Restoration of Proprioceptive and Cutaneous Sensation Using Regenerative Peripheral Nerve Interfaces in Humans with Upper Limb Amputations.

SUMMARY: Without meaningful and intuitive sensory feedback, even the most advanced prosthetic limbs remain insensate and impose an enormous cognitive burden during use. The regenerative peripheral nerve interface can serve as a novel bidirectional motor and sensory neuroprosthetic interface. In previous human studies, regenerative peripheral nerve interfaces demonstrated stable high-amplitude motor electromyography signals with excellent signal-to-noise ratio for prosthetic control. In addition, they can treat and prevent postamputation pain by mitigating neuroma formation. In this study, the authors investigated whether electrical stimulation applied to regenerative peripheral nerve interfaces could produce appreciable proprioceptive and/or tactile sensations in two participants with upper limb amputations. Stimulation of the interfaces resulted in both participants reporting proprioceptive sensations in the phantom hand. Specifically, stimulation of participant 1's median nerve regenerative peripheral nerve interface activated a flexion sensation in the thumb or index finger, whereas stimulation of the ulnar nerve interface evoked a flexion sensation of the ring or small finger. Likewise, stimulation of one of participant 2's ulnar nerve interfaces produced a sensation of flexion at the ring finger distal interphalangeal joint. In addition, stimulation of participant 2's other ulnar nerve interface and the median nerve interface resulted in perceived cutaneous sensations that corresponded to each nerve's respective dermatome. These results suggest that regenerative peripheral nerve interfaces have the potential to restore proprioceptive and cutaneous sensory feedback that could significantly improve prosthesis use and embodiment.

Simulating microgravity using a random positioning machine for inducing cellular responses to mechanotransduction in human osteoblasts.

The mechanotransduction pathways that mediate cellular responses to contact forces are better understood than those that mediate response to distance forces, especially the force of gravity. Removing or reducing gravity for significant periods of time involves either sending samples to space, inducing diamagnetic levitation with high magnetic fields, or continually reorienting samples for a period, all in a manner that supports cell culturing. Undesired secondary effects due to high magnetic fields or shear forces associated with fluid flow while reorienting must be considered in the design of ground-based devices. We have developed a lab-friendly and compact random positioning machine (RPM) that fits in a standard tissue culture incubator. Using a two-axis gimbal, it continually reorients samples in a manner that produces an equal likelihood that all possible orientations are visited. We contribute a new control algorithm by which the distribution of probabilities over all possible orientations is completely uniform. Rather than randomly varying gimbal axis speed and/or direction as in previous algorithms (which produces non-uniform probability distributions of orientation), we use inverse kinematics to follow a trajectory with a probability distribution of orientations that is uniform by construction. Over a time period of 6 h of operation using our RPM, the average gravity is within 0.001 23% of the gravity of Earth. Shear forces are minimized by limiting the angular speed of both gimbal motors to under 42 °/s. We demonstrate the utility of our RPM by investigating the effects of simulated microgravity on adherent human osteoblasts immediately after retrieving samples from our RPM. Cytoskeletal disruption and cell shape changes were observed relative to samples cultured in a 1 g environment. We also found that subjecting human osteoblasts in suspension to simulated microgravity resulted in less filamentous actin and lower cell stiffness.

Getting a Grip on the Impact of Incidental Feedback From Body-Powered and Myoelectric Prostheses.

Sensory feedback from body-powered and myoelectric prostheses are limited, but in different ways. Currently, there are no empirical studies on how incidental feedback differs between body-powered and myoelectric prostheses, or how these differences impact grasping. Thus, the purpose of this study was to quantify differences in grasping performance between body-powered and myoelectric prosthesis users when presented with different forms of feedback. Nine adults with upper limb loss and nine without (acting as controls) completed two tasks in a virtual environment. In the first task, participants used visual, vibration, or force feedback to assist in matching target grasp apertures. In the second task, participants used either visual or force feedback to identify the stiffness of a virtual object. Participants using either prosthesis type improved their accuracy and reduced their variability compared to the no feedback condition when provided with any form of feedback (p < 0.001). However, participants using body-powered prostheses were significantly more accurate and less variable at matching grasp apertures than those using myoelectric prostheses across all feedback conditions. When identifying stiffness, body-powered prosthesis users were more accurate using force feedback (64% compared to myoelectric users' 39%) while myoelectric users were more accurate using visual feedback (65% compared to body-powered users' 53%). This study supports previous findings that body-powered prosthesis users receive limited force and proprioceptive feedback, while myoelectric prosthesis users receive almost no force or proprioceptive feedback from their device. This work can inform future supplemental feedback that enhances rather than reproduces existing incidental feedback.

