Cognitive benefits of using non-invasive compared to implantable neural feedback

A non-optimal prosthesis integration into an amputee's body schema suggests some important functional and health consequences after lower limb amputation. These include low perception of a prosthesis as a part of the body, experiencing it as heavier than the natural limb, and cognitively exhausting use for users. Invasive approaches, exploiting the surgical implantation of electrodes in residual nerves, improved prosthesis integration by restoring natural and somatotopic sensory feedback in transfemoral amputees. A non-invasive alternative that avoids surgery would reduce costs and shorten certification time, significantly increasing the adoption of such systems. To explore this possibility, we compared results from a non-invasive, electro-cutaneous stimulation system to outcomes observed with the use of implants in above the knee amputees. This non-invasive solution was tested in transfemoral amputees through evaluation of their ability to perceive and recognize touch intensity and locations, or movements of a prosthesis, and its cognitive integration (through dual task performance and perceived prosthesis weight). While this managed to evoke the perception of different locations on the artificial foot, and closures of the leg, it was less performant than invasive solutions. Non-invasive stimulation induced similar improvements in dual motor and cognitive tasks compared to neural feedback. On the other hand, results demonstrate that remapped, evoked sensations are less informative and intuitive than the neural evoked somatotopic sensations. The device therefore fails to improve prosthesis embodiment together with its associated weight perception. This preliminary evaluation meaningfully highlights the drawbacks of non-invasive systems, but also demonstrates benefits when performing multiple tasks at once. Importantly, the improved dual task performance is consistent with invasive devices, taking steps towards the expedited development of a certified device for widespread use.