Above- and below-lesion EMG pattern mapping for controlling electrical stimulation of paraplegics to facilitate unbraced walker-assisted walking

We describe and evaluate above- and below-lesion EMG control of functional electrical stimulation (FES) in upper motor neuron paraplegics, in order to provide them with a patient-responsive system for walking with a walker support. Control is considered in terms of a combination of above-lesion EMG control and below-lesion response-EMG control. The above-lesion EMG is used to control the activation of limb functions involved in standing up and walking with FES, control being accomplished by analysing raw surface-EMG time-series patterns to discriminate between upper-trunk muscle contraction patterns, which in turn, are correlated with intended lower-limb functions involved in walking, so that natural and instinctive balance changes in paraplegics are controlled by the patient from above the lesion. The below-lesion response-EMG is the EMG produced in response to the FES pulses at the stimulation sites, for adjusting stimulation levels as needed when contractions weaken due to muscle fatigue. Above-lesion EMG is a stochastic (random-like) signal, being a response to unsynchronized motor neuron firings, whereas the below-lesion EMG is a deterministic signal responding to synchronized firings that result solely from the FES pulses. We also discuss the merits and difficulties of EMG control, and evaluate patient performance under such control, noting that FES-activated walking without adequate and patient-responsive control is of very limited use to paraplegics.     

Symmetry of FES responses in the lower extremities of paraplegic patients

Due to natural or artificial obstacles, gait is a less automatic and periodic process than it would appear when studying normal walking on the level. Pre-programmed functional electrical stimulation (FES) sequences, therefore, do not appear to be a suitable approach to the control of multichannel electrical stimulators in the restoration of paraplegic walking. Walking in paraplegic subjects must be, to a large extent, under voluntary control. To lessen the burden of this control, the symmetry of walking can be taken into account. Symmetric motion of the legs requires symmetric FES actuation. Symmetry of FES responses was studied in a group of 10 paraplegic subjects who had all undergone the FES training program. Recruitment curve, fatigue index and twitch delay were assessed. An average 80% symmetry was found in all parameters measured, thus allowing a reduction of complexity of control approach for FES locomotor aids.     

Unstable states in four-point walking

The presently utilized walking patterns in paraplegic subjects with complete spinal cord injury (SCI) are compared by the help of graphic representations. Improved four-point gait assisted by functional electrical stimulation (FES) and crutches is proposed by introducing unstable states into the walking sequence. The unstable states are defined as passive phases of walking where the centre of mass (COM) is gravity driven in the direction of progression. The unstable state is described by a simple inverted pendulum model. Kinematic measurements of the unstable state were performed in normal and paraplegic subjects.     

Optimal combination of minimum degrees of freedom to be actuated in the lower limbs to facilitate arm-free paraplegic standing

Arm-free paraplegic standing via functional electrical stimulation (FES) has drawn much attention in the biomechanical field as it might allow a paraplegic to stand and simultaneously use both arms to perform daily activities. However, current FES systems for standing require that the individual actively regulates balance using one or both arms, thus limiting the practical use of these systems. The purpose of the present study was to show that actuating only six out of 12 degrees of freedom (12-DOFs) in the lower limbs to allow paraplegics to stand freely is theoretically feasible with respect to multibody stability and physiological torque limitations of the lower limb DOF. Specifically, the goal was to determine the optimal combination of the minimum DOF that can be realistically actuated using FES while ensuring stability and able-bodied kinematics during perturbed arm-free standing. The human body was represented by a three-dimensional dynamics model with 12-DOFs in the lower limbs. Nakamura's method (Nakamura, Y., and Ghodoussi, U., 1989, "Dynamics Computation of Closed-Link Robot Mechanisms With Nonredundant and Redundant Actuators," IEEE Trans. Rob. Autom., 5(3), pp. 294-302) was applied to estimate the joint torques of the system using experimental motion data from four healthy subjects. The torques were estimated by applying our previous finding that only 6 (6-DOFs) out of 12-DOFs in the lower limbs need to be actuated to facilitate stable standing. Furthermore, it was shown that six cases of 6-DOFs exist, which facilitate stable standing. In order to characterize each of these cases in terms of the torque generation patterns and to identify a potential optimal 6-DOF combination, the joint torques during perturbations in eight different directions were estimated for all six cases of 6-DOFs. The results suggest that the actuation of both ankle flexionextension, both knee flexionextension, one hip flexionextension, and one hip abductionadduction DOF will result in the minimum torque requirements to regulate balance during perturbed standing. To facilitate unsupported FES-assisted standing, it is sufficient to actuate only 6-DOFs. An optimal combination of 6-DOFs exists, for which this system can generate able-bodied kinematics while requiring lower limb joint torques that are producible using contemporary FES technology. These findings suggest that FES-assisted arm-free standing of paraplegics is theoretically feasible, even when limited by the fact that muscles actuating specific DOFs are often denervated or difficult to access.     

