Neural Interfacing Architecture Enables Enhanced Motor Control and Residual Limb Functionality Postamputation
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Neural interfacing architecture enables enhanced motor control and residual limb functionality postamputation Shriya S. Srinivasana,b,c,1, Samantha Gutierrez-Arangoa, Ashley Chia-En Tengd, Erica Israela, Hyungeun Songa,b, Zachary Keith Baileya,e, Matthew J. Cartya,f,c, Lisa E. Freeda,b, and Hugh M. Herra,c,1 aMIT Center for Extreme Bionics, Biomechatronics Group, Massachusetts Institute of Technology, Cambridge, MA 02139; bHarvard-MIT Program in Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA 02139; cHarvard Medical School, Boston, MA 02114; dDepartment of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139; eDepartment of Mechanical Engineering, United States Air Force Academy, Colorado Springs, CO 80920; and fDivision of Plastics and Reconstructive Surgery, Brigham and Women’s Hospital, Boston, MA 02114 Edited by Peter L. Strick, University of Pittsburgh, Pittsburgh, PA, and approved December 30, 2020 (received for review September 16, 2020) Despite advancements in prosthetic technologies, patients with excurse, causing cocontraction of muscles and changing gait amputation today suffer great diminution in mobility and quality patterns (11–14). Together, these peripheral and central modi- of life. We have developed a modified below-knee amputation fications result in the poor production of efferent signals for (BKA) procedure that incorporates agonist–antagonist myoneural direct myoelectric control (15, 16). To compensate for these interfaces (AMIs), which surgically preserve and couple agonist– shortcomings, considerable effort has been spent on developing antagonist muscle pairs for the subtalar and ankle joints. AMIs are and deploying pattern-recognition–based myoelectric control designed to restore physiological neuromuscular dynamics, enable strategies (17–19). However, even with these advanced myo- bidirectional neural signaling, and offer greater neuroprosthetic electric devices and controllers, end users find their operation controllability compared to traditional amputation techniques. In cumbersome and time consuming (20). Motor control is also this prospective, nonrandomized, unmasked study design, 15 sub- challenged by the lack of proprioceptive sensory feedback from jects with AMI below-knee amputation (AB) were matched with 7 prostheses (12, 21–23). Together, the limitations of the current subjects who underwent a traditional below-knee amputation amputation approaches significantly lower the quality of life for (TB). AB subjects demonstrated significantly greater control of persons with amputation (24–27). ENGINEERING their residual limb musculature, production of more differentiable In recognition of these shortcomings, surgical researchers have efferent control signals, and greater precision of movement com- recently begun to explore new strategies to modify standard pared to TB subjects (P < 0.008). This may be due to the presence amputation procedures. Targeted muscle reinnervation (TMR) of greater proprioceptive inputs facilitated by the significantly (28, 29) and regenerative peripheral nerve interfaces (RPNIs) higher fascicle strains resulting from coordinated muscle excursion (30, 31) represent approaches that are designed to provide greater in AB subjects (P < 0.05). AB subjects reported significantly greater efferent motor signals for myoelectric control and mitigate neuroma phantom range of motion postamputation (AB: 12.47 ± 2.41, TB: – pain. However, neither approach offers muscle tendon afferent NEUROSCIENCE 10.14 ± 1.45 degrees) when compared to TB subjects (P < 0.05). Furthermore, AB subjects also reported less pain (12.25 ± 5.37) Significance than TB subjects (17.29 ± 10.22) and a significant reduction when compared to their preoperative baseline (P < 0.05). Compared with Despite advancements in prosthetic technologies, persons with traditional amputation, the construction of AMIs during amputa- amputation today suffer great diminution in mobility and tion confers the benefits of enhanced physiological neuromuscular quality of life. This is largely due to an outdated amputation dynamics, proprioception, and phantom limb perception. Subjects’ paradigm that precludes efficacious communication between activation of the AMIs produces more differentiable electromyog- the residual limb and prosthesis. An amputation method uti- raphy (EMG) for myoelectric prosthesis control and demonstrates lizing agonist–antagonist myoneural interfaces (AMIs) con- more positive clinical outcomes. structs neuromuscular substrates in the residual limb to avail enhanced sensorimotor signaling. In our study, subjects with neural engineering | amputation | physiology | sensory feedback | AMI