Individuals with knee osteoarthritis show few limitations in balance recovery responses after moderate gait perturbations.

BACKGROUND: Knee osteoarthritis causes structural joint damage. The resultant symptoms can impair the ability to recover from unexpected gait perturbations. This study compared balance recovery responses to moderate gait perturbations between individuals with knee osteoarthritis and healthy individuals. METHODS: Kinematic data of 35 individuals with end-stage knee osteoarthritis, and 32 healthy individuals in the same age range were obtained during perturbed walking on a treadmill at 1.0 m/s. Participants received anteroposterior (acceleration or deceleration) or mediolateral perturbations during the stance phase. Changes from baseline in margin of stability, step length, step time, and step width during the first two steps after perturbation were compared between groups using a linear regression model. Extrapolated center of mass excursion was descriptively analyzed. FINDINGS: After all perturbation modes, extrapolated center of mass trajectories overlapped between individuals with knee osteoarthritis and healthy individuals. Participants predominantly responded to mediolateral perturbations by adjusting their step width, and to anteroposterior perturbations by adjusting step length and step time. None of the perturbation modes yielded between-group differences in changes in margin of stability and step width during the first two steps after perturbation. Small between-group differences were observed for step length (i.e. 2 cm) of the second step after mediolateral and anteroposterior perturbations, and for step time (i.e. 0.01-0.02 s) of first step after mediolateral perturbations and the second step after outward and belt acceleration perturbations. INTERPRETATION: Despite considerable pain and damage to the knee joint, individuals with knee osteoarthritis showed comparable balance recovery responses after moderate gait perturbations to healthy participants.

Test-retest reliability of three life balance measures in people with neuromuscular disease: the activity card sort-NL, the activity calculator, and the occupational balance questionnaire.

Purpose: Life balance is a new and important concept in occupational therapy. New measurements are needed to assess and evaluate life balance and interventions aimed to achieve this concept. This article describes the test-retest reliability of three life balance measures: the Activity Calculator (AC), Activity Card Sort (ACS-NL(18-64)) and Occupational Balance Questionnaire (OBQ11-NL).Method: Data collection took place among 50 participants with neuromuscular diseases: facioscapulohumeral dystrophy (FSHD, n = 25) or mitochondrial myopathy (MM, n = 25). The AC, the ACS-NL(18-64) and the OBQ11-NL were assessed twice with an interval of one week. Intraclass correlation coefficients (ICC-agreement) were applied to examine test-retest reliability.Results: The ICC of the AC-average total day score was .95 (95% CI .91-.97), whereas the ICC of the weights allocated to each activity was 0.80 (95% CI .77-0.82). The ICC of the ACS-NL(18-64) percentage retained activities was 0.92 (95% CI 0.86 - 0.96) and the ICC of the importance score per activity was- .76 (95% CI . 0.68-0.89). The ICC of the OBQ11-NL total score was .76 (95% CI 0.62-0.86).Conclusion: All three tools showed good to excellent test-retest reliability in a sample of patients with FSHD or MM, which is promising for its use in clinical practice and research.

The AC, ACS-NL(18­64) and the OBQ11-NL are promising, reliable measures of life balance in patients with neuromuscular diseases.The development of three new instruments for life balance enlarges the possibility for health professionals to measure life balance in clinical practice and research.

Objective gait assessment in individuals with knee osteoarthritis using inertial sensors: A systematic review and meta-analysis.

