A perspective on the control of FES-supported standing

This special section is about the control of electrical stimulators to restore standing functions to paraplegics. It addresses several important topics regarding the interactions of the intact central nervous systems (CNS) with the artificial control system. The topics are as follows: how paraplegics use their arms to help themselves stand up with functional electrical stimulation (FES); the user-driven artificial control of FESsupported standing up; a controller which is promising for the control of sitting down; the application of reinforcement machine learning for the controllers of standing up; arms-free\ud standing with voluntary upper body balancing and artificially controlled ankle stiffness; and cognitive feedback in balancing. This Commentary introduces the papers in this section and relates them to earlier research

Voluntary Ambulation by Upper Limb-Triggered HAL® in Patients with Complete Quadri/Paraplegia Due to Chronic Spinal Cord Injury

Patients with complete paraplegia after spinal cord injury (SCI) are unable to stand or walk on their own. Standing exercise decreases the risk of decubitus ulcers, osteoporosis, and joint deformities in patients with SCI. Conventional gait training for complete paraplegia requires excessive upper limb usage for weight bearing and is difficult in cases of complete quadriplegia. The purpose of this study was to describe voluntary ambulation triggered by upper limb activity using the Hybrid Assistive Limb® (HAL) in patients with complete quadri/paraplegia after chronic SCI. Four patients (3 men, 1 woman) were enrolled in this study. The mean patient age ± standard deviation was 37.2 ± 17.8 (range, 20–67) years. Clinical evaluation before intervention revealed the following findings: case 1, neurological level C6, American Spinal Cord Injury Association impairment scale (AIS) grade B; case 2, T6, AIS A; case 3, T10 AIS A; and case 4, T11, AIS A. The HAL intervention consisted of 10 sessions. Each HAL session lasted 60–90 min. The HAL electrodes for hip and knee flexion-extension were placed on the anterior and posterior sides of the upper limbs contralaterally corresponding to each of the lower limbs. Surface electromyography (EMG) was used to evaluate muscle activity of the tensor fascia lata and quadriceps femoris (Quad) in synchronization with a Vicon motion capture system. The modified Ashworth scale (mAs) score was also evaluated before and after each session. All participants completed all 10 sessions. Cases 1, 2, and 3 demonstrated significant decreases in mAs score after the sessions compared to pre-session measurements. In all cases, EMG before the intervention showed no apparent activation in either Quad. However, gait phase dependent activity of the lower limb muscles was seen during voluntarily triggered ambulation driven by upper limb muscle activities. In cases 3 and 4, active contraction in both Quads was observed after intervention. These findings suggest that upper-limb-triggered HAL ambulation is a safe and feasible option for rehabilitation in patients with complete quadri/paraplegia caused by chronic SCI

Feedback Control of an Exoskeleton for Paraplegics: Toward Robustly Stable Hands-free Dynamic Walking

This manuscript presents control of a high-DOF fully actuated lower-limb exoskeleton for paraplegic individuals. The key novelty is the ability for the user to walk without the use of crutches or other external means of stabilization. We harness the power of modern optimization techniques and supervised machine learning to develop a smooth feedback control policy that provides robust velocity regulation and perturbation rejection. Preliminary evaluation of the stability and robustness of the proposed approach is demonstrated through the Gazebo simulation environment. In addition, preliminary experimental results with (complete) paraplegic individuals are included for the previous version of the controller.Comment: Submitted to IEEE Control System Magazine. This version addresses reviewers' concerns about the robustness of the algorithm and the motivation for using such exoskeleton

Functional Rehabilitation: Coordination of Artificial and Natural Controllers

International audienceWalking and standing abilities, though important for quality of life and participation in social and economic activities, can be adversely affected by central nervous system (CNS) disorders such as spinal cord injury, stroke or traumatic brain injury. One characteristic of motor deficiencies which affect lower extremities is their impact on both static and dynamic postural equilibrium. Depending on the impairment level, functional rehabilitation techniques may be needed for a patient to stand up and walk (Popovic and Sinkjær, 2003). Functional electrical stimulation (FES) can induce contraction of skeletal muscles by applying electrical stimuli to sensory-motor system via electrodes which can be placed on the skin (Kralj et al., 1983), or implanted (Guiraud et al., 2006). FES applications applied to lower limbs include foot drop correction, single joint control, cycling, standing up, walking... (Zhang and Zhu, 2007)..

