P. Hunter Peckham, PhD Address to the Conference

White House/VA Conference
Emerging Technologies in Support of the New Freedom Initiative:
Promoting Opportunities for People with Disabilities October 13-14, 2004

"Functional electrical stimulation (FES) can be used for exercise, muscle conditioning, retraining, and neural prosthetics. " — P. Hunter Peckham, PhD

P. Hunter Peckham received a BS degree in mechanical engineering from Clarkson College of Technology, Potsdam, NY, and MS and PhD degrees in biomedical engineering from Case Western Reserve University (CWRU), Cleveland, Ohio. He is currently a Professor of Biomedical Engineering and Orthopaedics at CWRU and also directs the Rehabilitation Engineering Center in the Department of Orthopaedics based at MetroHealth Medical Center (MHMC), Cleveland. He is Director of the Veterans Affairs (VA) Center of Excellence in Functional Electrical Stimulation (FES), a consortium involving the Cleveland VA Medical Center, CWRU, and MHMC. The FES Center focuses on the clinical development and implementation of systems employing FES to restore control of movement in patients with paralysis. The major area of Dr. Peckham´s research is in rehabilitation engineering and neuroprostheses. Dr. Peckham´s research effort focuses on functional restoration of the paralyzed upper extremity in individuals with spinal cord injury. He and collaborators have developed implantable neural prostheses which utilize electrical stimulation to control neuromuscular activation. They have implemented procedures to provide control of grasp-release in individuals with tetraplegia. This function enables individuals with central nervous system disability to regain the ability to perform essential activities of daily living. His present efforts concern the integration of technological rehabilitation and surgical approaches to restore functional capabilities. He is an awardee of the VA Magnusson Award and a member of the National Academy of Engineering.

I am honored to be asked to speak to you today.

Dr. Mindy Aisen [Director, Rehabilitation Research and Development Service, Office of Research and Development, VA] gave me the title for my talk, "Paralysis: Natural recovery versus assistive technology?" However, as I will try to demonstrate to you natural recovery and assistive technology are not competitive. They are complementary approaches to functional recovery.

Natural recovery can be enhanced or hastened by employing technology. Assistive technologies, such as neuroprostheses that interface directly with the nervous system, can improve function, even in the absence of natural recovery.

Our center, one of the national VA Rehabilitation Research and Development Centers, is focused on developing ways of using functional electrical stimulation (FES) in the peripheral nervous system. What can this do? Of course, many of you know that electrical stimulation can make muscles contract. It can also do numerous other things—stop spasms and activate or suppress networks of cells. Many of us also know about deep brain stimulation, and the incredible impact it´s having on movement disorders. Deep brain stimulation activates groups of neurons and modulates the activity of groups of neurons.

In the case of peripheral activation, we´re working in the domain of cases where the nerves are intact from the spinal cord out to the muscles. This technology can potentially impact groups of people, such as people with spinal cord injury, hemiplegia, head injury, and cerebral palsy.

The use of FES for exercise and muscle conditioning has been highly publicized by the extensive exercise regime the late Christopher Reeve endured throughout the time of his postspinal cord injury.

A second way FES can be beneficial is for retraining, perhaps taking advantage of the neural plasticity of the nervous system, perhaps in conjunction with body weight-supported walking and robotic therapies.

The third scenario is a neural prosthetic, a substitutional approach.

In the area of exercise and muscle conditioning, pressure ulcers are a huge problem. What can we do to manage these? Neuromuscular electrical stimulation can alter intrinsic and extrinsic pressure ulcer risk factors. Some of the intrinsic properties that can cause pressure ulcers are muscle atrophy and decreased blood supply. Electrically induced exercise can build muscle mass, increasing blood supply and decreasing atrophy.

We´ve built muscle mass for neuroprosthetic applications with percutaneous electrodes implanted in the buttock region to stimulate some of the muscles. This simple application increases the size of the muscle, providing cushioning and vascularity to the muscle. Pressure distribution is also modified, which is very important in terms of maintaining tissue health.

The second example is more complex, and is evolving as we speak. The idea of retraining involves the activity-dependent plasticity of the nervous system. Once again, we have employed a percutaneous approach for stimulating muscles in the shoulders of people who have subluxed shoulders. Their shoulders have "fallen out of joint, " which causes severe pain.

With implanted percutaneous electrodes, the shoulder comes back into joint, the subluxation is reduced, and pain is diminished. In some cases, when the pain eases, the patients begin to use their shoulder and function improves.