A regenerative peripheral nerve interface allows real-time control of an artificial hand in upper limb amputees.

Peripheral nerves provide a promising source of motor control signals for neuroprosthetic devices. Unfortunately, the clinical utility of current peripheral nerve interfaces is limited by signal amplitude and stability. Here, we showed that the regenerative peripheral nerve interface (RPNI) serves as a biologically stable bioamplifier of efferent motor action potentials with long-term stability in upper limb amputees. Ultrasound assessments of RPNIs revealed prominent contractions during phantom finger flexion, confirming functional reinnervation of the RPNIs in two patients. The RPNIs in two additional patients produced electromyography signals with large signal-to-noise ratios. Using these RPNI signals, subjects successfully controlled a hand prosthesis in real-time up to 300 days without control algorithm recalibration. RPNIs show potential in enhancing prosthesis control for people with upper limb loss.

Unilateral and Bilateral Virtual Springs: Contact Transitions Unmask Device Dynamics.

The study of haptic perception often makes use of haptic rendering to display the variety of impedances needed to run an experiment. Unacknowledged in many cases is the influence of the selected device hardware on what the user will feel, particularly in interactions featuring frequencies above the control bandwidth. While human motion is generally limited to 10 Hz, virtual environments with unilateral constraints are subject to excitation of a wider frequency spectrum through contact transitions. We employ the effective impedance decomposition to discuss the effects of parasitics outside the rendering bandwidth. We also introduce an analysis of the admittance and impedance controllers with respect to sensitivity to load cell noise. We explore these effects using a single degree-of-freedom device that can be configured for either a low or high mechanical advantage in a perceptual experiment, with experimental conditions designed through application of the effective impedance decomposition. We find that the excitation of high frequencies through contact transitions negatively impacts humans' ability to distinguish between stiffnesses.

Self-powered robots to reduce motor slacking during upper-extremity rehabilitation: a proof of concept study.

BACKGROUND: Robotic rehabilitation is a highly promising approach to recover lost functions after stroke or other neurological disorders. Unfortunately, robotic rehabilitation currently suffers from "motor slacking", a phenomenon in which the human motor system reduces muscle activation levels and movement excursions, ostensibly to minimize metabolic- and movement-related costs. Consequently, the patient remains passive and is not fully engaged during therapy. To overcome this limitation, we envision a new class of body-powered robots and hypothesize that motor slacking could be reduced if individuals must provide the power to move their impaired limbs via their own body (i.e., through the motion of a healthy limb). OBJECTIVE: To test whether a body-powered exoskeleton (i.e. robot) could reduce motor slacking during robotic training. METHODS: We developed a body-powered robot that mechanically coupled the motions of the user's elbow joints. We tested this passive robot in two groups of subjects (stroke and able-bodied) during four exercise conditions in which we controlled whether the robotic device was powered by the subject or by the experimenter, and whether the subject's driven arm was engaged or at rest. Motor slacking was quantified by computing the muscle activation changes of the elbow flexor and extensor muscles using surface electromyography. RESULTS: Subjects had higher levels of muscle activation in their driven arm during self-powered conditions compared to externally-powered conditions. Most notably, subjects unintentionally activated their driven arm even when explicitly told to relax when the device was self-powered. This behavior was persistent throughout the trial and did not wane after the initiation of the trial. CONCLUSIONS: Our findings provide novel evidence indicating that motor slacking can be reduced by self-powered robots; thus demonstrating promise for rehabilitation of impaired subjects using this new class of wearable system. The results also serve as a foundation to develop more sophisticated body-powered robots (e.g., with controllable transmissions) for rehabilitation purposes.

Toward Controllable Hydraulic Coupling of Joints in a Wearable Robot.

In this paper, we develop theoretical foundations for a new class of rehabilitation robot: body powered devices that route power between a user's joints. By harvesting power from a healthy joint to assist an impaired joint, novel bimanual and self-assist therapies are enabled. This approach complements existing robotic therapies aimed at promoting recovery of motor function after neurological injury. We employ hydraulic transmissions for routing power, or equivalently for coupling the motions of a user's joints. Fluid power routed through flexible tubing imposes constraints within a limb or between homologous joints across the body. Variable transmissions allow constraints to be steered on the fly, and simple valve switching realizes free space and locked motion. We examine two methods for realizing variable hydraulic transmissions: using valves to switch among redundant cylinders (digital hydraulics) or using an intervening electromechanical link. For both methods, we present a rigorous mathematical framework for describing and controlling the resulting constraints. Theoretical developments are supported by experiments using a prototype fluid-power exoskeleton.

