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SERIES ON BIOENGINEERING AND BIOMEDICAL ENGINEERING

Series Editor: John K-J Li (Department of Biomedical Engineering, Rutgers University, USA)

The aims of the book series are to present a publishing forum for established researchers, educators and professionals in the field of bioengineering and biomedical engineering to promote in-depth documentation of new scientific findings, technological advances, and to provide effective teaching tools of the fundamental aspects of the field. Single or multiple authored or edited books, research monographs, textbooks, lab manuals and specialized conference proceedings are welcome. Topics of interest include biosensors, biomedical devices and instrumentation, physiological modeling and signal processing, medical imaging, drug delivery systems, clinical monitoring, tissue engineering, systems biology and bioinformatics, biomechanics and biomaterials, rehabilitation and prostheses, nano and micro applications to biomedicine, biomedical optics, biofluid mechanics, artificial organs and assist devices.

Published

Vol. 10 Biomedical Engineering Principles of the Bionic Man Second Edition by George K Hung (Rutgers University, USA)

Vol. 9: Dynamics of the Vascular System: Interaction with the Heart Second Edition by John K-J Li (Rutgers University, USA)

Vol. 8: Neuroprosthetics: Theory and Practice Second Edition

edited by Kenneth Horch (University of Utah, USA) and Daryl Kipke (University of Utah, USA)

Vol. 7: Further Understanding of the Human Machine: The Road to Bioengineering edited by Max E Valentinuzzi (National Scientific and Technical Research Council (CONICET), Argentina)

Vol. 6: Cardiac Fibrillation-Defibrillation: Clinical and Engineering Aspects by Max E Valentinuzzi (University of Buenos Aires, Argentina & University of Tucumán, Argentina)

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Names: Hung, George K., editor.

Title: Biomedical engineering principles of the bionic man / [edited by] George K. Hung, Rutgers University, USA.

Description: Second edition. | New Jersey : World Scientific, [2023] | Series: Series on bioengineering and biomedical engineering, 2010-2909 ; vol. 10 | Includes bibliographical references and index.

Identifiers: LCCN 2022028858 | ISBN 9789811259180 (hardcover) | ISBN 9789811259197 (ebook for institutions) | ISBN 9789811259203 (ebook for individuals)

Subjects: LCSH: Prosthesis. | Biomedical engineering. | Gene therapy. | Tissue engineering.

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Tomycloseandlong-timegolfingfriend,MortReinhart,whose numerousmedicalproceduresinspiredthisbookonthebionicman. Hismedicalproceduresincludedintraocularlensimplantsfor cataracts,monovisioncorrection,quadrupleheartbypass, radioactiveseedimplanttreatmentforprostatecancer,andknee surgery.

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Foreword

Theinspirationforthisbookismyfather,MortReinhart,whoalso happenstobethegolfpartnerofDr.GeorgeHung,thisbook’s editor.At88,myfatherisstillabletomoveaboutevenwithmultiplereplaced,repaired,andrejuvenatedbodyparts.Hehasocular implants,akneereplacement,andundergonecardiacbypasssurgery; Georgekiddinglyreferstohimas“thebionicman”.

Tomeasanorthopedicsurgeon,myfatherseemstobeafairly typicalpatientwhohasbenefitedgreatlyfromthewonderfulbiomedicaldevicesandtechniqueswidelyutilizedinmanyareasofmedicine. Thistextbookdescribessomeofthesedevicesandconveysasense ofexcitementabouttheopportunityforfurtheradvancesasnew technologiesemergeinBiomedicalEngineering.

GolferslikemyfatherandDr.Hungoftenlooktoinnovations inequipmentdesignandmaterialstoimprovetheirperformance. Thesameprocessworksinmedicinewherephysicians,patients, andresearchershopeforimprovedpersonal“performance”through advancesintechnology.However,whereasingolftheideaisto improvetheexternalequipment,inmedicinetheideaistoimprove theinternalattributesoftheplayer.

