Home Medicine A flexible standalone system with integrated sensor feedback for multi-pad electrode FES of the hand
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A flexible standalone system with integrated sensor feedback for multi-pad electrode FES of the hand

  • Jan C. Loitz EMAIL logo , Aljoscha Reinert , Ann-Kristin Neumann , Fanny Quandt , Dietmar Schroeder and Wolfgang H. Krautschneider
Published/Copyright: September 30, 2016
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Current Directions in Biomedical Engineering
From the journal Current Directions in Biomedical Engineering Volume 2 Issue 1

Abstract

Functional electrical stimulation aims to help patients suffering from stroke or spinal cord injury to supplement lost motor function. Effective functional electrical stimulation requires precise placement of the stimulation electrode. Finding the correct placement, however, can be difficult and time consuming. Another common problem with functional electrical stimulation is early occurrence of muscle fatigue upon repetitive stimulation, limiting treatment efficiency. Both, precise electrode placement as well as the reduction of muscle fatigue can be achieved using multi-pad electrodes. Here we present a new standalone device for multi-pad functional electrical stimulation. The device is easy to use and designed to help patients recovering from stroke to train and perform opening of the hand.

Keywords: electrode arrays; electrode placement; functional electrical stimulation; multi-pad electrodes; muscle fatigue; neuromuscular electrical stimulation; stroke

1 Introduction

Neuromuscular electrical stimulation activates peripheral motor neurons with short electrical pulses delivered through the skin, thereby eliciting muscle contractions. Using these muscle contractions to supplement lost functions, e.g. after a stroke or spinal cord injury, is called functional electrical stimulation (FES) [1]. FES can be used to achieve functional tasks such as walking, cycling or grasping [2]. The effect of FES does strongly depend on the precise placement of the stimulation electrode over the muscle motor point [3]. The motor point is the area where the desired stimulation effect is achieved with the least amount of current. Manual search for these motor points is possible but time consuming, especially for inexperienced users or impaired patients.

The usage of multi-pad electrodes is one way to ease the process of electrode placement and has been the topic of many studies in the last years [4], [5], [6], [7]. One major concern performing neuromuscular electrical stimulation is the rapid occurrence of muscle fatigue, limiting treatment success [1]. Spatially distributed stimulation with multiple electrodes has shown some promising results to postpone muscle fatigue [8], [9], [10] and is an additional advantage of multi-pad electrodes. Most systems currently used for multi-pad FES require an external computer to control stimulation, complicating practical application of stimulation outside of the clinical setting.

In this paper, we present an easy to use, flexible standalone system for multi-pad electrode FES, which includes an automatic electrode search. It works without a computer and can be used with any electrical stimulation device.

2 System design

The presented system is designed for stimulation of the extensor digitorium muscle to achieve hand opening in stroke patients (see Figure 1). Flex sensors (Flex Sensor, Spectra Symbol, Salt Lake City, UT, USA) are attached to the fingers to measure finger movement upon stimulation. Multi-pad electrodes cover a large area over the extensor muscles of the forearm and an indifferent electrode is placed at the wrist. The major components of the devolved system are the multi-pad control hardware, custom-made multi-pad electrodes and a commercial stimulator (Motionstim8, Medel GmbH, Hamburg, Germany) (see Figure 2).

Figure 1 Schematic illustration of multi-pad electrode FES for hand opening with sensor feedback.
Figure 1

Schematic illustration of multi-pad electrode FES for hand opening with sensor feedback.

Figure 2 Block diagram of the multi-pad stimulation system and its components. Red and blue lines represent stimulation currents, solid lines control signals, dotted lines information, dashed dotted lines control signals as well as in information, and dashed lines power.
Figure 2

Block diagram of the multi-pad stimulation system and its components. Red and blue lines represent stimulation currents, solid lines control signals, dotted lines information, dashed dotted lines control signals as well as in information, and dashed lines power.

2.1 Multi-pad control hardware

Core of the multi-pad control hardware is an Arduino Due (AT91SAM3X8E microcontroller). The microcontroller communicates over SPI with a port expander (MAX7301) which switches reed relays. To switch the reed relays, Darlington transistor arrays are used. The port expander, Darlington transistors and reed relays build the demultiplexer (DEMUX). Each relay is connected in series with one electrode, which allows passing the stimulation current to a desired electrode by closing the normally open relay. The system supports up to 16 active electrodes.

