tag:theconversation.com,2011:/ca/topics/paralysis-2852/articlesParalysis – The Conversation2022-08-21T20:03:12Ztag:theconversation.com,2011:article/1889892022-08-21T20:03:12Z2022-08-21T20:03:12ZThe latest polio cases have put the world on alert. Here’s what this means for Australia and people travelling overseas<figure><img src="https://images.theconversation.com/files/479994/original/file-20220818-459-q63sig.jpg?ixlib=rb-1.1.0&rect=1%2C1%2C997%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/covid-19-measles-ebola-vaccinated-doctor-2120184491">Shutterstock</a></span></figcaption></figure><p>Until recently, polio had only been detected in a handful of countries, thanks to global eradication efforts.</p>
<p>But this year’s polio alerts in the United States, United Kingdom and Israel are a reminder that as long as poliovirus is found anywhere, it is a potential problem everywhere. </p>
<p>That could include Australia.</p>
<p>Here’s what the latest polio cases mean for Australia – including under-vaccinated communities and people travelling internationally.</p>
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<h2>The US case</h2>
<p>In July this year, a young man in Rockland County, New York, developed paralysis and was diagnosed with polio, the <a href="https://www.statnews.com/2022/07/21/n-y-state-detects-polio-case-first-in-the-u-s-since-2013/">first US case since 2013</a>.</p>
<p>He had never been vaccinated against polio, which is not uncommon among <a href="https://forward.com/news/512089/polio-rockland-county-new-york-vaccine-orthodox-jew/">Orthodox Jewish people</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8549591/">in some countries</a>. Rockland County has the highest percentage of Orthodox Jewish people in the US. Currently, only <a href="https://health.ny.gov/diseases/communicable/polio/county_vaccination_rates.htm">about 60%</a> of children in the county are vaccinated against polio, compared with <a href="https://www.cdc.gov/nchs/fastats/immunize.htm">more than 90%</a> nationally.</p>
<p>As of August 12, poliovirus was <a href="https://www1.nyc.gov/site/doh/about/press/pr2022/nysdoh-and-nycdohm-wastewater-monitoring-finds-polio-urge-to-get-vaccinated.page">still being detected</a> in sewage in New York City and other counties in New York State, indicating the virus is still circulating in the community.</p>
<p>The reason there have been no further cases of paralysis reflects the fact that only around <a href="https://www.who.int/news-room/fact-sheets/detail/poliomyelitis">one in 200 people</a> infected by the virus develops paralysis. </p>
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Read more:
<a href="https://theconversation.com/polio-in-new-york-an-infectious-disease-doctor-explains-this-exceedingly-rare-occurrence-187518">Polio in New York – an infectious disease doctor explains this exceedingly rare occurrence</a>
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<h2>A child in Israel</h2>
<p>One <a href="https://twitter.com/propublica/status/1558140096028737539">indirect link</a> to the New York man may be in Jerusalem where, in March 2022, poliovirus <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON366">was found</a> in sewage and <a href="https://www.nature.com/articles/s41564-022-01201-0">one case</a> of paralysis occurred in an unvaccinated child.</p>
<p>Vaccination rates among Ultra-Orthodox Jewish people in Israel have been historically low, including <a href="https://apnews.com/article/coronavirus-pandemic-health-middle-east-religion-israel-557e9d18f3f78f4fc141eeddaaefb8eb">low uptake</a> of COVID vaccines.</p>
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<h2>UK ramps up vaccination</h2>
<p>In June this year, the UK government <a href="https://www.gov.uk/government/news/poliovirus-detected-in-sewage-from-north-and-east-london">reported</a> wastewater surveillance in north and east London between February and May had identified poliovirus on consecutive occasions. </p>
<p>This indicated a provisional “silent” outbreak and prompted health officials to instigate catch-up vaccination campaigns. No cases of paralysis have been reported.</p>
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<p>This is reminiscent of an earlier “silent” outbreak of polio in 2013-2014 when, after decades without a case, Israel <a href="https://www.pnas.org/doi/10.1073/pnas.1808798115">detected</a> poliovirus in wastewater samples in many areas, mainly in southern regions.</p>
<p>Stool surveys indicated the outbreak was restricted mainly to children under the age of ten in the Bedouin population of <a href="https://pubmed.ncbi.nlm.nih.gov/27334457/">southern Israel</a>. The virus originated in Pakistan and arrived in Israel via Cairo and then, probably, through Bedouin communities in Egypt and Israel.</p>
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Read more:
<a href="https://theconversation.com/polio-vaccine-boosters-offered-to-london-children-an-expert-explains-whats-going-on-188564">Polio vaccine boosters offered to London children – an expert explains what's going on</a>
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<h2>Hang on, hasn’t polio been eradicated?</h2>
<p>It’s tempting to think polio has been eradicated. </p>
<p>The last case of locally acquired polio in Australia <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/cda-pubs-cdi-2002-cdi2602-cdi2602l.htm">was in 1972</a>. Australia was declared polio-free on October 29, 2000, along with the other 36 countries in the Western Pacific Region of the World Health Organization. The last case reported in Australia <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2660702/">was in 2007</a>, when a student contracted the infection in Pakistan.</p>
<p>The <a href="https://polioeradication.org">Global Polio Eradication Initiative</a>, launched in 1988, successfully eliminated wild poliovirus from all but two countries – Pakistan and Afghanistan – where in recent years there have been very few cases. </p>
<p>In <a href="https://polioeradication.org/where-we-work/afghanistan/">Afghanistan</a>, there were four cases last year and one so far this year. In <a href="https://polioeradication.org/where-we-work/pakistan/">Pakistan</a>, there was one case in 2021 and 14 so far this year.</p>
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Read more:
<a href="https://theconversation.com/polio-were-developing-a-safer-vaccine-that-uses-no-genetic-material-from-the-virus-185721">Polio: we're developing a safer vaccine that uses no genetic material from the virus</a>
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<p>The recent cases and wastewater detected polioviruses in the UK, US and Israel are not the wild variety. Instead, they are derived from the oral polio vaccine.</p>
<p>When a child receives a dose of the oral vaccine, they excrete the virus in the stool for several weeks. In very rare cases, the vaccine-derived virus mutates to a form that causes paralysis. This form is called a circulating vaccine-derived poliovirus (cVDPV). This occurs only in populations where polio vaccine coverage is low.</p>
<p>Just recently, cVDPV was reported in the Democratic Republic of the Congo, Mozambique and Yemen, as well as in wastewater in five other countries.</p>
<p>Australia, like all high-income countries, does not use the oral polio vaccine. Instead, children receive <a href="https://immunisationhandbook.health.gov.au/contents/vaccine-preventable-diseases/poliomyelitis">injectable inactivated polio vaccine</a>, which prevents paralysis but does not prevent transmission of the virus. </p>
<p>This is why so-called silent outbreaks can occur in countries that use the injectable vaccine. This is when the virus spreads from child to child but does not cause paralysis.</p>
<h2>What are the implications for Australia?</h2>
<p>Given Australia’s open international borders, there is no reason why someone who has recently received the oral polio vaccine wouldn’t enter the country and excrete the virus.</p>
<p>In Australia, at the age of five, <a href="https://www.health.gov.au/node/38782/childhood-immunisation-coverage/current-coverage-data-tables-for-all-children#five-year-olds">about 95% of children</a> are fully vaccinated against polio. </p>
<p>However, there are places with lower vaccine coverage, such as <a href="https://www.theguardian.com/australia-news/2021/aug/14/when-covid-came-to-the-anti-vax-capital-of-australia">Byron Shire</a> in northern New South Wales, with lower rates of childhood vaccination, including against polio.</p>
<p>This vaccine-hesitant community is vulnerable to the introduction of polio and has had cases of diphtheria, whooping cough, measles and tetanus in recent years.</p>
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<p>Unlike some other Orthodox Jewish communities overseas, there is no evidence this community in Australia is more vaccine hesitant than other Australians.</p>
<h2>How do we look out for cases?</h2>
<p>For years, wastewater monitoring has been routinely implemented in many countries. This acts as an early warning system to identify and rapidly mitigate the spread of many pathogens, <a href="https://theconversation.com/sewage-surveillance-is-the-next-frontier-in-the-fight-against-polio-105012">including poliovirus</a>, hepatitis viruses and, recently, SARS-CoV-2 (the virus that causes COVID).</p>
