功能性电刺激技术在截瘫行走中的应用研究进展

截瘫是由脊髓损伤所造成的双下肢严重残疾,近年来的发病率呈显著上升趋势。截瘫最主要的病症就是行走能力的丧失。经过40多年的研究表明,功能性电刺激技术能成功地恢复截瘫患者的部分运动功能,是现代康复工程领域很有应用前景的一项新技术,正在受到越来越多的重视。本文专门针对用于截瘫行走的功能性电刺激技术,介绍了与之相关的背景知识和研究进展。     

Reliability of neural-network functional electrical stimulation gait-control system

Functional electrical stimulation (FES) has been used for restoring walking in spinal-cord injured (SCI) persons. Using artificial intelligence (AI), FES controllers have been developed that allow the automatic phasing of stimulation, to replace the function of hand or heel switches. However, there has been no study to evaluate the reliability of these AI systems. Neural networks were used to construct FES controllers to control the timing of stimulation. Different numbers of sensors in the sensor set and different numbers of data points from each sensor were used. Two incomplete-SCI subjects were recruited, and each was tested on three separate occasions. The results show the neural-network controllers can maintain a high accuracy (around 90% for the two- and three-sensor groups and 80% for the one-sensor group) over a period of six months. Two or three sensors were sufficient to provide enough information to construct a reliable FES control system, and the number of data points did not have any effect on the reliability of the system.     

Reliability of neural-network functional electrical stimulation gait-control system

Functional electrical stimulation (FES) has been used for restoring walking in spinal-cord injured (SCI) persons. Using artificial intelligence (Al), FES controllers have been developed that allow the automatic phasing of stimulation, to replace the function of hand or heel switches. However, there has been no study to evaluate the reliability of these Al systems. Neural networks were used to construct FES controllers to control the timing of stimulation. Different numbers of sensors in the sensor set and different numbers of data points from each sensor were used. Two incomplete-SCI subjects were recruited, and each was tested on three separate occasions. The results show the neural-network controllers can maintain a high accuracy (around 90% for the two- and three-sensor groups and 80% for the onesensor group) over a period of six months. Two or three sensors were sufficient to provide enough information to construct a reliable FES control system, and the number of data points did not have any effect on the reliability of the system.     

Gait control system for functional electrical stimulation using neural networks

In functional electrical stimulation (FES) systems for restoring walking in spinal cord injured (SCI) individuals, hand switches are the preferred method for controlling stimulation timing. Through practice the user becomes an ‘expert’ in determining when stimulation should be applied. Neural networks have been used to ‘clone’ this expertise but these applications have used small numbers of sensors, and their structure has used a binary output, giving rise to possible controller oscillations. It was proposed that a threelayer structure neural network with continuous function, using a larger number of sensors, including ‘virtual’ sensors, can be used to ‘clone’ this expertise to produce good controllers. Using a sensor set of ten force sensors and another of 13 ‘virtual’ kinematic sensors, a good FES control system was constructed using a three-layer neural network with five hidden nodes. The sensor set comprising three sensors showed the best performance. The accuracy of the optimum three-sensor set for the force sensors and the virtual kinematic sensors was 90% and 93%, respectively, compared with 81% and 77% for a heel switch. With 32 synchronised sensors, binary neural networks and continuous neural networks were constructed and compared. The networks using continuous function had significantly fewer oscillations. Continuous neural networks offer the ability to generate good FES controllers.     

功能性电刺激在呼吸功能重建中的应用进展

目的:总结功能性电刺激技术在呼吸功能重建方面的应用进展。方法:以"膈神经刺激器""膈肌起搏""呼吸起搏器""脊髓电刺激""脊髓损伤""功能性电刺激""呼吸功能不全"以及"phrenic nerve stimulator""diaphragm pacing""respiratory pacemaker""spinal c...     

