Towards Natural Control of Artificial Limbs

The use of implantable electrodes has been long thought as the solution for a more natural control of artificial limbs, as these offer access to long-term stable and physiologically appropriate sources of control, as well as the possibility to elicit appropriate sensory feedback via neurostimulation. Although these ideas have been explored since the 1960’s, the lack of a long-term stable human-machine interface has prevented the utilization of even the simplest implanted electrodes in clinically viable limb prostheses.In this thesis, a novel human-machine interface for bidirectional communication between implanted electrodes and the artificial limb was developed and clinically implemented. The long-term stability was achieved via osseointegration, which has been shown to provide stable skeletal attachment. By enhancing this technology as a communication gateway, the longest clinical implementation of prosthetic control sourced by implanted electrodes has been achieved, as well as the first in modern times. The first recipient has used it uninterruptedly in daily and professional activities for over one year. Prosthetic control was found to improve in resolution while requiring less muscular effort, as well as to be resilient to motion artifacts, limb position, and environmental conditions.In order to support this work, the literature was reviewed in search of reliable and safe neuromuscular electrodes that could be immediately used in humans. Additional work was conducted to improve the signal-to-noise ratio and increase the amount of information retrievable from extraneural recordings. Different signal processing and pattern recognition algorithms were investigated and further developed towards real-time and simultaneous prediction of limb movements. These algorithms were used to demonstrate that higher functionality could be restored by intuitive control of distal joints, and that such control remains viable over time when using epimysial electrodes. Lastly, the long-term viability of direct nerve stimulation to produce intuitive sensory feedback was also demonstrated.The possibility to permanently and reliably access implanted electrodes, thus making them viable for prosthetic control, is potentially the main contribution of this work. Furthermore, the opportunity to chronically record and stimulate the neuromuscular system offers new venues for the prediction of complex limb motions and increased understanding of somatosensory perception. Therefore, the technology developed here, combining stable attachment with permanent and reliable human-machine communication, is considered by the author as a critical step towards more functional artificial limbs

Neuromusculoskeletal Arm Prostheses: Personal and Social Implications of Living With an Intimately Integrated Bionic Arm

People with limb loss are for the first time living chronically and uninterruptedly with intimately integrated neuromusculoskeletal prostheses. This new generation of artificial limbs are fixated to the skeleton and operated by bidirectionally transferred neural information. This unprecedented level of human–machine integration is bound to have profound psychosocial effects on the individuals living with these prostheses. Here, we examined the psychosociological impact on people as they integrate neuromusculoskeletal prostheses into their bodies and lives. Three people with transhumeral amputations participated in this study, all of whom had been living with neuromusculoskeletal prostheses in their daily lives between 2 and 6 years at the time of the interview. Direct neural sensory feedback had been enabled for 6 months to 2 years. Participants were interviewed about their experiences living with the neuromusculoskeletal prostheses in their home and professional daily lives. We analyzed these interviews to elucidate themes using an interpretive phenomenological approach that regards participants’ own experiences as forms of expertise and knowledge-making. Our participant-generated results indicate that people adapted and integrated the technology into functional and social arenas of daily living, with positive psychosocial effects on self-esteem, self-image, and social relations intimately linked to improved trust of the prostheses. Participants expressed enhanced prosthetic function, increased and more diverse prosthesis use in tasks of daily living, and improved relationships between their prosthesis and phantom limb. Our interviews with patients also generated critiques of the language commonly used to describe human-prosthetic relations, including terms such as “embodiment,” and the need for specificity surrounding the term “natural” with regard to control versus sensory feedback. Experiences living with neuromusculoskeletal prostheses were complex and subject-dependent, and therefore future research should consider human–machine interaction as a relationship that is constantly enacted, negotiated, and deeply contextualized

The rubber hand illusion is a fallible method to study ownership of prosthetic limbs

Enabling sensory feedback in limb prostheses can reverse a damaged body image caused by amputation. The rubber hand illusion (RHI) is a popular paradigm to study ownership of artificial limbs and potentially useful to assess sensory feedback strategies. We investigated the RHI as means to induce ownership of a prosthetic hand by providing congruent visual and tactile stimuli. We elicited tactile sensations via electric stimulation of severed afferent nerve fibres in four participants with transhumeral amputation. Contrary to our expectations, they failed to experience the RHI. The sensations we elicited via nerve stimulation resemble tapping as opposed to stroking, as in the original RHI. We therefore investigated the effect of tapping versus stroking in 30 able-bodied subjects. We found that either tactile modality equally induced ownership in two-thirds of the subjects. Failure to induce the RHI in the intact hand of our participants with amputation later confirmed that they form part of the RHI-immune population. Conversely, these participants use neuromusculoskeletal prostheses with neural sensory feedback in their daily lives and reported said prostheses as part of their body. Our findings suggest that people immune to the RHI can nevertheless experience ownership over prosthetic limbs when used in daily life and accentuates a significant limitation of the RHI paradigm

