Developing, Implementing, and Applying Novel Techniques During Systematic Reviews of Primary Space Medicine Data.

BACKGROUND: The Aerospace Medicine Systematic Review Group was set up in 2016 to facilitate high quality and transparent synthesis of primary data to enable evidence-based practice. The group identified many research methods specific to space medicine that need consideration for systematic review methods. The group has developed space medicine specific methods to address this and trialed usage of these methods across seven published systematic reviews. This paper outlines evolution of space medicine synthesis methods and discussion of their initial application.METHODS: Space medicine systematic review guidance has been developed for protocol planning, quantitative and qualitative synthesis, sourcing gray data, and assessing quality and transferability of space medicine human spaceflight simulation study environments.RESULTS: Decision algorithms for guidance and tool usage were created based on usage. Six reviews used quantitative methods in which no meta-analyses were possible due to lack of controlled trials or reporting issues. All reviews scored the quality and transferability of space simulation environments. One review was qualitative. Several research gaps were identified.CONCLUSION: Successful use of the developed methods demonstrates usability and initial validity. The current space medicine evidence base resulting in no meta-analyses being possible shows the need for standardized guidance on how to synthesize data in this field. It also provides evidence to call for increasing use of controlled trials, standardizing outcome measures, and improving minimum reporting standards. Space medicine is a unique field of medical research that requires specific systematic review methods.Winnard A, Caplan N, Bruce-Martin C, Swain P, Velho R, Meroni R, Wotring V, Damann V, Weber T, Evetts S, Laws J. Developing, implementing, and applying novel techniques during systematic reviews of primary space medicine data. Aerosp Med Hum Perform. 2021; 92(8):681688.

A comparison of exercise interventions from bed rest studies for the prevention of musculoskeletal loss.

Musculoskeletal loss in actual or simulated microgravity occurs at a high rate. Bed rest studies are a reliable ground-based spaceflight analogue that allow for direct comparison of intervention and control participants. The aim of this review was to investigate the impact of exercise compared to no intervention on bone mineral density (BMD) and muscle cross-sectional area (muscle CSA) in bed rest studies relative to other terrestrial models. Eligible bed rest studies with healthy participants had an intervention arm with an exercise countermeasure and a control arm. A search strategy was implemented for MEDLINE. After screening, eight studies were identified for inclusion. Interventions included resistive exercise (RE), resistive vibration exercise (RVE), flywheel resistive exercise, treadmill exercise with lower body negative pressure (LBNP) and a zero-gravity locomotion simulator (ZLS). Lower limb skeletal sites had the most significant BMD losses, particularly at the hip which reduced in density by 4.59% (p < 0.05) and the tibial epiphysis by 6% (p < 0.05). Exercise attenuated bone loss at the hip and distal tibia compared to controls (p < 0.05). Muscle CSA changes indicated that the calf and quadriceps were most affected by bed rest. Exercise interventions significantly attenuated loss of muscle mass. ZLS, LBNP treadmill and RE significantly attenuated bone and muscle loss at the hip compared to baseline and controls. Despite exercise intervention, high rates of bone loss were still observed. Future studies should consider adding bisphosphonates and pharmacological/nutrition-based interventions for consideration of longer-duration missions. These findings correlate to terrestrial bed rest settings, for example, stroke or spinal-injury patients.

The role of physiotherapy in the European Space Agency strategy for preparation and reconditioning of astronauts before and after long duration space flight.

Spaceflight and exposure to microgravity have wide-ranging effects on many systems of the human body. At the European Space Agency (ESA), a physiotherapist plays a key role in the multidisciplinary ESA team responsible for astronaut health, with a focus on the neuro-musculoskeletal system. In conjunction with a sports scientist, the physiotherapist prepares the astronaut for spaceflight, monitors their exercise performance whilst on the International Space Station (ISS), and reconditions the astronaut when they return to Earth. This clinical commentary outlines the physiotherapy programme, which was developed over nine long-duration missions. Principles of physiotherapy assessment, clinical reasoning, treatment programme design (tailored to the individual) and progression of the programme are outlined. Implications for rehabilitation of terrestrial populations are discussed. Evaluation of the reconditioning programme has begun and challenges anticipated after longer missions, e.g. to Mars, are considered.

Systematic review of countermeasures to minimise physiological changes and risk of injury to the lumbopelvic area following long-term microgravity.