Newtechnologyaloneisnotsufficienttodriveinnovationin medicine.Theotherfactorwhichcontinuestopushinnovationis theincreasinglyhighdemandsandexpectationsofpatients.Many individualswithavarietyofmedicalconditionsexpectthattheir problemscanbeaddressedsothattheycancontinuetopursueallof theiractivitiesatahighlevelandoverincreasinglyextendedperiods oftime.Moreandmorethefocusinhelpingpatientisnotsimplyin relievingsymptomsbutintrulyrestoringnear-normalfunction.

This2ndeditionbookpresentsafabulousandfascinatingarray oftechnologieswhicharealreadywelldevelopedorarecurrently underdevelopment.Advancesinmaterials,design,electronics,and biologictechniquesallhavethepotentialtoenablepatientstosense theworldaroundthemandmovethroughtheirdailyactivitieswith greaterenjoymentandease.

InmyspecialtyofOrthopedics,thetraditionalfocushasbeenon repairingorreplacingbrokenpartswithvariousmechanicaldevices. However,inOrthopedicsaswellasinmanyothermedicalspecialtiesasdescribedinthisbook,thefocusisbroadeningfromsimple mechanicalsolutionstobiologicalsolutionsaswell.Variousbiomedicaltechniquesaredescribedthataugmentorassistnormalstructures,thatmonitorandcorrectabnormalconditionsonaninstantaneousbasis,andthatcanstimulateorsubstituteforimpairedbodily symptoms.Thenewfrontiersinbiology,includingtissueengineeringandgenetherapy,offeropportunitiestoregenerateorrecreate healthiersystemsaswell.

Theconceptofa“bionicman”mayonthesurfaceseemtoimply amechanicalorroboticcondition.However,withthesenewtechniques,abionicmanisactuallyacombinationofenhancednatural functionsaswellassubstituteorartificialparts.Thisnewbionicman isactuallymorehumaninthathehasagreaterabilitytoenjoylife notonlyinhisrequiredday-to-dayactivitiesbutalsointhedesired activitieswhichbringhimpleasure.

Thisbookpresentsstudentswithbasicscientificprinciplesand hopefullyalsoprovidestheinspirationtopursuenewandcreative ideasandvisionarythinkingabouthowtocontinuetoimprovethis bionicman.

GlennReinhart,M.D.

FreibergOrthopedic&SportsPH:(513)221-55009825

KenwoodRdSte200FX:(513)221-1962 Cincinnati,OH45242EM:gareinhart@zoomtown.com

Dr.Reinhartisaspecialistinsportsmedicineandshouldersurgery andisamemberoftheAmericanAcademyofOrthopedicSurgeons andtheArthroscopyAssociationofNorthAmerica.Hecurrently

servesasthemedicaldirectoroftheKenwoodSurgeryCenterand hasprovidedcareasaphysicianfornumeroushighschools,collegiate,andprofessionalteams.Inaddition,hehasaspecialinterest inpediatricorthopedicsandshoulderreconstruction.

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Preface

Agingisasinevitableasthechangeofseasons,fromspringtosummer andthenwintertofall.Asweage,mobility,strength,andstamina alldecline.Thesearetheclassicsignsofaging.Theagingprocess iswritteninourgenes.Asthetelomerelengthrecedes,therateof celldivisiondeclines,andthefabricofourbonesandskinlosetheir resilience,leadingtothelossinvitality.

