Overground walking with a robotic exoskeleton elicits trunk muscle activity in people with high-thoracic motor-complete spinal cord injury

Background

The trunk muscles are critical for postural control. Recent neurophysiological studies have revealed sparing of trunk muscle function in individuals with spinal cord injury (SCI) classified with thoracic or cervical motor-complete injuries. These findings raise the possibility for recruiting and retraining this spared trunk function through rehabilitation. Robotic gait training devices may provide a means to promote trunk muscle activation. Thus, the objective of this study was to characterize and compare the activation of the trunk muscles during walking with two robotic gait training devices (Ekso and Lokomat) in people with high thoracic motor-complete SCI.

Methods

Participants with chronic motor-complete paraplegia performed 3 speed-matched walking conditions: Lokomat-assisted walking, Ekso-assisted walking overground, and Ekso-assisted walking on a treadmill. Surface electromyography (EMG) signals were recorded bilaterally from the rectus abdominis (RA), external oblique (EO), and erector spinae (ES) muscles.

Results

Greater recruitment of trunk muscle EMG was elicited with Ekso-assisted walking compared to the Lokomat. Similar levels of trunk EMG activation were observed between Ekso overground and Ekso on the treadmill, indicating that differences between Ekso and Lokomat could not be attributed to the use of a hand-held gait aid. The level of trunk EMG activation during Lokomat walking was not different than that recorded during quiescent supine lying.

Conclusions

Ekso-assisted walking elicits greater activation of trunk muscles compared to Lokomat-assisted walking, even after controlling for the use of hand-held assistive devices. The requirement of the Ekso for lateral weight-shifting in order to activate each step could lead to better postural muscle activation.

     

Validating attentive locomotion training using interactive treadmill: an fNIRS study

Background

Existing treadmill-based locomotion training, which has been used for gait function recovery, still has limitations, such as less attentive training. Interactive treadmills (ITMs) were developed to overcome these limitations, but it has not yet been verified that ITMs can make the user pay closer attention to walk training.

Methods

An experimental comparison between ITMs and conventional treadmills was conducted by measuring the level of the user’s attention using functional near-infrared spectroscopy (fNIRS). To consider the effect of task complexity on the subject’s attention, we provided two (slow and fast) speed conditions for walking on both treadmills.

Results

Both the cortical activity images and oxygenated hemoglobin (oxyHb) changes showed that the level of attention to walking induced by the ITM was significantly higher than that induced by the conventional treadmill. We found that the walking speed on the ITM also affected the level of attention.

Conclusion

ITM-based locomotion training would be a promising solution to the limitations of existing treadmill-based locomotion training currently used to improve gait function recovery.

Trial registration

DGIST-HR-150309-03-02. Registered 01 March 2015.

     

Energy storing and return prosthetic feet improve step length symmetry while preserving margins of stability in persons with transtibial amputation

Background

Energy storing and return (ESAR) feet are generally preferred over solid ankle cushioned heel (SACH) feet by people with a lower limb amputation. While ESAR feet have been shown to have only limited effect on gait economy, other functional benefits should account for this preference. A simple biomechanical model suggests that enhanced gait stability and gait symmetry could prove to explain part of the difference in the subjective preference between both feet.

Aim

To investigate whether increased push-off power with ESAR feet increases center of mass velocity at push off and enhance intact step length and step length symmetry while preserving the margin of stability during walking in people with a transtibial prosthesis.

Methods

Fifteen people with a unilateral transtibial amputation walked with their prescribed ESAR foot and a SACH foot at a fixed walking speed (1.2 m/s) over a level walkway while kinematic and kinetic data were collected. Push-off work generated by the foot, center of mass velocity, step length, step length symmetry and backward margin of stability were assessed and compared between feet.

Results

Push-off work was significantly higher when using the ESAR foot compared to the SACH foot. Simultaneously, center of mass velocity at toe-off was higher with ESAR compared to SACH, and intact step length and step length symmetry increased without reducing the backward margin of stability.