Evaluating Approaches to Rendering Braille Text on a High-Density Pin Display.

Refreshable displays for tactile graphics are typically composed of pins that have smaller diameters and spacing than standard braille dots. We investigated configurations of high-density pins to form braille text on such displays using non-refreshable stimuli produced with a 3D printer. Normal dot braille (diameter 1.5 mm) was compared to high-density dot braille (diameter 0.75 mm) wherein each normal dot was rendered by high-density simulated pins alone or in a cluster of pins configured in a diamond, X, or square; and to "blobs" that could result from covering normal braille and high-density multi-pin configurations with a thin membrane. Twelve blind participants read MNREAD sentences displayed in these conditions. For high-density simulated pins, single pins were as quickly and easily read as normal braille, but diamond, X, and square multi-pin configurations were slower and/or harder to read than normal braille. We therefore conclude that as long as center-to-center dot spacing and dot placement is maintained, the dot diameter may be open to variability for rendering braille on a high density tactile display.

Adjacent regenerative peripheral nerve interfaces produce phase-antagonist signals during voluntary walking in rats.

BACKGROUND: Regenerative Peripheral Nerve Interfaces (RPNIs) are neurotized muscle grafts intended to produce electromyographic signals suitable for motorized prosthesis control. Two RPNIs producing independent agonist/antagonist signals are required for each control axis; however, it is unknown whether signals from adjacent RPNIs are independent. The purpose of this work was to determine signaling characteristics from two adjacent RPNIs, the first neurotized by a foot dorsi-flexor nerve and the second neurotized by a foot plantar-flexor nerve in a rodent model. METHODS: Two Control group rats had electrodes implanted onto the soleus (tibial nerve) and extensor digitorum longus (peroneal nerve) muscles in the left hind limb. Two Dual-RPNI group rats had two separate muscles grafted to the left thigh and each implanted with electrodes: the extensor digitorum longus was neurotized with a transected fascicle from the tibial nerve, and the tibialis anterior was implanted with a transected peroneal nerve. Four months post-surgery, rats walked on a treadmill, were videographed, and electromyographic signals were recorded. Amplitude and periodicity of all signals relative to gait period were quantified. To facilitate comparisons across groups, electromyographic signals were expressed as a percent of total stepping cycle activity for each stance and swing gait phase. Independence between peroneal and tibial nerve activations were assessed by statistical comparisons between groups during stance and swing. RESULTS: Electromyographic activity for Control and Dual-RPNI rats displayed alternating activation patterns coinciding with stance and swing. Significant signal amplitude differences between the peroneal and tibial nerves were found in both the Control and Dual-RPNI groups. Non-inferiority tests performed on Dual-RPNI group signal confidence intervals showed that activation was equivalent to the Control group in all but the peroneal RPNI construct during stance. The similar electromyographic activity obtained for Control and RPNI suggests the latter constructs activate independently during both stance and swing, and contain minimal crosstalk. CONCLUSIONS: In-vivo myoelectric RPNI activity encodes neural activation patterns associated with gait. Adjacent RPNIs neurotized with agonist/antagonist nerves display activity amplitudes similar to Control during voluntary walking. The distinct and expected activation patterns indicate the RPNI may provide independent signaling in humans, suitable for motorized prosthesis control.

An Empirical Evaluation of Force Feedback in Body-Powered Prostheses.

Myoelectric prostheses have many advantages over body-powered prostheses, yet the absence of sensory feedback in myoelectric devices is one reason body-powered devices are often preferred by amputees. While considerable progress has been made in the mechanical design and control of myoelectric prostheses, research on haptic feedback has not had a similar impact. In this study, we seek to develop a fundamental understanding of the utility of force feedback and vision in the functional operation of a body-powered upper-limb prosthesis. Using a custom body-powered prosthesis in which force feedback can be conditionally removed, we asked N=10 non-amputee participants to identify objects based on stiffness in four separate conditions with and without visual and/or force feedback. Results indicate that the combination of visual and force feedback allows for the best accuracy, followed by force feedback only, then visual feedback only. In addition, combining force feedback with visual feedback does not significantly affect identification timing compared to visual feedback alone. These findings suggest that consideration should be given to the development of force feedback displays for myoelectric prostheses that function like a Bowden cable, coupling the amputee's control input to the resulting feedback.

