Robot-assisted task-oriented upper extremity skill training in cervical spinal cord injury: a feasibility study.

STUDY DESIGN: Prospective multiple case study. OBJECTIVES: To test (1) the feasibility of haptic robot technology (Haptic Master (HM)) use to improve arm-hand function (AHF) and arm-hand skill performance (AHSP) in persons with a cervical spinal cord injury (C-SCI), (2) inventory participants' motivation and expectation to work with the robot technology used and (3) to descriptively report the results in individual cases. SETTING: Rehabilitation Centre. METHODS: Five C-SCI patients were trained for 6 weeks, 3 days per week, 60 min per day. Therapists filled out the Usefulness, Satisfaction and Ease-of-use questionnaire (USE). The Intrinsic Motivational Inventory (IMI) and credibility and expectancy questionnaire (CEQ) were filled out by participants. Performance at activity level was gauged using the Van Lieshout test for AHF in Tetraplegia and the Spinal Cord Independence Measure. Function level was gauged using muscle strength testing and the International Classification for Surgery of the Hand in Tetraplegia. RESULTS: As to the feasibility of the application of haptic robot technology, the mean USE score was 65%. Mean IMI and CEQ results were 67% and 60%, respectively. Participants were motivated to train with the HM. All participants rated credibility higher than expectations regarding the improvement. In the current patients, little progress was demonstrated at the International Classification of Functioning, Disability and Health function and the activity level. CONCLUSION: It is feasible to train C-SCI persons with the HM. Therapists report that working with the HM is easy to learn and easy to perform. Usability of the HM may be improved. Further research is needed to assess in which group of C-SCI and at which stage of rehabilitation HM training may be most beneficial.

Improvement of the Van Lieshout hand function test for tetraplegia using a Rasch analysis.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: The Van Lieshout hand function test for tetraplegia (VLT) measures the quality of arm-hand functioning in persons with tetraplegia. It is valid, reliable and responsive. However, it does not satisfy all the criteria for interval level measurement. The present study aims to apply the Rasch model to the VLT short form (VLT-SF) to upgrade its scale type towards interval level, and to verify if the requirements of an objective measure are satisfied in the revised version. SETTING: Eight Dutch Rehabilitation centres. METHODS: The VLT-SF data of 73 tetraplegic patients were Rasch-analysed (RUMM2030 software, RUMM Laboratory Pty Ltd, Perth, Australia) to verify the order of response categories, unidimensionality and reliability of the VLT-SF, and to assess its applicability regardless of (motor) lesion completeness. RESULTS: Seven of the ten VLT-SF items showed disordered response categories. The six original response categories were therefore recoded into three or four categories. After recoding, all items satisfied the model requirement of unidimensionality. The items were relatively well-targeted on the subjects' arm-hand skilled performance measures, leading to a good person separation index (R=0.91). The difficulty hierarchy of the VLT-SF items was invariant across patient subgroups of (motor) lesion completeness. CONCLUSIONS: Provided that response categories are recoded, VLT-SF Rasch analysis showed that the requirements of an objective measure were satisfied. This allows to compare the measurements of different patients quantitatively, and to follow their results over time.

ToCUEST: a task-oriented client-centered training module to improve upper extremity skilled performance in cervical spinal cord-injured persons.

OBJECTIVES: Given (a) the importance of upper extremity skill performance in persons with cervical spinal cord injury (C-SCI), (b) the limited number of studies on arm hand functioning in C-SCI and (c) the discrepancy between the importance of client centeredness and the lack of a theoretical framework and practical guidelines on how to apply client centeredness into practice, the aim of the present study is to (1) develop a training concept in which rehabilitation of the upper extremity focuses on patient's needs and wishes and (2) to put this concept into practice for tetraplegic persons. METHODS: The training concept contains two main components. The client-centered component includes both extracting individual goals and defining and objectifying these goals. The task-oriented component incorporates a task analysis and the composition of an individual training program. RESULTS: A task-oriented client-centered training aimed at improving upper extremity skilled performance in tetraplegic persons is described step by step. The Canadian Occupational Performance Measure is used to identify patient's specific needs. The Goal Attainment Scale is applied to define and objectify individual goals. A task analysis is essential to map limiting and facilitating factors of the person, the task and the environment and to identify which aspects should be trained. An individual task-oriented training program is composed, based on principles of motor learning and training physiology and the use of assistive devices. Each step is explained and illustrated using a case example.

Evaluation of a task-oriented client-centered upper extremity skilled performance training module in persons with tetraplegia.

STUDY DESIGN: Clinical intervention study. OBJECTIVE: Arm hand skilled performance (AHSP) has a major role in the rehabilitation of persons with cervical spinal cord injury (C-SCI). A task-oriented client-centered upper extremity skilled performance-training (ToCUEST) module was developed. The present study aims to evaluate effects of ToCUEST on specific and general AHSP in C-SCI, during and after rehabilitation. SETTING: Adelante Rehabilitation Centre (The Netherlands). METHODS: C-SCI persons, either during or after rehabilitation, completed the ToCUEST training; a control group of patients during rehabilitation received standard rehabilitation. The training module was focused on patient's individual needs, combining principles of motor learning and training physiology. Three self-selected goals were trained 3 days per week, in three sessions of 30 min per day for 8 weeks. Measures were taken at 3 months after the start of the active rehabilitation (T0), before training (T1), after training (T2), at follow-up (3 months post-training; T3) and at discharge. RESULTS: For both ToCUEST groups during (n=11) and after (n=12) rehabilitation, an improvement (P<0.001) on specific AHSP (using the Goal Attainment Scale and the Canadian Occupational Performance Measure (satisfaction and performance)) was found between T1-T2 and T1-T3. Also an improvement (P<0.02) in general AHSP (using the Van Lieshout Test, the QIF and the motor FIM) was found in the total ToCUEST group between T1-T2 and T1-T3. No significant difference in improvement of general AHSP was found between the ToCUEST rehab and control group. CONCLUSION: The ToCUEST module leads to improvement in AHSP, not only persons with C-SCI during rehabilitation, but also after finishing rehabilitation. These effects remain at follow-up.

Efficacy and safety of acarbose in patients with cystic fibrosis and impaired glucose tolerance.

UNLABELLED: Impaired glucose tolerance (IGT) is an increasingly frequent complication of cystic fibrosis (CF). In CF patients, a fast postprandial rise in plasma glucose is typically followed by a delayed but prolonged insulin response. Patients may develop symptoms of both hyper- and hypoglycaemia. The alpha-glucosidase inhibitor, acarbose, delays the hydrolysis and subsequent absorption of ingested carbohydrates. The aim of this study was to investigate the efficacy of acarbose in CF patients with IGT. During a 2-week inpatient period for treatment of Pseudomonas infection, 12 CF patients with IGT were studied in a double-blinded, randomized crossover trial. Each patient received acarbose (50 mg t.i.d.) for 5 days and placebo for 5 days (days 3-8 and days 10-14, respectively). Glucose, insulin and C-peptide responses to a standardized nutritional load were measured at baseline and at the end of each study period (Days 2, 8 and 14). Treatment with acarbose was associated with significant reductions in the mean value, mean peak values and the area under the curve of plasma glucose, insulin and C-peptide, compared to respective baseline values and placebo. Gastro-intestinal disturbances were recorded in 67% of patients during therapy with acarbose. CONCLUSION: Acarbose has a positive therapeutic effect on glucose tolerance in cystic fibrosis patients, as shown by attenuation of postprandial plasma glucose increase and a significant decrease in insulin secretion response. However, acarbose treatment was associated with adverse gastro-intestinal effects that may prevent patients from accepting long-term therapy.

Comparison of localized proton NMR signals of skeletal muscle and fat tissue in vivo: two lipid compartments in muscle tissue.

In vivo 1H NMR spectra of small volumes-of-interest (VOI) were localized in human soleus muscle (8 ml) and compared with volume selective spectra of subcutaneous fat tissue and femoral yellow bone marrow (2 ml). All examinations were performed by the double spin echo (PRESS) localization technique. To provide comparability, spectra of different tissues were recorded using identical sequence timing. Clearly improved resolution of the lipid signals of muscle tissue was obtained using long echo times TE > 200 ms. The spectra of muscle tissue exhibit lipid signals that stem from two compartments with a difference of their resonance frequencies of about 0.2 ppm (Larmor frequency difference 12-13 Hz at 1.5 T). The existence of two fatty acid compartments is supported by measurements of the relaxation times and line shape analysis. Both compartments contain fatty acids or triglycerides with similar composition. Probably one compartment corresponds to fat cells within muscle tissue, the other compartment with lower Larmor frequency is located within muscle cells.

Localized proton MR spectroscopy of citrate in vitro and of the human prostate in vivo at 1.5 T.

Citrate is a secretory product of the normal prostate, a lack of citrate in prostate tissue is expected to be pathognomonic for adenocarcinoma. In the present study proton AB-signal characteristics of citrate at low field strength of 1.5 T were investigated by volume selective spectroscopic and theoretical methods. The nonappearance of fast phase modulation of the J-coupled system at low field strength in vivo is verified by measurements of sodium citrate solution. In vivo localized spectroscopy of small volume elements of (2 cm)3 with the double spin-echo method within the prostatic gland provides citrate signal reception even using a Helmholtz coil with 170-mm diameter. Volume selective proton spectra with different echo times are presented which are comparable to spectra acquired by former authors with endorectal coils.

Leukemic red bone marrow changes assessed by magnetic resonance imaging and localized 1H spectroscopy.

Red bone marrow of healthy persons has considerable contents of water and lipids. The cellularity and the corresponding fat-water ratio within the marrow show clear changes in hematological diseases. Magnetic resonance (MR) methods use the signals of the protons of water and lipids. This paper gives a comparison between different standard MR techniques and recently developed fat- and water-selective imaging methods, addressing their sensitivity to bone marrow changes in leukemia. Additionally, 1H results of spectroscopic methods are presented. The results and conclusions are based on the examination of 26 healthy volunteers and 106 patients with general or focal bone marrow alterations. Standard T1-weighted images did not distinguish bone marrow of young healthy volunteers with relatively high cellularity from acute leukemia. Using fat- and water-selective methods, patients with untreated leukemia showed only water proton signals and no lipid signals from red bone marrow of vertebral bodies and the pelvis. This phenomenon was never observed in healthy volunteers. Following chemotherapy, lipid and water contents normalize in successfully treated patients. Nonresponders did not show significant changes of the fat-water ratio after up to 3 weeks of therapy. Phase contrast imaging provides information about the difference between fat and water fractions within the bone marrow, but quantitative determination of the absolute fat and water fractions requires acquisition of several images and suffers from the susceptibility effects in trabecular bone marrow. The fat-water ratio and additional qualities of water and lipid protons (relaxation times) can be evaluated by volume-selective MR spectroscopy. Typical results of spectra from small-volume elements in hypercellular vertebral bone marrow of leukemic patients before cytotoxic treatment and of normocellular or hypocellular marrow after therapy are demonstrated.

Computed tomography (CT) and magnetic resonance imaging (MRI) in T-stage evaluation of oral and oropharyngeal carcinomas.

174 CT and 32 MRI investigations were carried out on patients with carcinomas of the mouth and oropharynx. The methods were compared and their value in predicting the pre-therapeutic T-staging studied. The combination of CT and clinical examination was able to improve the T-staging considerably compared with clinical examination alone. MRI was superior to CT in delineating the tumour margins in 78% of patients. T1-weighted and gradient echo sequences after intravenous gadolinium injection were particularly useful. Nevertheless, T-staging based on clinical and CT-findings was changed in only 5% of patients by MRI. MRI is especially useful in T1 tumours and in cancer of the base of the tongue. MRI should also be used instead of CT were dental fillings obscure the region of interest. If there are good MRI facilities and an experienced team available MRI can be used before CT.

Volume-selective proton MRS in vertebral bodies.

Volume-selective 1H magnetic resonance spectra of small volume elements of (13 mm)3 positioned in lumbar vertebral bodies have been investigated in 15 healthy persons of different ages and sexes and in 11 patients with leukemia using double spin-echo sequences. Signal intensities and positions of the spectral lines have been evaluated. Interindividual spectra of VOI located in the center of vertebral bodies, intraindividual spectra of central VOI in different vertebral bodies, and spectra of different localizations within the same vertebral body have been compared as well as spectra before and partly after cytostatic treatment in leukemia patients. Unexpected phenomena of the signal shapes have been found. The water signal distributions in healthy persons compared to patients after bone marrow transplantation show significant differences. The success of the cytostatic treatment in cases of leukemia is accompanied by an increase in the intensity of the lipid signals and a decrease in the water signals.

Subtle bone marrow edema assessed by frequency selective chemical shift MRI.

Subtle edema in yellow bone marrow from tumors (14 subjects) and osteomyelitis (9 subjects) were examined by selective nonexcitation (SENEX) water imaging using a short five pulse frequency selective excitation with lipid suppression greater than 96%. Standard spin-echo (SE) proton density-, T1- and T2-weighted images, and fat suppression methods such as short inversion time inversion recovery and also the chemical shift selective Dixon method are discussed in comparison with SENEX. Application of the SENEX method is described and images from four typical cases are demonstrated. Sensitivity to edema is obviously better using the SENEX chemical shift selective method than using other imaging techniques. Improved delineation of abnormal areas in yellow bone marrow is provided by SENEX water imaging in one slice after multislice standard imaging. After shimming, only one SE scan with frequency selective excitation is necessary to get a pure water image.