Yet,remarkableprogresshasbeenmadeintheunderstanding oftheagingprocessandinturnhowtoslowitsprogress.Avitally importantarsenalinanti-agingistheminimizationofoxidation,or rusting,ofthebody.Freeradicalsthatresultfromoxidationcan interferewiththenaturalrepairprocessinthecells,leadingtogenetic damagethatincreasestherateofaging.Propernutritionandexercise playsignificantrolesinslowingtheeffectsofaging.Nutrientswith antioxidantpropertiesactatthemicroscopicleveltocounteractthe damagingeffectsoffreeradicalsandinturnmaintaintheintegrityof thestructureofthecellsinthebody.Exerciseactsatthemacroscopic leveltostrengthenmuscles,joints,andbonesaswellasincreasethe functionsofthecardiovascular,respiratory,andhormonalsystems tobettercounteractthephysicalandemotionalstressesofdailylife. Nevertheless,thereisonlysomuchnutritionandexercisecando tostemthetideofaging.Eventually,somebodypartswillbegin tobreakdownovertime.Thebabyboomers,whohavedominated thesocial,economic,andpoliticaldemographicsofthepopulation overthelasthalfcentury,willnowdominatethesearchforelixirs andremediestoholdbacktheravagesoftimeastheyageand theirbodypartsbegintomalfunction.Repairorreplacementofthe bodypartsprovidesameansinasensetoreversetheagingprocess.

xii Preface

Biomedicalengineershavebuiltcomponentsordevicestoassistand revitalizetheaginghumanbody.Indeed,itisnownottooextraordinarytofindseniorpersonswhohavehadsurgeryforcataract, monovision,Lasik,heartbypass,hip,knee,and/orcochlearimplants. Thus,thematuringofthebabyboomersalsoheraldstheageofthe bionicman,whoisliterallycomposedofvariousreplacementorgans orbiomechanicalparts.

Thepurposeofthis2ndeditionbookistoprovideacomprehensiveandup-to-datescientificsourceofbiomedicalengineering principlesof“replacementpartsandassistdevices”forthebionic man.Itcoversbiomechanical,biochemical,rehabilitation,andtissue engineering,aswellasapplicationsincardiovascular,visual,auditory,andneurologicalsystems.Itcontainsupdatedchaptersfrom theoriginalbookaswellasnewchapters,includingTheBionic Pacemaker;BionicAgeHemodynamicMonitoring:Invasive,Noninvasive,Wearable,andWirelessApplications;andfourchapterson KinematicsandPosturalMechanicsinBaseballPitching.Itcanserve asatextorreferenceforstudents,scientists,andlaymeninterested inthefundamentalunderlyingprinciplesofbiomedicaldevicesand procedures,aswellasrecentadvancesintransplant,genetherapy, andstemcellresearch.Thebook’semphasisonfundamentalprinciplesthatarereviewedwithinrelevantchaptersensuresthecontent willremainrelevantandusefulforyearstocome.

c 2023WorldScientificPublishingCompany https://doi.org/10.1142/9789811259197 fmatter

AbouttheEditor

GeorgeK.Hung receivedaB.S.inmechanicalengineering,M.S.inbioengineering,and Ph.D.inphysiologicaloptics,allfromUC Berkeley.Heiscurrentlyaprofessorof BiomedicalEngineeringatRutgersUniversity. Hehaspublishedextensivelyintheareasofeye movementcontrol,nearsightednessdevelopment,andsportsscience,withover110refereed journalpublications.Hehasco-authoredorcoeditedfivebooks,alongwiththepresentvolume:(1) ModelsofOculomotorControl,WorldScientific,2001,(2) ModelsoftheVisual System,KluwerAcademic/PlenumPublishers,2002,(3) Biomedical EngineeringPrinciplesinSports,KluwerAcademic/PlenumPublishers,2004,(4) BiomedicalEngineeringPrinciplesoftheBionicMan, WorldScientific,2010,and(5) BiomechanicalEngineeringPrinciples andApplicationsinSports,Springer,2019.Outsideofacademics,he andhiswife,Joan,areavidlinedancingandsocialballroomdancing enthusiasts.