Another example is using residual voluntary function to trigger activation of paralyzed muscles. We trigger the stimulation of hand muscles with the activity that remains in the wrist extensor muscles, causing the hand to open. Here, a muscle that has voluntary control is activated, and the stimulation can be applied to that muscle or a synergistic muscle (one working in accompaniment with that muscle) to regain use of the hand. We call that an electromyographic (EMG)-triggered stimulation.

Looking at the control group versus the treatment group, EMG-triggered stimulation does not work in all cases. Patients have to have some level of function, but they do experience a greater return to function after applying this technique. Again, we don´t understand why, but our research is working to understand the basis.

In addition, we are exploring a combination of body weight-supported walking and FES to enhance movement. We´re beginning to learn how this technique can be used in rehabilitation to restore function, but we need to know the mechanisms. In this area, Dr. Igo Krebs´ robotic system is being developed in conjunction with Dr. Janis Daley´s work at our Louis Stokes Cleveland Veterans Affairs Medical Center (LSCVAMC).

What happens if recovery patterns cannot be facilitated? Then we might consider a neural prosthetic approach. Neural prostheses can have different applications—bowel and bladder control, upper extremity, lower extremity, standing.

Technology is absolutely, critically important. The question is how will the technology specifically address the needs of people with disabilities?

We´re developing a neural prosthesis for bowel and bladder control. It utilizes, in this case, an implanted receiver, which is an external telemetry device that sends impulses across the skin with a radio frequency technique to an interface with the nerves in the spinal groups pertaining to the bowel and bladder. This device provides voluntary bladder emptying and bowel evacuation.

The cost of the device implanted early on is about the same as a cochlear device. The cost of traditional care—disposable supplies—for people with bowel and bladder control issues is roughly a dollar a day and these are mostly eliminated by the neural prosthesis. After five or six years, the cost of the neural prosthesis is made up and after that there is a cost saving. If you count in the societal costs, the cost of drugs, the cost of treatment for bladder infections and other conditions, a neural prosthesis is a less expensive treatment in the long run.

Another example of an implanted neural prosthesis is one that we´re developing for the upper extremity. Same fundamental concept: An interface with the peripheral nerves is controlled by myoelectric information from the limb. One of our patients, Annette, was a service dog trainer prior to her injury, and has an implanted neural prosthesis in her left hand. She uses the electrical activity, the myoelectric information, from her wrist extensor to control the opening and closing of her hand.

This device is fully implanted, with the exception of an external control and a radio control placed over the device. With this device, she´s able to control the opening and closing of her hand, as well as pinch and hold onto objects. Annette can now perform the activities of daily living; eating, drinking, and grooming

The last thing I want to discuss is a standing transfer system that our colleagues Drs. Ron Triolo and Chip Davis are testing. Same basic configuration: The implantable device and external controller, in this case, are controlled by switches on the hand.

One of our patients, Marcus, has a thoracic level spinal cord injury. With the standing transfer system, he is able to stand up and move into a booth that is inaccessible to him from his wheelchair. The standing transfer system complements the wheelchair as a mobility device and also gives Marcus the ability to perform other functions in an upright position.

Another example is someone who has a high level, C5 spinal cord injury, so transferring people like him from one surface to another is important. It relieves the attendant care needs if the person can lift himself. Standing is provided by the electrical activation. With feet placed on a rotating platform, the person can move from one surface to another-the bed to the wheelchair, for example

In summary , I´ve tried to explain some of the ways FES might be effective in the peripheral motor system to restore function to the individual. FES complements other assistive technologies. It works in conjunction with the other approaches. FES enables recovery to be more complete, faster, and to substitute for the absence of recovery.

Many new opportunities are coming into place. Brain recording is one of them. John Donoghue [professor of neuroscience, Brown University] has told you in the preceding talk about brain recording and activation within dwelling electrodes. New platforms for implantable technology are going to be needed to deliver these tools, as well as new combined therapies and regenerative and neural prosthetic modulation techniques.

We face many challenges. We need to educate and train clinicians and scientists throughout their careers. I cannot speak enough about the importance of making people familiar with these tools during their training. We must prepare the healthcare system for these technologies as well as demonstrate the cost-effectiveness of these tools.

Interdisciplinary teams have been talked about extensively today, and I can´t say enough about how essential they are. In addition to interdisciplinary teams, we must facilitate clinical trials. We need to move things into testing and deployment as early as reasonably possible. We need to manage this regulatory process. It is extremely complex with these new technologies. Many of these new technologies are going to be combinational therapies and the regulatory process is burdensome.