BACKGROUND: No studies have been published on an astronaut population to assess the effectiveness of countermeasures for limiting physiological changes in the lumbopelvic region caused by microgravity exposure during spaceflight. However, several studies in this area have been done using spaceflight simulation via bed-rest. The purpose of this systematic review was to evaluate the effectiveness of countermeasures designed to limit physiological changes to the lumbopelvic region caused by spaceflight simulation by means of bed-rest. METHODS: Electronic databases were searched from the start of their records to November 2014. Studies were assessed with PEDro, Cochrane Risk of Bias and a bed-rest study quality tool. Magnitude based inferences were used to assess countermeasure effectiveness. RESULTS: Seven studies were included. There was a lack of consistency across studies in reporting of outcome measures. Some countermeasures were found to be successful in preventing some lumbopelvic musculoskeletal changes, but not others. For example, resistive vibration exercise prevented muscle changes, but showed the potential to worsen loss of lumbar lordosis and intervertebral disc height. CONCLUSION: Future studies investigating countermeasures should report consistent outcomes, and also use an actual microgravity environment. Additional research with patient reported quality of life and functional outcome measures is advocated.

The Effect of the Gravity Loading Countermeasure Skinsuit Upon Movement and Strength.

Carvil, PA, Attias, J, Evetts, SN, Waldie, JM, and Green, DA. The effect of the gravity loading countermeasure skinsuit upon movement and strength. J Strength Cond Res 31(1): 154-161, 2017-Effective countermeasures against musculoskeletal deconditioning induced by microgravity and disuse are required. A simple alternative to provision of artificial gravity by centrifugation is compressive axial loading. The Russian "Pingvin" suit was the first wearable suit to apply this concept using bungee cords tethered around the shoulders and feet. However, poor loading characteristics and severe thermal and movement discomfort were reported. The gravity loading countermeasure skinsuit (GLCS) uses a bidirectional weave to generate staged axial loading from shoulders to feet, better mimicking how Earth's gravity induces progressive loading head to foot. The Mk III GLCS's loading was evaluated and tolerability assessed during maximal joint motion, ambulation, and selected strength exercises. Eight subjects (5 male and 3 female; 28 ± 3 years; 179 ± 0.1 cm and 74.8 ± 2.9 kg), having given written informed consent, had an Mk III GLCS individually tailored. Axial loading imparted, body height, joint range of motion (ROM), ambulation, and strength tests (12 repetition maximum) were performed in the GLCS and gym attire, with subjective (rating of perceived exertion, thermal comfort, movement discomfort and body control) ratings recorded throughout. Gravity loading countermeasure skinsuit provided significant axial loading when standing but significantly reduced knee (-13°), spinal (-28°) and shoulder flexion/extension ROM (-34°/-13°), in addition to Sit and Reach (-12.8 cm). No thermal issues were reported but there was an increase in subjective discomfort. Gravity loading countermeasure skinsuit did not significantly impede strength exercise, with the exception of shoulder press. The GLCS (Mk III) demonstrates potential as a countermeasure by providing tolerable, static axial loading. Furthermore, it may serve as an elasticlike strength exercise adjunct, which may have utility as a rehabilitation modality after further design refinement.

Operational evaluation of the earlobe arterialized blood collector in critically ill patients.

BACKGROUND: The new Earlobe Arterialized Blood Collector (EABC®) is a minimally invasive prototype system able to perform capillary blood collection from the earlobe (EL) with minimal training and risk. This system could improve medical emergency management in extreme environments. Consequently, a prospective validation study was designed to evaluate operational performance of the EABC® in a cohort of critically ill patients. METHODS: Arterialized capillary blood was sampled from the EL of 55 invasively ventilated patients using the EABC® following a validated procedure. Operational characteristics such as the number of cuts and cartridges required, sampling failure/success ratio, bleeding complications, storage requirements and other auxiliary aspects were recorded. Result turnaround laboratory times (TAT) were compared with published references. RESULTS: Blood collection was as easily performed on one earlobe as the other. Twenty-six minutes (mean 25.8; SD = 3.8) were required to obtain results, 15 min for patient preparation (mean 15.3; SD = 2.6) + 11 min for sampling and analysis (mean 11.4; SD = 2.1), which is similar to published hospital reference laboratory TAT. The average number of cartridges required was 1.3 (1-3; mode = 1) with the mean number of cut attempts being 1.2 (1-4; mode = 1). Problems/difficulties occurred in 59% of cases but were mainly attributed to patient's demographic characteristics, with only 10% attributable to the collector (superficial cut, blood leak, collector misalignment and obstructed vision). Haemostasis was quickly achieved with minimum complications. Storage of the complete sampling kit required a 300 × 300 × 300 mm box. Two 9-V batteries were used during the 2-year study period. CONCLUSIONS: The new EABC® system concept is safe, fast and easy to use. Observed problems/difficulties are easily amendable with certain design modifications. Definitive versions of the prototype have the potential for significant benefits for isolated and extreme environments in medicine.

