Dynamic evaluation of spine kinematics in individuals with Parkinson's disease and freezing of gait.

BACKGROUND: Freezing of gait (FoG) is an episodic failure of gait exposing people with Parkinson's disease (PD) to a high risk of falling. Despite growing evidence of the interconnection between impaired trunk control and FoG, a detailed description of spinal kinematics during walking is still lacking in this population. RESEARCH QUESTION: Do spinal alterations impact gait performance in individuals with PD and FoG? METHODS: We analyzed kinematic data of 47 PD participants suffering (PD-FOG, N = 24) or not suffering from FoG (PD-NFOG, N = 23) and 15 healthy controls (HCO) during quiet standing and unperturbed walking. We estimated the main spinal variables (i.e., spinal length, lordosis and kyphosis angles, trunk inclination), the pelvis angles, and the shoulder-pelvis angles during gait and standing. We studied differences across conditions and groups and the relationships between postural and gait parameters using linear regression methods. RESULTS: During standing and walking, both PD groups showed increased trunk inclination and decreased lordosis angle with respect to HCO, as well as a decreased range in variation of kyphosis angle, pelvic obliquity, and shoulder-pelvis angles. Only PD-FOG participants showed reduced range of lordosis angle and spinal length compared to HCO. PD-FOG individuals were also not able to straighten their spine during walking compared to standing. Stride length and velocity were decreased in both patient groups compared to HCO, while swing duration was reduced only in the PD-FOG group. In individuals with FoG, trunk inclination and lordosis angle showed moderate but significant positive correlations with all gait alterations. SIGNIFICANCE: Spine alterations impacted gait performance in individuals with PD suffering from FoG. Excessive trunk inclination and poor mastering of the lordosis spinal region may create an unfavourable postural precondition for forward walking. Physical therapy should target combined spinal and stepping alterations in these individuals.

Evaluation of respiratory- and postural-induced changes on the ballistocardiogram signal by time warping averaging.

OBJECTIVE: The aim of this work was to evaluate the potential changes in the ballistocardiogram (BCG) signal induced by different respiratory patterns and posture, by using the dynamic time warping (DTW) technique. APPROACH: BCG signals were recorded in a group of 20 healthy volunteers, simultaneously with an electrocardiogram (ECG). Two recordings, one in a supine (SUP) and one in a standing (ST) position, including spontaneous breathing, two 1 min apneas (at full and empty-lungs, respectively) and 30 s of Valsalva, were analyzed. A warped averaged waveform was computed for each phase, from which amplitude and temporal parameters were extracted to characterize each condition. MAIN RESULTS: Variations were found in both amplitude and duration of BCG-derived parameters among manoeuvres, especially when compared to spontaneous breathing, suggesting a complex interaction between intra-thoracic pressure changes acting on venous return, together with the autonomic nervous system modulation on heart rate. The effect of a hydrostatic pressure gradient elicited by postural conditions was also evident. SIGNIFICANCE: Posture and respiratory manoeuvres affect the BCG signal in different ways, probably as a result of changes induced in preload and afterload. This supports the need to define separate normality ranges for each posture and/or breathing conditions, as well as the importance of applying specific manoeuvres to highlight any pathological response in the computed BCG parameters.

Beat-to-beat heart rate detection by smartphone's accelerometers: validation with ECG.

Mobile phones offer the possibility to monitor and track health parameters. Our aim was to test the feasibility and accuracy of measuring beat-to-beat heart rate using smartphone accelerometers by recording the vibrations generated by the heart during its function and transmitted to the chest wall, i.e. the so-called seismocardiographic signal (SCG). METHODS: 9 healthy male volunteers were studied in supine (SUP) and in standing (ST) posture. A smartphone (iPhone6, Apple) was positioned on the thorax (POS1) to acquire SCG signal. While supine, a second smartphone was positioned on the navel (POS2). The SCG signal was recorded for 3 minutes during spontaneous respiration, synchronous with 3-leads ECG. Using a fully automated algorithm based on amplitude thresholding after rectification, the characteristic peak of the SCG signal (IVC) was detected and used to compute beat-to-beat heart duration, to be compared with the corresponding RR intervals extracted from the ECG. RESULTS: A 100% feasibility of the approach resulted for POS1 in SUP, while 89% in POS2, and 78% for POS1 in ST. In supine, for each smartphones' position, the automated algorithm correctly identified the cardiac beats with >98% accuracy. Linear correlation (r2) with RR was very high (>0.98) in each posture and position, with no bias and narrow limits of agreement. CONCLUSIONS: The obtained results proved the feasibility of the proposed approach and the robustness of the applied algorithm in measuring the beat-to-beat heart rate from smartphone-derived SCG, with high accuracy compared to conventional ECG-derived measure.