amputation demonstrate improved motor control, phan- prosthetics tom sensations, range of motion, and decreased pain when compared to patients with traditional amputation. With the he standard-of-care surgical approach to amputation has not demonstrated increases in motor coordination and position Tseen considerable innovation since its conception in the mid- differentiation, our results suggest that patients with AMI 1800s (1), despite significant progress in biomechatronics and amputation will be able to more efficaciously control bionic advanced reconstructive techniques. The typical amputation prostheses. procedure neglects neurological substrates and disrupts key neuromuscular relationships responsible for bidirectional (ef- Author contributions: S.S.S., M.J.C., and H.M.H. designed research; S.S.S., S.G.-A., E.I., H.S., ferent, afferent) signaling. The deafferentation of lower motor Z.K.B., M.J.C., and L.E.F. performed research; S.S.S., S.G.-A., A.C.-E.T., E.I., Z.K.B., M.J.C., and L.E.F. analyzed data; and S.S.S., M.J.C., L.E.F., and H.M.H. wrote the paper. neurons triggers central reorganization of motor circuits, which Competing interest statement: H.M.H., M.J.C., and S.S.S. hold a patent related to AMI negatively impacts motor imagery and motor coordination (2, 3) surgical amputation procedures. and results in significant neuroma pain (4–6), phantom pain (7), This article is a PNAS Direct Submission. and maladaptive or diminishing phantom sensation (8–10). ’ This open access article is distributed under Creative Commons Attribution-NonCommercial- Phantom sensation, the perception of one s phantom limb while NoDerivatives License 4.0 (CC BY-NC-ND). at rest and in motion, is an important component of motor im- 1To whom correspondence may be addressed. Email: [email protected] or hherr@media. agery utilized in the preparation of motor control commands and mit.edu. can be a source of chronic irritation, if unpleasant. The hap- This article contains supporting information online at https://www.pnas.org/lookup/suppl/ hazard arrangement and myodesis of residual musculature fur- doi:10.1073/pnas.2019555118/-/DCSupplemental. ther constrain the ability for individual muscles to dynamically Published February 15, 2021. PNAS 2021 Vol. 118 No. 9 e2019555118 https://doi.org/10.1073/pnas.2019555118 | 1of8 Downloaded by guest on September 24, 2021 proprioceptive signaling, which is physiologically mediated by reinnervation (38), and another had undergone an osteomyoplastic “Ertl” agonist–antagonist muscle dynamics and critical for trajectory amputation (39, 40), techniques not specifically aimed at restoring mus- planning, fine motor control, and reflexes (32, 33). culotendinous proprioceptive feedback. Since our outcome measures were The agonist–antagonist myoneural interface (AMI) is a more largely targeted on aspects influenced by musculotendinous propriocep- recent surgical approach and neural interfacing strategy designed tion, we grouped these subjects in the TB category. to augment volitional motor control and restore muscle–tendon – Randomization and Blinding. Participant allocation was nonrandomized, and proprioception (11, 12, 34 37) by surgically coapting agonist and the study was not blinded as the AB cohort was drawn from a pool of patients antagonist muscles to restore natural physiological muscle pairing who had previously undergone the AMI BKA procedure at the Brigham and and dynamics. When the agonist muscle contracts, the antagonist Women’s Hospital (under NCT03374319) by Matthew Carty. Willingness to muscle stretches (or vice versa), giving rise to musculotendinous enroll in complementary functional outcomes testing at MIT was included as afferent feedback from muscle spindle fibers (length and velocity) an eligibility criterion for enrollment in the Brigham and Women’s Hospital and Golgi tendon organs (force). For each joint in a bionic limb, trial. Each subject in the TB cohort was prospectively matched to a subject one AMI is surgically constructed in the residuum. Functional within the AMI group to the degree possible based on age and time since electrical stimulation (FES) applied to the antagonist muscle of amputation. the AMI can provide force or position feedback onto the agonist (or vice versa) from a bionic prosthesis to inform the user of Interventions. Participants in the AB cohort had received two surgically prosthetic torque or position, respectively (11). In Clites et al. (11), constructed AMIs in their residuum during their amputation according to the method described in ref. 12 (Fig. 1A). Briefly, AMIs were constructed for the an early human subject with an AMI amputation demonstrated ankle and subtalar joints; the tibialis anterior (TA) and lateral gastrocnemius dynamic muscle excursions, individualized contraction of each (LG) were