Non-Colocated Kinesthetic Display Limits Compliance Discrimination in the Absence of Terminal Force Cues.

An important goal of haptic display is to make available the action/reaction relationships that define interactions between the body and the physical world. While in physical world interactions reaction cues invariably impinge on the same part of the body involved in action (reaction and action are colocated), a haptic interface is quite capable of rendering feedback to a separate body part than that used for producing exploratory actions (non-colocated action and reaction). This most commonly occurs with the use of vibrotactile display, in which a cutaneous cue has been substituted for a kinesthetic cue (a kind of sensory substitution). In this paper, we investigate whether non-colocated force and displacement cues degrade the perception of compliance. Using a custom non-colocated kinesthetic display in which one hand controls displacement and the other senses force, we ask participants to discriminate between two virtual springs with matched terminal force and adjustable non-linearity. An additional condition includes one hand controlling displacement while the other senses force encoded in a vibrotactile cue. Results show that when the terminal force cue is unavailable, and even when sensory substitution is not involved, non-colocated kinesthetic displays degrade compliance discrimination relative to colocated kinesthetic displays. Compliance discrimination is also degraded with vibrotactile display of force. These findings suggest that non-colocated kinesthetic displays and, likewise, cutaneous sensory substitution displays should be avoided when discrimination of compliance is necessary for task success.

In vivo characterization of regenerative peripheral nerve interface function.

OBJECTIVE: Regenerative peripheral nerve interfaces (RPNIs) are neurotized free autologous muscle grafts equipped with electrodes to record myoelectric signals for prosthesis control. Viability of rat RPNI constructs have been demonstrated using evoked responses. In vivo RPNI characterization is the next critical step for assessment as a control modality for prosthetic devices. APPROACH: Two RPNIs were created in each of two rats by grafting portions of free muscle to the ends of divided peripheral nerves (peroneal in the left and tibial in the right hind limb) and placing bipolar electrodes on the graft surface. After four months, we examined in vivo electromyographic signal activity and compared these signals to muscular electromyographic signals recorded from autologous muscles in two rats serving as controls. An additional group of two rats in which the autologous muscles were denervated served to quantify cross-talk in the electrode recordings. Recordings were made while rats walked on a treadmill and a motion capture system tracked the hind limbs. Amplitude and periodicity of signals relative to gait were quantified, correlation between electromyographic and motion recording were assessed, and a decoder was trained to predict joint motion. MAIN RESULTS: Raw RPNI signals were active during walking, with amplitudes of 1 mVPP, and quiet during standing, with amplitudes less than 0.1 mVPP. RPNI signals were periodic and entrained with gait. A decoder predicted bilateral ankle motion with greater than 80% reliability. Control group signal activity agreed with literature. Denervated group signals remained quiescent throughout all evaluations. SIGNIFICANCE: In vivo myoelectric RPNI activity encodes neural activation patterns associated with gait. Signal contamination from muscles adjacent to the RPNI is minimal, as demonstrated by the low amplitude signals obtained from the Denervated group. The periodicity and entrainment to gait of RPNI recordings suggests the transduced signals were generated via central nervous system control.

A Novel Application of Eddy Current Braking for Functional Strength Training During Gait.

Functional strength training is becoming increasingly popular when rehabilitating individuals with neurological injury such as stroke or cerebral palsy. Typically, resistance during walking is provided using cable robots or weights that are secured to the distal shank of the subject. However, there exists no device that is wearable and capable of providing resistance across the joint, allowing over ground gait training. In this study, we created a lightweight and wearable device using eddy current braking to provide resistance to the knee. We then validated the device by having subjects wear it during a walking task through varying resistance levels. Electromyography and kinematics were collected to assess the biomechanical effects of the device on the wearer. We found that eddy current braking provided resistance levels suitable for functional strength training of leg muscles in a package that is both lightweight and wearable. Applying resistive forces at the knee joint during gait resulted in significant increases in muscle activation of many of the muscles tested. A brief period of training also resulted in significant aftereffects once the resistance was removed. These results support the feasibility of the device for functional strength training during gait. Future research is warranted to test the clinical potential of the device in an injured population.

An exploration of grip force regulation with a low-impedance myoelectric prosthesis featuring referred haptic feedback.