Instrumental measures of spinal function: is it worth? A state-of-the art from a clinical perspective.

In the last decades, assessment of trunk posture and motion has gained importance in clinical practice, and several instrumental non-invasive techniques have been developed to overcome limitations of manual and radiological methods. Despite the large effort spent in improving the underlying technologies, the actual role of these measures in the clinical setting remains still undefined due to a variety of issues. The main question concerns the provision of parameters providing a significant contribution to the clinical decision making. In this paper, we review the available spine surface measurement techniques from a technical viewpoint, and point out their current and potential applications according to a clinical perspective. Conclusions are drawn on the basis of both the technical features and accessibility in daily clinical practice, as well as of the validity, reliability and clinical value of the provided parameters. A well-defined clinical role is established for surface topography in the follow-up of spine sagittal plane deformities, adulthood scoliosis and spine disorders involving the spino-pelvic alignment. Conversely, further studies are required to identify reliable key parameters for use in the clinical (adolescent scoliosis, back and neck pain), occupational (measurement of spine exposure to mechanical loads) and forensic (assessment of segmental functional impairments) fields.

Early signs of gait deviation in Duchenne muscular dystrophy.

BACKGROUND: Most analytical studies found in literature only focus on specific aspects of Duchenne muscular dystrophy (DMD) gait and posture (joint range of motion, standing balance, variations of gait spatial-temporal parameters). Some of them analyze single cases and do not provide a comprehensive evaluation of locomotion. There are few studies about DMD gait patterns, most of them concerning small groups of patients, sometimes not homogeneous, in which the clinical manifestations of the next stages of DMD were present. AIM: The goal of our study was to analyze the characteristics of gait patterns in early stage patients, when clinical and functional evaluation do not allow to quantify initial walking worsening or to identify the changes adopted to compensate for muscle weakness. SETTING: Gait Analysis Laboratory by using a six-camera motion capture system (Vicon, Oxford Metrics, UK), set at a sampling rate of 60 Hz. Subjects were asked to walk barefoot at their usual cadence, along a 10-m walkway, where one force platform (Kistler, Switzerland), embedded in the middle portion of the pathway, measured the foot-ground reaction forces. Retroreflective markers were placed on the subjects according to the protocol described in Davis et al. POPULATION: A group of 15 patients aging from 5 to 6.8 years was compared with a similar age control group composed of 9 healthy children. RESULTS: Spatial and temporal parameters showed significant differences between the two groups: cadence was increased and step length was decreased significantly in the DMD group. We found a significant increase in the range of anterior-posterior pelvic tilt and in pelvic rotation. In the frontal plane there was a tendency for an increased pelvic obliquity. Dynamic range of motion in sagittal plane showed a significant difference at the ankle, with an increased plantarflexion in swing in the dystrophic patients. Maximum dorsiflexion was reduced in the DMD group. Kinetic analysis showed significant differences in power generation and absorption at the hip joint and at the ankle joint. At knee there was a reduced flexor moment in mid-stance. Ankle showed a reduced dorsiflexor moment in terminal stance and pre-swing with a consequent reduction in the peak-to-peak excursion. CONCLUSION AND CLINICAL REHABILITATION IMPACT: It was shown that instrumented gait analysis, being more sensitive than other clinical and functional assessment methods, allowed to quantify the very early modifications characterizing locomotion worsening in the first stage of the DMD.

Functional evaluation and rehabilitation engineering.

