Arthur Prochazka presentation

NEW DEVELOPMENTS IN FES TECHNOLOGY FORSCI REHABILITATION:A CRITICAL EVALUATIONArthur ProchazkaCentre for Neuroscience,University of Alberta1

the wish listKimberley Anderson. 20042

Hand functionBladder control3

FES surface stimulatorsMedtronicRespondNeuromove EMG-triggeredEmpiFocusU of A Bionic GloveBioness H2004

Multicentre trial : 48 SCI subjects, 7 centres• Significant improvements in grasp-release release scores• ~50% kept using for > 6monthsPopovic study 1999:• “daily use increased power of grasp & ROM”• “Most manual tasks improved significantly“• “significantly improved independence in C5-C7 C7 SCI ifinitial FIM and QIF scores were 20%-50% of max.”5

Ness Handmaster (Bioness H200)7 C5-6 SCI subjectsSignificant improvements in:• grip strength (0.6N to 16.5N)• finger linear motion (0cm to 8.4cm)•Fugl-Meyer scoresAlon & McBride 20036

FES-assisted exercise therapyMilos R. Popovic, Toronto Rehab Institute22 sub-acute SCI subjects (13 treatment, 9 controls)12 weeks, 45 mins dailyREL ©stimulationelectrodespush button7

Popovic resultsPopovic et al, Spinal Cord 2006; 44(3):143-151.REL ©8REL ©

Daily FES-assisted exercise produces resultsBUTHow can it realistically be delivered?9

Need to:1. improve device design2. daily exercise training3. quantify outcomes10

1. Improve device designVibration sensor& transmitterelectrodecuffreceiver/stimulatorProchazka US 6,961,623 (2005),Licensed to Bioness Inc.11

Prochazka, Broughton, Kowalczewski, Chong 200712

ImplantedneuroprosthesesLoeb r.f. BionAdvanced Bionicsbattery BionNeurocontrol Freehand13

stim router: implanted lead onlyGan et al 200614

Stim Router wristlet (est. 2008)• minimally invasive, affordable• control 2 or 3 muscles independentlyProchazka 200415

2. Daily exercise trainingGritsenko et al. 200416

“Autocite” constraint-induced therapy systemLum et al. 200617

MIT RobotIMT InmotionPWS systemHocoma Armeo18

Telerehab Joystick(ReJoyce)Kowalczewski et al. US pending19

Rejoyce aims:•Affordable•Multi-task•No loose parts20

Rejoyce ADL games21

tele-rehab22

Replacing hand function23

Simple alternative:toothclick headmouse24

25Simpson et al. 2007

3. Quantify outcomesARAT Hand function test26

Rejoyce hand function test27

Bladder control28

dyssynergiacontractrelaxcontractcontract29

Spinal root stimulationMedtronic extradural sacralroot stimulator for stressincontinenceBrindley Finetech intradural sacralventral root stimulator for SCI (1982)30

Intraspinal microstimulation (ISMS)Nashold et al. 19711960’s: pilot study in spinal cats1970-1980, 25 paraplegic subjectsGood bladder contractionsSphincterotomies neededStim spread to leg and pelvic floor MNs31

Multi-electrode ISMSProchazka, Gaunt, Mushahwar 2002-200532

Problems•invasive•small targets• selective activation•unwanted reflexes• electrode migration•adaptation33

Pudendal nerve stim for stress incontinenceSeveral successful clinical studies 2002-200634

New concept: stim routeractivates pudendal nerve,maintaining continencelow-freq stimstimSkinnerveGaunt et al 2007urethrasphincter35

Hi-freq stim via router inhibitspudendal nerve, allowing voidinghi-freq stim stimSkinnerveGaunt et al 2007Urethra urethrasphincter36

Concept: wireless control of voiding (2009?)pud nerveEUS37

Bladder control conclusions• Stim in and around spinal cord problematic• Pudendal nerve stim by 200938

Summary• FES telerehab for hand function• Stim router: novel neuroprosthesis• Pudendal nerve stim for bladdercontrol39

• Jan Kowalczewski• Valeriya Gritsenko• Robert Gaunt• Liu Shi Gan• Tyler Simpson• Michel Gauthier• Al Denington• Su Ling Chong• Peter Ellaway• Colin Broughton• Canadian Institutes of Health Research• Alberta Heritage Foundation for Medical Research• NIH• International Spinal Research Trust• Alberta Paraplegic Foundation40