iVOMS: Instrumented Vestibular / Ocular motor screen in healthy controls and mild traumatic brain injury.

Objective Vestibular/ocular deficits occur with mild traumatic brain injury (mTBI). The vestibular/ocular motor screening (VOMS) tool is used to assess individuals post-mTBI, which primarily relies upon subjective self-reported symptoms. Instrumenting the VOMS (iVOMS) with technology may allow for more objective assessment post-mTBI, which reflects actual task performance. This study aimed to validate the iVOMS analytically and clinically in mTBI and controls. Methods Seventy-nine people with sub-acute mTBI (<12 weeks post-injury) and forty-four healthy control participants performed the VOMS whilst wearing a mobile eye-tracking on a one-off visit. People with mTBI were included if they were within 12 weeks of a physician diagnosis. Participants were excluded if they had any musculoskeletal, neurological or sensory deficits which could explain dysfunction. A series of custom-made eye tracking algorithms were used to assess recorded eye-movements. Results The iVOMS was analytically valid compared to the reference (ICC2,1 0.85-0.99) in mTBI and controls. The iVOMS outcomes were clinically valid as there were significant differences between groups for convergence, vertical saccades, smooth pursuit, vestibular ocular reflex and visual motion sensitivity outcomes. However, there was no significant relationship between iVOMS outcomes and self-reported symptoms. Conclusion The iVOMS is analytically and clinically valid in mTBI and controls, but further work is required to examine the sensitivity of iVOMS outcomes across the mTBI spectrum. Findings also highlighted that symptom and physiological issue resolution post-mTBI may not coincide and relationships need further examination.

Design and Evaluation of a Bilateral Semi-Rigid Exoskeleton to Assist Hip Motion.

This study focused on designing and evaluating a bilateral semi-rigid hip exoskeleton. The exoskeleton assisted the hip joint, capitalizing on its proximity to the body's center of mass. Unlike its rigid counterparts, the semi-rigid design permitted greater freedom of movement. A temporal force-tracking controller allowed us to prescribe torque profiles during walking. We ensured high accuracy by tuning control parameters and series elasticity. The evaluation involved experiments with ten participants across ten force profile conditions with different end-timings and peak magnitudes. Our findings revealed a trend of greater reductions in metabolic cost with assistance provided at later timings in stride and at greater magnitudes. Compared to walking with the exoskeleton powered off, the largest reduction in metabolic cost was 9.1%. This was achieved when providing assistance using an end-timing at 44.6% of the stride cycle and a peak magnitude of 0.11 Nm kg-1. None of the tested conditions reduced the metabolic cost compared to walking without the exoskeleton, highlighting the necessity for further enhancements, such as a lighter and more form-fitting design. The optimal end-timing aligns with findings from other soft hip exosuit devices, indicating a comparable interaction with this prototype to that observed in entirely soft exosuit prototypes.

Prefrontal Cortex Activity During Gait in People With Persistent Symptoms After Concussion.

BACKGROUND: Concussions result in transient symptoms stemming from a cortical metabolic energy crisis. Though this metabolic energy crisis typically resolves in a month, symptoms can persist for years. The symptomatic period is associated with gait dysfunction, the cortical underpinnings of which are poorly understood. Quantifying prefrontal cortex (PFC) activity during gait may provide insight into post-concussion gait dysfunction. The purpose of this study was to explore the effects of persisting concussion symptoms on PFC activity during gait. We hypothesized that adults with persisting concussion symptoms would have greater PFC activity during gait than controls. Within the concussed group, we hypothesized that worse symptoms would relate to increased PFC activity during gait, and that increased PFC activity would relate to worse gait characteristics. METHODS: The Neurobehavior Symptom Inventory (NSI) characterized concussion symptoms. Functional near-infrared spectroscopy quantified PFC activity (relative concentration changes of oxygenated hemoglobin [HbO2]) in 14 people with a concussion and 25 controls. Gait was assessed using six inertial sensors in the concussion group. RESULTS: Average NSI total score was 26.4 (13.2). HbO2 was significantly higher (P = .007) for the concussed group (0.058 [0.108]) compared to the control group (-0.016 [0.057]). Within the concussion group, HbO2 correlated with NSI total symptom score (ρ = .62; P = .02), sagittal range of motion (r = .79; P = .001), and stride time variability (r = -.54; P = .046). CONCLUSION: These data suggest PFC activity relates to symptom severity and some gait characteristics in people with persistent concussion symptoms. Identifying the neurophysiological underpinnings to gait deficits post-concussion expands our knowledge of motor behavior deficits in people with persistent concussion symptoms.