<p>At wastewater treatment facilities, sewage from an entire region is combined. This allows scientists to <a href="https://www.nature.com/articles/s41564-022-01201-0">detect pathogens</a> at the population level and before anyone presents with symptoms.</p>
<p>In December 2017, Victoria’s environmental testing program <a href="https://www.health.vic.gov.au/media-releases/health-surveillance-system-detects-poliovirus">detected</a> a rare type of poliovirus in pre-treated sewage from the Western Treatment Plant in Melbourne. </p>
<p>No cases of paralytic polio were detected but all Victorians up to the age of 19 were offered three doses of vaccine, free of charge, as part of catch-up arrangements.</p>
<p>Australia’s poliovirus infection outbreak response plan <a href="https://www.health.gov.au/sites/default/files/documents/2022/05/poliovirus-infection-outbreak-response-plan-for-australia.pdf">focuses on</a> clinical surveillance (where health workers report suspected cases to health authorities) and laboratory investigations of people who present with acute paralysis. </p>
<p>While the plan refers to examples of wastewater surveillance overseas, it does not propose a specific strategy in Australia. </p>
<p>Other than Victoria, it is not clear where wastewater polio surveillance is being conducted in Australia.</p>
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Read more:
<a href="https://theconversation.com/sewage-surveillance-is-the-next-frontier-in-the-fight-against-polio-105012">Sewage surveillance is the next frontier in the fight against polio</a>
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<h2>What happens next?</h2>
<p>Australia is just as vulnerable to importations of poliovirus – both wild and vaccine-derived – as any other country.</p>
<p>Australia should ensure routine wastewater surveillance for poliovirus is conducted, at least in metropolitan areas.</p>
<p>Community-based vaccination campaigns should be sensitively conducted in vaccine-hesitant communities, such as in Byron Shire, to achieve high coverage.</p>
<p>Education should also be provided through GPs to parents planning to travel to Jerusalem, New York City and Rockland County. They should ensure all travelling family members are fully vaccinated against polio. Visitors to Israel may be able to access a dose of oral polio vaccine in that country for their children (which will prevent them being infected) but this is not available in the US.</p>
<p>Poliovirus enters the body through the mouth, usually from hands contaminated with the stool of an infected person. So parents should also pay special attention to their children’s hand hygiene, particularly if travelling overseas to any of the locations mentioned.</p><img src="https://counter.theconversation.com/content/188989/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Toole receives funding from the National Health and Medical Research council.</span></em></p>Polio cases in the US, UK and Israel remind us that this could also happen in Australia. Here’s what we should watch out for.Michael Toole, Associate Principal Research Fellow, Burnet InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1154182022-03-30T12:39:37Z2022-03-30T12:39:37ZRestoring touch through electrodes implanted in the human brain will require engineering around a sensory lag<figure><img src="https://images.theconversation.com/files/454006/original/file-20220323-19-gkft50.jpg?ixlib=rb-1.1.0&rect=709%2C0%2C4832%2C2928&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The brain responds differently to natural touch on a finger versus a direct electrical stimulation.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/finger-reaching-for-a-brain-illustration-royalty-free-illustration/1215123867">Sebastian Kaulitzki/Science Photo Library</a></span></figcaption></figure><p>More than 5 million people in the United States are affected by <a href="https://doi.org/10.2105/AJPH.2016.303270">limb loss or paralysis</a>. Technological devices that directly interact with the brain, known as <a href="http://bci.cs.washington.edu/">brain-computer interfaces</a>, offer the potential to decode an individual’s thoughts and translate them into action <a href="https://www.youtube.com/watch?v=6h60UjIGGV4">using a robotic arm</a> or <a href="https://www.youtube.com/watch?v=9oka8hqsOzg">a cursor on a screen</a>. These neuroprosthetics can take the place of an amputated or paralyzed arm, for instance, helping the user take an action.</p>
<p>Much research in this field to date has focused on decoding brain signals – what is it that the person wants to do?</p>
<p>But there’s another equally important part of any real-world prosthetic system. It needs to be able to convey information in the other direction, too, back to the brain to provide feedback from the external world. Think about how challenging it would be to interact with the world in the absence of touch. Tasks such as lighting a match, picking up an egg and grasping a coffee cup become tremendously difficult.</p>
<p>At the University of Washington’s <a href="https://centerforneurotech.uw.edu/">Center for Neurotechnology</a>, our team is working out how best to <a href="https://www.youtube.com/watch?v=7t84lGE5TXA&t=13s">engineer stimulation to the brain</a> to restore tactile sensations that allow people to perform useful tasks. To this end, we are studying how people respond to sensation triggered by electrical stimulation of the brain. Our goal is to help devise a system that someday will allow someone who has lost the sense of touch to feel a loved one’s hand again.</p>
<h2>Speed of natural touch versus brain stimulation</h2>
<p>Collaborating with neurosurgeons <a href="https://scholar.google.com/citations?user=zQJMnscAAAAJ&hl=en&oi=ao">Jeffrey Ojemann</a> and <a href="https://scholar.google.com/citations?user=78GnqoAAAAAJ&hl=en&oi=ao">Andrew Ko</a>, we rely on patient volunteers who generously allow us to carry out research while they are undergoing treatment for epilepsy.</p>
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<a href="https://images.theconversation.com/files/454007/original/file-20220323-15-19jmijp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="patient with head immobilized in surgical suite" src="https://images.theconversation.com/files/454007/original/file-20220323-15-19jmijp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/454007/original/file-20220323-15-19jmijp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/454007/original/file-20220323-15-19jmijp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/454007/original/file-20220323-15-19jmijp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/454007/original/file-20220323-15-19jmijp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/454007/original/file-20220323-15-19jmijp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/454007/original/file-20220323-15-19jmijp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Many brain surgeries are performed with the patient awake and able to provide live feedback.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/photo-essay-at-the-regional-university-hospital-of-lille-news-photo/151046906">BSIP/Universal Images Group via Getty Images</a></span>
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<p>To help localize the origin of a patient’s seizures prior to removing brain tissue to potentially help their epilepsy, Ojemann and Ko temporarily implant small, metal electrodes on top of and within the patient’s brain. These electrodes monitor the brain’s epileptic seizures so the neurosurgeons know where – and where not – to operate.</p>
<p>Our experiments use those same electrodes in two ways. We can record the electrical activity of the brain’s neurons. And we are also able to inject small amounts of electric current into specific parts of the brain. When we send a small burst of electricity to the touch-processing areas of the brain, the person experiences tactile sensations. In other words, when we activate particular neurons with electricity, the volunteer experiences it as if we were touching a particular part of their body.</p>
<p>In one study, we wanted to understand which tactile sensation <a href="https://doi.org/10.1038/s41598-019-38619-2">an individual would perceive faster</a> – artificial stimulation due to direct electrical stimulation of the brain via electrode, or natural tactile sensation due to a real touch on the patient’s hand?</p>
<p>We asked our subjects to press a button as quickly as possible using the hand opposite to where they felt the sensation. They were blindfolded to eliminate the potential for visual feedback that might confound our results.</p>
