A Muscle-First, Electromechanical Hybrid Gait Restoration System in People With Spinal Cord Injury.

The development of a hybrid system for people with spinal cord injuries is described. The system includes implanted neural stimulation to activate the user's otherwise paralyzed muscles, an exoskeleton with electromechanical actuators at the hips and knees, and a sensory and control system that integrates both components. We are using a muscle-first approach: The person's muscles are the primary motivator for his/her joints and the motors provide power assistance.

Walking after incomplete spinal cord injury with an implanted neuromuscular electrical stimulation system and a hinged knee replacement: a single-subject study.

Study Design: Single-subject repeated measures study.

Objectives: Neuromuscular electrical stimulation (NMES) can enhance walking for people with partial paralysis from incomplete spinal cord injury (iSCI). This single-subject study documents an individual's experience who both received an experimental implanted NMES system and underwent clinical bilateral hinged total knee arthroplasty (TKA).

Oxygen Consumption While Walking With Multijoint Neuromuscular Electrical Stimulation After Stroke.

This case study evaluated the effect of implanted multijoint neuromuscular electrical stimulation gait assistance on oxygen consumption relative to walking without neuromuscular electrical stimulation after stroke. The participant walked slowly with an asymmetric gait pattern after stroke. He completed repeated 6-min walk tests at a self-selected walking speed with and without hip, knee, and ankle stimulation assistance.

Long-Term Performance and User Satisfaction With Implanted Neuroprostheses for Upright Mobility After Paraplegia: 2- to 14-Year Follow-Up.

Objective: To quantify the long-term (>2y) effects of lower extremity (LE) neuroprostheses (NPs) for standing, transfers, stepping, and seated stability after spinal cord injury.

Design: Single-subject design case series with participants acting as their own concurrent controls, including retrospective data review.

Setting: Hospital-based clinical biomechanics laboratory with experienced (>20y in the field) research biomedical engineers, a physical therapist, and medical monitoring review.

Effect of exoskeletal joint constraint and passive resistance on metabolic energy expenditure: Implications for walking in paraplegia.

An important consideration in the design of a practical system to restore walking in individuals with spinal cord injury is to minimize metabolic energy demand on the user. In this study, the effects of exoskeletal constraints on metabolic energy expenditure were evaluated in able-bodied volunteers to gain insight into the demands of walking with a hybrid neuroprosthesis after paralysis. The exoskeleton had a hydraulic mechanism to reciprocally couple hip flexion and extension, unlocked hydraulic stance controlled knee mechanisms, and ankles fixed at neutral by ankle-foot orthoses.

A muscle-driven approach to restore stepping with an exoskeleton for individuals with paraplegia.

Background: Functional neuromuscular stimulation, lower limb orthosis, powered lower limb exoskeleton, and hybrid neuroprosthesis (HNP) technologies can restore stepping in individuals with paraplegia due to spinal cord injury (SCI). However, a self-contained muscle-driven controllable exoskeleton approach based on an implanted neural stimulator to restore walking has not been previously demonstrated, which could potentially result in system use outside the laboratory and viable for long term use or clinical testing. In this work, we designed and evaluated an untethered muscle-driven controllable exoskeleton to restore stepping in three individuals with paralysis from SCI.

Accelerometer-based step initiation control for gait-assist neuroprostheses.

Electrical activation of paralyzed musculature can generate or augment joint movements required for walking after central nervous system trauma. Proper timing of stimulation relative to residual volitional control is critical to usefully affecting ambulation. This study evaluates three-dimensional accelerometers and customized algorithms to detect the intent to step from voluntary movements to trigger stimulation during walking in individuals with significantly different etiologies, mobility limitations, manual dexterities, and walking aids.

A stimulation-driven exoskeleton for walking after paraplegia.

An untethered version of a stimulation-driven exoskeleton was evaluated for its ability to restore walking after paralysis from spinal cord injury. The hybrid neuroprosthesis (HNP) combined a passive variable-constraint exoskeleton for stability and support with functional neuromuscular stimulation (FNS) to contract the paralyzed muscles to drive limb movement. This self-contained HNP was operated by an onboard controller that sampled sensor signals, generated appropriate commands to both the exoskeletal constraints and integrated stimulator, and transmitted data wirelessly via Bluetooth to an off-board computer for real-time monitoring and recording for offline analysis.

Feasibility of Restoring Walking in Multiple Sclerosis with Multichannel Implanted Electrical Stimulation.