Conclusion

Compared to the SACH foot, the ESAR foot allowed an improvement of step length symmetry while preserving the backward margin of stability at community ambulation speed. These benefits may possibly contribute to the subjective preference for ESAR feet in people with a lower limb amputation.

     

Laufbandbasierte Gangreferenzdaten für gesunde Probanden

Background

Clinical gait analysis is an established component in the evaluation of human physiological and pathological gait. Walking speed is one of the most important determinants of kinematic and kinetic parameters, and velocity-specific reference data are thus essential for interpretation of results. The aim of this study was to evaluate kinematic and kinetic gait treadmill data with respect to velocity, gender, height, and body mass.

Subjects and methods

On a dynamometric treadmill, 141 healthy volunteers underwent three trials (30?s per trial) at walking speeds of 2, 4, and 6?km/h. Kinematic and kinetic parameters were obtained using the zebris FDM-TF1.8 Treadmill (zebris Medical GmbH, Isny, Germany).

Results

In 80% (4/5) of the kinematic gait parameters, a significant influence (η² > 0.2) of walking velocity was demonstrated. This ranged from 89% (stance: η² = 0.243) to 98% (stride length: η² = 0.982). Gender effects were observed in two (40%) kinematic gait parameters (stride length: η² = 0.209; cadence: η² = 0.202).

Conclusion

Walking velocity has a large influence on the kinematics of gait on the treadmill. Therefore, clinical analysis of gait parameters should always be related to walking velocity. Use of a standardized velocity is highly recommended in a longitudinal investigation setting.

     

Relationship between gait kinematics and walking energy expenditure during pregnancy in South African women

Background

Various musculoskeletal changes occurring during pregnancy may lead to the change in gait and contribute to the increase in walking energy expenditure. Previous research indicates that changes in gait mechanics may lead to the increase in mechanical work required during walking. However, there is little information to indicate if changes in gait mechanics during pregnancy have impact on active or total energy expenditure. Therefore, the primary aim of this study was to investigate the relationship between changes in gait kinematics and walking energy expenditure in pregnant women.

Methods

Thirty-five women (mean age?=?27.5?±?6.1 years) volunteered for the study during various stages of pregnancy (1st trimester average?=?12.1?±?2.2 weeks; 2nd trimester?=?22.3?±?2.6 weeks; 3rd trimester?=?31.4?±?2.6 weeks). 3D motion analysis was used to assess changes in kinematic parameters during walking at self-selected pace. Resting metabolic rate, and walking energy expenditure expressed in terms of rate and cost of O₂ were analysed with portable metabolic analyser.

Results

Only medio-lateral deviation of centre of gravity (COG_ML) increased 13.6% between the 1st and 2nd, and 39.3% between 2nd and 3rd trimester (p?≤?0.001). However, self-selected walking speed depicted strong significant positive linear relationship with net O₂ rate (r?=?0.70; p?≤?0.001), and was strongly associated with the vertical excursion of the COG (r?=?0.75, p?≤?0.001).

Conclusions

Changes in gait mechanics during pregnancy may lead to an increase in walking energy expenditure. However, the consequent increase in walking energy cost may not be sufficient to offset the natural energy sparing mechanism.

     

Influence of virtual reality soccer game on walking performance in robotic assisted gait training for children

Background

Virtual reality (VR) offers powerful therapy options within a functional, purposeful and motivating context. Several studies have shown that patients' motivation plays a crucial role in determining therapy outcome. However, few studies have demonstrated the potential of VR in pediatric rehabilitation. Therefore, we developed a VR-based soccer scenario, which provided interactive elements to engage patients during robotic assisted treadmill training (RAGT). The aim of this study was to compare the immediate effect of different supportive conditions (VR versus non-VR conditions) on motor output in patients and healthy control children during training with the driven gait orthosis Lokomat^®.

Methods

A total of 18 children (ten patients with different neurological gait disorders, eight healthy controls) took part in this study. They were instructed to walk on the Lokomat in four different, randomly-presented conditions: (1) walk normally without supporting assistance, (2) with therapists' instructions to promote active participation, (3) with VR as a motivating tool to walk actively and (4) with the VR tool combined with therapists' instructions. The Lokomat gait orthosis is equipped with sensors at hip and knee joint to measure man-machine interaction forces. Additionally, subjects' acceptance of the RAGT with VR was assessed using a questionnaire.