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<a href="https://images.theconversation.com/files/455100/original/file-20220329-21-1rzyey5.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Line drawing illustrates slower response time to direct electrical stimulation of the brain" src="https://images.theconversation.com/files/455100/original/file-20220329-21-1rzyey5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/455100/original/file-20220329-21-1rzyey5.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=412&fit=crop&dpr=1 600w, https://images.theconversation.com/files/455100/original/file-20220329-21-1rzyey5.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=412&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/455100/original/file-20220329-21-1rzyey5.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=412&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/455100/original/file-20220329-21-1rzyey5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=517&fit=crop&dpr=1 754w, https://images.theconversation.com/files/455100/original/file-20220329-21-1rzyey5.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=517&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/455100/original/file-20220329-21-1rzyey5.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=517&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Response times to direct stimulation of neurons in the brain were slower than response times to natural touch.</span>
<span class="attribution"><span class="source">Caldwell and Rao</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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<p>What we discovered was surprising. Individuals responded <a href="https://www.nature.com/articles/s41598-019-38619-2#Sec2">more slowly to direct stimulation</a> of their brain’s primary somatosensory cortex compared to a natural touch to their fingers. Even though an electric signal directly from the electrode in the brain bypassed all the peripheral nerves between the hand and head, the signal that traveled the longer journey up the ascending sensory nerves registered first.</p>
<p>This result held up even when we tested subjects again after a short break, suggesting that it cannot be explained solely as a novel sensation that the subjects needed time to learn. </p>
<p>[<em>The Conversation’s science, health and technology editors pick their favorite stories.</em> <a href="https://memberservices.theconversation.com/newsletters/?nl=science&source=inline-science-favorite">Weekly on Wednesdays</a>.]</p>
<p><a href="https://doi.org/10.1088/1741-2560/11/4/046025">Previous studies in nonhuman primates</a> have found similar delays in reaction time relative to natural touch when researchers delivered electrical stimulation to a single location within somatosensory cortex. On the other hand, more recent research using multiple electrodes to stimulate somatosensory cortex in nonhuman primates found that such electrical stimulation could elicit response times <a href="https://doi.org/10.1088/1741-2552/ab5cf3">slightly faster than natural touch</a>.</p>
<p>Together, these studies demonstrate the complexities of stimulating the brain to replace natural tactile feedback. Future technologies and engineering strategies will need to take into account variability in touch sensation depending on how electrical stimulation is targeted in the brain.</p>
<h2>Engineering around a sensory lag</h2>
<p>By discovering a delay in how people respond to direct electrical stimulation of their brains, we have revealed potential limitations in how current engineered solutions perform. The delay might limit how well future sensory neuroprosthetic devices using these clinical electrodes can work.</p>
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<a href="https://images.theconversation.com/files/454009/original/file-20220324-21-198dllb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="hand removes egg from carton" src="https://images.theconversation.com/files/454009/original/file-20220324-21-198dllb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/454009/original/file-20220324-21-198dllb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/454009/original/file-20220324-21-198dllb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/454009/original/file-20220324-21-198dllb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/454009/original/file-20220324-21-198dllb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/454009/original/file-20220324-21-198dllb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/454009/original/file-20220324-21-198dllb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Fine motor movements – like picking up an egg without crushing it – rely on calibrating the effort based on what your sense of touch tells you.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/hand-selected-egg-in-egg-box-royalty-free-image/1367295987">Jackyenjoyphotography/Moment via Getty Images</a></span>
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<p><a href="https://www.youtube.com/watch?v=FUqgVHR6mpQ">Designers may need</a> to account for a significant lag in artificial sensation relative to natural touch. For instance, if a user doesn’t receive feedback from touch sensors on a robotic hand quickly enough, and the overall system does not account for this delay in perception, someone attempting to pick up an egg with a robotic hand could apply too much pressure and crush it.</p>
<p>To improve reaction times and more broadly to enhance the utility of direct brain stimulation, we will need to take into account ongoing brain activity and tailor the electrical stimulation patterns for each person’s brain and the task at hand.</p>
<p>To achieve this goal, we have recently proposed a <a href="https://www.youtube.com/watch?v=DH5HBQD69oI">new type of brain-computer interface</a> called a <a href="https://arxiv.org/abs/2012.03378">brain co-processor</a>, which uses artificial intelligence to compute the best stimulation patterns for a task given current brain activity. Such an approach allows multiple electrodes to be used, possibly targeting multiple regions, and relies on co-adaptation with the brain to better approximate natural sensations. </p>
<p>Can electrical stimulation meaningfully substitute for natural touch during a complex task in the real world? We believe so. It will require both understanding the intricacies of information processing in the brain and incorporating this knowledge into future brain co-processors and neuroprosthetic devices for restoring touch.</p><img src="https://counter.theconversation.com/content/115418/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Caldwell received funding from the National Science Foundation, National Institute of Health, University of Washington Institute for Neuroengineering, and the ARCS foundation. </span></em></p><p class="fine-print"><em><span>Rajesh P. N. Rao receives funding from the National Science Foundation, the Weill Neurohub Investigator program and a Cherng Jia & Elizabeth Yun Hwang Professorship.</span></em></p>When designing neuroprosthetic devices for users to control with their thoughts, engineers must take into account the sensory information brains collect from the environment and how it gets processed.David Caldwell, Neurological Surgery Resident, University of California, San FranciscoRajesh P. N. Rao, Professor of Computer Science and Engineering and Director of the Center for Sensorimotor Neural Engineering, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1225142019-09-19T11:18:18Z2019-09-19T11:18:18ZWe’re increasingly bombarded with choices – and it’s stressing us out<figure><img src="https://images.theconversation.com/files/292671/original/file-20190916-19055-kfifu0.jpg?ixlib=rb-1.1.0&rect=0%2C57%2C3169%2C1773&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When trying to find a romantic match, we're often overwhelmed with options.</span> <span class="attribution"><a class="source" href="https://www.reddit.com/r/Tinder/comments/8qm6ms/since_were_doing_this_tinder_in_new_york_city/">Reddit/WittyRepost</a></span></figcaption></figure><p>Log onto Netflix, and you’ll be presented with a menu of nearly <a href="https://www.businessinsider.com/netflix-movie-catalog-size-has-gone-down-since-2010-2018-2">6,000 titles</a>. Create an OkCupid account, and you’ll have the chance to connect with <a href="https://expandedramblings.com/index.php/okcupid-statistics-and-facts/">5 million other active users</a>. Search for a new toothbrush on Amazon, and you’ll be bombarded with <a href="https://www.amazon.com/s?k=toothbrush&ref=nb_sb_noss">over 20,000 options</a>, ranging from manual to mechanical, from packs of three to packs of 12.</p>
<p>As someone who is comically indecisive – <a href="https://scholar.google.com/citations?user=J_pWSRkAAAAJ&hl=en">and who studies stress</a> – I often think about the pressure of making decisions when presented with so many options. </p>
<p>What do we experience, in the moment, when we decide from an abundance of choices? Does it cause us to shut down or does it energize us? Does it make us feel more confident or less confident? Could it have a lasting impact on our health and well-being?</p>
<h2>We want choice – but not what we choose</h2>
<p>Freedom of choice <a href="https://fee.org/articles/freedom-of-choice/">is a pillar of Western culture</a>. </p>
<p>But there’s such a thing as too much choice.</p>
<p>Researchers such as Sheena Iyengar and Barry Schwartz have pioneered this area of study, finding that being overwhelmed with options can create an adverse experience called “<a href="https://www.researchgate.net/publication/265170803_Choice_Overload_A_Conceptual_Review_and_Meta-Analysis">choice overload</a> or ”<a href="http://wp.vcu.edu/univ200choice/wp-content/uploads/sites/5337/2015/01/The-Paradox-of-Choice-Barry-Schwartz.pdf">The Paradox of Choice</a>.“</p>
<p>People tend to want <a href="https://doi.org/10.1287/mksc.1060.0253">as many options as possible</a>. Whether it’s buying a car or a meal, they gravitate toward companies that offer more options versus fewer ones, because <a href="https://marketing.wharton.upenn.edu/wp-content/uploads/2016/10/diehl_poynor_great_expectations_final.pdf">they believe a large selection will maximize their chances of finding the best fit</a>. </p>
<p>But when it comes to actually making a decision from all of these options, people can become paralyzed – <a href="https://doi.org/10.1037//0022-3514.79.6.995">and avoid making choices altogether</a>. </p>
<p>Even worse, when they finally do come to a decision, <a href="https://doi.org/10.1016/j.jcps.2014.08.002">they’re more dissatisfied and regretful</a> about whatever choice they make.</p>
<h2>Getting to the heart of choice overload</h2>
<p>To me, this explains so much of the day-to-day malaise that plagues modern society. </p>
<p>It explains the sheer excitement first-time homebuyers feel when they begin their search, <a href="https://www.housingwire.com/articles/46384-americans-say-buying-a-home-is-most-stressful-event-in-modern-life">followed by the fear</a> that they won’t select the ideal neighborhood, school district or architectural style.</p>
<p>It explains the curiosity a sociable 20-something feels before checking out the opening of a new bar downtown, followed by the concern it won’t live up to her expectations.</p>
<p>Although we know choice overload <a href="https://doi.org/10.1016/j.jcps.2014.08.002">eventually leads to regret and disatisfaction</a>, it isn’t as clear what people are feeling when they’re in the middle of making these decisions. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/292674/original/file-20190916-19083-4ka3c5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/292674/original/file-20190916-19083-4ka3c5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=332&fit=crop&dpr=1 600w, https://images.theconversation.com/files/292674/original/file-20190916-19083-4ka3c5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=332&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/292674/original/file-20190916-19083-4ka3c5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=332&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/292674/original/file-20190916-19083-4ka3c5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=418&fit=crop&dpr=1 754w, https://images.theconversation.com/files/292674/original/file-20190916-19083-4ka3c5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=418&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/292674/original/file-20190916-19083-4ka3c5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=418&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sometimes it seems like we spend more time deciding than watching.</span>
<span class="attribution"><a class="source" href="https://www.kqed.org/arts/13836539/the-eradication-of-memory-on-netflix-amazon-and-other-streaming-video-sites">Rachael Myrow/KQED</a></span>
</figcaption>
</figure>
<p>My colleagues and I wondered: Do people genuinely feel confident about their ability to make a good decision? And, if so, when does this experience turn from good to bad – from brimming with potential to awash with dejection and doubt?</p>
<p>For our <a href="https://doi.org/10.1016/j.biopsycho.2019.03.010">studies</a>, we sought to peer into participants’ internal experiences as they made decisions, tracking their cardiovascular responses.</p>
<p>When people care more about a decision, <a href="https://doi.org/10.1111/spc3.12052">their hearts beat faster and harder</a>. Other measures – like how much blood the heart is pumping and how much the blood vessels are dilating – can indicate levels of confidence.</p>
<p>Participants in our studies reviewed online dating profiles. We asked them to choose one profile from many options or from just a few options. In other conditions of our studies, we simply asked them to rate profiles on a scale of one to 10. </p>
<p>We found that when the participants chose from many options, they felt more invested in the decision: Their hearts beat harder and faster. But their arteries also constricted – a sign that they also felt less confident about their decision.</p>
<p>In other words, when we’re presented with more choices, making the "right” or “correct” decision begins to feel more crucial and, at the same time, more unattainable.</p>
<p>The cardiovascular system responds the same way when we take an important exam feeling hopelessly unprepared, or commute to an interview for a dream job lacking the right qualifications.</p>
<p>Notably, even minor exposures to this kind of cardiac activity are believed to have long-term health consequences if they happen enough; they’re connected to <a href="https://doi.org/10.1177/0146167218795157">certain types of heart disease and hypertension</a>.</p>
<h2>Deciding how to decide</h2>
<p>Sensing high stakes over a decision – but not feeling particularly confident about making the right choice – may contribute to the deep-seated fear that we’ll make the wrong one. </p>
<p>I believe this fear could be tempered by putting the decision into perspective. It might help to remember that many of the day-to-day choices you make – what to have for lunch, what flavor best complements that caramel macchiato – aren’t going to matter in the grand scheme of things. Even seemingly more consequential choices, like accepting a new job, can ultimately be changed.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/292672/original/file-20190916-19030-1huqja8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/292672/original/file-20190916-19030-1huqja8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=389&fit=crop&dpr=1 600w, https://images.theconversation.com/files/292672/original/file-20190916-19030-1huqja8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=389&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/292672/original/file-20190916-19030-1huqja8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=389&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/292672/original/file-20190916-19030-1huqja8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=489&fit=crop&dpr=1 754w, https://images.theconversation.com/files/292672/original/file-20190916-19030-1huqja8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=489&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/292672/original/file-20190916-19030-1huqja8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=489&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Remember: It’s just cereal.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/kuala-lumpur-malaysia-august-25-2018-1163835241?src=6nFVH7XOAzogU5SmGAT17w-1-2">Din Mohd Yaman/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>When thinking this way, the consequences associated with making the “wrong” choice become less scary.</p>
<p>It could also help to enter these situations with just a few clear guidelines and ideas of what you want – and absolutely don’t want – from the range of options. This can winnow the possible choices, and also make you more confident about your decision-making abilities.</p>
<p>So the next time you spend hours browsing through Netflix unable to land on a title to watch – worried that the OkCupid date you contemplated asking out for days won’t like it – remember that removing the sheer weight of our choices can help us navigate a world overwhelmed by them.</p>
<p>[ <em><a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=expertise">Expertise in your inbox. Sign up for The Conversation’s newsletter and get a digest of academic takes on today’s news, every day.</a></em> ]</p><img src="https://counter.theconversation.com/content/122514/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thomas Saltsman receives funding from the National Science Foundation.</span></em></p>Freedom of choice is a pillar of Western culture. But can too much of it be a bad thing?Thomas Saltsman, Senior Lab Director, Social Psychophysiology Laboratory, University at BuffaloLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1117402019-02-19T22:10:35Z2019-02-19T22:10:35ZElectrical stimulation technique helps patients with spinal cord injury<figure><img src="https://images.theconversation.com/files/259126/original/file-20190214-1736-uei2ee.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For many individuals with spinal cord injury, restoring autonomic functions -- such as blood pressure control, bowel, bladder and sexual function -- is of a higher priority than walking again.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Paralysis (loss of muscle function) is the most visible consequence of a spinal cord injury. Historically, there have been few significant advances in the treatment of such paralysis in individuals with long-term injuries. </p>
<p>Electrical stimulation of the spinal cord — through the techniques of neuromodulation or neurostimulation — is now beginning to show real world promise. Two case series published towards the end of 2018 in the journals <a href="https://www.nature.com/articles/s41586-018-0649-2"><em>Nature</em></a> and <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1803588"><em>New England Journal of Medicine</em></a> demonstrated that neuromodulation, coupled with intensive physical therapy, allowed participants to start walking again. </p>
<p>One of the most common neuromodulation approaches — <a href="https://www.wingsforlifeworldrun.com/ko/news/3074/">epidural spinal cord stimulation — has been investigated over the past four decades</a> and was originally developed to treat chronic pain. </p>
<p>Briefly, a tiny panel of electrodes are implanted into the epidural space on top of the dura (the protective layer that encases the spinal cord) and are connected to a wireless electrical pulse generator. Electrical impulses are delivered to precise parts of the spinal cord.</p>
<p>Work from <a href="http://icord.org/researchers/dr-andrei-krassioukov/">our laboratory has pioneered a growing body of evidence</a> that epidural spinal cord stimulation can safely and effectively restore crucial autonomic functions — such as blood pressure control and bowel function — as well as improving exercise capacity — for patients with spinal cord injury. </p>
<h2>Research focuses on walking</h2>
<p>Walking-focused research has received a considerable amount of <a href="https://www.nationalgeographic.com/science/2018/10/news-spinal-cord-injuries-walk-again-electrical-stimulation-health/">mainstream media attention</a>. The hype may be driven by the general public’s perception that the ability to walk again would be the No. 1 priority for individuals with a spinal cord injury. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/Zvd82naSGRU?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
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<p>However, <a href="https://doi.org/10.1089/neu.2004.21.1371">survey information</a> collected from individuals with spinal cord injury suggests certain autonomic functions (blood pressure control, bowel, bladder and sexual function) are of a higher priority for their everyday quality of life than the ability to walk again.</p>
<p>Non-disabled individuals often take these functions for granted, as they are autonomous (without conscious thought or effort). Individuals with spinal cord injury commonly experience numerous invisible conditions that can have a profound impact on everyday life. </p>
<h2>Loss of bladder and bowel functions</h2>
<p>For example, orthostatic hypotension (a drop in blood pressure) can occur when changing position, such as sitting up, which is often accompanied by dizziness, blurred vision, nausea, confusion and loss of consciousness. Orthostatic hypotension can also have long-term detrimental health consequences, including an <a href="https://doi.org/10.1371/journal.pmed.1002143">increased risk of dementia</a> and <a href="https://doi.org/10.1161/01.STR.31.10.2307">stroke</a>. </p>
<p>The problem with using medication to manage orthostatic hypotension is that it takes too long to take effect. It then lasts longer than is necessary for such rapid changes in blood pressure.</p>
<p>Low blood pressure and altered autonomic cardiovascular regulation can also impair an individual’s response to exercise. For example, the volume of blood being pumped by the heart and thus the ability to transport oxygen to working muscles is reduced, leading to premature fatigue and a lower exercise capacity. </p>
<p>Individuals with spinal cord injury also experience impaired or even complete loss of bladder, bowel and sexual function. Most are unable to empty their bladder (requiring catheterization) or initiate bowel movement and also experience urinary and fecal incontinence. </p>
<p>Many men have erection and/or ejaculation difficulties and both sexes may be unable to experience an orgasm.</p>
<h2>Restoring the capacity for orgasm</h2>
<p>Our research team focusses on investigating and treating autonomic impairments following spinal cord injury. Evidence for the success of epidural spinal cord stimulation is mounting. </p>
<p>First, we completely resolved a sudden drop in blood pressure and brain blood flow using <a href="http://www.dx.doi.org/10.1001/jamaneurol.2017.5055">epidural spinal cord stimulation</a> in one individual with spinal cord injury. </p>
<p>Second, we have shown that epidural spinal cord stimulation is capable of <a href="https://doi.org/10.1212/WNL.0000000000006923">improving upper-body exercise capacity by 15 to 26 per cent</a>. This is equivalent to <a href="https://www.ncbi.nlm.nih.gov/pubmed/28753161">weeks or months of aerobic exercise training</a>. </p>
<p>Furthermore, we have shown that epidural spinal cord stimulation significantly reduced the time needed for bowel management, compared to a conventional bowel routine, <a href="https://doi.org/10.3389/fphys.2018.01816">by more than half (26 versus 58 min)</a>. </p>
<p>We believe this improvement is a result of enhanced contractions of abdominal muscles, which in turn increases the pressure in the abdomen and promotes bowel evacuation. We also showed that epidural spinal cord stimulation can affect bladder function. <a href="https://www.nature.com/articles/s41598-018-26602-2">Other researchers</a> have demonstrated a restoration of voluntary voiding. </p>
<p>Recent work has also demonstrated <a href="https://doi.org/10.1089/neu.2018.6006">the return of the ability to experience orgasm</a> in one woman with a five-year spinal cord injury.</p>
<h2>Promising research advances</h2>
<p>While this research is promising, it is worth emphasizing that the majority of these findings have only been shown in a small number of participants. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/259120/original/file-20190214-1742-1o9xbk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/259120/original/file-20190214-1742-1o9xbk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/259120/original/file-20190214-1742-1o9xbk0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/259120/original/file-20190214-1742-1o9xbk0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/259120/original/file-20190214-1742-1o9xbk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/259120/original/file-20190214-1742-1o9xbk0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/259120/original/file-20190214-1742-1o9xbk0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Most individuals with spinal cord injury are unable to empty their bladder or initiate bowel movement and also experience sexual dysfunction.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>A considerable amount of work is still required to understand how to use this technology to optimize each autonomic function and whether specific injury characteristics are best suited for this therapy. Additionally, the implantation of electrodes requires an invasive operation, which is not without risk, and may also be cost prohibitive for some individuals. </p>
<p>Fortunately, researchers are also beginning to make advances with non-invasive spinal cord stimulation approaches. The placement of electrodes on the skin (transcutaneous) at certain locations over the spinal cord has also showed improvements in <a href="https://doi.org/10.1089/neu.2017.5082">blood pressure control</a>, <a href="https://doi.org/10.3389/fnins.2018.00432">bladder function</a> and <a href="http://www.dx.doi.org/10.1109/TNSRE.2018.2834339">hand function</a>. </p>
<p>This less invasive approach is <a href="https://neurorecoverytechnologies.com/nrt/">currently being commercialized</a> and could be widely available in a matter of years, assuming larger scale clinical trials confirm benefits and safety. </p>
<p>Findings suggest that these exciting technologies have the potential to significantly improve quality of life in individuals with spinal cord injury.</p><img src="https://counter.theconversation.com/content/111740/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tom E Nightingale received funding from the Michael Smith Foundation for Health Research in partnership with the International Collaboration On Repair Discoveries (ICORD) (‘Research Trainee Award’ Grant No. 17767), as well as 2018 ICORD seed funding (operational grant). In addition, Tom E Nightingale received Travel Awards from the Physiological Society (2016), PLoS (2017), Physical Activity and Precision Health Cluster, University of British Columbia, Vancouver, Canada (2018), and American Spinal Injury Association (2019). Tom E Nightingale is a member of the American Spinal Injury Association and American College of Sports Medicine. </span></em></p><p class="fine-print"><em><span>Andrei V. Krassioukov is supported by funding from the BC Knowledge Translation Foundation, Canadian Foundation for Innovation, Canada Foundation for Innovation, Craig H. Neilsen Foundation, Heart and Stroke Foundation Canada, Michael Smith Foundation for Health Research, Rick Hansen Institute and Wings for Life Foundation. He is a member of the advisory boards for Coloplast (Urinary tract infections), the Craig H. Neilsen Foundation (Bladder and Bowel) and Wellspect (Management of neurogenic bowel). He is a member of the American Spinal Injury Association (ASIA), International Spinal Cord Society (ISCoS) and International Continence Society. Furthermore, he is the Chair of the International Autonomic Standards Committee for ASIA/ISCOS and the President elect of ASIA.
</span></em></p><p class="fine-print"><em><span>Matthias Walter received funding from Michael Smith Foundation for Health Research in partnership with the Rick Hansen Foundation (‘Research Trainee Award’ Grant No. 17110), Pfizer (grant-in-aid), Rick Hansen Institute (operational grant), Coloplast (grant-in-aid) and Wellspect (grant-in-aid). In addition, Matthias Walter received Travel Awards from the International Continence Society (2016), British Columbia Regeneration Medicine, Vancouver, Canada (2018), Faculty of Medicine, University of British Columbia, Vancouver, Canada (2018), and American Spinal Injury Association (2019).
Matthias Walter is a member of the American Spinal Injury Association, American Urology Association, European Association of Urology, and International Continence Society. </span></em></p>Researchers have successfully used ‘epidural spinal cord stimulation’ with patients to improve bowel function, restore blood pressure control and increase upper-body exercise capacity.Tom E Nightingale, Postdoctoral Research Fellow, Faculty of Medicine, University of British ColumbiaAndrei Krassioukov, Chair in Rehabilitation Research, ICORD and Professor, Department of Medicine, University of British ColumbiaMatthias Walter, Postdoctoral Fellow, Faculty of Medicine, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1068722018-11-16T16:20:14Z2018-11-16T16:20:14ZSpinal implant breakthroughs are helping people with paraplegia walk again<figure><img src="https://images.theconversation.com/files/245969/original/file-20181116-194488-f5xqxk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Jamani Caillet/EPFL</span></span></figcaption></figure><p>Someone in the world suffers a spinal cord injury <a href="http://www.who.int/news-room/fact-sheets/detail/spinal-cord-injury">every one to two minutes</a>, often leading to irreversible and life-changing loss of movement and feeling. But two research groups recently achieved something that had never been done before. By implanting electrical devices directly on the spinal cord, they reversed some of the effects of the spinal cord injury and allowed people to independently walk again.</p>
<p>So does this mark the end of the road in considering spinal cord injury as an incurable condition? Or is there still a long way to go before wheelchairs become a thing of the past?</p>
<p>Researchers have been trying to use electrical stimulation to reverse the effects of spinal cord injuries <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4824029/">for more than two decades </a>. Artificially increasing electrical activity in the spinal cord helps to activate the nerves that transmit information between the limbs and the brain. While some nerves are permanently damaged by spinal cord injuries, some healthy nerves usually still exist even in the most severely damaged spines, and the electrical impulses give them a boost. In the past two months two studies have been published that significantly push the boundaries of what can be done with this technology.</p>
<p><a href="https://www.nature.com/articles/s41591-018-0175-7">In a study</a> directed by Kendal Lee and Kristin Zhao at the Mayo Clinic in the US, a patient with complete paralysis in their lower body managed to walk 100 metres with a walking frame thanks to a spinal implant. This kind of device, called an epidural electrical stimulator (EES), sends electrical signals to the healthy nerves at the bottom part of the spine (which must be intact in order for the technique to work).</p>
<p>The device uses a pulse generator implanted under the skin to send the appropriate signal to electrodes attached to the dura, the protective layer for the nerves in the spinal cord. The procedure is minimally intrusive and patients can return home on the same day. Living with the implanted stimulator is in many ways similar to living with a pacemaker device. </p>
<p>EES devices have been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3154251/">tested on patients with paralysis before</a>, but to overcome these sorts of complete spinal cord injuries represents a phenomenal outcome and a new milestone in restoring motion. </p>
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<p>But the study only showed how improvements could be made while the implanted device remained operational. This shortcoming has now been addressed by <a href="https://www.nature.com/articles/s41586-018-0649-2">another study</a> of three patients with partial spinal cord damage by researchers from EPFL in Switzerland. After five months of spinal stimulation, the patients found some of their feeling and movement was restored even when their implants were turned off. One of the patients showed enough improvement when not using the device to change their <a href="https://asia-spinalinjury.org/wp-content/uploads/2016/02/International_Stds_Diagram_Worksheet.pdf">injury classification</a> from “C” to “D”, representing the least severe injuries.</p>
<p>The device worked in real time, delivering precise stimulation to the relevant part of the spinal cord at the exact time it was needed, which made using it much more intuitive. The initial results also emerged within a couple of weeks, rather than the months of rehabilitation usually needed.</p>
<h2>Unprecedented breakthrough</h2>
<p>These studies have shown unprecedented results in treating spinal cord injuries. These breakthroughs are coming as a result of both technological advancements in implanted devices as well as an increasing understanding on how our brain communicates with and controls our body. </p>
<p>Having demonstrated the proof of principle for applying spinal stimulation on people with paraplegia, it is now time to push the boundaries of this technique outside the confines of the lab and into the real world. Researchers will need to conduct bigger clinical studies that observe a much larger number of patients from their initial injury and device implantation through to the end of the rehabilitation. We need to assess the full advantages of the treatment and create standards for doctors to follow before this treatment can become available to the wider population.</p>
<p>It’s still uncertain if people with the most severe spinal cord injuries will benefit from the improvements when the device is switched off. Particularly for those with injuries so severe that no nerves are preserved at all, it is likely that this approach will not work, as there is no remaining signal to boost. In those cases, other techniques that try to <a href="https://journals.sagepub.com/doi/full/10.3727/096368915X687796">bridge and repair injury</a> will be needed to offer improvements.</p>
<p>Yet while we might not have so far found a way to cure spinal cord injuries once and for all, the growing volume of results from independent research groups using a <a href="https://www.nature.com/articles/srep30383">variety of approaches</a> makes it seem certain we will reach that day soon.</p><img src="https://counter.theconversation.com/content/106872/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ioannis Dimitrios Zoulias does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Researchers have found a way to boost damaged spinal cord nerves – in some cases permanently.Ioannis Dimitrios Zoulias, Postdoctoral researcher in biomedical engineering, University of ReadingLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/611832016-07-01T09:38:49Z2016-07-01T09:38:49ZHow brain implants can let paralysed people move again<figure><img src="https://images.theconversation.com/files/128823/original/image-20160630-30635-6j9u8x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The appliance of science.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Something as simple as picking up a cup of tea requires an awful lot of action from your body. Your arm muscles fire to move your arm towards the cup. Your finger muscles fire to open your hand then bend your fingers around the handle. Your shoulder muscles keep your arm from popping out of your shoulder and your core muscles make sure you don’t tip over because of the extra weight of the cup. All these muscles have to fire in a precise and coordinated manner, and yet your only conscious effort is the thought: “I know: tea!”</p>
<p>This is why enabling a paralysed limb to move again is so difficult. Most paralysed muscles can still work, but <a href="http://www.spinal-research.org/research-matters/spinal-cord-injury/">their communication with the brain has been lost</a>, so they are not receiving instructions to fire. We can’t yet repair damage to the spinal cord so one solution is to bypass it and provide the instructions to the muscles artificially. And thanks to the development of technology for reading and interpreting brain activity, these instructions could one day come direct from a patient’s mind.</p>
<p>We can make paralysed muscles fire by stimulating them with electrodes placed inside the muscles or around the nerves that supply them, a technique known as <a href="http://www.ncbi.nlm.nih.gov/pubmed/25287528">functional electrical stimulation</a> (FES). As well as helping paralysed people move, it is also used to restore bladder function, produce effective coughing and provide pain relief. It is a fascinating technology that can make a big difference to the lives of people with spinal cord injury.</p>
<p>Dimitra Blana and her colleagues at Keele are working on how to match this technology with the complex set of <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3608269/">instructions needed to operate an arm</a>. If you want to pick up that cup of tea, which muscles need to fire, when and by how much? The firing instructions are complicated, and not just because of the large number of core, shoulder, arm and finger muscles involved. As you slowly drink your tea, those instructions change, because the weight of the cup changes. To do something different, like scratch your nose, the instructions are completely different.</p>
<p>Instead of just trying out various firing patterns on the paralysed muscles in the hope of finding one that works, you can use <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4068297/">computer models of the musculoskeletal system</a> to calculate them. These models are mathematical descriptions of how muscles, bones and joints act and interact during movement. In the simulations, you can make muscles stronger or weaker, “paralysed” or “externally stimulated”. You can test different firing patterns quickly and safely, and you can make the models pick up their tea cups over and over again – sometimes more successfully than others.</p>
<h2>Modelling the muscles</h2>
<p>To test the technology, the team at Keele is working with the <a href="http://fescenter.org/">Cleveland FES Center</a> in the US, where they implant <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4470503/">up to 24 electrodes</a> into the muscles and nerves of research participants. They use modelling to decide where to place the electrodes because there are more paralysed muscles than electrodes in current FES systems.</p>
<p>If you have to choose, is it better to stimulate the subscapularis or the supraspinatus? If you stimulate the axillary nerve, should you place the electrode before or after the branch to the teres minor? To answer these difficult questions, <a href="http://www.rehab.research.va.gov/jour/2013/503/page395.html">they run simulations with different sets of electrodes</a> and choose the one that allows the computer models to make the most effective movements.</p>
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<p>Currently, the team is working on the shoulder, which is stabilised by a group of muscles called the rotator cuff. If you get the firing instructions for the arm wrong, it might reach for the soup spoon instead of the butter knife. If you get the instructions to the rotator cuff wrong, the arm might pop out of the shoulder. It is not a good look for the computer models, but they don’t complain. Research participants would be less forgiving.</p>
<p>Knowing how to activate paralysed muscles to produce useful movements like grasping is only half of the problem. We also need to know when to activate the muscles, for example when the user wants to pick up an object. One possibility is to read this information directly from the brain. Recently, <a href="http://www.ncbi.nlm.nih.gov/pubmed/27074513">researchers in the US</a> used an implant to listen to individual cells in the brain of a paralysed individual. Because different movements are associated with different patterns of brain activity, the participant was able to select one of six pre-programmed movements that were then generated by stimulation of hand muscles.</p>
<h2>Reading the brain</h2>
<p>This was an exciting step forward for the field of neural prosthetics, but many challenges remain. Ideally brain implants need to last for many decades – currently it is difficult to record the same signals even over several weeks so these systems need to be recalibrated regularly. Using <a href="http://www.ncbi.nlm.nih.gov/pubmed/24808859">new implant designs</a> or <a href="http://www.ncbi.nlm.nih.gov/pubmed/25394574">different brain signals</a> may improve long-term stability. </p>
<p>Also, implants listen only to a small proportion of the millions of cells that control our limbs, so the range of movements that can be read out is limited. However, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3641862/">brain control of robotic limbs</a> with multiple degrees-of-freedom (movement, rotation and grasping) has been achieved and the capabilities of this technology are advancing rapidly. </p>
<p>Finally, the smooth, effortless movements that we usually take for granted are guided by rich sensory feedback that tells us where our arms are in space and when our fingertips are touching objects. However, these signals can also be lost after injury so <a href="http://www.ncbi.nlm.nih.gov/pubmed/26504211">researchers are working</a> on brain implants that may one day restore sensation as well as movement.</p>
<p>Some scientists are speculating that brain-reading technology could help able-bodied individuals to communicate more efficiently with computers, mobile phones and even <a href="http://www.nature.com/articles/srep11869">directly to other brains</a>. However, this remains the realm of science fiction whereas brain control for medical applications is rapidly becoming clinical reality.</p><img src="https://counter.theconversation.com/content/61183/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dimitra Blana receives funding from the U.S. National Institutes of Health.</span></em></p><p class="fine-print"><em><span>Andrew Jackson receives funding from the Wellcome Trust, EPSRC and MRC.</span></em></p>Doctors are working to reconnect the brain to paralysed limbs.Dimitra Blana, Research Fellow in Biomedical Engineering, Keele UniversityAndrew Jackson, Wellcome Trust Senior Research Fellow, Newcastle UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/608012016-06-28T10:42:15Z2016-06-28T10:42:15ZForget Iron Man: skintight suits are the future of robotic exoskeletons<figure><img src="https://images.theconversation.com/files/127401/original/image-20160620-8894-6j681h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Supersuit</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Children with a rare neurological disease were recently given the chance to walk for the first time thanks to a <a href="http://www.huffingtonpost.co.uk/entry/exoskeleton-could-help-children-with-muscular-atrophy-walk-for-first-time_uk_57593d73e4b014b4f2533d5d">new robotic exoskeleton</a>. These devices – which are essentially robotic suits that give artificial movement to a user’s limbs – are set to become an increasingly common way of helping people who’ve lost the use of their legs to walk. But while today’s exoskeletons are mostly clumsy, heavy devices, new technology could make them much easier and more natural to use by creating a robotic skin.</p>
<p>Exoskeletons have been in development since the 1960s. <a href="http://www.gereports.com/post/78574114995/the-story-behind-the-real-iron-man-suit/">The first one</a> was a bulky set of legs and claw-like gloves reminiscent of the superhero, Iron Man, designed to use hydraulic power to help industrial workers lift hundreds of kilogrammes of weight. It didn’t work, but since then other designs for both the upper and lower body have successfully been used to <a href="http://time.com/4189590/exoskeleton-super-strength-ekso-bionics/">increase people’s strength</a>, help teach them to <a href="https://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-015-0048-y">use their limbs again</a>, or even as a way to interact with computers using touch or <a href="http://ieeexplore.ieee.org/xpls/abs_all.jsp?arnumber=5354834&tag=1">“haptic” feedback</a>.</p>
<p><a href="http://bleex.me.berkeley.edu/wp-content/uploads/hel-media/Publication/Elexo.pdf">These devices</a> usually consist of a chain of links and powered joints that align with the user’s own bones and joints. The links are strapped securely to the user’s limbs and when the powered joints are activated they cause their joints to flex. Control of the exoskeleton can be performed by a computer – for example if it is performing a physiotherapy routine – or by monitoring the electrical activity in the user’s muscles and then amplifying the force they are creating.</p>
<h2>Heavy and painful</h2>
<p>But despite half a century of research, exoskeletons still aren’t widely used. This is largely because they are usually very uncomfortable to wear for long periods of time, as individuals’ bodies differ from the one-size-fits-all structure of the suits. Some exoskeletons are designed to be adjusted to fit a user’s body better, but if the robotic joints and the user’s real joints don’t rotate in exactly the same position it can produce unnatural motion, causing discomfort or pain. This is made worse by the stiffness of each part of the suit.</p>
