Functional Electrical Stimulation mediated by Iterative Learning Control and 3D robotics reduces motor impairment in chronic stroke

Background: Novel stroke rehabilitation techniques that employ electrical stimulation (ES) and robotic technologies are effective in reducing upper limb impairments. ES is most effective when it is applied to support the patients’ voluntary effort; however, current systems fail to fully exploit this connection. This study builds on previous work using advanced ES controllers, and aims to investigate the feasibility of Stimulation Assistance through Iterative Learning (SAIL), a novel upper limb stroke rehabilitation system which utilises robotic support, ES, and voluntary effort. Methods: Five hemiparetic, chronic stroke participants with impaired upper limb function attended 18, 1 hour intervention sessions. Participants completed virtual reality tracking tasks whereby they moved their impaired arm to follow a slowly moving sphere along a specified trajectory. To do this, the participants’ arm was supported by a robot. ES, mediated by advanced iterative learning control (ILC) algorithms, was applied to the triceps and anterior deltoid muscles. Each movement was repeated 6 times and ILC adjusted the amount of stimulation applied on each trial to improve accuracy and maximise voluntary effort. Participants completed clinical assessments (Fugl-Meyer, Action Research Arm Test) at baseline and post-intervention, as well as unassisted tracking tasks at the beginning and end of each intervention session. Data were analysed using t-tests and linear regression. Results: From baseline to post-intervention, Fugl-Meyer scores improved, assisted and unassisted tracking performance improved, and the amount of ES required to assist tracking reduced. Conclusions: The concept of minimising support from ES using ILC algorithms was demonstrated. The positive results are promising with respect to reducing upper limb impairments following stroke, however, a larger study is required to confirm this

Multiple model adaptive control of functional electrical stimulation

This paper establishes the feasibility of multiple-model switched adaptive control to regulate functional electrical stimulation for upper limb stroke rehabilitation. An estimation-based multiple-model switched adaptive control (EMMSAC) framework for nonlinear time-invariant systems is described, and extensions are presented to enable application to time-varying Hammerstein structures that can accurately represent the stimulated arm. A principled design procedure is then developed to construct both a suitable set of candidate models from experimental data and a corresponding set of tracking controllers. The procedure is applied to a sample of able-bodied young participants to produce a general EMMSAC controller. This is then applied to a different sample of the population during an isometric nonvoluntary trajectory tracking task. The results show that it is possible to eliminate model identification while employing closed-loop controllers that maintain high performance in the presence of rapidly changing system dynamics. This paper hence addresses critical limitations to effective stroke rehabilitation in a clinical setting

Intraoperative Neurophysiological Monitoring for Endoscopic Endonasal Approaches to the Skull Base: A Technical Guide.

Intraoperative neurophysiological monitoring during endoscopic, endonasal approaches to the skull base is both feasible and safe. Numerous reports have recently emerged from the literature evaluating the efficacy of different neuromonitoring tests during endonasal procedures, making them relatively well-studied. The authors report on a comprehensive, multimodality approach to monitoring the functional integrity of at risk nervous system structures, including the cerebral cortex, brainstem, cranial nerves, corticospinal tract, corticobulbar tract, and the thalamocortical somatosensory system during endonasal surgery of the skull base. The modalities employed include electroencephalography, somatosensory evoked potentials, free-running and electrically triggered electromyography, transcranial electric motor evoked potentials, and auditory evoked potentials. Methodological considerations as well as benefits and limitations are discussed. The authors argue that, while individual modalities have their limitations, multimodality neuromonitoring provides a real-time, comprehensive assessment of nervous system function and allows for safer, more aggressive management of skull base tumors via the endonasal route

Design and Test of a Biomechanical Model for the Estimation of Knee Joint Angle During Indoor Rowing: Implications for FES-Rowing Protocols in Paraplegia