Life is complex and all about movement, which allows us to interact with the environment and communicate with each other. The human nervous system is capable of performing a simultaneous and integrated control of 100-150 mechanical degrees of freedom of movement in the body via tensions generated by about 700 muscles. In its widest context, movement is carried out by a sensory motor system comprising multiple sensors (visual,auditory, and proprioceptive),multiple actuators (muscles acting on the skeletal system),and an intermediary processor that can be summarized as a multiple-input­multiple-output nonlinear dynamic time-varying control system. This grand control system is capable of responding with remarkable accuracy,speed, appropriateness,versatility, and adaptability to a wide spectrum of continuous and discrete stimuli and conditions and is certainly orders of magnitude more complex and sophisticated than the most advanced robotic systems currently available. In the last decades,a great deal of research has been carried out in the fields of functional evaluation of human performance and rehabilitation engineering. These fields combine knowledge, concepts, and methods from across many disciplines (e.g., biomechanics,neuroscience, and physiology), with the aim of developing apparatuses and methods fort he measurement and analysis of complex sensory motor performance and the ultimate goal of enhancing the execution of different tasks in both healthy people and persons with reduced capabilities from different causes (injury, disease, amputation,and neural degeneration).

A dynamic model of quadriceps and hamstrings function.

The mechanical effect of hamstrings and quadriceps contractions on hip and knee joint motion was investigated using a dynamic model of the musculoskeletal system. The model consisted of 13 anatomically linked segments. The geometry of bones, joints, and muscle attachments was derived from magnetic resonance imaging of a healthy adult. The knee joint was represented by a crossing bars linkage to simulate cruciate ligament function, and muscles were represented by spring actuators. The effects of hamstring and quadriceps contractions, in various combinations, were tested on different configurations of hip and knee joint position in the absence of gravity. In the standing posture, with the foot free to move and the pelvis fixed in space, the effect of semimembranosus (SM) contraction was hip and knee flexion. If the foot was fixed to the ground, SM contraction produced hip extension and knee flexion. The addition of quadriceps contraction reduced or abolished the knee flexion and enhanced hip extension. In all other simulations, SM alone produced knee flexion and hip extension and the combination of SM with vastus (VA) and rectus femoris (RF) contractions resulted in knee extension and enhanced hip extension. Our findings suggest that co-contraction of quadriceps and hamstrings may be a strategy to increase the hip extension function of the hamstrings.

Effects of plantarflexion on pelvis and lower limb kinematics.

Modelling the effect of soleus and gastrocnemius contractions against the floor resistance in a forward dynamics simulation revealed that hip flexion, internal rotation and adduction together with external pelvic rotation could be attributed to a direct, but distant effect of triceps surae contraction. Knee flexion smoothed out the effect. To validate this clinically relevant biomechanical observation, ankle plantar flexion was correlated with hip and pelvic rotation retrospectively in children with spastic cerebral palsy. In 49 children with spastic hemiplegia, plantar flexion showed a significant correlation with increased pelvic retraction and hip internal rotation. In contrast, in 47 children with spastic diplegia no significant effect of the triceps surae on hip and pelvis kinematics was found. Bilateral hip and knee flexion in diplegia appeared to prevent the proximal effect of the triceps surae seen in the hemiplegics. In diplegia triceps surae overactivity did not appear to be a significant cause of internal rotation gait.

The heel-contact gait pattern of habitual toe walkers.

We used kinematic, kinetic and EMG analysis to compare the spontaneous heel-contact gait patterns of 13 children classified as habitual toe walkers (HTWs) and age-matched controls. In the HTWs, the incidence of spontaneous heel-contact strides during a single recording session ranged from 15% to 92%, with no correlation with age, passive ankle joint excursion, walking speed and trial order. Hallmarks of the heel-contact strides were premature heel-rise, reversal of the second rocker, relative shortening of the loading response and anticipation and enhancement of the electromyographic (EMG) activity normally observed in the triceps surae (TS) during the first half of the stance phase. This variant of the locomotor program is different from the walking patterns observed in normally developing toddlers and children with cerebral palsy (CP). It does not necessarily reflect a functional adaptation to changes in the rheological properties of the muscle-tendon complex.

Evaluation of an ambulatory system for gait analysis in hip osteoarthritis and after total hip replacement.