Modeling biological motor control for human locomotion with functional electrical stimulation

This paper develops a novel control system for functional electrical stimulation (FES) locomotion, which aims to generate normal locomotion for paraplegics via FES. It explores the possibility of applying ideas from biology to engineering. The neural control mechanism of the biological motor system, the central pattern generator, has been adopted in the control system design. Some artificial control techniques such as neural network control, fuzzy logic, control and impedance control are incorporated to refine the control performance. Several types of sensory feedback are integrated to endow this control system with an adaptive ability. A musculoskeletal model with 7 segments and 18 muscles is constructed for the simulation study. Satisfactory simulation results are achieved under this FES control system, which indicates a promising technique for the potential application of FES locomotion in future.     

Pre-swing deficits in forward propulsion,swing initiation and power generation by individual muscles during hemiparetic walking

Clinical studies of hemiparetic walking have shown pre-swing abnormalities in the paretic leg suggesting that paretic muscle contributions to important biomechanical walking subtasks are different than those of non-disabled individuals. Three-dimensional forward dynamics simulations of two representative hemiparetic subjects with different levels of walking function classified by self-selected walking speed (i.e., limited community=0.4–0.8 m/s and community walkers=>0.8 m/s) and a speed-matched control were generated to quantify individual muscle contributions to forward propulsion, swing initiation and power generation during the pre-swing phase (i.e., double support phase proceeding toe-off). Simulation analyses identified decreased paretic soleus and gastrocnemius contributions to forward propulsion and power generation as the primary impairment in the limited community walker compared to the control subject. The non-paretic leg did not compensate for decreased forward propulsion by paretic muscles during pre-swing in the limited community walker. Paretic muscles had the net effect to absorb energy from the paretic leg during pre-swing in the community walker suggesting that deficits in swing initiation are a primary impairment. Specifically, the paretic gastrocnemius and hip flexors (i.e., iliacus, psoas and sartorius) contributed less to swing initiation and the paretic soleus and gluteus medius absorbed more power from the paretic leg in the community walker compared to the control subject. Rehabilitation strategies aimed at diminishing these deficits have much potential to improve walking function in these hemiparetic subjects and those with similar deficits.     

Excitability Changes in Intracortical Neural Circuits Induced by Differentially Controlled Walking Patterns

Our previous single-pulse transcranial magnetic stimulation (TMS) study revealed that excitability in the motor cortex can be altered by conscious control of walking relative to less conscious normal walking. However, substantial elements and underlying mechanisms for inducing walking-related cortical plasticity are still unknown. Hence, in this study we aimed to examine the characteristics of electromyographic (EMG) recordings obtained during different walking conditions, namely, symmetrical walking (SW), asymmetrical walking 1 (AW1), and asymmetrical walking 2 (AW2), with left to right stance duration ratios of 1:1, 1:2, and 2:1, respectively. Furthermore, we investigated the influence of three types of walking control on subsequent changes in the intracortical neural circuits. Prior to each type of 7-min walking task, EMG analyses of the left tibialis anterior (TA) and soleus (SOL) muscles during walking were performed following approximately 3 min of preparative walking. Paired-pulse TMS was used to measure short-interval intracortical inhibition (SICI) and intracortical facilitation (ICF) in the left TA and SOL at baseline, immediately after the 7-min walking task, and 30 min post-task. EMG activity in the TA was significantly increased during AW1 and AW2 compared to during SW, whereas a significant difference in EMG activity of the SOL was observed only between AW1 and AW2. As for intracortical excitability, there was a significant alteration in SICI in the TA between SW and AW1, but not between SW and AW2. For the same amount of walking exercise, we found that the different methods used to control walking patterns induced different excitability changes in SICI. Our research shows that activation patterns associated with controlled leg muscles can alter post-exercise excitability in intracortical circuits. Therefore, how leg muscles are activated in a clinical setting could influence the outcome of walking in patients with stroke.     