Functional electrical stimulation of lower limb muscles during rowing provides a means for the cardiovascular conditioning in paraplegia. The possibility of shaping stimulation profiles according to changes in knee angle, so far conceived as changes in seat position, may help circumventing open issues associated with muscle fatigue and movement coordination.Here we present a subject-specific biomechanical model for the estimation of knee joint angle during indoor rowing. Anthropometric measurements and foot and seat position are inputs to the model. We tested our model on two samples of elite rowers; 15 able-bodied and 11 participants in the Rio 2016 Paralympic games. Paralympic rowers presented minor physical disabilities (LTA-PD classification), enabling them to perform the full rowing cycle (with legs, trunks and arms). Knee angle was estimated from the rowing machine seat position, measured with a linear encoder and transmitted wirelessly to a computer. Key results indicate the root mean square error (RMSE) between estimated and measured angles did not depend on group and stroke rate (p>0.267). Significantly greater RMSE values were observed however within the rowing cycle (p<0.001), reaching on average 8deg in the mid-recovery phase. Differences between estimated and measured knee angle values resulted in slightly earlier (5%) detection of knee flexion, regardless of the group and stroke rate considered. Offset of knee extension, knee angle at catch and range of knee motion were identified equally well with our model and with inertial sensors. These results suggest our model describes accurately the movement of knee joint during indoor rowing

New control strategies for neuroprosthetic systems

The availability of techniques to artificially excite paralyzed muscles opens enormous potential for restoring both upper and lower extremity movements with\ud neuroprostheses. Neuroprostheses must stimulate muscle, and control and regulate the artificial movements produced. Control methods to accomplish these tasks include feedforward (open-loop), feedback, and adaptive control. Feedforward control requires a great deal of information about the biomechanical behavior of the limb. For the upper extremity, an artificial motor program was developed to provide such movement program input to a neuroprosthesis. In lower extremity control, one group achieved their best results by attempting to meet naturally perceived gait objectives rather than to follow an exact joint angle trajectory. Adaptive feedforward control, as implemented in the cycleto-cycle controller, gave good compensation for the gradual decrease in performance observed with open-loop control. A neural network controller was able to control its system to customize stimulation parameters in order to generate a desired output trajectory in a given individual and to maintain tracking performance in the presence of muscle fatigue. The authors believe that practical FNS control systems must\ud exhibit many of these features of neurophysiological systems

Feasibility of Using Neuro-Fuzzy Subject-Specific Models for Functional Electrical Stimulation Induced Hand Movements

Functional Electrical Stimulation (FES) is a technique that artificially elicits muscle contractions and it is used to restore motor/sensory functions in both assistive and therapeutic applications. The use of multi-field surface electrodes is a novel popular approach in transcutaneous FES applications. Lately, hybrid systems that combine artificial neural networks and fuzzy logic have also been proposed for many applications in different areas. This paper presents the possibility of combining both approaches for obtaining subject-specific models of FES induced hand movements for grasping applications. Data of the hand and finger motion from two subjects affected by acquired brain injury were used to train two different approaches: coactive neuro-fuzzy inference system and recurrent fuzzy neural network. Preliminary results show that these approaches can be considered in modelling applications for their ability to learn and predict main characteristics of the system, as well as providing useful information from the original system that could be interpreted as subject-specific knowledge

Assessing Side-Differences in the Organization of Biceps Brachii Motor Units in Healthy Subjects and Stroke Patients. An Evaluation from Surface EMG and Incremental Electrical Stimulation

