Sie sind auf Seite 1von 164

DEVELOPMENT OF AN ELECTROMYOGRAM-BASED CONTROLLER FOR

FUNCTIONAL ELECTRICAL STIMULATION-ASSISTED WALKING AFTER PARTIAL


PARALYSIS

By

ANIRBAN DUTTA

Dissertation Advisor: Dr. Ronald J. Triolo

A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL


OF THE CASE WESTERN RESERVE UNIVERITY IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

Department of Biomedical Engineering

CASE WESTERN RESERVE UNIVERSITY

August, 2008

1
To the Almighty, Baba, Ma, Kiran, and Rachna

2
TABLE OF CONTENTS

page

LIST OF TABLES...........................................................................................................................6

LIST OF FIGURES .........................................................................................................................8

Introduction....................................................................................................................................13

Functional Electrical Stimulation (FES) for ambulation ........................................................13


Electromyogram as a command source for FES-controller for ambulation after iSCI ..........14
Electromyogram-based trigger for the FES-controller: specific objectives of the
work .............................................................................................................................16
Overview of the chapters ........................................................................................................17
References...............................................................................................................................17

Evaluation of surface electromyogram from partially paralyzed muscles as a command


source for functional electrical stimulation ............................................................................20

Abstract...................................................................................................................................20
Introduction.............................................................................................................................21
Methods ..................................................................................................................................22
Subjects............................................................................................................................22
Test of Controllability .....................................................................................................23
Test of Discriminability...................................................................................................24
Statistical Analysis ..........................................................................................................28
Results.....................................................................................................................................29
Results from the Test of Controllability..........................................................................29
Results from the Test of Discriminability .......................................................................30
Discussion...............................................................................................................................32
Conclusion ..............................................................................................................................33
References...............................................................................................................................34
Figures ....................................................................................................................................37
Tables......................................................................................................................................46

Feasibility analysis of surface EMG-triggered FES-assisted ambulation after incomplete


spinal cord injury ....................................................................................................................50

Abstract...................................................................................................................................50
Introduction.............................................................................................................................50
Methods ..................................................................................................................................52
Subjects............................................................................................................................52
Data Acquisition and Processing.....................................................................................53
Muscle Selection .............................................................................................................55
Classifier Development and Offline Testing...................................................................56
Classifier Testing During FES-assisted Ambulation.......................................................58
Results.....................................................................................................................................59

3
Classifier Performance ....................................................................................................59
Repeatability of the Classifier Performance....................................................................60
Discussion...............................................................................................................................60
Conclusion ..............................................................................................................................62
References...............................................................................................................................63
Figures ....................................................................................................................................66

Surface EMG-triggered FES-assisted gait parameters during over-ground walking in the


laboratory................................................................................................................................73

Abstract...................................................................................................................................73
Introduction.............................................................................................................................74
Methods ..................................................................................................................................75
Subjects............................................................................................................................75
Gait Data Acquisition ......................................................................................................76
Gait Parameters ...............................................................................................................78
Statistical Analysis ..........................................................................................................79
Results.....................................................................................................................................80
Discussion...............................................................................................................................81
Conclusion ..............................................................................................................................83
References...............................................................................................................................84
Figures ....................................................................................................................................85
Tables......................................................................................................................................90

Coordination and stability of surface EMG-triggered FES-assisted overground walking in


the laboratory ..........................................................................................................................92

Abstract...................................................................................................................................92
Introduction.............................................................................................................................92
Methods ..................................................................................................................................95
Subjects............................................................................................................................95
Gait Data Acquisition ......................................................................................................95
Coordination and Stability Analysis of Gait initiation ....................................................98
Results...................................................................................................................................103
Linear regression model for gait initiation ....................................................................103
Coordination and stability during FES-assisted gait initiation......................................104
Discussion.............................................................................................................................105
Conclusions...........................................................................................................................109
References.............................................................................................................................110
Figures ..................................................................................................................................113

Development of an implanted intramuscular EMG-triggered FES-system for ambulation


after incomplete spinal cord injury .......................................................................................123

Abstract.................................................................................................................................123
Introduction...........................................................................................................................124
Methods ................................................................................................................................126

4
Subjects..........................................................................................................................126
Command source selection............................................................................................127
Implantation of intramuscular EMG electrode..............................................................129
Classifier development for iEMG-triggered FES-assisted stepping .............................130
Online testing of the classifier in the laboratory ...........................................................134
Results...................................................................................................................................136
Muscles and location selection for intramuscular EMG ...............................................136
Classifier development and online performance ...........................................................137
Discussion.............................................................................................................................142
Conclusions...........................................................................................................................145
References.............................................................................................................................146
Figures ..................................................................................................................................149
Tables....................................................................................................................................163

5
LIST OF TABLES

Table page

Table 2.1: The mean, the minimum, and the maximum average absolute tracking error in
%MVC during the four parts (0-25 sec, 25-50 sec, 50-75 sec, 75-100 sec) of the Test
for Controllability. The p-value from the one-way two-tailed ANOVA test for the
average tracking error over the whole trial (100 sec) was not ‘statistically significant’
( ≥ 0.01)...............................................................................................................................46

Table 2.2: The results from the Test of Discriminability for the muscles Gluteus Medius
(GM), Biceps Femoris (BF), Medial Gastrocnemius (MG), Rectus Femoris (RF),
Tibialis Anterior (TA), and Erector Spinae (ES at T9) are presented for the able-
bodied subjects. The Wilcoxon statistic (W) was similar in magnitude to the
corresponding Discriminability Index (DI). Similarly the Standard Deviation (SD) of
the DI over 10 random partitions (i.e., 10-fold cross-validation) was similar in
magnitude to the Standard Error (SE) found for the Wilcoxon statistic (W). There
were ‘statistically significant’ (p ≥ 0.05) differences in the means of DI due to the
muscle type as well as the classifier type...........................................................................47

Table 2.3a: The results from the Test of Discriminability of iSCI-1 for the left step classifier.
The Wilcoxon statistic (W) was similar in magnitude to the corresponding value of
the Discriminability Index (DI). Similarly the Standard Deviation (SD) of the DI was
similar in magnitude to the Standard Error (SE) found for the Wilcoxon statistic (W).
There were ‘statistically significant’ (p ≥ 0.05) differences in the means of DI due to
the muscle type as well as the classifier type.....................................................................48

Table 2.3b: The results from the Test of Discriminability of iSCI-1 for the right step. The
Wilcoxon statistic (W) was similar in magnitude to the corresponding value of the
Discriminability Index (DI). Similarly the Standard Deviation (SD) of the DI was
similar in magnitude to the Standard Error (SE) found for the Wilcoxon statistic (W).
There were ‘statistically significant’ (p ≥ 0.05) differences in the means of DI due to
the muscle type as well as the classifier type.....................................................................48

Table 2.4a: The results from the Test of Discriminability of iSCI-2 for the left step. The
Wilcoxon statistic (W) and the corresponding value of the Discriminability Index
(DI) were similar. The Standard Deviation (SD) of the DI and the Standard Error
(SE) found for the Wilcoxon statistic (W) were similar. There were ‘statistically
significant’ (p ≥ 0.05) differences in the means of DI due to the muscle type as well
as the classifier type. ..........................................................................................................49

Table 2.4 b: The results from the Test of Discriminability of iSCI-2 for the right step
classifier. The Wilcoxon statistic (W) and the corresponding value of the
Discriminability Index (DI) were similar. The Standard Deviation (SD) of the DI and
the Standard Error (SE) found for the Wilcoxon statistic (W) were similar. There
were ‘statistically significant’ (p ≥ 0.05) differences in the means of DI due to the
muscle type as well as the classifier type...........................................................................49

6
Table 4.1: The Mean, Standard Deviation (S.D), coefficient of variation (C.V.), 95%
confidence interval (95% C.I.) over 10 trials (N=10) of the EMG-triggered and
switch-triggered gait parameters – gait speed (m/s), left step length (m), right step
length (m), left double support duration (s), right double support duration (s), left
swing phase duration (s), right swing phase duration (s) for the subject iSCI 1. [
‘statistically significant’ (p<0.05) difference between the command sources are
shaded] ...............................................................................................................................90

Table 4.2: The Mean, Standard Deviation (S.D), coefficient of variation (C.V.), 95%
confidence interval (95% C.I.) over 10 trials (N=10) of the EMG-triggered and
switch-triggered gait parameters – gait speed (m/s), left step length (m), right step
length (m), left double support duration (s), right double support duration (s), left
swing phase duration (s), right swing phase duration (s) for the subject iSCI 2. [
‘statistically significant’ (p<0.05) difference between the command sources are
shaded] ...............................................................................................................................91

Table 6.1: The performance of the threshold-based classifier for iSCI-2....................................163

Table 6.2: The performance of the pattern recognition classifier for iSCI-2...............................163

Table 6.3: The minimum achievable sample time in µs for the classifier algorithm in
different hardware that can serve as single board computer............................................164

7
LIST OF FIGURES

Figure page

Figure 2.1: Experimental setup for the Test of Controllability of the surface EMG from
Rectus Femoris using visual pursuit tasks while the knee is fixed in a dynamometer. .....37

Figure 2.2: Experimental setup for surface EMG data collection with switch-triggered FES-
assisted overground walking..............................................................................................38

Figure 2.3: Experimental protocol for surface EMG data collection during overground
walking, where the subject had to start from standing and achieve a self-selected gait
speed within 5m. ................................................................................................................39

Figure 2.4: The left column shows the cumulative distribution function for the three cases,
0 < DI ≤ 0.5, 0.5 ≤ DI < 1, DI = 1 and the right column shows the corresponding
Receiver Operating Characteristics curve..........................................................................40

Figure 2.5: TRACKING (broken black line) and TARGET (solid black line) signals during
visual pursuit task for the Test of Controllability. The boxes at each data point show
the lower quartile and upper quartile values of the TRACKING signal. Whiskers
extending at the top and bottom of the boxes show the range of the TRACKING
signal. The top panel presents the results for iSCI-1 and the bottom panel for iSCI-2.
The left panel presents the results for the left Rectus Femoris and the right panel
presents the results for the right Rectus Femoris. ..............................................................41

Figure 2.6: TRACKING (broken black line) and TARGET (solid black line) signals during
visual pursuit task for the Test of Controllability with able-bodied subjects. The
boxes at each data point show the lower quartile and upper quartile values of the
TRACKING signal. Whiskers extending at the top and bottom of the boxes show the
range of the TRACKING signal. .......................................................................................42

Figure 2.7: Top panel shows the results from the post hoc analysis of the Discriminability
Index with their critical values from Scheffe’s S procedure for the muscles – Gluteus
Medius (GM), Biceps Femoris (BF), Medial Gastrocnemius (MG), Rectus Femoris
(RF), Tibialis Anterior (TA), and Erector Spinae (ES at T9) obtained from the Test
of Discriminability with able-bodied subjects. The bottom panel shows the results
from the post hoc analysis of the Discriminability Index with their critical values
from Scheffe’s S procedure for different classifiers – Pattern Recognition Classifier
(PRC) and Threshold-based Classifier (TC) obtained from the Test of
Discriminability with able-bodied subjects. ......................................................................43

Figure 2.8: Top panel shows the results from the post hoc analysis of the Discriminability
Index with their critical values from Scheffe’s S procedure for the muscles – Gluteus
Medius (GM), Biceps Femoris (BF), Medial Gastrocnemius (MG), Rectus Femoris
(RF), Tibialis Anterior (TA), and Erector Spinae (ES at T9) obtained from the Test
of Discriminability of the left and right step classifiers of iSCI-1. The bottom panel

8
shows the results from the post hoc analysis of the Discriminability Index with their
critical values from Scheffe’s S procedure for different classifiers – Pattern
Recognition Classifier (PRC) and Threshold-based Classifier (TC) obtained from the
Test of Discriminability of the left and the right step classifiers of iSCI-1.......................44

Figure 2.9: Top panel shows the results from the post hoc analysis of the Discriminability
Index with their critical values from Scheffe’s S procedure for the muscles – Gluteus
Medius (GM), Biceps Femoris (BF), Medial Gastrocnemius (MG), Rectus Femoris
(RF), Tibialis Anterior (TA), and Erector Spinae (ES at T9) obtained from the Test
of Discriminability of the left and right step classifiers of iSCI-2. The bottom panel
shows the results from the post hoc analysis of the Discriminability Index with their
critical values from Scheffe’s S procedure for different classifiers – Pattern
Recognition Classifier (PRC) and Threshold-based Classifier (TC) obtained from the
Test of Discriminability of the left and the right step classifiers of iSCI-2.......................45

Figure 3.1: a) X-ray of the iSCI subject implanted with implantable receiver-stimulator
(IRS-8) b) iSCI subject stepping with the switch-triggered FES system ..........................66

Figure 3.2: Experimental setup for testing EMG-triggered FES-assisted walking with the
block-diagram for the EMG-triggered FES-system (ECU: external control unit, LE:
linear envelope)..................................................................................................................67

Figure 3.3: Processing of the sampled EMG from Erector Spinae for training the classifier a)
rectified and reconstructed EMG signal b) linear envelope found from processed
EMG signal ........................................................................................................................68

Figure 3.4: Muscle selection for the classifier using receiver operating characteristics curve
from switch-triggered FES-assisted gait data (FS: Foot-Strike, FO: Foot-Off) a)
linear envelope (LE) indicating class ‘True’ b) linear envelope (LE) indicating class
‘False’ ................................................................................................................................69

Figure 3.5: Receiver operating characteristics curve of the classifiers using the test data ............70

Figure 3.6: State transition diagram of the EMG-based FES-controller .......................................71

Figure 3.7: Offline testing of the classifier using receiver operating characteristics curve a)
time-error (negative means prediction) in detection of foot-off by the classifier b)
duration of the gait phases (Left DS: double support phase following left swing
phase, Right DS: double support phase following right swing phase, SW: swing
phase) .................................................................................................................................72

Figure 4.1: Experimental setup for testing EMG-triggered FES-assisted walking with the
block-diagram for the EMG-triggered FES-system (ECU: external control unit). ...........85

Figure 4.2: EMG-based gait event detector for triggering FES-assisted steps. ............................86

Figure 4.3: Plot of the Root Mean Square Error (RMSE) between the low-pass filtered and
unfiltered foot progression in sagittal plane with cut-off frequencies to find the

9
optimum cut-off frequency for low-pass filtering the gait kinematics data. Optimum
cut-off frequency was found to be 3.5 Hz for iSCI data....................................................87

Figure 4.4: Gait data collection protocol in laboratory conditions where the subject had to
start from standing and achieve a self-selected gait speed within ViconTM volume of
data capture (~5m). ............................................................................................................88

Figure 4.5: Boxplot of average body weight support provided by the walker during EMG-
triggered (N=10 trials) and switch-triggered (N=10 trials) gait normalized by the
mean of that during EMG-triggered trials of iSCI 2. The box shows the lower
quartile, median, and upper quartile with whiskers extending at each end showing the
range of the data. The notches around the median show the estimate of the
uncertainty. The boxes whose notches don’t overlap indicate that their medians differ
at 5% significance level. ....................................................................................................89

Figure 5.1: Laboratory setup for EMG-triggered FES-assisted walking shown with a
flowchart for the EMG-based gait event detector for triggering FES-assisted steps.......113

Figure 5.2: Top panel: Selection of optimum cut-off frequencies for low-pass filtering the
kinematic data. Bottom panel: Most of power content in the signals was below the
optimum cut-off frequency, which were 6 Hz for able-bodied and 3.5 Hz for iSCI
data...................................................................................................................................114

Figure 5.3: Gait initiation protocol during the data collection.....................................................115

Figure 5.4: Typical pelvis motion in the direction of progression during gait initiation.............116

Figure 5.5: Euclidean distance from the origin of the perturbation of the 36 states during gait
initiation at the maximum left knee flexion. Left panel: able-bodied data (4 subjects).
Middle panel: iSCI data (subject C1). Right panel: iSCI data (subject C2).
[Normative: 4 subjects, 10 trials each; iSCI EMG-trigger: 2 subjects, 10 trials each;
iSCI Switch-trigger: 2 subjects, 10 trials each; iSCI Auto-trigger: 2 subjects, 10 trials
each].................................................................................................................................117

Figure 5.6: Percent Variance Accounted For (%VAF) by the Principal Components (PC).
Top panel: able-bodied data. Middle panel: iSCI-1 walking with EMG, switch, and
auto triggered FES. Bottom panel: iSCI-2 walking with EMG, switch, and auto
triggered FES. All the plots show the data averaged over 6 gait events..........................118

Figure 5.7: Typical loading of the first 3 Principal Components (PCs) on the joint angles
(HA: Hip Angle, KA: Knee Angle, AA: Ankle Angle) found from the weight
matrix W of the subject Able1. The prefix ‘l’ indicates the left side and ‘r’ indicates
the right side. The suffix ‘x’ denotes sagittal plane, ‘y’ denotes frontal plane, and ‘z’
denotes transverse plane for the joint angles. ..................................................................119

Figure 5.8: Euclidean distance from the origin of the perturbation of the 5 principal
components at maximum left knee flexion Left panel: able-bodied (4 subjects).
Middle panel: iSCI-1 subject C1. Right panel: iSCI-2 subject C2. [Normative: 4

10
subjects, 10 trials each; iSCI EMG-trigger: 2 subjects, 10 trials each; iSCI Switch-
trigger: 2 subjects, 10 trials each; iSCI Auto-trigger: 2 subjects, 10 trials each] ............120

Figure 5.9: Top panel: Scatter plot of QoF and Av. Eig. at 6 gait events for the groups; the 4
able-bodied subjects: Able1, Able2, Able3, Able4, and the 2 iSCI subjects with
different trigger modes: EMG1, EMG2, SW1, SW2, Auto1, Auto2. Bottom panel:
MANOVA cluster dendrogram plot of the groups ..........................................................121

Figure 5.10: Mahalanobis distances matrix between each pair of group means .........................122

Figure 6.1: Experimental setup for data collection during FES-assisted walking with the
block-diagram for the FES-system (ECU: external control unit, LE: linear envelope)...149

Figure 6.2: Processing of the sampled surface EMG a) rectified and reconstructed sEMG
signal b) linear envelope found from processed sEMG signal. .......................................150

Figure 6.3: Experimental protocol for the collection of EMG data during over-ground
walking in the laboratory. ................................................................................................151

Figure 6.4: Multi-electrode matrix for simultaneous collection of the surface EMG from
multiple locations on the muscle belly.............................................................................152

Figure 6.5: The steps during the implantation of intramuscular EMG electrode a) insertion of
probe, b) deployment of peelable sheath over probe, c) insertion of the iEMG
electrode through the peelable sheath, d) peeling off of the polymer sheath leaving
the iEMG electrode in place. ...........................................................................................153

Figure 6.6: Pulse-width map of the stimulation patterns used for walking shown as an
example. ...........................................................................................................................154

Figure 6.7: The real-time cycle in IST with 50 ms time period for stimulation frequency of
20 Hz................................................................................................................................155

Figure 6.8: Parameters for the iEMG classifier computed from the training data that was
collected with the switch-triggered FES system..............................................................156

Figure 6.9: The flow chart of the iEMG-based two-stage classifier for triggering FES for
walking.............................................................................................................................157

Figure 6.10: Usability Rating Scale to find the user perspective on ease/difficulty of using
the classifier [6.29]...........................................................................................................158

Figure 6.11: Best location found from the surface EMG for implanting intramuscular EMG
electrodes a) Left gastrocnemius and right erector spinae b) Left and right
gastrocnemius. .................................................................................................................159

Figure 6.12: a) Discriminability Index (DI) of left medial gastrocnemius (MG) for the swing
phase (SW) and double support phase (DS) during over-ground walking for the

11
subject iSCI-1 at each data point of the gait cycle b) Discriminability Index (DI) of
right erector spinae (ES) for the swing phase (SW) and double support phase (DS)
during over-ground walking for the subject iSCI-1 at each data point of the gait
cycle. ................................................................................................................................160

Figure 6.13: Inhibition of iEMG from right erector spinae during right swing phase (SW) as
shown in the top panel due to electrical stimulation of the same muscle when
compared to that in absence of electrical stimulation shown in the bottom panel of
the subject iSCI-1.............................................................................................................161

Figure 6.14b: a) Discriminability Index (DI) of right medial gastrocnemius (MG) for the
swing phase (SW) and double support phase (DS) during over-ground walking for
the subject iSCI-2 at each data point of the gait cycle b) Discriminability Index (DI)
of left medial gastrocnemius (MG) for the swing phase (SW) and double support
phase (DS) during over-ground walking for the subject iSCI-2 at each data point of
the gait cycle. ...................................................................................................................162

12
CHAPTER 1
INTRODUCTION

Functional Electrical Stimulation (FES) for ambulation

Paralysis can be caused by an injury to the spinal cord that may partially or completely

damage the communication between the brain and the muscles. The spinal cord injury (SCI) can

be complete or incomplete based on the extent of damage to the communication channels

between the brain and the lower motor neurons below the level of injury. There are

approximately 250,000 people living with SCI in USA and about 11,000 new cases each year

[1.1]. If the paralyzed muscles below the level of injury remain innervated after the injury then

they can be electrically activated by applying a series of electrical current pulses. Functional

Electrical Stimulation (FES) refers to the application of electrical pulses to restore

neuromuscular function after paralysis. FES was first used by Liberson for actuating paralyzed

limbs [1.2]. FES has been successful in providing walking function to spinal cord injured

individuals with limited or no walking abilities [1.3]. Most of the commercially available FES-

systems as well as the one that is currently used by our group needs user input to select menu

options and to trigger FES-assisted stepping action. The current command interface for our FES-

system is a push-button, which can be mounted on the walker or worn on a finger [1.4-1.7]. The

push-button as a command interface is plausible for selecting menu options during standing but it

is an impediment when it has to be actuated with fingers during walking to trigger every step.

Some individuals with limited finger and hand function find it difficult to press push-buttons,

more so while trying to maintain balance during ambulation. This particular function of the push-

button as a trigger for stepping action can be replaced by a gait event detector. The gait event

detector can identify the event (appropriate time during a gait cycle) to activate the required

pattern of electrical stimulation. Some of the gait event detectors investigated in past by other

13
researchers are based on foot-switches, accelerometers, gyroscopes, and the electromyogram

(EMG)/electroneurogram (ENG) [1.8-1.16]. We decided to investigate electromyogram (EMG)

since it temporally precedes the joint kinetics and kinematics (electromechanical delay about 100

ms [1.17]) and may be feasible as a control source even for individuals with incomplete spinal

cord injury (iSCI), who may have lost their ability to move but may still have volitionally

controllable EMG activity [1.18]. The natural latency between electrophysiological and

biomechanical events provides time to detect the intent and then assist the intended movement

with FES. EMG-based triggering of FES patterns should integrate the FES-generated movement

seamlessly with the volitional effort that is necessary in the case of iSCI individuals who have

some sensory and motor function below the level of injury.

Electromyogram as a command source for FES-controller for ambulation after iSCI

The gait is roughly a cyclic process which can be divided into stepping of one side

followed by the other. A step defines the phase of the gait between foot-off that is the instant

when foot loses contact with the ground to the foot-off of the contralateral limb. Gait is

nevertheless a dynamic process where the steps dynamics are not isolated but one step leads to

the other steps in terms of the dynamics of the locomotor system. The transition between the

steps involves energy injection through push-off that generates a burst of energy causing the foot

to plantarflex and shifts the body towards the contralateral limb and subsequently allowing the

limb to swing forward. The push-off correlates with a burst in the muscle activity over multiple

synergist muscles, mainly the ankle plantar-flexors. Electromyogram (EMG) is the time history

of electrical activity in the muscle that can be used to find the activation of the muscles. The

burst in the muscle acitivity during the push-off produces burst in the volitional EMG of all the

synergist muscles which have a pattern of activation during the transition phase of gait (i.e. left

to right step and right to left step transitions). This synergistic modulation of the volitional EMG,

14
if present in partially paralyzed muscles, can be used as a feature template to identify the intent

to transition from the left to right step and right to left step even when partially paralyzed

muscles are too weak to produce enough moment at the joint to produce effective push-off.

Prior work has shown that the EMG synergies found by principal component analysis can

provide information related to gait events and also gait-speed [1.19]. Transition specific EMG

features can be identified using principal component analysis which can then be used to identify

the transition phase of the gait. A binary classifier to trigger the transition from left to the right

step and vice versa can be trained with the parameters from correlation analysis of the EMG

pattern with transition specific EMG feature template. The correlation coefficients of the features

associated with these transitions are postulated to be clustered in the feature space. During online

operation, the classifier will have to identify the cluster from windowed EMG using cross-

correlation with the specified features and determine the ‘intended’ transition. This method can

be conceptually extended to identify the transitions to other tasks like side-stepping, stair-

climbing, different gait-speeds etc. It is postulated that EMG-triggered FES-controller will have

an impact on the coordination of the FES-assisted iSCI gait. Seamlessly integrating the FES-

generated movement with the volitional movement should significantly enhance the transitions

from one gait phase to the other during walking.

There are challenges associated with the implementation of this method. The nature of

motor deficits in incomplete SCI population is very heterogeneous. Some individuals can walk to

a certain extent with upper-body support, some can stand using the extensor tone and some are

completely non-ambulatory. The partially paralyzed muscles had to be selected appropriately

such that the volitional EMG from those muscles had enough information to identify the gait

phase transitions. The EMG had to be blanked during the stimulation to remove stimulation

15
artifact that reduced the information content in the EMG. This may produce overlapping clusters

in EMG feature space that will be difficult to classify with low false positive rate. More EMG

channels (more than preferred two) may be needed in order to reduce the false positive rate in

that case. In this study, the enhanced coordination during ambulation was investigated by

dynamical systems tools like return map analysis [1.20]. Subjective impressions of the two

controllers were captured by a Usability Rating Scale (URS) [1.21].

Electromyogram-based trigger for the FES-controller: specific objectives of the work

The overall goal was to develop and evaluate an EMG-based trigger for the FES-controller

which can assist volitional motor function synergistically with electrical stimulation during gait.

The overall goal was divided into three specific aims.

Aim 1 - Muscle selection for EMG-based trigger: Select a set of two partially paralyzed

muscles in individuals with iSCI that yield consistent and reliable command information for

FES-assisted gait.

Hypothesis 1: The two partially paralyzed muscles will have volitionally controllable

EMG pattern similar to that in able-bodied individuals.

1. The iSCI subjects have volitional control over the surface EMG from the partially

paralyzed muscles that are comparable to able-bodied controls.

2. The iSCI subjects have EMG pattern in 2 partially paralyzed muscles with enough

information to identify the gait phase transitions during over-ground walking.

Aim 2 - Feasibility analysis of EMG-triggered FES-assisted ambulation: Development

and online-testing of a FES-controller for ambulation with a surface EMG-based classifier for

triggering FES-assisted steps in subjects with iSCI.

Hypothesis 2: It was hypothesized that two muscles can be used to detect intention for

foot-off with false-positive rate less that 2 % and true-positive rate greater than 85 %.

16
Aim 3 - Evaluation of EMG-triggered FES-assisted gait: Compare the FES-assisted gait

with the surface EMG-triggered FES-controller with the switch-triggered one with dynamical

systems tools like return map analysis and subjective tools like Usability Rating Scale to evaluate

enhancement in coordination, especially during the gait phase transitions.

Hypothesis 3: EMG-triggered FES-controller will enhance the FES-assisted over-ground

ambulation when compared to switch-triggered one.

Overview of the chapters

Chapter 2 addresses Hypothesis 1 and discusses the evaluation of surface electromyogram

from partially paralyzed muscles as a command source for triggering FES-assisted steps during

walking.

Chapter 3 addresses Hypothesis 2 and assesses the feasibility of triggering FES-assisted

steps with surface EMG-based classifier running in real-time during over-ground ambulation.

Chapter 4 and 5 address Hypothesis 3 and compare EMG-triggered FES-assisted gait to

switch-triggered stepping. Chapter 4 discusses the gait parameters during over-ground walking in

the laboratory. Chapter 5 discusses the coordination and stability during stand-to-walk transition

in the laboratory.

Chapter 6 presents a proof-of-concept implementation of a simple binary classifier based

on intramuscular EMG from a completely implanted neuroprosthesis using methods developed

in the earlier chapters for triggering FES-assisted steps with a fully implantable FES system.

References

1.1. SCIIN, Spinal cord injury: facts and figures at a glance - June 2005. 2005, Spinal Cord
Injury Information Network.

17
1.2. W. T. Liberson, H. J. Holmquest, D. Scott, M.Dow, “Functional electrotherapy: stimulation
of the peroneal nerve synchronized with the swing phase of the gait of hemiplegic
patients,” Arch Phys Med Rehabil, vol. 42, 1961, pp. 101-105.