Localized in vivo 1H spectroscopy of human skeletal muscle: normal and pathologic findings.

To obtain high signal to noise ratio in small volume elements (8 cm3), in vivo 1H NMR spectroscopy of normal and diseased human skeletal muscle was performed using a double spin-echo localization method on a 1.5-T whole body system. High resolved spectra of normal calf muscle show the well known resonances of lipids (methyl, methylene, olefinic, and other fatty acid resonances), creatine/phosphocreatine, choline/carnitine, taurine, and histidine with good intraindividual reproducibility. Pronounced intraindividual differences in the lipid range were found between different upper thigh muscle groups. On pathologic conditions like myopathy, myositis or irradiation damage the spectral lipid content was increased. Three months after local irradiation of the medial vastus muscle (50 Gy), the localized 1H NMR spectrum showed a complete loss of the choline and creatine signals. In a case of M. Behçet with muscular involvement the relative reduction of the choline signal may provide an insight in the pathobiochemistry. The results of our investigations in nine healthy volunteers and three patients are presented in detail including relaxation times of the metabolites.

[Value of magnetic resonance tomography in gastroenterological diagnosis]. / Wertigkeit der magnetischen Resonanztomographie in der gastroenterologischen Diagnostik.

The value of magnetic resonance imaging (MRI) in the gastrointestinal tract has not yet been determined. In neoplastic disease, MRI has a high sensitivity in the detection of liver metastases secondary to colorectal cancer. MRI is superior to CT in differentiating recurrent rectal cancer from fibrosis. The high sensitivity of MRI in the detection of fistulae in Crohn's disease and the differentiation from fibrosis represents an advantage over other modalities in imaging of inflammatory bowel disease. Further development of MRI and the use of contrast media for both oral and intravenous administration may offer new perspectives of MRI in diseases of the gastrointestinal tract.

Follicular dynamics and superovulatory response in Holstein cows treated with FSH-P in different endocrine states.

The effect of follicular and/or endocrine environments on superovulatory response was tested. Eighteen nonlactating Holstein cows were superovulated with 32 mg FSH-P given in decreasing doses at 12-h intervals plus two injections of prostaglandin F2-alpha (25 mg each) on the third day of treatment. Cows were assigned randomly to treatments: T1, superovulatory treatment initiated on estrous cycle Day 10.5; T2, CIDR (intravaginal device containing 1.9 g of progesterone) inserted from Days 3 to 9 and superovulation initiated on Day 6.5; T3, identical to T2 but Buserelin (GnRH agonist) was injected (8 microg, i.m.) on Day 3 at the time of CIDR insertion. Embryos were recovered on Day 7 after the superovulatory estrus. Cows were examined daily by ultrasonography and blood was collected for progesterone and estradiol determinations. Mean diameter of the dominant follicle (frequency of first-wave dominant follicle) at the beginning of FSH injections was 13.7 mm (4/6), 11.2 mm (6/6) and 8.7 mm (6/6) (P<0.01) for T1, T2 and T3, respectively. Following initiation of superovulation, follicles moved into larger follicle classes (Class I, <3 mm; Class II, 3 to 4 mm; Class III, 5 to 9 mm; Class IV >9 mm) earliest in T1 (P<0.01). Cumulative follicular diameter and plasma concentrations of estradiol at Day 4 of superovulation were higher (P<0.01) in T1 (200 mm, 82 pg/ml) compared with T2 (123 mm, 24 pg/ml) and T3 (130 mm, 18 pg/ml). Proportion of cows in estrus prior to 12 h vs 12 to 24 h differed (P<0.05) between groups (T1: 5 vs 1; T2: 2 vs 4; T3: 1 vs 5). Mean number of follicles on the last day of superovulation treatment, number of CL and number of embryos plus unfertilized ova recovered were 17.5, 12.2 and 13.3; 13.8, 10 and 8.2 (P<0.1) and 8.7, 4.5 and 2.3 (P<0.05) for T1, T2 and T3, respectively. The developmental stage of the dominant follicle was associated with not only the number of ovulations, but also the size and periestrous concentrations of plasma estradiol associated with the recruited follicles.