BACKGROUND: Objective assessment of gait using inertial sensors has shown promising results for functional evaluations in individuals with knee osteoarthritis (OA). However, the large number of possible outcome measures calls for a systematic evaluation of most relevant parameters to be used for scientific and clinical purposes. AIM: This systematic review and meta-analysis aimed to identify gait parameters derived from inertial sensors that reflect gait deviations in individuals with knee OA compared to healthy control subjects (HC). METHODS: A systematic search was conducted in five electronic databases (Medline, Embase, Web of Science, CINAHL, IEEE) to identify eligible articles. Risk of bias was assessed using a modified version of the Downs and Black scale. Data regarding study population, experimental procedures, and biomechanical outcomes were extracted. When a gait parameter was reported by a sufficient number of studies, a random-effects meta-analysis was conducted using the inverse variance method. RESULTS: Twenty-three articles comparing gait between 411 individuals with knee OA and 507 HC were included. Individuals with knee OA had a lower gait speed than HC (standardized mean difference = -1.65), driven by smaller strides with a longer duration. Stride time variability was slightly higher in individuals with knee OA than in HC. Individuals with knee OA walked with a lower range of motion of the knee during the swing phase, less lumbar motion in the coronal plane, and a lower foot strike and toe-off angle compared to HC. SIGNIFICANCE: This review shows that inertial sensors can detect gait impairments in individuals with knee OA. Large standardized mean differences found on spatiotemporal parameters support their applicability as sensitive endpoints for mobility in individuals with knee OA. More advanced measures, including kinematics of knee and trunk, may reveal gait adaptations that are more specific to knee OA, but compelling evidence was lacking.

The effect of limited sensory information on exoskeleton performance in people with complete spinal cord injury.

Despite the absence of somatosensory information from the lower extremities, people with complete spinal cord injury (SCI) can maintain postural stability in an exoskeleton. This is partly because humans are able to reweigh the relative dependence on each of the senses. However, when the sensory environment is changed, people with complete SCI are limited in their ability to reweigh their sensory organization towards more dependence on somatosensory information. The aim of this study was to investigate the effect of limited visual and/or auditory information on exoskeleton performance in people with complete SCI. Three experienced exoskeleton users performed twelve walking trials in the ReWalk exoskeleton. In each trial, the presence or absence of visual and/or auditory information was varied. Exoskeleton performance was operationalized as the walking distance covered and the amount of crutch loading. In one participant, the distance covered decreased when visual information was limited. The other two participants did not show substantial differences in distance covered between sensory conditions. Two participants decreased crutch loading when visual information was restricted, and one participant decreased crutch loading when auditory information was limited. The current study suggests a limited influence of the presence or absence of visual and auditory information on the distance covered in people with complete SCI walking in an exoskeleton. Interestingly, crutch loading seemed to decrease rather than increase when visual or auditory information was limited.

Task-specific training for improving propulsion symmetry and gait speed in people in the chronic phase after stroke: a proof-of-concept study.

BACKGROUND: After stroke, some individuals have latent, propulsive capacity of the paretic leg, that can be elicited during task-specific gait training. The aim of this proof-of-concept study was to investigate the effect of five-week robotic gait training for improving propulsion symmetry by increasing paretic propulsion in chronic stroke survivors. METHODS: Twenty-nine individuals with chronic stroke and impaired paretic propulsion (≥ 8% difference in paretic vs. non-paretic propulsive impulse) were enrolled. Participants received ten 60-min sessions of individual robotic gait training targeting paretic propulsion (five weeks, twice a week), complemented with home exercises (15 min/day) focusing on increasing strength and practicing learned strategies in daily life. Propulsion measures, gait kinematics and kinetics, self-selected gait speed, performance of functional gait tasks, and daily-life mobility and physical activity were assessed five weeks (T0) and one week (T1) before the start of intervention, and one week (T2) and five weeks (T3) after the intervention period. RESULTS: Between T0 and T1, no significant differences in outcomes were observed, except for a marginal increase in gait speed (+ 2.9%). Following the intervention, propulsion symmetry (+ 7.9%) and paretic propulsive impulse had significantly improved (+ 8.1%), whereas non-paretic propulsive impulse remained unchanged. Larger gains in propulsion symmetry were associated with more asymmetrical propulsion at T0. In addition, following the intervention significantly greater paretic trailing limb angles (+ 6.6%) and ankle plantarflexion moments (+ 7.1%) were observed. Furthermore, gait speed (+ 7.2%), 6-Minute Walk Test (+ 6.4%), Functional Gait Assessment (+ 6.5%), and daily-life walking intensity (+ 6.9%) had increased following the intervention. At five-week follow-up (T3), gains in all outcomes were retained, and gait speed had further increased (+ 3.6%). CONCLUSIONS: The post-intervention gain in paretic propulsion did not only translate into improved propulsion symmetry and gait speed, but also pertained to performance of functional gait tasks and daily-life walking activity levels. These findings suggest that well-selected chronic stroke survivors may benefit from task-specific targeted training to utilize the residual propulsive capacity of the paretic leg. Future research is recommended to establish simple baseline measures for identification of individuals who may benefit from such training and confirm benefits of the used training concepts in a randomized controlled trial. TRIAL REGISTRATION: Registry number ClinicalTrials.gov ( www.clinicaltrials.gov ): NCT04650802, retrospectively registered 3 December 2020.