1.3. R. Kobetic, R. J. Triolo, J. P. Uhlir, C. Bieri, M. Wibowo, G. Polando, E. B. Marsolais, J.


A. Davis Jr., K. A. Ferguson, and M. Sharma, “Implanted Functional Electrical Stimulation
System for Mobility in Paraplegia: A Follow-Up Case Report,” IEEE Trans. Rehabil. Eng.,
vol. 7, no. 4, Dec. 1999, pp. 390–398.

1.4. B. Smith, Z. Tang, M.W. Johnson, S. Pourmehdi, M.M. Gazdik, J.R. Buckett, and P.H.
Peckham, “An externally powered, multichannel, implantable stimulator-telemeter for
control of paralyzed muscle,” IEEE Trans Biomed Eng., vol. 45, no. 4, 1998, pp. 463-475.

1.5. Z. Tang, B. Smith, J.H. Schild, and P.H. Peckham, “Data transmission from an implantable
biotelemeter by load-shift keying using circuit configuration modulator,” IEEE Trans
Biomed Eng., vol. 42, no. 5, 1995, pp. 525-528.

1.6. N. Bhadra, K.L. Kilgore, and P.H. Peckham, “Implanted stimulators for restoration of
function in spinal cord injury,” Med. Eng. Phys., vol. 23, 2001, pp. 19-28.

1.7. J. Knutson, M. Audu, and R. Triolo, “Interventions for mobility and manipulation after
spinal cord injury: a review of orthotic and neuroprosthetic options,” Topics in Spinal Cord
Rehab, in press.

1.8. J. R.W. Morris, “Accelerometry a technique for the measurement of human body
movements,” J Biomech., vol. 6, 1973, pp. 729–36.

1.9. I. P. Pappas, M. R. Popovic, T. Keller, V. Dietz, and M. Morari, “A reliable gait phase
detection system,” IEEE Trans. Neural Syst. Rehabil. Eng., vol. 9, no. 2, Jun. 2001, pp.
113-125.

1.10. A. Mansfield, and G. M. Lyons, “The use of accelerometry to detect heel contact events for
use as a sensor in FES assisted walking,” Med. Eng. Phys., vol. 25, no. 10, Dec. 2003, pp.
879-885.

1.11. R. Williamson, and B. J. Andrews, “Gait event detection for FES using accelerometers and
supervised machine learning,” IEEE Transactions on Rehabilitation Engineering, vol. 8,
2000, pp. 312–319.

1.12. T. Sinkjaer, M. Haugland, A. Inman, M. Hansen, and K. D. Nielsen, “Biopotentials as


command and feedback signals in functional electrical stimulation systems,” Med. Eng.
Phys., vol 25, no. 1, Jan. 2003, pp. 29-40.

1.13. R. T. Lauer, R. T. Smith, and R. R. Betz, “Application of a neuro-fuzzy network for gait
event detection using electromyography in the child with cerebral palsy,” IEEE Trans.
Rehabil. Eng., vol. 52, no. 9, Sep. 2005, pp. 1532–1540.

18
1.14. D. Graupe, and H. Kordylewski, “Artificial neural network control of FES in paraplegics
for patient responsive ambulation,” IEEE Trans. Biomed Eng., vol. 42, no. 7, Jul. 1995, pp.
699-707.

1.15. R. J. Triolo, and G. D. Moskowitz, “The theoretical development of a multichannel time-


series myoprocessor for simultaneous limb function detection and muscle force
estimation,” IEEE Trans. Biomed Eng., vol. 36, no. 10, Oct. 1989, pp. 1004-1017.

1.16. A. Dutta, R. Kobetic, and R. J. Triolo, “EMG based triggering and modulation of
stimulation patterns for FES assisted ambulation – a conceptual study,” presented at XXth
Congress of the International Society of Biomechanics, Cleveland, OH, Aug. 2005.

1.17. S. Zhou, M. F. Carey, R. J. Snow, D. L. Lawson, and W. E. Morrison, “Effects of muscle


fatigue and temperature on electromechanical delay,” Electromyogr Clin Neurophysiol.,
vol 38, no. 2, Mar. 1998, pp. 67-73.

1.18. A. Dutta, and R. J. Triolo, “Volitional surface EMG based control of FES-assisted gait after
incomplete spinal cord injury – a single case feasibility study,” presented at NIH Neural
Interfaces Workshop, Bethesda, MD, Sep. 2005.

1.19. A. Hof, H. Elzinga, W. Grimmius, and J. Halbertsma, “Speed dependence of averaged


EMG pro-files in walking,” Gait and Posture, vol. 16, 2002, pp. 78–86.

1.20. Y. Hurmuzlu, and C. Basdogan, “On the measurement of stability in human locomotion,”
ASME Journal of Biomechanical Engineering, vol. 116, 1994, pp. 30-36.

1.21. E. Steinfeld, G. Danford, Eds. Enabling Environments: Measuring the Impact of


Environment on Disability and Rehabilitation. Kluwer/Plenum, 1999.

19
CHAPTER 2
EVALUATION OF SURFACE ELECTROMYOGRAM FROM PARTIALLY PARALYZED
MUSCLES AS A COMMAND SOURCE FOR FUNCTIONAL ELECTRICAL
STIMULATION

Abstract

Functional Electrical Stimulation (FES) facilitates ambulatory function after paralysis by

electrically activating the muscles of the lower extremities by exciting the peripheral motor

nerves. The FES-assisted stepping can be triggered by a manual switch or by a gait event

detector (GED). The objective of this study was to evaluate the performance of the surface

electromyogram (EMG) from partially paralyzed muscles for detecting the intent to step during

level over-ground walking. Two subjects with incomplete spinal cord injuries (iSCI) and four

able-bodied subjects volunteered for this study. Subject iSCI-1 (age 23 years, C6 ASIA C) was

non-ambulatory without the assistance of FES. Subject iSCI-2 (age 34 years, T1 ASIA D) could

walk only short distances without FES. The four able-bodied subjects, Able-1 (age 26 years),

Able-2 (age 25 years), Able-3 (age 25 years) and Able-4 (age 54 years) had no known injury or

pathology to either lower extremity during the study. Partially paralyzed muscles showed

performance similar (one-way two-tailed ANOVA, p<0.01) to able-bodied muscles in visual

pursuit tasks involving contraction of the muscle in a controlled fashion. Ipsilateral erector

spinae and ipsilateral medial gastrconemius consistently performed well to identify the intent to

step in both able-bodied subjects and subjects with iSCI. Left erector spinae with a mean

Discriminability Index (DI) of 0.87 for left step trigger and right erector spinae with a mean DI

of 0.83 for the right step trigger were best command sources for iSCI-1. Left erector spinae with

a mean DI of 0.93 for left step trigger and right medial gastrocnemius with a mean DI of 0.88 for

the right step trigger were the best command sources for iSCI-2.

20
Introduction

Functional electrical stimulation (FES) provides an opportunity for brace-free ambulation

to wheelchair dependent individuals with incomplete spinal cord injuries (iSCI). FES systems

can electrically activate a customized set of muscles selected to address individual gait deficits

with pre-programmed patterns of stimulation to produce cyclic movement of the lower

extremities for ambulation [2.1], [2.2]. Users normally use a switch to manually trigger each step

and progress through the customized pattern of stimulation to achieve walking function. In this

study we evaluated the controllability (the ability to volitionally modulate the surface

electromyogram (EMG) in a visual pursuit task) and discriminability (the ability to determine the

intent to step during level overground walking) of the surface EMG from both able-bodied

volunteers and individuals with iSCI. Our goal was to specify a process and criterion for

selecting two muscles for a new command and control interface that can be implemented with

two channels of implanted EMG recording electrodes with our next family of implantable

stimulator-telemeters (IST) [2.3-2.6]. This report summarizes the evaluation of the surface EMG

from partially paralyzed muscles of two subjects with iSCI and its comparison with normative

data from 4 able-bodied subjects.

While gait event detection is possible with physical sensors such as force sensitive

resistors, accelerometers, gyroscopes [2.7], [2.8], biopotentials such as EMG can also provide

useful and reliable information [2.9-2.11]. The EMG temporally precedes the generation of force

in a muscle and the resulting movement of a joint. This makes EMG an attractive signal for

detection of intent and can allow the desired movement to be assisted by FES. Graupe and

Kordylewski presented a neural network based classifier with on-line learning capabilities for

individuals with complete paraplegia [2.11], [2.12]. Thorsen et al. showed improved wrist

extension with stimulation controlled by surface EMG from partially paralyzed wrist extensors

21
[2.13]. Futami et al. showed the feasibility of proportional control of FES with the surface EMG

from the same muscle (partially paralyzed knee extensors) in incomplete hemiplegia [2.14]. Our

preliminary study demonstrated the feasibility of FES-assisted walking triggered by the surface

EMG during double-support phase of gait (when both the feet are on ground) [2.5]. A

quantitative method is presented in this paper to evaluate the electromyogram from partially

paralyzed muscles as a command source for triggering FES-assisted steps during ambulation.

Methods

Subjects

Two male subjects with incomplete spinal cord injury (iSCI) volunteered for this study.

iSCI-1 was a 23 years old male with C7 motor and C6 sensory incomplete spinal cord injury

(ASIA C) who could stand but could not initiate a step without the assistance from FES. iSCI-2

was a 34 years old male with T1 motor and C6 sensory incomplete spinal cord injury (ASIA D)

who could walk only short distances without the assistance from FES. They each received an 8

channel Implantable Receiver Stimulator (IRS-8) and eight surgically implanted intramuscular

electrodes in a related study designed to facilitate household and limited community ambulation

[2.15]. The four able-bodied subjects, Able-1 (age 26 years), Able-2 (age 25 years), Able-3 (age

25 years) and Able-4 (age 54 years) provided the normative data for comparison. They had no

known injury or pathology to either lower extremity during the course of the study.

The subject iSCI-1 received intramuscular stimulating electrodes bilaterally recruiting

iliopsoas, vastus intermedius and lateralis, tensor fasciae latae, tibialis anterior, and peroneus

longus muscles. The subject iSCI-2 received stimulation electrodes only on his left side

recruiting iliopsoas, vastus intermedius and lateralis, tensor fasciae latae, gluteus medius, gluteus

maximus, posterior portion of adductor magnus, and tibialis anterior (2 electrodes). Temporal

patterns of stimulation to activate the muscles were customized for their particular gait deficits

22
according to established tuning procedures in order to achieve forward stepping in a rolling

walker [2.16], [2.17]. The subjects completed 6 weeks of over-ground gait training (2 hour

sessions, 3 times per week) with a physical therapist using the implanted FES system. After

discharge from rehabilitation, they volunteered for the studies using the myoelectric control of

the FES system.

Informed consent was obtained from all the subjects before their participation and all study

related procedures were approved by the Institutional Review Board of the Louis Stokes

Cleveland Department of Veterans Affairs Medical Center.

Test of Controllability

Controllability was defined as the ability to modulate the EMG activity from one level to

another in a finite time during a visual pursuit task. The experimental setup for evaluating the

controllability of a muscle with biofeedback is shown in Figure 2.1. The surface EMG was

collected from the rectus femoris while the subject was asked to track the absolute value of a

sinusoid of amplitude 0.7 and frequency 0.01 Hz over one time-period (i.e., the TARGET signal)

during a trial. The rectus femoris was maintained in an isometric condition by Biodex System3

(Biodex Medical Systems, USA) dynamometer as shown in Figure 2.1. The EMG was pre-

amplified and low-pass filtered (anti-aliasing, frequencycutoff=1000 Hz) by CED 1902

preamplifier (Cambridge Electronic Design, England) before being sampled at 2200 Hz by the

data-acquisition card (AT-MIO-64F-5, National Instruments, USA) in a personal computer (PC).

The data processing and graphical display (GUI) were performed using Matlab R13 (The

MathWorks, Inc., USA) in the same PC. The EMG sampled by the data-acquisition card was

band-pass filtered (5th order zero-lag Butterworth, 20-500 Hz), de-trended and rectified before

being evaluated as a command signal (i.e., the TRACKING signal). The average EMG during

two seconds of maximum voluntary isometric contraction (MVC) was used for normalization.

23
The average magnitude of the EMG over two seconds while the subject was asked to relax the

muscle provided an estimate of the baseline activity. During visual pursuit, the estimated

baseline was subtracted from the EMG and then it was normalized by the MVC. The normalized

EMG was then divided into bins, each holding 0.1 sec of data. The TRACKING signal (i.e., the

processed EMG) pursuing the TARGET signal was updated every 0.1 sec with the average value

of the data in the latest bin only if the mean was greater by twice the standard deviation, or less

by one standard deviation, of the data in the preceding bin.

Both TARGET and TRACKING signals were projected on the wall in front of the subject

seated in the dynamometer. A set of five trials with a minimum 5 minutes of rest in between the

trials were conducted on the left and right rectus femoris of the subjects with iSCI. A set of five

trials were conducted only on the right rectus femoris of the right-handed able-bodied subjects.

The absolute value of the difference between the TARGET and TRACKING signals, the

tracking error signal ( ERROR signal = TRACKING signal - TARGET signal ), was ensemble averaged

over the set of five trials. The trial period of 100 sec was divided into four parts of 25 sec each.

The first (0-25 sec) and the third (50-75 sec) parts were the periods during which the subject was

trying to contract the muscle to catch-up with the TARGET signal. The second (25-50 sec) and

the fourth parts (75-100 sec) were the periods when the subject was trying to relax the muscle.

The mean of the absolute tracking error was computed for each of these four parts for

comparison.

Test of Discriminability

Discriminability was defined as the ability to detect the intent to step using the surface

EMG during the double-support phase of gait when both the feet are in contact with the ground.

Surface EMG signals were collected from gluteus medius (GM), biceps femoris (BF), medial

24
gastrocnemius (MG), rectus femoris (RF), tibialis anterior (TA), and erector spinae (ES at T9)

bilaterally. In case of iSCI subjects, the surface EMG was collected during switch-triggered FES-

assisted gait when each step was initiated by depression of ring-mounted finger switch. The

experimental setup is shown in Figure 2.2 where subject is walking with an implanted switch-

triggered FES-system based on an IRS-8 implanted pulse generator under the control of an

external control unit (ECU). Surface EMG was collected using Ag/AgCl electrodes with 2 cm.

inter-electrode distance following the SENIAM guidelines [2.18]. The EMG signals were

amplified and low-pass filtered (anti-aliasing, frequencycutoff=1000 Hz) by CED 1902 amplifiers

(Cambridge Electronic Design, England) before being sampled at 2400 Hz (AT-MIO-64F-5,

National Instruments, USA) in the host personal computer (PC). The CED 1902 amplifier has a

switching circuit (clamp) which was activated by a trigger pulse that disconnected the electrode

inputs from the amplifier and connected them to the common electrode just before the start of the

stimulation pulse. The input channels of CED 1902 were clamped this way when stimulation

pulses were applied to the muscles to prevent stimulation artifact. The gain of each channel was

set separately in the CED 1902 amplifiers to prevent saturation at the maximum muscle activity

during the gait-cycle. The implanted FES system (i.e., IRS-8) delivered electrical pulses at a

frequency of 20 Hz, so the sampled EMG was divided into bins of 50ms duration. In each bin,

30ms following the start of the stimulation pulse was blanked to remove the residual stimulation

artifact and M-wave, thus leaving signal related to voluntary muscle activity. The remaining 20

ms of data in each bin was detrended, band-pass filtered (5th order zero-lag Butterworth, 20-500

Hz), and rectified. The blanked portion of the EMG was reconstructed with the average value of

the EMG in the preceding and succeeding blocks [2.19]. Then the whole EMG pattern was low

pass filtered (5th order zero-lag Butterworth, frequencycutoff=3 Hz) to get the linear envelope. The

25
EMG pattern for each muscle was normalized by the maximum value of the EMG linear

envelope (LE) during a gait cycle. The normalized LEs during a gait cycle were then divided into

double-support and swing phase of gait based on the occurrence of foot-strike and foot-off. The

foot and ground contact sequences were determined from the insole foot switches (B&L

Engineering, USA) placed bilaterally at the medial and lateral heel, first and fifth metatarsal, and

big toe. The intent to step can be detected based on the magnitude of the LE when it crosses a

selected threshold (threshold-based) or by matching the LE pattern with a specified pattern of

muscle activity using cross-correlation analysis (pattern-recognition).

The subjects were asked to start walking after standing for 3 sec and reach a self-selected

speed within 5m from the start position. After reaching the self-selected speed the subjects had to

decelerate and return to standing. The experimental protocol is shown in Figure 2.3. The subjects

were asked to wait in terminal stance for 3 sec. The normalized LEs of each muscle were divided

into two classes: the class ‘True’ was comprised of LEs (~ 150) during double-support phase

prior to foot-off and the class ‘False’ consisted of the LEs (~150) during terminal stance and

initial standing. Half of the data were randomly allocated to training and used to find a

characteristic pattern of activation by ensemble averaging the LEs. The characteristic pattern

found for the class ‘True’ was cross-correlated with the LEs from the other half of the data (test

data) for the classes – ‘True’ and ‘False’. A Receiver Operating Characteristics (ROC) curve

shows the tradeoff between sensitivity (True Positive Rate) and 1 – specificity (False Positive

Rate) of a binary classifier [2.20]. The ROC curve was computed from the cross-correlation

coefficient (i.e., PRC for the pattern-recognition classifier) and the amplitude (i.e., TC for the

threshold-based classifier) of the LEs as the decision threshold was varied over the range of data

in the two classes, ‘True’ and ‘False’. The LEs from all the able-bodied subjects were pooled

26
together. In case of able-bodied data, the left and the right sides were considered similar and the

performance of the PRC and TC was evaluated only for the right side. The ipsilateral muscles are

the muscles of the right side and contralateral muscles are the muscles of the left side for the

classifiers (PRC and TC) trying to detect the ‘intent to step’ on the right side.

Discriminability Index (DIPRC and DITC) was defined as the area under the ROC curve

(AUC) which gave a measure of performance for the binary classifiers, PRC and TC. Bradley

showed that AUC exhibits a number of desirable properties when compared to overall accuracy

of the classifiers like increased sensitivity in Analysis of Variance (ANOVA) tests – standard

error decreased as both AUC and the number of test samples increased. AUC is also decision

threshold independent and it is invariant to a priori class probabilities [2.21]. The area under the

ROC curve was numerically computed with trapezoidal integration. Figure 2.4 illustrates the

three cases, where 0 < DI ≤ 0.5, 0.5 ≤ DI < 1, DI = 1 . We are interested in 0.5 ≤ DI < 1 such that the

mean of the ‘True’ data is greater than or equal to the mean of the ‘False’ data and the values

greater than the discrimination threshold are classified as ‘True’.

The data were randomly partitioned ten times into training and test data-sets for a 10-fold

cross-validation. For consistency the same training and test data-sets were used by both the

classifiers (PRC and TC) for the computation of the ROC curves in a paired experimental design.

Therefore, 10 ROC curves for each classifier were generated by randomly pooling the LEs into

training and test data-sets. The DI was computed for each ROC curve and then averaged to find

the mean (DIPRC and DITC) and standard deviation (SD(DIPRC) and SD(DITC)) for each classifier

(DIPRC for pattern-recognition classifier and DITC for the threshold-based classifier) [2.21].

Wilcoxon statistic (W) was computed as an alias of DI (i.e., a performance measure of the

classifier) to compare the two for robustness. The standard error (SE(WPRC) and SE(WTC)) was

27
computed from an approximation of the Wilcoxon statistic (WPRC and WTC) which assumes

exponential distribution of the data in the classes, ‘True’ and ‘False’. SE (W) has been shown to

be conservative as it overestimates the standard error [2.22]

W (1 − W ) + (C p − 1)(Q1 − W 2 ) + (C n − 1)(Q2 − W 2 )
SE (W ) =
C p Cn
2
W 2W
Q1 = ; Q2 =
(2 − W ) (1 + W )

Where Cp and Cn are the number of data points in the classes, ‘True’ and ‘False’

respectively.

Statistical Analysis

One-way two-tailed analysis of variance (‘anova1’ in MatlabTM R14, The MathWorks,

Inc., USA) was performed on the absolute tracking error that was obtained from the Test of

Controllability. All observations were considered to be mutually independent for the ANOVA

test. The p-value was computed for the null hypothesis that the absolute tracking error parameter

has the same mean for all the cases. If the p-value was close to zero (<0.01) then the null

hypothesis was rejected and the result was considered statistically significant.

Two-way two-tailed analysis of variance (‘anova2 in MatlabTM R14, The MathWorks, Inc.,

USA) was performed on Discriminability Index (DI) – the performance measure for the classifier

and muscle, that was obtained from the Test of Discriminability. All observations were

considered to be mutually independent for the ANOVA test. The p-value was computed for the

null hypotheses: 1 – the performance measure for the pattern-recognition classifier (PRC) and

threshold-based classifier (TC) have equal means, 2 – the performance measure for all the

muscles have equal means, 3 – there is no interactions between the classifier type and muscle

type. If the p-value was close to zero (<0.05) then that null hypothesis was rejected and the result

28
was considered statistically significant. To find which pairs were significantly different, post hoc

tests were performed with the critical values found from Scheffe’s S procedure.

ANOVA is insensitive to departures from the assumption of equal variances when the

sample sizes are equal, as in our case. Moreover, prior work has shown that ANOVA is “robust”

to violations of its assumptions [2.23]

Results

Results from the Test of Controllability

The TRACKING signal (broken black line) using the surface EMG of rectus femoris and

the TARGET signal (solid black line) that was the absolute value of a 0.01 Hz sinusoid of

amplitude 0.7 during visual pursuit over 100 ms is shown in Figure 2.5 and 2.6. The top panel of

Figure 2.5 shows the results for the rectus femoris of the left and the right sides of iSCI-1 and the

bottom panel shows the same for iSCI-2. Figure 2.6 shows the results for surface EMG from

rectus femoris of the right side for the able-bodied subjects. The solid black line is the TARGET

signal and the broken black line shows the TRACKING signal that was ensemble averaged over

5 trials. The boxes at each data point show the lower quartile and upper quartile values of the

TRACKING signal. Whiskers extending at the top and bottom of the boxes show the range of

the TRACKING signal. Table 2.1 presents the mean, the minimum, and the maximum average

absolute tracking error during four parts (0-25 sec, 25-50 sec, 50-75 sec, 75-100 sec) of the trial.

The p-value from the one-way two-tailed ANOVA test for the average tracking error over the

whole trial (100 sec) was not statistically significant ( ≥ 0.01). This shows that all the subjects

(iSCI and able-bodied) performed similarly in the visual pursuit task for the Test of

Controllability. Individuals with iSCI were able to control the contraction of their muscles

equally well as able-bodied individuals.

29
The average absolute tracking error was smallest (mean = 5.48) in the first part (0-25 sec)

of the trial period, for the subjects with iSCI, corresponding to the initial period of increasing

isometric contraction. There was a slight deterioration in the performance of the iSCI subjects in

the third part of the trial, corresponding to the second period of increasing contraction (50-75

sec, mean=7.96) when compared to the first part (0-25 sec, mean=5.48). The subjects with iSCI

performed worse in the second (25-50 sec, mean=9.11) and fourth (75-100 sec, mean=10.27)

parts of the trial period, which required relaxing the muscle in a controlled fashion.

Results from the Test of Discriminability

Table 2.2 shows the results from the Test of Discriminability for the muscles gluteus

medius (GM), biceps femoris (BF), medial gastrocnemius (MG), rectus femoris (RF), tibialis

anterior (TA), and erector spinae (ES at T9) for the able-bodied subjects. The Wilcoxon statistic

(W) was similar in magnitude to the corresponding Discriminability Index (DI). Similarly the

Standard Deviation (SD) of the DI over 10 random partitions (i.e., 10-fold cross-validation) was

similar in magnitude to the Standard Error (SE) found for the Wilcoxon statistic (W). There were

statistically significant (p ≥ 0.05) differences in the means of DI due to the muscle type as well as

the classifier type. The results from the post hoc analysis are presented in Figure 2.7. The top

panel of Figure 2.7 shows that the Ipsilateral MG, Ipsilateral ES, Contralateral BF, Contralateral

GM, and Contralateral TA in black markers that have performed the best (mean DI=1) as a

command source in the Test of Discriminability. The bottom panel of Figure 2.7 shows that the

Pattern Recognition Classifier (mean DIPRC=0.7586) performed much better than the Threshold-

based Classifier (mean DITC=0.5016).

Table 2.3a and b show the results from the Test of Discriminability of iSCI-1 for the left

step and right step classifiers respectively. The Wilcoxon statistic (W) was similar in magnitude

to the corresponding value of the Discriminability Index (DI). Similarly the Standard Deviation

30
(SD) of the DI was similar in magnitude to the Standard Error (SE) found for the Wilcoxon

statistic (W). There were statistically significant (p ≥ 0.05) differences in the means of DI due to

the muscle type as well as the classifier type. The results from post hoc analysis are presented in

Figure 2.8. The top panel first column of Figure 2.8 shows that Left ES (mean DI=0.8705) in

black marker performed the best followed by Left MG (mean DI=0.7881) in gray marker in the

Test of Discriminability for the left step. The bottom panel first column of Figure 2.8 shows that

Pattern Recognition Classifier (mean DIPRC=0.6486) in black marker performed slightly better

than the Threshold-based Classifier (mean DITC=0.6071) in gray marker in the Test of

Discriminability for the left step. The top panel second column of Figure 2.8 shows that Right ES

(mean DI=0.8299) performed the best followed by Right MG (mean DI=0.7989) in the Test of

Discriminability for the right step. The bottom panel first column of Figure 2.8 shows that

Pattern Recognition Classifier (mean DIPRC=0.6559) in black marker performed slightly better

than the Threshold-based Classifier (mean DITC=0.5886) in gray marker in the Test of

Discriminability for the right step.

Table 2.4a and b show the results from the Test of Discriminability of iSCI-2 for the left

step and right step classifiers respectively. The Wilcoxon statistic (W) and the corresponding

value of the Discriminability Index (DI) were similar. The Standard Deviation (SD) of the DI

and the Standard Error (SE) found for the Wilcoxon statistic (W) were similar. There were

statistically significant (p ≥ 0.05) differences in the means of DI due to the muscle type as well as

the classifier type. The results from post hoc analysis are presented in Figure 2.9. The top panel

first column of Figure 2.9 shows that Left ES (mean DI=0.9293) in black marker performed the

best followed by Left MG (mean DI=0.8736) and Right RF (mean DI=0.8536 in the Test of

Discriminability for the left step. The bottom panel first column of Figure 2.9 shows that Pattern

31
Recognition Classifier (mean DIPRC=0.71856) in black marker performed much better than the

Threshold-based Classifier (mean DITC=0.45457) in gray marker in the Test of Discriminability

for the left step. The top panel second column of Figure 2.9 shows that Right MG (mean

DI=0.8805) performed the best followed by Right ES (mean DI=0.853) and Left RF (mean

DI=0.8484) in the Test of Discriminability for the right step. The bottom panel first column of

Figure 2.9 shows that Pattern Recognition Classifier (mean DIPRC=0.6853) in black marker

performed slightly better than the Threshold-based Classifier (mean DITC=0.54613) in black

marker in the Test of Discriminability for the right step.

Discussion

The controllability of the surface EMG from partially paralyzed rectus femoris of subjects

with incomplete SCI was evaluated in a visual pursuit task and found to have performance

similar (p<0.01) to able-bodied subjects (Figure 2.5 & 2.6, Table 2.1). The average absolute

tracking error was the performance measure during the visual pursuit task which was smallest in

the first part (0-25 sec) of the trial period for the subjects with iSCI. The subjects with iSCI

found it difficult to relax the muscle in a controlled fashion after the first part (0-25 sec), which

deteriorated the performance in the second part (25-50 sec) of the trial period. Subject iSCI-1

found it difficult to reach the baseline at the end of second part (25-50 sec) which deteriorated

the performance during the muscle contraction task in the third part (50-75 sec). Subject iSCI-2

could reach the baseline at the end of the second part (25-50 sec) with his right rectus femoris but

not with his left. Subject iSCI-2 had more volitional control over his right side than his left.

Overall, subjects with iSCI performed better in muscle contraction tasks (0-25 sec and 50-75 sec)

than the muscle relaxation tasks (25-50 sec and 75-100 sec). The muscles that are under

contraction and increased muscle activity during the double-support phase of the gait would be

more robust for triggering the subsequent step. The partially paralyzed muscles were evaluated

32
for classification in the Test of Discriminability, where the muscles which had 0.5 ≤ DI < 1 were

considered, such that the mean of the ‘True’ data is greater than or equal to the mean of the

‘False’ data and the values greater than the discrimination threshold were classified as ‘True’.