Advanced technology has given us great opportunities to enhance the independence and functioning of people with disabilities. The rest is up to us. Thank you very much. 28

Main Page > Welcome Page > Dr. Peckhan´s Address

	P. Hunter Peckham received a BS degree in mechanical engineering from Clarkson College of Technology, Potsdam, NY, and MS and PhD degrees in biomedical engineering from Case Western Reserve University (CWRU), Cleveland, Ohio. He is currently a Professor of Biomedical Engineering and Orthopaedics at CWRU and also directs the Rehabilitation Engineering Center in the Department of Orthopaedics based at MetroHealth Medical Center (MHMC), Cleveland. He is Director of the Veterans Affairs (VA) Center of Excellence in Functional Electrical Stimulation (FES), a consortium involving the Cleveland VA Medical Center, CWRU, and MHMC. The FES Center focuses on the clinical development and implementation of systems employing FES to restore control of movement in patients with paralysis. The major area of Dr. Peckham´s research is in rehabilitation engineering and neuroprostheses. Dr. Peckham´s research effort focuses on functional restoration of the paralyzed upper extremity in individuals with spinal cord injury. He and collaborators have developed implantable neural prostheses which utilize electrical stimulation to control neuromuscular activation. They have implemented procedures to provide control of grasp-release in individuals with tetraplegia. This function enables individuals with central nervous system disability to regain the ability to perform essential activities of daily living. His present efforts concern the integration of technological rehabilitation and surgical approaches to restore functional capabilities. He is an awardee of the VA Magnusson Award and a member of the National Academy of Engineering.
I am honored to be asked to speak to you today.

Dr. Mindy Aisen [Director, Rehabilitation Research and Development Service, Office of Research and Development, VA] gave me the title for my talk, "Paralysis: Natural recovery versus assistive technology?" However, as I will try to demonstrate to you natural recovery and assistive technology are not competitive. They are complementary approaches to functional recovery.


Natural recovery can be enhanced or hastened by employing technology. Assistive technologies, such as neuroprostheses that interface directly with the nervous system, can improve function, even in the absence of natural recovery.

Our center, one of the national VA Rehabilitation Research and Development Centers, is focused on developing ways of using functional electrical stimulation (FES) in the peripheral nervous system. What can this do? Of course, many of you know that electrical stimulation can make muscles contract. It can also do numerous other things—stop spasms and activate or suppress networks of cells. Many of us also know about deep brain stimulation, and the incredible impact it´s having on movement disorders. Deep brain stimulation activates groups of neurons and modulates the activity of groups of neurons.

In the case of peripheral activation, we´re working in the domain of cases where the nerves are intact from the spinal cord out to the muscles. This technology can potentially impact groups of people, such as people with spinal cord injury, hemiplegia, head injury, and cerebral palsy.

The use of FES for exercise and muscle conditioning has been highly publicized by the extensive exercise regime the late Christopher Reeve endured throughout the time of his postspinal cord injury. A second way FES can be beneficial is for retraining, perhaps taking advantage of the neural plasticity of the nervous system, perhaps in conjunction with body weight-supported walking and robotic therapies. The third scenario is a neural prosthetic, a substitutional approach.

In the area of exercise and muscle conditioning, pressure ulcers are a huge problem. What can we do to manage these? Neuromuscular electrical stimulation can alter intrinsic and extrinsic pressure ulcer risk factors. Some of the intrinsic properties that can cause pressure ulcers are muscle atrophy and decreased blood supply. Electrically induced exercise can build muscle mass, increasing blood supply and decreasing atrophy.

We´ve built muscle mass for neuroprosthetic applications with percutaneous electrodes implanted in the buttock region to stimulate some of the muscles. This simple application increases the size of the muscle, providing cushioning and vascularity to the muscle. Pressure distribution is also modified, which is very important in terms of maintaining tissue health.

The second example is more complex, and is evolving as we speak. The idea of retraining involves the activity-dependent plasticity of the nervous system. Once again, we have employed a percutaneous approach for stimulating muscles in the shoulders of people who have subluxed shoulders. Their shoulders have "fallen out of joint, " which causes severe pain.

With implanted percutaneous electrodes, the shoulder comes back into joint, the subluxation is reduced, and pain is diminished. In some cases, when the pain eases, the patients begin to use their shoulder and function improves.

Another example is using residual voluntary function to trigger activation of paralyzed muscles. We trigger the stimulation of hand muscles with the activity that remains in the wrist extensor muscles, causing the hand to open. Here, a muscle that has voluntary control is activated, and the stimulation can be applied to that muscle or a synergistic muscle (one working in accompaniment with that muscle) to regain use of the hand. We call that an electromyographic (EMG)-triggered stimulation.