Alpha Oscillation in Phantom Limb Pain Patients: A Neuropathic Pain Signature

People with acquired amputation face oftentimes the onset of chronic pain, which develops as either residual limb pain, neuroma or nociceptive phantom limb pain (PLP), or neuropathic PLP.\ua0 To date, the pathophysiology giving raise to PLP is still object of debate, with previous literature mainly focusingon whether and how reorganization takes place in the primary somatosensory and motor cortices. Striving to understand how changes in somatotopy and mototopy relate to PLP, brain imaging studies have traditionally been conducted with a task-based fMRI approaches which measure the neuralactivity in an indirect way. Yet, little is known about the effect of amputation on the global brain organization and electrophysiological techniques, such as EEG, have not been taken fully advantage of. In this study we analyse the power of spontaneous and ongoing EEG activity as a function offrequency. The rationale for this choice stems from the assumption that brain at rest, in opposition to task-based paradigms, allows to capture dynamics related to the processing of pain which would otherwise be masked by other sensory or cognitive functions processes

The stochastic entanglement and phantom motor execution hypotheses: A theoretical framework for the origin and treatment of Phantom limb pain

Phantom limb pain (PLP) is a debilitating condition common after amputation that can considerably hinder patients\u27 quality of life. Several treatments have reported promising results in alleviating PLP. However, clinical evaluations are usually performed in small cohorts and rigorous clinical trials are scarce. In addition, the underlying mechanisms by which novel interventions alleviate PLP are often unclear, potentially because the condition itself is poorly understood. This article presents a theoretical framework of PLP that can be used as groundwork for hypotheses of novel treatments. Current hypotheses on the origins of PLP are discussed in relation to available clinical findings. Stochastic entanglement of the pain neurosignature, or connectome, with impaired sensorimotor circuitry is proposed as an alternative hypothesis for the genesis of PLP, and the implications and predictions this hypothesis entails are examined. In addition, I present a hypothesis for the working mechanism of Phantom Motor Execution (PME) as a treatment of PLP, along with its relation to the aforementioned stochastic entanglement hypothesis, which deals with PLP\u27s incipience. PME aims to reactivate the original central and peripheral circuitry involved in motor control of the missing limb, along with increasing dexterity of stump muscles. The PME hypothesis entails that training of phantom movements induces gradual neural changes similar to those of perfecting a motor skill, and these purposefully induced neural changes disentangle pain processing circuitry by competitive plasticity. This is a testable hypothesis that can be examined by brain imaging and behavioral studies on subjects undergoing PME treatment. The proposed stochastic entanglement hypothesis of PLP can be generalized to neuropathic pain due to sensorimotor impairment, and can be used to design suitable therapeutic treatments

A multi-dimensional framework for prosthetic embodiment: a perspective for translational research

The concept of embodiment has gained widespread popularity within prosthetics research. Embodiment has been claimed to be an indicator of the efficacy of sensory feedback and control strategies. Moreover, it has even been claimed to be necessary for prosthesis acceptance, albeit unfoundedly. Despite the popularity of the term, an actual consensus on how prosthetic embodiment should be used in an experimental framework has yet to be reached. The lack of consensus is in part due to terminological ambiguity and the lack of an exact definition of prosthetic embodiment itself. In a review published parallel to this article, we summarized the definitions of embodiment used in prosthetics literature and concluded that treating prosthetic embodiment as a combination of ownership and agency allows for embodiment to be quantified, and thus useful in translational research. Here, we review the potential mechanisms that give rise to ownership and agency considering temporal, spatial, and anatomical constraints. We then use this to propose a multi-dimensional framework where prosthetic embodiment arises within a spectrum dependent on the integration of volition and multi-sensory information as demanded by the degree of interaction with the environment. This framework allows for the different experimental paradigms on sensory feedback and prosthetic control to be placed in a common perspective. By considering that embodiment lays along a spectrum tied to the interactions with the environment, one can conclude that the embodiment of prosthetic devices should be assessed while operating in environments as close to daily life as possible for it to become relevant

Electrical stimulation to promote osseointegration of bone anchoring implants: a topical review