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Foreword vii

Preface xi

AbouttheEditor xiii

IBrainandRehabilitation 1

1.TechnologiesforRestoringLimbFunction3 WilliamCraelius IIEye 37

2.VisionCorrectionSurgery:RefractiveSurgeryand IntraocularLensImplants39

DanielJ.HuandPeterA.Rapoza

3.ApplicationsofAdvancedTechnologiestoRetinal Prosthesis83 DeanScribnerandLeeJohnson

4.ModelsofMyopiaDevelopment127

AndrewJ.Fiedler,JimoLiu,GeorgeK.Hung, andKennethJ.Ciuffreda

5.AdvancesintheDesignofHearingAids159 IanC.Bruce

6.RestorationofHearingbyElectricalStimulation oftheHumanCochlea,Brainstem,andMidbrain203 RobertV.Shannon

7.TheBionicPacemaker237 GaryM.Drzewiecki

8.BionicAgeHemodynamicMonitoring:Invasive, Non-invasive,Wearable,andWirelessApplications257 JohnK.-J.Li

9.TissueEngineeringoftheHeart287 MichaelO.Zembala,RicardoA.Bello,and RobertE.Michler

10.GeneTherapyfortheHeart329 ChristianSpiesandGaryL.Schaer

11.StemCellTransplantationTherapyforHeartDisease355 WangdeDaiandRobertA.Kloner

12.TotalKneeReplacement397 W.ThomasGutowski

13.MedicalAdvancesinTreatingtheMastersAthlete435 AnthonyLukeandMarcR.Safran

14.BaseballPitchingKinematicsandPostural Metrics:IntroductionandMethodology469

CourtneySemkewycandWilliamCraelius

15.BaseballPitchingKinematicsandPostural Metrics: Velocity 485

CourtneySemkewycandWilliamCraelius

16.BaseballPitchingKinematicsandPostural Metrics: Torque 503

CourtneySemkewycandWilliamCraelius

17.BaseballPitchingKinematicsandPostural Metrics: OptimalAttributesofHighVelocity andLowTorqueinPitching 523

CourtneySemkewycandWilliamCraelius

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PartI

BrainandRehabilitation

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Chapter1

TechnologiesforRestoring LimbFunction

WilliamCraelius

DepartmentofBiomedicalEngineering, RutgersUniversity,599TaylorRoad, Piscataway,NJ08854,USA billcraelius@gmail.com

1.1Introduction

1.1.1 Needsofthepopulation

Motorimpairmentsofthelimbsaccompanymanyneurologicalor musculoskeletalconditionsandinjuries,includingstroke,cerebral palsy,Parkinson’s,injurytothecentralnervoussystem(CNS), rheumatoidarthritis,andmanyothers.Strokeistheleadingcauseof seriouslong-termdisability,affectingoverhalfofthesurvivorsover 60yearsofage.AccordingtotheU.S.CDC,over795,000peoplein theUnitedStatessufferfromstrokeseachyear,andabout610,000 ofthesearefirstornewstrokes,andthereareover4.8millionstroke survivors,makingittheleadingcauseofparalysisintheU.S.Stroke affectsupto8peopleinevery1,000overtheageof25yearsand 47peopleinevery1,000overtheageof55years.Intheyear2007, theestimatedeconomicimpactofstrokewas$62.7billion.Together, braininjuriesfromaccidentandbraindamagefromstrokeaccount forover10millionpeopleintheUnitedStatesleftwithlong-term disabilities.Incidenceofstrokeislikelytoincrease,asriskfactors forstroke,suchashighbloodpressureandcarotidarterydisease, andagingincrease.Cerebrovasculareventsusuallyaffectprimarily oneside,resultinginhemiplegia.Thisconditionlimitsfundamental

W.Craelius

activitiesofdailyliving(ADL),suchaswalking,eating,dressing, drivingacar,writingandtyping,telephoneusage,equipmentoperation,andself-care.Beyondfunctionalloss,peoplecanexperience chronicpainanddistortionintheaffectedlimb,aswellasinexorable musculoskeletaldeteriorationandfurtherneuronalthroughlearned disuse(Platz etal.,2001).

