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Toward a hybrid exoskeleton for crouch gait in children with cerebral palsy: neuromuscular electrical stimulation for improved knee extension.

ABSTRACT: BACKGROUND:Neuromuscular Electrical Stimulation (NMES) has been utilized for many years in cerebral palsy (CP) with limited success despite its inherent potential for improving muscle size and/or strength, inhibiting or reducing spasticity, and enhancing motor performance during functional activities such as gait. While surface NMES has been shown to successfully improve foot drop in CP and stroke, correction of more complex gait abnormalities in CP such as flexed knee (crouch) gait remains challenging due to the level of stimulation needed for the quadriceps muscles that must be balanced with patient tolerability and the ability to deliver NMES assistance at precise times within a gait cycle. METHODS:This paper outlines the design and evaluation of a custom, noninvasive NMES system that can trigger and adjust electrical stimulation in real-time. Further, this study demonstrates feasibility of one possible application for this digitally-controlled NMES system as a component of a pediatric robotic exoskeleton to provide on-demand stimulation to leg muscles within specific phases of the gait cycle for those with CP and other neurological disorders who still have lower limb sensation and volitional control. A graphical user interface was developed to digitally set stimulation parameters (amplitude, pulse width, and frequency), timing, and intensity during walking. Benchtop testing characterized system delay and power output. System performance was investigated during a single session that consisted of four overground walking conditions in a 15-year-old male with bilateral spastic CP, GMFCS Level III: (1) his current Ankle-Foot Orthosis (AFO); (2) unassisted Exoskeleton; (3) NMES of the vastus lateralis; and (4) NMES of the vastus lateralis and rectus femoris. We hypothesized in this participant with crouch gait that NMES triggered with low latency to knee extensor muscles during stance would have a modest but positive effect on knee extension during stance. RESULTS:The system delivers four channels of NMES with average delays of 16.5?±?13.5?ms. Walking results show NMES to the vastus lateralis and rectus femoris during stance immediately improved mean peak knee extension during mid-stance (p?=?0.003*) and total knee excursion (p?=?0.009*) in the more affected leg. The electrical design, microcontroller software and graphical user interface developed here are included as open source material to facilitate additional research into digitally-controlled surface stimulation ( github.com/NIHFAB/NMES ). CONCLUSIONS:The custom, digitally-controlled NMES system can reliably trigger electrical stimulation with low latency. Precisely timed delivery of electrical stimulation to the quadriceps is a promising treatment for crouch. Our ultimate goal is to synchronize NMES with robotic knee extension assistance to create a hybrid NMES-exoskeleton device for gait rehabilitation in children with flexed knee gait from CP as well as from other pediatric disorders. TRIAL REGISTRATION:clinicaltrials.gov, ID: NCT01961557 . Registered 11 October 2013; Last Updated 27 January 2020.

SUBMITTER: Shideler BL

PROVIDER: S-EPMC7469320 | biostudies-literature | 2020 Sep

REPOSITORIES: biostudies-literature

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Toward a hybrid exoskeleton for crouch gait in children with cerebral palsy: neuromuscular electrical stimulation for improved knee extension.

Shideler Blynn L BL Bulea Thomas C TC Chen Ji J Stanley Christopher J CJ Gravunder Andrew J AJ Damiano Diane L DL

Journal of neuroengineering and rehabilitation 20200903 1

<h4>Background</h4>Neuromuscular Electrical Stimulation (NMES) has been utilized for many years in cerebral palsy (CP) with limited success despite its inherent potential for improving muscle size and/or strength, inhibiting or reducing spasticity, and enhancing motor performance during functional activities such as gait. While surface NMES has been shown to successfully improve foot drop in CP and stroke, correction of more complex gait abnormalities in CP such as flexed knee (crouch) gait rema ...[more]

PMID: 32883297

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Project description:BackgroundGait abnormalities from neuromuscular conditions like cerebral palsy (CP) limit mobility and negatively affect quality of life. Increasing walking speed and stride length are essential clinical goals in the treatment of gait disorders from CP.Research questionHow does over-ground gait training with an untethered ankle exoskeleton providing adaptive assistance affect mobility-related spatiotemporal outcomes and lower-extremity muscle activity in people with CP?MethodsA diverse cohort of individuals with CP (n = 6, age 9-31, Gross Motor Function Classification System Level I - III) completed four over-ground training sessions (98 ± 17 min of assisted walking) and received pre- and post-training assessments. On both assessments, participants walked over-ground with and without the exoskeleton while we recorded spatiotemporal outcomes and muscle activity. We used two-tailed paired t-tests to compare all parameters pre- and post-training, and between assisted and unassisted conditions.ResultsFollowing training, walking speed increased 0.24 m/s (p = 0.006) and stride length increased 0.17 m (p = 0.013) during unassisted walking, while walking speed increased 0.28 m/s (p = 0.023) and stride length increased 0.15 m (p = 0.002) during exoskeleton-assisted walking. Exoskeleton training improved stride-to-stride repeatability of soleus and vastus lateralis muscle activation by up to 51 % (p ≤ 0.046), while the amount of integrated stance-phase muscle activity was similar across visits and conditions. Relative to baseline, post-training walking with the exoskeleton resulted in a soleus activity pattern that was 39 % more similar to the typical pattern from unimpaired individuals (p < 0.001).SignificanceThis study demonstrates acute spatiotemporal and neuromuscular benefits from over-ground training with adaptive ankle exoskeleton assistance, and provides rationale for completion of a longer randomized controlled training protocol.

Project description:BackgroundCerebral palsy (CP) is a leading cause of childhood disability. The motor impairments of individuals with CP significantly affect the kinematics of an efficient gait pattern. Robotic therapies have become increasingly popular as an intervention to address this. Powered lower limb exoskeletons (PoLLE) are a novel form of robotic therapy that allow the individual to perform over-ground gait training and yet its effectiveness for CP is unknown.PurposeTo determine the effectiveness of PoLLE use on gait in individuals with CP.MethodA systematic search of eight electronic databases was conducted in March 2020. Studies included children (0-18 years) and or adults (18+ years) diagnosed with CP who used a PoLLE for gait training. This review was conducted and reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement, with the methodology registered with PROSPERO (CRD42020177160). A modified version of the McMaster critical review form for quantitative studies was used to assess the methodological quality. Due to the heterogeneity of the included studies, a descriptive synthesis using the National Health & Medical Research Council (NHMRC) FORM framework was undertaken.ResultsOf the 2089 studies screened, ten case series and three case studies met the inclusion criteria highlighting the current evidence base is emerging and low level. A range of PoLLEs were investigated with effectiveness measured by using a number of outcome measures. Collectively, the body of evidence indicates there is some consistent positive evidence on the effectiveness of PoLLE in improving gait in individuals with CP, with minimal adverse effects. While this is a positive and encouraging finding for an emerging technology, methodological concerns also need to be acknowledged.ConclusionWith rapidly evolving technology, PoLLEs could play a transformative role in the lives of people impacted by CP. Ongoing research is required to further strengthen the evidence base and address current methodological concerns.

Dataset Information

Toward a hybrid exoskeleton for crouch gait in children with cerebral palsy: neuromuscular electrical stimulation for improved knee extension.

Publications

Toward a hybrid exoskeleton for crouch gait in children with cerebral palsy: neuromuscular electrical stimulation for improved knee extension.

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