A decision support system for electrode shaping in multi-pad FES foot drop correction

Jovana Malešević, Suzana Dedijer Dujović, Andrej M Savić, Ljubica Konstantinović, Aleksandra Vidaković, Goran Bijelić, Nebojša Malešević, Thierry Keller, Jovana Malešević, Suzana Dedijer Dujović, Andrej M Savić, Ljubica Konstantinović, Aleksandra Vidaković, Goran Bijelić, Nebojša Malešević, Thierry Keller

Abstract

Background: Functional electrical stimulation (FES) can be applied as an assistive and therapeutic aid in the rehabilitation of foot drop. Transcutaneous multi-pad electrodes can increase the selectivity of stimulation; however, shaping the stimulation electrode becomes increasingly complex with an increasing number of possible stimulation sites. We described and tested a novel decision support system (DSS) to facilitate the process of multi-pad stimulation electrode shaping. The DSS is part of a system for drop foot treatment that comprises a custom-designed multi-pad electrode, an electrical stimulator, and an inertial measurement unit.

Methods: The system was tested in ten stroke survivors (3-96 months post stroke) with foot drop over 20 daily sessions. The DSS output suggested stimulation pads and parameters based on muscle twitch responses to short stimulus trains. The DSS ranked combinations of pads and current amplitudes based on a novel measurement of the quality of the induced movement and classified them based on the movement direction (dorsiflexion, plantar flexion, eversion and inversion) of the paretic foot. The efficacy of the DSS in providing satisfactory pad-current amplitude choices for shaping the stimulation electrode was evaluated by trained clinicians. The range of paretic foot motion was used as a quality indicator for the chosen patterns.

Results: The results suggest that the DSS output was highly effective in creating optimized FES patterns. The position and number of pads included showed pronounced inter-patient and inter-session variability; however, zones for inducing dorsiflexion and plantar flexion within the multi-pad electrode were clearly separated. The range of motion achieved with FES was significantly greater than the corresponding active range of motion (p < 0.05) during the first three weeks of therapy.

Conclusions: The proposed DSS in combination with a custom multi-pad electrode design covering the branches of peroneal and tibial nerves proved to be an effective tool for producing both the dorsiflexion and plantar flexion of a paretic foot. The results support the use of multi-pad electrode technology in combination with automatic electrode shaping algorithms for the rehabilitation of foot drop.

Trial registration: This study was registered at the Current Controlled Trials website with ClinicalTrials.gov ID NCT02729636 on March 29, 2016.

Keywords: Decision support system; Foot drop; Functional electrical stimulation; Multi-pad electrode; Stroke.

Figures

Fig. 1
Fig. 1
Fesia Walk system (Tecnalia R&I, Donostia/San Sebastián, Spain). a Electrical stimulator and multi-pad electrode with physical coordinates attached to the garment. b Position of a patient during setup process. c FES-assisted gait
Fig. 2
Fig. 2
a Determination of the transverse plane peak - X. Zero on the time axis marks the stimulus onset, and X was determined as the global extreme with a shorter latency to the stimulus. b Three graphs showing representative 12 epochs (4 pads × 3 current amplitudes) of the twitch protocol (vertical dotted lines separate the individual twitch epochs) from one twitch protocol of one patient. The top panel shows the stimulus trains, with black bars marking the individual train timing, duration and intensity. The middle and bottom panels show the foot angular velocities in the sagittal and transverse planes, respectively. The X and Y peaks are marked with different symbols for each twitch epoch. Blue symbols mark the movements classified as UP, green - DOWN and orange - RIGHT. cBottom panel shows the estimated twitch points (X, Y) in a 2D coordinate system. The symbols and color-coding correspond to those from (b). The points with the highest Q factors are circled with a black line. For selected representative set epochs, none of the twitches was classified as LEFT (i.e., IV)
Fig. 3
Fig. 3
Chosen pad (SetFIN) allocation and current intensities for DF (black pads) and PF (gray pads) for the first three, middle three and last three sessions of patient 8. Pads with one asterisk in the upper right corner are the top-ranked pads (Q1) by DSS, and those with 2 asterisks are the 2nd-ranked pads (Q2) by DSS
Fig. 4
Fig. 4
Pie charts of all patterns for DF (a) and PF (b). Gray slices represent the patterns comprising pads suggested by DSS, yellow slices are the patterns including at least one pad for EV or IV, and white slices are the patterns containing a non-suggested pad. Patterns not including the top-ranked pad (Q1) are hatched
Fig. 5
Fig. 5
Electrode coordinate system with coordinates of 10 patients’ global mean pads and associated standard deviations, marked with different symbols
Fig. 6
Fig. 6
Percentage of pad inclusions in the final patterns for DF (upper panel) and PF (lower panel) in 200 sessions (all patients and all sessions)
Fig. 7
Fig. 7
ROMa (black) and ROMs (yellow) values presented in boxplots. Lines connect the median values (in degrees) for all patients in 20 sessions. Gray asterisks represent the inter-session significant differences between ROMa and ROMs. Horizontal bars denote significant differences between the first session and those sessions marked with vertical ticks for ROMa (black) and ROMs (yellow)

