Evaluating wearable multimodal sensor insoles for motion-pattern measurements in stroke rehabilitation - A pilot study.

The majority of stroke patients experience deficits in motoric functions, especially in gait and mobility. They need rehabilitation to regain walking independence, which is a major goal of rehabilitation after stroke. To document and assess the rehabilitation progress, instrumented motion analysis and clinical assessments are commonly used. In a clinical pilot study the applicability of an instrumented insole system in stroke rehabilitation is evaluated. Motion parameter of 35 stroke patients were gathered with the system while completing 90 s level walking and Timed Up & Go test at the beginning and end of four weeks inpatient rehabilitation. For level walking the motion parameter were gathered with the clinical reference system simultaneously. The mean stride time for level walking decreased from 1.20 s to 1.16 s (clinical system), or from 1.19 s to 1.12 s (insole system), respectively. Focusing on individual comparison of each patient's progress, 9 gait parameters are extracted for level walking, 6 sub-phases of Timed Up & Go test are detected and analyzed, as well as progress of Center of Pressure in the sub-phases is examined. Although the overall data show wide distribution, the system proofed to be applicable in clinical stroke rehabilitation routine. As the system is location-independent, and has the advantage of assessing additional parameters of the Timed Up & Go test, it is additionally suitable for integration in a tele-or home rehabilitation system.

A Framework for (Tele-) Monitoring of the Rehabilitation Progress in Stroke Patients: eHealth 2015 Special Issue.

BACKGROUND: Preservation of mobility in conjunction with an independent life style is one of the major goals of rehabilitation after stroke. OBJECTIVES: The Rehab@Home framework shall support the continuation of rehabilitation at home. METHODS: The framework consists of instrumented insoles, connected wirelessly to a 3G ready tablet PC, a server, and a web-interface for medical experts. The rehabilitation progress is estimated via automated analysis of movement data from standardized assessment tests which are designed according to the needs of stroke patients and executed via the tablet PC application. RESULTS: The Rehab@Home framework's implementation is finished and ready for the field trial (at five patients' homes). Initial testing of the automated evaluation of the standardized mobility tests shows reproducible results. CONCLUSIONS: Therefore it is assumed that the Rehab@Home framework is applicable as monitoring tool for the gait rehabilitation progress in stroke patients.

Vibration stimulation during non-fatiguing tonic contraction induces outlasting neuroplastic effects.

The objective was to explore if vibration superposed to tonic contraction induces plastic changes in the contra- and ipsilateral motor cortex. Healthy subjects (n=12) abducted the right index finger with a force 5% of maximal voluntary contraction (MVC) against the lever of a torque motor while a 60 Hz vibration stimulus of 10 min was delivered. Motor evoked potentials (MEPs) after single and paired-pulse transcranial magnetic stimulation (TMS) were recorded from the first dorsal interosseous muscle of right and left hand pre, during, post and 30 min post-stimulation. The TMS assessments were employed with tonic contraction alone (TONIC) and with superposed vibrostimulation (VIBRO), each for the ipsi- and contralateral cortex separately. In the contralateral cortex: resting motor threshold (rMT) decreased, MEP amplitudes increased, short-interval intracortical inhibition (SICI) reduced and intracortical facilitation (ICF) increased post VIBRO, while no changes occurred post TONIC. In the ipsilateral cortex: rMT decreased, MEP amplitude increased and SICI reduced during TONIC, while no changes occurred post TONIC, during and post VIBRO. Vibration superposed to tonic contraction, induces lasting (30 min) plastic changes, whereas contraction alone caused no outlasting effects. Mainly intrinsic intracortical mechanisms are involved because spinal adaptation could be excluded (F-wave assessments). These findings have a therapeutic potential in the functional recovery of motor deficits with robot-aided devices.

Influence of contact forces on wrist photoplethysmography--prestudy for a wearable patient monitor.

The practical setting shows that gentle manual pressure on a photosensor suffices to improve the detectability of arterial pulses, but changes in the pressure applied may also produce signal artefacts. To study these effects, stepwise increasing contact forces (0.5 to 4 N) were applied to a photosensor placed over the radial artery. Additionally, the influence of optical coupling between sensor and skin surface was examined by introducing an elastic distance ring. The AC and DC components from the recorded photoplethysmogram were analysed. The AC component (absorption due to arterial pulsation) increased with the pressure applied; at lower forces (0.5 to 3 N) an introduction of the ring enhanced this effect. The characteristic of the DC component (backscattering from non-pulsating tissues) depends on optical coupling: without the ring the DC component increased stepwise with force (slope 0.035 V/N), but with the ring in place this component decreased (slope -0.075 V/N). Since the sensitivity of the pulse signal to artifacts is related to the slope of the DC component, such artefacts can be minimized by making the slope small. The utilization of these results to improve pulse detection and reduce motion artefacts in a wearable wrist device is discussed.