Effect of assist-as-needed robotic gait training on the gait pattern post stroke: a randomized controlled trial.

BACKGROUND: Regaining gait capacity is an important rehabilitation goal post stroke. Compared to clinically available robotic gait trainers, robots with an assist-as-needed approach and multiple degrees of freedom (AANmDOF) are expected to support motor learning, and might improve the post-stroke gait pattern. However, their benefits compared to conventional gait training have not yet been shown in a randomized controlled trial (RCT). The aim of this two-center, assessor-blinded, RCT was to compare the effect of AANmDOF robotic to conventional training on the gait pattern and functional gait tasks during post-stroke inpatient rehabilitation. METHODS: Thirty-four participants with unilateral, supratentorial stroke were enrolled (< 10 weeks post onset, Functional Ambulation Categories 3-5) and randomly assigned to six weeks of AANmDOF robotic (combination of training in LOPES-II and conventional gait training) or conventional gait training (30 min, 3-5 times a week), focused on pre-defined training goals. Randomization and allocation to training group were carried out by an independent researcher. External mechanical work (WEXT), spatiotemporal gait parameters, gait kinematics related to pre-defined training goals, and functional gait tasks were assessed before training (T0), after training (T1), and at 4-months follow-up (T2). RESULTS: Two participants, one in each group, were excluded from analysis because of discontinued participation after T0, leaving 32 participants (AANmDOF robotic n = 17; conventional n = 15) for intention-to-treat analysis. In both groups, WEXT had decreased at T1 and had become similar to baseline at T2, while gait speed had increased at both assessments. In both groups, most spatiotemporal gait parameters and functional gait tasks had improved at T1 and T2. Except for step width (T0-T1) and paretic step length (T0-T2), there were no significant group differences at T1 or T2 compared to T0. In participants with a pre-defined goal aimed at foot clearance, paretic knee flexion improved more in the AANmDOF robotic group compared to the conventional group (T0-T2). CONCLUSIONS: Generally, AANmDOF robotic training was not superior to conventional training for improving gait pattern in subacute stroke survivors. Both groups improved their mechanical gait efficiency. Yet, AANmDOF robotic training might be more effective to improve specific post-stroke gait abnormalities such as reduced knee flexion during swing. Trial registration Registry number Netherlands Trial Register ( www.trialregister.nl ): NTR5060. Registered 13 February 2015.

Generation of a novel decay accelerating factor (DAF) knock-out rat model using clustered regularly-interspaced short palindromic repeats, (CRISPR)/associated protein 9 (Cas9), genome editing.