Characterization and control of muscle response to electrical stimulation

The maintenance of upright posture in neurologically intact human subjects is mediated by two major nervous pathways. The first, leading from the cerebral cortex through the spinal cord to motor neurons, activates muscles which produce postural movements. The second, leading from various sensory organs to higher centers, provides sensory feedback regarding the postural state. The path through the spinal cord is no longer intact in victims of spinal cord injury and loss of normal control of muscle activity results. Functional neuromuscular stimulation (FNS) has been shown as a feasible method for obtaining muscle contraction in paraplegic and has been proposed as a means for control of antero-posterior sway to make upright posture possible for these individuals. Before muscle can be controlled through the use of FNS, the response of muscle to electrical stimulation must be understood. In past studies, linear control theory has been applied to the analysis of this response and to the testing of various controllers. The aim of this study was to demonstrate some control issues in FNS using linear control theory, as it applies to electrical stimulation of muscle for stabilization of posture. The linearity of the muscle response was improved through closed-loop control using pole compensation techniques. The excess phase shift of the system due to the time delay in the muscle response, however, limits the ability to increase the open-loop gain in order to obtain improved performance. A suggestion for further study is the application of this methodology for uses in posture control.     

振荡电场刺激治疗脊髓损伤的研究进展

脊髓损伤是一种发病率较高的致残病变.振荡电场刺激可以促进损伤的轴突再生.就近年来振荡电场刺激治疗脊髓损伤的进展进行了综述,包括人体临床试验、联合疗法的应用、治疗领域的拓展以及作用机理上的进展,同时指出了目前研究中存在的问题,并对发展趋势进行了展望.     

Functional electrical stimulation for the upper limb in tetraplegic spinal cord injury: a systematic review

Abstract

Technological advances have helped to improve functional ability in spinal cord injury survivors. The aim of this study is to systematically review the evidence for functional electrical stimulation (FES) on functional tasks involving the upper limb in people with spinal cord injuries. The authors systematically searched from September 2009 to September 2014 in relevant databases using a combination of keywords covering spinal cord injury and FES. Studies were selected using pre-determined criteria. The search yielded 144 studies. Only five studies met the inclusion criteria. All five reported improvements immediately and at follow-up in functional ability as a result of FES or FES combined with conventional therapy. There is some preliminary evidence that FES may reduce disability due to upper limb-related activity limitations in tetraplegic spinal cord injury. Further work needs to examine the role of FES in more detail and in combination with other treatments.     

Initiating extension of the lower limbs in subjects with complete spinal cord injury by epidural lumbar cord stimulation

We provide evidence that the human spinal cord is able to respond to external afferent input and to generate a sustained extension of the lower extremities when isolated from brain control. The present study demonstrates that sustained, nonpatterned electrical stimulation of the lumbosacral cord—applied at a frequency in the range of 5–15 Hz and a strength above the thresholds for twitches in the thigh and leg muscles—can initiate and retain lower-limb extension in paraplegic subjects with a long history of complete spinal cord injury. We hypothesize that the induced extension is due to tonic input applied by the epidural stimulation to primary sensory afferents. The induced volleys elicit muscle twitches (posterior root muscle-reflex responses) at short and constant latency times and coactivate the configuration of the lumbosacral interneuronal network, presumably via collaterals of the primary sensory neurons and their connectivity with this network. We speculate that the volleys induced externally to the lumbosacral network at a frequency of 5–15 Hz initiate and retain an extension pattern generator organization. Once established, this organization would recruit a larger population of motor units in the hip and ankle extensor muscles as compared to the flexors, resulting in an extension movement of the lower limbs. In the electromyograms of the lower-limb muscle groups, such activity is reflected as a characteristic spatiotemporal pattern of compound motor-unit potentials.Abbreviations C Cervical - CMUP Compound motor-unit potential - EMG Potential - CNS Central nervous system - EMG Electromyography, electromyographic - H Hamstring - L Lumbar - MLR Mesencephalic locomotor region - PARA Paraspinal muscles - Q Quadriceps - S Sacral - SCI Spinal cord injury, spinal cord-injured - SCS Spinal cord stimulation - T Thoracic - TA Tibialis anterior - TS Triceps surae     

Identification of nonlinear model of ankle joint dynamics during electrical stimulation of soleus

