Identifying candidates for targeted gait rehabilitation: better prediction through biomechanics-informed characterization

BACKGROUND: Walking speed has been used to predict the efficacy of gait training; however, poststroke motor impairments are heterogeneous and different biomechanical strategies may underlie the same walking speed. Identifying which individuals will respond best to a particular gait rehabilitation program using walking speed alone may thus be limited. The objective of this study was to determine if, beyond walking speed, participants' baseline ability to generate propulsive force from their paretic limbs (paretic propulsion) influences the improvements in walking speed resulting from a paretic propulsion-targeting gait intervention. METHODS: Twenty seven participants >6 months poststroke underwent a 12-week locomotor training program designed to target deficits in paretic propulsion through the combination of fast walking with functional electrical stimulation to the paretic ankle musculature (FastFES). The relationship between participants' baseline usual walking speed (UWSbaseline), maximum walking speed (MWSbaseline), and paretic propulsion (propbaseline) versus improvements in usual walking speed (∆UWS) and maximum walking speed (∆MWS) were evaluated in moderated regression models. RESULTS: UWSbaseline and MWSbaseline were, respectively, poor predictors of ΔUWS (R 2  = 0.24) and ΔMWS (R 2  = 0.01). Paretic propulsion × walking speed interactions (UWSbaseline × propbaseline and MWSbaseline × propbaseline) were observed in each regression model (R 2 s = 0.61 and 0.49 for ∆UWS and ∆MWS, respectively), revealing that slower individuals with higher utilization of the paretic limb for forward propulsion responded best to FastFES training and were the most likely to achieve clinically important differences. CONCLUSIONS: Characterizing participants based on both their walking speed and ability to generate paretic propulsion is a markedly better approach to predicting walking recovery following targeted gait rehabilitation than using walking speed alone

Mechanisms to increase propulsive force for individuals poststroke

Background: Propulsive force generation is critical to walking speed. Trialing limb angle and ankle moment are major contributors to increases in propulsive force during gait. For able-bodied individuals, trailing limb angle contributes twice as much as ankle moment to increases in propulsive force during speed modulation. The aim of this study was to quantify the relative contribution of ankle moment and trailing limb angle to increases in propulsive force for individuals poststroke. Methods: A biomechanical-based model previously developed for able-bodied individuals was evaluated and enhanced for individuals poststroke. Gait analysis was performed as subjects (N = 24) with chronic poststroke hemiparesis walked at their self-selected and fast walking speeds on a treadmill. Results: Both trailing limb angle and ankle moment increased during speed modulation. In the paretic limb, the contribution from trailing limb angle versus ankle moment to increases in propulsive force is 74% and 17%. In the non-paretic limb, the contribution from trailing limb angle versus ankle moment to increases in propulsive force is 67% and 22%. Conclusions: Individuals poststroke increase propulsive force mainly by changing trailing limb angle in both the paretic and non-paretic limbs. This strategy may contribute to the inefficiency in poststroke walking patterns. Future work is needed to examine whether these characteristics can be modified via intervention

Changes in Predicted Muscle Coordination with Subject-Specific Muscle Parameters for Individuals after Stroke

Muscle weakness is commonly seen in individuals after stroke, characterized by lower forces during a maximal volitional contraction. Accurate quantification of muscle weakness is paramount when evaluating individual performance and response to after stroke rehabilitation. The objective of this study was to examine the effect of subject-specific muscle force and activation deficits on predicted muscle coordination when using musculoskeletal models for individuals after stroke. Maximum force generating ability and central activation ratio of the paretic plantar flexors, dorsiflexors, and quadriceps muscle groups were obtained using burst superimposition for four individuals after stroke with a range of walking speeds. Two models were created per subject: one with generic and one with subject-specific activation and maximum isometric force parameters. The inclusion of subject-specific muscle data resulted in changes in the model-predicted muscle forces and activations which agree with previously reported compensation patterns and match more closely the timing of electromyography for the plantar flexor and hamstring muscles. This was the first study to create musculoskeletal simulations of individuals after stroke with subject-specific muscle force and activation data. The results of this study suggest that subject-specific muscle force and activation data enhance the ability of musculoskeletal simulations to accurately predict muscle coordination in individuals after stroke

Changes in the activation and function of the ankle plantar flexor muscles due to gait retraining in chronic stroke survivors

Background A common goal of persons post-stroke is to regain community ambulation. The plantar flexor muscles play an important role in propulsion generation and swing initiation as previous musculoskeletal simulations have shown. The purpose of this study was to demonstrate that simulation results quantifying changes in plantar flexor activation and function in individuals post-stroke were consistent with (1) the purpose of an intervention designed to enhance plantar flexor function and (2) expected muscle function during gait based on previous literature. Methods Three-dimensional, forward dynamic simulations were created to determine the changes in model activation and function of the paretic ankle plantar flexor muscles for eight patients post-stroke after a 12-weeks FastFES gait retraining program. Results An median increase of 0.07 (Range [−0.01,0.22]) was seen in simulated activation averaged across all plantar flexors during the double support phase of gait from pre- to post-intervention. A concurrent increase in walking speed and plantar flexor induced forward center of mass acceleration by the plantar flexors was seen post-intervention for seven of the eight subject simulations. Additionally, post-training, the plantar flexors had an simulated increase in contribution to knee flexion acceleration during double support. Conclusions For the first time, muscle-actuated musculoskeletal models were used to simulate the effect of a gait retraining intervention on post-stroke muscle model predicted activation and function. The simulations showed a new pattern of simulated activation for the plantar flexor muscles after training, suggesting that the subjects activated these muscles with more appropriate timing following the intervention. Functionally, simulations calculated that the plantar flexors provided greater contribution to knee flexion acceleration after training, which is important for increasing swing phase knee flexion and foot clearance