To control the system, a keypad and two buttons are used. A display allows the user to navigate through different stimulation protocols. The multi-pad control hardware is displayed in Figure 3 [left]. Power supply is currently achieved over the micro USB-port of the Arduino Due. An external battery can be used to power the system. Flex sensors can be attached to the multi-pad control hardware to measure finger movement. Up to four sensors are supported at the moment.

Figure 3 Left: Multi-pad control hardware with keypad, display and front panel to connect electrodes and sensors. Right: Custom-made multi-pad electrode and sleeve.
Figure 3

Left: Multi-pad control hardware with keypad, display and front panel to connect electrodes and sensors. Right: Custom-made multi-pad electrode and sleeve.

Optionally, a computer can be connected via USB to control the system and to visualize sensor values more precisely, however, is not necessary for normal operation.

2.2 Multi-pad electrodes

Similar to [11] flexible printed circuit boards were designed and manufactured (LeitOn GmbH, Berlin, Germany). In contrast to some other multi-pad electrodes [4], [12] we chose square over rectangular or elliptical electrodes. The optimal electrode geometry depends on the orientation of motor axons or motor axon branches, which are unknown or hard to determine. Therefore square or round electrodes are favored [13]. Electrode size was 20 × 20 mm2 with a spacing of 5 mm. Each multi-pad consists of seven electrodes (see Figure 3 [right]). Two multi-pads with seven electrodes each can be used at the same time (see Figure 1), allowing an expert to place two additional electrodes manually.

The conductive electrode surface is made of electroless nickel immersion gold, which is a good conductor and suitable for transcutaneous applications without permanent skin contact [11]. A thin layer of immersion gold covers the nickel completely and prevents oxidation as well as direct skin contact. For skin contact a hydrogel layer is required. The hydrogel layer (e.g. AG700 Series Hydrogel, Axelgaard, Fallbrook, CA, USA) allows a homogeneous current distribution and can provide adhesive contact to the skin. As an inexpensive alternative we used ultrasound gel (Seidel medipool GmbH, Buchendorf, Germany), which has similar conductive properties but no adhesive effect. The multi-pad electrodes were mounted in custom-made sleeves (see Figure 3 [right]) to secure arm attachment.

2.3 Stimulation protocols

One useful feature of the developed system is a search function, automatically determining the desired stimulation electrode. In this protocol single stimulation electrodes are activated successively and the finger movements are measured with the flex sensors. After the search protocol the two electrodes eliciting the greatest range of motion will be displayed for each flex sensor.

The actual stimulation protocol should be performed after appropriate electrode selection. There are three stimulation protocols realized so far: stimulation with one electrode, simultaneous stimulation with two electrodes as well as alternating stimulation with two electrodes. During alternating stimulation two relays will be switched with a certain frequency passing the stimulation current first through one and then through the other electrode. The switching frequency should match the stimulation frequency, reducing the stimulation frequency of each electrode in half.

3 System demonstration

Our stimulation setup can be seen in Figure 4. Flex sensors are attached to fingers with custom-made rings and are mounted to a wrist bandage, which also reduces wrist movement, with Velcro stripes. One commercial electrode (PALS, Axelgaard, Fallbrook, CA, USA) is placed at the wrist as the indifferent electrode and the multi-pad electrodes are attached to the arm using sleeves. All tests were performed with 30 Hz, 20–30 mA and 50–90 µs.

Figure 4 Stimulation setup with flex sensors and multi-pad electrodes.
Figure 4

Stimulation setup with flex sensors and multi-pad electrodes.

Figure 5 shows the results of a search protocol with 14 electrodes and two sensors connected to the index and ring finger for one exemplary participant. The third and fourth electrode produced the greatest range of motion in the index finger, whereas the ring finger was moved the most by stimulation of electrode three and five. Overall, electrode three produced the greatest combined movement, followed by electrode five. Each stimulation lasted 3 s, followed by a 2 s break, resulting in a total duration of less than 90 s.

Figure 5 Maximal sensor values for each electrode during an electrode search protocol.
Figure 5

Maximal sensor values for each electrode during an electrode search protocol.

In Figure 6 single electrode stimulation of electrode three is compared to alternating stimulation of electrodes three and five for the same participant. In general it can be seen that alternating stimulation does work and can produce a steady hand opening, even though the sensor values during single electrode stimulation are more constant.