Surface myomechanical responses recorded on a scanner galvanometer.

A moving magnet galvanometer equipped with lever and indentor was evaluated for mechanomyography (MMG). First, the precision of the galvanometer was tested on a piezo-electric disc actuator. Using a 50 mm lever, synthesised micromotions with an amplitude of 1 microm could be detected (noise level < 0.2 microm) at static indentation forces ranging from 0.1 to 2 N. Then the galvanometer was mounted on an isometric ankle dynamometer to sense calf-muscle responses (N = 6). In the first protocol, twitch contractions were elicited by electrical stimulation while the indentation force was increased. Twitch amplitudes, twitch contraction times and twitch half-relaxation times were analysed from the surface and contraction responses. With indentation force (0.1-0.5 N), the amplitude of the surface responses increased (+61%), contraction and half-relaxation times, however, were not influenced. The mean twitch contraction time from the surface responses (60 +/- 11 ms) was shorter than that from the contraction responses (115 +/- 7 ms), indicating more fast-contracting fibres under the indented area. In the second protocol, voluntary target contractions were produced, and the surface responses were simultaneously recorded on an accelerometer. After double differentiation of the galvanometer signal, both acceleration MMGs showed a high coincidence in the time and frequency domains. With an indentation force of 2 N applied on the accelerometer, the signal amplitude (-10%) and the mean frequency (-19%) decreased. A specific application of this galvanometer-dynamometer test system is the assessment of regeneration processes in paraplegics with long-term denervated muscles.

Polygraphic belt with force-sensing expander for physiological tests on cosmonauts.

To study cardiorespiratory and neuromotor functions in cosmonauts a novel belt with embedded polygraphic sensors and a force sensing expander were developed. The sensors are: a three-electrode ECG/impedance plethysmographic system to capture cardiac and respiratory activity, two triaxial accelerometers to record limb micromotions and an IR reflex-sensor to detect peripheral pulse waves. The expander consists of an elastic cable in series with a load cell to measure the extension force and to adjust the extensions by visual feedback. The cable stiffness was chosen rather high (150-200 N/m) in order to induce involuntary limb oscillations at higher extension levels. The equipment was tested in MIR spaceflights and is projected for physiological tests on the ISS.

Pruritometer 2: portable recording system for the quantification of scratching as objective criterion for the pruritus.

Studies to evaluate therapies for itching (pruritus) related diseases often require the quantification of the itch sensation. Like all subjective symptoms the evaluation of itching is difficult and can only be done indirectly. With the Pruritometer 2 a measuring system is introduced that evaluates itching by detecting scratching movements. Based on the Pruritometer 1, that processes the signals of a piezoelectric vibration sensor, fixed on the midfinger of the patients dominant hand, and triggers a simple counter, the Pruritometer 2 allows to store the scratch activity during a 24 hours period. For each adjustable time slice of this time period, the amount of scratches and the scratch intensity are recorded. All data can be transferred to a PC via infrared link for further processing with a standard software package. An additional PC-software allows to set various parameters for optimal scratch detection and to test the patient attached system, also via the infrared link. All electronic components are shockproof encapsulated in a milled housing and are attached to a textile watchstrap that is worn by the patient like a wristwatch.

Basic design and construction of the Vienna FES implants: existing solutions and prospects for new generations of implants.

We can distinguish 3 generations of FES implants for activation of neural structures: 1. RF-powered implants with antenna displacement dependent stimulation amplitude; 2. RF-powered implants with stabilised stimulation amplitude; and 3. battery powered implants. In Vienna an 8-channel version of the second generation type has been applied clinically to mobilisation of paraplegics and phrenic pacing. A 20-channel implant of the second generation type for mobilisation of paraplegics and an 8-channel implant of the third generation type for cardiac assist have been tested in animal studies. A device of completely new design for direct stimulation of denervated muscles is being tested in animal studies. There is a limited choice of technologically suitable biocompatible and bioresistant materials for implants. The physical design has to be anatomically shaped without corners or edges. Electrical conductors carrying direct current (D.C.) have to be placed inside a hermetic metal case. The established sealing materials, silicone rubber and epoxy resin, do not provide hermeticity and should only embed DC-free components. For electrical connections outside the hermetic metal case welding is preferable to soldering; conductive adhesives should be avoided. It is advisable to use a hydrophobic oxide ceramic core for telemetry antenna coils embedded in sealing polymer. Cleaning of all components before sealing in resin is of the utmost importance as well as avoidance of rapid temperature changes during the curing process.

