The effect of FES-rowing training on cardiac structure and function: pilot studies in people with spinal cord injury.

STUDY DESIGN: Two studies were conducted: Study-1 was cross-sectional; and Study-2 a longitudinal repeated measures design. OBJECTIVES: To examine the influence of functional electrical stimulation (FES) rowing training on cardiac structure and function in people with spinal cord injury (SCI). SETTING: A university sports science department and home-based FES-training. METHODS: Fourteen participants with C4-T10 SCI (American Spinal Injury Association Impairment Scale A or B) were recruited for the studies. Cardiac structure and function, and peak: oxygen uptake ([Vdot ]O2peak), power output (POpeak) and heart rate (HRpeak), were compared between two FES-untrained groups (male n=3, female n=3) and an FES-trained group (male n=3) in Study-1 and longitudinally assessed in an FES-naive group (male n=1, female n=4) in Study-2. Main outcome measures left ventricular-dimensions, volumes, mass, diastolic and systolic function, and [Vdot ]O2peak, POpeak and HRpeak. In Study-2, in addition to peak values, the [Vdot ]O2 sustainable over 30 min and the related PO and HR were also assessed. RESULTS: Sedentary participants with chronic SCI had cardiac structure and function at the lower limits of non-SCI normal ranges. Individuals with chronic SCI who habitually FES-row have cardiac structure and function that more closely resemble non-SCI populations. A programme of FES-rowing training improved cardiac structure and function in previously FES-naive people. CONCLUSION: FES-rowing training appears to be an effective stimulus for positive cardiac remodelling in people with SCI. Further work, with greater participant numbers, should investigate the impact of FES-rowing training on cardiac health in SCI. SPONSORSHIP: We thank the INSPIRE Foundation, UK, for funding these studies.

Can FES-rowing mediate bone mineral density in SCI: a pilot study.

STUDY DESIGN: A single case study. OBJECTIVES: To compare proximal tibia trabecular bone mineral density (BMD) of a participant with complete spinal cord injury (SCI), long-termed functional electrical stimulation-rowing (FES-R) trained, with previously reported SCI and non-SCI group norms. To estimate lower limb joint contact forces (JCFs) in the FES-R trained participant. SETTING: UK University and orthopaedic hospital research centre. METHODS: Bilateral proximal tibial trabecular BMD of the FES-R trained participant was measured using peripheral quantitative computerised tomography, and the data were compared with SCI and non-SCI groups. An instrumented four-channel FES-R system was used to measure the lower limb JCFs in the FES-R trained participant. RESULTS: Structurally, proximal tibial trabecular BMD was higher in the FES-R trained participant compared with the SCI group, but was less than the non-SCI group. Furthermore, left (184.7 mg cm(-3)) and right (160.7 mg cm(-3)) BMD were well above the threshold associated with non-traumatic fracture. The knee JCFs were above the threshold known to mediate BMD in SCI, but below threshold at the hip and ankle. CONCLUSION: As pathological fractures predominate in the distal femur and proximal tibia in chronic SCI patients, the fact that the FES-R trained participant's knee JCFs were above those known to partially prevent bone loss, suggests that FES-R training may provide therapeutic benefit. Although the elevated bilateral proximal tibial BMD of the FES-R participant provides circumstantial evidence of osteogenesis, this single case precludes any statement on the clinical significance. Further investigations are required involving larger numbers and additional channels of FES to increase loading at the hip and ankle.

FES-rowing in tetraplegia: a preliminary report.

STUDY DESIGN: A training intervention study using functional electrical stimulation-rowing (FES-R) in a group of eight individuals with tetraplegia. OBJECTIVES: To assess the feasibility of a structured progressive FES-R training programme in people with tetraplegia, and to explore the number and type of FES-training sessions required to enable continuous FES-R for 30 min. SETTING: A fully integrated sports centre, elite rowing training centre and university sport science department. METHODS: Eight participants with chronic complete and incomplete tetraplegia (C4 to C7, American Spinal Injury Association Impairment Scale A, B and C) who had not previously used any form of FES-assisted exercise, participated in the study. Participants completed a progressive FES-assisted training programme building to three continuous 30-min FES-R sessions per week at 60-80% of their predetermined peak power output. Thereafter, rowing performance was monitored for 12 months. MAIN OUTCOME MEASURES: number and type of FES-training sessions required before achieving 30-min continuous FES-R, and FES-R average power output (POav) pre and post 12 months training. Participant feedback of perceived benefits was also documented. RESULTS: All participants were able to continuously FES-row for 30 min after completing 13±7 FES-R training sessions. Each individual POav during 30 min FES-R increased over 12 months FES-training. FES-R was found safe and well tolerated in this group of individuals with tetraplegia. CONCLUSION: Individuals with tetraplegia are able to engage in a progressive programme of FES-R training. Future research examining FES-R training as an adjunctive therapy in people with tetraplegia is warranted.