Figure 6 Up: Sensor data of index and ring finger during 20 s of single electrode stimulation. Bottom: Sensor data of index and ring finger during 20 s of alternating stimulation.
Figure 6

Up: Sensor data of index and ring finger during 20 s of single electrode stimulation. Bottom: Sensor data of index and ring finger during 20 s of alternating stimulation.

4 Discussion and conclusion

Here we present a newly developed multi-pad electrode FES system. The system is easy to use and does not require an external computer, making it more feasible for the practical application in patients. Importantly, attaching all electrodes and sensors and starting a search protocol takes <5 min. Even though here we demonstrate its use with the Motionstim8, it can also be combined with any other stimulator.

Spatially distributed alternating stimulation has been suggested as one way to reduce fatigue during FES [7], [8], [9]. The presented system allows alternating stimulation with two electrodes. We plan to assess the effectiveness of this technique in the future.

On the one hand multi-pads with smaller electrodes would provide an even more accurate search for the most effective stimulation electrode. Moreover, simultaneous activation of multiple electrodes to form virtual electrodes as well as alternating stimulation with more than two electrodes would become reasonable. On the other hand smaller electrodes would cover a smaller area, making placement of the multi-pad electrodes more difficult or would require a larger number of electrodes and relays, which would enlarge the hardware. Geometry, number of electrodes and material of the multi-pad electrodes are all items that may be optimized in the future, nevertheless the current version provides good results.

Having the hardware for demultiplexing of the stimulation current separated from the high voltage generation works as an additional safety layer. As long as the relays are open no stimulation currents can reach the patient.

The presented system offers a reliable and practical option to investigate the possibilities of multi-pad electrode FES.

Author’s Statement

Research funding: This work was supported by a grant from the Federal Ministry of Education and Research (BMBF, ESiMED [16 M3201]). Conflict of interest: Authors state no conflict of interest. Material and Methods: Informed consent: Informed consent has been obtained from all individuals included in this study. Ethical approval: The research related to human use complies with all the relevant national regulations, institutional policies and was performed in accordance with the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee.

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Published Online: 2016-9-30
Published in Print: 2016-9-1

©2016 Jan C. Loitz et al., licensee De Gruyter.

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License.

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https://doi.org/10.1515/cdbme-2016-0087
Keywords for this article
electrode arrays; electrode placement; functional electrical stimulation; multi-pad electrodes; muscle fatigue; neuromuscular electrical stimulation; stroke
Creative Commons
BY-NC-ND 4.0