Spatial and temporal parameters of gait have clinical relevance in the assessment of motor pathologies, particularly in orthopaedics. A new gait analysis system is proposed which consists of (a) an ambulatory device (Physilog) including a set of miniature gyroscopes and a portable datalogger, and (b) an algorithm for gait analysis. The aim of this study was the validation of this system, for accuracy and clinical applicability. Eleven patients with coxarthrosis, eight patients with total hip arthroplasty and nine control subjects were studied using this portable system and also a reference motion analyzer and force plate. The small differences in the stance period (19 +/- ms), stride length and velocity (0.4 +/- 9.6 cm and 2.5 +/- 8.3 cm/s, respectively), as well as thigh and shank rotations (2.4 +/- 4.3 degrees and 0.3 +/- 3.3 degrees, respectively), confirmed good agreement of the proposed system with the reference system. In addition, nearly the same accuracy was obtained for all three groups. Gait analysis based on Physilog was also in agreement with their Harris Hip Scores (HHS): the subjects with lower scores had a greater limp, a slower walking speed and a shorter stride. This ambulatory gait analysis system provides an easy, reproducible and objective method of quantifying changes in gait after joint replacement surgery for coxarthrosis.

The upper body segmental movements during walking by young females.

OBJECTIVES: To characterise the physiological pattern of trunk and shoulders movements during walking and provide a reference for further studies on spine deformities. DESIGN: Implementation of a model for measuring spine and shoulder girdle movements during gait. Data collection on a population of eighteen, young, healthy, female subjects. BACKGROUND: The analysis of gait modifications in subjects with idiopathic scoliosis could offer an insight to better understand the functional relationship with the pathology. METHODS: Retroreflective markers were positioned on the main spine processes and acromions to be detected by a TV-based motion analysis system. A model of kinematic computation was implemented and integrated in a previously developed protocol for multifactorial gait analysis. Movements in the main reference planes and in relation to pelvis were analysed. RESULTS: The trunk was on average bent forward by 3.4 degrees with respect to standing; of the two physiological curves in the sagittal plane only lordosis changed during walking; in the frontal plane, a dynamic spine deformation appeared, that was maximum at heel strike-early stance; the trunk was bent controlaterally of the foot on the ground, while the shoulders remained stable; in the horizontal plane, the shoulders rotated contralaterally to the pelvis. CONCLUSIONS: In our population all the segmental movements analysed were smaller than 5 degrees during gait, except the angle of proximal curvature in the frontal plane, shoulder rotation, and angle between shoulders and pelvis; all the measured angles were far below their possible ranges of motion. RELEVANCE: Quantitative data on upper body kinematics as a complement to gait analysis can help understanding movement disorders and compensation strategies in several pathologies.

Standing-up exerciser based on functional electrical stimulation and body weight relief.

The goal of the present work was to develop and test an innovative system for the training of paraplegic patients when they are standing up. The system consisted of a computer-controlled stimulator, surface electrodes for quadricep muscle stimulation, two knee angle sensors, a digital proportional-integrative-derivative (PID) controller and a mechanical device to support, partially, the body weight (weight reliever (WR)). A biomechanical model of the combined WR and patient was developed to find an optimum reference trajectory for the PID controller. The system was tested on three paraplegic patients and was shown to be reliable and safe. One patient completed a 30-session training period. Initially he was able to stand up only with 62% body weight relief, whereas, after the training period, he performed a series of 30 standing-up/sitting-down cycles with 45% body weight relief. The closed-loop controller was able to keep the patient standing upright with minimum stimulation current, to compensate automatically for muscle fatigue and to smooth the sitting-down movement. The limitations of the controller in connection with a highly non-linear system are considered.

SHV-16, a beta-lactamase with a pentapeptide duplication in the omega loop.