The mechanical impedance of the ankle joint was estimated in two conditions: during submaximal surface electrical stimulation of the soleus muscle, and with no stimulation applied. Both neurologically intact (n=5) and spinal cord injured subjects (n=4) were used. The mechanical impedance was measured by applying angular step and constant velocity (13–100° s⁻¹) perturbations at 10° to the ankle and measuring the resulting changes in torque. A five-element lumped model consisting of an inertial element, a parallel elastic element, and an elastic element in series with a viscous element and a pure tension generator produced a good fit for predicting the compliance characteristics of the ankle for both the relaxed and stimulated conditions. The elastic elements were piecewise linear with different values for the dorsiflexion and plantarflexion directions. The viscous element was velocity-dependent and it decreased in value as the velocity increased. The average torque error between the measured and model's response during soleus stimulation was 10·56% for the dorsiflexed and 11·93% for the plantarflexed perturbations. However, the average error was skewed by several subjects who had excessive error, due to volitional intervention or flexor withdrawal reflex. The average model error for the perturbations without stimulation was 7·12% for dorsiflexed and 5·58% for plantarflexed perturbations.     

Quantitative weightbearing and gait evaluation of paraplegics using functional electrical stimulation

In this study functional electrical stimulation (FES) was used to generate supported gait in paraplegic patients with traumatic upper-motor-neuron lesions, between the T5 and T12 spinal levels. Four patients have so far been treated and studied over a period of one year. The quadriceps and gluteus maximus muscles are stimulated simultaneously to achieve a supported standing position, while hip, knee and ankle flexions are achieved, alternately for each leg by stimulating the shank surface at two selected locations (flexion reflex). The stimulus used has an intensity of 120V, duration of 0·3 ms and frequency of 24 Hz. The standing and walking behaviour of patients was monitored in the gait laboratory of the Loewenstein Hospital. The amount of weightbearing on each foot during standing was established by time integration, over a standard period of time, of the reaction forces, as measured by ‘Kistler’ force platforms, on which the patient was required to stand, while taking care to support his walking aids outside the platform area. The gait of the patients was evaluated by means of an electrical contact system in which time/distance parameters of the stride were measured. Some typical results indicate a walking velocity of 10 cm s⁻¹ and weightbearing on the feet during standing of 80 per cent of body weight. Computer processing of the data acquired was used to obtain objective evaluation of the patients' progress during their training period towards easier and more independent mobility.     

Effect of gradually modulated electrical stimulation on the plasticity of artificially evoked movements

The paper presents a feasibility study to show that movement plasticity can be improved using a gradually modulated stimulation sequence. The stimulation amplitude can be adjusted to eight above-threshold levels for 16 equal intervals within the walking cycle. The efficiency of such stimulation was demonstrated on the drop-foot correction with two hemiparetic patients. The pretibial muscle group was stimulated and a significant improvement of the ankle-joint goniograms was shown. This fact suggests that a more important correction of hemiplegic gait using multichannel continuously modulated sequences can be achieved.     

Myosin heavy chain isoform transformation in single fibres from m. vastus lateralis in spinal cord injured individuals: Effects of long-term functional electrical stimulation (FES)

The myosin heavy chain (MHC) composition of single fibres from m. vastus lateralis of five spinal-cord-injured (SCI) individuals was analysed by Sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) before, and after 6 and 12 months of functional electrical stimulation (FES)-training, administrated for 30 min three times per week. Prior to FES training 37.2% of the fibres contained only MHC HB, 21.2% only MHC IIA, and 40.7% co-expressed MHC IIA and MHC IIB. After 6 months of FES-training the number of fibres containing only MHC IIB was reduced to 2.6% (P < 0.05), the number of fibres containing only MHC IIA was increased to 44.3 (P < 0.05), and the number of fibres co-expressing MHC IIA and MHC HB was 50.9% (ns). After 12 months almost all fibres (91.2%,P < 0.05) contained only MHC IIA. The number of fibres containing only MHC IIB was 2.3 % and the fibres co-expressing MHC HA and HB had decreased to 4.6% (P < 0.05). The amount of fibres containing only MHC I never exceeded 0.5%. Likewise, the number of fibres co-expressing MHC I and MHC IIA was below 2% throughout the study period. In total, the MHC composition of 1596 single fibres was determined. This study shows that FES-training of paralysed human skeletal muscle administrated over a prolonged period of time, can lead to a marked switch in MHC expression from about equal amounts of MHC HA and MHC HB to an almost total dominance of MHC HA.     