Exercise Intolerance After Mild Traumatic Brain Injury Occurs in All Subtypes in the Adult Population.

Thematically grouped symptom clusters are present during the acute timeline of post-mild traumatic brain injuries (mTBI), representing clinical profiles called subtypes. Exercise intolerance has not been evaluated within the subtype classifications and, because guidelines support early submaximal aerobic exercise, further knowledge is required in regard to the exercise capabilities among the concussion subtypes. This cross-sectional study (n = 78) aimed to characterize the presence of exercise intolerance within the clinical subtypes and to explore performance on the Buffalo Concussion Treadmill Test (BCTT) in the adult subacute (2-12 weeks post-injury) mTBI population. All participants were evaluated using the BCTT to determine exercise tolerance. We first used the Neurobehavioral Symptom Inventory (NSI) questionnaire to assign each participant a primary subtype(s). To further explore all five subtypes (headache, cognitive, vestibular, ocular motor, and mood), participants were assessed using a multitude of thematically grouped assessments including self-reported questionnaires, clinical tests of vestibular and ocular motor function, balance function, and computerized cognitive testing. Thirty-seven (47%) subjects were exercise tolerant and 41 (53%) were exercise intolerant. There was no difference in the distribution of primary subtypes between the exercise tolerant and exercise intolerant groups. In addition, no significant differences were found between the exercise tolerant and exercise intolerant groups on other thematically grouped subtype assessments. The exercise intolerant group had a significantly higher resting heart rate (HR), lower percentage of age-predicted maximum HR achieved, lower Borg Rate of Perceived Exertion (RPE), and could walk on the treadmill for less time (lower duration) compared with the exercise tolerant group. The current findings suggest that exercise intolerance is common and pervasive across all five mTBI subtypes. A comprehensive mTBI assessment should include evaluation for exercise intolerance regardless of the primary clustering of symptoms and across patient populations. Therefore, early referral to physical therapists, athletic trainers, or medical clinics that can perform the BCTT may be helpful to initiate appropriate exercise prescriptions for patients with mTBI.

Quantifying Turning Tasks With Wearable Sensors: A Reliability Assessment.

OBJECTIVE: The aim of this study was to establish the test-retest reliability of metrics obtained from wearable inertial sensors that reflect turning performance during tasks designed to imitate various turns in daily activity. METHODS: Seventy-one adults who were healthy completed 3 turning tasks: a 1-minute walk along a 6-m walkway, a modified Illinois Agility Test (mIAT), and a complex turning course (CTC). Peak axial turning and rotational velocity (yaw angular velocity) were extracted from wearable inertial sensors on the head, trunk, and lumbar spine. Intraclass correlation coefficients (ICCs) were established to assess the test-retest reliability of average peak turning speed for each task. Lap time was collected for reliability analysis as well. RESULTS: Turning speed across all tasks demonstrated good to excellent reliability, with the highest reliability noted for the CTC (45-degree turns: ICC = 0.73-0.81; 90-degree turns: ICC = 0.71-0.83; and 135-degree turns: ICC = 0.72-0.80). The reliability of turning speed during 180-degree turns from the 1-minute walk was consistent across all body segments (ICC = 0.74-0.76). mIAT reliability ranged from fair to excellent (end turns: ICC = 0.52-0.72; mid turns: ICC = 0.50-0.56; and slalom turns: ICC = 0.66-0.84). The CTC average lap time demonstrated good test-retest reliability (ICC = 0.69), and the mIAT average lap time test-retest reliability was excellent (ICC = 0.91). CONCLUSION: Turning speed measured by inertial sensors is a reliable outcome across a variety of ecologically valid turning tasks that can be easily tested in a clinical environment. IMPACT: Turning performance is a reliable and important measure that should be included in clinical assessments and clinical trials.

Assessing the Effects of Mild Traumatic Brain Injury on Vestibular Home Exercise Performance with Wearable Sensors.

After a mild traumatic brain injury (mTBI), dizziness and balance problems are frequently reported, affecting individuals' daily lives and functioning. Vestibular rehabilitation is a standard treatment approach for addressing these issues, but its efficacy in this population remains inconclusive. A potential reason for suboptimal outcomes is the lack of objective monitoring of exercise performance, which is crucial for therapeutic success. This study utilized wearable inertial measurement units (IMUs) to quantify exercise performance in individuals with mTBI during home-based vestibular rehabilitation exercises. Seventy-three people with mTBI and fifty healthy controls were enrolled. Vestibular exercises were performed, and IMUs measured forehead and sternum velocities and range of motions. The mTBI group demonstrated a slower forehead peak angular velocity in all exercises, which may be a compensatory strategy to manage balance issues or symptom exacerbation. Additionally, the mTBI group exhibited a larger forehead range of motion during specific exercises, potentially linked to proprioceptive deficits. These findings emphasize the usefulness of utilizing IMUs to monitor the quality of home-based vestibular exercises for individuals with mTBI and the potential for IMUs improving rehabilitation outcomes.

Relation Between Cognitive Assessment and Clinical Physical Performance Measures After Mild Traumatic Brain Injury.

OBJECTIVES: To investigate the relation between cognitive and motor performance in individuals with mild traumatic brain injury (mTBI) and examine differences in both cognitive and motor performance between adults after mTBI and healthy controls. DESIGN: Multi-center, cross-sectional study. SETTING: Three institutional sites (Courage Kenny Research Center, Minneapolis, MN, Oregon Health & Science University, Portland, OR, and University of Utah, Salt Lake City, UT). PARTICIPANTS: Data were collected from 110 participants (N=110), including those with mTBI and healthy controls, who completed cognitive and physical performance assessments. INTERVENTIONS: Not applicable. OUTCOME MEASURES: Cognitive assessments involved the Automated Neuropsychological Assessment Metrics to evaluate domains of attention, memory, reaction time, processing speed, and executive function. Physical performance was evaluated through clinical performance assessments, such as the 1-min walk test, the modified Illinois Agility Test, the Functional Gait Assessment Tool, the High-Level Mobility Assessment Tool, a complex turning course, and a 4-Item Hybrid Assessment of Mobility for mTBI. Participants also completed additional trials of the 1-min walk test, modified Illinois Agility Test, and complex turning course with a simultaneous cognitive task. RESULTS: Individuals with mTBI performed worse on cognitive assessments, as well as several of the physical performance assessments compared with healthy controls. Complex tasks were more strongly related to cognitive assessments compared with simple walking tasks. CONCLUSIONS: Combining complex motor tasks with cognitive demands may better demonstrate functional performance in individuals recovering from mTBI. By understanding the relation between cognitive and physical performance in individuals recovering from mTBI, clinicians may be able to improve clinical care and assist in return to activity decision-making.

Central sensorimotor integration assessment reveals deficits in standing balance control in people with chronic mild traumatic brain injury.