[EMG monitoring in functional electrostimulation]. / EMG-Monitoring bei funktioneller Elektrostimulation.

When using functional electrical stimulation (FES), correct adjustment of stimulation parameters, and monitoring of the stimulated muscle is mandatory if tissue damage is to be avoided. Although several FES systems are already in regular use, a method for direct muscle monitoring is still lacking. This paper investigates the suitability of the electromyogram (EMG) for such a purpose. In six sheep, the right latissimus dorsi muscle (LDM) and the associated thoracodorsal nerve were exposed. Stimulation was effected via electrodes placed on the nerve. Three electrodes were placed in the LDM for EMG recording, and the tendon was connected to a force transducer for isometric force measurement. Stimulation was applied for one second (burst), followed by a three-second pause. The stimulation current was increased in 0.2 mA steps, starting at 0 mA and ending at 4 mA. Throughout the investigation, the EMG signal was monitored with an oscilloscope. In addition, the EMG signal and the force transducer signal were recorded for subsequent analysis. An analysis of the data of all six sheep revealed an almost linear relationship between muscle force and m-wave amplitude (magnitude of r = 0.95, p < 0.001). M-wave monitoring during EMG recording with three intramuscular electrodes is a reliable method of monitoring FES-induced muscle activity, but the absolute force cannot be measured.

Long-term electromyogram recording from the posterior cricoarytenoid muscle as a potential biological trigger for phrenic pacing: results of an animal study.

Diaphragm pacing has been used to restore respiration in approximately 1,000 patients worldwide suffering from high quadriplegia or from central alveolar hypoventilation syndrome. Compared with conventional mechanical ventilation, electrophrenic respiration (EPR) reduces the risk of pulmonary infections and increases the mobility of patients. Voluntary activation of the pacemaker during speech would improve patients' quality of life and allow application of EPR in a more physiological way. An animal study was performed to investigate the electromyogram (EMG) of the posterior cricoarytenoid (PCA) muscle and the movement of the glottis via impedance measurement (electroglottography) with the aim to examine reproducibility and stability of the recordings from the PCA muscle as a potential biological trigger for a phrenic pacemaker. The EMG of the PCA muscle was recorded via implanted electrodes for a 200 day period. The EMG signal proved stable for that period, artifacts caused by movements can be suppressed, and swallowing can be detected. In contrast, impedance measurement to detect movement of the glottis proved not useful. Based on the results of this study, the use of the PCA EMG as a biological trigger for a phrenic pacemaker has to be considered a realistic option.

Battery-powered implantable nerve stimulator for chronic activation of two skeletal muscles using multichannel techniques.

Chronic activation of skeletal muscle is used clinically in representative numbers for diaphragm pacing to restore breathing and for dynamic graciloplasty to achieve fecal continence. The 3 different stimulation techniques currently used for electrophrenic respiration (EPR) all apply high frequency powered implants. It was our goal to make these stimulation methods applicable for EPR by a battery-powered nerve stimulator that would maximize the patient's freedom of movement. Additionally, the system should allow the implementation of multichannel techniques and alternating stimulation of 2 skeletal muscles as a further improvement in graciloplasty. Generally, the developed implantable nerve stimulator can be used for simultaneous and alternating activation of 2 skeletal muscles. Stimulation of the motor nerve is achieved by either single channel or multichannel methods. Carousel stimulation and sequential stimulation can be used for graciloplasty as well as for EPR. For EPR we calculated an operating time of the implant battery of 4.1 years based on the clinically used stimulation parameters with carousel stimulation. The multichannel pulse generator is hermetically sealed in a titanium case sized 65 x 17 mm (diameter x height) and weighs 88 g.

MYOSTIM-FES to prevent muscle atrophy in microgravity and bed rest: preliminary report.