References

    1. Burridge J, Taylor P, Hagan S, Wood D, Swain I. The effect of common peroneal nerve stimulation on quadriceps spasticity in hemiplegia. Physiotherapy. 1997;83:82–89. doi: 10.1016/S0031-9406(05)65582-4.
    1. Laufer Y, Hausdorff JM, Ring H. Effects of a foot drop neuroprosthesis on functional abilities, social participation, and gait velocity. Am J Phys Med Rehabil. 2009;88:14–20. doi: 10.1097/PHM.0b013e3181911246.
    1. Bajd T, Kralj A, Štefančič M, Lavrač N. Use of functional electrical stimulation in the lower extremities of incomplete spinal cord injured patients. Artif Organs. 1999;23:403–409. doi: 10.1046/j.1525-1594.1999.06360.x.
    1. Laufer Y, Ring H, Sprecher E, Hausdorff JM. Gait in individuals with chronic hemiparesis: one-year follow-up of the effects of a neuroprosthesis that ameliorates foot drop. J Neurol Phys Ther. 2009;33:104–110. doi: 10.1097/NPT.0b013e3181a33624.
    1. Burridge J, Taylor P, Hagan S, Swain I. Experience of clinical use of the Odstock DroppedFoot stimulator. Artif Organs. 1997;21:254–260. doi: 10.1111/j.1525-1594.1997.tb04662.x.
    1. Bethoux F, Rogers HL, Nolan KJ, Abrams GM, Annaswamy TM, Brandstater M, et al. The effects of Peroneal nerve functional electrical stimulation versus ankle-foot Orthosis in patients with chronic stroke a randomized controlled trial. Neurorehabil Neural Repair. 2014;28:688–697. doi: 10.1177/1545968314521007.
    1. Stein RB, Everaert DG, Thompson AK, Chong SL, Whittaker M, Robertson J, et al. Long-term therapeutic and orthotic effects of a foot drop stimulator on walking performance in progressive and nonprogressive neurological disorders. Neurorehabil Neural Repair. 2010;24:152–67. doi: 10.1177/1545968309347681.
    1. Melo P, Silva M, Martins J, Newman D. Technical developments of functional electrical stimulation to correct drop foot: sensing, actuation and control strategies. Clin Biomech. 2015;30:101–113. doi: 10.1016/j.clinbiomech.2014.11.007.
    1. G. M. Lyons, T. Sinkjær, J. H. Burridge, and D. J. Wilcox, “A review of portable FES-based neural orthoses for the correction of drop foot,” Neural Systems and Rehabilitation Engineering, IEEE Transactions on, vol. 10, pp. 260-279, 2002.
    1. Neptune R, Kautz S, Zajac F. Contributions of the individual ankle plantar flexors to support, forward progression and swing initiation during walking. J Biomech. 2001;34:1387–98. doi: 10.1016/S0021-9290(01)00105-1.
    1. Burridge J, Taylor P, Hagan S, Wood DE, Swain ID. The effects of common peroneal stimulation on the effort and speed of walking: a randomized controlled trial with chronic hemiplegic patients. Clin Rehabil. 1997;11:201–210. doi: 10.1177/026921559701100303.
    1. Malešević NM, Popović LZ, Schwirtlich L, Popović DB. Distributed low-frequency functional electrical stimulation delays muscle fatigue compared to conventional stimulation. Muscle Nerve. 2010;42:556–562. doi: 10.1002/mus.21736.
    1. Taylor P, Burridge J, Dunkerley A, Wood D, Norton J, Singleton C, et al. Clinical audit of 5 years provision of the Odstock dropped foot stimulator. Artif Organs. 1999;23:440–442. doi: 10.1046/j.1525-1594.1999.06374.x.
    1. Valtin M, Seel T, Raisch J, Schauer T. Iterative learning control of drop foot stimulation with array electrodes for selective muscle activation. IFAC Proceedings Volumes. 2014;47:6587–92. doi: 10.3182/20140824-6-ZA-1003.01991.
    1. Kenney LP, Heller BW, Barker AT, Reeves ML, Healey TJ, Good TR, et al. The design, development and evaluation of an array-based FES system with automated setup for the correction of drop foot. IFAC-PapersOnLine. 2015;48:309–314. doi: 10.1016/j.ifacol.2015.10.157.
    1. Hausdorff JM, Ring H. Effects of a new radio frequency–controlled neuroprosthesis on gait symmetry and rhythmicity in patients with chronic hemiparesis. Am J Phys Med Rehabil. 2008;87:4–13. doi: 10.1097/PHM.0b013e31815e6680.
    1. Bijelić G, Popović-Bijelić A, Jorgovanović N, Bojanić D, Popović DB. E Actitrode: the new selective stimulation interface for functional movements in hemiplegics patients. Serbian J Electrical Eng. 2004;1:21–28. doi: 10.2298/SJEE0403021B.
