Dustin L. Crouch

A Cyber Expert System for Auto-Tuning Powered Prosthesis Impedance Control Parameters

Typically impedance control parameters (e.g., stiffness and damping) in powered lower limb prostheses are fine-tuned by human experts (HMEs), which is time and resource intensive. Automated tuning procedures would make powered prostheses more practical for clinical use. In this study, we developed a novel cyber expert system (CES) that encoded HME tuning decisions as computer rules to auto-tune control parameters for a powered knee (passive ankle) prosthesis. The tuning performance of CES was preliminarily quantified on two able-bodied subjects and two transfemoral amputees. After CES and HME tuning, we observed normative prosthetic knee kinematics and improved or slightly improved gait symmetry and step width within each subject. Compared to HME, the CES tuning procedure required less time and no human intervention. Hence, using CES for auto-tuning prosthesis control was a sound concept, promising to enhance the practical value of powered prosthetic legs. However, the tuning goals of CES might not fully capture those of the HME. This was because we observed that HME tuning reduced trunk sway, while CES sometimes led to slightly increased trunk motion. Additional research is still needed to identify more appropriate tuning objectives for powered prosthetic legs to improve amputees’ walking function.

Biomechanical Contributions of Posterior Deltoid and Teres Minor in the Context of Axillary Nerve Injury: A Computational Study

PURPOSE To determine whether transfer to only the anterior branch of the axillary nerve will restore useful function after axillary nerve injury with persistent posterior deltoid and teres minor paralysis. METHODS We used a computational musculoskeletal model of the upper limb to determine the relative contributions of posterior deltoid and teres minor to maximum joint moment generated during a simulated static strength assessment and to joint moments during 3 submaximal shoulder movements. Movement simulations were performed with and without simulated posterior deltoid and teres minor paralysis to identify muscles that may compensate for their paralysis. RESULTS In the unimpaired limb model, teres minor and posterior deltoid accounted for 16% and 14% of the total isometric shoulder extension and external rotation joint moments, respectively. During the 3 movement simulations, posterior deltoid produced as much as 20% of the mean shoulder extension moment, whereas teres minor accounted for less than 5% of the mean joint moment in all directions of movement. When we paralyzed posterior deltoid and teres minor, the mean extension moments generated by the supraspinatus, long head of triceps, latissimus dorsi, and middle deltoid increased to compensate. Compensatory muscles were not fully activated during movement simulations when posterior deltoid and teres minor were paralyzed. CONCLUSIONS Reconstruction of the anterior branch of the axillary nerve only is an appropriate technique for restoring shoulder abduction strength after isolated axillary nerve injury. When shoulder extension strength is compromised by extensive neuromuscular shoulder injury, reconstruction of both the anterior and posterior branches of the axillary nerve should be considered. CLINICAL RELEVANCE By quantifying the biomechanical role of muscles during submaximal movement, in addition to quantifying muscle contributions to maximal shoulder strength, we can inform preoperative planning and permit more accurate predictions of functional outcomes.

Computational sensitivity analysis to identify muscles that can mechanically contribute to shoulder deformity following brachial plexus birth palsy.