Effect of walking speed changes on tibialis anterior EMG during healthy gait for FES envelope design in drop foot correction.

Functional electrical stimulation may be used to correct hemiplegic drop foot. An optimised stimulation envelope to reproduce the EMG pattern observed in the tibialis anterior (TA) during healthy gait has been proposed by O'Keeffe et al. [O'Keeffe, D.T., Donnelly, A.E., Lyons, G.M., 2003. The development of a potential optimised stimulation intensity envelope for drop foot applications. IEEE Transactions on Neural Systems and Rehabilitation Engineering]. However this envelope did not attempt to account for changes in TA activity with walking speed. The objective of this paper was to provide data to enable the specification of an algorithm to control the adaptation of an envelope with walking speed. Ten young healthy subjects walked on a treadmill at 11 different walking speeds while TA EMG was recorded. The results showed that TA EMG recorded around initial contact and at toe off changed with walking speed. At the slowest velocities, equivalent to hemiplegic walking, the toe-off burst (TOB) of EMG activity had larger peak amplitude than that of the heel-strike burst (HSB). The peak amplitude ratio of TOB:HSB was 1:0.69 at the slowest speed compared to, 1:1.18 and 1:1.5 for the self-selected and fastest speed, respectively. These results suggest that an FES envelope, which produces larger EMG amplitude for the TOB than the HSB, would be more appropriate at walking speeds typical of hemiplegic patients.     

Energetics of paraplegic walking

A group of 35 paraplegic subjects using reciprocating walking orthoses have been examined in order to gain an insight into the potential functional benefits of using such devices. Measurements have been made of walking speeds and of the energy costs of ambulation using an established technique based on heart rate recordings. It was found that orthotically aided walking for paraplegics was slow and energy costly compared with both normal walking and wheelchair propulsion and, as it additionally requires the use of a walking aid in both hands, cannot be considered to confer the functional benefits frequently claimed for it. Nevertheless, the majority of the subjects studied liked their orthosis and did well in it, with many subjectively reporting improvements in mobility and independence.     

Between-day repeatability of lower limb EMG measurement during running and walking

There are minimal data describing the between-day repeatability of EMG measurements during running. Furthermore, there are no data characterising the repeatability of surface EMG measurement from the adductor muscles, during running or walking. The purpose of this study was to report on the consistency of EMG measurement for both running and walking across a comprehensive set of lower limb muscles, including adductor magnus, longus and gracilis. Data were collected from 12 lower limb muscles during overground running and walking on two separate days. The coefficient of multiple correlation (CMC) was used to quantify waveform similarity across the two sessions for signals normalised to either maximal voluntary isometric contraction (MVIC) or mean/peak signal magnitude. For running, the data showed good or excellent repeatability (CMC = 0.87–0.96) for all muscles apart from gracilis and biceps femoris using the MVIC method. Similar levels of repeatability were observed for walking. Importantly, using the peak/mean method as an alternative to the MVIC method, resulted in only marginal improvements in repeatability. The proposed protocol facilitated the collection of repeatable EMG data during running and walking and therefore could be used in future studies investigating muscle patterns during gait.     