BACKGROUND: Haptic display technologies are well suited to relay proprioceptive, force, and contact cues from a prosthetic terminal device back to the residual limb and thereby reduce reliance on visual feedback. The ease with which an amputee interprets these haptic cues, however, likely depends on whether their dynamic signal behavior corresponds to expected behaviors-behaviors consonant with a natural limb coupled to the environment. A highly geared motor in a terminal device along with the associated high back-drive impedance influences dynamic interactions with the environment, creating effects not encountered with a natural limb. Here we explore grasp and lift performance with a backdrivable (low backdrive impedance) terminal device placed under proportional myoelectric position control that features referred haptic feedback. METHODS: We fabricated a back-drivable terminal device that could be used by amputees and non-amputees alike and drove aperture (or grip force, when a stiff object was in its grasp) in proportion to a myoelectric signal drawn from a single muscle site in the forearm. In randomly ordered trials, we assessed the performance of N=10 participants (7 non-amputee, 3 amputee) attempting to grasp and lift an object using the terminal device under three feedback conditions (no feedback, vibrotactile feedback, and joint torque feedback), and two object weights that were indiscernible by vision. RESULTS: Both non-amputee and amputee participants scaled their grip force according to the object weight. Our results showed only minor differences in grip force, grip/load force coordination, and slip as a function of sensory feedback condition, though the grip force at the point of lift-off for the heavier object was significantly greater for amputee participants in the presence of joint torque feedback. An examination of grip/load force phase plots revealed that our amputee participants used larger safety margins and demonstrated less coordination than our non-amputee participants. CONCLUSIONS: Our results suggest that a backdrivable terminal device may hold advantages over non-backdrivable devices by allowing grip/load force coordination consistent with behaviors observed in the natural limb. Likewise, the inconclusive effect of referred haptic feedback on grasp and lift performance suggests the need for additional testing that includes adequate training for participants.

Providing a sense of touch to prosthetic hands.

Each year, approximately 185,000 Americans suffer the devastating loss of a limb. The effects of upper limb amputations are profound because a person's hands are tools for everyday functioning, expressive communication, and other uniquely human attributes. Despite the advancements in prosthetic technology, current upper limb prostheses are still limited in terms of complex motor control and sensory feedback. Sensory feedback is critical to restoring full functionality to amputated patients because it would relieve the cognitive burden of relying solely on visual input to monitor motor commands and provide tremendous psychological benefits. This article reviews the latest innovations in sensory feedback and argues in favor of peripheral nerve interfaces. First, the authors examine the structure of the peripheral nerve and its importance in the development of a sensory interface. Second, the authors discuss advancements in targeted muscle reinnervation and direct neural stimulation by means of intraneural electrodes. The authors then explore the future of prosthetic sensory feedback using innovative technologies for neural signaling, specifically, the sensory regenerative peripheral nerve interface and optogenetics. These breakthroughs pave the way for the development of a prosthetic limb with the ability to feel.

Refreshing Refreshable Braille Displays.

The increased access to books afforded to blind people via e-publishing has given them long-sought independence for both recreational and educational reading. In most cases, blind readers access materials using speech output. For some content such as highly technical texts, music, and graphics, speech is not an appropriate access modality as it does not promote deep understanding. Therefore blind braille readers often prefer electronic braille displays. But, these are prohibitively expensive. The search is on, therefore, for a low-cost refreshable display that would go beyond current technologies and deliver graphical content as well as text. And many solutions have been proposed, some of which reduce costs by restricting the number of characters that can be displayed, even down to a single braille cell. In this paper, we demonstrate that restricting tactile cues during braille reading leads to poorer performance in a letter recognition task. In particular, we show that lack of sliding contact between the fingertip and the braille reading surface results in more errors and that the number of errors increases as a function of presentation speed. These findings suggest that single cell displays which do not incorporate sliding contact are likely to be less effective for braille reading.

Negotiated control between the manual and visual systems for visually guided hand reaching movements.