PURPOSE Two mechanisms, strength imbalance or impaired longitudinal muscle growth, potentially cause osseous and postural shoulder deformity in children with brachial plexus birth palsy. Our objective was to determine which muscles, via either deformity mechanism, were mechanically capable of producing forces that could promote shoulder deformity. METHODS In an upper limb computational musculoskeletal model, we simulated strength imbalance by allowing each muscle crossing the shoulder to produce 30% of its maximum force. To simulate impaired longitudinal muscle growth, the functional length of each muscle crossing the shoulder was reduced by 30%. We performed a sensitivity analysis to identify muscles that, through either simulated deformity mechanism, increased the posteriorly directed, compressive glenohumeral joint force consistent with osseous deformity or reduced the shoulder external rotation or abduction range of motion consistent with postural deformity. RESULTS Most of the increase in the posterior glenohumeral joint force by the strength imbalance mechanism was caused by the subscapularis, latissimus dorsi, and infraspinatus. Posterior glenohumeral joint force increased the most owing to impaired growth of the infraspinatus, subscapularis, and long head of biceps. Through the strength imbalance mechanism, the subscapularis, anterior deltoid, and pectoralis major muscles reduced external shoulder rotation by 28°, 17°, and 10°, respectively. Shoulder motion was reduced by 40° to 56° owing to impaired growth of the anterior deltoid, subscapularis, and long head of triceps. CONCLUSIONS The infraspinatus, subscapularis, latissimus dorsi, long head of biceps, anterior deltoid, pectoralis major, and long head of triceps were identified in this computational study as being the most capable of producing shoulder forces that may contribute to shoulder deformity following brachial plexus birth palsy. CLINICAL RELEVANCE The muscles mechanically capable of producing deforming shoulder forces should be the focus of experimental studies investigating the musculoskeletal consequences of brachial plexus birth palsy and are potentially critical targets for treating shoulder deformity.

Computer Simulation of Nerve Transfer Strategies for Restoring Shoulder Function After Adult C5 and C6 Root Avulsion Injuries

PURPOSE Functional ability after nerve transfer for upper brachial plexus injuries relies on both the function and magnitude of force recovery of targeted muscles. Following nerve transfers targeting either the axillary nerve, suprascapular nerve, or both, it is unclear whether functional ability is restored in the face of limited muscle force recovery. METHODS We used a computer model to simulate flexing the elbow while maintaining a functional shoulder posture for 3 nerve transfer scenarios. We assessed the minimum restored force capacity necessary to perform the task, the associated compensations by neighboring muscles, and the effect of altered muscle coordination on movement effort. RESULTS The minimum force restored by the axillary, suprascapular, and combined nerve transfers that was required for the model to simulate the desired movement was 25%, 40%, and 15% of the unimpaired muscle force capacity, respectively. When the deltoid was paralyzed, the infraspinatus and subscapularis muscles generated higher shoulder abduction moments to compensate for deltoid weakness. For all scenarios, movement effort increased as restored force capacity decreased. CONCLUSIONS Combined axillary and suprascapular nerve transfer required the least restored force capacity to perform the desired elbow flexion task, whereas single suprascapular nerve transfer required the most restored force capacity to perform the same task. Although compensation mechanisms allowed all scenarios to perform the desired movement despite weakened shoulder muscles, compensation increased movement effort. Dynamic simulations allowed independent evaluation of the effect of restored force capacity on functional outcome in a way that is not possible experimentally. CLINICAL RELEVANCE Simultaneous nerve transfer to suprascapular and axillary nerves yields the best simulated biomechanical outcome for lower magnitudes of muscle force recovery in this computer model. Axillary nerve transfer performs nearly as well as the combined transfer, whereas suprascapular nerve transfer is more sensitive to the magnitude of reinnervation and is therefore avoided.

Contributions of Muscle Imbalance and Impaired Growth to Postural and Osseous Shoulder Deformity Following Brachial Plexus Birth Palsy: A Computational Simulation Analysis

