Erika G. Spaich

Methods for gait event detection and analysis in ambulatory systems

After stroke, hemiparesis is a common problem resulting in very individual needs for walking assistance. Often patients suffer from foot drop, i.e. inability to lift the foot from the ground during the swing phase of walking. Functional electrical stimulation is commonly used to correct foot drop. For all supporting stimulation devices, it is vital to adequately detect the gait events, which is traditionally obtained by a foot switch placed under the heel. To investigate present methods of gait analysis and detection for use in ambulatory rehabilitation systems, we carried out a meta-analysis on research studies. We found various sensors and sensor combinations capable of analyzing gait in ambulatory settings, ranging form simple force based binary switches to complex setups involving multiple inertial sensors and advanced algorithms. However additional effort is needed to minimize donning/doffing efforts, to overcome cosmetical aspects, and to implement those systems into closed loop ambulatory devices.

Expansion of nociceptive withdrawal reflex receptive fields in spinal cord injured humans

OBJECTIVE In spinal cord injured (SCI) subjects, exaggerated withdrawal reflexes associated with a dominant flexor pattern irrespective of stimulation site have been reported. In the present study, withdrawal reflex receptive field (RRF) was determined in complete SCI subjects (N=9). METHODS Distributed electrical stimulation was applied to the sole of the foot, and reflexes in tibialis anterior, soleus, biceps femoris, and vastus lateralis muscles were recorded together with knee and ankle movement trajectories. A group of spinally intact subjects (N=10) were included as controls. With the subjects in supine position, stimulation was applied to 10 different sites on the foot sole. Based on the tibialis anterior reflex threshold for stimulation on the mid foot sole, two stimulus intensities (1.1 times the reflex threshold and 1.4 times the reflex threshold) were used for all 10 sites. RESULTS In SCI subjects, dorsi-flexion dominated independent of stimulus site and the tibialis anterior RRF covered the entire foot sole in contrast to a well-defined tibialis anterior receptive field at the medial, distal foot sole in the spinally intact subjects. Further, the soleus RRF also covered the entire sole in the SCI subjects. The reflexes in biceps femoris and vastus lateralis muscles were small and associated with weak knee flexion at all 10 sites in the SCI subjects and in the controls. CONCLUSIONS The RRF of the ankle flexor and the ankle extensor muscles both covered the entire sole of the foot indicating an expansion of the RRFs following spinal cord injury. The expansion is most likely due to lack of descending inhibitory control and/or increased sensitivity of the spinal reflex loop in the SCI subjects. SIGNIFICANCE The study improves the understanding of spinal reflex control in spinal intact and spinal cord injured subjects.

Gradual enlargement of human withdrawal reflex receptive fields following repetitive painful stimulation

Dynamic changes in the topography of the human withdrawal reflex receptive fields (RRF) were assessed by repetitive painful stimuli in 15 healthy subjects. A train of five electrical stimuli was delivered at a frequency of 3 Hz (total train duration 1.33 s). The train was delivered in random order to 10 electrode sites on the sole of the foot. Reflexes were recorded from tibialis anterior, soleus, vastus lateralis, biceps femoris, and iliopsoas (IL). The RRF changes during the stimulus train were assessed during standing with even support on both legs and while seated. The degree of temporal summation was depending on stimulation site. At the most sensitive part of the RRF, a statistically significant increase in reflex size was seen after two stimuli while four stimuli were needed to observe reflex facilitation at less sensitive electrode sites. Hence, the region from which reflexes could be evoked using the same stimulus intensity became larger through the train, that is, the RRF was gradually expanding. Reflexes evoked by stimuli four and five were of the same size. No reflex facilitation was seen at other stimulus sites outside the RRF. In all muscles except in IL, the largest reflexes were evoked when the subjects were standing. In the ankle joint, the main withdrawal pattern consisted of plantar flexion and inversion when the subjects were standing while dorsi-flexion was prevalent in the sitting position. Up to 35 degrees of knee and hip flexion were evoked often leading to a lift of the foot from the floor during standing. In conclusion, a gradual expansion of the RRF was seen in all muscles during the stimulus train. Furthermore, the motor programme task controls the reflex sensitivity within the reflex receptive field and, hence, the sensitivity of the temporal summation mechanism.