Studies have suggested a degeneration of lower motoneurons in muscles affected after stroke, with a possible collateral reinnervation from the surviving motoneurons to the denervated muscle fibers. If this assumption holds, each surviving motoneuron would innervate a greater amount of muscle fibers following stroke, i.e., motor units’ size would increase in muscles affected after stroke. By combining neuromuscular electrical stimulation with surface electromyography, the present PhD thesis aimed at investigating whether muscle reinnervation following stroke leads to greater variations in the amplitude of M waves elicited in muscles of the affected side of stroke patients, with respect to the contralateral, unaffected side. This issue was verified by applying current pulses at progressively greater intensities in the motoneurons that supply the biceps brachii muscle. Then, the size of increases in the amplitude of M waves elicited consecutively, hereafter defined as increments, was considered to evaluate structural adaptations in biceps brachii motor units following stroke. Changes in the amplitude of M waves evoked in a muscle is usually assumed to reflect changes in the number of motoneurons and, consequently, of muscle fibers activated. Hence, we hypothesized that for similar, relative increases in current intensity, greater increments in the M-waves amplitude would be observed in muscles of the affected than unaffected side of stroke patients. Before verifying this hypothesis, however, we investigated whether the size of increments in biceps brachii M waves differ between arms of healthy subjects. This question was motivated by the fact that, usually, humans tend to control more finely the muscle force production in dominant than non-dominant upper limbs. Once it is well established the recruitment of motor units is a key mechanism for which muscle force is controlled, we hypothesized that a relatively smaller number of motor units maybe recruited in muscles of dominant than nondominant limbs, for any given increase in synaptic input. Hence, we expected to observe smaller increments in the amplitude of M waves evoked in biceps brachii of dominant than non-dominant arms. This PhD thesis was, therefore, based on two main researches, entitled: (1) “Does the biceps brachii muscle respond similarly in both limbs during staircase, electrically elicited contractions?” and (2) “Assessing structural adaptation of biceps brachii motor units after stroke”. Both studies were investigated with the same methodological approach mentioned above. Our main findings showed that: (1) increments were significantly smaller in biceps brachii of dominant than non-dominant arms. These results suggest there was a more gradual motor units’ recruitment and, therefore, a broader spectrum of motor units’ recruitment thresholds in muscles of dominant than non-dominant arms, which may contribute for a finer regulation of force production; (2) there was a clear trend towards greater increments in the amplitude of M waves elicited in biceps brachii of the affected than unaffected arms of most of the stroke patients evaluated. Although for few of these patients it was not clear whether side-differences in the increments magnitude were an outcome of dominance or stroke, the results found corroborate with the notion that collateral reinnervation takes place after stroke, increasing the number of muscle fibers per unit and, therefore, the magnitude of the muscle responses. Overall, the findings of this PhD thesis strengthen the idea that the organization of the neuromuscular system may contribute to accounting for upper limb dominance and that stroke may lead to structural adaptations in motor units of affected muscles

Exercise training reverses myocardial dysfunction induced by CaMKIIδC overexpression by restoring Ca2+-homeostasis

Several conditions of heart disease, including heart failure and diabetic cardiomyopathy, are associated with upregulation of cytosolic Ca2+/calmodulin-dependent protein kinase II (CaMKIIδC) activity. In the heart, CaMKIIδC isoform targets several proteins involved in intracellular Ca2+ homeostasis. We hypothesized that high-intensity endurance training activates mechanisms that enable a rescue of dysfunctional cardiomyocyte Ca2+ handling and thereby ameliorate cardiac dysfunction despite continuous and chronic elevated levels of CaMKIIδC. CaMKIIδC transgenic (TG) and wild-type (WT) mice performed aerobic interval exercise training over 6 wk. Cardiac function was measured by echocardiography in vivo, and cardiomyocyte shortening and intracellular Ca2+ handling were measured in vitro. TG mice had reduced global cardiac function, cardiomyocyte shortening (47% reduced compared with WT, P &#60; 0.01), and impaired Ca2+ homeostasis. Despite no change in the chronic elevated levels of CaMKIIδC, exercise improved global cardiac function, restored cardiomyocyte shortening, and reestablished Ca2+ homeostasis to values not different from WT. The key features to explain restored Ca2+ homeostasis after exercise training were increased L-type Ca2+ current density and flux by 79 and 85%, respectively (P &#60; 0.01), increased sarcoplasmic reticulum (SR) Ca2+-ATPase (SERCA2a) function by 50% (P &#60; 0.01), and reduced diastolic SR Ca2+ leak by 73% (P &#60; 0.01), compared with sedentary TG mice. In conclusion, exercise training improves global cardiac function as well as cardiomyocyte function in the presence of a maintained high CaMKII activity. The main mechanisms of exercise-induced improvements in TG CaMKIIδC mice are mediated via increased L-type Ca2+ channel currents and improved SR Ca2+ handling by restoration of SERCA2a function in addition to reduced diastolic SR Ca2+ leak