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  80. A service for monitoring the quality of intraoperative cone beam CT images
  81. Resectoscope with an easy to use twist mechanism for improved handling
  82. In vitro simulation of distribution processes following intramuscular injection
  83. Adjusting inkjet printhead parameters to deposit drugs into micro-sized reservoirs
  84. A flexible standalone system with integrated sensor feedback for multi-pad electrode FES of the hand
  85. Smart control for functional electrical stimulation with optimal pulse intensity
  86. Tactile display on the remaining hand for unilateral hand amputees
  87. Effects of sustained electrical stimulation on spasticity assessed by the pendulum test
  88. An improved tracking framework for ultrasound probe localization in image-guided radiosurgery
  89. Improvement of a subviral particle tracker by the use of a LAP-Kalman-algorithm
  90. Learning discriminative classification models for grading anal intraepithelial neoplasia
  91. Regularization of EIT reconstruction based on multi-scales wavelet transforms
  92. Assessing MRI susceptibility artefact through an indicator of image distortion
  93. EyeGuidance – a computer controlled system to guide eye movements
  94. A framework for feedback-based segmentation of 3D image stacks
  95. Doppler optical coherence tomography as a promising tool for detecting fluid in the human middle ear
  96. 3D Local in vivo Environment (LivE) imaging for single cell protein analysis of bone tissue
  97. Inside-Out access strategy using new trans-vascular catheter approach
  98. US/MRI fusion with new optical tracking and marker approach for interventional procedures inside the MRI suite
  99. Impact of different registration methods in MEG source analysis
  100. 3D segmentation of thyroid ultrasound images using active contours
  101. Designing a compact MRI motion phantom
  102. Cerebral cortex classification by conditional random fields applied to intraoperative thermal imaging
  103. Classification of indirect immunofluorescence images using thresholded local binary count features
  104. Analysis of muscle fatigue conditions using time-frequency images and GLCM features
  105. Numerical evaluation of image parameters of ETR-1
  106. Fabrication of a compliant phantom of the human aortic arch for use in Particle Image Velocimetry (PIV) experimentation
  107. Effect of the number of electrodes on the reconstructed lung shape in electrical impedance tomography
  108. Hardware dependencies of GPU-accelerated beamformer performances for microwave breast cancer detection
  109. Computer assisted assessment of progressing osteoradionecrosis of the jaw for clinical diagnosis and treatment
  110. Evaluation of reconstruction parameters of electrical impedance tomography on aorta detection during saline bolus injection
  111. Evaluation of open-source software for the lung segmentation
  112. Automatic determination of lung features of CF patients in CT scans
  113. Image analysis of self-organized multicellular patterns
  114. Effect of key parameters on synthesis of superparamagnetic nanoparticles (SPIONs)
  115. Radiopacity assessment of neurovascular implants
  116. Development of a desiccant based dielectric for monitoring humidity conditions in miniaturized hermetic implantable packages
  117. Development of an artifact-free aneurysm clip
  118. Enhancing the regeneration of bone defects by alkalizing the peri-implant zone – an in vitro approach
  119. Rapid prototyping of replica knee implants for in vitro testing
  120. Protecting ultra- and hyperhydrophilic implant surfaces in dry state from loss of wettability
  121. Advanced wettability analysis of implant surfaces
  122. Patient-specific hip prostheses designed by surgeons
  123. Plasma treatment on novel carbon fiber reinforced PEEK cages to enhance bioactivity
  124. Wear of a total intervertebral disc prosthesis
  125. Digital health and digital biomarkers – enabling value chains on health data
  126. Usability in the lifecycle of medical software development
  127. Influence of different test gases in a non-destructive 100% quality control system for medical devices
  128. Device development guided by user satisfaction survey on auricular vagus nerve stimulation
  129. Empirical assessment of the time course of innovation in biomedical engineering: first results of a comparative approach
  130. Effect of left atrial hypertrophy on P-wave morphology in a computational model
  131. Simulation of intracardiac electrograms around acute ablation lesions
  132. Parametrization of activation based cardiac electrophysiology models using bidomain model simulations
  133. Assessment of nasal resistance using computational fluid dynamics
  134. Resistance in a non-linear autoregressive model of pulmonary mechanics
  135. Inspiratory and expiratory elastance in a non-linear autoregressive model of pulmonary mechanics
  136. Determination of regional lung function in cystic fibrosis using electrical impedance tomography
  137. Development of parietal bone surrogates for parietal graft lift training
  138. Numerical simulation of mechanically stimulated bone remodelling
  139. Conversion of engineering stresses to Cauchy stresses in tensile and compression tests of thermoplastic polymers
  140. Numerical examinations of simplified spondylodesis models concerning energy absorption in magnetic resonance imaging
  141. Principle study on the signal connection at transabdominal fetal pulse oximetry
  142. Influence of Siluron® insertion on model drug distribution in the simulated vitreous body
  143. Evaluating different approaches to identify a three parameter gas exchange model
  144. Effects of fibrosis on the extracellular potential based on 3D reconstructions from histological sections of heart tissue
  145. From imaging to hemodynamics – how reconstruction kernels influence the blood flow predictions in intracranial aneurysms
  146. Flow optimised design of a novel point-of-care diagnostic device for the detection of disease specific biomarkers
  147. Improved FPGA controlled artificial vascular system for plethysmographic measurements
  148. Minimally spaced electrode positions for multi-functional chest sensors: ECG and respiratory signal estimation
  149. Automated detection of alveolar arches for nasoalveolar molding in cleft lip and palate treatment
  150. Control scheme selection in human-machine- interfaces by analysis of activity signals
  151. Event-based sampling for reducing communication load in realtime human motion analysis by wireless inertial sensor networks
  152. Automatic pairing of inertial sensors to lower limb segments – a plug-and-play approach
  153. Contactless respiratory monitoring system for magnetic resonance imaging applications using a laser range sensor
  154. Interactive monitoring system for visual respiratory biofeedback
  155. Development of a low-cost senor based aid for visually impaired people
  156. Patient assistive system for the shoulder joint
  157. A passive beating heart setup for interventional cardiology training
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