Decay accelerating factor (DAF), a key complement activation control protein, is a 70 kDa membrane bound glycoprotein which controls extent of formation of the C3 and C5 convertases by accelerating their decay. Using clustered regularly-interspaced short palindromic repeats, (CRISPR)/associated protein 9 (Cas9) genome editing we generated a novel DAF deficient (Daf-/-) rat model. The present study describes the renal and extrarenal phenotype of this model and assesses renal response to complement-dependent injury induced by administration of a complement-fixing antibody (anti-Fx1A) against the glomerular epithelial cell (podocyte). Rats generated were healthy, viable and able to reproduce normally. Complete absence of DAF was documented in renal as well as extra-renal tissues at both protein and mRNA level compared to Daf+/+ rats. Renal histology in Daf-/- rats showed no differences regarding glomerular or tubulointerstitial pathology compared to Daf+/+ rats. Moreover, there was no difference in urine protein excretion (ratio of urine albumin to creatinine) or in serum creatinine and urea levels. In Daf-/- rats, proteinuria was significantly increased following binding of anti-Fx1A antibody to podocytes while increased C3b deposition was observed. The DAF knock-out rat model developed validates the role of this complement cascade regulator in immune-mediated podocyte injury. Given the increasing role of dysregulated complement activation in various forms of kidney disease and the fact that the rat is the preferred animal for renal pathophysiology studies, the rat DAF deficient model may serve as a useful tool to study the role of this complement activation regulator in complement-dependent forms of kidney injury.

[Movement technology in the rehabilitation after stroke: hype or hope?] / Bewegingstechnologische therapieën na een beroerte.

Application of movement technology in the rehabilitation of neurological disorders has gained a firm position within a short time span, but the effectiveness of many technological innovations is still poorly supported by evidence. Should this burst of movement technology be considered a hype or is it offering realistic hope? This perspective focuses on motor rehabilitation after unilateral stroke and addresses the value of rehabilitation robots, virtual-reality training, peripheral neurostimulation, and brain stimulation. Current rehabilitation robots offer added value compared to conventional training, but only early after stroke for patients who are not yet able to walk independently. The effects of peripheral neurostimulation or brain stimulation are still hard to prove or relatively small. Virtual-reality training seems to be most promising for regaining motor skills, particularly when adjusted to individual capacities. Overall, functional benefits of movement technology in the rehabilitation of neurological disorders keep the middle between hype and hope.

Correction to: Adaptive capacity of 2- to 5-month-old infants to the flow, shape, and flexibility of different teats during bottle feeding: a cross-sectional study.

Following the publication of the article [1], the authors noticed that Fig. 3 used is not the updated version. The correct version is shown below.

Effectiveness of rehabilitation interventions to improve paretic propulsion in individuals with stroke - A systematic review.

BACKGROUND: Stroke survivors often show reduced walking velocity and gait asymmetry. These gait abnormalities are associated with reduced propulsion of the paretic leg. This review aimed to provide an overview of the potential effectiveness of post-stroke rehabilitation interventions to improve paretic propulsion, ankle kinetics and walking velocity. METHODS: A systematic search was performed in Pubmed, Web of Science, Embase, and Pedro. Studies were eligible if they reported changes in propulsion measures (impulse, peak value and symmetry ratios) or ankle kinetics (moment and power) following intervention in stroke survivors (group size ≥10). Study selection, data extraction and quality assessment were performed independently by two authors. FINDINGS: A total of 28 studies were included, of which 25 studies applied exercise interventions, two studies focused on surgical interventions, and one on non-invasive brain stimulation. The number of high-quality trials was limited (N = 6; score Downs and Black scale ≥19). Propulsion measures were the primary outcome in eight studies. In general, mixed results were reported with 14 interventions yielding improvements in propulsion and ankle kinetics. In contrast, gains in walking velocity were observed in the vast majority of studies (N = 20 out of 23). INTERPRETATION: Interventions that yielded gains in propulsion appeared to have in common that they challenged and/or enabled the utilization of latent propulsive capacity of the paretic leg during walking. Walking speed generally increased, regardless of the observed change in propulsion, suggesting the use of compensatory mechanisms. Findings should, however, be interpreted with some caution, as the evidence base for this emerging focus of rehabilitation is limited.

Adaptive capacity of 2- to 5-month-old infants to the flow, shape, and flexibility of different teats during bottle feeding: a cross-sectional study.