A clinical isolate of Klebsiella pneumoniae was found to be resistant to ampicillin (MIC of 128 microg/ml), ticarcillin (MIC of 512 microg/ml), and ceftazidime (MIC of 128 microg/ml) and susceptible to all other beta-lactams; a synergistic effect between clavulanate and ceftazidime suggested the presence of an extended-spectrum beta-lactamase (ESBL). Transconjugants in Escherichia coli were obtained at low levels (10(-7) per donor cell) and exhibited a similar beta-lactam resistance pattern (resistant to ampicillin, ticarcillin, and ceftazidime at 64 microg/ml). The ESBL, pI 7.6, was encoded by a large plasmid (>100 kb) which did not carry any other resistance determinant. The ESBL-encoding gene was amplified by PCR using bla(SHV)-specific primers and was sequenced. The deduced amino acid sequence of the SHV-16 ESBL showed that it differed from SHV-1 by only a pentapeptide insertion (163DRWET167) corresponding to a tandem duplication in the omega loop. The implication of the 163a-DRWET163b-DRWET sequence in ceftazidime resistance was confirmed by cloning either bla(SHV-1) or bla(SHV-16) in the same vector, subsequently introduced in the same E. coli strain. Under these isogenic conditions, SHV-16 conferred a 32-fold increase in ceftazidime MIC compared to that with SHV-1. Furthermore, site-directed mutagenesis experiments modifying either E166aA or E166bA revealed that the functional glutamic residue was that located in the first copy of the duplicated sequence. But surprisingly, the second E166b also conferred a low-level resistance to ceftazidime. This work is the first description of a class A enzyme exhibiting an extended substrate specificity due to an insertion instead of a nucleotide substitution(s) in a clinical isolate.

Nosocomial outbreak due to a multiresistant strain of Pseudomonas aeruginosa P12: efficacy of cefepime-amikacin therapy and analysis of beta-lactam resistance.

Over a 3-year period, 67 patients of the Hospital of Pau (Pau, France), including 64 patients hospitalized in the adult intensive care unit (ICU), were colonized and/or infected by strains of Pseudomonas aeruginosa P12, resistant to all potentially active antibiotics except colistin. Most patients were mechanically ventilated and presented respiratory tract infections. Since cefepime and amikacin were the least inactive antibiotics by MIC determination, all ICU patients were treated with this combination, and most of them benefited. Cefepime-amikacin was found highly synergistic in vitro. Ribotyping and arbitrary primer-PCR analysis confirmed the presence of a single clonal isolate. Isoelectrofocusing revealed that the epidemic strain produced large amounts of the chromosomal cephalosporinase and an additional enzyme with a pI of 5.7, corresponding to PSE-1, as demonstrated by PCR and sequencing. Outer membrane protein profiles on sodium dodecyl sulfate-polyacrylamide gel electrophoresis showed the absence of a ca. 46-kDa protein, likely to be OprD, and increased production of two ca. 49- and 50-kDa proteins, consistent with the outer membrane components of the efflux systems, MexAB-OprM and MexEF-OprN. Thus, we report here a nosocomial outbreak due to multiresistant P. aeruginosa P12 exhibiting at least four mechanisms of beta-lactam resistance, i.e., production of the penicillinase PSE-1, overproduction of the chromosomal cephalosporinase, loss of OprD, and overexpression of efflux systems, associated with a better activity of cefepime than ceftazidime.

Ground reaction: intrinsic and extrinsic variability assessment and related method for artefact treatment.

Ground reaction (GR) components measured by a dynamometric platform represent the dynamic interaction of the moving human body with the ground and depend on the subject-platform relative position and orientation. The observed variability among the GR measurements of the walking trials of an individual is either due to variability in the motor performance (intrinsic variability) or due to changes in the direction of walking and in the position and orientation of the striking foot relative to the platform (extrinsic variability). A method, based on the median operator, is presented here which lets us quantify the two components of variability. The application of the method to a large data set of normal subjects evidenced changes in progression direction/foot orientation (95th percentile value is 6.9 degrees ), which can dramatically change the patterns of GR components. This result warns about improper analysis of ground reaction measurement. An algorithm for restoring GR measurements affected by artefact was derived from the above method. This tool can be of valuable aid in clinical practice where patients' conditions suggest to not insist on repetition of trials even if the required number of correct foot placements has not been achieved. The artefact correction algorithm has been applied to a large data set artificially corrupted to evaluate its robustness.

EMG signals detection and processing for on-line control of functional electrical stimulation.