Predicting muscle forces of individuals with hemiparesis following stroke

<p>Abstract</p> <p>Background</p> <p>Functional electrical stimulation (FES) has been used to improve function in individuals with hemiparesis following stroke. An ideal functional electrical stimulation (FES) system needs an accurate mathematical model capable of designing subject and task-specific stimulation patterns. Such a model was previously developed in our laboratory and shown to predict the isometric forces produced by the quadriceps femoris muscles of able-bodied individuals and individuals with spinal cord injury in response to a wide range of clinically relevant stimulation frequencies and patterns. The aim of this study was to test our isometric muscle force model on the quadriceps femoris, ankle dorsiflexor, and ankle plantar-flexor muscles of individuals with post-stroke hemiparesis.</p> <p>Methods</p> <p>Subjects were seated on a force dynamometer and isometric forces were measured in response to a range of stimulation frequencies (10 to 80-Hz) and 3 different patterns. Subject-specific model parameter values were obtained by fitting the measured force responses from 2 stimulation trains. The model parameters thus obtained were then used to obtain predicted forces for a range of frequencies and patterns. Predicted and measured forces were compared using intra-class correlation coefficients, r²values, and model error relative to the physiological error (variability of measured forces).</p> <p>Results</p> <p>Results showed excellent agreement between measured and predicted force-time responses (r²>0.80), peak forces (ICCs>0.84), and force-time integrals (ICCs>0.82) for the quadriceps, dorsiflexor, and plantar-fexor muscles. The <it>model error </it>was within or below the +95% confidence interval of the <it>physiological error </it>for >88% comparisons between measured and predicted forces.</p> <p>Conclusion</p> <p>Our results show that the model has potential to be incorporated as a feed-forward controller for predicting subject-specific stimulation patterns during FES.</p

Stimulation of paralysed quadriceps muscles with sequentially and spatially distributed electrodes during dynamic knee extension

Background: During functional electrical stimulation (FES) tasks with able-bodied (AB) participants, spatially distributed sequential stimulation (SDSS) has demonstrated substantial improvements in power output and fatigue properties compared to conventional single electrode stimulation (SES). The aim of this study was to compare the properties of SDSS and SES in participants with spinal cord injury (SCI) in a dynamic isokinetic knee extension task simulating knee movement during recumbent cycling. Method: Using a case-series design, m. vastus lateralis and medialis of four participants with motor and sensory complete SCI (AIS A) were stimulated for 6 min on both legs with both electrode setups. With SES, target muscles were stimulated by a pair of electrodes. In SDSS, the distal electrodes were replaced by four small electrodes giving the same overall stimulation frequency and having the same total surface area. Torque was measured during knee extension by a dynamometer at an angular velocity of 110 deg/s. Mean power of the left and right sides (PmeanL,R) was calculated from all stimulated extensions for initial, final and all extensions. Fatigue is presented as an index value with respect to initial power from 1 to 0, whereby 1 means no fatigue. Results: SDSS showed higher PmeanL,R values for all four participants for all extensions (increases of 132% in participant P1, 100% in P2, 36% in P3 and 18% in P4 compared to SES) and for the initial phase (increases of 84%, 59%, 66%, and 16%, respectively). Fatigue resistance was better with SDSS for P1, P2 and P4 but worse for P3 (0.47 vs 0.35, 0.63 vs 0.49, 0.90 vs 0.82 and 0.59 vs 0.77, respectively). Conclusion: Consistently higher PmeanL,R was observed for all four participants for initial and overall contractions using SDSS. This supports findings from previous studies with AB participants. Fatigue properties were better in three of the four participants. The lower fatigue resistance with SDSS in one participant may be explained by a very low muscle activation level in this case. Further investigation in a larger cohort is warranted

Development of a mathematical model for predicting electrically elicited quadriceps femoris muscle forces during isovelocity knee joint motion

<p>Abstract</p> <p>Background</p> <p>Direct electrical activation of skeletal muscles of patients with upper motor neuron lesions can restore functional movements, such as standing or walking. Because responses to electrical stimulation are highly nonlinear and time varying, accurate control of muscles to produce functional movements is very difficult. Accurate and predictive mathematical models can facilitate the design of stimulation patterns and control strategies that will produce the desired force and motion. In the present study, we build upon our previous isometric model to capture the effects of constant angular velocity on the forces produced during electrically elicited concentric contractions of healthy human quadriceps femoris muscle. Modelling the isovelocity condition is important because it will enable us to understand how our model behaves under the relatively simple condition of constant velocity and will enable us to better understand the interactions of muscle length, limb velocity, and stimulation pattern on the force produced by the muscle.</p> <p>Methods</p> <p>An additional term was introduced into our previous isometric model to predict the force responses during constant velocity limb motion. Ten healthy subjects were recruited for the study. Using a KinCom dynamometer, isometric and isovelocity force data were collected from the human quadriceps femoris muscle in response to a wide range of stimulation frequencies and patterns. % error, linear regression trend lines, and paired t-tests were used to test how well the model predicted the experimental forces. In addition, sensitivity analysis was performed using Fourier Amplitude Sensitivity Test to obtain a measure of the sensitivity of our model's output to changes in model parameters.</p> <p>Results</p> <p>Percentage RMS errors between modelled and experimental forces determined for each subject at each stimulation pattern and velocity showed that the errors were in general less than 20%. The coefficients of determination between the measured and predicted forces show that the model accounted for ~86% and ~85% of the variances in the measured force-time integrals and peak forces, respectively.</p> <p>Conclusion</p> <p>The range of predictive abilities of the isovelocity model in response to changes in muscle length, velocity, and stimulation frequency for each individual make it ideal for dynamic applications like FES cycling.</p