Post space mission lumbo-pelvic neuromuscular reconditioning: a European perspective.

Long-duration exposure to the space environment causes physical adaptations that are deleterious to optimal functioning on Earth. Post-mission rehabilitation traditionally concentrates on regaining general muscle strength, neuromuscular control, and lumbo-pelvic stability. A particular problem is muscle imbalance caused by the hypertrophy of the flexor and atrophy of the extensor and local lumbo-pelvic muscles, increasing the risk of post-mission injury. A method currently used in European human spaceflight to aid post-mission recovery involves a motor control approach, focusing initially on teaching voluntary contraction of specific lumbo-pelvic muscles and optimizing spinal position, progressing to functional retraining in weight bearing positions. An alternative approach would be to use a Functional Readaptive Exercise Device to appropriately recruit this musculature, thus complementing current rehabilitation programs. Advances in post-mission recovery of this nature may both improve astronaut healthcare and aid terrestrial healthcare through more effective treatment of low back pain and accelerated post bed rest rehabilitation.

The MARS2013 Mars analog mission.

We report on the MARS2013 mission, a 4-week Mars analog field test in the northern Sahara. Nineteen experiments were conducted by a field crew in Morocco under simulated martian surface exploration conditions, supervised by a Mission Support Center in Innsbruck, Austria. A Remote Science Support team analyzed field data in near real time, providing planning input for the management of a complex system of field assets; two advanced space suit simulators, four robotic vehicles, an emergency shelter, and a stationary sensor platform in a realistic work flow were coordinated by a Flight Control Team. A dedicated flight planning group, external control centers for rover tele-operations, and a biomedical monitoring team supported the field operations. A 10 min satellite communication delay and other limitations pertinent to human planetary surface activities were introduced. The fields of research for the experiments were geology, human factors, astrobiology, robotics, tele-science, exploration, and operations research. This paper provides an overview of the geological context and environmental conditions of the test site and the mission architecture, in particular the communication infrastructure emulating the signal travel time between Earth and Mars. We report on the operational work flows and the experiments conducted, including a deployable shelter prototype for multiple-day extravehicular activities and contingency situations.

Earlobe arterialized capillary blood gas analysis in the intensive care unit: a pilot study.

BACKGROUND: Earlobe arterialized capillary blood gas analysis can be used to estimate arterial gas content and may be suitable for diagnosis and management of critically ill patients. However, its utility and applicability in the ICU setting remains unexplored. METHODS: A prospective observational validation study was designed to evaluate this technique in a cohort of mechanically ventilated adult critically ill patients admitted to a polyvalent ICU. Precision and agreement between capillary gas measures and arterial references was examined. Acute Respiratory Distress Syndrome (ARDS) diagnosis capabilities with the proposed technique were also evaluated. Finally, factors associated with sampling failure were explored. RESULTS: Fifty-five patients were included into this study. Precision of capillary samples was high (Coefficient of Variation PO2 = 9.8%, PCO2 = 7.7%, pH = 0.3%). PO2 measures showed insufficient agreement levels (Concordance Correlation Coefficient = 0.45; bias = 12 mmHg; percentage of error = 19.3%), whereas better agreement was observed for PCO2 and pH (Concordance Correlation Coefficient = 0.94 and 0.93 respectively; depreciable bias; percentage of error 11.4% and 0.5% respectively). The sensitivity and specificity for diagnosing ARDS were 100% and 92.3% using capillary gasometric measures. Sampling was unsuccessful in 43.6% of cases due to insufficient blood flow. Age > 65 years was independently associated with failure (odds ratio = 1.6), however hemodynamic failure and norepinephrine treatment were also influencing factors. CONCLUSIONS: Earlobe capillary blood gas analysis is precise and can be useful for detecting extreme gasometrical values. Diagnosis of ARDS can be done accurately using capillary measurements. Although this technique may be insufficient for precise management of patients in the ICU, it has the potential for important benefits in the acute phase of various critical conditions and in other critical care arenas, such as in emergency medicine, advanced medical transport and pre-hospital critical care.