Long-term flights in microgravity cause atrophy and morphological changes of skeletal muscles. Training with mechanical devices is insufficient regarding the required time to exercise and space for devices. The objective of this project is to develop a passive training method based on functional electrostimulation (FES) to preserve muscle mass and fiber composition with minimal impairment to the cosmonaut. For a pilot experiment on the MIR space station, a suitable 8 channel FES device was developed. It consists of electrode trousers that carry surface electrodes and cables, 2 interconnected 4 channel stimulators, and a laptop personal computer (PC) for stimulator programming and processing compliance data. An automatic extensive training of 4 muscle groups of the lower extremities is performed for 6 h/day, with 1 s on and 2 s off tetanic contractions at 20-30% of maximum tetanic muscle force. The synchronous activation of antagonists of the thigh and lower leg prevents uncoordinated movements.

Dynamic force responses in electrically stimulated triceps surae muscles: effects of fatigue and temperature.

To elicit dynamic force responses (unfused tetani) in isometric triceps surae muscles, low frequency electrical stimulation ranging from 12.5 to 30.0 Hz was applied. The fusing frequency (FF) and the relative dynamic force amplitude (DF) at the 20% and 40% maximum voluntary contraction (MVC) levels were calculated as parameters to determine effects of muscle fatigue (n = 6) and local muscle cooling. In the fatigued muscle (15 min plantar flexion at a 20% MVC level), the FF and DF increased when the fatigue was induced by voluntary contraction (FF increased from 19.6 to 22.5 Hz at 20% MVC) and also when induced by electrical stimulation (FF increased from 19.2 to 23.3 Hz). Cooling of the muscles showed an inverse effect on both parameters, indicating contractile slowing. The responsible physiological mechanisms as well as practical applications, using low frequency stimulation to monitor degenerative changes in muscles, are discussed.

Systematic distortions in magnetic position digitizers.

Medical devices equipped with position sensors enable applications like image guided surgical interventions, reconstruction of three-dimensional 3D ultrasound (US) images, and virtual or augmented reality systems. The acquisition of three-dimensional position data in real time is one of the key technologies in this field. The systematic distortions induced by various metals, surgical tools, and US scan probes in different commercial electromagnetic tracking systems were assessed in the presented work. A precise nonmetallic six degree-of-freedom measurement rack was built that allowed a quantitative comparison of different electromagnetic trackers. Also, their performance in the presence of large metallic structures was quantified in a phantom study on an acrylic skull model in an operating room (OR). The trackers used were alternating current (ac) and direct current (dc) based systems. The ac trackers were, on average, distorted by 0.7 mm and 0.5 degree by metallic objects positioned at a distance greater than 120 mm between the geometrical center of the sample and the sensor. In the OR environment, the ac system exhibits mean errors of 3.2 +/- 2.4 mm and 2.9 degrees +/- 1.9 degrees. The dc trackers are more sensitive to distortions caused by ferromagnetic materials (averaged value: 1.6 mm and 0.5 degree beyond a distance of 120 mm). The dc tracker shows no distortions from other conductive materials but was less accurate in the OR environment (typical error: 6.4 +/- 2.5 mm and 4.9 degrees +/- 2.0 degrees). At distances smaller than approximately 100 mm between sample and sensor error increases quickly. It is also apparent from our measurements that the influence of US scan probes is governed by their shielding material. The results show that surgical instruments not containing conductive material are to be preferred when using an ac tracker. Nonferromagnetic instruments should be used with dc trackers. Static distortions caused by the OR environment have to be compensated by precise calibration methods.

Useful applications and limits of battery powered implants in functional electrical stimulations.

Battery powered stimulation implants have been well-known for a long time as heart pacemakers. In the last few years, fully implantable stimulators have been used in the field of functional electrical stimulation (FES) for applications like dynamic cardiomyoplasty and electro-stimulated graciloplasty for fecal incontinence. The error rate of battery powered implants is significantly smaller than that for conventional stimulator systems, and the quality of life for the patients is increased because the need for an external power and control unit is eliminated. The use of battery powered implants is limited by the complexity of the stimulation control strategies and the battery capacity. Therefore, applications like the stimulation of lower extremities for walking, cochlea stimulation, or direct muscle stimulation cannot be supported. The improvement of implantable batteries, microcontrollers, and ultralow power products is ongoing. In the future, battery powered implants will also meet the requirements of complex applications. Systems for restoration of hand and breathing functions after spinal cord injury can be the next field of use for battery powered implants. For these purposes, we developed a battery powered multichannel implant with a sufficient life span for phrenic pacing. The problems during development and the limits of this system are described in this paper.

[Pruritometer 1: Portable measuring system for quantifying scratching as an objective measure of cholestatic pruritus]. / Pruritometer 1: Portables Messsystem zur Quantifizierung des Kratzens als objektives Mass für den cholestatischen Pruritus.