Activation of lower back muscles via FES for pressure sores prevention in paraplegia: a case study.

The aim of this paper is to show the feasibility of the use of functional electrical stimulation (FES) applied to the lower back muscles for pressure sores prevention in paraplegia. The hypothesis under study is that FES induces a change in the pressure distribution on the contact area during sitting. Tests were conducted on a paraplegic subject (T5), sitting on a standard wheelchair and cushion. Trunk extensors (mainly the erector spinae) were stimulated using surface electrodes placed on the skin. A pressure mapping system was used to measure the pressure on the sitting surface in four situations: (a) no stimulation; (b) stimulation on one side of the spine only; (c) stimulation on both sides, at different levels; and (d) stimulation at the same level on both sides, during pressure-relief manoeuvres. A session of prolonged stimulation was also conducted. The experimental results show that the stimulation of the erector spinae on one side of the spine can induce a trunk rotation on the sagittal plane, which causes a change in the pressure distribution. A decrease of pressure on the side opposite to the stimulation was recorded. The phenomenon is intensified when different levels of stimulation are applied to the two sides, and such change can be sustained for a considerable time (around 5 minutes). The stimulation did not induce changes during pressure-relief manoeuvres. Finally, from this research we can conclude that the stimulation of the trunk extensors can be a useful tool for pressure sores prevention, and can potentially be used in a routine for pressure sores prevention based on periodical weight shifts.

The emergence of retinopathy of prematurity in Guatemala.

Retinopathy of prematurity is an emerging cause of blindness in Latin America. In 2007, the authors examined 88 consecutive infants in Guatemala City, Guatemala, who met the screening criteria for retinopathy of prematurity; 14 (16%) had either "plus" or stage V disease. The incidence of retinopathy of prematurity in Guatemala City is likely high, and a formal screening program is warranted.

Switching curve control of functional electrical stimulation assisted rowing exercise in paraplegia.

An indoor rowing machine has been modified for functional electrical stimulation (FES) assisted rowing exercise in paraplegia. To perform the rowing manoeuvre successfully, however, the voluntarily controlled upper body movements must be co-ordinated with the movements of the electrically stimulated paralysed legs. To achieve such co-ordination, an automatic FES controller was developed that employs two levels of hierarchy. At the upper level, a finite state controller identifies the state or phase of the rowing cycle and activates the appropriate lower-level controller, in which electrical stimulation to the paralysed leg muscles is applied with reference to switching curves representing the desired seat velocity as a function of the seat position. In a pilot study, the hierarchical control of FES rowing was shown to be intuitive, reliable and easy to use. Compared with open-loop control of stimulation, all three variants of the closed-loop switching curve controllers used less muscle stimulation per rowing cycle (73% of the open-loop control on average). Further, the closed-loop controller that used switching curves derived from normal rowing kinematics used the lowest muscle stimulation (65% of the open-loop control) and was the most convenient to use for the client.

Detecting absolute human knee angle and angular velocity using accelerometers and rate gyroscopes.

Knee joint angle and angular velocity were calculated in real time during standing up and sitting down. Two small modules comprising rate gyroscopes and accelerometers were attached to the thigh and shank of two able-bodied volunteers and one T5 ASIA(A) paraplegic assisted by functional electrical stimulation (FES). The offset and drift of the rate gyroscopes was compensated for by auto-resetting and auto-nulling algorithms. The tilt of the limb segments was calculated by combining the signals of the accelerometer and the rate gyroscope. The joint angle was calculated as the difference in tilt of the segments. The modules were also tested on a two-dimensional model. The mean differences between the rate gyroscope-accelerometer system and the reference goniometer for the model, able-bodied and paraplegic standing trials were 2.1 degrees, 2.4 degrees and 2.3 degrees respectively for knee angle and 2.3 degrees s(-1), 5.0 degrees s(-1) and 11.8 degrees s(-1) respectively for knee velocity. The rate gyroscope-accelerometer system was more accurate than using the accelerometer as a tilt meter, possibly due to the greater bandwidth of the rate gyroscope-accelerometer system.