Electrical stimulation has shown to be a promising approach for promoting osseointegration in bone anchoring implants, where osseointegration defines the biological bonding between the implant surface and bone tissue. Bone-anchored implants are used in the rehabilitation of hearing and limb loss, and extensively in edentulous patients. Inadequate osseointegration is one of the major factors of implant failure that could be prevented by accelerating or enhancing the osseointegration process by artificial means. In this article, we reviewed the efforts to enhance the biofunctionality at the bone-implant interface with electrical stimulation using the implant as an electrode. We reviewed articles describing different electrode configurations, power sources, and waveform-dependent stimulation parameters tested in various in vitro and in vivo models. In total 55 English-language and peer-reviewed publications were identified until April 2020 using PubMed, Google Scholar, and the Chalmers University of Technology Library discovery system using the keywords: osseointegration, electrical stimulation, direct current and titanium implant. Thirteen of those publications were within the scope of this review. We reviewed and compared studies from the last 45\ua0years and found nonuniform protocols with disparities in cell type and animal model, implant location, experimental timeline, implant material, evaluation assays, and type of electrical stimulation. The reporting of stimulation parameters was also found to be inconsistent and incomplete throughout the literature. Studies using in vitro models showed that osteoblasts were sensitive to the magnitude of the electric field and duration of exposure, and such variables similarly affected bone quantity around implants in in vivo investigations. Most studies showed benefits of electrical stimulation in the underlying processes leading to osseointegration, and therefore we found the idea of promoting osseointegration by using electric fields to be supported by the available evidence. However, such an effect has not been demonstrated conclusively nor optimally in humans. We found that optimal stimulation parameters have not been thoroughly investigated and this remains an important step towards the clinical translation of this concept. In addition, there is a need for reporting standards to enable meta-analysis for evidence-based treatments

Mindful SensoriMotor Therapy combined with brain modulation for the treatment of pain in individuals with disarticulation or nerve injuries: a single-arm clinical trial

INTRODUCTION: Neuropathic pain is a complex and demanding medical condition that is often difficult to treat. Regardless of the cause, the impairment, lesion or damage to the nervous system can lead to neuropathic pain, such as phantom limb pain (PLP). No treatment has been found widely effective for PLP, but plasticity-guided therapies have shown the least severe side effects in comparison to pharmacological or surgical interventions. Phantom motor execution (PME) is a plasticity-guided intervention that has shown promising results in alleviating PLP. The potential mechanism underlying the effectiveness of PME can be explained by the Stochastic Entanglement hypothesis for neurogenesis of neuropathic pain resulting from sensorimotor impairment. We have built on this hypothesis to investigate the efficacy of enhancing PME interventions by using phantom motor imagery to facilitate execution and with the addition of sensory training. We refer to this new treatment concept as Mindful SensoriMotor Therapy (MiSMT). In this study, we further complement MiSMT with non-invasive brain modulation, specifically transcranial direct current stimulation (tDCS), for the treatment of neuropathic pain in patients with disarticulation or peripheral nerve injury. METHODS AND ANALYSIS: This single-arm clinical trial investigates the efficacy of MiSMT and tDCS as a treatment of neuropathic pain resulting from highly impaired extremity or peripheral nerve injury in eight participants. The study consists of 12 sessions of MiSMT with anodal tDCS in the motor cortex, pretreatment and post-treatment assessments, and follow-up sessions (up to 6 months). The primary outcome is the change in pain intensity as measured by the Pain Rating Index between the first and last treatment sessions. ETHICS AND DISSEMINATION: The study is performed under the approval of the governing ethical committee in Sweden (approval number 2020-07157) and in accordance with the Declaration of Helsinki. TRIAL REGISTRATION NUMBER: NCT04897425

Design of an open-source transfemoral bypass socket

The development of control algorithms and prosthetic hardware for lower limb prostheses involves an iterative testing process. Here, we present the design and validation of a bypass socket to enable able-bodied researchers to wear a leg prosthesis for evaluation purposes. The bypass socket can be made using a 3D-printer and standard household tools. It has an open-socket design that allows for electromyography recordings. It was designed for people with a height of 160 – 190 cm and extra caution should be observed with users above 80 kg. The use of a safety harness when wearing a prosthesis with the bypass socket is also recommended for additional safety

Stationary wavelet processing and data imputing in myoelectric pattern recognition on a low-cost embedded system

Pattern recognition-based decoding of surface electromyography allows for intuitive and flexible control of prostheses but comes at the cost of sensitivity to in-band noise and sensor faults. System robustness can be improved with wavelet-based signal processing and data imputing, but no attempt has been made to implement such algorithms on real-time, portable systems. The aim of this work was to investigate the feasibility of low-latency, wavelet-based processing and data imputing on an embedded device capable of controlling upper-arm prostheses. Nine able-bodied subjects performed Motion Tests while inducing transient disturbances. Additional investigation was performed on pre-recorded Motion Tests from 15 able-bodied subjects with simulated disturbances. Results from real-time tests were inconclusive, likely due to the low number of disturbance episodes, but simulated tests showed significant improvements in most metrics for both algorithms. However, both algorithms also showed reduced responsiveness during disturbance episodes. These results suggest wavelet-based processing and data imputing can be implemented in portable, real-time systems to potentially improve robustness to signal distortion in prosthetic devices with the caveat of reduced responsiveness for the typically short duration of signal disturbances. The trade-off between large-scale signal corruption robustness and system responsiveness warrants further studies in daily life activities