In the Test of Discriminability, Ipsilateral ES and Ipsilateral MG consistently performed

well in both able-bodied subjects and the subjects with iSCI. The Discriminability Index (DI)

was computed from the Area under the ROC curve which was similar to the Wilcoxon

Statististic (W) which assumes that the data in the ‘True’ and ‘False’ classes have exponential

distributions. The variability associated with DI was estimated from the Standard Error (SE)

associated with W which was similar in magnitude to the Standard Deviation (SD) computed

from 10-fold cross-validation partitions. Also, the Pattern Recognition Classifier (PRC)

consistently performed better than the Threshold-based Classifier (TC) in both the cases – able-

bodied subjects and subjects with iSCI. The basic PRC used an ensemble average of the LEs in

the ‘True’ class as the feature for pattern recognition. The PRC performance can improve with

better feature extraction using principal component analysis [2.5]. The two best muscles for the

command source and the type of the classifier were selected with post hoc analysis using the

critical values found from Scheffe’s S procedure after two-way ANOVA of the Discriminability

Index. Left ES with mean DI=0.87 for left step PRC and Right ES with mean DI=0.83 for the

right step PRC were the best command sources for iSCI-1. Left ES with mean DI=0.93 for left

step PRC and Right MG with mean DI=0.88 for the right step PRC were the best command

sources for iSCI-2. It was found that the distal muscle like MG was more susceptible to muscle

spasms in iSCI-1.

Conclusion

The goal was to define a procedure to select EMG command sources from partially

paralyzed muscles and evaluate the classifier performance prior to surgical installation of an

33
implanted stimulator-telemeter that acquire and transmit EMG information from implanted EMG

electrodes. The new family of implantable stimulator-telemeter (IST-12) has only 2 implanted

EMG channels and the capability to perform the signal processing required by the classifier

[2.6]. Partially paralyzed muscles showed controllability similar (p<0.01) to able-bodied muscles

in visual pursuit tasks involving contraction of the muscle in a controlled fashion during the Test

of Controllability. Test of discriminability was used to select two best muscles for classification

to identify the ‘intent to step.’ Bilateral ES were the best command sources for iSCI-1 and Left

ES & Right MG were the best command sources for iSCI-2. Ipsilateral ES and MG performed

the best in the Test of Discriminability for able-bodied as well as iSCI subjects.

References

2.1. Graupe, D. and K. Kohn, Functional Electrical Stimulation for Ambulation by Paraplegics.
1994: Krieger.

2.2. Kralj, A. and T. Bajd, Functional Electrical Stimulation: Standing and Walking After
Spinal Cord Injury. 1989: CRC Press.

2.3. R. Kobetic, R. J. Triolo, J. P. Uhlir, C. Bieri, M. Wibowo, G. Polando, E. B. Marsolais, J.


A. Davis Jr., K. A. Ferguson, and M. Sharma, “Implanted Functional Electrical Stimulation
System for Mobility in Paraplegia: A Follow-Up Case Report,” IEEE Trans. Rehabil. Eng.,
vol. 7, no. 4, Dec. 1999, pp. 390–398.

2.4. B. Smith, Z. Tang, M.W. Johnson, S. Pourmehdi, M.M. Gazdik, J.R. Buckett, and P.H.
Peckham , “An externally powered, multichannel, implantable stimulator-telemeter for
control of paralyzed muscle,” IEEE Trans Biomed Eng., vol. 45, no. 4, 1998, pp. 463-475.

2.5. A. Dutta, R. Kobetic, and R. Triolo, “Ambulation after incomplete spinal cord injury with
EMG-triggered Functional Electrical Stimulation,” IEEE Transactions on Biomedical
Engineering, 55:2, February 2008.

2.6. N. Bhadra, K.L. Kilgore, and P.H. Peckham, “Implanted stimulators for restoration of
function in spinal cord injury,” Med. Eng. Phys., vol. 23, 2001, pp. 19-28.

2.7. I. P. Pappas, M. R. Popovic, T. Keller, V. Dietz, and M. Morari, “A reliable gait phase
detection system,” IEEE Trans. Neural Syst. Rehabil. Eng., vol. 9, no. 2, Jun. 2001, pp.
113-125.

34
2.8. A. Mansfield, and G. M. Lyons, “The use of accelerometry to detect heel contact events for
use as a sensor in FES assisted walking,” Med. Eng. Phys., vol. 25, no. 10, Dec. 2003, pp.
879-885.

2.9. T. Sinkjaer, M. Haugland, A. Inman, M. Hansen, and K. D. Nielsen, “Biopotentials as


command and feedback signals in functional electrical stimulation systems,” Med. Eng.
Phys., vol 25, no. 1, Jan. 2003, pp. 29-40.

2.10. R. T. Lauer, R. T. Smith, and R. R. Betz, “Application of a neuro-fuzzy network for gait
event detection using electromyography in the child with cerebral palsy,” IEEE Trans.
Rehabil. Eng., vol. 52, no. 9, Sep. 2005, pp. 1532–1540.

2.11. D. Graupe, and H. Kordylewski, “Artificial neural network control of FES in paraplegics
for patient responsive ambulation,” IEEE Trans. Biomed Eng., vol. 42, no. 7, Jul. 1995, pp.
699-707.

2.12. H. Kordylewski, and D. Graupe, “Control of Neuromuscular Stimulation for Ambulation


by Complete Paraplegics via Artificial Neural Networks,” Neurol. Research, vol. 23, July
2001, pp.472-481.

2.13. R. Thorsen, R. Spadone, and M. Ferrarin, “A pilot study of myoelectrically controlled FES
of upper extremity,” IEEE Trans. Rehabil. Eng., vol. 9, no. 2, June 2001, pp. 161–167.

2.14. R.Futami, K.Seki, T.Kawanishi, T.Sugiyama, I.Cikajlo, and Y.Handa, “Application of local
EMG-driven FES to incompletely paralyzed lower extremities,” presented at 10th Annual
Conference of the International FES Society, Montreal, Canada, July 2005.

2.15. E. Hardin, R. Kobetic, L. Murray, M. Corado-Ahmed, G. Pinnault, J. Sakai, S. Nogan, C.


Ho, and R. Triolo, “Ambulation after incomplete spinal cord injury with an implanted FES
system: a case report,” Jour. Rehab R&D, 44:3, 2007, pp. 333-346.

2.16. R. Kobetic, and E.B. Marsolais, “Synthesis of paraplegic gait with multichannel functional
neuromuscular stimulation,” IEEE Trans Rehab Eng., vol. 2, no. 2, 1994, pp. 66-79.

2.17. R. Kobetic, R. J. Triolo, and E. B. Marsolais, “Muscle selection and walking performance
of multichannel FES systems for ambulation in paraplegia,” IEEE Trans. Rehabil. Eng.,
vol. 5, no. 1, Mar. 1997, pp. 23–29.

2.18. H. J. Hermens, B. Freriks, R. Merletti, D. Stegeman, J. Blok, G. Rau, C. Disselhorst-Klug,


and G. Hagg, SENIAM 8 European Recommendations for Surface ElectroMyoGraphy.
Enschede, Netherlands: Roessingh Research and Development, 1999.

2.19. A. E. Hines, P. E. Crago, G. J. Chapman, and C. Billian, “Stimulus artifact removal in


EMG from muscles adjacent to stimulated muscles,” J. Neurosci. Methods, vol. 64, no. 1,
Jan. 1996, pp. 55-62.

2.20. T. D. Dickens, Elementary Signal Detection Theory. US: Oxford University Press, 2001,
pp. 66, 121.

35
2.21. A. P. Bradley, "The use of the area under the ROC curve in the evaluation of machine
learning algorithms,"Pattern Recognition, vol. 30, no. 7, 1997, pp. 1145-1159.

2.22. J. A. Hanley and B. J. McNeil, "The meaning and use of the area under a receiver operating
characteristic (ROC) curve," Radiology, vol. 143, 1982, pp. 29-36.

2.23. R. E. Walpole and R. H. Myers, Probability and Statistic for Engineers and Scientists.
Macmillan, New York, 1990

36
Figures

Figure 2.1: Experimental setup for the Test of Controllability of the surface EMG from Rectus
Femoris using visual pursuit tasks while the knee is fixed in a dynamometer.

37
Figure 2.2: Experimental setup for surface EMG data collection with switch-triggered FES-
assisted overground walking.

38
Figure 2.3: Experimental protocol for surface EMG data collection during overground walking,
where the subject had to start from standing and achieve a self-selected gait speed
within 5m.

39
Figure 2.4: The left column shows the cumulative distribution function for the three cases,
0 < DI ≤ 0.5, 0.5 ≤ DI < 1, DI = 1 and the right column shows the corresponding Receiver
Operating Characteristics curve.

40
Figure 2.5: TRACKING (broken black line) and TARGET (solid black line) signals during
visual pursuit task for the Test of Controllability. The boxes at each data point show
the lower quartile and upper quartile values of the TRACKING signal. Whiskers
extending at the top and bottom of the boxes show the range of the TRACKING
signal. The top panel presents the results for iSCI-1 and the bottom panel for iSCI-2.
The left panel presents the results for the left Rectus Femoris and the right panel
presents the results for the right Rectus Femoris.

41
Figure 2.6: TRACKING (broken black line) and TARGET (solid black line) signals during
visual pursuit task for the Test of Controllability with able-bodied subjects. The boxes
at each data point show the lower quartile and upper quartile values of the
TRACKING signal. Whiskers extending at the top and bottom of the boxes show the
range of the TRACKING signal.

42
Figure 2.7: Top panel shows the results from the post hoc analysis of the Discriminability Index
with their critical values from Scheffe’s S procedure for the muscles – Gluteus
Medius (GM), Biceps Femoris (BF), Medial Gastrocnemius (MG), Rectus Femoris
(RF), Tibialis Anterior (TA), and Erector Spinae (ES at T9) obtained from the Test of
Discriminability with able-bodied subjects. The bottom panel shows the results from
the post hoc analysis of the Discriminability Index with their critical values from
Scheffe’s S procedure for different classifiers – Pattern Recognition Classifier (PRC)
and Threshold-based Classifier (TC) obtained from the Test of Discriminability with
able-bodied subjects.

43
Figure 2.8: Top panel shows the results from the post hoc analysis of the Discriminability Index
with their critical values from Scheffe’s S procedure for the muscles – Gluteus
Medius (GM), Biceps Femoris (BF), Medial Gastrocnemius (MG), Rectus Femoris
(RF), Tibialis Anterior (TA), and Erector Spinae (ES at T9) obtained from the Test of
Discriminability of the left and right step classifiers of iSCI-1. The bottom panel
shows the results from the post hoc analysis of the Discriminability Index with their
critical values from Scheffe’s S procedure for different classifiers – Pattern
Recognition Classifier (PRC) and Threshold-based Classifier (TC) obtained from the
Test of Discriminability of the left and the right step classifiers of iSCI-1.

44
Figure 2.9: Top panel shows the results from the post hoc analysis of the Discriminability Index
with their critical values from Scheffe’s S procedure for the muscles – Gluteus
Medius (GM), Biceps Femoris (BF), Medial Gastrocnemius (MG), Rectus Femoris
(RF), Tibialis Anterior (TA), and Erector Spinae (ES at T9) obtained from the Test of
Discriminability of the left and right step classifiers of iSCI-2. The bottom panel
shows the results from the post hoc analysis of the Discriminability Index with their
critical values from Scheffe’s S procedure for different classifiers – Pattern
Recognition Classifier (PRC) and Threshold-based Classifier (TC) obtained from the
Test of Discriminability of the left and the right step classifiers of iSCI-2.

45
Tables

Table 2.1: The mean, the minimum, and the maximum average absolute tracking error in %MVC
during the four parts (0-25 sec, 25-50 sec, 50-75 sec, 75-100 sec) of the Test for
Controllability. The p-value from the one-way two-tailed ANOVA test for the
average tracking error over the whole trial (100 sec) was not ‘statistically significant’
( ≥ 0.01).

Part 1 Part 2 Part 3 Part 4


%MVC (0-25 sec) (25-50 sec) (50-75 sec) (75-100 sec)
Mean Min Max Mean Min Max Mean Min Max Mean Min Max
iSCI-1 Left RF 5.34 0.01 11.6 10.68 1.24 25.8 8.98 0.16 21.39 16.05 1.02 26.97
iSCI-1 Right
RF 6.57 0.57 15.02 9.4 1.44 20.61 8.49 0.44 20.97 9.58 0.59 21.04
iSCI-2 Left RF 7.18 0.45 16.42 9.84 0.14 32.31 9.75 0.33 33.1 9.23 0.28 26.18
iSCI-2 Right
RF 2.81 0.02 5.77 6.52 0.34 16.9 4.63 0.05 9.4 6.23 0.66 15.55
Able-1 Right
RF 4.05 0.29 9.5 2.42 0.02 7.86 3.29 0.42 10.92 3.26 0.02 10.77
Able-2 Right
RF 8.98 5.28 13.19 4.99 0.09 14.49 7.75 0.07 23.11 13.19 0.06 26.8
Able-3 Right
RF 4.79 0.11 9.49 5.11 0.02 13.63 3.51 0.18 10.37 2.46 0.02 8.11
Able-4 Right
RF 12.89 4.56 18.71 6.66 0.32 15.76 5.93 0.2 13.71 6.66 0.81 11.72

46
Table 2.2: The results from the Test of Discriminability for the muscles Gluteus Medius (GM),
Biceps Femoris (BF), Medial Gastrocnemius (MG), Rectus Femoris (RF), Tibialis
Anterior (TA), and Erector Spinae (ES at T9) are presented for the able-bodied
subjects. The Wilcoxon statistic (W) was similar in magnitude to the corresponding
Discriminability Index (DI). Similarly the Standard Deviation (SD) of the DI over 10
random partitions (i.e., 10-fold cross-validation) was similar in magnitude to the
Standard Error (SE) found for the Wilcoxon statistic (W). There were ‘statistically
significant’ (p ≥ 0.05) differences in the means of DI due to the muscle type as well as
the classifier type.

Muscles for right step


SD SE SD SE
classifier for able-bodied DIPRC WPRC DITC WTC
(DIPRC) (WPRC) (DITC) (WTC)
subjects
Ipsilateral GM 0.42 0 0.43 0 0 0 0 0
Ipsilateral BF 0.29 0 0.3 0 0 0 0 0
Ipsilateral MG 1 0 1 0 1 0 1 0
Ipsilateral RF 0.74 0.01 0.75 0.01 0.59 0.05 0.59 0.05
Ipsilateral TA 0.52 0 0.54 0 0 0 0 0
Ipsilateral ES 1 0 1 0 1 0 1 0
Contralateral GM 1 0 1 0 1 0 1 0
Contralateral BF 1 0 1 0 1 0 1 0
Contralateral MG 0.26 0 0.28 0 0 0 0 0
Contralateral RF 1 0 1 0 0.42 0.04 0.42 0.04
Contralateral TA 1 0 1 0 1 0 1 0
Contralateral ES 0.49 0.02 0.49 0.01 0 0 0 0

47
Table 2.3a: The results from the Test of Discriminability of iSCI-1 for the left step classifier. The
Wilcoxon statistic (W) was similar in magnitude to the corresponding value of the
Discriminability Index (DI). Similarly the Standard Deviation (SD) of the DI was
similar in magnitude to the Standard Error (SE) found for the Wilcoxon statistic (W).
There were ‘statistically significant’ (p ≥ 0.05) differences in the means of DI due to
the muscle type as well as the classifier type.
Muscles for left step SD SE SD SE
classifier of iSCI-1 DIPRC (DIPRC) WPRC (WPRC) DITC (DITC) WTC (WTC)
Left GM 0.77 0.06 0.78 0.06 0.66 0.06 0.67 0.06
Left BF 0.56 0.03 0.56 0.03 0.57 0.05 0.58 0.05
Left MG 0.81 0.02 0.81 0.02 0.77 0.06 0.77 0.06
Left RF 0.72 0.04 0.73 0.04 0.57 0.05 0.57 0.05
Left TA 0.63 0.08 0.64 0.08 0.58 0.06 0.58 0.06
Left ES 0.96 0.04 0.96 0.038 0.78 0.06 0.79 0.06
Right GM 0.5 0.04 0.5 0.039 0.53 0.03 0.55 0.03
Right BF 0.56 0.04 0.57 0.036 0.56 0.05 0.56 0.05
Right MG 0.58 0.04 0.59 0.039 0.56 0.06 0.56 0.06
Right RF 0.65 0.08 0.67 0.075 0.53 0.06 0.54 0.05
Right TA 0.56 0.05 0.56 0.045 0.55 0.06 0.56 0.06
Right ES 0.51 0.06 0.51 0.057 0.60 0.05 0.61 0.05

Table 2.3b: The results from the Test of Discriminability of iSCI-1 for the right step. The
Wilcoxon statistic (W) was similar in magnitude to the corresponding value of the
Discriminability Index (DI). Similarly the Standard Deviation (SD) of the DI was
similar in magnitude to the Standard Error (SE) found for the Wilcoxon statistic (W).
There were ‘statistically significant’ (p ≥ 0.05) differences in the means of DI due to
the muscle type as well as the classifier type.

Muscles for right step SD SE SD SE


classifier of iSCI-1 DIPRC (DIPRC) WPRC (WPRC) DITC (DITC) WTC (WTC)
Left GM 0.48 0.07 0.49 0.07 0.57 0.06 0.57 0.059
Left BF 0.55 0.07 0.56 0.07 0.58 0.04 0.59 0.04
Left MG 0.68 0.06 0.68 0.06 0.59 0.04 0.6 0.04
Left RF 0.66 0.05 0.67 0.05 0.55 0.05 0.55 0.05
Left TA 0.53 0.05 0.53 0.05 0.56 0.07 0.57 0.07
Left ES 0.57 0.05 0.57 0.05 0.55 0.05 0.56 0.04
Right GM 0.77 0.04 0.78 0.04 0.53 0.03 0.53 0.03
Right BF 0.52 0.04 0.53 0.04 0.52 0.06 0.53 0.06
Right MG 0.85 0.05 0.86 0.05 0.75 0.05 0.75 0.05
Right RF 0.69 0.05 0.7 0.05 0.53 0.05 0.54 0.05
Right TA 0.68 0.04 0.68 0.04 0.56 0.05 0.57 0.06
Right ES 0.89 0.06 0.89 0.06 0.77 0.04 0.77 0.05

48
Table 2.4a: The results from the Test of Discriminability of iSCI-2 for the left step. The
Wilcoxon statistic (W) and the corresponding value of the Discriminability Index
(DI) were similar. The Standard Deviation (SD) of the DI and the Standard Error (SE)
found for the Wilcoxon statistic (W) were similar. There were ‘statistically
significant’ (p ≥ 0.05) differences in the means of DI due to the muscle type as well as
the classifier type.

Muscles for left step SD SE SD SE


classifier of iSCi-2 DIPRC (DIPRC) WPRC (WTC) DITC (DITC) WTC (WTC)
Left GM 0.49 0.07 0.49 0.062 0 0 0 0
Left BF 0.47 0.026 0.47 0.026 0 0 0 0
Left MG 0.99 0 0.99 0 0.743 0.06 0.74 0.06
Left RF 0.46 0.041 0.46 0.04 0.68 0.028 0.68 0.024
Left TA 0.47 0.0042 0.48 0.004 0 0 0 0
Left ES 0.99 0 0.99 0 0.87 0.034 0.87 0.04
Right GM 0.83 0.002 0.83 0.002 0.71 0.027 0.70 0.027
Right BF 0.87 0.003 0.89 0.003 0.6 0.02 0.59 0.02
Right MG 0.83 0.008 0.84 0.008 0.69 0.022 0.69 0.02
Right RF 0.99 0 0.99 0 0.71 0.02 0.70 0.01
Right TA 0.82 0.013 0.82 0.012 0.48 0.02 0.48 0.02
Right ES 0.41 0.075 0.41 0.075 0 0 0 0

Table 2.4 b: The results from the Test of Discriminability of iSCI-2 for the right step classifier.
The Wilcoxon statistic (W) and the corresponding value of the Discriminability Index
(DI) were similar. The Standard Deviation (SD) of the DI and the Standard Error (SE)
found for the Wilcoxon statistic (W) were similar. There were ‘statistically
significant’ (p ≥ 0.05) differences in the means of DI due to the muscle type as well as
the classifier type.

Muscles for right step SD SE SD SE


classifier of iSCI-2 DIPRC (DIPRC) WPRC (WPRC) DITC (DITC) WTC (WTC)
Left GM 0.74 0.003 0.74 0.003 0.69 0.017 0.698 0.017
Left BF 0.88 0.012 0.87 0.012 0.59 0.029 0.598 0.028
Left MG 0.68 0.007 0.69 0.007 0.66 0.016 0.67 0.016
Left RF 0.99 0.003 0.99 0.003 0.69 0.020 0.698 0.02
Left TA 0.68 0.019 0.69 0.016 0.7 0.019 0.699 0.016
Left ES 0.49 0.014 0.51 0.014 0.57 0.018 0.57 0.017
Right GM 0.40 0.017 0.47 0.015 0 0 0 0
Right BF 0.37 0.018 0.37 0.018 0 0 0 0
Right MG 0.99 0 0.99 0.001 0.75 0.056 0.75 0.055
Right RF 0.59 0.007 0.61 0.006 0.56 0.037 0.57 0.037
Right TA 0.41 0.019 0.41 0.017 0.58 0.019 0.59 0.017
Right ES 0.99 0.001 0.99 0.001 0.71 0.045 0.71 0.46

49
CHAPTER 3
FEASIBILITY ANALYSIS OF SURFACE EMG-TRIGGERED FES-ASSISTED
AMBULATION AFTER INCOMPLETE SPINAL CORD INJURY

A part of this chapter was published in IEEE Trans Biomed Eng. 2008 Feb; 55(2).

Abstract

Ambulation after spinal cord injury is possible with the aid of functional electrical

stimulation (FES). Individuals with incomplete spinal cord injury (iSCI) retain partial volitional

control of muscles below the level of injury, necessitating careful integration of FES with intact

voluntary motor function for efficient walking. In this study, the surface electromyogram (EMG)

of the volitionally controlled erector spinae was used to detect the intent to step and trigger FES-

assisted walking in a volunteer with iSCI via an 8-channel implanted stimulation system. The

classifier was able to trigger the FES-assisted swing-phase of gait with a false positive rate less

than 1% and true positive rate greater than 82% during over-ground ambulation on a level

surface. The performance of the EMG classifier highlights its potential as a natural command

interface to better coordinate stimulated and volitional muscle activities than conventional

manual switches and facilitate FES-assisted community ambulation.

Introduction

Functional electrical stimulation (FES) provides an opportunity for brace-free ambulation

to wheelchair dependent individuals with incomplete spinal cord injuries (iSCI). The implanted

FES systems can electrically activate a customized set of muscles selected to address individual

gait deficits with pre-programmed patterns of stimulation to produce cyclic movement of the

lower extremities for ambulation. Our 8-channel implantable receiver-stimulator (IRS-8) delivers

stimulation via implanted electrodes to the targeted motor nerves activating the muscles required

to produce stepping motions [3.1]. Power and stimulus control information are transmitted to the

implanted receiver stimulator through the skin via an inductive link by a wearable external

50
control unit (ECU). Implant recipients normally use a ring-mounted thumb switch connected to

the ECU to manually trigger each step and progress through the customized pattern of

stimulation to achieve walking function. This study was undertaken to evaluate the potential for

better coordinating the actions of the stimulator with remaining volitional movements through a

more natural command interface than the manual switch.

The objective of this study was to evaluate the feasibility of detecting the intent to take a

step using the surface electromyogram (EMG) in an implant recipient with iSCI and eliminate

the need for manual triggering during FES-assisted ambulation. Our long-term goal is to specify

a new command and control interface that can be implemented with two channels of implanted

EMG recording electrodes with our next family of multichannel implantable stimulator-

telemeters (IST) [3.2-3.4]. This report summarizes the development and testing of a new

command structure for FES-assisted ambulation that integrates stimulated and voluntary muscle

activity in a method suitable for eventual realization in a fully implantable neuroprosthesis for

walking after iSCI. While gait event detection is possible with physical sensors such as force

sensitive resistors, accelerometers, gyroscopes, as well as with biopotentials such as the

electroneurogram [3.5-3.7], the EMG can provide useful and reliable information prior to the gait

events during ambulation [3.8]. The electromyogram temporally precedes the generation of force

in a muscle (electromechanical delay) and resulting movement of a joint. This makes the EMG

an attractive signal for detection of intent and then the desired movement can be assisted by FES.

Graupe et al. proposed EMG based control of FES with time-series model of EMG [3.9].

Auto-regressive (AR) time-series models of EMG can give information related to limb function

[3.10] and can provide patient-responsive control of FES-assisted walking [3.11]. The AR

parameters determined offline from the time-series model of the above-lesion upper-trunk EMG

51
were used for function identification [3.11]. Recently, Graupe and Kordylewski presented a

neural network based classifier for complete paraplegics with on-line learning capabilities [3.12,

3.13]. Our preliminary studies indicate that the EMG from partially paralyzed muscles in

incomplete paraplegics can also provide significant information related to the volitional activity

of the muscle and can be used for gait-event detection [3.14, and 3.15]. Thorsen et al. have

showed improved wrist extension with stimulation controlled by EMG from partially paralyzed

wrist extensor [3.16]. Futami et al. showed the feasibility of proportional control of FES with the

EMG from the same muscle (partially paralyzed knee extensors) in incomplete hemiplegia

[3.17]. The ratio of the volitional EMG with the intended effort changes with the intensity of the

stimulation and the time since the stimulation pulse, when the EMG from the same muscle is the

control signal for stimulation [3.18].

This paper presents a linear classifier for foot-off intent detection with EMG from two

partially paralyzed muscles below the level of injury. The classifier detects the intent to initiate

swing-phase and integrates that information in the FES controller to trigger FES-assisted swing

of the limb.

Methods

Subjects

The subject iSCI-1 was a 23 years old male with C7 motor and C6 sensory incomplete

spinal cord injury (ASIA C) who could stand but could not initiate a step without the assistance

of FES. About eight months before the start of this study, he received an IRS-8 and eight

surgically implanted intramuscular electrodes in a related study designed to facilitate household

and community ambulation [3.19]. Electrodes were implanted bilaterally at the lumbar spinal

roots to activate iliopsoas for hip flexion, in the tensor fasciae latae for hip flexion and abduction,

vastus intermedius/lateralis for knee extension, and tibialis anterior and peroneous longus for

52
ankle dorsiflexion. Temporal patterns of stimulation to activate those muscles were customized

for his particular gait deficits according to established tuning procedures [3.20, and 3.21] in order

to achieve forward stepping in a rolling walker. Each step was triggered by depression of a

manual switch to progress through the stimulation pattern and initiate FES-assisted swing phase,

as shown in Figure 3.1. The limited range of motion of his fingers made it difficult to operate the

standard manual ring-mounted thumb switch. Switches were adapted and mounted to the frame

of the walker to allow him to independently trigger stimulation manually.

The subject completed 6 weeks of over-ground gait training (2 hour sessions 3 times per

week) with a physical therapist using the implanted FES system. After discharge from

rehabilitation as an independent limited community ambulator with the neuroprosthesis, the

subject volunteered for studies related to the myoelectric control of the FES system.

Informed consent was obtained from the subject before his participation and all study

related procedures were approved by the Institutional Review Board of the Louis Stokes

Cleveland Department of Veterans Affairs Medical Center.

Data Acquisition and Processing

The experimental set-up for EMG-triggered FES-assisted walking is shown in Figure 3.2.

Surface EMG signals were collected from gluteus medius, biceps femoris, medial gastrocnemius,

rectus femoris, tibialis anterior, and erector spinae (at T9) bilaterally during manually-triggered

FES-assisted gait. Surface EMG was collected using Ag/AgCl electrodes with 2 cm. inter-

electrode distance following the SENIAM guidelines [3.22]. The EMG signals were amplified

and low-pass (fcutoff=1000 Hz) filtered by CED 1902 amplifiers (Cambridge Electronic Design,

England) before being sampled at 2400 Hz (AT-MIO-64F-5, National Instruments, USA) in the

host personal computer. The CED 1902 amplifier has a switching circuit (clamp) which is

activated by a pulse that disconnects the electrode inputs from the amplifier and connects it to the

53
common electrode to prevent stimulation artifact. The input channels of CED 1902 were

clamped when stimulation pulses were applied to the muscles to prevent stimulation artifact as

described below and illustrated in Figure 3.3. The gain of each channel was set separately in the

CED 1902 amplifiers to prevent saturation at the maximum muscle activity during the gait-cycle.

Baseline EMG data were collected during trials of quiet standing for 3 seconds.

Retro-reflective markers were placed on the body segments according to the ‘plug-in’ gait

marker set in the Vicon WorkstationTM (Vicon Peak, USA) software to acquire lower-body

kinematics data using a seven camera ViconTM (Vicon Peak, USA) motion capture system. The

fifteen markers were placed on the anterior superior iliac spine, thigh (on a wand at 1/3rd distance

between the greater trochanter and lateral femoral epicondyle), lateral femoral epicondyle, shank

(on a wand at 1/3rd distance between the lateral femoral epicondyle and lateral malleolus), lateral

malleolus, toe (dorsum of the foot over second metatarsal head), heel (inline with the toe marker

on the long axis of the foot) bilaterally, and at the sacrum (midway between the posterior

superior iliac spines). The measurement volume of the motion capture system was approximately

5m from the starting position on the walkway, ensuring collection of steady state walking data.

The marker trajectories were captured at 60 Hz for the computation of the joint angles. Gait

events (foot-strike and foot-off) were derived from foot-floor contact patterns obtained from

insole-mounted foot switches placed bilaterally at medial and lateral heel, first and fifth

metatarsal, and big toe, and confirmed with the kinematics data acquired.

The subject was asked to make multiple passes across the straight level walkway. Each

pass constituted one trial and multiple trials were collected during a session. The EMG data

collection was evenly spread over multiple sessions over a month to capture the day-to-day

variability. 150 steps for each side (total 300 steps) were captured over multiple sessions during

54
this period. The sampled EMG and joint kinematics were processed in MATLAB TM R14 (The

MathWorks, Inc., USA).

The implanted FES system delivered electrical pulses at a frequency of 20 Hz, so the

sampled EMG was divided into bins of 50ms duration in the host personal computer. In each bin,

30ms following the start of the stimulation pulse was blanked to remove residual stimulation

artifact and M-wave. The remaining 20 ms of data in each bin was detrended, band-pass filtered

(5th order zero-lag Butterworth, 20-500 Hz), and rectified. The blanked portion of the EMG was

reconstructed with the average value of the EMG in the pre- and post- blocks [3.23] as shown in

Figure 3.3a. Then the whole EMG pattern was low pass filtered (5th order zero-lag Butterworth,

fcutoff=3 Hz) to get the linear envelope (Figure 3.3b). The EMG linear envelopes during a gait

cycle were then divided into double-support and swing phases of left and the right side based on

the occurrence of foot-strike and foot-off as determined from the insole foot switch data. The

EMG pattern for each muscle was normalized by the maximum value of its linear envelope.

Muscle Selection

The next family of implantable stimulator-telemeter (IST) developed and being tested

clinically at our center has 2 channels of implanted EMG signal acquisition [3.4]. Therefore, the

number of muscles was limited to 2 for this feasibility study. The muscles were selected based

on the difference between their EMG linear envelopes during double-support phase when

compared with that during terminal stance, as described below.

The processed linear envelopes (LE) for the EMG from each muscle pair were divided into

two classes: the class ‘True’ was comprised of LEs during double-support prior to foot-off (150

EMG patterns) and the class ‘False’ consisted of the LE during terminal stance (150 EMG

patterns). The muscle selection was performed separately, prior to classifier development to limit

the size of the data (each muscle has two classes and each class has 150 EMG patterns). The

55
characteristic pattern of activation for each class was found by ensemble averaging the LE,

shown in Figures 3.4a, b. The characteristic pattern found for class ‘True’ was cross-correlated

with the LE patterns for classes ‘True’ and ‘False’. The cross-correlation coefficients for both

the classes had a normal distribution and passed the Lilliefors test for normality (α=0.05;

MatlabTM function ‘lillietest’) [3.24]. A normal distribution function was estimated for each class

using minimum variance unbiased estimator (MatlabTM ‘normfit’ function). The Receiver

Operating Characteristics (ROC) curve shows the trade-off between selectivity (i.e. false positive

rate) and sensitivity (i.e. true positive rate) as the threshold is varied from one extreme to the

other to cover the probability density function of both (‘True’ and ‘False) the classes [3.25]. A

statistic, the Discriminability Index (DI), was computed from the area under the ROC curve

[3.25]. DI equal to 1 (maximum) is the best case when the probability density function for the

two classes has no overlap. The bilateral Erector Spinae (ES) exhibited the highest DI (=0.875)

and were selected as the command sources for the classifier.

Classifier Development and Offline Testing

The LE of EMG from bilateral ES was selected as inputs to the classifiers to identify the

intent to initiate swing-phase of the ipsilateral limb during FES-assisted gait. The LE of EMG

from each ES for the classes ‘True’ (150 patterns) and ‘False’ (150 patterns) were pooled

together in a single dataset. The first step was to find a minimum set of uncorrelated patterns

(vectors) such that their linear combinations accounted for most of the variance in the mean-

adjusted dataset. This was achieved by principal component analysis which seeks such

orthonormal vectors (principal components) and their associated eigen-values from the

covariance matrix of the mean-adjusted data [3.26]. The first 4 principal components (PCs)

ranked by their eigen-values accounted for more than 90% of the variance in the data. The

56
orthogonal rotation (MATLABTM ‘varimax’) was applied to minimize the number of factors (i.e.

PCs after rotation) and increase the loading on fewer factors for the classes ‘True’ and ‘False’

[3.26]. Loadings found for each LE of EMG represent a point in the space defined by the four

factors (feature space),

4
th
e.g. for the i Linear Envelope, LEi = ∑ loadingi , j × factorj ,
j =1
loadingi , j (j=1,2,3, and 4) serve as the coordinates of the LEi (i=1,2,3 ... 300)
in the feature space defined by the vectors, factorj (j=1,2,3, and 4)

The loadings on the factors after the ‘varimax’ rotation created separate clusters of points

for the classes in the feature space. The loadings found for each LE of EMG were normalized by

the square-root of the sum of the squared loadings to define a unit vector from the origin to each

point. The mean of all the points in the cluster was computed for each class and called the

centroid of that class. The classifier estimated the factor loadings for LE of a candidate EMG to

detect the intent (i.e. case ‘True’). The factor loading was estimated for each feature from the dot

product between the factor (i.e. feature) and the mean-adjusted LE of the candidate EMG. The

Euclidean distance between the normalized loading and the centroid of the case ‘True’ was used

to detect the intent. An appropriate threshold was selected for this distance measure based on the

ROC plot shown in Figure 3.5. The classification threshold was specified such that the false

positive rate was below a reasonable value of 2% found based on our preliminary study [3.14].

The true positive rate was around 82% for the same threshold, as seen in Figure 3.5.

The classifier was implemented in SimulinkTM (The MathWorks, Inc., USA) and

incorporated into the real-time FES control system. The ECU was controlled in real-time by a

dedicated personal computer running xPC-targetTM (The MathWorks, Inc., USA) that executed

the control algorithm to deliver pre-programmed stimulation patterns to the muscles via the IRS-

8. The classifier started scanning the LE of EMG from ES after the end of the stimulation pattern

57
(swing-phase) of the contralateral limb to detect the intent (foot-off) to initiate swing of the

ipsilateral limb. The classifier was first evaluated offline using test data to find the error in

timing of the FES-assisted foot-off with EMG control compared to that found from the insole

foot switches during manual switch-triggering. For safety, the classifier was allowed to trigger

the FES-assisted swing-phase of the ipsilateral limb 1.5 sec after the end of the swing-phase of

the contralateral limb. A minimum duration of 1.5 seconds for the double-support phase was

found necessary for the subject to maintain balance The duration of swing phase was determined

by the pre-programmed temporal pattern of the stimulation and therefore was highly repeatable

while the duration of the double-support phase was determined by the subject with the manual

switch triggering and therefore exhibited increased variability.

Classifier Testing During FES-assisted Ambulation

The EMG classifier was integrated into the FES controller to trigger pre-programmed

stimulation patterns during FES-assisted walker-aided ambulation. The subject was first asked to

walk a few steps using the manual switch-triggered FES system for calibration purposes. During

calibration the classifier found the maximum muscle activity in ES, which was used to normalize

the EMG for the remaining trials of the session.

The subject practiced with the EMG-based FES-controller for about 9 days (2 hours each

day) over 3 weeks to get accustomed to the classifier before initial testing. During testing, the

subject was asked to walk across a straight walkway with the EMG-triggered FES-controller.

Multiple passes were made across the walkway, each pass constituted a trial. The subject

triggered the first step manually from the ‘stand’ state using a start switch after which the

subsequent steps were triggered by the EMG classifier. The FES controller returned to the

‘stand’ state when the classifier failed to trigger the next step within 3 seconds of entering the

double support phase. The subject used a switch to manually stop the FES controller if it

58
triggered a step when none was intended (false positive). If the FES controller stopped and failed

to trigger an intended step (false negative) then the subject was able to over ride the controller to

manually trigger the step, after which the EMG classifier would resume operation. The state

transition diagram of the EMG-based FES-controller is shown in Figure 3.6

During each trial the subject tried to reach a self-selected steady gait from stand position.

The subject maintained a double-support phase after reaching the end of the walkway and waited

for 3 sec. to return the FES controller to the ‘stand’ state. The performance of the classifier was

evaluated over 60 steps (each side) on level ground in a single session (1 day) of data collection.

The repeatability of system performance was evaluated with randomized trials of EMG-triggered

and switch-triggered FES-systems performed over 2 more sessions distributed over 2 additional

days of testing.

Results

Classifier Performance

Off-line timing analysis indicated that with the selected threshold, the classifier output

preceded actual foot-off (a negative timing difference) when predicting both left and right swing

as shown in Figure 3.7a. The duration of the double-support (DS) and swing (SW) gait phases is

shown in Figure 3.7b. The classifier successfully minimized the possibility of triggering a step

unexpectedly. During the first session of testing, the false positive rate was limited to 1.66%

while the true positive rate was close to 80%. The one false positive observed for the right leg

over 60 steps was during terminal stance. The false negatives were mostly observed during the

first 3 steps (each side) when the gait is transitioning from stand position to a steady state. The

user learned to convert the last step of the walking pattern into a short step to decelerate, by not

moving his body forward with the walker and then stop the classifier by delaying the shift of the

59
body weight to the contralateral support limb by 3 seconds after the end of its swing phase. This

helped to prevent false positives during terminal stance in the subsequent trials.

Repeatability of the Classifier Performance

Repeatability of system performance was assessed with data collected during the two

additional sessions in which switch- and EMG-triggered controllers were presented randomly to

the subject. No false positives were reported by the subject during more than 50 steps taken at

these 2 sessions. When combined with data from the initial testing day, the system exhibited

overall false positive rate of less than 1% and true positive rate of 82% for left foot-off and 83%

for right foot-off over total of 110 steps taken (total 3 sessions over 3 days).

Discussion

The EMG-triggered FES-assisted ambulation was successfully implemented and evaluated

in the laboratory. The classifier developed during current study detected unloading of the limb

and shift of body-weight to the contralateral limb that took place during double-support phase

preceding the swing-phase of the ipsilateral side. The user of the EMG-triggered FES-system

exercised the voluntary muscles in conjunction with the stimulated muscles. The EMG-triggered

implanted FES system reduced the need to manipulate manual switches which triggered each

step with current FES systems, or make special adaptations to them for the specific motor

deficits of individuals with cervical level injuries. The subject easily learned to use the system

and their practice with EMG-triggered system improved the switch-triggered walking. This

interesting result associated with learning was a reduction in the duration of the double-support

phase with switch-triggered walking from around 4 seconds (Figure 3.6b) during training data

collection to around 2 seconds during online testing sessions when the switch-triggered system

was presented in a random order with the EMG-triggered system. The gait speed was limited by

the ability to move the body forward using upper-body support while maintaining balance. The

60
gait-speed was similar for EMG-triggered and switch-triggered walking. The gait speed that was

close to 0.1 m/sec was significantly lower than able-bodied slow-cadence gait, in part due to the

subject’s cervical level injury which limited his ability to move the body forward with his upper

extremities. This necessitated a minimum duration of 1.5 sec for double-support phase to prepare

for the next step.

Proximal muscles were found to be more suitable as command sources than the distal

muscles. Proximal muscles were also less susceptible to muscle spasms. The classifier was

considered to be more robust to muscle spasms and fatigue since it was based on pattern

recognition instead of EMG amplitude threshold-based. The characteristic EMG pattern from the

ES that was used by the classifier for event detection was similar to normative EMG pattern

during late stance and early swing of the ipsilateral limb [3.27].

The classifier was not tested specifically for robustness to muscle spasms and fatigue. The

number of trials during a session was decided by the subject. The erector spinae was free from

muscle spasms during all the trials. In case of muscle spasms and fatigue, the user could

manually actuate the stop switch to return the controller to the ‘stand’ state. This would switch-

off the classifier and prevent false triggers. The potential exists to make the classifier adaptive by

updating it during operation (online training) using the EMG patterns related to false positives

and false negatives, thus having it learn to accommodate for fatigue or other time varying factors

that may influence long-term performance.

The classifier needed to be customized which involved individualized muscle selection and

feature extraction from EMG training data of the main muscle groups (extensors and flexors)

involved with gait. Training data was collected during switch-triggered FES-assisted walking in

the laboratory utilizing surface stimulation and EMG recording, or with the EMG added to the

61
systems of other recipients of our older 8-channel stimulation-only implanted neuroprostheses.

The processes of muscle selection and feature extraction also lend themselves to automation,

thus eliminating much of the clinical decision making currently required. One limitation of

selecting muscles based on the EMG and surface stimulation is that the optimal set of command

sources and motor targets will be determined only from the most superficial muscles accessible

from the skin’s surface. Deeper muscles can be accessed with intramuscular stimulating or

recording electrodes temporarily implanted for acute testing.

Conclusion

The feasibility of using EMG for triggering FES-assisted ambulation on level ground for

individuals with iSCI was demonstrated. An EMG-based trigger for swing-phase significantly

reduced the need to rely on manual switch during FES-assisted iSCI gait, which was the typical

command source in the currently available implanted neuroprostheses for ambulation. The

classifier did not completely obviate the need for the manual trigger, since about 18% of the false

negatives produced by the classifier still needed to be over-ridden with the manual switch during

testing sessions. The false positives were successfully reduced to 1% minimizing the likelihood

of potentially more disruptive event of initiating a step unexpectedly. Two channels of surface

EMG were shown to be sufficient for triggering steps during FES-assisted walking. The subject

learned to effectively command the EMG-based FES-controller within about 18 hours of use

over 9 days. The FES-system used by the subject for this feasibility study was a laboratory based

tethered system. The new family of implantable stimulator-telemeters (IST-12) has 2 EMG

channels and the capability to perform the signal processing required by the classifier. This study

provided the basis for the development of a fully portable FES-system based on IST-12. The next

phase of this study will focus on the development of a classifier and the FES–controller that

could be implemented in the current ECU with the IST family of implants for a fully portable

62
FES-system for outdoor use. It is postulated that incomplete SCI subjects with reduced hand and

finger function will prefer the reduced dependence on manual switch and accept automatic FES-

assisted stepping that is synchronized with unloading of that limb.

References

3.1. R. Kobetic, R. J. Triolo, J. P. Uhlir, C. Bieri, M. Wibowo, G. Polando, E. B. Marsolais, J.


A. Davis Jr., K. A. Ferguson, and M. Sharma, “Implanted Functional Electrical Stimulation
System for Mobility in Paraplegia: A Follow-Up Case Report,” IEEE Trans. Rehabil. Eng.,
vol. 7, no. 4, Dec. 1999, pp. 390–398.

3.2. B. Smith, Z. Tang, M.W. Johnson, S. Pourmehdi, M.M. Gazdik, J.R. Buckett, and P.H.
Peckham , “An externally powered, multichannel, implantable stimulator-telemeter for
control of paralyzed muscle,” IEEE Trans Biomed Eng., vol. 45, no. 4, 1998, pp. 463-475.

3.3. Z. Tang, B. Smith, J.H. Schild, and P.H. Peckham, “Data transmission from an implantable
biotelemeter by load-shift keying using circuit configuration modulator,” IEEE Trans
Biomed Eng., vol. 42, no. 5, 1995, pp. 525-528.

3.4. N. Bhadra, K.L. Kilgore, and P.H. Peckham, “Implanted stimulators for restoration of
function in spinal cord injury,” Med. Eng. Phys., vol. 23, 2001, pp. 19-28.

3.5. I. P. Pappas, M. R. Popovic, T. Keller, V. Dietz, and M. Morari, “A reliable gait phase
detection system,” IEEE Trans. Neural Syst. Rehabil. Eng., vol. 9, no. 2, Jun. 2001, pp.
113-125.

3.6. A. Mansfield, and G. M. Lyons, “The use of accelerometry to detect heel contact events for
use as a sensor in FES assisted walking,” Med. Eng. Phys., vol. 25, no. 10, Dec. 2003, pp.
879-885.

3.7. T. Sinkjaer, M. Haugland, A. Inman, M. Hansen, and K. D. Nielsen, “Biopotentials as


command and feedback signals in functional electrical stimulation systems,” Med. Eng.
Phys., vol 25, no. 1, Jan. 2003, pp. 29-40.

3.8. R. T. Lauer, R. T. Smith, and R. R. Betz, “Application of a neuro-fuzzy network for gait
event detection using electromyography in the child with cerebral palsy,” IEEE Trans.
Rehabil. Eng., vol. 52, no. 9, Sep. 2005, pp. 1532–1540.

3.9. D. Graupe, K. H. Kohn, S. Basseas, and E. Naccarato, “Patient controlled electrical


stimulation via EMG signature discrimination for providing certain paraplegics with
primitive walking functions,” J. Biomed. Eng., vol. 5, 1983, pp. 220-226.

3.10. R. J. Triolo, and G. D. Moskowitz, “The theoretical development of a multichannel time-


series myoprocessor for simultaneous limb function detection and muscle force
estimation,” IEEE Trans. Biomed Eng., vol. 36, no. 10, Oct. 1989, pp. 1004-1017.

63
3.11. D. Graupe, “EMG pattern analysis for patient-responsive control of FES in paraplegics for
walker-supported walking,” IEEE Trans. Biomed. Eng., vol. 36, no. 7, July 1989, pp. 711-
719.

3.12. D. Graupe, and H. Kordylewski, “Artificial neural network control of FES in paraplegics
for patient responsive ambulation,” IEEE Trans. Biomed Eng., vol. 42, no. 7, Jul. 1995, pp.
699-707.

3.13. H. Kordylewski, and D. Graupe, “Control of Neuromuscular Stimulation for Ambulation


by Complete Paraplegics via Artificial Neural Networks,” Neurol. Research, vol. 23, July
2001, pp.472-481.

3.14. A. Dutta, R. Kobetic, and R. J. Triolo, “EMG based triggering and modulation of
stimulation patterns for FES assisted ambulation – a conceptual study,” presented at XXth
Congress of the International Society of Biomechanics, Cleveland, OH, Aug. 2005.

3.15. A. Dutta, and R. J. Triolo, “Volitional surface EMG based control of FES-assisted gait after
incomplete spinal cord injury – a single case feasibility study,” presented at NIH Neural
Interfaces Workshop, Bethesda, MD, Sep. 2005.

3.16. R. Thorsen, R. Spadone, and M. Ferrarin, “A pilot study of myoelectrically controlled FES
of upper extremity,” IEEE Trans. Rehabil. Eng., vol. 9, no. 2, June 2001, pp. 161–167.

3.17. R.Futami, K.Seki, T.Kawanishi, T.Sugiyama, I.Cikajlo, and Y.Handa, “Application of local
EMG-driven FES to incompletely paralyzed lower extremities,” presented at 10th Annual
Conference of the International FES Society, Montreal, Canada, July 2005.

3.18. P. N. Taylor, and P. H. Chappell, “Variation in system gain when using voluntary EMG to
control electrical stimulation of the same muscle,” presented at 9th Annual Conference of
the International FES Society, Bournemouth, U.K., 2004.

3.19. R. Kobetic, R. J. Triolo, G. Pinnault, L. Murray, M. Corado-Ahmed, E. Hardin, J. Sakai, S.


Nogan, M. Marsolais, and C. Ho, “Facilitating Ambulation after Incomplete Spinal Cord
Injury with Implanted FES System,” presented at 10th Annual Conference of the
International FES Society, Montreal, Canada, July 2005.

3.20. R. Kobetic, and E.B. Marsolais, “Synthesis of paraplegic gait with multichannel functional
neuromuscular stimulation,” IEEE Trans Rehab Eng., vol. 2, no. 2, 1994, pp. 66-79.

3.21. R. Kobetic, R. J. Triolo, and E. B. Marsolais, “Muscle selection and walking performance
of multichannel FES systems for ambulation in paraplegia,” IEEE Trans. Rehabil. Eng.,
vol. 5, no. 1, Mar. 1997, pp. 23–29.

3.22. H. J. Hermens, B. Freriks, R. Merletti, D. Stegeman, J. Blok, G. Rau, C. Disselhorst-Klug,


and G. Hagg, SENIAM 8 European Recommendations for Surface ElectroMyoGraphy.
Enschede, Netherlands: Roessingh Research and Development, 1999.

64
3.23. A. E. Hines, P. E. Crago, G. J. Chapman, and C. Billian, “Stimulus artifact removal in
EMG from muscles adjacent to stimulated muscles,” J. Neurosci. Methods, vol. 64, no. 1,
Jan. 1996, pp. 55-62.

3.24. H. W. Lilliefors, “On the Kolmogorov-Smirnov test for normality with mean and variance
unknown,” J. of Am. Stat. Assoc., vol. 62, 1967, pp. 339-402.

3.25. T. D. Dickens, Elementary Signal Detection Theory. US: Oxford University Press, 2001,
pp. 66, 121.

3.26. I. T. Jolliffe, Principal Component Analysis, New York: Springer, 1986, pp. 44-48, 269-
296.

3.27. D. A. Winter, Biomechanics and Motor Control of Human Gait: Normal, Elderly and
Pathological. Waterloo Biomechanics, 1991, ch.1.

3.28. J. B. Dingwell, B. L. Davis, and D. M. Frazier, “Use of an instrumented treadmill for real-
time gait symmetry evaluation and feedback,” Prosthet. Orthot. Int., vol. 20, no. 2, Aug.
1996, pp. 101-110.

65
Figures

a b
Figure 3.1: a) X-ray of the iSCI subject implanted with implantable receiver-stimulator (IRS-8)
b) iSCI subject stepping with the switch-triggered FES system

66
Figure 3.2: Experimental setup for testing EMG-triggered FES-assisted walking with the block-
diagram for the EMG-triggered FES-system (ECU: external control unit, LE: linear
envelope)

67
a

Figure 3.3: Processing of the sampled EMG from Erector Spinae for training the classifier a)
rectified and reconstructed EMG signal b) linear envelope found from processed
EMG signal

68
a

Figure 3.4: Muscle selection for the classifier using receiver operating characteristics curve from
switch-triggered FES-assisted gait data (FS: Foot-Strike, FO: Foot-Off) a) linear
envelope (LE) indicating class ‘True’ b) linear envelope (LE) indicating class ‘False’

69
Figure 3.5: Receiver operating characteristics curve of the classifiers using the test data

70
EMG during Feature Set
double-support & Threshold

Estimate feature loadings


via correlation analysis

Loadings
Find the distance from centroid
of case ‘T’ in feature space

Euclidean distance

Distance Y Trigger
< swing-
threshold phase

STOP
Double- Y Wait for
support manual
> 3 sec? trigger

N
Get next
EMG sample

Figure 3.6: State transition diagram of the EMG-based FES-controller

71
a

Figure 3.7: Offline testing of the classifier using receiver operating characteristics curve a) time-
error (negative means prediction) in detection of foot-off by the classifier b) duration
of the gait phases (Left DS: double support phase following left swing phase, Right
DS: double support phase following right swing phase, SW: swing phase)

72
CHAPTER 4
SURFACE EMG-TRIGGERED FES-ASSISTED GAIT PARAMETERS DURING OVER-
GROUND WALKING IN THE LABORATORY

Abstract

Functional Electrical Stimulation (FES) facilitates ambulatory function after paralysis by

activating the muscles of the lower extremities. The FES-assisted stepping can either be triggered

by a manual switch (switch-trigger), or by an electromyogram-based gait event detector (EMG-

trigger). The two command sources were presented in random order to two subjects with

incomplete spinal cord injuries (iSCI) during ten trials over two alternate days. Subject iSCI-1

(C6 ASIA C) was non-ambulatory without the assistance of FES and could stand but not initiate

a step volitionally. Subject iSCI-2 (T1 ASIA D) could walk only short distances with great

difficulty without FES. Gait kinematics were captured during FES-assisted over-ground walking

with a rolling walker under laboratory conditions. Basic parameters of gait like speed, left and

right step length, left and right double support duration, left and right swing phase duration were

extracted from the kinematics data. Mean, standard deviation, coefficient of variation, and 95%

confidence interval were computed for each gait parameter under each triggering condition.

Average body weight support provided by an instrumented walker was also recorded for iSCI-2.

One way analysis of variance (ANOVA) was performed on each gait parameter to determine

whether significant differences existed between command sources. The left and right double

support duration was significantly (p<0.05) lower during EMG-triggered gait than switch-

triggered for iSCI-1. The average body weight support from the walker was significantly

(p<0.05) higher during switch-triggered gait than EMG-triggered one for iSCI-2

73
Introduction

Functional electrical stimulation (FES) provides an opportunity for wheelchair dependent

individuals with spinal cord injuries (SCI) to achieve brace-free ambulation. Implanted FES

systems have allowed individuals with either complete or partial paralysis to stand and step via

activation of a customized set of muscles selected to address individual gait deficits with pre-

programmed patterns of stimulation to produce cyclic movement of the lower extremities [4.1],

[4.2]. The 8-channel implantable receiver-stimulator (IRS-8) utilized in these systems delivered

stimulation via implanted electrodes to the targeted motor nerves activating the muscles required

for walking [4.3]. Implant recipients used a ring-mounted thumb switch connected to a wearable

external control unit to manually trigger each step and activate a customized pattern of

stimulation to achieve reciprocal walking. Our studies have indicated that surface EMG from

partially paralyzed muscles in people with paraplegia due to incomplete spinal cord injuries

(iSCI) can provide significant information related to the volitional activity of the muscle and can

be used for gait-event detection [4.4]. While the electromyogram showed promise of being a

feasible and more natural command source than manual switches for triggering the FES-assisted

stepping, its benefits for improving walking function remained to be investigated [4.4].

The objective of the study was to evaluate the relative benefits of switch-triggered and

EMG-triggered FES-assisted walking based on their effects on basic spatio-temporal gait

parameters. The basic gait parameters that were investigated were gait speed, left and right step

length, left and right double support duration, left and right swing phase duration [4.5]. In

addition, upper extremity exertion in terms of the body weight placed on the rolling walker was

also measured. One way analysis of variance (ANOVA) was performed on each gait parameter

to find if significant differences exist between the EMG-triggered and switch-triggered over-

ground walking under indoor laboratory conditions.

74
Methods

Subjects

Two male subjects with incomplete spinal cord injury volunteered for this study. The

subject iSCI-1 was a 23 years old male with C7 motor and C6 sensory incomplete spinal cord

injury (ASIA C) who could stand but could not initiate a step without the assistance from FES.

The subject iSCI-2 was a 34 years old male with T1 motor and C6 sensory incomplete spinal

cord injury (ASIA grade D) who could walk only short distances without the assistance from

FES. They each received an eight channel Implantable Receiver Stimulator (IRS-8) and eight

surgically implanted intramuscular electrodes in a related study designed to facilitate household

and limited community ambulation [4.3], [4.6].

The subject iSCI-1 presented with bilateral hip and ankle weakness and received

stimulating electrodes bilaterally to recruit iliopsoas, vastus intermedius/lateralis, tensor fasciae

latae, and tibialis anterior/peroneus longus muscles. FES assisted limb advancement during

swing phase and knee stability during single limb stance, while the subject achieved forward

progression through the voluntary contractions of his hip extensor musculature. Subject iSCI-2

presented with unilateral weakness and received stimulating electrodes only on his left side to

recruit iliopsoas, vastus intermedius/ lateralis, tensor fasciae latae, gluteus medius, gluteus

maximus, posterior portion of adductor magnus, and tibialis anterior (2 electrodes). Temporal

patterns of stimulation to activate the muscles were customized for each subject’s individual gait

deficits according to established tuning procedures [4.7], [4.8] in order to achieve forward

stepping in a rolling walker. The subjects completed 6 weeks of over-ground gait training (2

hour sessions, 3 times per week) with a physical therapist using the implanted FES system. After

discharge from rehabilitation, they volunteered for the studies using the myoelectric control of

the FES system.

75
Informed consent was obtained from both the subjects before their participation and the

Institutional Review Board of the Louis Stokes Cleveland Department of Veterans Affairs

Medical Center approved the study related procedures.

Gait Data Acquisition

The laboratory set-up for EMG-triggered FES-assisted walking is shown in Figure 4.1.

Surface electromyogram (EMG) was collected according to SENIAM guidelines [4.10]. The

EMG signals were pre-amplified (gain: 100), and low-pass (fcutoff=1000 Hz) filtered by CED

1902 (Cambridge Electronic Design, England) amplifier (gain: 330 or 990) before being sampled

at 2400 Hz (AT-MIO-64F-5, National Instruments, USA) in the host personal computer. The

sampled data were detrended, band-pass filtered (5th order zero-lag Butterworth, 20-500 Hz),

and rectified before being low pass filtered (5th order zero-lag Butterworth, fcutoff=3 Hz) to get

the linear envelope (LE) of the signal. Surface EMG signals from bilateral erector spinae (at T9)

were used by the gait event detector (GED) for triggering FES-assisted left and right steps of

iSCI-1. The GED for iSCI-2 used EMG from left gastrocnemius and right tibialis anterior for

triggering only the FES-assisted left step during EMG-triggered walking. A pattern recognition

algorithm (i.e., the EMG-classifier) based on feature templates derived from the first three

principal components of the time course of the LEs during double support was trained for each

subject to detect the intention to take a step. Details of the development, testing and technical

performance of the EMG-classifier GED have been presented in Chapter 3 [4.4]. A flow chart

summarizing the algorithm is shown in Figure 4.2. The EMG-classifier was trained to look for a

set of features (templates found from the training data) in the EMG LEs that indicated the

intention to trigger the next step. The features were detected using correlation analysis of the

windowed EMG LE, which was represented as a weighted (weights = correlation coefficients)

mean of those features. If the weights (or loadings) of those features fell within a certain

76
Euclidean distance (a threshold found from training data) of the centroid for the class associated

with initiating a step, then the next FES-assisted step was triggered. The EMG-classifier kept

looking for those features for a given time (typically 3 seconds or less) while the user was in the

double support phase of gait. If the EMG-classifier couldn’t find those features in the given time

then it stopped scanning the EMG LEs and waited for the user to trigger the next step with a

manual switch. The EMG-classifier and stimulation control system operated in real time on xPC

TargetTM platform (The MathWorks, Inc., USA).

Retro-reflective markers were placed on the body segments according to the ‘plug-in’ gait

marker set in the Vicon WorkstationTM (Vicon Peak, USA) software to acquire lower-body

kinematics data using a seven camera ViconTM 360 motion capture system. The fifteen markers

were placed on the anterior superior iliac spine (ASIS), thigh (on a wand at 1/3rd the distance

between the greater trochanter and lateral femoral epicondyle), lateral femoral epicondyle, shank

(on a wand at 1/3rd the distance between the lateral femoral epicondyle and lateral malleolus),

lateral malleolus, toe (dorsum of the foot over second metatarsal head), and heel (in line with the

toe marker on the long axis of the foot) bilaterally. The final marker was placed at the sacrum

(midway between the posterior superior iliac spines). The measurement volume of the motion

capture system was approximately 5m from the position from where the subjects started walking

on the walkway. The marker trajectories were captured at 60 frames/sec. The optimum cut-off

frequency (5th order zero-lag Butterworth) for low-pass filtering the kinematic data was found to

balance the Root Mean Square Error (RMSE) due to noise and RMSE due to the attenuation of

the true signal [4.5]. Foot progression in the sagittal plane was selected to find the optimum low

pass cut-off frequency since it has the highest frequency content [4.9]. The Figure 4.3 shows the

RMSE with the optimum cut-off frequency, which was found to be 3.5 Hz for the iSCI data. Gait

77
events related to foot-floor contact (foot-strike – when any portion of the foot first touched the

ground, and foot-off – when the whole foot was off the ground) were derived from foot insole-

mounted foot switches (B&L Engineering, USA) placed bilaterally at the medial and lateral heel,

first and fifth metatarsal, and big toe, and confirmed with the kinematics data acquired.

The FES-assisted stepping in the iSCI subjects was triggered with one of the two command

sources – manually triggered with a switch (switch-trigger) or triggered with the EMG-based

GED (EMG-trigger). The two command sources were presented in a random order to the

subjects. The iSCI subjects initiated the gait with a switch-triggered left step and then walked in

a rolling walker with FES-assisted steps triggered by one of the two command sources. All the

subjects were asked to make multiple passes across the straight level walkway with a period of 5-

10 minutes of rest period in between the passes. Each pass constituted one trial and 10 trials were

collected during a session. Sessions were repeated on two separate days for a total of 20 trials,

representing 10 trials consisting of two passes of the walkway for each command source. During

each trial the subjects were instructed to reach a self-selected steady-state gait at a comfortable

velocity from the standing position. The ViconTM motion capture system recorded marker

trajectories for four or more strides starting after the first (switch initiated) step, as illustrated in

Figure 4.4. The joint kinematics data were analyzed using custom programs developed in

MATLABTM R14 (The MathWorks, Inc., USA). The trials were considered independent for

statistical analysis, to compute and compare the basic spatio-temporal gait parameters.

Gait Parameters

The basic gait parameters were computed from the kinematics data where the definitions

for the gait events were modified to account for the gait characteristics of iSCI subjects. It was

often difficult to identify heel strike and toe off during iSCI walking with FES, so these events

were replaced with initial contact/foot-strike (when one or more of the foot switches first

78
registered contact with the ground) and foot-off (when all the foot switches registered loss of

contact). Gait speed was defined as the average velocity of progression over a stride period

which was computed from the velocity of the sacrum marker and reported in meters per second

(m/s). Left and right step lengths were determined by the horizontal distance covered along the

plane of progression during a step, which were measured from the contact position of the

contralateral foot to the subsequent contact position of the ipsilateral foot and reported in meters

(m). The step period (left and right) was the duration of one step, which was measured from the

contact time of the contralateral foot to the subsequent contact time of the ipsilateral foot and

reported in seconds (sec). The double support period was the time in seconds (sec) when both the

feet were on the ground as measured from the foot-strike of the contralateral foot to the

ipsilateral foot-off. The swing period was the duration of time in seconds (sec) when only one

foot was in contact with the ground and was measured from ipsilateral foot-off to subsequent

ipsilateral foot-strike. During walking, swing period is exactly equal to the single support period

of the contralateral limb. The stance period in seconds (sec) was defined as the time in seconds

(sec) when the foot was in contact with the ground, and was sum of the double support period

and single support period of that limb.

The average body weight support provided by the rolling walker over a stride was also

measured for iSCI-2. For comparison, the average body weight supported during switch and

EMG triggered gait were each normalized by the mean of that observed during EMG-triggered

gait.

Statistical Analysis

One way analysis of variance (‘anova1’ in MATLABTM R14, The MathWorks, Inc., USA)

was performed on each gait parameter to determine if significant differences existed between the

EMG-triggered and switch-triggered spatio-temporal gait parameters. All observations were

79
considered to be mutually independent for the ANOVA test. The p-value was computed for the

null hypothesis that a particular EMG-triggered gait parameter and switch-triggered gait

parameter had the same mean. If the p-value was close to zero (<0.05) then the null hypothesis

was rejected and the difference between the mean of that gait parameter for EMG-trigger and

Switch-trigger was considered statistically significant.

Results

Subject iSCI-1 could trigger FES-assisted steps with the EMG-based GED with a false

positive rate lower than 1% and a true positive rate higher than 82% for the left step and 83% for

the right step. Subject iSCI-2 could trigger a FES-assisted left step with the EMG-based GED

with a false positive rate lower than 1% and a true positive rate higher than 96%. The mean,

standard deviation (S.D. ), coefficient of variation (C.V. ), and 95% confidence interval (C.I.) of

the EMG-triggered and switch-triggered gait parameters over 10 trials (N=10) for subjects iSCI-

1 and iSCI-2 are summarized in Table 4.1 and Table 4.2, respectively. The gait parameters that

show statistically significant (p<0.05) difference are shaded. The subject iSCI-1 had a

statistically significant decrease in double support duration bilaterally with the EMG-triggered

FES-system, indicating a more dynamic walking pattern than with switch triggering. Gait speed

increased slightly due to the decrease in the double support duration, but failed to reach

significance (p=0.092). Boxplot of the normalized average body weight supported by the walker

for iSCI-2 during EMG-triggered (N=10 trials) and switch-triggered (N=10 trials) gait is shown

in Figure 4.5. The average body weight support over a stride during the switch-triggered gait was

almost 1.4 times that of EMG-triggered gait, which was statistically significant (p<0.05) and

indicated a more erect posture and less upper extremity effort for stability and forward

propulsion.

80
Discussion

Gait performance with EMG-triggering was at least as good to standard switch-triggering

for most of the spatio-temporal parameters measured for both subjects in spite of the differences

in their injury levels, degree of preserved volitional motor control, and muscle set chosen for

stimulation. Due to individual variations in their FES systems and levels of paralysis, EMG-

triggering demonstrated significant benefits over standard switch triggering for different aspects

of gait in each individual subjects. Both subjects could increase or decrease walking velocity by

either advancing or delaying depressions of the command switch between successive steps, or

modifying the timing of the voluntary contraction of the muscles used as inputs to the EMG

classifier.

Because iSCI-1 could not initiate a step without FES-assistance and required bilateral

stimulation to advance his swing limb, the duration of swing phase was determined by the timing

of the pre-programmed pattern of stimulation for both switch- and EMG-triggered systems. The

spatiotemporal parameters of the swing phase were therefore similar for both the command

sources for this subject. The only method for modulating gait speed available to iSCI-1,

therefore, involved altering the time spent in stance phase. He exhibited a statistically significant

decrease in double support duration bilaterally with automatic triggering of stimulation with the

EMG-based GED, which tended to increase his walking velocity. These results have functional

implications and indicate improved confidence and dynamic stability with EMG triggering.

Subject iSCI-2, in contrast, exhibited a thoracic level motor injury and could walk short

distances without FES-assistance, albeit with significant effort. Because his FES system was

implemented unilaterally, he was able to modulate his walking speed by adjusting not only the

time spent in double support, but also by the timing of his volitional right step. He walked

slightly faster with switch-trigger (0.215 ± 0.112 m/s) than with EMG-trigger (0.202 ± 0.063 m/s)

81
though this minor difference was not statistically significant. In terms of all the spatio-temporal

gait parameters measured, iSCI-2 could walk as well with the EMG-trigger as with the switch-

trigger. A significant difference was found in the body weight placed on the rolling walker,

which was significantly higher for switch-triggered gait. EMG-triggering enabled the subject to

place more of his body weight on his lower extremities, better balance himself in swing and

stance, and be more effective in unloading and advancing his walker.

These results imply that EMG-triggering may have the potential to lower energy

expenditure due to reduced double support phase and decreased upper extremity exertion on the

walker during long distance walking. Because of the laboratory nature of this preliminary

feasibility study, the impact of EMG control on walking distance, energy expenditure and

community ambulation remain to be determined.

Subject iSCI-1 exhibited difficulty operating the standard manual finger switch due to

reduced hand and finger function. Customized reed switches were interfaced to the external

controller of the neuroprosthesis and mounted on his walker to allow him to manually trigger the

system via gross extension movements of his wrist or metacarpal joints. Such specialized

adaptations were not necessary with EMG triggering. Other individuals with incomplete SCI

with reduced hand and finger function may benefit from the reduced dependence on manual

switches possible with EMG-based systems for assisted ambulation.

The goal of this work is to facilitate limited community ambulation by giving the FES

system users command sources that are natural, intuitive and easily incorporated into their

walking patterns. It demonstrates the initial feasibility of one method of automatically triggering

FES-assisted stepping to reduce dependence on the manual switch and better integrate

stimulation with the preserved voluntary movements associated with walking. The EMG-based

82
GED used in this feasibility study was implemented in a PC which was tethered to the subject,

and is therefore obviously unsuitable for community use. The new family of implantable

stimulator-telemeters (IST) developed at Case Western Reserve University and the Louis Stokes

Cleveland Department of Veterans Affairs Medical Center is capable of processing two channels

of EMG signals from implanted recording electrodes and deriving the commands required to

control 12 channels of stimulation [4.3]. The next step in the development of EMG-controlled

neuroprostheses to facilitate ambulation after incomplete SCI is to implement EMG-controlled

assisted ambulation with a completely implantable technology. Implanting the control and

activation sources in a single system will enable the evaluation of the benefits of EMG control in

the home and community environments, during activities of daily living and over long,

functionally relevant distances.

Conclusion

The gait performances of individuals with partial paralysis due to incomplete SCI with

EMG-triggered functional electrical stimulation were equivalent or superior to standard switch-

triggered command sources. The spatio-temporal characteristics of EMG-triggered FES-assisted

gait were found to be at least as good as those exhibited by switch-triggered FES systems FES-

assisted stepping with EMG-triggering can reduce the duration of double support and thus

improve dynamic stability. Stepping with EMG-triggered stimulation also reduced the body

weight exerted on the rolling walker or other assistive device when compared to switch-triggered

gait. Specialized adaptive equipment and customizations for individuals with upper extremity

impairments were minimized or eliminated through application of EMG control. The benefits

derived from EMG triggering depend on the extent of paralysis, level of impairment and

individual configuration of the FES system. This study presented the results from indoor walking

under laboratory conditions. It is hypothesized that EMG-triggered FES-system will have more

83
significant benefit during gait transitions and dynamic stability during that period than that

during steady state gait since it allows the user to transition more fluidly and stably from one

speed to another by possible seamless modulation of the step frequency.

References

4.1. R. Kobetic, R. J. Triolo, J. P. Uhlir, C. Bieri, M. Wibowo, G. Polando, E. B. Marsolais, J.


A. Davis Jr., K. A. Ferguson, and M. Sharma, “Implanted Functional Electrical Stimulation
System for Mobility in Paraplegia: A Follow-Up Case Report,” IEEE Trans. Rehabil. Eng.,
vol. 7, no. 4, Dec. 1999, pp. 390–398.

4.2. B. Smith, Z. Tang, M.W. Johnson, S. Pourmehdi, M.M. Gazdik, J.R. Buckett, and P.H.
Peckham , “An externally powered, multichannel, implantable stimulator-telemeter for
control of paralyzed muscle,” IEEE Trans Biomed Eng., vol. 45, no. 4, 1998, pp. 463-475.

4.3. N. Bhadra, K.L. Kilgore, and P.H. Peckham, “Implanted stimulators for restoration of
function in spinal cord injury,” Med. Eng. Phys., vol. 23, 2001, pp. 19-28.

4.4. A. Dutta, R. Kobetic, and R. Triolo, “Ambulation after incomplete spinal cord injury with
EMG-triggered Functional Electrical Stimulation,” IEEE Transactions on Biomedical
Engineering, 55:2, February 2008.

4.5. D. A. Winter, The Biomechanics and Motor Control of Human Movement, 2nd edition,
New York: Wiley, 1991.

4.6. E. Hardin, R. Kobetic, L. Murray, M. Corado-Ahmed, G. Pinnault, J. Sakai, S. Nogan, C.


Ho, and R. Triolo, “Ambulation after incomplete spinal cord injury with an implanted FES
system: a case report,” Jour. Rehab R&D, 44:3, 2007, pp. 333-346.

4.7. R. Kobetic, and E.B. Marsolais, “Synthesis of paraplegic gait with multichannel functional
neuromuscular stimulation,” IEEE Trans Rehab Eng., vol. 2, no. 2, 1994, pp. 66-79.

4.8. R. Kobetic, R. J. Triolo, and E. B. Marsolais, “Muscle selection and walking performance
of multichannel FES systems for ambulation in paraplegia,” IEEE Trans. Rehabil. Eng.,
vol. 5, no. 1, Mar. 1997, pp. 23–29.

4.9. C. Angeloni, P. O. Riley, and E. D. Krebs, “Frequency Content of Whole Body Gait
Kinematic Data,” IEEE Trans. Rehabilitation Engineering, vol. 2, no. 1, 1994, pp. 40-46.

4.10. H. J. Hermens, B. Freriks, R. Merletti, D. Stegeman, J. Blok, G. Rau, C. Disselhorst-Klug,


and G. Hagg, SENIAM 8 European Recommendations for Surface ElectroMyoGraphy.
Enschede, Netherlands: Roessingh Research and Development, 1999.

84
Figures

Figure 4.1: Experimental setup for testing EMG-triggered FES-assisted walking with the block-
diagram for the EMG-triggered FES-system (ECU: external control unit).

85
EMG during Feature Set
double-support & Threshold

Estimate feature loadings


via correlation analysis

Loadings
Find the distance from centroid
of case ‘T’ in feature space

Euclidean distance

Distance Y Trigger
< swing-
threshold phase

STOP
Double- Y Wait for
support manual
> 3 sec? trigger

N
Get next
EMG sample

Figure 4.2: EMG-based gait event detector for triggering FES-assisted steps.

86
Figure 4.3: Plot of the Root Mean Square Error (RMSE) between the low-pass filtered and
unfiltered foot progression in sagittal plane with cut-off frequencies to find the
optimum cut-off frequency for low-pass filtering the gait kinematics data. Optimum
cut-off frequency was found to be 3.5 Hz for iSCI data.

87
Figure 4.4: Gait data collection protocol in laboratory conditions where the subject had to start
from standing and achieve a self-selected gait speed within ViconTM volume of data
capture (~5m).

88
Figure 4.5: Boxplot of average body weight support provided by the walker during EMG-
triggered (N=10 trials) and switch-triggered (N=10 trials) gait normalized by the
mean of that during EMG-triggered trials of iSCI 2. The box shows the lower
quartile, median, and upper quartile with whiskers extending at each end showing the
range of the data. The notches around the median show the estimate of the
uncertainty. The boxes whose notches don’t overlap indicate that their medians differ
at 5% significance level.

89
Tables

Table 4.1: The Mean, Standard Deviation (S.D), coefficient of variation (C.V.), 95% confidence
interval (95% C.I.) over 10 trials (N=10) of the EMG-triggered and switch-triggered
gait parameters – gait speed (m/s), left step length (m), right step length (m), left
double support duration (s), right double support duration (s), left swing phase
duration (s), right swing phase duration (s) for the subject iSCI 1. [ ‘statistically
significant’ (p<0.05) difference between the command sources are shaded]

Command Source Mean S.D. C.V. 95% C.I.

Gait Speed (m/s) EMG-trigger 0.124 0.037 0.298 0.101 - 0.147


Switch-trigger 0.105 0.035 0.332 0.083 - 0.126

Left Step Length (m) EMG-trigger 0.381 0.107 0.280 0.315 - 0.447
Switch-trigger 0.337 0.066 0.194 0.297 - 0.378

Right Step Length (m) EMG-trigger 0.422 0.167 0.395 0.319 - 0.526
Switch-trigger 0.428 0.075 0.174 0.382 - 0.475

Left Double Support Duration (s)


* EMG-trigger 3.271 0.095 0.029 3.212 - 3.330
Switch-trigger 4.488 0.094 0.021 4.430 - 4.546

Right Double Support Duration (s)


* EMG-trigger 3.164 0.077 0.024 3.116 - 3.212
Switch-trigger 4.005 0.067 0.017 3.964 - 4.046

Left Swing Phase Duration (s) EMG-trigger 0.697 0.123 0.176 0.621 - 0.773
Switch-trigger 0.642 0.128 0.199 0.563 - 0.721

Right Swing Phase Duration (s) EMG-trigger 0.635 0.133 0.209 0.553 - 0.717
Switch-trigger 0.635 0.120 0.189 0.560 - 0.709

90
Table 4.2: The Mean, Standard Deviation (S.D), coefficient of variation (C.V.), 95% confidence
interval (95% C.I.) over 10 trials (N=10) of the EMG-triggered and switch-triggered
gait parameters – gait speed (m/s), left step length (m), right step length (m), left
double support duration (s), right double support duration (s), left swing phase
duration (s), right swing phase duration (s) for the subject iSCI 2. [ ‘statistically
significant’ (p<0.05) difference between the command sources are shaded]

Command Source Mean S.D. C.V. 95% C.I.

Gait Speed (m/s) EMG-trigger 0.202 0.063 0.310 0.163 - 0.241


Switch-trigger 0.215 0.112 0.520 0.146 - 0.284

Left Step Length (m) EMG-trigger 0.359 0.009 0.026 0.353 - 0.364
Switch-trigger 0.346 0.069 0.199 0.304 - 0.389

Right Step Length (m) EMG-trigger 0.450 0.138 0.307 0.365 - 0.536
Switch-trigger 0.521 0.176 0.338 0.412 - 0.630

Left Double Support Duration (s) EMG-trigger 1.192 0.171 0.144 1.086 - 1.299
Switch-trigger 1.060 0.294 0.278 0.878 - 1.243

Right Double Support Duration (s) EMG-trigger 1.165 0.059 0.051 1.128 - 1.201
Switch-trigger 1.148 0.076 0.066 1.101 - 1.196

Left Swing Phase Duration (s) EMG-trigger 1.255 0.062 0.050 1.216 - 1.293
Switch-trigger 1.271 0.093 0.073 1.213 - 1.328

Right Swing Phase Duration (s) EMG-trigger 1.043 0.058 0.056 1.007 - 1.079
Switch-trigger 1.054 0.065 0.062 1.013 - 1.094

91
CHAPTER 5
COORDINATION AND STABILITY OF SURFACE EMG-TRIGGERED FES-ASSISTED
OVERGROUND WALKING IN THE LABORATORY

A manuscript based on this chapter was accepted for publication in ASME Journal of

Biomechanical Engineering.

Abstract

Functional Electrical Stimulation (FES) facilitates ambulatory function after paralysis by

activating the muscles of the lower extremities. Individuals with incomplete spinal cord injury

(iSCI) retain partial volitional control of muscles below the level of injury, necessitating careful

integration of FES with intact voluntary motor function for efficient walking. The FES-assisted

stepping can be triggered automatically at a fixed rate (auto-trigger), by a manual switch (switch-

trigger), or by an electromyogram-based gait-event-detector (EMG-trigger). It has been

postulated that EMG being a more natural command source than manual switches will enable

better coordination of stimulated and volitional motor function necessary during gait. In this

study, the above stated hypothesis was investigated in two volunteers with iSCI during the over-

ground FES-assisted gait initiation. Four able-bodied volunteers provided the normative data for

comparison. The EMG-triggered FES-assisted gait initiation was found to be more coordinated

and dynamically more stable than auto-triggered and switch-triggered cases. This highlighted the

potential of surface EMG as a natural command interface to better coordinate stimulated and

volitional muscle activities during gait transitions.

Introduction

Functional electrical stimulation (FES) provides an opportunity for brace-free ambulation

to wheelchair dependent individuals with spinal cord injuries. Implanted FES systems have

allowed individuals with either complete or partial paralysis to stand and step via activation of a

customized set of muscles selected to address individual gait deficits with pre-programmed

92
patterns of stimulation to produce cyclic movement of the lower extremities [5.1][5.2]. The 8-

channel implantable receiver-stimulator (IRS-8) utilized in these systems delivers stimulation via

implanted electrodes to the targeted motor nerves activating the muscles required for walking.

Implant recipients have used a ring-mounted thumb switch connected to a wearable external

control unit (ECU) to manually trigger each step activated by the customized pattern of

stimulation to achieve walking. This pattern of stimulation can also be cycled automatically at a

fixed rate with the user initiating and terminating the cyclic pattern with the manual switch.

Graupe et al. proposed an alternative EMG-based control of FES based on time-series models of

the surface electromyogram (EMG) [5.3]. Auto-regressive (AR) time-series models of EMG

from the intact musculature above the level of lesion can give information related to limb

function [5.4] and can provide patient-responsive control of FES-assisted walking [5.5].

Recently, Graupe and Kordylewski presented a neural network based classifier that has online

learning capabilities for individuals with complete paraplegia due to spinal cord injuries [5.6],

[5.7]. Our studies indicate that EMG from partially paralyzed muscles in people with paraplegia

due to incomplete spinal cord injuries can provide significant information related to the

volitional activity of the muscle and can be used for gait-event detection [5.8], [5.9]. While the

electromyogram showed promise of being a more natural command signal than manual switches

but the postulated improvement in function in terms of better coordination and dynamic stability

of gait remained to be determined.

Gait initiation refers to the transient state between standing and steady state walking.

Analysis of gait initiation is an important diagnostic tool to study pathologic gait [5.22]. In

steady state normal gait, the net mechanical work over one stride is zero [5.23]. So enough

momentum is generated during gait initiation for the body to reach a steady state velocity [5.22].

93
The first step is used to propel the body into a dynamic state, and then in the next step a major

energy input takes place to raise the energy level of the body [5.22]. This energy input is a

disturbance to the locomotor system to propel the body forward. In the subsequent steps (3rd step

and onwards), this disturbance decays and the body readjusts to attain a steady gait speed [5.22].

Hurmuzlu and Basdogan presented a method to investigate orbital dynamic stability of human

gait in terms of its response to disturbances [5.10]. Based on their methods, Hurmuzlu et al.

found that gait in post-polio patients is less stable than able-bodied controls [5.11]. Recently

Dingwell et al. found that neuropathic patients do not improve their orbital dynamic gait stability

by lowering their gait speed and are also not less stable than able-bodied controls in spite of their

sensory deficits [5.12].

The current study used the method of gait analysis introduced by Hurmuzlu and Basdogan

to evaluate dynamic stability of walking with FES under a variety of control schemes [5.10]. It is

desirable that the user with incomplete spinal cord injury (iSCI) fluidly and stably transition from

a static ‘stand’ state to a dynamic ‘walk’ state during the FES-assisted gait initiation. The goal of

this study was to determine the effects of the command input to the FES system on dynamic

stability and convergence to a normal gait pattern. The working hypothesis of the investigation

was that coordinating the actions of the stimulator with the remaining volitional movements with

a more natural command interface like EMG would result in improvements in gait transitions

from standing to walking. An EMG-based gait-event-detector (GED) was used to trigger the

FES-assisted stepping [5.9]. The linear classifier in the GED detected the intent to initiate swing-

phase from the EMG of two partially paralyzed muscles and used that information to trigger

FES-assisted swing of the limb.

94
Methods

Subjects

Two subjects with incomplete spinal cord injury (iSCI) volunteered for this study. The first

subject (iSCI-1) was a 23 years old male with C7 motor and C6 sensory incomplete spinal cord

injury (ASIA C) who could stand but could not initiate a step without the assistance from FES.

The second subject (ISCI-2) was a 34 years old male with T1 motor and C6 sensory incomplete

spinal cord injury (ASIA D) that resulted in left hemiplegia (unilateral paralysis) who could walk

only short distances with great difficulty without the assistance from FES. Each subject received

an IRS-8 and eight surgically implanted intramuscular electrodes in a related study designed to

facilitate household and community ambulation [5.1], [5.2]. Temporal patterns of stimulation to

activate the muscles were customized for their particular gait deficits according to established

tuning procedures [5.13], [5.14] in order to achieve forward stepping in a rolling walker. The

subjects completed 6 weeks of over-ground gait training (2 hour sessions 3 times per week) with

a physical therapist using the implanted FES system. After discharge from rehabilitation, they

volunteered for the studies related to the myoelectric control of the FES system. Four able-

bodied volunteers (Able1: 25 years, Able2: 52 years, Able3: 26 years, Able4: 54 years), who had

no known injury or pathology during the study, provided the normative gait data.

Informed consent was obtained from the subjects before their participation and the

Institutional Review Board of the Louis Stokes Cleveland Department of Veterans Affairs

Medical Center approved the study related procedures.

Gait Data Acquisition

The laboratory set-up for EMG-triggered FES-assisted walking is shown in Figure 5.1a.

Two channels of surface EMG (EMG) from bilateral Erector Spinae (at T9) for iSCI-1 and from

left gastrocnemius & right tibialis anterior for iSCI-2 were used by the gait-event-detector (GED)

95
for EMG-triggered FES-assisted gait. Details of the development, testing and technical

performance of the EMG-classifier GED have been published elsewhere [5.9]. A flow chart

summarizing the algorithm is shown in Figure 5.1b. The EMG-classifier was trained to look for a

set of features (or pattern of muscle activity) in the EMG linear envelopes (LEs) that indicated

the intention to trigger the next step. The features were detected using correlation analysis of the

windowed EMG LE, which was represented as a weighted (weights = correlation coefficients)

mean of those features. If the weights (or loadings) of those features lie within a certain

Euclidean distance (i.e. a threshold) of the centroid for the class associated with initiating a step

found from the training data, then the next FES-assisted step was triggered. The EMG-classifier

kept looking for those features for a given time while the user was in the double support phase of

gait. If the EMG-classifier couldn’t find those features in the given time then it stopped scanning

the EMG LEs and waited for the user to trigger the next step with a manual switch. The EMG-

classifier and stimulation control system was implemented in a real time using xPC TargetTM

(The MathWorks Inc., USA).

Retro-reflective markers were placed on the body segments according to the ‘plug-in’ gait

marker set in the Vicon WorkstationTM (Vicon Peak, USA) software to acquire lower-body

kinematic data using a seven camera ViconTM (Vicon Peak, USA) motion capture system. The

fifteen markers were placed on the anterior superior iliac spine (ASIS), thigh (on a wand at 1/3rd

distance between the greater trochanter and lateral femoral epicondyle), lateral femoral

epicondyle, shank (on a wand at 1/3rd distance between the lateral femoral epicondyle and lateral

malleolus), lateral malleolus, toe (dorsum of the foot over second metatarsal head), heel (inline

with the toe marker on the long axis of the foot) bilaterally, and at the sacrum (midway between

the posterior superior iliac spines). The measurement volume of the motion capture system was

96
approximately 5m from the position from where the subjects started walking on the walkway.

The marker trajectories were captured at 60 Hz for the computation of the joint angles.

The joint angles were low-pass filtered before Euler differentiation to compute the joint

velocity. Numerical differentiation amplifies the noise so the noise in the joint angles data was

reduced with low pass filtering. The optimum cut-off frequency (5th order zero-lag Butterworth)

for the able-bodied and iSCI data was found to balance the Root Mean Square Error (RMSE) due

to noise and RMSE due to the attenuation of the true signal [5.24]. The foot kinematic data were

selected to find the optimum low pass cut-off frequency since the high frequency noise induced

by the foot-strike (i.e. collision) during walking affects the foot kinematic data the most (highest

frequency noise expected) and then the physiological damping of high-frequency content occurs

caudal to the head [5.25]. The Figure 5.2a shows the RMSE with the optimum cut-off

frequencies, which were 6 Hz for the able-bodied and 3.5 Hz for the iSCI kinematic data. The

RMSE value was similar for the able-bodied and iSCI data after low-pass filtering (Figure 5.2a).

The Figure 5.2b shows that most of the power-content of the signal was below their respective

optimum cut-off frequency for low pass filtering. Gait events (foot-strike and foot-off) were

derived from foot-floor contact patterns obtained from insole-mounted foot switches (B&L

Engineering) placed bilaterally at the medial and lateral heel, first and fifth metatarsal, and big

toe, and confirmed with the kinematic data acquired.

The FES-assisted swing-phase in iSCI subjects could be triggered with three command

interfaces – manually triggered with a switch that is mounted on the walker (switch-trigger),

triggered with EMG-based GED (EMG-trigger), triggered automatically at a user-selected rate

without user-intervention (auto-trigger). The three trigger modes were presented randomly to the

iSCI subjects during a trial and the iSCI subjects initiated the gait with their left leg (i.e. the

97
initiator limb). All the subjects were asked to make ten passes across the straight level walkway.

Each pass constituted one trial and 10 trials were collected during a session of data capture.

During each trial the subjects tried to reach a self-selected steady gait from standing. ViconTM

(Vicon Peak, USA) motion capture system recorded marker trajectories for four or more strides

starting after the first (initiator) step, as illustrated in Figure 5.3. Able-bodied subjects usually

reach steady state gait within three to four steps from standing [5.22], [5.11].

The time-series analysis used to evaluate the stand-to-walk transition required that the

subjects complete the transition from standing to a walking state. The time-series model

evaluated how well this transition happened based on a linear model. Hence, the time-series

analysis was performed only on the trials in which the pelvis position estimated from the

centroid of the ASIS markers and the sacrum marker had a positive progression velocity after the

first step from standing during the whole trial, as shown in Figure 5.4 The time-series analysis

was performed to compare the stability and coordination of the FES-assisted iSCI gait initiation

(with the three trigger modes) with the able-body normative data, as discussed below. The joint

kinematic data were analyzed using custom programs developed in MATLABTM R14 (The

MathWorks, Inc., USA).

Coordination and Stability Analysis of Gait initiation

The 18 joint angles (bilateral extension-flexion, abduction-adduction, and internal-external

rotations at the ankle, knee, and hip) and the corresponding 18 joint velocities (for a total of 36

states) represented the human locomotor system during gait initiation. The swing and stance

phases were identified from the foot-floor contact patterns recorded with insole-mounted foot

switches. The time-series analysis was primarily based on the method presented by Hurmuzlu

and Basdogan [5.10]. The asymptotic behavior of the dynamical locomotor system during the

gait initiation was assumed to be a bounded set which would be called the steady-state gait. The

98
convergence of the gait during the gait initiation towards a nearly periodic cyclic steady state

was investigated [5.22]. The cyclic time-series of the joint kinematics was probed at a particular

gait event from gait cycle to cycle. Any gait event can be selected for this analysis. Theoretically

the measure should be invariant to the selection of the gait event although this invariance

property may not hold for the simplified model of the gait dynamics [5.11]. To test this

invariance, we selected six gait-events to do the same analysis. The gait events were bilateral

foot-strike, foot-off, and maximum-knee-flexion (during the swing-phase).

A mapping function was then found that returns the cross-section of the flow (or

trajectory) to itself (called a return map) from gait cycle to cycle at the gait event. If the

disturbance is not large enough then a linear return map can be found which can then be

subjected to further analysis for stability using methods for linear systems analysis [5.10]. Our

preliminary studies showed that this mapping function during gait initiation was mostly linear for

able-bodied subjects [5.15]. A more rigorous analysis of this linearity was performed for

pathological gait. The degree of linearity was postulated to be a measure of fluidity or

coordination of gait initiation. A linearized mapping function was approximated from the joint

kinematic data with linear regression techniques. The Jacobian of the linear model provided an

estimate of the rate of convergence during the first few steps taken from standing even if the gait

did not reach a steady state in the volume of motion capture. The shorter the gait initiation phase,

the more stable the gait. A rate parameter found from the Jacobian gave a measure of stability, as

discussed below.

Let Xn be the ‘36 x 1’ dimensional vector of the 36 states at the nth gait event i.e. at the nth

gait cycle (GC) during the gait initiation ( n = 1K m ) of a trial. The last GC (i.e. the mth gait

event) of the trial was considered to have reached a steady state. Let a ‘36 x 1’ dimensional

99
vector X* represent the 36 states at the mth (i.e. the last) gait event of the trial. The discrete

mapping of the states of the system at the nth gait event to the (n+1)th gait event (called the

‘returns’) was represented by an equation, Xn+1 =f (Xn), where f is the (return) mapping function.

The mapping function, f was linearized in the vicinity of X*

(X n +1
− X* = ) df
dx
(X n
− X* )
x= X Equation 1
*

δ X n +1 = J • δ X n
( 36×1) ( 36×36 ) ( 36×1)

A multivariate linear regression model of the gait kinematics over ‘p’ gait initiations (i.e. p

trials) gave an estimate of the Jacobian J . The 36 perturbations at the first (m-1) gait events

( i.e. n = 1K m − 1 ) served as the predictor variables δ Xn . The average of the magnitude of the

eigenvalues of the transposed estimated Jacobian matrix J T has been proposed to be an overall

stability measure (α-measure of stability) by Hurmuzlu and Basdogan [5.10]. (1-α) gives an

estimate of the rate of convergence during the gait initiation and smaller values of α-measure

will denote a faster gait initiation and a gait more resilient to disturbances.

For multivariate linear regression analysis, the 36-predictor variables at (m-1) gait events

during a trial were stacked by trials in a ( ( m − 1) p × 36 ) dimensional design matrix δXn . The

response variables were the corresponding ‘returns’ of the 36 perturbations ( i.e. n = 2 K m ) during

gait initiation, stacked by trials in a ( ( m − 1) p × 36 ) dimensional response matrix δXn +1 . The

multivariate linear regression model was

δX n+1 = δX n • J + ε Equation 2
( ( m −1) p ×36 ) ( ( m −1) p × 36 ) ( 36× 36 ) ( ( m −1) p ×36 )

100
The residuals ε , and the parameter matrix J , were the unknowns [5.16]. The 36 columns of

the residuals ε are expected to have zero mean since the perturbations should ideally decay to

zero. The least squares estimate of J was given by


−1
 
J =  δX n
T
• δX n  • δX n T • δX n +1 Equation 3
( 36× 36 )  ( 36×( m −1) p ) ( ( m −1) p×36 )  ( 36×( m −1) p ) ( ( m −1) p×36)

The data collected from 4 able-bodied subjects showed multi-colinearity for the ill-

conditioned matrix ( δXn T • δXn ) , which was expected since joint angles co-vary during human

gait [5.17]. Principal Component Analysis (PCA) was performed to address the problem of

multi-colinearity (redundancy) of the predictor variables and to improve the condition number

[5.18]. PCA determines fewer linear combinations of the 36 predictor variables that can explain

most of the variance-covariance structure. Principal Components (PCs) being orthogonal to each

other will solve the problem of multi-collinearity of the predictor variables. The dimension

reduction with PCA was performed on the 36 standardized perturbation states, which were

stacked in a ( mp × 36 ) dimensional matrix δZ . The weight matrix W from PCA was used to

project the 36 standardized response ( δZn+1 ) and predictor variables ( δZn ) on to new basis

vectors [5.18].

δPn+1 = δZ n +1 • W
( ( m −1) p×36) ( ( m −1) p×36) ( 36×36)
δPn = δZ n • W
( ( m −1) p×36) ( ( m −1) p×36) ( 36×36)

Equation 4

The multivariate linear regression model in terms of the new response δPn+1 and predictor

δPn variables was

δPn+1 = δPn • J * + ε* Equation 5


( ( m −1) p ×36 ) ( ( m −1) p×36 ) ( 36×36 ) ( ( m −1) p×36 )

101
The adequate number of principal components ( η ) was determined from the cumulative

percent variance accounted for (%VAF) by the PCs such that %VAF ≥ 90% . If η is less than 36

(dimension of the original model) then there is a reduction in the dimension of the model, which

will improve the confidence on the elements of J * for the same number of observations ( m − 1) p .

For a multivariate linear regression model with the first η PCs as the predictor and response

variables, we will define a quality of fit ( QoFη ) for the reduced dimension linear regression

model:

δPn+1 ( .,1Kη ) = δPn ( .,1Kη )• J *η + ε *η


( ( m −1) p×η ) ( ( m −1) p ×η ) (η ×η ) ( ( m −1) p×η )

also δPn+1 ( .,1Kη ) • δPn+1 (.,1Kη ) = δPn (.,1Kη ) • J *η ( ) • ( δP (.,1Kη ) • J )+


T
• ε*
T *
n η
ε*η
T
η
 SStot η=
total sum of the squares   SS η = predicted sum of the squares η = residual sum of the
 SSres
 and cross-products 
 squares 
 pred   and cross-products 
   and cross-products   

or SS totη = SS predη + SS resη


(η ×η ) (η ×η ) (η ×η )

     
or trace  SS totη  = trace  SS predη  + trace  SS resη 
 (η ×η )   (η ×η )   (η ×η ) 

QoFη = 1 −
( )
trace SS resη
trace ( SS ) tot
η

Since the columns of δPn+1 and δPn are linearly independent so SS totη and SS predη will be diagonal
Also trace(X ) is the sum of all the diagonal elements of the matrix X
Equation 6

The QoFη , which should lie between 0 and 1 gives a measure of the quality of the linear

regression model for cycle-to-cycle coordination during the gait initiation whiles the eigenvalues

of J*η T provide a measure of rate of convergence to a steady state. The measures, QoFη and the

average eigenvalue of J *η T (called Av. Eig.) were used to compare between able-bodied and iSCI

gait initiation.

102
Results

Linear regression model for gait initiation

The Euclidean distance of the perturbation of 36 states to the origin (18 joint angles and 18

joint velocities) at a gait event (maximum left knee flexion) during gait initiation is shown in

Figure 5.5. Among all the gait events, the knee flexion was found to give results with lowest

variance especially with pathological data [5.11]. The multivariate linear regression model fitted

the convergence in a 36-D space while the Figure 5.5 shows the convergence lumped in

Euclidean distance for ease of illustration. The perturbation as seen from the Euclidean distance

converged towards zero for able-bodied gait initiation, as shown in Figure 5.5a. The iSCI

subjects made, on an average five strides within the volume of motion capture due to their

shorter stride length while the able-bodied could take only four strides.

This convergence of 36-dimensional perturbation during gait initiation was analyzed with a

linear regression model (Equation 2, 3). The condition number for δX n T • δX n (in Equation 3) was

found to be very high (~1020) which indicated numerical instability during the computation of its

inverse.

Principal component analysis (PCA) was performed to reduce the dimensionality of the linear

regression model and to improve the condition number. Five principal components (PCs)

accounted for greater than 90% variance in the data, as shown in Figure 5.6. Thus the number of

principal components (denoted byη ) selected for the reduced dimension linear regression model

(Equation 6) was 5 (i.e. η = 5 ). The rest of the variance (<10% VAF) was accounted for by the

PCs from 6 – 36. These small amplitude movements were not included in the overall

coordination and stability analysis. The condition number of δX nT • δX n improved after PCA,

which was of the order of 10. The first three principal components accounted for greater than

103
70% variance in the data, as shown in Figure 5.6. In Figure 5.7, the sagittal plane angles (suffix

‘x’) have the highest loading for the first two principal components (PCs) while the 3rd PC also

accounted for the pronation/supination at the ankle. The first three PCs mostly accounted for the

kinematic coupling in the sagittal plane where most of the limb movements occur during gait.

Lilliefors test for goodness of fit to a normal distribution (‘lillietest’ MatlabTM) couldn’t reject

the hypothesis that each of those error vectors ε*η in the reduced dimension linear regression

model (Equation 6, η = 5 ) had a normal distribution with significance level of 5%. The

perturbation of 5 Principal Components (PC) to the origin as seen from the Euclidean distance

for the ease of illustration is shown in Figure 5.8. After dimension reduction of the linear

regression model, the perturbation as seen from the Euclidean distance still converged towards

zero for able-bodied normative gait. The convergence of the perturbation during EMG-triggered

iSCI gait initiation as seen with the Euclidean distance was more similar to normative gait for the

iSCI subjects, iSCI-1 and iSCI-C2. The multivariate linear regression model will provide the

quantitative measure of this convergence in 5-D, as discussed in the next section.

Coordination and stability during FES-assisted gait initiation

The scatter plot of QoF5 and average eigenvalue magnitude (Av. Eig.) at the six gait events

is shown in Figure 5.9a for each of the able-bodied and iSCI subjects with different trigger

modes. There are six data points corresponding to 6 gait events for each group in Figure 5.9a.

The QoF and Av. Eig. varied substantially based on the selection of the gait event, as shown in

Figure 5.9a. Three clusters shown with ellipses on Figure 5.9a correspond to the able-bodied

data, EMG and switch – triggered iSCI data, and the auto-triggered iSCI data. One-way

Multivariate Analysis Of Variance (MANOVA, ‘manova1’ in MatlabTM) was performed to find

if there is a significant difference in the entire set of means (of QoF5 and Av. Eig.) from group to

104
group. It was found that the means differ and the difference lies on a plane (dimensionality=2,

p=0.0002). Figure 5.9b shows the dendogram plot (‘manovacluster’ MatlabTM), which is the

hierarchical binary cluster tree formed using the average distance between all pairs of data-points

in the two clusters. The height of each of the U-shaped lines connecting the two objects in the

binary tree shows the average distance between them. Closest are Able1 and Able3, Able2 and

Able4, EMG1 and EMG2, SW1 and SW2, Auto1 and Auto2. Then at the next level, all the

groups with able-bodied data are close, and so are the groups with EMG-triggered and switch-

triggered data. Then farthest are the groups with iSCI data and those with the able-bodied data.

The able-bodied gait initiation (based on QoF and Av. Eig.) was found to be significantly

(p=0.0002) different from the pathological iSCI gait initiation. Figure 5.10 shows the

Mahalanobis distance between each pair of group means, which is a dissimilarity measure

(higher the distance, more is the dissimilarity). Unlike the Euclidean distance, the Mahalanobis

distance takes into account the covariance and it is scale-invariant. In spite of the statistically

significant difference between the able-bodied and iSCI gait initiation, the EMG-triggered FES-

assisted iSCI gait initiation was closest to the able-bodied normative clusters with lowest

Mahalanobis distance (darker on the color scale) when compared to other trigger modes, as

shown in Figure 5.10.

Discussion

The EMG-triggered FES-assisted ambulation was successfully implemented by many

researchers in past but the resulting improvement in the gait dynamics was never investigated in

depth. Gait parameters like gait-speed, step length and time, stride length and time, and duration

of single and double support phases averaged over multiple gait cycles provide a static picture of

the gait dynamics, ignoring the gait time-series. EMG-triggered FES was postulated to provide

better coordination between the stimulated and volitional motor activity and the resulting

105
functional gain should be seen in terms of kinematic coordination [5.9]. A time-series model is

required to investigate kinematic coordination and stability of a dynamic task like gait. Carletti

et al. presented a univariate linear regression model using stride-to-stride interval for non-

invasive diagnosis of neurodegenerative diseases [5.19]. They could differentiate between the

gaits of individuals with Parkinson’s Disease, Huntington’s Disease, Amyotropic Lateral

Sclerosis, and healthy controls with a rate parameter and the variance of the error term of the

linear regression model. Our pathological gait analysis is based on a similar idea but with a

multivariate linear regression model using the kinematic data. We also looked at a rate parameter

(i.e. Av. Eig.) computed from the Jacobian of the linear model and a normalized stochastic

amplitude parameter (i.e., QoF ) computed from the sum of the squares of the error or residuals.

The EMG classifier detected the unloading of the limb and shift of body-weight to the

contralateral limb that takes place during double-support phase preceding the swing-phase of the

ipsilateral side [5.9]. It then triggered the FES-assisted stepping of the ipsilateral limb. It is

necessary that FES-assisted gait initiation be coordinated and stable. It should be noted that

push-off during iSCI gait wasn’t assisted by FES so the energy input during FES-assisted gait

initiation mostly came from the upper-body support on the walker. The upper-body movements

necessary to push the rolling walker and then pull the body forward, needed to be coordinated

with the FES-assisted lower limb movements during gait initiation. Faster transition and better

coordination during this transition phase will mean a gait more resilient to disturbances, which

should make the EMG-trigger a better and preferred command source for outdoor ambulation.

The Euclidean distance of the perturbation to the origin computed from the 36 states (as

shown in Figure 5.5) for iSCI subjects didn’t converge steadily towards zero, except for the

subject iSCI-1 walking with EMG-trigger. This is because most of the frontal plane movements

106
during walker-supported iSCI gait didn’t converge to a steady state. The FES-assisted

movements during iSCI gait were mostly in the sagittal plane and the frontal plane movements

were mostly volitional as a result of upper extremity interactions with the walker. More

prominent frontal plane movements of the partially paralyzed right limb of the subject iSCI-2

were due to weak hip abductors since only his left limb musculature were activated by FES.

The condition number of δX nT • δX n for the full-state 36-dimensional linear regression

model (Equation 3) was too high (~1020) for reliable computation of its inverse. This was due to

synergistic movement of the joints, which make joint angles covary during gait [5.17]. Principal

component analysis decreased the dimension of the linear regression model to five, which

accounted for greater than 90% of the variance in the original model (Figure 5.6). Mah et al. has

showed that gait kinematics has much lower dimensionality because of these movement

synergies. The dimension reduction to five improved the condition number (~10) of δX nT • δX n

by several orders of magnitude from 1020 to 10. The first 3 principal components accounted for

more than 70% of the variance observed, and primarily represented the movements in the sagittal

plane during able-bodied gait initiation (Figure 5.6 and 5.7). The goal of the reduced-dimension

model was to capture the convergence of the major joint trajectories to a steady state during gait

initiation. The convergence of the Euclidean distance of the perturbations towards the origin

computed from the first five principal components for EMG-triggered iSCI gait initiation looked

more similar to able-bodied data in both the iSCI subjects (Figure 5.8). It should be noted that

Figure 5.5 and 5.8 give a marginal view of the convergence since it only shows the Euclidean

distance of the perturbations from origin whereas the multivariate linear regression model

captures the convergence across all the states/predictor variables.

107
The linearity of the reduced-dimension model was chosen as one of the features of

normative gait initiation. The Quality of Fit ( QoF ) of the reduced-dimension linear regression

model was used to measure the linearity of the return-map data. The rate of convergence was

determined from the Jacobian of the linear model, which gave an estimate of the stability since

faster convergence from disturbances means a more stable gait. A linear return-map model with

high rate of convergence is desirable since that will ensure a stable gait initiation.

Able-bodied gait initiation was found to be more stable than FES-assisted iSCI gait

initiation (Figure 5.9). Interestingly, the dendrogram plot of Figure 5.9b showed that the cluster

for Able1 (age: 25 years) was closer to Able3 (age: 26 years) and the cluster for Able2 (age: 52

years) was closer to Able4 (age: 54 years) possibly showing the effect of age on those

parameters. Also the iSCI data clusters of same trigger mode were closer to each other. The

average steady-state gait speed reached by the 4 able-bodied subjects was much higher (1.12

m/sec) as compared to 0.16 m/sec for the 2 iSCI subjects. Based on the results from Dingwell et

al. it was assumed that the orbital gait stability was not greatly mediated by gait speed [5.12].

Nevertheless, gait speed is one of the main predictors of independent community ambulation and

the improvement in gait speed is necessary along with better coordination and stability [5.20].

Both the EMG-triggered and switch-triggered iSCI gait initiations were more similar to the

able-bodied data in terms of coordination and stability than auto-triggered iSCI data (Figure 5.9).

This is because auto-triggered iSCI gait had a fixed step frequency that could not be modulated

as needed during the gait initiation. Both the switch and the EMG trigger gave an opportunity to

modulate the step frequency that was necessary to fluidly transition from stationary standing to a

steady gait. Overall, EMG-triggered FES-assisted gait initiation was found to be closest to the

able-bodied data based on Mahalonobis distance between the clusters (Figure 5.10). This

108
proximity can also be seen in Figure 5.9 where EMG-triggered and switch-triggered iSCI data

have comparable QoF5 but the EMG-triggered iSCI data has lower Av. Eig than switch-triggered

iSCI data. This means faster convergence to steady state and better stability for EMG-triggered

FES-assisted iSCI gait. Also, the user of the EMG-triggered FES-system had to exercise the

voluntary muscles in conjunction with the stimulated muscles to trigger the steps which may

have long-term therapeutic benefits [5.21].

Conclusions

The EMG-triggered FES-assisted iSCI gait was shown to be more normative in terms of

coordination and rate of convergence during gait transition from standing to walking. This paper

developed a method based on prior work on time-series analysis of dynamical systems and

applied that to evaluate gait transitions using a well accepted tool called return-map analysis. The

results presented in this paper indicated that the user of the EMG-triggered FES-system

successfully exercised the voluntary muscles in conjunction with the stimulated muscles to

synergistically generate the volitional EMG to trigger the FES-assisted steps. This enhanced the

coordination between the voluntary and stimulated muscles, as presented in the results. The

EMG-triggered FES-assisted iSCI gait was therefore more normative than switch- and auto-

triggered iSCI gait during gait transitions which is needed for outdoor walking. The feasibility

study and gait evaluation were performed with a tethered system in the laboratory which needs to

be translated to a portable system for outdoor use. The newer family of implantable stimulator-

telemeters (IST-12) has 2 EMG channels and the capability to perform the signal processing

required by the GED. The GED and the FES–controller can be implemented in the current

portable External Control Unit (ECU) with the IST family of implants. Based on the results

presented in this paper from a laboratory based evaluation, it is hypothesized that EMG-triggered

109
portable FES-system will allow the user to transition more fluidly and stably from one speed to

another by modulating the step frequency, which is required for better outdoor ambulation.

References

5.1. R. Kobetic, R. J. Triolo, J. P. Uhlir, C. Bieri, M. Wibowo, G. Polando, E. B. Marsolais, J.


A. Davis Jr., K. A. Ferguson, and M. Sharma, “Implanted Functional Electrical Stimulation
System for Mobility in Paraplegia: A Follow-Up Case Report,” IEEE Trans. Rehabil. Eng.,
vol. 7, no. 4, Dec. 1999, pp. 390–398.

5.2. E. Hardin, R. Kobetic, L. Murray, M. Corado-Ahmed, G. Pinnault, J. Sakai, S. Nogan, C.


Ho, and R. Triolo, “Walking after incomplete spinal cord injury using an implanted FES
system: A case report.,” Jour. Rehabil. Res. Dev., vol. 44, no. 3, 2007, pp. 333–346.

5.3. D. Graupe, K. H. Kohn, S. Basseas, and E. Naccarato, “Patient controlled electrical


stimulation via EMG signature discrimination for providing certain paraplegics with
primitive walking functions,” J. Biomed. Eng., vol. 5, 1983, pp. 220-226.

5.4. R. J. Triolo, and G. D. Moskowitz, “The theoretical development of a multichannel time-


series myoprocessor for simultaneous limb function detection and muscle force
estimation,” IEEE Trans. Biomed Eng., vol. 36, no. 10, Oct. 1989, pp. 1004-1017.

5.5. D. Graupe, “EMG pattern analysis for patient-responsive control of FES in paraplegics for
walker-supported walking,” IEEE Trans. Biomed. Eng., vol. 36, no. 7, July 1989, pp. 711-
719.

5.6. D. Graupe, and H. Kordylewski, “Artificial neural network control of FES in paraplegics
for patient responsive ambulation,” IEEE Trans. Biomed Eng., vol. 42, no. 7, Jul. 1995, pp.
699-707.

5.7. H. Kordylewski, and D. Graupe, “Control of Neuromuscular Stimulation for Ambulation


by Complete Paraplegics via Artificial Neural Networks,” Neurol. Research, vol. 23, July
2001, pp.472-481.

5.8. A. Dutta, R. Kobetic, and R. J. Triolo, “EMG based triggering and modulation of
stimulation patterns for FES assisted ambulation – a conceptual study,” presented at XXth
Congress of the International Society of Biomechanics, Cleveland, OH, Aug. 2005.

5.9. A. Dutta, R. Kobetic, and R. Triolo, “Ambulation after incomplete spinal cord injury with
EMG-triggered Functional Electrical Stimulation,” IEEE Transactions on Biomedical
Engineering, 55:2, February 2008.

5.10. Y. Hurmuzlu, and C. Basdogan, “On the measurement of dynamic stability of human
locomotion,” Journal of Biomechanical Engineering, vol. 116, 1994, pp. 30-36.

110
5.11. Y. Hurmuzlu, C. Basdogan, and D. Stoianovici, “Kinematics dynamic stability of the
locomotion of post-polio patients,” Journal of Biomechanical Engineering, vol. 118, no. 3,
1996, pp. 405–411.

5.12. J. B. Dingwell, K. H. Gu, and L. C. Marin, “The effects of sensory loss and walking speed
on the orbital dynamic stability of human walking,” Journal of Biomechanics, vol. 40,
2007, pp. 1723-1730.

5.13. R. Kobetic, and E.B. Marsolais, “Synthesis of paraplegic gait with multichannel functional
neuromuscular stimulation,” IEEE Trans Rehab Eng., vol. 2, no. 2, 1994, pp. 66-79.

5.14. R. Kobetic, R. J. Triolo, and E. B. Marsolais, “Muscle selection and walking performance
of multichannel FES systems for ambulation in paraplegia,” IEEE Trans. Rehabil. Eng.,
vol. 5, no. 1, Mar. 1997, pp. 23–29.

5.15. A. Dutta, and R. Triolo, “Stability analysis of Functional Electrical Stimulation (FES)-
assisted overground gait in an incomplete spinal cord injured subject,” Journal of
Biomechanics, vol. 39, 2006, pp. S113.