    1. Westerveld AJ, Schouten AC, Veltink PH, van der Kooij H. Selectivity and resolution of surface electrical stimulation for grasp and release. IEEE Trans Neural Syst Rehabil Eng. 2012;20:94–101. doi: 10.1109/TNSRE.2011.2178749.
    1. T. Keller, M. Lawrence, A. Kuhn, and M. Morari, “New multi-channel transcutaneous electrical stimulation technology for rehabilitation,” In Engineering in Medicine and Biology Society, 2006. EMBS’06. 28th Annual International Conference of the IEEE, 2006, pp. 194-197.
    1. Popović DB, Popović MB. Automatic determination of the optimal shape of a surface electrode: selective stimulation. J Neurosci Methods. 2009;178:174–181. doi: 10.1016/j.jneumeth.2008.12.003.
    1. C. Azevedo-Coste, G. Bijelic, L. Schwirtlich, and D. B. Popovic, “Treating drop-foot in hemiplegics: the role of matrix electrode,” In 11th Mediterranean Conference on Medical and Biomedical Engineering and Computing 2007, 2007, pp. 654–657.
    1. Koutsou AD, Moreno JC, del Ama AJ, Rocon E, Pons JL. Advances in selective activation of muscles for non-invasive motor neuroprostheses. J Neuroeng Rehabil. 2016;13:56. doi: 10.1186/s12984-016-0165-2.
    1. De Marchis C, Monteiro TS, Simon-Martinez C, Conforto S, Gharabaghi A. Multi-contact functional electrical stimulation for hand opening: electrophysiologically driven identification of the optimal stimulation site. J Neuroeng Rehabil. 2016;13:22. doi: 10.1186/s12984-016-0129-6.
    1. A. Elsaify, “A self-optimising portable FES system using an electrode array and movement sensors,” Engineering, 2005.
    1. Heller BW, Clarke AJ, Good TR, Healey TJ, Nair S, Pratt EJ, et al. Automated setup of functional electrical stimulation for drop foot using a novel 64 channel prototype stimulator and electrode array: results from a gait-lab based study. Med Eng Phys. 2013;35:74–81. doi: 10.1016/j.medengphy.2012.03.012.
    1. Kenney LP, Heller BW, Barker AT, Reeves ML, Healey J, Good TR, et al. A review of the design and clinical evaluation of the ShefStim array-based functional electrical stimulation system: Med Eng Phys; 2016.
    1. Prenton S, Kenney LP, Stapleton C, Cooper G, Reeves ML, Heller BW, et al. Feasibility study of a take-home array-based functional electrical stimulation system with automated setup for current functional electrical stimulation users with foot-drop. Arch Phys Med Rehabil. 2014;95:1870–1877. doi: 10.1016/j.apmr.2014.04.027.
    1. Tan Z, Liu H, Yan T, Jin D, He X, Zheng X, et al. The effectiveness of functional electrical stimulation based on a normal gait pattern on subjects with early stroke: a randomized controlled trial. Biomed Res Int. 2014;2014:545408.
    1. Takeuchi N, Izumi S-I. Rehabilitation with poststroke motor recovery: a review with a focus on neural plasticity. Stroke Res Treat. 2013;2013:128641.
    1. J. Malesevic, N. Malesevic, G. Bijelic, T. Keller, and L. Konstantinovic, “Multi-pad stimulation device for treating foot drop: Case study,” In Functional Electrical Stimulation Society Annual Conference (IFESS), 2014 IEEE 19th International, 2014, pp. 1–4.
    1. Malešević NM, Maneski LZP, Ilić V, Jorgovanović N, Bijelić G, Keller T, et al. A multi-pad electrode based functional electrical stimulation system for restoration of grasp. J Neuro Eng Rehab. 2012;9:66. doi: 10.1186/1743-0003-9-66.
    1. Maneski LZP, Malešević NM, Savić AM, Keller T, Popović DB. Surface-distributed low-frequency asynchronous stimulation delays fatigue of stimulated muscles. Muscle Nerve. 2013;48:930–937. doi: 10.1002/mus.23840.
    1. J. Axelgaard and S. Heard, “Medical electrode,” ed: Google Patents, 2000.
    1. K. Tuck, “Tilt sensing using linear accelerometers,” Freescale Semiconductor Application Note AN3107, 2007.
    1. Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the human knee and its functional importance. Am J Sports Med. 1982;10:329–335. doi: 10.1177/036354658201000601.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel