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    Simulator information

    SUMMARY
    OF
    RESULTS
    AND
    SETTINGS
    Four
    different
    programs
    have
    been
    saved
    on
    your
    stimulator
    that
    can
    be
    accessed
    by
    the
    remote
    control
    and
    are
    named
    Program
    D1,
    D2,
    D3,
    D4.
    All
    programs
    have
    a
    fixed
    frequency
    of
    40Hz
    and
    a
    pulse
    width
    of
    200ms.
    The
    amplitude/intensity
    of
    stimulation
    can
    be
    adjusted
    through
    the
    remote
    control,
    as
    was
    explained
    when
    you
    were
    here.
    Stimulation
    configuration
    of
    Program
    D1--‐4
    With
    each
    program,
    a
    different
    combination
    of
    electrodes
    is
    activated
    on
    the
    array
    that
    has
    been
    implanted
    on
    your
    spinal
    cord.
    See
    program
    name
    and
    configuration
    below:
    D1
    D2
    D3
    D4
    Generalization
    of
    functional
    outcome
    D1:
    whole
    leg
    activation
    L
    +
    R
    (extensors
    and
    flexors)
    D2:
    hip
    flexion
    and
    adduction
    D3:
    knee
    extension
    D4:
    knee/hip
    extension
    and
    adduction
    Activation
    for
    training
    standing
    For
    training
    standing
    you
    want
    to
    increase
    mostly
    extensor
    activity
    (with
    little
    flexor
    activity
    for
    stabilization).
    For
    this
    reason
    the
    best
    program
    to
    use
    while
    training
    standing
    is
    a
    combination
    of
    D1
    and
    D4.
    The
    intensity
    of
    these
    programs
    needs
    to
    be
    tuned
    properly
    to
    have
    a
    balance
    between
    activation
    of
    flexors
    and
    extensors.
    We
    saw
    that
    this
    can
    most
    easily
    be
    checked
    when
    looking
    at
    the
    muscle
    activation
    of
    the
    thigh,
    just
    above
    the
    knee.
    Best
    is
    to
    balance
    the
    muscle
    activation
    so
    you
    have
    a
    bit
    more
    activation
    of
    extensors
    (frontside
    of
    leg)
    compared
    to
    flexors
    (backside
    of
    leg).
    Be
    careful
    to
    start
    with
    low
    intensity
    around
    the
    threshold
    for
    muscle
    activation
    (see
    below).
    Starting
    at
    high
    intensity
    will
    give
    a
    ‘hock’effect
    when
    stimulation
    is
    started.
    At
    a
    later
    stage
    of
    training,
    to
    perform
    a
    flexion
    movement
    at
    the
    hip
    e.g.
    for
    lifting
    the
    knee,
    it
    might
    be
    helpful
    to
    involve
    program
    D2,
    but
    this
    all
    depends
    on
    the
    results
    of
    training.
    Threshold
    for
    muscle
    activation
    The
    thresholds
    can
    change
    quite
    a
    bit
    when
    comparing
    different
    positions
    such
    as
    lying
    down
    or
    standing.
    The
    threshold
    for
    muscle
    activation
    for
    Program
    D1
    +
    D4
    was
    around
    2.8--‐3.0V.
    This
    is
    when
    you
    start
    seeing
    the
    first
    signs
    of
    activation
    of
    muscles
    in
    the
    legs.
    Optimal
    stimulation
    for
    muscle
    activation
    for
    standing
    The
    goal
    for
    the
    most
    appropriate
    training,
    is
    to
    find
    the
    optimal
    stimulation
    for
    1)
    activating
    the
    legs
    with
    stimulation,
    combined
    with
    2)
    the
    possibility
    to
    activate
    your
    legs
    yourself.
    This
    can
    be
    different
    from
    day
    to
    day
    (especially
    when
    you
    start
    using
    stimulation),
    this
    can
    change
    within
    a
    session
    (due
    to
    e.g.
    fatigue),
    and
    can
    evolve
    with
    training.
    So
    the
    optimal
    setting
    should
    be
    quickly
    checked
    every
    time
    you
    use
    the
    stimulation,
    to
    see
    if
    it
    can
    be
    optimized.
    Careful:
    this
    can
    be
    either
    an
    increase
    or
    a
    decrease
    of
    intensity.
    As
    pointed
    out
    above,
    first
    start
    stimulation
    around
    the
    threshold,
    then
    gradually
    increase
    the
    intensity
    until
    the
    point
    where
    you
    see
    good
    muscle
    activation
    for
    standing.
    --‐ Start
    with
    increasing
    the
    intensity
    of
    1
    program
    e.g.
    Program
    D4
    and
    tune
    the
    extensor
    activity
    of
    the
    leg
    above
    the
    knee
    on
    the
    frontside
    of
    the
    leg.
    --‐ When
    you
    see
    nice
    activation,
    change
    to
    Program
    D1
    and
    tune
    the
    intensity
    of
    this
    program
    as
    well,
    activating
    (together
    with
    others)
    the
    muscles
    above
    the
    knee
    on
    the
    backside
    of
    the
    leg.
    --‐ Usually
    you’l
    have
    to
    go
    back
    to
    Program
    D4
    to
    adjust
    a
    little
    bit,
    to
    balance
    out
    the
    activation
    between
    the
    frontside
    and
    backside
    of
    the
    leg.
    Here
    we
    found
    quite
    a
    difference
    between
    the
    two
    days.
    --‐
    DAY
    1:
    Program
    D1
    optimal:
    6.8V
    Program
    D4
    optimal:
    5V
    --‐
    DAY
    2:
    Program
    D1
    optimal:
    9.4V
    Program
    D4
    optimal:
    8V
    What
    we
    saw
    was
    that
    on
    Day
    1
    you
    were
    able
    to
    willingly
    decrease
    the
    activation
    of
    muscles
    (that
    were
    activated
    by
    stimulation),
    however
    this
    happened
    when
    you
    tried
    to
    activate
    the
    legs.
    On
    Day
    2
    you
    also
    showed
    what
    you
    showed
    on
    Day
    1,
    however
    on
    this
    day
    you
    were
    also
    able
    to
    increase
    the
    activation
    of
    extensor
    muscles
    of
    the
    leg,
    which
    are
    needed
    to
    stand.
    This
    is
    very
    appropriate/useful
    activation
    to
    learn
    and
    improve
    active
    standing.
    And
    this
    is
    what
    should
    be
    trained.
    REMINDER:
    the
    stimulation
    has
    been
    optimized
    for
    training
    standing,
    since
    it
    focuses
    on
    constantly
    activating
    mainly
    extensor
    muscles
    and
    whole
    limb
    extension
    for
    bearing
    weight
    on
    your
    legs.
    This
    is
    the
    first
    task
    that
    should
    be
    trained.
    If
    rhythmic
    movements
    can
    be
    made
    voluntarily
    with
    bending
    and
    straightening
    both
    legs
    independently,
    another
    program
    should
    be
    used
    to
    optimize
    the
    training
    of
    such
    movements.
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