BackgroundA major desire of individuals with spinal cord injury (SCI) is the ability to maintain a stable trunk while in a seated position. Such stability is invaluable during many activities of daily living (ADL) such as regular work in the home and office environments, wheelchair propulsion and driving a vehicle. Functional neuromuscular stimulation (FNS) has the ability to restore function to paralyzed muscles by application of measured low-level currents to the nerves serving those muscles.MethodsA feedback control system for maintaining seated balance under external perturbations was designed and tested in individuals with thoracic and cervical level spinal cord injuries. The control system relied on a signal related to the tilt of the trunk from the vertical position (which varied between 1.0 ≡ erect posture and 0.0 ≡ most forward flexed posture) derived from a sensor fixed to the sternum to activate the user’s own hip and trunk extensor muscles via an implanted neuroprosthesis. A proportional-derivative controller modulated stimulation between trunk tilt values indicating deviation from the erect posture and maximum desired forward flexion. Tests were carried out with external perturbation forces set at 35%, 40% and 45% body-weight (BW) and maximal forward trunk tilt flexion thresholds set at 0.85, 0.75 and 0.70.ResultsPreliminary tests in a case series of five subjects show that the controller could maintain trunk stability in the sagittal plane for perturbations up to 45% of body weight and for flexion thresholds as low as 0.7. The mean settling time varied across subjects from 0.5(±0.4) and 2.0 (±1.1) seconds. Mean response time of the feedback control system varied from 393(±38) ms and 536(±84) ms across the cohort.ConclusionsThe results show the high potential for robust control of seated balance against nominal perturbations in individuals with spinal cord injury and indicates that trunk control with FNS is a promising intervention for individuals with SCI.
Objective To quantify the effects of stabilizing the paralyzed trunk and pelvis with electrical stimulation on manual wheelchair propulsion. Design Single-subject design case series with subjects acting as their own concurrent controls. Setting Hospital-based clinical biomechanics laboratory. Participants Six (4M, 2F age 46±10.8yrs) long-time users (6.1±3.9yrs) of implanted neuroprostheses for lower extremity function with chronic (8.6±2.8yrs) mid-cervical or thoracic level injuries (C6-T10). Interventions Continuous low level stimulation to the hip (gluteus maximus, posterior adductor or hamstrings) and trunk extensor (lumbar erector spinae and/or quadratus lumborum) muscles with implanted intramuscular electrodes. Main Outcome Measure(s) Pushrim kinetics (peak resultant force, fraction effective force), kinematics (cadence, stroke length and maximum forward lean), and peak shoulder moment at preferred speed over 10m level surface; speed, pushrim kinetics and subjective ratings of effort for level 100m sprints and up a 30.5m ramp of approximately 5% grade. Results Three out of five subjects demonstrated reduced peak resultant pushrim forces (p≤0.014) and improved efficiency, (p≤0.048) with stimulation during self-paced level propulsion. Peak sagittal shoulder moment remained unchanged in three subjects and increased in two others (p<0.001). Maximal forward trunk lean also increased by 19-26% (p<0.001) with stimulation in these three subjects. Stroke lengths were unchanged by stimulation in all subjects, and two showed extremely small (5%) but statistically significant increases in cadence (p≤0.021). Performance measures for sprints and inclines were generally unchanged with stimulation, however subjects consistently rated propulsion with stimulation to be easier for both surfaces. Conclusions Stabilizing the pelvis and trunk with low levels of continuous electrical stimulation to the lumbar trunk and hip extensors can positively impact the mechanics of manual wheelchair propulsion and reduce both perceived and physical measures of effort.
BackgroundFunctional neuromuscular stimulation, lower limb orthosis, powered lower limb exoskeleton, and hybrid neuroprosthesis (HNP) technologies can restore stepping in individuals with paraplegia due to spinal cord injury (SCI). However, a self-contained muscle-driven controllable exoskeleton approach based on an implanted neural stimulator to restore walking has not been previously demonstrated, which could potentially result in system use outside the laboratory and viable for long term use or clinical testing. In this work, we designed and evaluated an untethered muscle-driven controllable exoskeleton to restore stepping in three individuals with paralysis from SCI.MethodsThe self-contained HNP combined neural stimulation to activate the paralyzed muscles and generate joint torques for limb movements with a controllable lower limb exoskeleton to stabilize and support the user. An onboard controller processed exoskeleton sensor signals, determined appropriate exoskeletal constraints and stimulation commands for a finite state machine (FSM), and transmitted data over Bluetooth to an off-board computer for real-time monitoring and data recording. The FSM coordinated stimulation and exoskeletal constraints to enable functions, selected with a wireless finger switch user interface, for standing up, standing, stepping, or sitting down. In the stepping function, the FSM used a sensor-based gait event detector to determine transitions between gait phases of double stance, early swing, late swing, and weight acceptance.ResultsThe HNP restored stepping in three individuals with motor complete paralysis due to SCI. The controller appropriately coordinated stimulation and exoskeletal constraints using the sensor-based FSM for subjects with different stimulation systems. The average range of motion at hip and knee joints during walking were 8.5°–20.8° and 14.0°–43.6°, respectively. Walking speeds varied from 0.03 to 0.06 m/s, and cadences from 10 to 20 steps/min.ConclusionsA self-contained muscle-driven exoskeleton was a feasible intervention to restore stepping in individuals with paraplegia due to SCI. The untethered hybrid system was capable of adjusting to different individuals’ needs to appropriately coordinate exoskeletal constraints with muscle activation using a sensor-driven FSM for stepping. Further improvements for out-of-the-laboratory use should include implantation of plantar flexor muscles to improve walking speed and power assist as needed at the hips and knees to maintain walking as muscles fatigue.
Abstract-Spinal cord injury (SCI) can compromise the ability to maintain an erect seated posture. This study examined the feasibility of a sensor-based threshold controller to automatically modulate stimulation to paralyzed hip and trunk extensor muscles to restore upright sitting from forward leaning postures. Forward trunk tilt was estimated from the anterior-posterior component of gravitational acceleration sensed by a sternum-mounted wireless accelerometer. Stimulation increased if trunk tilt exceeded a specified flexion threshold and ceased once upright sitting was resumed. The controller was verified experimentally in five volunteers with SCI and successfully returned all subjects to upright postures from forward leaning positions. Upper-limb effort exerted while returning to erect posture was significantly reduced (to 7.4% +/-3.7% of body mass) pooled across all volunteers while using the controller compared with using continuous and no stimulation (p < 0.03). Controller response times were consistent among subjects when applied while sitting with (0.30 +/-0.05 s) or without (0.34 +/-0.11 s) a backrest. The controller enabled volunteers to lean farther forward (59.7° +/-16.4°) in wheelchairs without upper-limb effort than with no stimulation. Clinical utility of the system for facilitating reach or preventing falls remains to be determined in future studies.
Recently our laboratory team focused on training five individuals with complete spinal cord injuries for an overground FES bike race in the 2016 Cybathlon held in Zurich Switzerland. A unique advantage team Cleveland had over other teams was the use of implanted pulse generators that provide more selective activation of muscles compared to standard surface stimulation. The advancements in muscle strength and endurance and ultimately cycling power our pilots made during this training period helped propel our competing pilot to win gold at the Cybathlon and allowed our pilots to ride their bikes outside within their communities. Such positive outcomes has encouraged us to further explore more widespread use of FES overground cycling as a rehabilitative tool for those with spinal cord injuries. This review will describes our approach to this race including information on the pilots, stimulation strategy, bike details and training program.
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