Sensor systems for lower limb functional electrical stimulation (FES) control.

Two sensor systems comprising clusters of accelerometers, magnetic sensors, a rate gyroscope, and a strain gauge were designed. For one system, the clusters were located at the belt and AFO. In the other system, the clusters were located at the AFO and the thigh. The maximum cluster size was 14 cm(3) and 75 g. The clusters of each sensor system were interconnected by a single flexible wire bus, which minimized the effects of cabling. The sensors detected five phases of normal gait to a resolution of 40 ms in an able bodied test. Using a threshold method, the sensor system repeatedly predicted an incipient knee buckle in a paraplegic individual by a minimum of 30 ms. One system detected knee flexion angle analytically to an accuracy of 3.2 degrees during sit to stand trials. The second system determined knee and hip flexion angle to an accuracy of 3.8 degrees during sit to stand trials through neural networks. The signal processing of the acquired sensor signals in each system was performed on a MC68332 microcomputer in conjunction with the data sampling, and suggested the possibility for each sensor system to be used in real time control of FES.

Gait event detection for FES using accelerometers and supervised machine learning.

Rule based detectors were used with a single cluster of accelerometers attached to the shank for the real time detection of the main phases of normal gait during walking. The gait phase detectors were synthesized from two rule induction algorithms, Rough Sets (RS) and Adaptive Logic Networks (ALNs), and compared with to a previously reported stance/swing detector based on a hand crafted, rule based algorithm. Data was sampled at 100 Hz and the detection errors determined at each sample for 50 steps. For three able bodied subjects, the sample by sample accuracy of stance/swing detection ranged within 94-97%, 87-94%, and 87-95% for the RS, ALN, and the handcrafted methods, respectively. A heuristically formulated postdetector filter improved the RS and ALN detectors' accuracy to 98%. RS and ALN also detected five gait phases to an overall accuracy of 82-89% and 86-91%, respectively. The postdetector filter localized the errors to the phase transitions, but did not change the detection accuracy. The average duration of the error at each transition was 40 ms and 23 ms for RS and ALN, respectively. When implemented on a microcontroller, the RS-based detector executed ten times faster and required one tenth of the memory than the ALN-based detector.

Functional electrical stimulation effect on orthostatic hypotension after spinal cord injury.

OBJECTIVE: To investigate the possibility of using functional electrical stimulation (FES) to control orthostatic hypotension in patients with spinal cord injury (SCI) and to clarify the mechanism of the response. DESIGN: Subjects were tilted by 10 degree increments with varying intensities of lower-extremity FES. Stimulation over muscles was compared to stimulation over noncontractile sites. SETTING: Physical therapy department of a major rehabilitation center. PATIENTS: Six patients with SCI above T6 (3 with recent injury recruited consecutively from an inpatient spinal cord rehabilitation unit, and 3 from the community with longstanding injury, recruited as volunteers). MAIN OUTCOME MEASURES: Blood pressure, heart rate, and perceived presyncope score recorded at each tilt angle and analyzed using a multivariate analysis of variance statistical methodology. RESULTS: Systolic and diastolic blood pressure increased with increasing stimulation intensities (systolic, p = .001; diastolic, p = .0019) and decreased with increasing angle of tilt (p < .001) regardless of the site of stimulation. Subjects tolerated higher angles of incline with electrical stimulation than without (p = .03). CONCLUSIONS: FES causes a dose-dependent increase in blood pressure independent of stimulation site that may be useful in treating orthostatic hypotension.

Regulation of transcription at the Saccharomyces cerevisiae start transition by Stb1, a Swi6-binding protein.

In Saccharomyces cerevisiae, gene expression in the late G(1) phase is activated by two transcription factors, SBF and MBF. SBF contains the Swi4 and Swi6 proteins and activates the transcription of G(1) cyclin genes, cell wall biosynthesis genes, and the HO gene. MBF is composed of Mbp1 and Swi6 and activates the transcription of genes required for DNA synthesis. Mbp1 and Swi4 are the DNA binding subunits for MBF and SBF, while the common subunit, Swi6, is presumed to play a regulatory role in both complexes. We show that Stb1, a protein first identified in a two-hybrid screen with the transcriptional repressor Sin3, binds Swi6 in vitro. The STB1 transcript was cell cycle periodic and peaked in late G(1) phase. In vivo accumulation of Stb1 phosphoforms was dependent on CLN1, CLN2, and CLN3, which encode G(1)-specific cyclins for the cyclin-dependent kinase Cdc28, and Stb1 was phosphorylated by Cln-Cdc28 kinases in vitro. Deletion of STB1 caused an exacerbated delay in G(1) progression and the onset of Start transcription in a cln3Delta strain. Our results suggest a role for STB1 in controlling the timing of Start transcription that is revealed in the absence of the G(1) regulator CLN3, and they implicate Stb1 as an in vivo target of G(1)-specific cyclin-dependent kinases.