Cerebro-vascularevents(CVEs)generallycausehemiplegia, aweaknessthatprimarilyaffectsonesideofthebody,resultingin asymmetricbodydysfunction.Incaseswherethelocomotiveparts ofthebrainaredestroyed,walkingisdifficultorimpossible.Itisa majorconcernforpeoplesurvivingastrokebecauseitmaynegativelyaffecttheabilitytoperformactivitiesofdailylivingandlimit overallindependence.Asaresult,improvingmobilityisoneofthe maingoalsofstrokerehabilitationandhasrelevancethroughoutthe strokesurvivor’slife.Asecondresultofastrokeisthattherecanbe atleastpartiallossofbodilyawarenessoftheaffectedside.

Someambulatoryabilitycanberestoredbyimmobilizingor assistingtheaffectedanklewithanorthosis,butthisassistance tendstoinhibitneurorehabilitationthatdependsonactiveneuromuscularefforts.Restorationofnormalgaitandlower-limb(LL) functionisthusrareafterhemiplegia.Restorationofupper-limb (UL)functionisevenmoreproblematicdueto(1)itsenormous complexityand(2)thehigherprioritiesgiventorestoringambulation.Furthermore,compensatorystrategies,learnedbythepatient forADL,tendtoinhibitrecovery.Asaresult,manypeoplewithUL paralysisareunlikelytorecovermuchfunctionality.Forexample,a studyofstrokepatientsenteringrehabilitationwithnon-functional armsrevealedthat61%showednoimprovementafter2years (Turton etal.,2002).Manyindividualsthatdorecoversignificant armfunctionexperienceepisodicrelapses,makingitriskyforthem tocarrythings.

Ingeneral,recoveryoutlookaftercentralhemiplegiaispoor,and mostindividualscanexpecttoregainonlypartialmobilityandlimitedULfunctionality.Mountingevidencesuggests,however,that theCNSissufficientlyplastictoeffectmoresignificantreversals fromparalysis,whengiventheproperstimuli(Edgerton etal.,2001; Krebs etal.,2003;Feys etal.,2004;Reinkensmeyer etal.,2004;

Bharadwaj etal.,2005;Riener etal.,2005).Itisbelievedthatsensorimotorstimulationprovidedbyrepeatedvoluntaryattemptsto extendmovementsofthelimbs,orevenappliedsensorystimulation, cancausethebraintoreorganizeandre-gaincontrolandcoordination.Restorationofatleastsomefunctionalitymaybepossible throughintensivephysicaltherapyinvolvingrepetitiveexercising, bothpassiveandactive,oftheaffectedlimb.Wecannotpredict, however,thetypes,amount,anddurationofmovements,exercise,or stimulationthatwillbeeffectivenorpredictwhichindividualswill respondtogivenprotocolsandwhethertheoutcomeofsuchdemandingtherapywillbeworthwhile.Moreover,therearefewtoolsavailabletohelptheprocess,andonlyalimitedavailabilityofrehabilitationservices,sincetheyarecostly,constrainedbytime,practicality, traveldistance,andmotivationandarevariablyapplieddepending onindividualproviders.

Tosummarize,bionictechnologiesappliedtopeoplewithhemiplegiaareincreasinglycapableofrestoringsignificantfunctionality topeoplewithstrokeorotherinjuries.

1.1.2 Potentialforfunctionalrestoration

Fortunately,mostindividualswithhemiplegiahaveaccesstophysiotherapydeliveredbydedicatedprofessionals,butthisaccessis necessarilylimitedbytimeandavailabletechnology.Eventherapiesthatemploystate-of-the-artapproachesofferlittleforneural recovery,sincetheyfocusonassistivedevices,encouragingcompensatorystrategiesthroughconstraint-inducedmovementtherapy, oronactivemanipulationofthejointswithroboticdevices.Except forsimpleassistivedevices,theseregimensanddevicesaregenerally impracticalformostindividualswithoutexpertassistanceandlarge expense,andthemoreadvancedapproachesareunlikelytobewidely availablesoon.Asaresult,afterterminationofregularphysiotherapy,neglect-induceddeclinesinfunctionareinevitable,andclients mayincreasinglydependonmedicalandpharmacologicaltreatments forspasticity,sores,andpain.