The surface EMG signal detected from voluntarily activated muscles can be used as a control signal for functional neuromuscular electrical stimulation. A proper positioning of the recording electrodes in relation to the stimulation electrodes, and a proper processing of the recorded signals is required to reduce the stimulus artefact and the non-voluntary contribution (M-wave). Six orientations and six locations of the recording electrodes were investigated in the present work. A comb filter (with and without a blanking windowing) was applied to remove the signal components synchronously correlated to the stimulus. An operative definition of the signal to noise ratio and an efficiency index were implemented. It resulted that when the recording electrodes were located within the two stimulation electrodes the best orientation was perpendicular to the longitudinal line. However the best absolute indexes were obtained when the recording electrodes were located externally of the stimulation electrodes, and in that case the best orientation was longitudinal. Concerning the filtering procedure, the use of a blanking window before the application of the comb filter, gave the best performance.

Patient-driven control of FES-supported standing up and sitting down: experimental results.

A patient-driven control strategy for standing-up and sitting-down was experimentally tested on two paraplegic patients by applying functional electrical stimulation (FES) to the quadriceps muscle. The strategy--also known as "patient-driven motion reinforcement" (PDMR)--was developed by computer simulations reported in a former study. It is based on an inverse dynamic model (IDM) that predicts the stimulation pattern required to maintain the movement as it is initiated by the patient's voluntary effort. For reasons of safety and weight relief, the movement was supported by a seesaw construction. After some practice the patients were able to influence the stimulator output and to control the movement by their voluntary effort. Consequently, no pre-programmed reference trajectory was required. As a positive side effect, upper body effort could be minimized compared to trials without FES. To achieve a satisfactory performance of the PDMR controller a careful parameter identification of the inverse dynamic model was fundamental.

Functional control of the hand in tetraplegics based on residual synergistic EMG activity.

A microprocessor controlled device (MeCFES) was used for the investigation of the possibility of restoring hand function in C5 tetraplegics with paralysis of the hand. To date, 3 tetraplegics have been testing the system. The myoelectric signals from wrist extension were recorded and used as control signals for functional electrical stimulation (FES) of thumb adduction/flexion. The results have shown that the device can improve the hand function of tetraplegics. In this part of the work, a hand function test was designed and used to assess the results.

[Instrumental studies in laboratories dedicated to the examination of disk overload in health workers]. / Indagini strumentali in laboratori dedicati per la rilevazione del sovraccarico discale negli operatori sanitari.

The main factors to be considered when applying movement analysis techniques to complex situations are analysed. In particular, when the mechanical interactions of the operator with an object to be handled are not easily measurable, as in the case of lifting a patient in a nursery, an approach in which the ground reaction forces are measured through a force platform is more convenient. In these situations the posture and the movement of the subject, that are also difficult to track, do not need to be analysed. The only information needed is the position and orientation of the intervertebral disk and some estimation of the anthropometric parameters of the part of the body which is below the vertebral level of interest. This can be achieved by a relatively simple approach and a few reasonable assumptions. In addition, the method can enable us to analyse forces and moments in 3-D. The results presented refer to several kinds of operations that are usually performed with hospital patients. They include bed to wheelchair transfer, assistance with standing up from a chair, repositioning the patient in bed. It is shown that the compression loads (1810 N to 5110 N) are comparable to those already reported in the literature. In addition, the transversal components (anterior (260 N-707 N) and lateral (5 N-200 N) shear) are of considerable interest. It is also shown how the use of appropriate ergonomical devices to help patient lifting and handling can considerably reduce the loads on the spine: in fact the compression loads are between 991 N and 1644 N.

Instrumented staircase for ground reaction measurement.

A staircase was developed to record ground reactions during stair climbing at different slopes (inclinations). Each step is instrumented with six strain-gauge-based force transducers which allow the measurement of three-dimensional ground reaction force and moment as well as the centre of pressure (COP) location. A specific sensor arrangement permits accurate recording, especially of the COP location. The overall design of the staircase and details of a single instrumented step are presented. Static and dynamic characteristics have been evaluated by different experimental procedures. Preliminary results of ground reaction forces are shown.