Optimal control of FES-assisted standing up in paraplegia using genetic algorithms.

A practical system for Functional Electrical Stimulation (FES) assisted standing up in paraplegia should involve only a minimum of manual set up and tuning. An improved tuning method, using a genetic algorithm (GA) is proposed and demonstrated using computer simulation. Specifically, the GA adjusts the parameters of fuzzy logic (FL) and gain-scheduling proportional integral derivative (GS-PID) controllers that electrically stimulate the hip and knee musculature during the sit-stand maneuver. These new GA designed controllers were found to be effective in coordinating volitional and FES control according to formulated criteria. The latter was based on the deviations from a desired trajectory of the knee and hip joints and the magnitude of the voluntary upper body forces. The magnitude of the average arm forces were slightly higher when compared with the open-loop maximal stimulation of the hip and knee musculature; however, the terminal knee velocities were significantly reduced to less than 10 degrees /s. For practical implementation, the number of trials required to optimize the FL and GS-PID controllers can be reduced by a proposed pre-training procedure using a computer model scaled to the individual. The GA designed controllers remain near optimal provided the model-subject mismatch is small.

Computer simulation of FES standing up in paraplegia: a self-adaptive fuzzy controller with reinforcement learning.

Using computer simulation, the theoretical feasibility of functional electrical stimulation (FES) assisted standing up is demonstrated using a closed-loop self-adaptive fuzzy logic controller based on reinforcement machine learning (FLC-RL). The control goal was to minimize upper limb forces and the terminal velocity of the knee joint. The reinforcement learning (RL) technique was extended to multicontroller problems in continuous state and action spaces. The validated algorithms were used to synthesize FES controllers for the knee and hip joints in simulated paraplegic standing up. The FLC-RL controller was able to achieve the maneuver with only 22% of the upper limb force required to stand-up without FES and to simultaneously reduce the terminal velocity of the knee joint close to zero. The FLC-RL controller demonstrated, as expected, the closed loop fuzzy logic control and on-line self-adaptation capability of the RL was able to accommodate for simulated disturbances due to voluntary arm forces, FES induced muscle fatigue and anthropometric differences between individuals. A method of incorporating a priori heuristic rule based knowledge is described that could reduce the number of the learning trials required to establish a usable control strategy. We also discuss how such heuristics may also be incorporated into the initial FLC-RL controller to ensure safe operation from the onset.

Switching curve controller for FES-assisted standing up and sitting down.

A low-level, closed-loop controller for FES-assisted standing up and sitting down is described. If, for able-bodied individuals, when standing up and sitting down, the knee angular velocity is plotted against knee angle, consistent phase-plane trajectories are produced. The bang-bang controller uses a model of this trajectory as a switching curve. The design rationale for the controller was the desire to avoid injuries that might occur if knee-locking on standing up and seat-contact on sitting down are not adequately controlled. This switching curve controller (SCC) was incorporated within a hierarchical, finite state control scheme, with electrical stimulation applied bilaterally to the knee extensors. The SCC was tested in a pilot study on a female volunteer with paraplegia (T5/6 ASIA A) and evaluated against an unramped, open-loop controller (OLC). The vertical hand forces and knee angles were measured. The subject was able to achieve standing up and sitting down safely using both controllers. For standing up, the SCC was not found to offer any quantifiable advantages over the OLC and was found to increase the hand force by 8.4%. In contrast, for sitting down the SCC was found to reduce the knee angular velocities as the subject approached the seat by 27%, demonstrating a safer, softer landing.

A role for the Pcl9-Pho85 cyclin-cdk complex at the M/G1 boundary in Saccharomyces cerevisiae.