Results

The mixed ANOVA revealed significant main effects for the factor CONDITIONS (p < 0.001) and a significant interaction CONDITIONS × GROUP (p = 0.01). Tests of between-subjects effects showed no significant main effect for the GROUP (p = 0.592). Active participation in patients and control children increased significantly when supported and motivated either by therapists' instructions or by a VR scenario compared with the baseline measurement "normal walking" (p < 0.001).

Conclusions

The VR scenario used here induces an immediate effect on motor output to a similar degree as the effect resulting from verbal instructions by the therapists. Further research needs to focus on the implementation of interactive design elements, which keep motivation high across and beyond RAGT sessions, especially in pediatric rehabilitation.

     

Pedometer use and self-determined motivation for walking in a cardiac telerehabilitation program: a qualitative study

Background

Exercise-based cardiac rehabilitation reduces morbidity and mortality. Walking is a convenient activity suitable for people with cardiac disease. Pedometers count steps, measure walking activity and motivate people to increase physical activity. In this study, patients participating in cardiac telerehabilitation were provided with a pedometer to support motivation for physical activity with the purpose of exploring pedometer use and self-determined motivation for walking experienced by patients and health professionals during a cardiac telerehabilitation program.

Methods

A qualitative research design consisting of observations, individual interviews and patient documents made the basis for a content analysis. Data was analysed deductively using Self Determination Theory as a frame for analysis and discussion, focusing on the psychological needs of autonomy, competence and relatedness. Twelve cardiac patients, 11 health professionals, 6 physiotherapists and 5 registered nurses were included.

Results

The pedometer offered independence from standardised rehabilitation since the pedometer supported tailoring, individualised walking activity based on the patient’s choice. This led to an increased autonomy. The patients felt consciously aware of health benefits of walking, and the pedometer provided feedback on walking activity leading to an increased competence to achieve goals for steps. Finally, the pedometer supported relatedness with others. The health professionals’ surveillance of patients’ steps, made the patients feel observed, yet supported, furthermore, their next of kin appeared to be supportive as walking partners.

Conclusion

Cardiac patients’ motivation for walking was evident due to pedometer use. Even though not all aspects of motivation were autonomous and self determined, the patients felt motivated for walking. The visible steps and continuous monitoring of own walking activity made it possible for each individual patient to choose their desired kind of activity and perform ongoing adjustments of walking activity. The immediate feedback on step activity and the expectations of health benefits resulted in motivation for walking. Finally, pedometer supported walking made surveillance possible, giving the patients a feeling of being looked after and supported.

Trial registration

Current study is a part of The Teledi@log project.

     

The Effectiveness of Trimetazidine Treatment in Patients with Stable Angina Pectoris of Various Durations: Results from the CHOICE-2 Study

Introduction

Trimetazidine (TMZ) has been shown to reduce angina symptoms and to increase exercise capacity in randomized clinical trials, but more extensive data would be useful to assess its effects in real-world clinical practice and in patients with different durations of disease.

Methods

CHOICE-2 was a Russian, multicenter, 6-month, open-label, prospective observational study that assessed the effect of adding TMZ modified release 35 mg bid to antianginal treatment in a real-world setting. The present analysis of CHOICE-2 results explored the effects of adding TMZ to background antianginal therapies with regard to the duration of stable angina.

Results

A total of 741 patients with known durations of disease were divided into four groups according to stable angina pectoris (AP) duration, ranging from less than 1 year to more than 9 years. Addition of TMZ led to a significant decrease in the frequency of angina attacks and in the use of short-acting nitrates in all groups. In patients with recently diagnosed angina (AP duration < 1 year), the average number of angina attacks per week decreased significantly from 3.75 ± 4.63 to 0.67 ± 1.51 and in those with advanced disease (AP duration > 9 years) from 5.63 ± 5.24 to 1.32 ± 2.07. Angina-free walking distance also improved significantly. Addition of TMZ also improved patient well-being. Results were achieved rapidly (within 2 weeks), were maintained over 6 months, and were obtained in all patient groups regardless of angina duration.