Imbalance is common following mild Traumatic Brain Injury (mTBI) and can persist months after the initial injury. To determine if mTBI subjects with chronic imbalance differed from healthy age- and sex-matched controls (HCs) we used both the Central SensoriMotor Integration (CSMI) test, which evaluates sensory integration, time delay, and motor activation properties and the standard Sensory Organization Test (SOT). Four CSMI conditions evoked center-of-mass sway in response to: surface tilts with eyes closed (SS/EC), surface tilts with eyes open viewing a fixed visual surround (SS/EO), visual surround tilts with eyes open standing on a fixed surface (VS/EO), and combined surface and visual tilts with eyes open (SS+VS/EO). The mTBI participants relied significantly more on visual cues during the VS/EO condition compared to HCs but had similar reliance on combinations of vestibular, visual, and proprioceptive cues for balance during SS/EC, SS/EO, and SS+VS/EO conditions. The mTBI participants had significantly longer time delays across all conditions and significantly decreased motor activation relative to HCs across conditions that included surface-tilt stimuli with a sizeable subgroup having a prominent increase in time delay coupled with reduced motor activation while demonstrating no vestibular sensory weighting deficits. Decreased motor activation compensates for increased time delay to maintain stability of the balance system but has the adverse consequence that sensitivity to both internal (e.g., sensory noise) and external disturbances is increased. Consistent with this increased sensitivity, SOT results for mTBI subjects showed increased sway across all SOT conditions relative to HCs with about 45% of mTBI subjects classified as having an "Aphysiologic" pattern based on published criteria. Thus, CSMI results provided a plausible physiological explanation for the aphysiologic SOT pattern. Overall results suggest that rehabilitation that focuses solely on sensory systems may be incomplete and may benefit from therapy aimed at enhancing rapid and vigorous responses to balance perturbations.

Metabolically efficient walking assistance using optimized timed forces at the waist.

The metabolic rate of walking can be reduced by applying a constant forward force at the center of mass. It has been shown that the metabolically optimal constant force magnitude minimizes propulsion ground reaction force at the expense of increased braking. This led to the hypothesis that selectively assisting propulsion could lead to greater benefits. We used a robotic waist tether to evaluate the effects of forward forces with different timings and magnitudes. Here, we show that it is possible to reduce the metabolic rate of healthy participants by 48% with a greater efficiency ratio of metabolic cost reduction per unit of net aiding work compared with other assistive robots. This result was obtained using a sinusoidal force profile with peak timing during the middle of the double support. The same timing could also reduce the metabolic rate in patients with peripheral artery disease. A model explains that the optimal force profile accelerates the center of mass into the inverted pendulum movement during single support. Contrary to the hypothesis, the optimal force timing did not entirely coincide with propulsion. Within the field of wearable robotics, there is a trend to use devices to mimic biological torque or force profiles. Such bioinspired actuation can have relevant benefits; however, our results demonstrate that this is not necessarily optimal for reducing metabolic rate.

Differentiating fallers from nonfallers using nonlinear variability analyses of data from a low-cost portable footswitch device: a feasibility study.

PURPOSE: Falls are one of the main causes of injuries in older adults. This study evaluated a low-cost footswitch device that was designed to measure gait variability and investigates whether there are any relationships between variability metrics and clinical balance tests for individuals with a history of previous falls. METHODS: Sixteen older adults completed a history of falls questionnaire, three functional tests related to fall risk, and walked on a treadmill with the footswitch device. We extracted the stride times from the device and applied two nonlinear variability analyses: coefficient of variation and detrended fluctuation analysis. RESULTS: The temporal variables and variability metrics from the footswitch device correlated with gold-standard measurements based on ground reaction force data. One variability metric (detrended fluctuation analysis) showed a significant relationship with the presence of past falls with a sensitivity of 43%. CONCLUSION: This feasibility study demonstrates the basis for using low-cost footswitch devices to predict fall risk.

Differences between joint-space and musculoskeletal estimations of metabolic rate time profiles.