Objective assessment of subjective symptoms such as pruritus always presents problems, which can often be resolved only indirectly. The objectification of pruritus was necessitated by a study on the efficacy of a serotonin antagonist used as treatment of cholestatic pruritus. In the present paper, a portable measuring system for the indirect objective assessment of pruritus via the quantification of scratching is described. A piezoelectric scratch-vibration sensor for attachment to the middle finger of the patient's dominant hand was developed. A sensor interface detects the scratching signals and generates pulses that are then summed in an adapted sports watch. The entire system-Pruritometer 1- is worn by the patient like a wrist watch, and is characterized by ease of handling. Acceptance by the patient is reported to be good. A statistically good correlation between measured (Pruritometer) and visually counted scratches was demonstrated. Pruritometer 2, which will enable scratch frequency and intensity distribution over time to be determined, is presently being developed.

Body fixed ankle dynamometer for isometric tests in space flights.

To study neuromuscular variables in isometric contraction, a body-fixed ankle dynamometer with integrated electromyographic (EMG) system and software-controlled load tests was developed. It consists of a footplate acting against a load cell in plantar flexion. Counteraction is supported by a perpendicular telescopic stand which runs from the heel to the thigh with the knee flexed at an angle of 90 degrees C. Additional to contraction force, force tremor and surface EMG from the triceps surae and tibialis anterior muscles are recorded. The software consists of three load tests to assess variables of muscle fatigue, motor performance and motor memory. The dynamometer was optimised in relation to functionality and selection of construction materials for the use on the Russian MIR space station.

Instrumentation for assessment of tremor, skin vibrations, and cardiovascular variables in MIR space missions.

A versatile and simple to use biomedical instrumentation for noninvasive examinations of cosmonauts at the Russian MIR space station was developed. It consists of a comfortable sensor jacket to assess signals from the body surface, a precision hand dynamometer to produce muscular and cardiovascular loads, and a small interactive microprocessor unit that controls the examination and stores measurement data. The sensor jacket includes highly sensitive piezo-resistive accelerometers, pulse sensors, an ECG system, and a skin-mountable mechanical vibrator. The functionality of this instrumentation was evaluated during long-term space flights and also proved very useful in laboratory and clinical studies.

Physiological tremor and control of limb position in 1 and 0 G.

Muscle and skeletal mechanoreceptors play an important role for the regulation of muscular tone and the genesis of normal Physiological Tremor (PT). For example if a big limb as the arm or leg is kept against the gravity vector, the la afferent spindle discharges continuously control the load bearing flexor in a negative feedback manner in order to compensate the gravity vector and to the stabilize arm position. This servo-like action, denoted as 'stretch reflex', not only increases static postural stability (tonic stretch reflex) but also counteracts against external disturbances by dynamically increasing the muscle tone. Muscle spindles are very sophisticated sensory organs. They have an own innervation and the endings of the nuclear bag fibres are highly sensitive for small microstretches. EMG and microneurografic studies showed their importance in the mechanism of the 8-12 Hz component for PT. In a 0 G a limb becomes position controlled. In contrast to 1g, where control of limb position is a subordinated function of force compensation in the load bearing muscle, an antagonistic control scheme is necessary in 0 G to compensate the arm against positional drifts. As a consequence there is a shift from load dependent (muscular) to position dependent (skeletal) mechanoreceptors that become involved in the neural control process. As the control process is reflected in the tremor pattern, we investigated arm tremor in a constant limb position in 1 and 0 G.

[Noninvasive fetal pulse oximetry sub partu. Experiences with the Ohmeda Biox 3700 and the Baxter Asat 1000 Pulse Oximeter]. / Nichtinvasive fetale Pulsoximetrie sub partu. Erfahrungen mit dem Ohmeda-Biox-3700- und dem Baxter-Asat-100-Pulsoximeter.

In this study oxygen saturation was measured at the presenting part of the fetus during labour. We used two different reflectance sensors together with two different pulse oximeters. The Baxter Asat 100 displayed a 25% lower functional oxygen saturation of haemoglobin (SaO2) compared to the Ohmeda Biox 3700 pulse oximeter. The mean duration of application using the Ohmeda Biox 3700 together with an adapted finger sensor was 36 min (SD +/- 17 min), an effective measurement was achieved for 15 min (SD +/- 9 min). The mean duration of application using the Baxter Asat 100 together with a commercial Baxter reflex sensor was 88 min (SD +/- 96 min), an effective measurement was attained for 73 min (SD +/- 77 min).