Fatigue compensation during FES using surface EMG

Muscle fatigue limits the effectiveness of FES when applied to regain functional movements in spinal cord injured (SCI) individuals. The stimulation intensity must be manually increased to provide more force output to compensate for the decreasing muscle force due to fatigue. An artificial neural network (ANN) system was designed to compensate for muscle fatigue during functional electrical stimulation (FES) by maintaining a constant joint angle. Surface electromyography signals (EMG) from electrically stimulated muscles were used to determine when to increase the stimulation intensity when the muscle’s output started to drop.

In two separate experiments on able-bodied subjects seated in hard back chairs, electrical stimulation was continuously applied to fatigue either the biceps (during elbow flexion) or the quadriceps muscle (during leg extension) while recording the surface EMG. An ANN system was created using processed surface EMG as the input, and a discrete fatigue compensation control signal, indicating when to increase the stimulation current, as the output. In order to provide training examples and test the systems’ performance, the stimulation current amplitude was manually increased to maintain constant joint angles. Manual stimulation amplitude increases were required upon observing a significant decrease in the joint angle. The goal of the ANN system was to generate fatigue compensation control signals in an attempt to maintain a constant joint angle.

On average, the systems could correctly predict 78.5% of the instances at which a stimulation increase was required to maintain the joint angle. The performance of these ANN systems demonstrates the feasibility of using surface EMG feedback in an FES control system.     

Stabilization of human standing posture using functional neuromuscular stimulation

Functional neuromuscular stimulation (FNS)/functional electrical stimulation (FES) is a potential way to restore some functionality to the limbs of patients with spinal cord injury through direct/indirect stimulation of the motoneuron. One of the constraints for wider use of FNS on paraplegic patients is the lack of efficient control algorithm. Most of the published works on FNS/FES control are based on oversimplified models of human body dynamics. An innovative control strategy for stabilizing the standing posture of paraplegic patients is proposed here which is a combination of a proportional-plus-derivative controller for motions of the skeletal system and a control action prediction mechanism to produce musculotendon activation. The goal is to produce musculotendon torque which can approximate those demanded by the controller for the skeletal system. In computer simulations, using a detailed skeletal–musculotendon–muscle activation dynamics model of human body, this FNS/FES control approach can stabilize a paraplegic patient's standing posture with the minimum number of musculotendon groups. Also, it is found that this control strategy can maintain stability even in the presence of reasonable variations in the controller's musculotendon parameters.     

Immediate effects of co-contraction training on motor control of the trunk muscles in people with recurrent low back pain

Although deficits in the activation of abdominal muscles are present in people with low back pain (LBP), this can be modified with motor training. Training of deep abdominal muscles in isolation from the other trunk muscles, as an initial phase of training, has been shown to improve the timing of activation of the trained muscles, and reduce symptoms and recurrence of LBP. The aim of this study was to determine if training of the trunk muscles in a non-isolated manner can restore motor control of these muscles in people with LBP. Ten subjects with non-specific LBP performed a single session of training that involved three tasks: “abdominal curl up”, “side bridge” and “birdog”. Electromyographic activity (EMG) of trunk and deltoid muscles was recorded with fine-wire and surface electrodes during rapid arm movements and walking, before and immediately following the intervention. Onset of trunk muscle EMG relative to that of the prime mover (deltoid) during arm movements and the mean, standard deviation (SD) and coefficient of variation of abdominal muscle EMG during walking were calculated. There was no significant change in the times of onset of trunk muscle EMG during arm movements nor was there any change in the variability of EMG of the abdominal muscles during walking. However, the mean amplitude and SD of abdominal EMG was reduced during walking after training. The results of this study suggest that unlike isolated voluntary training, co-contraction training of the trunk muscles does not restore the motor control of the deep abdominal muscles in people with LBP after a single session of training.     

Transcutaneous FES of the paralyzed quadriceps: is knee torque affected by unintended activation of the hamstrings?