PURPOSE Two potential mechanisms leading to postural and osseous shoulder deformity after brachial plexus birth palsy are muscle imbalance between functioning internal rotators and paralyzed external rotators and impaired longitudinal growth of paralyzed muscles. Our goal was to evaluate the combined and isolated effects of these 2 mechanisms on transverse plane shoulder forces using a computational model of C5-6 brachial plexus injury. METHODS We modeled a C5-6 injury using a computational musculoskeletal upper limb model. Muscles expected to be denervated by C5-6 injury were classified as affected, with the remaining shoulder muscles classified as unaffected. To model muscle imbalance, affected muscles were given no resting tone whereas unaffected muscles were given resting tone at 30% of maximal activation. To model impaired growth, affected muscles were reduced in length by 30% compared with normal whereas unaffected muscles remained normal in length. Four scenarios were simulated: normal, muscle imbalance only, impaired growth only, and both muscle imbalance and impaired growth. Passive shoulder rotation range of motion and glenohumeral joint reaction forces were evaluated to assess postural and osseous deformity. RESULTS All impaired scenarios exhibited restricted range of motion and increased and posteriorly directed compressive glenohumeral joint forces. Individually, impaired muscle growth caused worse restriction in range of motion and higher and more posteriorly directed glenohumeral forces than did muscle imbalance. Combined muscle imbalance and impaired growth caused the most restricted joint range of motion and the highest joint reaction force of all scenarios. CONCLUSIONS Both muscle imbalance and impaired longitudinal growth contributed to range of motion and force changes consistent with clinically observed deformity, although the most substantial effects resulted from impaired muscle growth. CLINICAL RELEVANCE Simulations suggest that treatment strategies emphasizing treatment of impaired longitudinal growth are warranted for reducing deformity after brachial plexus birth palsy.

Biomechanical Basis of Shoulder Osseous Deformity and Contracture in a Rat Model of Brachial Plexus Birth Palsy.

BACKGROUND The purpose of this study was to investigate the relative contributions of two proposed mechanisms, strength imbalance and impaired longitudinal muscle growth, to osseous and postural deformity in a rat model of brachial plexus birth palsy (BPBP). METHODS Thirty-two Sprague-Dawley rat pups were divided into four groups on the basis of surgical interventions to induce a strength imbalance, impaired growth, both a strength imbalance and impaired growth (a combined mechanism), and a sham condition in the left forelimb. Maximum passive external shoulder rotation angle (ERmax) was measured bilaterally at four and eight weeks postoperatively. After the rats were killed at eight weeks, the glenohumeral geometry (on microcomputed tomography) and shoulder muscle architecture properties were measured bilaterally. RESULTS Bilateral muscle mass and optimal length differences were greatest in the impaired growth and combined mechanism groups, which also exhibited >15° lower ERmax (p < 0.05; four weeks postoperatively), 14° to 18° more glenoid declination (p < 0.10), and 0.76 to 0.94 mm more inferior humeral head translation (p < 0.10) on the affected side. Across all four groups, optimal muscle length was significantly correlated with at least one osseous deformity measure for six of fourteen muscle compartments crossing the shoulder on the affected side (p < 0.05). In the strength imbalance group, the glenoid was 5° more inclined and the humeral head was translated 7.5% more posteriorly on the affected side (p < 0.05). CONCLUSIONS Impaired longitudinal muscle growth and shoulder deformity were most pronounced in the impaired growth and combined mechanism groups, which underwent neurectomy. Strength imbalance was associated with osseous deformity to a lesser extent. CLINICAL RELEVANCE Treatments to alleviate shoulder deformity should address mechanical effects of both strength imbalance and impaired longitudinal muscle growth, with an emphasis on developing new treatments to promote growth in muscles affected by BPBP.

Lumped-Parameter Electromyogram-Driven Musculoskeletal Hand Model: A Potential Platform For Real-Time Prosthesis Control