Conclusion

TMZ added to other antianginal therapies proved to be effective for reducing angina attacks and short-acting nitrate use, increasing angina-free walking distance, and improving patient well-being in a real-life setting, irrespective of angina duration, including patients with recently diagnosed angina. This provides an opportunity for intensification of treatment early on in the disease process, with the aim of decreasing angina burden and improving patient quality of life.

Funding

Servier.

Trial Registration

ISRCTN identifier ISRCTN65209863.

Plain Language Summary

Plain language summary available for this article.

     

Olanzapine vs haloperidol: treating delirium in a critical care setting

Objective

To compare the safety and estimate the response profile of olanzapine, a second-generation antipsychotic, to haloperidol in the treatment of delirium in the critical care setting.

Design

Prospective randomized trial

Setting

Tertiary care university affiliated critical care unit.

Patients

All admissions to a medical and surgical intensive care unit with a diagnosis of delirium.

Interventions

Patients were randomized to receive either enteral olanzapine or haloperidol.

Measurements

Patient’s delirium severity and benzodiazepine use were monitored over 5 days after the diagnosis of delirium.

Main results

Delirium Index decreased over time in both groups, as did the administered dose of benzodiazepines. Clinical improvement was similar in both treatment arms. No side effects were noted in the olanzapine group, whereas the use of haloperidol was associated with extrapyramidal side effects.

Conclusions

Olanzapine is a safe alternative to haloperidol in delirious critical care patients, and may be of particular interest in patients in whom haloperidol is contraindicated.

     

Increased maximum common carotid intima-media thickness is associated with smoking and hypertension in Tochigi Prefecture residents

Objective

We investigated maximum intima-media thickness of the common carotid artery (IMT-C_max) in residents of Tochigi Prefecture, who have been reported to have high stroke mortality.

Method

Our study included 840 individuals. All participants underwent carotid ultrasonography and answered a questionnaire during participation in a health festival in Tochigi Prefecture. The questionnaire was designed to collect information on age, gender, and risk factors for stroke. IMT-C_max was measured. Statistical analyses were performed to identify factors contributing to IMT-C_max values ≥1.1 mm.

Results

In total, 117 subjects had an IMT-C_max value ≥1.1 mm. IMT-C_max correlated significantly with age, current smoking, hypertension, diabetes mellitus, heart disease, and previous symptomatic stroke (p < 0.05) in univariate analysis. Current smoking (p < 0.001, odds ratio 3.88) and hypertension (p = 0.0070, odds ratio 1.83) were seen as significant contributing factors to IMT-C_max ≥1.1 mm in logistic regression analysis adjusted by age, gender, and previous symptomatic stroke.

Conclusion

We identified current smoking and hypertension as the most significant contributing factors to increased IMT-C_max in residents of Tochigi Prefecture, emphasizing the importance of routine blood pressure monitoring and anti-smoking education in this population.

     

Femoroazetabuläres Impingement

Background

There is a high prevalence of femoroacetabular impingement (FAI) in the population and it is associated with an increased risk for the development of coxarthrosis, particularly in impact sports (2–8 times).

Material and methods

Methods for screening and prevention of FAI and their application are demonstrated. Cross-sectional and longitudinal cohort studies are presented in this article and expert recommendations and meta-analyses are discussed.

Results

The development of a cam FAI and also the formation of secondary hip arthritis can (and should) be prevented by avoidance of certain impact sports (training methods) during the skeletal growth phase. The internal rotation of the hips during flexion is a useful screening test to identify individuals with FAI. A recently developed specific examination chair has clearly improved the precision of this test compared to the classical clinical test.