This study addresses the question whether unintended response of the knee flexors (hamstrings) accompanies transcutaneous functional electrical stimulation (FES) of the quadriceps and whether the knee torque is hereby affected. Transcutaneous FES of the right quadriceps of two paraplegic subjects was applied and measurements were made of the net torque and of the myoelectric activities of the quadriceps and hamstrings muscles of the right leg. A low correlation was obtained between the peak-to-peak amplitudes of the M-waves of the two muscles. This correlation decreased further with the development of fatigue, which indicated that the electromyography (EMG) signals from the hamstrings were not the result of cross-talk between adjacent recording sites. The force profile of each muscle was determined from a developed model incorporating EMG-based activation, muscle anthropometry as obtained from in vivo magnetic resonance imaging of the thigh, and metabolic fatigue function, based on data acquired by 31P nuclear magnetic resonance spectroscopy. A sensitivity analysis revealed that the muscle specific tension and the muscle moment arms have a major influence on the resulting muscle forces and should therefore be accurately provided. The results show that during the unfatigued phase of contraction the estimated maximal force in the hamstrings was lower than 20% of that in the quadriceps and could be considered to be practically negligible. As fatigue progressed the hamstrings-to-quadriceps force ratio increased, reaching up to 45%, and the effect of co-activation on the torque partition between the two muscles was no longer negligible.     

Vascular responses to tilting in paraplegic subject compared to normal (author's transl)]

1 Vascular tone is higher in paraplegics than in normals, both in capacitance and resistance vessels. This is possibly correlated with the increase in circulating catecholamines which has recently been reported. 2 Tilting at 30 degrees from horizontal induces a hydrostatic increase in transmural pressure in the affected vascular bed. This pressure change causes: an initial decrease in resistance, followed by a progressive increase which can be explained by the Bayliss reflex. The time sequence and amplitude of the responses are comparable for normal and paraplegic subjects; an increase in vascular tone of the capacitance vessels (increase in venous pressure, decrease in local blood volume). This response was constantly observed in paraplegic subjects and was absent or weak in normal subjects. 3 In conclusion, reflex changes in vascular tone due to upright posture persist after traumatic section of the spinal chord. Orthostatic hypotension and blood pooling in the lower limbs in paraplegic subjects is probably due primarly to a deficit of the pumping action of the leg muscles.     

Afferent feedback in the control of human gait.

Sensory activity contributes to motor control in two fundamentally different ways. It may mediate 'error signals' following sudden external perturbations and it may contribute to the pre-programmed motoneuronal drive. Here we review data, which illustrate these two functions of sensory feedback in relation to human walking. When ankle plantarflexors are unloaded in the stance phase there is a sudden decrease in the sensory activity in muscle and tendon afferents from the active muscles. This decrease in sensory activity results in a drop in EMG activity recorded from the soleus muscle, which demonstrates that the sensory activity contributes importantly to the activation of the muscles. Data suggests that a spinal pathway from gr. II muscle afferents is responsible for this positive feedback contribution to the motoneuronal drive during walking.When cutaneous nerves from the foot are stimulated in the early swing phase of walking a late reflex response may be observed in the tibialis anterior muscle. This reflex may help to ensure that the foot is lifted effectively over an obstacle. Data suggest that this reflex response is at least partly mediated by a transcortical reflex pathway. It seems to be important that reactions to external perturbations are integrated at a supraspinal level during human walking.     

Effect of functional electrical stimulation on the effort and walking speed,surface electromyography activity,and metabolic responses in stroke subjects

ObjectiveTo investigate the effects of functional electrical stimulation (FES) combined with conventional rehabilitation program on the effort and speed of walking, the surface electromyographic (sEMG) activity and metabolic responses in the management of drop foot in stroke subjects.MethodsFifteen patients with a drop foot resulting from stroke at least 3 months prior to the start of the trial took part in this study. All subjects were treated 1 h a day, 5 days a week, for 12 weeks, including conventional stroke rehabilitation program and received 30 min of FES to the tibialis anterior (TA) muscle of the paretic leg in clinical settings. Baseline and post-treatment measurements were made for temporal and spectral EMG parameters of TA muscle, walking speed, the effort of walking as measured by physiological cost index (PCI) and metabolic responses.ResultsThe experimental results showed a significant improvement in mean-absolute-value (21.7%), root-mean-square (66.3%) and median frequency (10.6%) of TA muscle EMG signal, which reflects increased muscle strength. Mean increase in walking speed was 38.7%, and a reduction in PCI of 34.6% between the beginning and at end of the trial. Improvements were also found in cardiorespiratory responses with reduction in oxygen consumption (24.3%), carbon dioxide production (19.9%), heart rate (7.8%) and energy cost (22.5%) while walking with FES device.ConclusionsThe results indicate that the FES may be a useful therapeutic tool combined with conventional rehabilitation program to improve the muscle strength, walking ability and metabolic responses in the management of drop foot with stroke patients.     