Gait event detection for use in FES rehabilitation by radial and tangential foot accelerations

Gait rehabilitation by Functional Electrical Stimulations (FESs) requires a reliable trigger signal to start the stimulations. This could be obtained by a simple switch under the heel or by means of an inertial sensor system. This study provides an algorithm to detect gait events in differential acceleration signals of the foot. The key feature of differential measurements is that they compensate the impact of gravity. The real time detection capability of a rule based algorithm in healthy and hemiparetic individuals was investigated. Detection accuracy and precision compared to signals from foot switches were evaluated. The algorithm detected curve features of the vectorial sum of radial and tangential accelerations and mapped those to discrete gait states. The results showed detection rates for healthy and hemiparetic gait ranging form 84.2% to 108.5%. The sensitivity was between 0.81 and 1, and the specificity between 0.85 and 1, depending on gait phase and group of subjects. The algorithm detected gait phase changes earlier than the reference. Differential acceleration signals combined with the proposed algorithm have the potential to be implemented in a future FES system.

Modulation of the withdrawal reflex during hemiplegic gait: effect of stimulation site and gait phase.

OBJECTIVE The objective of the study was to investigate the sensitivity of the nociceptive withdrawal reflex to stimulation of different locations on the sole of the foot during hemiplegic gait. METHODS Reflexes were evoked by cutaneous electrical stimulation of 4 locations on the sole of the foot of 7 hemiplegic and 6 age-matched healthy persons. The stimuli were delivered at heel-contact, during foot-flat, at heel-off, and during mid-swing. Reflexes were recorded from muscles of the stimulated and the contralateral leg. Ankle, knee, and hip joints angles were recorded using goniometers. RESULTS In the hemiplegic persons, the size of tibialis anterior reflexes, and the latency of soleus reflexes were site- and phase-modulated. In both groups, the tibialis anterior reflexes were significantly smaller with stimulation to the fifth metatarsophalangeal joint and the heel compared with the first metatarsophalangeal joint and the arch of the foot. The tibialis anterior reflexes evoked at heel-off and mid-swing were larger in hemiplegic persons than in healthy persons. Reflexes in the proximal and contralateral limb muscles were not site-modulated during hemiplegic gait. The kinematic response at the ankle joint was also different in the two groups during mid-swing. CONCLUSIONS Hemiplegic and healthy middle-aged people presented different phase-modulation of the kinematic and muscle nociceptive reflex responses evoked by stimulation delivered on the sole of the foot. SIGNIFICANCE The results have potential application in programs to rehabilitate hemiplegic gait.

Characterization of gait pattern by 3D angular accelerations in hemiparetic and healthy gait

Characterization of gait pattern is of interest for clinical gait assessment. Past developments of ambulatory measurement systems have still limitations for daily usage in the clinical environment. This study investigated the potential of 3D angular accelerations of foot, shank, and thigh to characterize gait events and phases of ten healthy and ten hemiparetic subjects. The key feature of the system was the use of angular accelerations obtained by differential measurement. Further, the effect of sensor position and walking cadence on the signal was investigated. We found that gait phases are characterized as modulated amplitudes of angular accelerations of foot, shank, and thigh. Increasing the gait cadence from 70 steps/min to 100 steps/min caused an amplitude increase of the magnitude of the vector, summing all 3D angular accelerations on the sensor position (p<0.001). Comparison of healthy and hemiparetic gait showed a lower mean of the magnitude of the vector during the loading response in the hemiparetic gait (p<0.05), while during pre-swing and swing no significant differences between healthy and hemiparetic gait were observed. A comparison of the tangential acceleration component in the frontal plane showed no statistically significant difference between healthy and hemiparetic gait. Further, no statistically significant difference between the tangential components was found for both groups. This method demonstrated promising results for a possible use for gait assessment.

Rehabilitation of the hemiparetic gait by nociceptive withdrawal reflex-based functional electrical therapy: a randomized, single-blinded study

BackgroundGait deficits are very common after stroke and improved therapeutic interventions are needed. The objective of this study was therefore to investigate the therapeutic use of the nociceptive withdrawal reflex to support gait training in the subacute post-stroke phase.MethodsIndividuals were randomly allocated to a treatment group that received physiotherapy-based gait training supported by withdrawal reflex stimulation and a control group that received physiotherapy-based gait training alone. Electrical stimuli delivered to the arch of the foot elicited the withdrawal reflex at heel-off with the purpose of facilitating the initiation and execution of the swing phase. Gait was assessed before and immediately after finishing treatment, and one month and six months after finishing treatment. Assessments included the Functional Ambulation Category (FAC) test, the preferred and maximum gait velocities, the duration of the stance phase in the hemiparetic side, the duration of the gait cycle, and the stance time symmetry ratio.ResultsThe treatment group showed an improved post treatment preferred walking velocity (p < 0.001) and fast walking velocity (p < 0.001) compared to the control group. Furthermore, subjects in the treatment group with severe walking impairment at inclusion time showed the best improvement as assessed by a longer duration of the stance phase in the hemiparetic side (p < 0.002) and a shorter duration of the gait cycle (p < 0.002). The stance time symmetry ratio was significantly better for the treatment than the control group after finishing training (p < 0.02). No differences between groups were detected with the FAC test after finishing training (p = 0.09).ConclusionWithdrawal reflex-based functional electrical therapy was useful in the rehabilitation of the hemiparetic gait of severely impaired patients.