5.16. R. A. Johnson, and D. W. Wichern, Applied Multivariate Statistical Analysis. Prentice Hall,
2002.

5.17. L. Bianchi, D. Angelini, G. P. Orani, and F. Lacquaniti, “Kinematic Coordination in


Human Gait: Relation to Mechanical Energy Cost,” The Journal of Neurophysiology, vol.
79, no. 4, April 1998, pp. 2155-2170.

5.18. I. T. Jolliffe, Principal Component Analysis, New York: Springer, 1986, pp. 44-48, 269-
296.

5.19. T. Carletti, D. Fanelli, and A. Guarino, “A new route to non invasive diagnosis in
neurodegenerative diseases,” Neuroscience Letters, vol. 394, 2006, pp. 252-255.

5.20. P. J. Friedman, D. E. Richmond, and J. J. Baskett, “A prospective trial of serial gait speed
as a measure of rehabilitation in the elderly,” Age and Aging, vol. 17, no. 4, 1988, pp. 227-
235.

5.21. M. R. Popovic, T. A. Thrasher, M. E. Adams, V. Takes, V. Zivanovic, and M. I. Tonack,


“Functional electrical therapy: retraining grasping in spinal cord injury,” Spinal Cord, vol.
44, 2006, pp. 143–151.

5.22. C. A. Miller, and M. C. Verstraete, “Determination of the step duration of gait initiation
using mechanical energy analysis,” Journal of Biomechanics, vol. 29, no. 9, 1996, pp.
1195-1199.

5.23. D. A. Winter, A. O. Quantbury, and G. D. Reimer, “Analysis of the instantaneous energy


of normal gait,” Journal of Biomechanics, vol. 9, 1976, pp. 253-257.

111
5.24. D. A. Winter, The Biomechanics and Motor Control of Human Movement, 2nd edition, New
York: Wiley, 1991.

5.25. C. Angeloni, P. O. Riley, and E. D. Krebs, “Frequency Content of Whole Body Gait
Kinematic Data,” IEEE Trans. Rehabilitation Engineering, vol. 2, no. 1, 1994, pp. 40-46.

5.26. C. D. Mah, M. Hulliger, R. G. Lee, I. S. O’Callaghan, “Quantitative analysis of human


movement synergies: constructive pattern analysis for gait,” Journal of Motor Behavior,
vol. 26, 1994, pp. 83-102.

5.27. E. H. Melis, R. Torres-Moreno, H. Barbeau, E. D. Lemaire, “Analysis of assisted-gait


characteristics in persons with incomplete spinal cord injury,” Spinal Cord, vol. 37, no. 6,
June 1999, pp. 430-439.

112
Figures

EMG during Feature Set


double-support & Threshold

Estimate feature loadings


via correlation analysis

Loadings
Find the distance from centroid
of case ‘T’ in feature space

Euclidean distance

Distance Y Trigger
< swing-
threshold phase

STOP
Double- Y Wait for
support manual
> 3 sec? trigger

N
Get next
EMG sample

Figure 5.1: Laboratory setup for EMG-triggered FES-assisted walking shown with a flowchart
for the EMG-based gait event detector for triggering FES-assisted steps.

113
Figure 5.2: Top panel: Selection of optimum cut-off frequencies for low-pass filtering the
kinematic data. Bottom panel: Most of power content in the signals was below the
optimum cut-off frequency, which were 6 Hz for able-bodied and 3.5 Hz for iSCI
data.

114
volume of marker data capture (~4-5 steps)

first step from catch a self-selected reached steady return to ‘stand’


‘stand’ position gait speed state position
last gait cycle for
time series for stability analysis gait parameters
Figure 5.3: Gait initiation protocol during the data collection

115
Figure 5.4: Typical pelvis motion in the direction of progression during gait initiation

116
Figure 5.5: Euclidean distance from the origin of the perturbation of the 36 states during gait
initiation at the maximum left knee flexion. Left panel: able-bodied data (4 subjects).
Middle panel: iSCI data (subject C1). Right panel: iSCI data (subject C2).
[Normative: 4 subjects, 10 trials each; iSCI EMG-trigger: 2 subjects, 10 trials each;
iSCI Switch-trigger: 2 subjects, 10 trials each; iSCI Auto-trigger: 2 subjects, 10 trials
each]

117
Figure 5.6: Percent Variance Accounted For (%VAF) by the Principal Components (PC). Top
panel: able-bodied data. Middle panel: iSCI-1 walking with EMG, switch, and auto
triggered FES. Bottom panel: iSCI-2 walking with EMG, switch, and auto triggered
FES. All the plots show the data averaged over 6 gait events.

118
Figure 5.7: Typical loading of the first 3 Principal Components (PCs) on the joint angles (HA:
Hip Angle, KA: Knee Angle, AA: Ankle Angle) found from the weight matrix W of
the subject Able1. The prefix ‘l’ indicates the left side and ‘r’ indicates the right side.
The suffix ‘x’ denotes sagittal plane, ‘y’ denotes frontal plane, and ‘z’ denotes
transverse plane for the joint angles.

119
Figure 5.8: Euclidean distance from the origin of the perturbation of the 5 principal components
at maximum left knee flexion Left panel: able-bodied (4 subjects). Middle panel:
iSCI-1 subject C1. Right panel: iSCI-2 subject C2. [Normative: 4 subjects, 10 trials
each; iSCI EMG-trigger: 2 subjects, 10 trials each; iSCI Switch-trigger: 2 subjects, 10
trials each; iSCI Auto-trigger: 2 subjects, 10 trials each]

120
Figure 5.9: Top panel: Scatter plot of QoF and Av. Eig. at 6 gait events for the groups; the 4
able-bodied subjects: Able1, Able2, Able3, Able4, and the 2 iSCI subjects with
different trigger modes: EMG1, EMG2, SW1, SW2, Auto1, Auto2. Bottom panel:
MANOVA cluster dendrogram plot of the groups

121
Figure 5.10: Mahalanobis distances matrix between each pair of group means

122
CHAPTER 6
DEVELOPMENT OF AN IMPLANTED INTRAMUSCULAR EMG-TRIGGERED FES-
SYSTEM FOR AMBULATION AFTER INCOMPLETE SPINAL CORD INJURY

Abstract

Ambulation after spinal cord injury is possible with the aid of neuroprosthesis employing

functional electrical stimulation (FES). Individuals with incomplete spinal cord injury (iSCI)

retain partial volitional control of muscles below the level of injury, necessitating careful

integration of FES with intact voluntary motor function for efficient walking. In this study, the

intramuscular electromyogram (iEMG) was used to detect the intent to step and trigger FES-

assisted walking in two volunteers with iSCI via an implanted neuroprosthesis consisting of two

channels of bipolar iEMG signal acquisition and 12 independent channels of stimulation. The

detection was performed with two types of classifiers – a threshold-based classifier that

compared the running mean of the iEMG with a discrimination threshold to generate the trigger

and a pattern recognition classifier that compared the time-history of the iEMG with a specified

template of activity to generate the trigger whenever the cross-correlation coefficient exceeded a

discrimination threshold. The two classifiers were presented in a random order to one of the iSCI

volunteers for evaluation under indoor laboratory conditions. The pattern recognition classifier

generally outperformed the threshold-based classifier, particularly with respect to minimizing

False Positive triggers. The overall True Positive rates for the threshold-based classifier were

61.6% and 87.2% for the right and left steps with overall False Positive rates of 38.4% and

33.3%. The overall True Positive rates for the left and right step with the pattern recognition

classifier were 57.2% and 93.3% and the overall False Positive rates were 11.9% and 24.4%.

Subjects showed no preference for either the threshold- or pattern recognition-based classifier as

determined by the Usability Rating Scale (URS) score collected after each trial. The average

123
URS score was 2 out of a 7 point scale for both the classifiers, indicating that both the classifiers

were perceived as equally moderately easy to use.

Introduction

Motor system neuroprostheses utilizing functional electrical stimulation (FES) can

improve or restore walking function in individuals paralyzed by spinal cord injuries by

electrically activating a customized set of muscles selected to address individual gait deficits

with pre-programmed patterns of stimulation to augment or produce cyclic movements of the

lower extremities [6.1]. Users can trigger each step with a manual switch and progress through

the customized pattern of stimulation to achieve walking function. The potential for triggering

FES from the electromyographic (EMG) activity of muscles which remain under volitional

control after partial paralysis to coordinate the actions of the stimulated muscles with voluntary

movement has previously been evaluated with signals acquired from the surface of the skin [6.2].

The main objective of this study was to develop a method to identify optimal command sources

and evaluate the feasibility of detecting the intent to take a step using the intramuscular

electromyogram (iEMG) acquired from recording electrodes implanted permanently in the

partially paralyzed muscles in two implant recipients with incomplete spinal cord injury (iSCI).

The overall aim was to specify the development of a new command and control interface to

trigger FES-assisted stepping that can be implemented with two channels of intramuscular EMG

electrodes with a multichannel implantable stimulator-telemeter (IST) [6.3], [6.4]. This report

summarizes the development of the iEMG-based command interface for FES-assisted

ambulation that integrated stimulated and voluntary muscle activity in a fully implantable

neuroprosthesis.

Prior work has shown that gait event detection for the control of electrical stimulation is

possible with physical sensors such as force sensitive resistors, accelerometers, gyroscopes, as

124
well as with biopotentials such as the electroneurogram and electromyogram [6.5-6.8]. The

electromyogram temporally precedes the generation of force in the muscle and resulting

movement of a joint. This makes the EMG an attractive signal for detection of intent so that the

desired movement can then be assisted with FES. Graupe et al. proposed EMG based control of

FES with time-series model of surface EMG (sEMG) [6.9]. Auto-regressive (AR) time-series

models of four channels of sEMG has been shown to give information related to limb function

[6.10] and can provide patient-responsive control of FES-assisted walking [6.11]. The AR

parameters determined offline from the time-series model of the above-lesion upper-trunk

surface EMG were used to identify standing and walking functions [6.11]. Recently, Graupe and

Kordylewski presented a neural network based EMG classifier with on-line learning capabilities

to control stimulation for achieving stepping motions in individuals with complete paraplegia

[6.12, 6.13]. Our preliminary studies indicate that the surface EMG from partially paralyzed

muscles of individuals with incomplete paraplegia can provide significant information related to

the volitional activity of the muscle and can be used for gait-event detection [6.14, and 6.15].

Thorsen et al. have showed improved wrist extension with stimulation controlled by surface

EMG from partially paralyzed wrist extensors [6.16]. Futami et al. showed the feasibility of

proportional control of FES with the sEMG from the same muscle (partially paralyzed knee

extensors) in incomplete hemiplegia [6.17].

This chapter outlines the development of a binary classifier as a command interface for

foot-off intent detection with iEMG from partially paralyzed muscles via implanted recording

electrodes in two subjects wit hiSCI. The classifier detected the intent to initiate stepping and

integrated that information in the FES controller to trigger FES-assisted stepping with that limb.

The real-time operation of the iEMG–based classifier was evaluated by one iSCI volunteer for

125
FES-assisted walking under laboratory conditions. The technical challenges and preliminary

results from initial attempts to implement iEMG-based control systems in real-time with

available implanted neuroprostheses are discussed at the end of the chapter.

Methods

Subjects

Two male subjects with incomplete spinal cord injury volunteered for this study. Subject

iSCI-1 was a male volunteer with C6 incomplete spinal cord injury (ASIA C). Subject iSCI-2

was a male volunteer with T1 motor and C6 sensory incomplete spinal cord injury (ASIA D)

who could walk only short distances with great difficulty without the assistance from FES. They

each received a 12 channel stimulator-telemeter (IST-12), 12 surgically implanted intramuscular

stimulating electrodes [6.3] and two implanted intramuscular recording electrodes as part of a

neuroprosthesis designed to facilitate household and limited community ambulation.

Subject iSCI-1 presented with more extensive paralysis on his right side. In a single

surgical procedure, he received stimulating electrodes to recruit iliopsoas, vastus

intermedius/lateralis, erector spinae, and gluteus maximus bilaterally, as well as hamstrings,

posterior adductor magnus, tensor fasciae latae, and tibialis anterior muscles on the right side

only. Subject iSCI-2 presented with more extensive weakness primarily on his left side. He had

previously received a neuroprosthesis to assist with ambulation based on an eight-channel

implanted receiver-stimulator (IRS-8). His original eight-channel system included intramuscular

stimulating electrodes only on his left side to recruit iliopsoas, vastus intermedius/lateralis, tensor

fasciae latae, gluteus medius, gluteus maximus, posterior portion of adductor magnus, and

tibialis anterior (2 electrodes). He was re-evaluated for the 12-channel EMG-controlled system

and upgraded to the IST-12 for iEMG triggered walking. The original IRS-8 was disconnected

from the stimulating electrodes and replaced with the IST-12. At the time of his revision

126
surgery, additional intramuscular stimulating electrodes were inserted into the bilateral erector

spinae, right iliopsoas, right gluteus maximus, and right tibialis anterior to complete the 12-

channel system. Temporal patterns of stimulation to activate the muscles were customized for

each subject’s individual gait deficits according to established tuning procedures [6.7], [6.8] in

order to achieve forward stepping in a rolling walker.

Informed consent was obtained from both the subjects before their participation and the

Institutional Review Board of the Louis Stokes Cleveland Department of Veterans Affairs

Medical Center approved the study related procedures.

Command source selection

Two recording channels were available in the implantable stimulator-telemeters for

intramuscular EMG recording electrodes [6.2-6.4]. Therefore two muscles and the best location

within those muscles had to be selected for implanting intramuscular recording electrode based

on surface EMG (sEMG) data. Subjects were asked to walk either volitionally or with surface

FES for the pre-surgery data collection. The experimental setup for collecting sEMG data during

walking is shown in Figure 6.1. Surface EMG signals were collected from gluteus medius (GM),

biceps femoris (BF), medial gastrocnemius (MG), rectus femoris (RF), tibialis anterior (TA), and

erector spinae (ES) bilaterally.

The sEMG was collected using Ag/AgCl electrodes with 2 cm. inter-electrode distance

following the SENIAM guidelines [6.22]. The sEMG signals were amplified and low-pass

(fcutoff=1000 Hz) filtered by CED 1902 amplifiers (Cambridge Electronic Design, England)

before being sampled at 2400 Hz (AT-MIO-64F-5, National Instruments, USA) in the host

personal computer. The CED 1902 amplifier has a switching circuit (clamp) which was activated

by a square pulse that disconnected the electrode inputs from the amplifier and connected it to

the common electrode to prevent stimulation artifact. The input channels of CED 1902 were

127
clamped when the stimulation pulses were applied to the muscles to prevent stimulation artifact.

The blanked portion of the sEMG was reconstructed with the average value of the sEMG in the

pre- and post- blanking periods [6.23] as shown in Figure 6.2a. Then the whole sEMG pattern

was low pass filtered (5th order zero-lag Butterworth, fcutoff=3 Hz) to get the linear envelope

(Figure 6.2b). The gain of each channel was set separately in the CED 1902 amplifiers to prevent

saturation at the maximum muscle activity during the gait-cycle.

Baseline sEMG data were collected during 3 seconds of initial standing before the start of

each trial. During each trial, the subjects were asked to reach a self selected speed within ~5m of

the start position and then decelerate to come to rest at the end of the walkway. They had to wait

in the terminal stance for 3 seconds at the end of every trial. The experimental protocol is shown

in Figure 6.3. The subjects made multiple passes across the straight level walkway. Gait events

(foot-strike and foot-off) were derived from foot-floor contact patterns obtained from insole-

mounted foot switches placed bilaterally at medial and lateral heel, first and fifth metatarsal, and

big toe, and confirmed with the kinematic data that were acquired simultaneously.

Each pass constituted one trial and multiple trials were collected during a session. The

sEMG data were sampled and processed in MATLAB TM R14 (The MathWorks, Inc., USA). The

sEMG linear envelopes (LEs) during a gait cycle were then divided into double-support (DS)

phase – when both the feet were in contact with the ground, and swing (SW) phase – when the

foot was not in contact with the ground [6.27]. The sEMG LE during each trial was normalized

by its maximum magnitude during that trial.

The normalized LEs of each muscle were divided into two classes: the class ‘True’ was

comprised of LEs during double-support phase prior to foot-off and the class ‘False’ consisted of

the LEs during terminal stance and initial standing. Half of the data were randomly allocated to

128
training and used to find a characteristic pattern of activation by ensemble averaging the LEs.

The characteristic pattern found for the class ‘True’ was cross-correlated with the LEs from the

other half of the data (test data) for the classes ‘True’ and ‘False’. A Receiver Operating

Characteristics (ROC) curve showed the tradeoff between sensitivity (i.e. True Positive rate) and

1 – specificity (i.e. False Positive rate) of the binary classifier [6.24]. A Discriminability Index

(DI) was defined as the area under the ROC curve (AUC) which gave a measure of performance

for the binary classifier [6.25]. The data were randomly partitioned ten times into training and

test data-sets for a 10-fold cross-validation. Therefore, 10 ROC curves for the pattern recognition

classifier were generated by randomly pooling the LEs into training and test data-sets. The DI

was computed for each ROC curve and then averaged to find the mean DI and standard deviation

(SD(DI)) for the pattern recognition classifier [6.25]. This identified the muscles yielding the

best separation of classes, and hence the primary targets for the implanted recording electrodes.

The best location for implantation of the intramuscular recording electrode was estimated

based on a similar analysis of the DI form the sEMG acquired from different locations on the

bellies of the target muscles. A matrix of sEMG electrodes was placed to cover the whole muscle

belly, as shown in Figure 6.4. Multiple bipolar sEMG recordings were made along the length of

the muscle. The sEMG data were collected with the same experimental protocol and analyzed

similarly to find the best location on the muscle belly that had the highest DI. The best location

was noted with respect to the anatomical landmarks for easy identification during surgery when

the subject was under general anesthesia.

Implantation of intramuscular EMG electrode

The implantation procedure for the iEMG electrode is shown in Figure 6.5. First a

stimulation probe was inserted subcutaneously to the best location that was identified based on

anatomical landmarks, as shown in Figure 6.5a. Stimulation was applied by clipping a cable to

129
the probe to ensure that the tip of the probe is at the desired site with viable muscle fibers. A

peelable polymer sheath was then inserted on the top of the probe with the help of the markings

such that its tip approximately coincided with the probe tip, as shown in Figure 6.5b. The probe

was then removed and the intramuscular EMG electrode was inserted in the place of the probe

with the help of the lead carrier. The cannula-like lead carrier held the iEMG electrode lead in

place during insertion through the sheath. The lead carrier was then removed which left the

iEMG electrode lead in the peelable sheath, as shown in Figure 6.5c. The polymer sheath was

then gently peeled off leaving the iEMG electrode at the selected location, as shown in Figure

6.5d.

Classifier development for iEMG-triggered FES-assisted stepping

Temporal patterns of pulse-width modulated stimulation for bilateral stepping were

customized for each subject [6.20, and 6.21] in order to achieve forward stepping in a rolling

walker, as shown in Figure 6.6. The stimulation current was fixed at 20 mA and the stimulation

frequency was fixed at 20 Hz (50 ms inter-pulse-interval). Each step could be triggered either by

the depression of a manual switch or with an iEMG-based classifier to progress through the

stimulation pattern.

Two kinds of iEMG-based classifier – one based on thresholding and the other based on a

pattern recognition algorithm [6.2] were developed. The left foot-off (i.e., the intent to initiate

left swing) and right foot-off (i.e., the intent to initiate right swing) were detected sequentially

and independently by the classifiers to trigger FES-assisted left and right steps respectively. The

20 Hz sampling rate for the iEMG signal corresponded with the stimulation frequency. The

sampling period was divided between the two iEMG channels which were multiplexed in the

IST-12 to use the same gain and integration circuitry. The iEMG from each channel was pre-

amplified, rectified, and blanked in the hardware during the electrical stimulation before being

130
integrated for 10 ms. The iEMG of the each channel was sampled and integrated for 10ms

sequentially one after the other every 100 ms. The IST-12 therefore telemetered back to the

External Control Unit (ECU) the integrated iEMG of each channel at 10 Hz.

The real-time operation cycle in the IST is illustrated in Figure 6.7. The real-time cycle of

operation was 50 ms (corresponding to the inter-pulse-interval between stimulus pulses). The

iEMG channel (i.e., 1 or 2) to be sampled was set after 4ms into the real-time cycle with the gain

set to zero to minimize switching transients. After 6ms into the real-time cycle, the gain was then

set to an appropriate level such that it did not cause saturation. After 13ms into the real-time

cycle, the integrator started integrating the iEMG for 10ms. The integrated iEMG was read after

23ms into the real-time cycle. After 25ms into the real-time cycle, the iEMG channel gain was

reset back to zero so that 12-channels of stimulation can be applied to the muscles from 28ms

onwards. About 10ms of time was needed at the end of the real-time cycle to update the events

and do housekeeping tasks. The data from each iEMG channel were reconstructed during the

next 50ms time step and held at that value when the other channel was sampled. A 10-point

moving-average smoothing filter was applied to the iEMG signal in the ECU to reduce random

noise.

The threshold-based binary classifier started computing the running mean of the relevant

iEMG signal after waiting a fixed duration (twait) from the start of the stimulation pattern of a

step. The ‘twait’ was found from the training data. The wait duration was long enough such that

the iEMG activity processed by the classifier represented the unloading of the contralateral limb

in preparation for the swing phase of that side. When the running mean exceeded a selected

threshold (thrTC), the stimulation pattern advanced and stepping of the contralateral limb was

triggered. The pattern recognition classifier started processing the iEMG time history at the same

131
time as the threshold-based classifier started processing the iEMG level. The pattern recognition

classifier cross-correlated a windowed portion (of length twin) of the relevant iEMG signals to

detect feature templates required for triggering the contralateral step. A trigger was then

generated when the cross-correlation coefficient exceeded a discrimination threshold (thrPRC).

Classifier parameters such as twait, thrTC, twin are illustrated in Figure 6.8. The start of the

stimulation is shown to coincide with foot-off in Figure 6.8 to coincide just for illustration

purposes, and such timing may not necessarily be true in reality. The foot-off may precede the

start of stimulation pattern for stepping in subjects who have enough volitional strength or there

may be a delay in case of more affected subjects.

Figure 6.8 also shows trigdelay which is the delay in generating the trigger by the threshold-

based classifier primarily due to the 10-point moving average FIR filter. The group delay of the

10-point moving average FIR filter is (10-1)/2=4.5 samples long for each channel of iEMG (i.e.

225 msec for a nominal stimulating and sampling rate of 20 Hz). By definition, it takes 9

samples i.e. 450 msec to reach the unit amplitude after the unit step is applied to the 10-point

moving average filter. These delays were largely unavoidable due to the processing embedded

in the implanted system.

Most of the parameters for the pattern recognition and the threshold-based classifiers were

found from the training data collected with the IST-12 during FES-assisted switch-triggered

walking in the laboratory. Training data collection followed the same experimental protocol

explained earlier in Chapter 4 and shown in Figure 6.3. The iEMG patterns during walking were

normalized by the average of the baseline iEMG data collected during 3 seconds standing. The

iEMG patterns during steps taken while walking constituted the class ‘True’ and the iEMG

patterns during initial standing and terminal step constituted the class ‘False’ of the binary

132
classifier for that side. All the iEMG patterns in both the classes were time normalized such that

they each contained 50 data points. This allowed comparison of the iEMG patterns and iEMG

levels at different time points to be selected for classification by the Discriminability Index (DI).

All patterns were randomly partitioned 10 times into training and test data-sets for a 10-

fold cross-validation. The data sets were used to generate separate ROC curves for each of the

classifiers. Ten ROC curves for each point in the gait cycle were generated for the threshold-

based classifier by randomly pooling data from different iEMG patterns in the training and test

data-sets. The pattern recognition classifier works with a pattern of iEMG activity. Therefore, 10

ROC curves for each phase of the gait cycle, such as left and right swing (SW) and double

support (DS), were generated from the same training and test data-sets as used to quantify the

performance of the threshold-based classifier The DI was computed from each ROC curve and

then averaged to find the mean DI and standard deviation [6.25]. The classification region was

defined as the largest set of contiguous data points with a high (>0.7) mean DI where the

decision has to be made whether to trigger the FES-assisted contralateral step or not. The

classification regions were identified from the results from the threshold-based classifier and

used to define the wait time (twait), which was equal to the elapsed time from the start of the FES-

assisted step until the beginning of the classification region.

For the pattern recognition classifier, the iEMG patterns from the class ‘True’ in the

classification region were ensemble averaged and served as the feature for classification. One

feature served as the template for one muscle for identifying left foot-off and another feature

served as the template for another muscle for right foot-off. The window-size parameter twin was

equal to the average duration of that classification region for all the steps in the training data. The

feature was cross-correlated with all the iEMG patterns in the class ‘True’ and the average cross-

133
correlation coefficient served as the thrPRC. The parameter thrTC was equal to the average running

mean of the iEMG signal over the classification region for all the iEMG patterns in the class

‘True’.

The pattern recognition and threshold-based classifiers were tested separately during online

operation in the gait laboratory, as explained in the following section.

Online testing of the classifier in the laboratory

The two classifiers were developed as separate models in the Simulink (The MathWorks,

Inc., USA) and compiled via C-code to run standalone in the portable ECU that also executed the

control algorithm to deliver pre-programmed stimulation patterns to the muscles via the IST-12.

The IST-12 telemetered back the iEMG signal that was used by the classifier to trigger the

stimulation pulses for the subsequent steps.

The standalone FES controller occasionally experienced overrun errors which occurred

when the ECU couldn’t finish all the required tasks in the 50ms time window for real-time

operation. The stack size for the FES controller running in ECU was set at 4096 which was the

space needed for the arguments, the stack variables, and all the variables. The computational

demand of the classification algorithm alone was investigated with a Matlab (The MathWorks,

Inc., USA) utility called ‘XPCBENCH’. The Simulink model for the classification algorithm

consisting only of the pattern recognition or the threshold-based components was made to run in

a PC environment with synthesized EMG signals as the inputs and a binary output as the trigger

signal. The pattern recognition algorithm mostly experienced overrun error and was simplified

from the one published earlier [6.2] such that only one feature was cross-correlated with iEMG

from one muscle for classification. The minimum achievable sample time for running only the

simplified pattern recognition classifier model (i.e., no FES stimulation) was 3800 µs on an Intel

134
486DX 40 MHz. The 50ms real time window was sufficient for running the pattern recognition

classification algorithm in isolation. The overrun error issue during online operation even with

the simplified pattern recognition classifier was possibly due to the hardware events required to

integrate the iEMG signal with implanted stimulation (like changing the stimulus, the iEMG

gain, the iEMG channel, etc), which took up most of the cycle time. Figure 6.7 shows the

hardware events taking place in the 50 ms sampling window, which provided only about 9 ms of

free cycle time prior to the initiation of the next cycle, which was probably insufficient for robust

operation under all conditions.

The stimulation pattern for the first step was triggered with a manual switch. The classifier

started scanning the iEMG after waiting ‘twait’ duration from the start of stimulation pattern of

that step to detect the intent to initiate stepping with the contralateral limb. For safety, the

classifier was allowed to trigger the stimulation pattern for stepping of the contralateral limb

within 1 sec after entering the double support phase. If the user was unable to trigger the

stimulation pattern with iEMG (i.e., a “false negative”) within 1 sec after entering the double

support phase then the manual switch could be used as a trigger, and the classifier then resumed

processing the iEMG to determine the intent to trigger subsequent steps. When the user was

unable to stop with the classifier (i.e., “false positive”) then a manual switch could be used to

stop the classifier from triggering subsequent steps.

Subject iSCI-2 evaluated walking and stopping with both the classifiers while the true

positive (1-false negative) and false positive rates were recorded as measures of performance.

The subject walked with the iEMG triggered FES assisted stepping on a straight walkway across

the gait laboratory. The iEMG classifier was started with a manual switch during standing to

trigger the first step. After that the iEMG triggered the steps during ambulation across

135
approximately 8m before stopping with the iEMG classifier. The delay (trigdelay) in triggering

the FES-assisted step from the instant the desired muscle activity was detected was also recorded

to further compare the technical performance of the classifiers. The pattern recognition and the

threshold-based classifiers were presented in a random order during two days of evaluation.

Total eight trials (39 left steps and 39 right steps) for the threshold-based classifier and nine trials

for the pattern recognition classifier (45 left steps and 42 right steps) were captured.

After each trial, the subjective assessments of perceived ease of use of each classifier

during FES-assisted stepping in real-time were evaluated with Usability Rating Scale (URS)

[6.29]. The URS, depicted in Figure 6.10 is a 7 point scale originally developed to determine

differences in the perceived ease of use. After each walking trial, the subject was asked to rate

the EMG-triggered system as “Difficult”, “Moderate” or “Easy” to use. After selecting one of

those three choices, the subject was asked to refine his selection as “Very”, Moderately” or

“Barely”. Each final subjective rating was assigned a numerical value from -3 (very difficult) to

+3 (very easy). Each walking trial was evaluated independently so the subject only rated his

most recent walking experience and was not required to compare his current perception to a prior

walking trial.