Simple, lumped-parameter musculoskeletal models may be more adaptable and practical for clinical real-time control applications, such as prosthesis control. In this study, we determined whether a lumped-parameter, EMG-driven musculoskeletal model with four muscles could predict wrist and metacarpophalangeal (MCP) joint flexion/extension. Forearm EMG signals and joint kinematics were collected simultaneously from 5 able-bodied (AB) subjects. For one subject with unilateral transradial amputation (TRA), joint kinematics were collected from the sound arm during bilateral mirrored motion. Twenty-two model parameters were optimized such that joint kinematics predicted by EMG-driven forward dynamic simulation closely matched measured kinematics. Cross validation was employed to evaluate the model kinematic predictions using Pearson׳s correlation coefficient (r). Model predictions of joint angles were highly to very highly positively correlated with measured values at the wrist (AB mean r=0.94, TRA r=0.92) and MCP (AB mean r=0.88, TRA r=0.93) joints during single-joint wrist and MCP movements, respectively. In simultaneous multi-joint movement, the prediction accuracy for TRA at the MCP joint decreased (r=0.56), while r-values derived from AB subjects and TRA wrist motion were still above 0.75. Though parameters were optimized to match experimental sub-maximal kinematics, passive and maximum isometric joint moments predicted by the model were comparable to reported experimental measures. Our results showed the promise of a lumped-parameter musculoskeletal model for hand/wrist kinematic estimation. Therefore, the model might be useful for EMG control of powered upper limb prostheses, but more work is needed to demonstrate its online performance.

Musculoskeletal model predicts multi-joint wrist and hand movement from limited EMG control signals

Electromyography (EMG)-driven human-machine systems permit volitional control of external devices, including powered prosthetic arms. However, current control schemes are either non-intuitive to operate or lack robustness across different arm postures and dynamics, partly because these methods did not incorporate the full knowledge of biological movement production. In this study, we developed and evaluated a new musculoskeletal model to predict hand and wrist motion based on surface EMG signals. Kinematic and EMG data were collected from an able-bodied subject while performing wrist and metacarpophalangeal (MCP) joint movements with either a fixed or random speed in two static upper limb postures. A part of data collected in one posture was used to develop the model with four virtual muscles. Four parameters were optimized for each of four muscles in one posture. The model kinematic predictions were evaluated offline using the other part of the data recorded from both postures. Mean (±SD) RMS errors in predicting the joint movement were significantly lower at the MCP joint (10.1±2.5°) than at the wrist (23.5±5.2°) (p<;0.05). At both the wrist and MCP joints, the model predicted the timing and trend of joint movements reasonably well across postures and for both simple (fixed speed, single joint) and complex (random speed, simultaneous, multi-joint) movements. The results implied that our EMG-driven musculoskeletal model was promising for predicting simultaneous joint motions without significant posture and dynamics dependency. Additional engineering efforts are still needed to improve the musculoskeletal model for various human-machine interfacing applications.

Association of a Surgical Task During Training With Team Skill Acquisition Among Surgical Residents: The Missing Piece in Multidisciplinary Team Training

Importance The human patient simulators that are currently used in multidisciplinary operating room team training scenarios cannot simulate surgical tasks because they lack a realistic surgical anatomy. Thus, they eliminate the surgeon’s primary task in the operating room. The surgical trainee is presented with a significant barrier when he or she attempts to suspend disbelief and engage in the scenario. Objective To develop and test a simulation-based operating room team training strategy that challenges the communication abilities and teamwork competencies of surgeons while they are engaged in realistic operative maneuvers. Design, Setting, and Participants This pre-post educational intervention pilot study compared the gains in teamwork skills for midlevel surgical residents at Wake Forest Baptist Medical Center after they participated in a standardized multidisciplinary team training scenario with 3 possible levels of surgical realism: (1) SimMan (Laerdal) (control group, no surgical anatomy); (2) “synthetic anatomy for surgical tasks” mannequin (medium-fidelity anatomy), and (3) a patient simulated by a deceased donor (high-fidelity anatomy). Interventions Participation in the simulation scenario and the subsequent debriefing. Main Outcomes and Measures Teamwork competency was assessed using several instruments with extensive validity evidence, including the Nontechnical Skills assessment, the Trauma Management Skills scoring system, the Crisis Resource Management checklist, and a self-efficacy survey instrument. Participant satisfaction was assessed with a Likert-scale questionnaire. Results Scenario participants included midlevel surgical residents, anesthesia providers, scrub nurses, and circulating nurses. Statistical models showed that surgical residents exposed to medium-fidelity simulation (synthetic anatomy for surgical tasks) team training scenarios demonstrated greater gains in teamwork skills compared with control groups (SimMan) (Nontechnical Skills video score: 95% CI, 1.06-16.41; Trauma Management Skills video score: 95% CI, 0.61-2.90) and equivalent gains in teamwork skills compared with high-fidelity simulations (deceased donor) (Nontechnical Skills video score: 95% CI, −8.51 to 6.71; Trauma Management Skills video score: 95% CI, −1.70 to 0.49). Conclusions and Relevance Including a surgical task in operating room team training significantly enhanced the acquisition of teamwork skills among midlevel surgical residents. Incorporating relatively inexpensive, medium-fidelity synthetic anatomy in human patient simulators was as effective as using high-fidelity anatomies from deceased donors for promoting teamwork skills in this learning group.