Activity and functions of the human gluteal muscles in walking,running, sprinting,and climbing

It has been suggested that the uniquely large gluteus maximus (GMAX) muscles were an important adaptation during hominin evolution based on numerous anatomical differences between humans and extant apes. GMAX electromyographic (EMG) signals have been quantified for numerous individual movements, but not across the range of locomotor gaits and speeds for the same subjects. Thus, comparing relative EMG amplitudes between these activities has not been possible. We assessed the EMG activity of the gluteal muscles during walking, running, sprinting, and climbing. To gain further insight into the function of the gluteal muscles during locomotion, we measured muscle activity during walking and running with external devices that increased or decreased the need to control either forward or backward trunk pitch. We hypothesized that 1) GMAX EMG activity would be greatest during sprinting and climbing and 2) GMAX EMG activity would be modulated in response to altered forward trunk pitch demands during running. We found that GMAX activity in running was greater than walking and similar to climbing. However, the activity during sprinting was much greater than during running. Further, only the inferior portion of the GMAX had a significant change with altered trunk pitch demands, suggesting that the hip extensors have a limited contribution to the control of trunk pitch movements during running. Overall, our data suggest that the large size of the GMAX reflects its multifaceted role during rapid and powerful movements rather than as a specific adaptation for a single submaximal task such as endurance running. Am J Phys Anthropol 153:124–131, 2014. © 2013 Wiley Periodicals, Inc.     

The patterns of changes in the electromyographic profile of muscles in some gait disorders

Electromyograms (EMGs) of subjects with different gait pathologies have been used to analyze the most typical forms of transformation of the muscle EMG profile: (1) a decrease in the muscle electrical activity during a locomotor cycle, either uniform or with a predominant reduction in the region of maximum values (the Mx zone); the former variant is characteristic of structural damage to nerves and muscles, whereas the latter variant is of functional origin because it is related to the alterations in the biomechanical conditions of muscle work during walking; (2) an increase in muscle electrical activity during the cycle, its maxima being prolonged from the Mx zone to the zone of moderate activity (the Md zone); and (3) a complete shift of the activity peaks to another phase of the cycle, usually from the Mx to the Md zone. It has been assumed that all forms of the transformation of the muscle EMG profile except a drastic uniform decrease in activity on damage to nerve and muscle structures are of afferent origin. These types of alterations in the EMG profile are accounted for by disturbance of the biomechanical conditions of muscle activity, such as an increased or decreased muscle load.     

Current topics in clinical FES in Japan

This paper reviews recent topics of clinical application of functional electrical stimulation (FES) for the paralyzed extremities in Japan. Transcutaneous and percutaneous FES systems have been clinically used in Japan. Candidates of extremity FES arer mostly stroke and spinal cord injury patients. By using percutaneous FES system, all of the joints of the upper extremity including the shoulder have been controlled for activities of daily living in the hemiplegic patient. Simultaneous FES control of the hand and wrist and the bilateral hands have also been achieved in C5 and C6 quadriplegics, respectively. Hybrid FES systems using percutaneous and surface electrodes, where FES is used in combination with orthoses, have been applied to the paraplegics because they are highly practical for assisting their locomotive activities. Percutaneous FES have been also provided the amyotropic lateral sclerosis patients with standing up motion. A total implant FES system with 16 output channels is currently developing as a next generation FES system.