle extensor muscles both covered the entire sole of the foot indicating an expansion of the RRFs following spinal cord injury. The expansion is most likely due to lack of descending inhibitory control and/or increased sensitivity of the spinal reflex loop in the SCI subjects.

SIGNIFICANCE

The study improves the understanding of spinal reflex control in spinal intact and spinal cord injured subjects.

Modulation of lower limb withdrawal reflexes during gait: a topographical study

The aim of this study was to investigate the modulation and topography of the nociceptive withdrawal reflex elicited by painful electrical stimulation of the foot sole during gait. Fifteen healthy volunteers participated in this study. Cutaneous electrical stimulation was delivered on five locations of the foot sole after heel-contact, during foot-flat, after heel-off, and during the mid-swing phase of the gait cycle during treadmill walking. Reflexes were recorded from muscles of the ipsilateral and contralateral legs. Furthermore, the kinematic responses in the sagittal plane of the ipsilateral ankle, knee, and hip joints were recorded. Reflexes in the distal muscles showed a site-dependent modulation. The largest responses in tibialis anterior were evoked at the arch of the foot and the smallest at the heel (P < 0.05). The largest soleus responses were also elicited at the arch of the foot (P < 0.04). The EMG responses in flexors and extensors of the knee and extensors of the contralateral leg were generally not dependent on the stimulation site. The response at the three joints showed site dependency, especially during the swing phase where maximal flexion was obtained by stimulation at the arch of the foot (P < 0.05). The withdrawal reflex was modulated during the gait cycle and presented distinctive characteristics for the different muscles studied. Minimal kinematic responses were observed during stance in contrast to swing phase. Modulation of the reflex probably ensures an appropriate withdrawal but primarily secures balance and continuity of movement.