Neglectingtheaffectedmusclesandjointsiscounter-productive, sincedisusepatternsandassociatedpathologycommencesoonafter

W.Craelius

immobilizationoflimbs.Thissituationcouldberemediedifscientificallydesignedtoolswereavailabletoencourageclientstoimplement provensensorimotorprotocolsathome.Thevalueofrelativelyshorttermsensorimotorexercisetraining,withinsupervisedrehabilitation protocols,iswellestablished(Ouellette etal.,2004;Pang etal.,2006; Lam etal.,2008),andtheadditivebenefitsofin-homeexercisecarriedonfor12weeksbeyondthestandardpost-stroketherapyhave beenshowninclinicalstudies(Duncan etal.,2003).Thus,thereis noreasontobelievethatprogresswouldnotcontinueindefinitely withpropertrainingtools.

1.2RehabilitationApproaches

1.2.1 General

Amyriadofstrategies,devices,andprotocolshavebeendevelopedto helprestorefunctiontopeoplewithhemiplegia,eachofwhichmay infactbeefficaciousforneurorehabilitation,butnoneofwhichis apriori superiororindicatedforanygivenclient.Therearetwo assumptionscommonlyheldamongtheemergingandcompeting therapyoptions:(1)theCNSissufficientlyplastictoreorganizeitself andregainsensorimotorcontrolafterinjuryand(2)sustainedand repetitivemovementsoftheaffectedlimbscanpromotere-learning bytheCNS,leadingtosensorimotorrecovery.Beyondthese,thereis insufficienttheoryuponwhichtobuildarationaltreatmentplan,due totheenormouscomplexityofhemiplegiaanditssequelae,involving notonlytheCNSbutalsotheperipheralnervoussystem(PNS), muscles,joints,metabolism,aswellaspsychology.Forthisreason,it hasbeensuggestedthatthemostpromisingtherapyregimensshould beopentoempiricallycombininganarrayoftechnologies(Hogan etal.,2006).

Whileneurorehabilitationstrategiesdifferwidely,andoftenoverlapinmethods,theygenerallycanbecategorizedasthosethatwork on(1)strengtheningorrelaxingindividualmusclesor(2)promoting functionalmovements.Thefirstcategoryincludesstandardphysiotherapeuticexercisesadministeredbyaprofessional.Thesecondcategoryincludestools,suchasconstraint-inducedmovementtherapy,

biofeedbackdevices,movementassistivedevices,andelectricalstimulation,thatgenerallyinduceorencouragebothpassiveandactive motions.

Thesecondcategoryisknownas“sensorimotortraining”(SMT), wherebytheclientattemptstomovetheaffectedlimbwhilereceiving sensoryinputregardinghissuccessatnormalmotion.The goalof SMTisthustocoercere-organizationofthedamagedmotorcortex byhelpingtheclientassociatehisvolitionswithsubsequentmovementswiththeirsensoryconsequences,includingproprioceptive,tactile,andvisualmodalities.SMTrequiresactivevolitionbytheclient, whetherornothe/sheisassistedbymechanicalrobots.

1.2.2 TrainingtheaffectedUL

RehabilitativeapproachestoparalysisoftheULcanbecategorizedas(1)standardsupervisedexerciseprotocols,(2)constraintinducedmovements,(3)assistivedevices,(4)activedevices,and (5)biofeedbackofmovementsusingelectromyographic(EMG)and virtualreality.Theseapproachesinvolvesensorimotortrainingto variousdegreesthatencouragesand/orassistsrepetitivemotionsof theaffectedlimbs.