Brain-controlled cycling system for rehabilitation following paraplegia with delay-time prediction

Objective: Robotic rehabilitation systems have been investigated to assist with motor dysfunction recovery in patients with lower-extremity paralysis caused by central nervous system lesions. These systems are intended to provide appropriate sensory feedback associated with locomotion. Appropriate feedback is thought to cause synchronous neuron firing, resulting in the recovery of function. Approach: In this study, we designed and evaluated an ergometric cycling wheelchair, with a brain-machine interface (BMI), that can force the legs to move by including normal stepping speeds and quick responses. Experiments were conducted in five healthy subjects and one patient with spinal cord injury (SCI), who experienced the complete paralysis of the lower limbs. Event-related desynchronization (ERD) in the β band (18‐28 Hz) was used to detect lower-limb motor images. Main results: An ergometer-based BMI system was able to safely and easily force patients to perform leg movements, at a rate of approximately 1.6 seconds/step (19 rpm), with an online accuracy rate of 73.1% for the SCI participant. Mean detection time from the cue to pedaling onset was 0.83±0.31 s Significance: This system can easily and safely maintain a normal walking speed during the experiment and be designed to accommodate the expected delay between the intentional onset and physical movement, to achieve rehabilitation effects for each participant. Similar BMI systems, implemented with rehabilitation systems, may be applicable to a wide range of patients

Enhancing Nervous System Recovery through Neurobiologics, Neural Interface Training, and Neurorehabilitation.

After an initial period of recovery, human neurological injury has long been thought to be static. In order to improve quality of life for those suffering from stroke, spinal cord injury, or traumatic brain injury, researchers have been working to restore the nervous system and reduce neurological deficits through a number of mechanisms. For example, neurobiologists have been identifying and manipulating components of the intra- and extracellular milieu to alter the regenerative potential of neurons, neuro-engineers have been producing brain-machine and neural interfaces that circumvent lesions to restore functionality, and neurorehabilitation experts have been developing new ways to revitalize the nervous system even in chronic disease. While each of these areas holds promise, their individual paths to clinical relevance remain difficult. Nonetheless, these methods are now able to synergistically enhance recovery of native motor function to levels which were previously believed to be impossible. Furthermore, such recovery can even persist after training, and for the first time there is evidence of functional axonal regrowth and rewiring in the central nervous system of animal models. To attain this type of regeneration, rehabilitation paradigms that pair cortically-based intent with activation of affected circuits and positive neurofeedback appear to be required-a phenomenon which raises new and far reaching questions about the underlying relationship between conscious action and neural repair. For this reason, we argue that multi-modal therapy will be necessary to facilitate a truly robust recovery, and that the success of investigational microscopic techniques may depend on their integration into macroscopic frameworks that include task-based neurorehabilitation. We further identify critical components of future neural repair strategies and explore the most updated knowledge, progress, and challenges in the fields of cellular neuronal repair, neural interfacing, and neurorehabilitation, all with the goal of better understanding neurological injury and how to improve recovery

Feasibility of Rehabilitation Training With a Newly Developed Wearable Robot for Patients With Limited Mobility

ObjectiveTo investigate the feasibility of rehabilitation training with a new wearable robot.DesignBefore-after clinical intervention.SettingUniversity hospital and private rehabilitation facilities.ParticipantsA convenience sample of patients (N=38) with limited mobility. The underlying diseases were stroke (n=12), spinal cord injuries (n=8), musculoskeletal diseases (n=4), and other diseases (n=14).InterventionsThe patients received 90-minute training with a wearable robot twice per week for 8 weeks (16 sessions).Main Outcome MeasuresFunctional ambulation was assessed with the 10-m walk test (10MWT) and the Timed Up & Go (TUG) test, and balance ability was assessed with the Berg Balance Scale (BBS). Both assessments were performed at baseline and after rehabilitation.ResultsThirty-two patients completed 16 sessions of training with the wearable robot. The results of the 10MWT included significant improvements in gait speed, number of steps, and cadence. Although improvements were observed, as measured with the TUG test and BBS, the results were not statistically significant. No serious adverse events were observed during the training.ConclusionsEight weeks of rehabilitative training with the wearable robot (16 sessions of 90min) could be performed safely and effectively, even many years after the subjects received their diagnosis

Uner Tan Syndrome: History, Clinical Evaluations, Genetics, and the\ud Dynamics of Human Quadrupedalism

Abstract: This review includes for the first time a dynamical systems analysis of human quadrupedalism in Uner Tan syndrome, which is characterized by habitual quadrupedalism, impaired intelligence, and rudimentary speech. The first family was discovered in a small village near Iskenderun, and families were later found in Adana and two other small villages near Gaziantep and Canakkale. In all the affected individuals dynamic balance was impaired during upright walking,and they habitually preferred walking on all four extremities. MRI scans showed inferior cerebellovermian hypoplasia with slightly simplified cerebral gyri in three of the families, but appeared normal in the fourth. PET scans showed a decreased glucose metabolic activity in the cerebellum, vermis and, to a lesser extent the cerebral cortex, except for one patient,\ud whose MRI scan also appeared to be normal. All four families had consanguineous marriages in their pedigrees,\ud suggesting autosomal recessive transmission. The syndrome was genetically heterogeneous. Since the initial discoveries\ud more cases have been found, and these exhibit facultative quadrupedal locomotion, and in one case, late childhood onset. It has been suggested that the human quadrupedalism may, at least, be a phenotypic example of reverse evolution. From the viewpoint of dynamic systems theory, it was concluded there may not be a single factor that predetermines human quadrupedalism in Uner Tan syndrome, but that it may involve self-organization, brain plasticity, and rewiring, from the many decentralized and local interactions among neuronal, genetic, and environmental subsystems