Finite state control of functional electrical stimulation for the rehabilitation of gait

Finite state control is an established technique for the implementation of intention detection and activity co-ordination levels of hierarchical control in neural prostheses, and has been used for these purposes over the last thirty years. The first finite state controllers (FSC) in the functional electrical stimulation of gait were manually crafted systems, based on observations of the events occurring during the gait cycle. Subsequent systems used machine learning to automatically learn finite state control behaviour directly from human experts. Recently, fuzzy control has been utilised as an extension of finite state control, resulting in improved state detection over standard finite state control systems in some instances. Clinical experience over the last thirty years has been positive, and has shown finite state control to be an effective and intuitive method for the control of functional electrical stimulation (FES) in neural prostheses. However, while finite state controlled neural prostheses are of interest in the research community, they are not widely used outside of this setting. This is largely due to the cumbersome nature of many neural prostheses which utilise externally mounted gait sensors and FES electrodes. FES-based control of movement has been subject to the constraints of artificial sensor and FES actuator technologies. However, continued advances in natural sensors and implanted multi-channel stimulators are broadening the boundaries of artificial control of movement, driving an evolutionary process towards increasingly human-like control of FES-based gait rehabilitation systems.     

Injectable microstimulator for functional electrical stimulation

A family of digitally controlled devices is constructed for functional electrical stimulation in which each module is an hermetically sealed glass capsule that is small enough to be injected through the lumen of a hypodermic needle. The overall design and component characteristics of microstimulators that receive power and command signals by inductive coupling from a single, externally worn coil are described. Each device stores power between stimulus pulses by charging an electrolytic capacitor formed by its two electrodes, made of sintered, anodised tantalum and electrochemically activated iridium, respectively. Externally, a highly efficient class E amplifier provides power and digitally encoded command signals to control the amplitude, duration and timing of pulses from up to 256 such microstimulators.     

Regulating knee joint position by combining electrical stimulation with a controllable friction brake

Hybrid FES gait restoration systems which combine stimulation with controllable mechanical damping elements at the joints show promise for providing good control of limb motion despite variations in muscle properties. In this paper we compared three controllers for position tracking of the free swinging shank in able-bodied subjects. The controllers were open-loop (OL), proportional-derivative closed-loop (PD), and bang-bang plus controlled-brake control (CB). Both OL and PD controllers contained a forward path element, which inverted a model of the electrically stimulated muscle and limb system. The CB control was achieved by maximally activating the appropriate muscle group and controlling the brake to be a “moving-wall” against which the limb pushed. The CB control resulted in superior tracking performance for a wide range of position tracking tasks and muscle fatigue states but required no calibration or knowledge of muscle properties. The disadvantages of CB control include excess mechanical power dissipation in the brake and impact forces applied to the skeletal system.     

Dose dependence of the 5-HT agonist quipazine in facilitating spinal stepping in the rat with epidural stimulation