<p>Another problem, especially with upper-body exoskeletons, is how heavy they are, usually because of the strong materials needed to support the body weight and the powerful actuators that move the joints. Current suits also aren’t designed to cope with temperature changes or rain, which makes them difficult to use in the real world. And their appearance, which hasn’t been a primary concern of designers so far, can put people off. </p>
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<p>To make exoskeletons more practical and appealing, we need innovations to make them more like a “second skin” than a giant robotic suit. Exoskeletons typically use heavy electric motors, but lightweight actuators such as <a href="http://www.tandfonline.com/doi/full/10.1080/01691864.2016.1154801">pneumatic muscles</a> are now being considered. These can produce similar forces to electric motors but at a fraction of the weight. The muscles consist of a rubber bladder surrounded by a woven sleeve. When pressurised, they increase in diameter and contract in length, pulling the joint. They are made from lightweight materials but can generate the force needed to lift many hundreds of kilogrammes. </p>
<h2>Soft robotics</h2>
<p>However, even these lightweight actuators still need to be attached to a rigid mechanical structure mounted to the user’s body. Myself and my colleagues at the University of Salford’s <a href="http://www.salford.ac.uk/computing-science-engineering/research/autonomous-systems-and-robotics/cognitive-robotics-and-autonomous-systems">Centre for Autonomous Systems and Robotics</a> are developing another alternative: soft robotics. This technology uses physically soft advanced materials to carry out similar tasks to traditional rigid robotic devices. They are particularly well suited to interaction with humans as they are typically lightweight which means if they collide with a person they are unlikely to cause injury. </p>
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<p>We recently developed a new “soft continuum actuator”, a joint that bends like an <a href="https://youtu.be/jwQXRfORBRc">elephant’s trunk</a>. Unlike a traditional rigid robot joint, if it encounters resistance in one part of its body it will still bend but at a different location elsewhere along its length. By equipping a skintight material suit with these actuators, we can create a <a href="https://youtu.be/dvkkv3YuqGo">soft exoskeleton</a> that bends at the precise location of the wearer’s joints. This means the suit will fit a range of users comfortably without needing mechanical adjustment or calibration. Plus, the system is lightweight and can be worn like clothing rather than a bulky mechanical frame.</p>
<p>Exoskeletons are now starting to be sold commercially and we’ll probably see more of them in the coming years. In 2012, paralysed woman Claire Lomas even completed the <a href="http://www.popsci.com/technology/article/2012-05/paralyzed-woman-completes-london-marathon-bionic-suit-after-16-days">London Marathon</a> wearing one. But there are still significant engineering challenges to be addressed before we will see widespread use of these systems. For one thing, we need a way for people to power the suits without having to plug themselves in every half an hour.</p><img src="https://counter.theconversation.com/content/60801/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Steve Davis receives research funding from EU and national research councils. He works for the University of Salford. </span></em></p>How soft robotics could help paralysed people walk again without the need for clunky equipment.Steve Davis, University of SalfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/251072014-04-02T14:03:18Z2014-04-02T14:03:18ZNew discovery gives hope to spinal injury patients<figure><img src="https://images.theconversation.com/files/45417/original/cmyjwr8r-1396446972.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Regenerating the nerves that can return function to our spinal cords.</span> <span class="attribution"><a class="source" href="http://michaeldorausch.com/">Michael Dorausch</a></span></figcaption></figure><p>Spinal cord injuries are currently irreparable. When nerve fibres in the central nervous system are damaged there is, as yet, no way of reversing this. But research we’ve been doing has led to the discovery of a mechanism for regrowing damaged nerve fibres. </p>
<p>A new study, published in <a href="http://www.nature.com/ncomms/2014/140401/ncomms4527/full/ncomms4527.html">Nature Communications</a>, highlights the role of a protein called PCAF, which seems to successfully trigger a series of chemical and genetic events that allow nerves to regenerate. When we injected PCAF into mice with damage to their central nervous system, this significantly increased the number of nerve fibres that grew back, indicating that it may be possible to chemically control the regeneration of nerves in the central nervous systems.</p>
<p>Nerves are crucial to human activity – they facilitate the constant communication that our brain has with the rest of our body. So, if you touch a hot pan, signals relay this information back to the brain where they are processed and then a signal is sent back to the hand to pull it free from danger. Neurons are the cells that transmit these specific messages.</p>
<p>When the connections between these cells are lost, such as after a spinal cord injury, signals can no longer be transmitted through your body and paralysis occurs. Millions of people worldwide suffer from spinal cord injury, stroke and traumatic brain injury. As yet there are no successful treatments that lead to full regeneration of these lost connections.</p>
<h2>Responding to damage</h2>
<p>The reason why our central nervous system and peripheral nervous system differ in their ability to regenerate and re-establish lost connections has been at the centre of our research. The logic is that if we can understand how the body is able to regrow nerves in the peripheral nervous system, we can apply this knowledge to the central nervous system. This would enable us to help patients suffering from strokes, traumatic brain injuries, spinal cord injuries and even neurodegenerative diseases. </p>
<p>We found that epigenetics was at the core of the peripheral nervous system’s capacity to regenerate. <a href="https://theconversation.com/explainer-what-is-epigenetics-13877">Epigenetic mechanisms</a> are processes that, without altering our core DNA sequence, manage to activate or deactivate genes in response to the environment. </p>
<p>Finding out how to turn genes “on” has been an important part of the process of regrowing nerves, and this is initiated by signals from the injured nerve itself. Until recently it was believed that epigenetic alterations were inherited just as we inherit DNA from our parents. Now, however, it is also clear that environmental signals can trigger these modifications to our DNA, which can temporarily or permanently alter gene expression.</p>
<p>Through tracking how the peripheral nervous system injury signals communicate to neurons that genes involved in nerve regrowth should be switched on, we have managed to discover the link between injury signals and turning on the right genes.</p>
<p>This work is still preliminary and we would like to determine if this regrowth of neurons establishes connections that lead to increased function. We believe this work can potentially lead to a pharmaceutical way of triggering the nerves to repair and grow, enabling patients suffering from CNS injuries to recover feeling and movement, but there are many hurdles to overcome first.</p>
<p>The next step is to see whether we can bring about some form of recovery of movement and function in mice after we have stimulated nerve growth through the PCAF-dependent epigenetic mechanisms. If this is successful, then there could be a move towards developing a drug and running clinical trials with people.</p><img src="https://counter.theconversation.com/content/25107/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Radhika Puttagunta receives funding from HIH.</span></em></p><p class="fine-print"><em><span>Simone Di Giovanni receives funding from DFG, WFL, HIH.</span></em></p>Spinal cord injuries are currently irreparable. When nerve fibres in the central nervous system are damaged there is, as yet, no way of reversing this. But research we’ve been doing has led to the discovery…Radhika Puttagunta, Post-doctoral researcher at the Hertie Institute for Clinical Brain Research, University of TübingenSimone Di Giovanni, Chair in Restorative Neuroscience, Imperial College LondonLicensed as Creative Commons – attribution, no derivatives.