Conclusion

The prevention of FAI and secondary hip arthritis may occur at two levels: during the sensitive (prepubertal) phase the development of FAI can (should) be prevented by avoiding activities that potentially injure the growth plate of the femoral head. Furthermore, screening tests could enable early detection of patients with FAI. These individuals could (should) be advised regarding appropriate behavioral modifications and treatment options depending on the symptoms.

     

Spinal Cord Stimulation,MILD Procedure,and Regenerative Medicine,Novel Interventional Nonopioid Therapies in Chronic Pain

Purpose of Review

Chronic pain is a highly prevalent condition affecting millions of individuals.

Recent Findings

In recent years, newer treatments have emerged that are changing the way clinicians treat pain pathogenesis, including novel nonopioid strategies. In this regard, spinal cord stimulation, the MILD procedure, and regenerative medicine have shown promise. This review summarizes recent literature on these three emerging treatment strategies.

Summary

The results of this review suggest that under certain conditions, spinal cord stimulation, the MILD procedure, and regenerative medicine can be effective treatment modalities.

     

Work-aged stroke survivors’ psychosocial challenges narrated during and after participating in a dialogue-based psychosocial intervention: a feasibility study

Background

Studies point to the lack of psychosocial support and rehabilitation services that are adjusted to the work-aged stroke survivors’ specific needs in order to promote psychosocial well-being. The aim of the study was to illuminate the psychosocial challenges work-aged participants (i.e. aged 18–67 years) thematised during and after participating a dialogue-based psychosocial intervention during the first year following a stroke.

Methods

The study was a feasibility study guided by the UK Medical Research Council Framework for developing and evaluating complex interventions. Qualitative data from in-depth interviews with fourteen stroke-survivors aged 33–66 years, researcher field notes and log notes written during the intervention were analysed applying a hermeneutic-phenomenological approach.

Results

The stroke and its consequences had a substantial impact on family and work life. Their experiences were summarised in the two themes The threat of becoming marginalised in family life and The threat of becoming marginalised in work life.

Conclusion

Life as a work-aged stroke survivor was experienced as challenging and created a threat of becoming marginalised in family and work life. The study highlights the need to understand the specific psychosocial challenges and needs facing work-aged stroke survivors’ in order to promote their psychosocial well-being. More research is needed concerning specific life-span challenges amongst work-aged stroke survivors in order to further develop appropriate interventions that helps address this issue.

     

Deep learning with convolutional neural network for objective skill evaluation in robot-assisted surgery

Purpose

With the advent of robot-assisted surgery, the role of data-driven approaches to integrate statistics and machine learning is growing rapidly with prominent interests in objective surgical skill assessment. However, most existing work requires translating robot motion kinematics into intermediate features or gesture segments that are expensive to extract, lack efficiency, and require significant domain-specific knowledge.

Methods

We propose an analytical deep learning framework for skill assessment in surgical training. A deep convolutional neural network is implemented to map multivariate time series data of the motion kinematics to individual skill levels.

Results

We perform experiments on the public minimally invasive surgical robotic dataset, JHU-ISI Gesture and Skill Assessment Working Set (JIGSAWS). Our proposed learning model achieved competitive accuracies of 92.5%, 95.4%, and 91.3%, in the standard training tasks: Suturing, Needle-passing, and Knot-tying, respectively. Without the need of engineered features or carefully tuned gesture segmentation, our model can successfully decode skill information from raw motion profiles via end-to-end learning. Meanwhile, the proposed model is able to reliably interpret skills within a 1–3 second window, without needing an observation of entire training trial.

Conclusion

This study highlights the potential of deep architectures for efficient online skill assessment in modern surgical training.

     

Low dose quetiapine induced galactorrhoea: a case report

Background

Quetiapine causes less prolactin elevation and/or galactorrhoea than other atypical antipsychotics.

Case Presentation

Ms AB had galactorrhoea and raised prolactin levels at only 100 mg of quetiapine daily.

Conclusion

Low dose quetiapine can also cause galactorrhoea.

     

Knowledge transfer for surgical activity prediction

Purpose

Lack of annotated training data hinders automatic recognition and prediction of surgical activities necessary for situation-aware operating rooms. We propose using knowledge transfer to compensate for data deficit and improve prediction.