Localized Larmor frequency-guided fat and water proton MRI of the spine: a method to emphasize pathological findings.

A measurement protocol providing a correct adjustment of the irradiation frequencies for well separated fat and water images of the lumbar spine is presented. To determine accurately the Larmor frequencies of water and fat protons within the vertebral bodies, a volume selective spectrum of a volume element (13 mm)3 located in a lumbar vertebral body was acquired with the 90 degrees-180 degrees-180 degrees double spin-echo method. These Larmor frequencies are used to adjust the frequency-selective pulse of the SENEX chemical-shift imaging sequence. This procedure provides well separated fat and water images for a large field of view even in the inhomogeneous region of the vertebral column. Their clinical importance is demonstrated by localized Larmor frequency-guided (LLFG) SENEX 1H images of the lumbar spine in healthy persons of different age and in a patient with acute myeloid leukemia.

[Rapid and high-resolution 3D-imaging in MR tomographic diagnosis of diseases of the knee joint]. / Schnelle und hochauflösende 3D-Bildgebung für die kernspintomographische Diagnostik von Erkrankungen des Kniegelenks.

A new technique was developed for MR imaging of diseases of the knee joint to shorten the time required for examination. The acquisition of an isotropic 3D-dataset using a FLASH- or a FISP-sequence is the base for secondary reconstructions of planar high-resolution images (spatial resolution less than or equal to 1 mm) in free orientations. Acquisition time of the 3D-dataset is 16 minutes, additional one up to five minutes are needed for image calculation. The method can image structures of the knee joint such as the cartilage, the menisci or the ligament. The advantage of the decreased examination time of about 30 minutes has been proved, but further comparative clinical studies are needed to establish the diagnostic equivalence of this method and conventional techniques.

[The clinical value of contrast CT in lymph node staging in the neck region]. / Klinische Wertigkeit der Kontrastmittel-CT beim Lymphknotenstaging in der Halsregion.

Pre-treatment CT examinations of 333 patients with squamous carcinomas in the head and neck region have been analysed. Two hundred and six patients had lymph-node metastases and lymph-node staging was ascertained. The criteria for metastatic involvement were lymph node size greater than 15 mm. and changes in structure (inhomogeneity, central hypodensity and ring enhancement). CT had a sensitivity of 93% and accuracy of 89%. This was better than palpation (sensitivity 64%, accuracy 72%). CT can be regarded as a reliable basis for treatment planning.

[T-staging of tongue and mouth floor tumors: comparison of ultrasonography and computerized tomography]. / T-Staging von Zungen- und Mundbodentumoren: Sonographie und Computertomographie im Vergleich.

A comparison was made between the pretherapeutic CT and ultrasound findings of 43 patients with tumors of the oral tongue and the floor of the mouth. Two tumors of the edge of the tongue (T1) each were not diagnosed by computed tomography and by sonography. In three cases a more precise determination of the tumor size was achieved by sonography. In 25 out of 38 cases the contrast between tumor and sound tissue was better in the sonographic image. The reduction and regressive modification of the tumor following to radiotherapy could be observed in eleven cases. Despite the benefits of sonographic investigation in this area due to the excellent contrast without any need of contrast media, the good availability and the absence of metal and movement artefacts, this method is not able to replace computed tomography. The most important disadvantages of sonography were found to be the incapability to show osseous erosions and the restricted or lacking possibility to assess the parapharyngeal and the retropharyngeal area.

[The clinical value of computed tomography in the pretherapeutic T-staging of orofacial tumors]. / Klinische Wertigkeit der Computertomographie beim prätherapeutischen T-Staging von orofazialen Tumoren.

The clinical role of contrast-enhanced CT for pre-operative T-staging of oro-facial tumours was evaluated in 174 patients. During stages T1 and T2, clinical examination is 90% accurate and has a significantly higher sensitivity than CT, with an accuracy of only 53%. The clinical diagnosis of T1 and T2 is, however, made with undue frequency; CT makes it possible to obtain correct staging. Combination of CT and clinical examination can improve correct staging from 46% to 81%. During stages T3 and T4. CT has sensitivity of 91% and is markedly superior to clinical examination, with a sensitivity of 34%. Combined clinical and CT examination improves the predictive value from 52% to 92%. Combination of clinical and CT staging, when the higher stage is accepted as being correct, has a sensitivity and reliability of over 90%. It can be used as a firm basis for treatment planning, judging the prognosis and the effects of treatment.