Looking at the control group versus the treatment group, EMG-triggered stimulation does not work in all cases. Patients have to have some level of function, but they do experience a greater return to function after applying this technique. Again, we don´t understand why, but our research is working to understand the basis. In addition, we are exploring a combination of body weight-supported walking and FES to enhance movement. We´re beginning to learn how this technique can be used in rehabilitation to restore function, but we need to know the mechanisms. In this area, Dr. Igo Krebs´ robotic system is being developed in conjunction with Dr. Janis Daley´s work at our Louis Stokes Cleveland Veterans Affairs Medical Center (LSCVAMC).

What happens if recovery patterns cannot be facilitated? Then we might consider a neural prosthetic approach. Neural prostheses can have different applications—bowel and bladder control, upper extremity, lower extremity, standing. Technology is absolutely, critically important. The question is how will the technology specifically address the needs of people with disabilities? We´re developing a neural prosthesis for bowel and bladder control. It utilizes, in this case, an implanted receiver, which is an external telemetry device that sends impulses across the skin with a radio frequency technique to an interface with the nerves in the spinal groups pertaining to the bowel and bladder. This device provides voluntary bladder emptying and bowel evacuation.

The cost of the device implanted early on is about the same as a cochlear device. The cost of traditional care—disposable supplies—for people with bowel and bladder control issues is roughly a dollar a day and these are mostly eliminated by the neural prosthesis. After five or six years, the cost of the neural prosthesis is made up and after that there is a cost saving. If you count in the societal costs, the cost of drugs, the cost of treatment for bladder infections and other conditions, a neural prosthesis is a less expensive treatment in the long run.

Another example of an implanted neural prosthesis is one that we´re developing for the upper extremity. Same fundamental concept: An interface with the peripheral nerves is controlled by myoelectric information from the limb. One of our patients, Annette, was a service dog trainer prior to her injury, and has an implanted neural prosthesis in her left hand. She uses the electrical activity, the myoelectric information, from her wrist extensor to control the opening and closing of her hand.

This device is fully implanted, with the exception of an external control and a radio control placed over the device. With this device, she´s able to control the opening and closing of her hand, as well as pinch and hold onto objects. Annette can now perform the activities of daily living; eating, drinking, and grooming

The last thing I want to discuss is a standing transfer system that our colleagues Drs. Ron Triolo and Chip Davis are testing. Same basic configuration: The implantable device and external controller, in this case, are controlled by switches on the hand. One of our patients, Marcus, has a thoracic level spinal cord injury. With the standing transfer system, he is able to stand up and move into a booth that is inaccessible to him from his wheelchair. The standing transfer system complements the wheelchair as a mobility device and also gives Marcus the ability to perform other functions in an upright position.

Another example is someone who has a high level, C5 spinal cord injury, so transferring people like him from one surface to another is important. It relieves the attendant care needs if the person can lift himself. Standing is provided by the electrical activation. With feet placed on a rotating platform, the person can move from one surface to another-the bed to the wheelchair, for example

In summary , I´ve tried to explain some of the ways FES might be effective in the peripheral motor system to restore function to the individual. FES complements other assistive technologies. It works in conjunction with the other approaches. FES enables recovery to be more complete, faster, and to substitute for the absence of recovery.

Many new opportunities are coming into place. Brain recording is one of them. John Donoghue [professor of neuroscience, Brown University] has told you in the preceding talk about brain recording and activation within dwelling electrodes. New platforms for implantable technology are going to be needed to deliver these tools, as well as new combined therapies and regenerative and neural prosthetic modulation techniques.

We face many challenges. We need to educate and train clinicians and scientists throughout their careers. I cannot speak enough about the importance of making people familiar with these tools during their training. We must prepare the healthcare system for these technologies as well as demonstrate the cost-effectiveness of these tools.

Interdisciplinary teams have been talked about extensively today, and I can´t say enough about how essential they are. In addition to interdisciplinary teams, we must facilitate clinical trials. We need to move things into testing and deployment as early as reasonably possible. We need to manage this regulatory process. It is extremely complex with these new technologies. Many of these new technologies are going to be combinational therapies and the regulatory process is burdensome.

Advanced technology has given us great opportunities to enhance the independence and functioning of people with disabilities. The rest is up to us. Thank you very much. 28

White House/VA Conference Emerging Technologies in Support of the New Freedom Initiative: Promoting Opportunities for People with Disabilities October 13-14, 2004

"Functional electrical stimulation (FES) can be used for exercise, muscle conditioning, retraining, and neural prosthetics. " — P. Hunter Peckham, PhD

White House/VA Conference
Emerging Technologies in Support of the New Freedom Initiative:
Promoting Opportunities for People with Disabilities October 13-14, 2004