Methods

We used two approaches to extract and transfer surgical process knowledge. First, we encoded semantic information about surgical terms using word embedding. Secondly, we passed knowledge between different clinical datasets of neurosurgical procedures using transfer learning.

Results

The combination of two methods provided 22% improvement of activity prediction. We also made several pertinent observations about surgical practices based on the results of the performed transfer.

Conclusion

Word embedding boosts learning process. Transfer learning was shown to be more effective than a simple combination of data, especially for less similar procedures.

     

Respiratory variations in aortic blood flow predict fluid responsiveness in ventilated children

Objective

To investigate whether respiratory variations in aortic blood flow velocity (ΔVpeak ao), systolic arterial pressure (ΔPS) and pulse pressure (ΔPP) could accurately predict fluid responsiveness in ventilated children.

Design and setting

Prospective study in a 18-bed pediatric intensive care unit.

Patients

Twenty-six children [median age 28.5 (16–44) months] with preserved left ventricular (LV) function.

Intervention

Standardized volume expansion (VE).

Measurements and main results

Analysis of aortic blood flow by transthoracic pulsed-Doppler allowed LV stroke volume measurement and on-line ΔVpeak ao calculation. The VE-induced increase in LV stroke volume was >?15% in 18 patients (responders) and p?=?0.001], whereas ΔPP and ΔPS did not significantly differ between groups. The prediction of fluid responsiveness was higher with ΔVpeak ao [ROC curve area 0.85 (95% IC 0.99–1.8), p?=?0.001] than with ΔPS (0.64) or ΔPP (0.59). The best cut-off for ΔVpeak ao was 12%, with sensitivity, specificity, and positive and negative predictive values of 81.2%, 85.7%, 93% and 66.6%, respectively. A positive linear correlation was found between baseline ΔVpeak ao and VE-induced gain in stroke volume (rho?=?0.68, p?=?0.001).

Conclusions

While respiratory variations in aortic blood flow velocity measured by pulsed Doppler before VE accurately predict the effects of VE, ΔPS and ΔPP are of little value in ventilated children.

     

Self-guided training for deep brain stimulation planning using objective assessment

Objective

Deep brain stimulation (DBS) is an increasingly common treatment for neurodegenerative diseases. Neurosurgeons must have thorough procedural, anatomical, and functional knowledge to plan electrode trajectories and thus ensure treatment efficacy and patient safety. Developing this knowledge requires extensive training. We propose a training approach with objective assessment of neurosurgeon proficiency in DBS planning.

Methods

To assess proficiency, we propose analyzing both the viability of the planned trajectory and the manner in which the operator arrived at the trajectory. To improve understanding, we suggest a self-guided training course for DBS planning using real-time feedback. To validate the proposed measures of proficiency and training course, two experts and six novices followed the training course, and we monitored their proficiency measures throughout.

Results

At baseline, experts planned higher quality trajectories and did so more efficiently. As novices progressed through the training course, their proficiency measures increased significantly, trending toward expert measures.

Conclusion

We developed and validated measures which reliably discriminate proficiency levels. These measures are integrated into a training course, which quantitatively improves trainee performance. The proposed training course can be used to improve trainees’ proficiency, and the quantitative measures allow trainees’ progress to be monitored.

     

A Review of Echocardiography Training for Internal Medicine Residents: Proposed Goals,Methods, and Metrics

Purpose of the review

Focused cardiac ultrasound (FCU) is a useful bedside tool that is often utilized by internal medicine residents. Multiple studies have shown that FCU adds valuable information beyond the history and physical. No formal recommendations exist regarding which physiologic parameters should be included in FCU, how those parameters should be assessed, or how to adequately train residents in its use. This review highlights the available literature on FCU training for medicine residents and provides in-depth analysis of the existing programs.

Recent findings

There is significant variability among FCU training of internal medicine residents.

Summary

A standard FCU training protocol should be considered to incorporate this powerful modality throughout the American Post-Graduate Medical Education System. This review offers recommendations for standard training.