Epidural electrical stimulation (ES) at spinal cord segment L2 can produce coordinated step-like movements in completely spinalized adult rats [R.M. Ichiyama, Y.P. Gerasimenko, H. Zhong, R.R. Roy, V.R. Edgerton, Hindlimb stepping movements in complete spinal rats induced by epidural spinal cord stimulation, Neurosci. Lett. 383 (2005) 339-344]. Plantar placement of the paws, however, was rarely observed. Here, we sought to determine the dose dependence of a 5-HT agonist (quipazine) on stepping kinematics when administered in combination with ES. Six adult female Sprague-Dawley rats received a complete mid-thoracic spinal cord transection and were implanted with epidural electrodes at the L2 spinal cord level. Quipazine (i.p.) was tested at doses of 0.1, 0.2, 0.3, 0.4, and 0.5 mg/kg. Rats were placed in a body weight support system, allowing them to walk bipedally on a moving treadmill belt (7 cm/s). 3D step kinematics analysis revealed that coordinated alternating bilateral stepping was induced by L2 stimulation (50 Hz) alone and by quipazine alone. Furthermore, the combination treatment produced significantly greater numbers of plantar steps and improved quality of stepping compared to either intervention alone. Both number and quality of stepping peaked at the intermediate dose of 0.3-0.4 mg/kg. The results indicate that quipazine and ES can have complementary effects on spinal circuits and that quipazine dosage is an important factor in differentially modulating these circuitries to improve the quality of the bipedal stepping on a treadmill belt.     

Field distribution of epidural electrical stimulation

Epidural electrical stimulation has been applied in clinics for many years. However, there is still a concern about possible injury to spinal nerves. This study investigated electrical field and current density distribution during direct epidural electrical stimulation. Field distribution models were theoretically deduced, while the distribution of potentials and current were analyzed. The current density presented an increase of 70–80%, with one peak value ranging from −85° to 85° between the two stimulated poles. The effect of direct epidural electrical stimulation is mainly on local tissue surrounding the electrodes, concentrated around the two stimulated positions.     

Long-term spinal cord injury increases susceptibility to isometric contraction-induced muscle injury

Complete spinal cord injury (SCI) results in inactivation and unloading of affected skeletal muscles. Unloading causes an increased susceptibility of muscle to contraction-induced injury. This study used magnetic resonance imaging (MRI) to test the hypothesis that isometric contractions would evoke greater muscle damage to the quadriceps femoris muscle (mQF) of SCI subjects than that of able-bodied (AB) controls. MR images were taken of the mQF prior to, immediately post, and 3 days post electromyostimulation (EMS). EMS consisted of five sets of ten isometric contractions (2 s on/6 s off, 1 min between sets) followed by another three sets of ten isometric contractions (1 s on/1 s off, 30 s between sets). Average muscle cross-sectional area (CSA) and the relative areas of stimulated and injured muscle were obtained from MR images by quantifying the number of pixels with an elevated T2 signal. SCI subjects had significantly greater relative area [90 (2)% versus 66 (4)%, P<0.05; mean (SE)] but a lesser absolute area [16 (3) cm² versus 44 (6) cm², P<0.05] of mQF stimulated than AB controls. During EMS, peak torque was reduced by 66% and 37% for SCI and control subjects, respectively. Three days post EMS, there was a greater relative area of stimulated mQF injured for the SCI subjects [25 (6)% versus 2 (1)%, P<0.05]. Peak torque remained decreased by 22% on day 3 in the SCI group only. These results indicate that affected muscle years after SCI is more susceptible to contraction-induced muscle damage, as determined by MRI, compared to AB controls. They also support the contention that electrically elicited isometric contractions are sufficient to cause muscle damage after a prolonged period of inactivity.     

The relationship between exercise work intervals and duration of exercise on lower extremity training induced by electrical stimulation in humans with spinal cord injuries

A group of 90 male paraplegics were studied to determine the optimal training protocol for isokinetic exercise induced by functional electrical stimulation of the quadriceps muscles. The parameters that were varied were the number of training sessions a week, the length of the training sessions each day, and the work-rest intervals in each training session. Training for 3 days a week for 30 min a day with 6 s of exercise and 6 s of rest proved the optimal protocol. Training for 5 days or for 1 day a week was not as effective in training strength or endurance. A combination of 50% work and 50% rest produced a much greater gain in strength and endurance than work:rest ratios of 66%:33% or 25%:75%. When training was conducted for 5 min, 15 min or 30 min each day, the greatest increase was found when the muscles were exercised for 30 min each day. While more variables need to be examined, this study has provided some initial guidelines for isokinetic training of humans using electrical stimulation. Accepted: 9 April 2000