A patient with multiple sclerosis-related gait dysfunction was followed over the course of his disease. Despite aggressive treatment, he developed significant weakness in ankle dorsiflexors and hip and knee flexors and was no longer capable of consistently taking a step on his own. With electrical stimulation of hip and knee flexors and ankle dorsiflexors using implanted electrodes, he was able to consistently walk short distances as far as 30 m, thus significantly improving his Expanded Disability Status Scale score.

Improving Walking with an Implanted Neuroprosthesis for Hip, Knee, and Ankle Control After Stroke.

Objective: The objective of this work was to quantify the effects of a fully implanted pulse generator to activate or augment actions of hip, knee, and ankle muscles after stroke.

Design: The subject was a 64-year-old man with left hemiparesis resulting from hemorrhagic stroke 21 months before participation. He received an 8-channel implanted pulse generator and intramuscular stimulating electrodes targeting unilateral hip, knee, and ankle muscles on the paretic side.

Improving stand-to-sit maneuver for individuals with spinal cord injury.

Background: Users of neuroprostheses employing electrical stimulation (ES) generally complete the stand-to-sit (STS) maneuver with high knee angular velocities, increased upper limb support forces, and high peak impact forces at initial contact with the chair. Controlling the knee during STS descent is challenging in individuals with spinal cord injury (SCI) due to the decreasing joint moment available with increased knee angle in response to ES.

Methods: The goal of this study was to investigate the effects of incorporating either (1) a coupling mechanism that coordinates hip and knee flexion or (2) a mechanism that damps knee motion to keep the knee angular velocity constant during the STS transition.

Powered Lower-Limb Exoskeletons to Restore Gait for Individuals with Paraplegia - a Review.

Individuals with paraplegia due to spinal cord injury rank restoration of walking high on the list of priorities to improving their quality of life. Powered lower-limb exoskeleton technology provides the ability to restore standing up, sitting down, and walking movements for individuals with paraplegia. The robotic exoskeletons generally have electrical motors located at the hip and knee joint centers, which move the wearers' lower limbs through the appropriate range of motion for gait according to control systems using either trajectory control or impedance control.

Feasibility of a Hydraulic Power Assist System for Use in Hybrid Neuroprostheses.

Feasibility of using pressurized hydraulic fluid as a source of on-demand assistive power for hybrid neuroprosthesis combining exoskeleton with functional neuromuscular stimulation was explored. Hydraulic systems were selected as an alternative to electric motors for their high torque/mass ratio and ability to be located proximally on the exoskeleton and distribute power distally to assist in moving the joints. The power assist system (PAS) was designed and constructed using off-the-shelf components to test the feasibility of using high pressure fluid from an accumulator to provide assistive torque to an exoskeletal hip joint.

Forward stair descent with hybrid neuroprosthesis after paralysis: Single case study demonstrating feasibility.

The ability to negotiate stairs is important for community access and independent mobility but requires more effort and strength than level walking. For this reason, previous attempts to utilize functional neuromuscular stimulation (FNS) to restore stair navigation after spinal cord injury (SCI) have had limited success and are not readily generalizable. Stair descent is particularly challenging because it requires energy absorption via eccentric muscle contractions, a task not easily accomplished with FNS.

Functional electrical stimulation and spinal cord injury.

Spinal cord injuries (SCI) can disrupt communications between the brain and the body, resulting in loss of control over otherwise intact neuromuscular systems. Functional electrical stimulation (FES) of the central and peripheral nervous system can use these intact neuromuscular systems to provide therapeutic exercise options to allow functional restoration and to manage medical complications following SCI. The use of FES for the restoration of muscular and organ functions may significantly decrease the morbidity and mortality following SCI.

Sensor-based hip control with hybrid neuroprosthesis for walking in paraplegia.

The objectives of this study were to test whether a hybrid neuroprosthesis (HNP) with an exoskeletal variable-constraint hip mechanism (VCHM) combined with a functional neuromuscular stimulation (FNS) controller can maintain upright posture with less upper-limb support and improve gait speed as compared with walking with either an isocentric reciprocating gait orthosis (IRGO) or FNS only. The results show that walking with the HNP significantly reduced forward lean in FNS-only walking and the maximum upper-limb forces by 42% and 19% as compared with the IRGO and FNS-only gait, respectively. Walking speed increased significantly with VCHM as compared with 1:1 reciprocal coupling and by 15% when using the sensor-based FNS controller as compared with HNP with fixed baseline stimulation without the controller active.