Toapplyappropriatetechnology,therehabilitationengineer shouldhaveanunderstandingofthepotentialuser.Thefollowing tables(Tables1.1and1.2)arenotexhaustivebutaremeanttooutlinespecificproblemsofthetargetpopulationsandtheirpotential forrehabilitation.

Commonstrategiesforrehabilitationfromapplyingrigorousprotocolstoencouragemovementexerciseswithorbyconstrainingthe soundarmforseveralhoursperweekcanforceclientstousetheir affectedlimb,therebyencouragingplasticreorganizationwithinthe CNS.Highlymotivatedclientswhoconstantlyusetheiraffectedarm forseveralmonths,eitherwithexerciseregimenorbyconstraint,have regainedconsiderablefunction(Page etal.,2005;Wolf,2007).Toprovidestructureforpatientsdoingconstraint-inducedtherapy,aworkstationfordirectingandrecordingtaskshasbeendeveloped(Lum etal.,2004).Unsupervisedexerciseandconstrainttherapieshave limitations,however,sincetheymayteachcompensatorystrategies

W.Craelius

Table1.1.ProblemsofstrokeandTBIandpotentialsolutions.

ResidualAbilities

“Irrepairable”damage toareasofthebrain thatformerly controlledoneor morelimbs,i.e., strokeandTBI.

Centralnervoussystem plasticity;sensory perceptionintact.

Fixedflexureof affectedarmand generallystiffjoints andco-contraction ofagonistand antagonistduring movement,i.e., “synergy”.

Lossofwristandhand dexterity.Poorforce control.

Usuallycanbe extendedby unaffectedarm. Proprioceptionmay beintactbutpossibly anomalous.

Somemusclesare usuallyactive,even inearlyrecovery.

Re-learningmovements throughproper trainingandsensory feedbacktoreduce conflict.Repetitive tasktrainingand playinginan engaging environment.

Anti-flexionexercise, stretching,and weightbearing.

Stagedprotocolsthat beginwithrestoring reachingabilityand progresstohand grasping.

Source :Corrias etal. (2021). involvingthetrunkandshoulder,withlittleimpactontheunderlying paralysis.

Thetypicalproblemsandresidualabilitiesofpeoplewithstroke arelistedinTable1.1.

AsshowninTable1.1,strokedestroysmanyaspectsofmotor controlneuronsinthebrain,causinglossoflimbfunction.Recovering limbfunctionafterstrokeisdifficult,andrecoveryprospectsdecline withtime.Standardrehabilitationexercisesattempttorecruitsurvivingneuronsforthetaskofrestoringspecificmotorfunctions,however,theseareseldomentirelysuccessful.Successisdependenton manyfactors,includingearlytherapeuticinterventionandoptimal retraining.

Table1.2.ProblemsofSCIandpotentialsolutions.

ResidualAbility

C1-C2

Allvegetativeand motorfunctionsare notcontrolled.

C3-C5

Lostallmotor functionsbelowneck.

Braincognitionintact.Brainsignals,either fromEEGorinternal electrodes,can controlcomputerfor communicationwith humanandrobot BCI.

Usuallycanbe extendedby unaffectedarm. Proprioceptionmay beintactbutpossibly anomalous.

C6-C8Somemusclesare usuallyactive,even inearlyrecovery.

Anti-flexionexercise, stretching,and weightbearing. Neuroprosthesesto restorestanding.

Stagedprotocolsthat beginwithrestoring reachingabilityand progresstohand grasping. Neuroprosthesesfor armandlegs.