Simple EMG-driven musculoskeletal model enables consistent control performance during path tracing tasks

Consistent, robust performance is critical for the utility and user-acceptance of neurally-controlled powered upper limb prostheses. We preliminarily evaluated the performance consistency of an electromyography (EMG)-driven controller based on a two degree-of-freedom musculoskeletal hand model, whose simplified structure is more practical for real-time prosthesis control than existing, complex models. Parameters of four virtual muscles were computed by numerical optimization from an able-bodied subjects kinematic and EMG data collected during wrist and metacarpophalangeal (MCP) flexion/extension movements. The subject attempted to trace a series of paths of different complexity (straight and curved) with the fingertip of a virtual hand displayed on a computer screen; the straight-path tracing tasks were repeated on a second test day to evaluate performance consistency over time. The subjects tracing accuracy during the tasks was consistent both between tasks of varying complexity (i.e. straight vs curved) and between test days when tracing the straight paths. Additionally, task duration, straightness, and smoothness did not significantly differ between the two straight-path test days. The consistent performance between days was achieved even with a very short (~15 seconds) calibration period to re-normalize EMG. The subject also coordinated movements of the wrist and MCP joints simultaneously during the task, much like with healthy, intact limb movement. Our promising results suggest that a musculoskeletal model-based controller may provide consistent and effective performance across a range of operating conditions, making it potentially practical for prosthesis control. Further research is needed to determine whether musculoskeletal model-based control (1) is effective for executing real-world tasks, and (2) can be extended to populations with neuromuscular impairment (e.g. amputation).Consistent, robust performance is critical for the utility and user-acceptance of neurally-controlled powered upper limb prostheses. We preliminarily evaluated the performance consistency of an electromyography (EMG)-driven controller based on a two degree-of-freedom musculoskeletal hand model, whose simplified structure is more practical for real-time prosthesis control than existing, complex models. Parameters of four virtual muscles were computed by numerical optimization from an able-bodied subjects kinematic and EMG data collected during wrist and metacarpophalangeal (MCP) flexion/extension movements. The subject attempted to trace a series of paths of different complexity (straight and curved) with the fingertip of a virtual hand displayed on a computer screen; the straight-path tracing tasks were repeated on a second test day to evaluate performance consistency over time. The subjects tracing accuracy during the tasks was consistent both between tasks of varying complexity (i.e. straight vs curved) and between test days when tracing the straight paths. Additionally, task duration, straightness, and smoothness did not significantly differ between the two straight-path test days. The consistent performance between days was achieved even with a very short (~15 seconds) calibration period to re-normalize EMG. The subject also coordinated movements of the wrist and MCP joints simultaneously during the task, much like with healthy, intact limb movement. Our promising results suggest that a musculoskeletal model-based controller may provide consistent and effective performance across a range of operating conditions, making it potentially practical for prosthesis control. Further research is needed to determine whether musculoskeletal model-based control (1) is effective for executing real-world tasks, and (2) can be extended to populations with neuromuscular impairment (e.g. amputation).