Motion capture laboratories can measure multiple variables at high frame rates, but we can only measure the average metabolic rate of a stride using respiratory measurements. Biomechanical simulations with equations for calculating metabolic rate can estimate the time profile of metabolic rate within the stride cycle. A variety of methods and metabolic equations have been proposed, including metabolic time profile estimations based on joint parameters. It is unclear whether differences in estimations are due to differences in experimental data or due to methodological differences. This study aimed to compare two methods for estimating the time profile of metabolic rate, within a single dataset. Knowledge about the consistency of different methods could be useful for applications such as detecting which part of the gait cycle causes increased metabolic cost in patients. Here we compare estimations of metabolic rate time profiles using a musculoskeletal and a joint-space method. The musculoskeletal method was driven by kinematics and electromyography data and used muscle metabolic rate equations, whereas the joint-space method used metabolic rate equations based on joint parameters. Both estimations of changes in stride average metabolic rate correlated significantly with large changes in indirect calorimetry from walking on different grades showing that both methods accurately track changes. However, estimations of changes in stride average metabolic rate did not correlate significantly with more subtle changes in indirect calorimetry due to walking with different shoe inclinations, and both the musculoskeletal and joint-space time profile estimations did not correlate significantly with each other except in the most downward shoe inclination. Estimations of the relative cost of stance and swing matched well with previous simulations with similar methods and estimations from experimental perturbations. Rich experimental datasets could further advance time profile estimations. This knowledge could be useful to develop therapies and assistive devices that target the least metabolically economic part of the gait cycle.

A System for Simple Robotic Walking Assistance With Linear Impulses at the Center of Mass.

Walking can be simplified as an inverted pendulum motion where both legs generate linear impulses to redirect the center of mass (COM) into every step. In this work, we describe a system to assist walking in a simpler way than exoskeletons by providing linear impulses directly at the COM instead of providing torques at the joints. We developed a novel waist end-effector and high-level controller for an existing cable-robot. The controller allows for the application of cyclic horizontal force profiles with desired magnitudes, timings, and durations based on detection of the step timing. By selecting a lightweight rubber series elastic element with optimal stiffness and carefully tuning the gains of the closed-loop proportional-integral-derivative (PID) controller in a number of single-subject experiments, we were able to reduce the within-step root mean square error between desired and actual forces up to 1.21% of body weight. This level of error is similar or lower compared to the performance of other robotic tethers designed to provide variable or constant forces at the COM. The system can produce force profiles with peaks of up to 15 ± 2% of body weight within a root mean square error (RMSE) of 2.5% body weight. This system could be used to assist patient populations that require levels of assistance that are greater than current exoskeletons and in a way that does not make the user rely on vertical support.

Modular footwear that partially offsets downhill or uphill grades minimizes the metabolic cost of human walking.

Walking on different grades becomes challenging on energetic and muscular levels compared to level walking. While it is not possible to eliminate the cost of raising or lowering the centre of mass (COM), it could be possible to minimize the cost of distal joints with shoes that offset downhill or uphill grades. We investigated the effects of shoe outsole geometry in 10 participants walking at 1 m s-1 on downhill, level and uphill grades. Level shoes minimized metabolic rate during level walking (P second-order effect < 0.001). However, shoes that entirely offset the (overall) treadmill grade did not minimize the metabolic rate of walking on grades: shoes with a +3° (upward) inclination minimized metabolic rate during downhill walking on a -6° grade, and shoes with a -3° (downward) inclination minimized metabolic rate during uphill walking on a +6° grade (P interaction effect = 0.023). Shoe inclination influenced (distal) ankle joint parameters, including soleus muscle activity, ankle moment and work rate, whereas treadmill grade influenced (whole-body) ground reaction force and COM work rate as well as (distal) ankle joint parameters including tibialis anterior and plantarflexor muscle activity, ankle moment and work rate. Similar modular footwear could be used to minimize joint loads or assist with walking on rolling terrain.

Stride-time variability is related to sensorimotor cortical activation during forward and backward walking.