Design and Test of a Novel Closed-Loop System That Exploits the Nociceptive Withdrawal Reflex for Swing-Phase Support of the Hemiparetic Gait

A novel closed-loop system for improving gait in hemiparetic patients by supporting the production of the swing phase using electrical stimulations evoking the nociceptive withdrawal reflex was designed. The system exploits the modular organization of the nociceptive withdrawal reflex and its stimulation site- and gait-phase modulation in order to evoke movements of the hip, knee, and ankle joints during the swing phase. A modified model reference adaptive controller (MRAC) was designed to select the best stimulation parameters from a set of 12 combinations of four electrode locations on the sole of the foot and three different stimulation onset times between heel-off and toe-off. It was hypothesized that the MRAC system would result in a better walking pattern compared with an open-loop preprogrammed fixed pattern of stimulation (FPS) controller. Thirteen chronic or subacute hemiparetic subjects participated in a study to compare the performance of the two control schemes. Both control schemes resulted in a more functional gait compared to no stimulation (P <; 0.05) with a weighted joint angle peak change of 4.0 ± 1.6 (mean ± Standard deviation) degrees and 3.1 ± 1.4 degrees for the MRAC and FPS schemes, respectively. This indicates that the MRAC scheme performed better than the FPS scheme (P <; 0.001) in terms of reaching the control target.

Modulating effects of bodyweight unloading on the lower limb nociceptive withdrawal reflex during symmetrical stance

OBJECTIVE To investigate the effects of bodyweight unloading on the excitability of the nociceptive withdrawal reflex (NWR) and of its receptive fields organisation during quiet stance in humans. METHODS The NWR was elicited in 14 volunteers by electrical stimulation of the sole of the foot at mid-forefoot, arch, and heel points. Participants stood upright and wore a whole-body harness connected via a rope to a pulley. Data were recorded at 0%, 10%, 25% and 40% of the bodyweight unloading. The root mean square of the EMG activity was measured bilaterally from several lower limb muscles. Kinematics of ankle, knee, and hip were measured bilaterally using goniometers. RESULTS Two-way ANOVA for repeated measures revealed higher reflex sizes at higher degrees of unloading in the tibialis anterior, soleus, and biceps femoris muscles and in the kinematics of the knee joint of the ipsilateral limb. No interaction between stimulation site and unloading was revealed. CONCLUSIONS Unloading induced a generalised enhancement of NWR excitability without modifying the reflex receptive field organisation. SIGNIFICANCE Our study indicates that bodyweight unloading in general enhances the NWR excitability and suggests that only load-related afferent inputs in concert with joint movements may modify the modular organisation of the NWR.

Tibialis Anterior and Soleus Withdrawal Reflexes Elicited by Electrical Stimulation of the Sole of the Foot during Gait

The aim of the present study was to investigate the modulation and functional importance of nociceptive withdrawal reflexes elicited from the sole of the foot and recorded from the soleus (SOL) and tibialis anterior (TA) muscles during gait. Cutaneous electrical stimulation delivered at four locations of the sole of the foot was used to elicit the withdrawal reflex. Reflexes were recorded from eight healthy subjects during treadmill walking. The reflexes were elicited at heel‐contact, during foot‐flat, at heel‐off, and during mid‐swing. The reflexes evoked in TA were largest when the arch of the foot was stimulated, and smallest following stimulation of the heel (significant difference during stance, p ≤ 0.002). The largest soleus responses were elicited when the arch of the foot was stimulated (significant difference compared with the fifth metatarsophalangeal joint, stimulation after heel‐contact, p < 0.05). The TA reflex, expressed as a proportion of the electromyogram during unperturbed gait, was smallest during swing (p < 0.05, compared with stance) whereas the SOL reflex was maximal during swing (p < 0.05, compared with stance). The results suggest that the modulation of the reflex promotes an appropriate withdrawal while preserving balance and continuity of motion. These results may have applications in assisting gait of hemiplegics.