PHO85 is a cyclin-dependent kinase (CDK) with roles in phosphate and glycogen metabolism and cell cycle progression. As a CDK, Pho85 is activated by association with Pho85 cyclins (Pcls), of which 10 are known. PCL1, PCL2 and PCL9 are the only members of the Pho85 cyclin family that are expressed in a cell cycle-regulated pattern. We found that PCL9 is expressed in late M/early G1 phase of the cell cycle and is activated by the transcription factor, Swi5. This pattern of regulation is different from PCL1 and PCL2, which are expressed later in G1 phase and are regulated primarily by the transcription factor SBF. Co-immunoprecipitation experiments using in vitro translated proteins showed that Pcl9 and Pho85 form a complex. Furthermore, immunoprecipitated Pcl9 complexes from yeast lysates were capable of phosphorylating the exogenous substrate Pho4. The Pcl9-associated kinase activity was dependent on PHO85, showing that Pcl9 and Pho85 form a functionally active kinase complex in vivo. Deletion of PCL9 in diploid cells caused random, rather than bipolar, budding in 18% of cells. In contrast, deletion of PCL2, the closest relative of PCL9, had no effect on the budding pattern. Deleting more members of the PCL1,2 subfamily (which includes PCL9) increased the percentage of random budding in the cell population. When all members of the PCL1,2 subfamily were deleted, 73% of cells budded randomly, a value similar to that obtained when the CDK partner PHO85 was deleted. Our results show that PCL9 and PHO85 form a functional kinase complex and suggest a role for Pho85 CDKs at the M/G1 boundary.

Control of FES in paraplegia: modeling voluntary arm forces.

Skilled behavior is difficult or impossible to articulate explicitly by the performers. Likewise biomechanical models of skilled motor actions are often limited by the lack of knowledge of the underlying mechanisms. A 'behavioral cloning' technique is described, based on a trained artificial neural network (ANN), that precisely mimics an individual's learned skill. In this paper the motor skill considered is that of paraplegics using their upper limbs whilst standing-up with FES. In a group of eight paraplegics with complete spinal injuries, it was possible to develop clones that followed closely the observed behavior of the subjects. Each subject used a unique and consistent voluntary control strategy. Subjects with more experience in using FES were more consistent in the use of their arms from trial to trial. Comparison of the clones revealed features suggestive of some common underlying voluntary control strategies.

Application of tilt sensors in functional electrical stimulation.

Tilt sensors, or inclinometers have been investigated for the control of Functional Electrical Stimulation (FES) to improve the gait of persons who had a stroke or incomplete spinal cord injury (SCI). Different types of tilt sensors were studied for their characteristics and their performance in measuring the angular displacement of leg segments during gait. Signal patterns of the lower leg with inertial tilt sensors were identified with control subjects and subjects with footdrop who are being stimulated during level walking. To minimize acceleration responses when the foot swings or hits the ground, we use low-pass filtering (1.5-2 Hz). A finite state approach allows the sensor fixed on the shank to effectively detect the step intention in a population of stroke and incomplete SCI subjects and to control the FES. When the lower leg tilts backward, the common peroneal nerve is stimulated to bring the foot up and forward. We have designed a miniature footdrop stimulator with a magnetoresistive tilt sensor built in, so no external sensor cables are required. The thresholds to turn the stimulator on and off can be adjusted, as well as the maximum period of stimulation and the minimum interval between periods of stimulation. This device features several important advantages over traditional AFO's or stimulators controlled by foot switches. Initial trials with stroke and SCI subjects have demonstrated substantial gait improvement for some subjects, while most liked the good cosmesis and ease of using the device with a tilt sensor.

Binding to the yeast SwI4,6-dependent cell cycle box, CACGAAA, is cell cycle regulated in vivo.

In Saccharomyces cerevisiae commitment to cell division occurs late in the G1 phase of the cell cycle at a point called Start and requires the activity of the Cdc28 protein kinase and its associated G1 cyclins. The Swi4,6-dependent cell cycle box binding factor, SBF, is important for maximal expression of the G1 cyclin and HO endonuclease genes at Start. The cell cycle regulation of these genes is modulated through an upstream regulatory element termed the SCB (SwI4,6-dependent cell cycle box, CACGAAA), which is dependent on both SWI4 and SWI6. Although binding of SWI4 and SWI6 to SCB sequences has been well characterized in vitro, the binding of SBF in vivo has not been examined. We used in vivo dimethyl sulfate footprinting to examine the occupancy of SCB sequences throughout the cell cycle. We found that binding to SCB sequences occurred in the G1 phase of the cell cycle and was greatly reduced in G2. In the absence of either SWI4 or SWI6, SCB sequences were not occupied at any cell cycle stage. These results suggest that the G1-specific expression of SCB-dependent genes is regulated at the level of DNA binding in vivo.