Fitness, blood, and urine measurements from the 2009 European astronaut selection medical examination.

INTRODUCTION: The European Space Agency conducted an astronaut selection campaign in 2008-09 which attracted over 8000 applicants. Of those, 45 made the final assessment stage: the medical examination (MEX). This retrospective, observational study reports exercise and fitness data, lipid profiles and other results of interest from the blood and urine samples of this niche subpopulation. METHODS: All the applicants that reached the MEX completed a Bruce protocol test and a standard blood draw (12 h of fasting, water intake was ad libitum) was collected together with a 24-h urine collection. All the results were compared to either a comparative population or reference range. RESULTS: The applicants had comparable fitness levels to the 90th percentile of their age group. The lipid profiles were observed to be within the 'optimal' or 'desirable' ranges. Bilirubin and creatinine clearance were measured at 1.2 (+/- 0.40) mg x dl(-1) and 131.0 (+/- 25.81) ml x min(-1), respectively, and both were shown to be significantly higher than their respective normative ranges, while urinary creatinine (0.65 (+/- 0.19) g x L(-1)) was significantly lower than the reference range. DISCUSSION: Overall, the results from the Bruce protocol and lipid profile show that the final round applicants were in good health and physically active. The most likely cause of the elevated bilirubin and creatinine levels was 'last-minute' exercise conducted by the final round applicants before the MEX and the low levels of urinary creatinine may be attributed to drinking high quantities of water with an associated hypovolemia, diluting the urine.

A device for sampling arterialized earlobe blood in austere environments.

INTRODUCTION: There is currently no effective method of measuring arterial blood gas tensions in austere environments such as in space or at high altitude. An alternative to direct arterial measurement is the sampling of arterialized earlobe blood, an accurate technique that has been in use in clinical medicine and physiology for more than 50 yr. We, therefore, developed an earlobe arterialized blood (EAB) collector for practical use in extreme environments. METHODS: The results from the EAB collector were compared with simultaneous samples of blood drawn from the radial artery. Six healthy subjects breathed a gas mixture of 12.8% O2 in N2 during 15 min of 8 degree head-down tilt. The blood samples were analyzed immediately. RESULTS: The mean differences in Po2 between arterialized earlobe and radial artery samples were 0.25 +/- 1.25 mmHg for Po2 and 1.0 +/- 0.75 mmHg for Pco2; neither difference was significant. There was no difference between the pH values obtained by the two techniques. CONCLUSION: This study suggests that arterialized blood sampled from the earlobe using the EAB collector may provide sufficiently accurate measurements of the Po2, Pco2 and pH of arterial blood for clinical or research use in extreme environments.

Basic life support in microgravity: evaluation of a novel method during parabolic flight.

BACKGROUND: If a cardiac arrest occurs in microgravity, the aim of current emergency procedures is to treat the patient using a medical restraint system within 2 min. The patient may require treatment while medical equipment is being deployed. The capability for one person, unaided, to successfully perform cardiopulmonary resuscitation (CPR) is, therefore, of paramount importance. A new technique has been developed whereby the practitioner encircles the thorax of the patient with his/her legs to restrain the patient to allow CPR to be performed in microgravity. METHOD: Two investigators performed both this method (during parabolic microgravity) and traditional CPR (at +1 Gz) on an instrumented CPR mannequin. The mannequin was modified to ensure accurate chest compression and ventilation measurements during microgravity. RESULTS: The mean (+/-SE) depth and rate of chest compression were 44.0+/-4.99 mm and 68.3+/-17.0 compressions x min(-1) respectively. Although the mean microgravity rate of compression proved significantly less (p < 0.05) than the +1 Gz mean (97.1+/-3.4 compressions x min(-1)), chest compression depth did not differ (p > 0.05) from +1 Gz measures (43.6+/-0.59 mm). The mean (+/-SE) microgravity tidal volume (VT) was 491+/-50.4 ml, which also did not differ (p > 0.05) from +1 Gz values (507.6+/-11.5 ml). DISCUSSION: Although difficulties in performing this method during parabolic flight primarily affected compression rate, it may be possible to conduct basic life support using this technique in any microgravity environment.