Previous research has used functional near-infrared spectroscopy (fNIRS) to show that motor areas of the cortex are activated more while walking backward compared to walking forward. It is also known that head movement creates motion artifacts in fNIRS data. The aim of this study was to investigate cortical activation during forward and backward walking, while also measuring head movement. We hypothesized that greater activation in motor areas while walking backward would be concurrent with increased head movement. Participants performed forward and backward walking on a treadmill. Participants wore motion capture markers on their head to quantify head movement and pressure sensors on their feet to calculate stride-time. fNIRS was placed over motor areas of the cortex to measure cortical activation. Measurements were compared for forward and backward walking conditions. No significant differences in body movement or head movement were observed between forward and backward walking conditions, suggesting that conditional differences in movement did not influence fNIRS results. Stride-time was significantly shorter during backward walking than during forward walking, but not more variable. There were no differences in activation for motor areas of the cortex when outliers were removed. However, there was a positive correlation between stride-time variability and activation in the primary motor cortex. This positive correlation between motor cortex activation and stride-time variability suggests that forward walking variability may be represented in the primary motor cortex.

Altering gait variability with an ankle exoskeleton.

Exoskeletons can influence human gait. A healthy gait is characterized by a certain amount of variability compared to a non-healthy gait that has more inherent variability; however which exoskeleton assistance parameters are necessary to avoid increasing gait variability or to potentially lower gait variability below that of unassisted walking are unknown. This study investigated the interaction effects of exoskeleton timing and power on gait variability. Ten healthy participants walked on a treadmill with bilateral ankle-foot exoskeletons under ten conditions with different timing (varied from 36% to 54% of the stride) and power (varied from 0.2 to 0.5 W∙kg-1) combinations. We used the largest Lyapunov exponent (LyE) and maximum Floquet multiplier (FM) to evaluate the stride-to-stride fluctuations of the kinematic time series. We found the lowest LyE at the ankle and a significant reduction versus powered-off with exoskeleton power (summed for both legs) of 0.45 W∙kg-1 and actuation timing at 48% of the stride cycle. At the knee, a significant positive effect of power and a negative interaction effect of power and timing were found for LyE. We found significant positive interaction effects of the square of timing and power for LyE at the knee and hip joints. In contrast, the FM at the ankle increased with increasing power and later timing. We found a significant negative effect of power and a positive interaction effect of power and timing for FM at the knee and no significant effects of any of the exoskeleton parameters for FM at the hip. The ability of the exoskeleton to reduce the LyE at the ankle joint offers new possibilities in terms of altering gait variability, which could have applications for using exoskeletons as rehabilitation devices. Further efforts could examine if it is possible to simultaneously reduce the LyE and FM at one or more lower limb joints.

Improvement of Oxygen-Uptake Kinetics and Cycling Performance With Combined Prior Exercise and Fast Start.

PURPOSE: To investigate whether oxygen-uptake ([Formula: see text]) kinetics and simulated 4-km cycling performance are synergistically improved by prior "priming" exercise and an all-out starting strategy. METHODS: Nine men completed 4 target work trials (114 ± 17 kJ) to assess [Formula: see text] kinetics and cycling performance in a repeated-measures, crossover experimental design. Trials were initiated with either a 12-s all-out start or a self-selected start and preceded by prior severe-intensity (70%Δ) priming exercise or no priming exercise. RESULTS: The [Formula: see text] mean response time (MRT) was lower (indicative of faster [Formula: see text] kinetics) in the all-out primed condition (20 ± 6 s) than in the all-out unprimed (23 ± 6 s), self-paced-unprimed (42 ± 13 s), and self-paced-primed (42 ± 11 s) trials (P < .05), with the [Formula: see text] MRT also lower in the all-out unprimed than the self-paced unprimed and self-paced primed trials (P < .05). Trial-completion time was shorter (performance was enhanced) in the all-out primed trial (402 ± 14 s) than in the all-out unprimed (408 ± 14 s), self-paced unprimed (411 ± 16 s), and self-paced primed (411 ± 19 s) trials (P < .05), with no differences between the latter 3 trials. CONCLUSIONS: The findings from this study suggest that combining severe-intensity priming exercise with a short-duration all-out starting strategy can expedite the adjustment of [Formula: see text] and lower completion time during a cycling performance trial to a greater extent than either intervention administered independently. These results might have implications for optimizing performance in short-duration high-intensity competitive events such as a 4-km cycling time trial.