Results

Muscles and location selection for intramuscular EMG

The left medial gastrocnemius (MG) and the right erector spinae (ES) were selected as the

command sources for iSCI-1. The best location for intramuscular EMG was estimated based on

the DI from the surface EMG from the Left MG and Right ES of iSCI-1, which are shown with

color scale in Figure 6.11a. The best location on Left MG was 6 cm medial and 18 cm distal

from the popliteal crease line. The best location found on Right ES was 2.75 cm lateral to the

spinous process of L2 and 2 cm superior to the L2 level. The Right MG and Left MG were

136
selected as the command sources for iSCI-2. The best location for intramuscular EMG that was

estimated based on the DI from the surface EMG from the Left MG and Right MG of iSCI-2 are

shown with color scale in Figure 6.11b. The best location found on the Left and Right MG was 6

cm medial and 13 cm distal from the popliteal crease line.

Classifier development and online performance

The iEMG was collected and processed to determine the parameters for each classifier. The

iEMG pattern during walking was divided into swing phase (SW) and double support (DS)

phases of gait based on the foot-floor contact patterns obtained from the foot switches. Figure

6.12a and Figure 6.12b show the Discriminability Index (DI) at each time normalized data point

from the ROCs obtained with the threshold-based classifier during the gait cycle that was used to

identify the classification region. Figure 6.12a shows that the iEMG pattern of the left medial

gastrocnemius had DI close to 0.5 at the end of left SW phase, a DI close to 0.8 at the end of left

DS phase, a DI close to 0.95 at the end of right SW phase, and a DI close to 1 which means very

good discriminability during the right DS phase. Figure 6.12b shows that the iEMG pattern of

right ES had low DI at the end of the left SW phase of gait which was close to 0.5, a poor

discriminability with DI less than 0.5 during left DS, a good discriminability with DI close to 1

during right SW and again a good discriminability with DI close to 0.9 during right DS.

The gait phases of interest for the classifier are the left and right DS phases, which should

be a subset of the classification region when the decision has to be made to trigger the FES-

assisted SW phase of the contralateral limb. For the right ES, left DS was not good for

classification since the DI was less than 0.5. Figure 6.12b shows that the right ES had a

classification region that started at data point 25 in the right swing phase (SW) and covered the

whole right double support phase (DS) of the gait.

137
The iEMG training data were collected in absence of right ES stimulation; however the

electrical stimulation of the right ES during FES-assisted walking created an artifact in the iEMG

from right ES during the right SW that is shown in Figure 6.13. Taylor and Chappel have shown

that the ratio of the volitional EMG with the intended effort changes with the intensity of the

stimulation and the time since the stimulation pulse as in this case when the EMG from the same

muscle is the control signal for stimulation [6.18]. Because of this inhibitory action of the

stimulation on the iEMG from the same muscle during right SW (right ES was only stimulated

during right SW), the classification region was started after the end of electrical stimulation to

assist right ES i.e., at the data point 1 in the right DS. Right ES was used by the classifier to

trigger the left step in this classification region which started at 1.8 seconds into the right step

and was 0.8 seconds long, as found from the foot switch data. The right step determined from the

foot switch data started on an average 0.2 seconds before the start of its stimulation pattern so

twait=1.6 seconds and twin=0.6 seconds for the left step classifier. The thrTC in the classification

region was about 1.1 times the baseline level of the iEMG during quiet standing.

Since right ES was found suitable only to trigger the left step, left MG was selected to

trigger the right step. The classification region started at data point 2 in the left DS and covered

the whole left DS of the gait. Left MG was used to trigger the right step during this classification

region which started 1.45 seconds after the start of the left step and was 0.9 seconds long, as

found from the foot switch data. The left step found from the foot switch data started 0.15

seconds before the start of the stimulation pattern so twait=1.3 seconds and twin=0.75 seconds for

the right step classifier. The thrTC during the classification region was equal to 0.45 times the

baseline level of iEMG during quiet standing. The pattern recognition classifier used a

monotonically increasing feature – [0.2418 0.3406 0.3984 0.5056 0.5231] with a cross-

138
correlation threshold, thrPRC=0.6. The monotonically increasing nature of the feature is necessary

since the iEMG pattern in that case will cross the threshold only once in the classification region.

The subject iSCI-1 is currently using the iEMG classifier in the laboratory during his

rehabilitation phase. No performance data have been collected yet for the subject iSCI-1 since he

is currently learning to use the iEMG-based system.

Figure 6.14a and Figure 6.14b show the Discriminability Index (DI) at each time

normalized data point during the gait cycle that was used to identify the classification region of

iSCI-2. The Figure 6.14a shows that the iEMG pattern of right MG had moderate DI at the end

of the left SW phase of gait (~0.8), a good DI (~0.8) as the beginning of left DS and a poor DI at

the end (~0.5), a poor discriminability with DI close to 0.5 during right SW and a poor

discriminability during the right DS phase with DI close to 0.6. The Figure 6.14b shows a

moderate DI at the start which deteriorated to a low DI by the end of left SW phase of gait

(~0.5), a low DI close to 0.5 during left DS, a moderate discriminability with DI close to 0.7 at

the end of right SW, a moderate discriminability during the right DS phase with DI close to 0.7.

Figure 6.14a shows that the right MG had a classification region starting at data point 35 in

the left SW and extended till data point 2 in the left DS of the gait. Right MG was used by the

classifier to trigger the right step during this classification region which started at 1.5 seconds

into the left step and was 0.85 seconds long, as found from the foot switch data. The left step

found from the foot switch data started 0.3 seconds before the start of its stimulation pattern so

twait=1.2 seconds and twin=0.55 seconds for the right step classifier. The thrTC was equal to 1

times the baseline magnitude of iEMG during quiet standing. The pattern recognition classifier

used a monotonically increasing feature – [1.0436 1.0651 1.0900 1.1423 1.2358] with a

cross-correlation threshold, thrPRC=0.65.

139
Figure 6.14b shows that the left MG had a classification region starting at data point 30 in

the right SW and extended till the end of the right DS of the gait. Left MG was used by the

classifier to trigger the left step in this classification region which started at 1.55 seconds into the

right step and was 0.85 seconds long, as found from the foot switch data. The right step

determined from the foot switch data started 0.5 seconds before the start of the stimulation

pattern so twait=1.05 seconds and twin=0.35 seconds for the left step classifier. The thrTC was equal

to 1.1 times the baseline magnitude of iEMG during quiet standing. The pattern recognition

classifier used a monotonically increasing feature – [0.9480 0.9876 1.0415 1.1109

1.1991] with cross-correlation threshold, thrPRC=0.65.

Both the the pattern recognition and the threshold-based classifier incurred similar delays

(trigdelay) in triggering the FES-assisted step. The elapsed time from the instant of the desired

muscle activity to initiation of stimulation was 0.53 ± 0.12 seconds. Table 6.1 shows the

performance of the threshold-based classifier for iSCI-2. The threshold-based classifier for

triggering the right step had a false positive rate of 38.4% and a true positive rate of 61.6%. The

threshold-based classifier for triggering the left step had a false positive rate of 33.3% and a true

positive rate of 87.2%. Table 6.2 shows the performance of the pattern recognition classifier for

iSCI-2. The pattern recognition classifier for triggering the right step had a false positive rate of

11.9% and a true positive rate of 57.2%. The pattern recognition classifier for triggering the left

step had a false positive rate of 24.4% and a true positive rate of 93.3%. The standard deviation

of the false positives and false negatives from trial-to-trial as seen in Tables 6.1and 6.2 indicated

that the threshold-based classifier was more sensitive to natural variations in the EMG activity

from the left side of iSCI-2 which had more extensive weaknesses.

140
The average Usability Rating Scale (URS) score was found to be 2 in a 7 point scale for

both the classifiers, indicating that both the classifiers were moderately easy to use. The subject

didn’t show any preference for a particular classifier as determined from URS score after each

trial.

Because the threshold-based classifier was found to be susceptible to false positives while

the pattern recognition classifier was found to be susceptible to false negatives. Therefore after

testing each classifier separately in the gait laboratory, the final implementation in the ECU for

use by the subject had the two classifiers integrated in to a two-stage classifier to reduce the

overall false positives, as illustrated in Figure 6.9. Moreover, it was found during the testing that

the classification threshold (thrTC) for the threshold-based subsystem was sensitive to natural

variation in the EMG activity over time. Therefore a provision was made in the final

implementation in ECU to retrain only the classification threshold (thrTC) for the threshold-based

subsystem which could be adjusted during online operation using binary search. In the two-stage

implementation, the threshold-based subsystem served as the primary classifier while the pattern

recognition subsystem could be turned on or off for a given subject as needed. False positives

(i.e., unintended initiations of swing) were considered to be more disruptive and potentially

unsafe during walking than false negatives (i.e. failure to initiate an intended swing) because of

the risk of falling during unanticipated unloading of one of the limbs during double support. The

iEMG-based two-stage classifier triggered the stimulation pattern of the contralateral step when

both the threshold-based and pattern recognition subsystems agreed on initiating swing. The two-

stage classifier was computationally more demanding and so worsened the failure rate of the

ECU hardware.

141
Discussion

This work presented a method for selecting command sources for iEMG-triggered FES-

assisted ambulation, and evaluated two kinds of classifiers based on either the pattern recognition

or simple thresholding during online operation under laboratory conditions. Two muscles and the

location for implantation of intramuscular EMG electrode in those two muscles determined prior

to implantation, and two kinds of iEMG-based classifiers were implemented in the external

control unit (ECU) that works with the current family of ISTs.

The two classifiers were made computationally simple to work with the limited resources

available with the portable ECU based on Motorola HC12 16-bit family of microcontrollers.

Only 10 ms of integrated iEMG data sampled every 100 ms from each iEMG channel was

available to the classifiers. In order to limit the computational load on the ECU that was causing

overrun errors when the ECU was not able to finish all the computations in the allocated 50ms

real-time cycle time, the pattern recognition classifier used only one feature template to identify

the iEMG pattern as compared to three that were presented in our prior work in Chapter 4 [6.2].

The iEMG-triggered FES-assisted ambulation with both the classifiers was evaluated in the

laboratory during the rehabilitation phase of the subject.

The interference with the iEMG due to electrical stimulation of the same muscle was

observed with right erector spinae of the subject iSCI-1 (Figure 6.13). The electrical stimulation

of the same muscle inhibited the EMG activity in the right erector spinae muscle. This has

previously been observed by other researchers as well [6.18]. Therefore the electrical stimulation

of the same muscle during EMG recording was avoided in this study.

The performance of the threshold-based classifier that was based on the iEMG from the

left side with more extensive weaknesses of the subject iSCI-2 varied from trial-to-trial. This

variation was due to the sensitivity of the threshold-based classifier to spasms and other natural

142
variation of EMG activity like fatigue. In the final implementation of the classifier as a two-stage

system with a threshold-based and a pattern recognition subsystems, the threshold of the

threshold-based subsystem (thrTC) was made adaptive by updating it during operation (online

training) with a binary-search using the iEMG levels related to false positives and false

negatives, thus having it learn to accommodate for fatigue or other day-to-day time varying

factors. In view of the online training that was needed during real-time operation of the

classifiers, the extensiveness of the offline training to find the threshold (thrTC) and other

parameters could be reduced significantly. The two-stage classifier (Figure 6.9) was

computationally more demanding and so worsened the failure rate of the ECU hardware.

The processing power of the ECU limited the performance since the amount of

computations required for pattern recognition algorithm that was developed in prior work

presented in Chapter 4 could not be implemented [6.2]. The pattern recognition algorithm

presented in this study was based on pattern matching of the iEMG activity with just one feature

as compared to three in the prior work. Moreover, a sampling frequency of only 10 Hz was

possible with IST as compared to 2400 Hz in an xPC TargetTM (The Mathworks, Inc., USA) that

was presented in the prior work which reduced the SNR of the iEMG signal. Most of the time in

the 50ms real-time cycle was taken up by the hardware events. The classifier algorithm had

limited time to process the iEMG data which caused frequent overrun errors, especially with the

two-stage classifier. A faster processing unit will decrease the processing time for a more

complex classifier algorithm like the one presented in Chapter 4 and should help in eliminating

overrun errors.

A way to provide the processing power needed by the controller algorithm is to implement

the controller on a more powerful but compact PC/104 (size 3.6 by 3.8 inches) single board

143
computer (SBC) running xPC targetTM(The MathWorks, Inc., USA) [6.31]. The xPC targetTM

SBC can serve as the main processor for implementing the classifier and other software control

algorithms while ECU can handle the RF power and command link with the IST for stimulus

control, stimulus current regulation, iEMG data control, stimulus blanking control, and system

control. The compact PC/104 SBC can be made to fit inside the enclosure of ECU and the

PC/104 architecture supports self stacking of different modules like data acquisition board that

can provide extra analog and digital input/output channels for interfacing with more sensors.

The quality of the iEMG signal can be significantly affected by the location of the

intramuscular electrode in the partially paralyzed muscle. The optimal set of command sources

and motor targets was determined only from the superficial muscles accessible from the skin’s

surface. It was challenging to find the optimal location for implanting the intramuscular electrode

in a partially paralyzed muscle based on EMG recordings from the surface of the skin. Deeper

muscles can be accessed with intramuscular stimulating or recording electrodes temporarily

implanted for acute testing. Advanced source localization techniques can be applied to multi-

electrode surface EMG recordings to determine an optimal command sources. It was not possible

to record from the muscle during implantation of the iEMG electrode since the subject was under

general anesthesia so the best location had to be found before the surgery.

Additional physical sensors in parallel to the iEMG may be able to enhance the

performance of the classifiers. Sensors like linear accelerometers and gyroscopes can be placed

in the ECU that is worn externally close to the center of mass (COM) of the body. Gyroscopes

may be able to capture the orientation and the accelerometers the acceleration of body segments.

The tilt and acceleration of the upper body during a rolling walker aided ambulation will have

significant information related to gait cycle. If the sensors can be placed in the shoe then it has

144
been shown that foot linear acceleration and foot angular velocity can be used to correctly

identify foot-off in spinal cord injured subjects [6.30].

Conclusions

This study presented a selection criterion to identify the command sources for an iEMG-

based classifier to trigger FES-assisted gait. The selection is based on surface EMG recordings

from multiple muscles that are associated with ambulation to identify two best muscles to trigger

FES-assisted left and right step. The location for implanting the intramuscular electrode in those

two muscles were also found using the same selection criteria that was then applied on multi-

electrode surface EMG recordings from the muscle belly.

The feasibility of a simplified threshold-based classifier and a pattern recognition classifier

based on iEMG for triggering FES-assisted steps was demonstrated during real-time operation in

one subject. The pattern recognition classifier generally outperformed the threshold-based

classifier, particularly with respect to minimizing false triggers. Subject showed no preference

for either the threshold- or pattern-recognition based classifier as determined by the Usability

Rating Scale (URS) score collected after each trial.

The performance of the threshold-based classifier was sensitive to day-to-day variability in

the iEMG from the side with more extensive weakness. In the final implementation of the

classifier as a two-stage system with a threshold-based and a pattern recognition subsystem, a

provision was made to retrain the threshold of the threshold-based subsystem with binary search

during online operation.

The pattern recognition classifier algorithm was simplified significantly to run with the

limited processing power available in ECU. This significantly deteriorated the performance when

compared to the results presented in Chapter 4. The reliability of the final implementation of the

145
classifier as a two-stage adaptive system was compromised because of hardware instability due

to limited computational power.

More research needs to be done in evaluating the optimality of the implantation site for the

intramuscular EMG electrode found from non-invasive surface EMG recordings from the muscle

belly. The location of the implantation site is critical in order to record good iEMG from a

partially paralyzed muscle. Additional sensors should also be explored in conjunction to two

channels of iEMG to reduce false positives and negatives of the classifier.

References

6.1. R. Kobetic, R. J. Triolo, J. P. Uhlir, C. Bieri, M. Wibowo, G. Polando, E. B. Marsolais, J.


A. Davis Jr., K. A. Ferguson, and M. Sharma, “Implanted Functional Electrical Stimulation
System for Mobility in Paraplegia: A Follow-Up Case Report,” IEEE Trans. Rehabil. Eng.,
vol. 7, no. 4, Dec. 1999, pp. 390–398.

6.2. A. Dutta, R. Kobetic, and R. Triolo, “Ambulation after incomplete spinal cord injury with
EMG-triggered Functional Electrical Stimulation,” IEEE Transactions on Biomedical
Engineering, 55:2, February 2008.

6.3. B. Smith, Z. Tang, M.W. Johnson, S. Pourmehdi, M.M. Gazdik, J.R. Buckett, and P.H.
Peckham , “An externally powered, multichannel, implantable stimulator-telemeter for
control of paralyzed muscle,” IEEE Trans Biomed Eng., vol. 45, no. 4, 1998, pp. 463-475.

6.4. N. Bhadra, K.L. Kilgore, and P.H. Peckham, “Implanted stimulators for restoration of
function in spinal cord injury,” Med. Eng. Phys., vol. 23, 2001, pp. 19-28.

6.5. I. P. Pappas, M. R. Popovic, T. Keller, V. Dietz, and M. Morari, “A reliable gait phase
detection system,” IEEE Trans. Neural Syst. Rehabil. Eng., vol. 9, no. 2, Jun. 2001, pp.
113-125.

6.6. A. Mansfield, and G. M. Lyons, “The use of accelerometry to detect heel contact events for
use as a sensor in FES assisted walking,” Med. Eng. Phys., vol. 25, no. 10, Dec. 2003, pp.
879-885.

6.7. T. Sinkjaer, M. Haugland, A. Inman, M. Hansen, and K. D. Nielsen, “Biopotentials as


command and feedback signals in functional electrical stimulation systems,” Med. Eng.
Phys., vol 25, no. 1, Jan. 2003, pp. 29-40.

6.8. R. T. Lauer, R. T. Smith, and R. R. Betz, “Application of a neuro-fuzzy network for gait
event detection using electromyography in the child with cerebral palsy,” IEEE Trans.
Rehabil. Eng., vol. 52, no. 9, Sep. 2005, pp. 1532–1540.

146
6.9. D. Graupe, K. H. Kohn, S. Basseas, and E. Naccarato, “Patient controlled electrical
stimulation via EMG signature discrimination for providing certain paraplegics with
primitive walking functions,” J. Biomed. Eng., vol. 5, 1983, pp. 220-226.

6.10. R. J. Triolo, and G. D. Moskowitz, “The theoretical development of a multichannel time-


series myoprocessor for simultaneous limb function detection and muscle force
estimation,” IEEE Trans. Biomed Eng., vol. 36, no. 10, Oct. 1989, pp. 1004-1017.

6.11. D. Graupe, “EMG pattern analysis for patient-responsive control of FES in paraplegics for
walker-supported walking,” IEEE Trans. Biomed. Eng., vol. 36, no. 7, July 1989, pp. 711-
719.

6.12. D. Graupe, and H. Kordylewski, “Artificial neural network control of FES in paraplegics
for patient responsive ambulation,” IEEE Trans. Biomed Eng., vol. 42, no. 7, Jul. 1995, pp.
699-707.

6.13. H. Kordylewski, and D. Graupe, “Control of Neuromuscular Stimulation for Ambulation


by Complete Paraplegics via Artificial Neural Networks,” Neurol. Research, vol. 23, July
2001, pp.472-481.

6.14. A. Dutta, R. Kobetic, and R. J. Triolo, “EMG based triggering and modulation of
stimulation patterns for FES assisted ambulation – a conceptual study,” presented at XXth
Congress of the International Society of Biomechanics, Cleveland, OH, Aug. 2005.

6.15. A. Dutta, and R. J. Triolo, “Volitional surface EMG based control of FES-assisted gait after
incomplete spinal cord injury – a single case feasibility study,” presented at NIH Neural
Interfaces Workshop, Bethesda, MD, Sep. 2005.

6.16. R. Thorsen, R. Spadone, and M. Ferrarin, “A pilot study of myoelectrically controlled FES
of upper extremity,” IEEE Trans. Rehabil. Eng., vol. 9, no. 2, June 2001, pp. 161–167.

6.17. R.Futami, K.Seki, T.Kawanishi, T.Sugiyama, I.Cikajlo, and Y.Handa, “Application of local
EMG-driven FES to incompletely paralyzed lower extremities,” presented at 10th Annual
Conference of the International FES Society, Montreal, Canada, July 2005.

6.18. P. N. Taylor, and P. H. Chappell, “Variation in system gain when using voluntary EMG to
control electrical stimulation of the same muscle,” presented at 9th Annual Conference of
the International FES Society, Bournemouth, U.K., 2004.

6.19. R. Kobetic, R. J. Triolo, G. Pinnault, L. Murray, M. Corado-Ahmed, E. Hardin, J. Sakai, S.


Nogan, M. Marsolais, and C. Ho, “Facilitating Ambulation after Incomplete Spinal Cord
Injury with Implanted FES System,” presented at 10th Annual Conference of the
International FES Society, Montreal, Canada, July 2005.

6.20. R. Kobetic, and E.B. Marsolais, “Synthesis of paraplegic gait with multichannel functional
neuromuscular stimulation,” IEEE Trans Rehab Eng., vol. 2, no. 2, 1994, pp. 66-79.

147
6.21. R. Kobetic, R. J. Triolo, and E. B. Marsolais, “Muscle selection and walking performance
of multichannel FES systems for ambulation in paraplegia,” IEEE Trans. Rehabil. Eng.,
vol. 5, no. 1, Mar. 1997, pp. 23–29.

6.22. H. J. Hermens, B. Freriks, R. Merletti, D. Stegeman, J. Blok, G. Rau, C. Disselhorst-Klug,


and G. Hagg, SENIAM 8 European Recommendations for Surface ElectroMyoGraphy.
Enschede, Netherlands: Roessingh Research and Development, 1999.

6.23. A. E. Hines, P. E. Crago, G. J. Chapman, and C. Billian, “Stimulus artifact removal in


EMG from muscles adjacent to stimulated muscles,” J. Neurosci. Methods, vol. 64, no. 1,
Jan. 1996, pp. 55-62.

6.24. T. D. Dickens, Elementary Signal Detection Theory. US: Oxford University Press, 2001,
pp. 66, 121.

6.25. A. P. Bradley, "The use of the area under the ROC curve in the evaluation of machine
learning algorithms," Pattern Recognition, vol. 30, no. 7, 1997, pp. 1145-1159.

6.26. I. T. Jolliffe, Principal Component Analysis, New York: Springer, 1986, pp. 44-48, 269-
296.

6.27. D. A. Winter, Biomechanics and Motor Control of Human Gait: Normal, Elderly and
Pathological. Waterloo Biomechanics, 1991, ch.1.

6.28. E. Hardin, R. Kobetic, L. Murray, M. Corado-Ahmed, G. Pinnault, J. Sakai, S. Nogan, C.


Ho, and R. Triolo, “Ambulation after incomplete spinal cord injury with an implanted FES
system: a case report,” Jour. Rehabil. Res. Dev., vol. 44, no. 3, 2007, pp. 333-346.

6.29. E. Steinfeld, G. Danford, Eds. Enabling Environments: Measuring the Impact of


Environment on Disability and Rehabilitation. Kluwer/Plenum, 1999.

6.30. J. M. Jasiewicz, J. H. J. Allum, J. W. Middleton, A. Barriskill, P. Condie, B. Purcell, and R.


C. T. Li, “Gait event detection using linear accelerometers or angular velocity transducers
in able-bodied and spinal-cord injured individuals.” Gait and Posture, vol 24, no. 4, 2006,
pp. 502-509.

6.31. http://www.pc104.org/pc104_specs.php

148
Figures

Figure 6.1: Experimental setup for data collection during FES-assisted walking with the block-
diagram for the FES-system (ECU: external control unit, LE: linear envelope).

149
a

Figure 6.2: Processing of the sampled surface EMG a) rectified and reconstructed sEMG signal
b) linear envelope found from processed sEMG signal.

150
Figure 6.3: Experimental protocol for the collection of EMG data during over-ground walking in
the laboratory.

151
T9 level

L2 level

crease line

Figure 6.4: Multi-electrode matrix for simultaneous collection of the surface EMG from multiple
locations on the muscle belly.

152
a b

c c d

Figure 6.5: The steps during the implantation of intramuscular EMG electrode a) insertion of
probe, b) deployment of peelable sheath over probe, c) insertion of the iEMG
electrode through the peelable sheath, d) peeling off of the polymer sheath leaving the
iEMG electrode in place.

153
Figure 6.6: Pulse-width map of the stimulation patterns used for walking shown as an example.

154
Figure 6.7: The real-time cycle in IST with 50 ms time period for stimulation frequency of 20
Hz.

155
Figure 6.8: Parameters for the iEMG classifier computed from the training data that was
collected with the switch-triggered FES system.

156
Figure 6.9: The flow chart of the iEMG-based two-stage classifier for triggering FES for
walking.

157
Figure 6.10: Usability Rating Scale to find the user perspective on ease/difficulty of using the
classifier [6.29].

158
a

Figure 6.11: Best location found from the surface EMG for implanting intramuscular EMG
electrodes a) Left gastrocnemius and right erector spinae b) Left and right
gastrocnemius.

159
a) Left MG

b) Right ES

Figure 6.12: a) Discriminability Index (DI) of left medial gastrocnemius (MG) for the swing
phase (SW) and double support phase (DS) during over-ground walking for the
subject iSCI-1 at each data point of the gait cycle b) Discriminability Index (DI) of
right erector spinae (ES) for the swing phase (SW) and double support phase (DS)
during over-ground walking for the subject iSCI-1 at each data point of the gait cycle.
[shaded portion is the classification region]

160
Figure 6.13: Inhibition of iEMG from right erector spinae during right swing phase (SW) as
shown in the top panel due to electrical stimulation of the same muscle when
compared to that in absence of electrical stimulation shown in the bottom panel of the
subject iSCI-1.

161
a) Right MG

b) Left MG

Figure 6.14b: a) Discriminability Index (DI) of right medial gastrocnemius (MG) for the swing
phase (SW) and double support phase (DS) during over-ground walking for the
subject iSCI-2 at each data point of the gait cycle b) Discriminability Index (DI) of
left medial gastrocnemius (MG) for the swing phase (SW) and double support phase
(DS) during over-ground walking for the subject iSCI-2 at each data point of the gait
cycle. [shaded portion is the classification region]

162
Tables

False False False False


Trial # Left # Right Negative Negative Positive Positive
Remarks
# steps steps (FN) (FN) (FP) (FP)
Right Side Left Side Right Side Left Side
1 5 5 1 0 2 0
2 6 5 0 0 3 3 couldn't stop with EMG-trigger
3 5 4 2 2 2 2
4 5 5 0 0 3 3 couldn't stop with EMG-trigger
5 4 5 3 0 1 0
6 5 5 5 0 3 3 couldn't stop with EMG-trigger
7 5 5 1 0 0 1
8 4 5 3 3 1 1
Total 39 39 15 5 15 13
Mean 1.875 0.625 1.875 1.625
SD 1.73 1.19 1.13 1.3

FP & FN
0.384 0.128 0.384 0.333
rates

Table 6.1: The performance of the threshold-based classifier for iSCI-2.

False False False False


Trial # Left # Right Negative Negative Positive Positive
Remarks
# steps steps (FN) (FN) (FP) (FP)
Right Side Left Side Right Side Left Side
1 5 4 1 0 0 1
2 6 5 3 0 0 1
3 5 5 1 0 0 1
4 5 5 0 3 0 1
5 5 4 3 0 0 0
6 5 6 6 0 0 1
7 5 4 1 0 3 3 couldn't stop with EMG-trigger
8 4 4 1 0 2 2
9 5 5 2 0 0 1
Total 45 42 18 3 5 11
Mean 2 0.33 0.56 1.22
SD 1.8 1 1.13 0.83
FP & FN
0.428 0.067 0.119 0.244
rates

Table 6.2: The performance of the pattern recognition classifier for iSCI-2.

163
Intel PIII 600MHz 97
Intel PII 400MHz 135
AMD K6-2 400MHz 159
Intel PI 166MHz 567
Intel PI 90MHz 1400
Intel 486DX 40MHz 3800

Table 6.3: The minimum achievable sample time in µs for the classifier algorithm in different
hardware that can serve as single board computer.

164

Das könnte Ihnen auch gefallen