AnexampleofasimplerehabilitationdeviceisDynawheel. Dynawheeltherapyengagestheuserwithagripchallengegame basedonFitts’paradigm.Theuserispromptedtoexecutevarious handgripswithDynawheelandisscoredbasedonthesuccessofthe user’sgripforcetrackingoftheprompts.Therapycanbeenhanced byAI,whichwilllogandreporttheneurologicalfeatureswhichproduceoptimalperformance,intermsofgripforceanddexterity.This paradigmissimilartothosethatmyresearchgroupandothershave developedforspinalcordstimulation.Thus,theAIsystemrecords themechanicalandelectricalinputsfromtheuserandselectsthose mostefficaciousforgainingoptimalperformance.

EfficacyofDynawheelwasdemonstratedinastudyof6subjects withrightupper-limbparesiscausedbystroke.Agerangewas64–72 years,andtheaveragepost-stroketimewas7.3years.RehabilitationtrainingwithDynawheelconsistedofgripforcedynamometry. Grippingstrengthsandfunctionalityweretestedfollowing6weeks

W.Craelius

oftraining.Subjectsshowedmajorgainsinstrengthandcontrolof grip.Thetherapythusrestoredsignificantfunctiontotheaffected upperlimb.Theseresultsareparticularlysignificant,sincefunctional recoveryisseldomsuccessfulwithsubjectswhosestrokeoccurred morethan5yearspreviously.Ourstudieson6ULpatientshaving experiencedstrokeformorethan7yearspreviouslyshowedthat trainingwithDynawheelrestoredsignificantdexterity.Thisstudy wasselectedforspecialmentionbythe JournalofPhysicalTherapy (Kim etal.,2010).

Functionalelectricalstimulation(FES)ofmusclesrepresentsa typeofsensorimotortraining.Theearliestcommercialversionswere developedatCaseWesternReserveUniversity(CWRU),suchasthe FreeHand(Fig.1.1).ThevalueofFESintheacutephaseofstroke wasshowninarandomizedtrialinvolving100patientswhowere givenSMTfor6weeksshortlyfollowingtheevent.Thesepatients outperformedthecontrolsevenafter5years(Feys etal.,2004). ArmandhandfunctioncanberestoredtosomedegreeusingFES. TheFreehandusedimplantedmyoelectrodestostimulatemuscles forgraspingandbendingtheelbow.Theelectrodes,andsubsequent movementsoftheparalyzedUL,wereactivatedbythemovements ofacontralateralarm.

Figure1.1.TheFreehand,showingelectrodesimplantedintothearm,atransmittingcoiltoactivatethem,ashoulderpositionsensortoindicatevolitionto grasp,andanexternalcontroller.

Figure1.2.GraspcontrolwithsurfaceEMGelectrodes.Thewristpositioncontrolsopeningandclosings.

VariationsoftheFreehandincludeastrictlyexternalorthosis thatactivatesthegripmusclesusingnon-invasiveEMGelectrodes, withactivationbybuttons,asshowninFig.1.2.

Amoresophisticatedinterfacetomuscularcontrolisthe BIONSTM ,asshowninFig.1.3.Bionsarethesizeofagrainof riceandcanbeinjectedintomuscles,withoutexternalwires(Micera etal.,2006).Theyareactivatedbyanexternalradiofrequency (RF)coilthatisactivatedbytheuser.ClinicaltrialswithBions haveshowntheirefficacyinreversingshouldersubluxationfollowing stroke,byrestoringtonetoparalyzedshouldermuscles(Salter etal., 2004).Tobettercontrolmuscleactivity,usingclosed-loopfeedback, Bionswillhavemusclesensingability.

AdvancedassistivedevicesuseFES,eitherexternallyappliedor usingBIONSTM .Adepictionofagraspingcontrolsystem,controlling theextrinsicforearmmuscles,isshowninFig.1.4.

1.2.3 SMTandfeedbacktools

Task-orientedsensorimotortraining,sometimesaidedbyconstrainingthesoundarm,iscentraltopromotingneuroplasticrehabilitationoftheupperlimb(Platz,2003;Winstein etal.,2004;Goffredo etal.,2008).Incomparisontoprotocolsforstrengtheningspecific