BACKGROUND: Control of reaching movements for manual work, vehicle operation, or interactions with manual interfaces requires concurrent gaze control for visual guidance of the hand. We hypothesize that reaching movements are based on negotiated strategies to resolve possible conflicting demands placed on body segments shared by the visual (gaze) and manual (hand) control systems. Further, we hypothesize that a multiplicity of possible spatial configurations (redundancy) in a movement system enables a resolution of conflicting demands that does not require sacrificing the goals of the two systems. METHODS: The simultaneous control of manual reach and gaze during seated reaching movements was simulated by solving an inverse kinematics model wherein joint trajectories were estimated from a set of recorded hand and head movements. A secondary objective function, termed negotiation function, was introduced to describe a means for the manual reach and gaze directing systems to balance independent goals against (possibly competing) demands for shared resources, namely the torso movement. For both systems, the trade-off may be resolved without sacrificing goal achievement by taking advantage of redundant degrees of freedom. Estimated joint trajectories were then compared to joint movement recordings from ten participants. Joint angles were predicted with and without the negotiation function in place, and model accuracy was determined using the root-mean-square errors (RMSEs) and differences between estimated and recorded joint angles. RESULTS: The prediction accuracy was generally improved when negotiation was included: the negotiated control reduced RMSE by 16% and 30% on average when compared to the systems with only manual or visual control, respectively. Furthermore, the RMSE in the negotiated control system tended to improve with torso movement amplitude. CONCLUSIONS: The proposed model describes how multiple systems cooperate to perform goal-directed human movements when those movements draw upon shared resources. Allocation of shared resources can be undertaken by a negotiation process that is aware of redundancies and the existence of multiple solutions within the individual systems.

The effect of haptic cues on motor and perceptual based implicit sequence learning.

We introduced haptic cues to the serial reaction time (SRT) sequence learning task alongside the standard visual cues to assess the relative contributions of visual and haptic stimuli to the formation of motor and perceptual memories. We used motorized keys to deliver brief pulse-like displacements to the resting fingers, expecting that the proximity and similarity of these cues to the subsequent response motor actions (finger-activated key-presses) would strengthen the motor memory trace in particular. We adopted the experimental protocol developed by Willingham (1999) to explore whether haptic cues contribute differently than visual cues to the balance of motor and perceptual learning. We found that sequence learning occurs with haptic stimuli as well as with visual stimuli and we found that irrespective of the stimuli (visual or haptic) the SRT task leads to a greater amount of motor learning than perceptual learning.

Reconstructing surface EMG from scalp EEG during myoelectric control of a closed looped prosthetic device.

In this study, seven able-bodied human subjects controlled a robotic gripper with surface electromyography (sEMG) activity from the biceps. While subjects controlled the gripper, they felt the forces measured by the robotic gripper through an exoskeleton fitted on their non-dominant left arm. Subjects were instructed to identify objects with the force feedback provided by the exoskeleton. While subjects operated the robotic gripper, scalp electroencephalography (EEG) and functional near infrared spectroscopy (fNIRS) were recorded. We developed neural decoders that used scalp EEG to reconstruct the sEMG used to control the robotic gripper. The neural decoders used a genetic algorithm embedded in a linear model with memory to reconstruct the sEMG from a plurality of EEG channels. The performance of the decoders, measured with Pearson correlation coefficients (median r-value = 0.59, maximum r-value = 0.91) was found to be comparable to previous studies that reconstructed sEMG linear envelopes from neural activity recorded with invasive techniques. These results show the feasibility of developing EEG-based neural interfaces that in turn could be used to control a robotic device.

The objective assessment of experts' and novices' suturing skills using an image analysis program.

PURPOSE: To objectively assess suturing performance using an image analysis program and to provide validity evidence for this assessment method by comparing experts' and novices' performance. METHOD: In 2009, the authors used an image analysis program to extract objective variables from digital images of suturing end products obtained during a previous study involving third-year medical students (novices) and surgical faculty and residents (experts). Variables included number of stitches, stitch length, total bite size, travel, stitch orientation, total bite-size-to-travel ratio, and symmetry across the incision ratio. The authors compared all variables between groups to detect significant differences and two variables (total bite-size-to-travel ratio and symmetry across the incision ratio) to ideal values. RESULTS: Five experts and 15 novices participated. Experts' and novices' performances differed significantly (P < .05) with large effect sizes attributable to experience (Cohen d > 0.8) for total bite size (P = .009, d = 1.5), travel (P = .045, d = 1.1), total bite-size-to-travel ratio (P < .0001, d = 2.6), stitch orientation (P = .014,d = 1.4), and symmetry across the incision ratio (P = .022, d = 1.3). CONCLUSIONS: The authors found that a simple computer algorithm can extract variables from digital images of a running suture and rapidly provide quantitative summative assessment feedback. The significant differences found between groups confirm that this system can discriminate between skill levels. This image analysis program represents a viable training tool for objectively assessing trainees' suturing, a foundational skill for many medical specialties.