Understanding stand-to-sit maneuver: implications for motor system neuroprostheses after paralysis.

Standing up, standing, and walking functions can be restored to people with spinal cord injury by contracting the paralyzed hip, knee, and ankle muscles with electrical stimulation. Restoring these functions using electrical stimulation requires controlled activation to provide coordinated movements. However, the stand-to-sit (STS) maneuver involves eccentric contractions of the quadriceps to control lowering of the body to the seated position, which is difficult to achieve with stimulation alone and presents unique challenges to lower-limb neuroprostheses.

Stance controlled knee flexion improves stimulation driven walking after spinal cord injury.

Background: Functional neuromuscular stimulation (FNS) restores walking function after paralysis from spinal cord injury via electrical activation of muscles in a coordinated fashion. Combining FNS with a controllable orthosis to create a hybrid neuroprosthesis (HNP) has the potential to extend walking distance and time by mechanically locking the knee joint during stance to allow knee extensor muscle to rest with stimulation turned off. Recent efforts have focused on creating advanced HNPs which couple joint motion (e.

Ambulation and spinal cord injury.

Walking is possible for many patients with a spinal cord injury. Avenues enabling walking include braces, robotics and FES. Among the benefits are improved musculoskeletal and mental health, however unrealistic expectations may lead to negative changes in quality of life.

Finite state control of a variable impedance hybrid neuroprosthesis for locomotion after paralysis.

We have previously reported on a novel variable impedance knee mechanism (VIKM). The VIKM was designed as a component of a hybrid neuroprosthesis to regulate knee flexion. The hybrid neuroprosthesis is a device that uses a controllable brace to support the body against collapse while stimulation provides power for movement.

Walking after partial paralysis assisted with EMG-triggered or switch-triggered functional electrical stimulation--two case studies.

Functional Electrical Stimulation (FES) facilitates walking after paralysis by activating the muscles of the lower extremities. The FES-assisted stepping triggered either by a manual switch (switch-trigger), or by an electromyogram-based gait event detector (EMG-trigger) were presented in random order to two subjects with incomplete spinal cord injuries (iSCI) during ten trials over two alternate days. Subject iSCI-1 (C6 ASIA C) was non-ambulatory without the assistance of FES and could stand but not initiate a step volitionally.

Development of a self-contained accelerometry based system for control of functional electrical stimulation in hemiplegia.

For stroke patients, functional electrical stimulation (FES) has been shown in the past to greatly reduce gait impairments. A critical element of the success of this intervention is accurate and reliable triggering of the stimulation for step initiation. Foot switches are the most commonly used devices for triggering hemiplegic FES gait, but they have been known to produce unreliable results and degrade over time.

Restoration of stance phase knee flexion during walking after spinal cord injury using a variable impedance orthosis.

A hybrid neuroprosthesis (HNP) combines lower extremity bracing with functional neuromuscular stimulation (FNS) to restore walking function and enhance the efficiency of ambulation. This report details the development of a novel HNP containing a variable impedance knee mechanism (VIKM) capable of supporting the knee against collapse while allowing controlled stance phase knee flexion. The design of a closed loop, finite state controller for coordination of VIKM activity with FNS-driven gait is presented.

An objective method for selecting command sources for myoelectrically triggered lower-limb neuroprostheses.

Functional electrical stimulation (FES) facilitates ambulatory function after paralysis of persons with spinal cord injury (SCI) by exciting the peripheral motor nerves to activate the muscles of the lower limbs. This study identified a process for selecting command sources for triggering FES with the surface electromyogram (EMG) from muscles partially paralyzed by incomplete SCI, given its high degree of intersubject variability. We found Discriminability Index (DI) to be a good metric to evaluate the potential of controlling FES-assisted ambulation in four nondisabled volunteers and two participants with incomplete paralysis.

Stance control knee mechanism for lower-limb support in hybrid neuroprosthesis.

A hydraulic stance control knee mechanism (SCKM) was developed to fully support the knee against flexion during stance and allow uninhibited motion during swing for individuals with paraplegia using functional neuromuscular stimulation (FNS) for gait assistance. The SCKM was optimized for maximum locking torque for body-weight support and minimum resistance when allowing for free knee motion. Ipsilateral and contralateral position and force feedback were used to control the SCKM.