BACKGROUND: Nutritive sucking is a complex activity, the biomechanical components of which may vary in relation to respiratory phase, swallow-rate per minute, suck-swallow ratio, and swallow non-inspiratory flow (SNIF). Quantitative measurement of these components during nutritive sucking in healthy infants could help us to understand the complex development of sucking, swallowing, and breathing. This is important because the coordination between these components is often disturbed in infants with feeding difficulties. The aims of this study were to describe the biomechanical components of sucking and swallowing in healthy 2- to 5-month-old infants during bottle feeding, to assess whether infants adapt to the characteristics of two different teats, and to determine which independent variables influence the occurrence of SNIF. METHODS: Submental muscle activity, nasal airflow, and cervical auscultation were evaluated during bottle-feeding with two different teats. RESULTS: Sixteen term-born infants (6 boys) aged 2-5 months were included. All infants showed variable inhalation and exhalation after swallowing. The swallow rate per minute was significantly higher when infants fed with a higher flow teat (Philips Avent Natural 2.0™). Infants had suck:swallow ratios ranging from 1:1 to 4:1. A suck:swallow ratio of 1:1 occurred significantly more often when infants fed with a higher flow teat, whereas a suck:swallow ratio of 2:1 occurred significantly more often when infants fed with a low-flow teat (Philips Avent Classic+™). A suck:swallow ratio of 1:1 was negatively correlated with SNIF, whereas a suck:swallow ratio of 2:1 was positively correlated with SNIF. CONCLUSION: Healthy infants aged 2-5 months can adapt to the flow, shape, and flexibility of different teats, showing a wide range of biomechanical and motor adaptations.

Excessive short-latency stretch reflexes in the calf muscles do not cause postural instability in patients with hereditary spastic paraplegia.

OBJECTIVE: To identify the role of hyperexcitable short-latency stretch reflexes (SLRs) on balance control in people with hereditary spastic paraplegia (PwHSP). METHODS: Sixteen PwHSP with triceps surae spasticity and 9 healthy control subjects were subjected to toes-up support-surface perturbations. EMG data were recorded from gastrocnemius, soleus and tibialis anterior. Furthermore, center-of-mass trajectories were recorded. RESULTS: PwHSP were less able to withstand the perturbations. Triceps surae SLRs (40-80 ms post perturbation) in PwHSP were increased compared to healthy subjects. Furthermore, a sustained triceps surae EMG activity at 220-320 ms post perturbation was observed in PwHSP, whereas control subjects demonstrated suppression of triceps surae activity. Center of mass trajectories started to diverge between PwHSP and controls only after ∼500 ms, with greater excursions being observed in the PwHSP. CONCLUSIONS: The present results confirm that balance control is impaired in PwHSP. However, the late instant of center of mass divergence argues against a direct, causative role of hyperexcitable SLRs in the triceps surae. SIGNIFICANCE: We postulate that enhanced short-latency stretch reflexes of the triceps surae do not underlie poor balance control in PwHSP. Instead, we suggest the lack of suppression of later triceps surae activity to be the main cause.

Immediate after-effects of robot-assisted gait with pelvic support or pelvic constraint on overground walking in healthy subjects.

BACKGROUND: Recovery of walking is a primary rehabilitation goal of most stroke survivors. Control of pelvic movements is one of the essential determinants of gait, yet surprisingly, conventional robot-assisted gait trainers constrain pelvic movements. Novel robot-assisted gait trainers, such as LOPES II, are able to support pelvic movements during gait. The aim of this cross-over study was to investigate the immediate after-effects of pelvic support (PS) or pelvic constraint (PC) gait training with LOPES II on overground walking in healthy subjects. METHODS: Thirteen able-bodied subjects (22.8 ± 2.1 years) participated in two 20-min gait training sessions with LOPES II; one with PS and one with PC. During the PS-training, the LOPES II actively guided the lateral displacement of the pelvis, while pelvic rotations were free. During the PC-condition, both lateral displacement and pelvic rotations were constrained and reduced to a minimum. The training sessions were separated by a 30-min resting period. Lateral displacement of the pelvis, hip and knee kinematics, and spatiotemporal parameters during overground walking were determined at baseline and immediately following the training using 3D gait analysis. RESULTS: During the PS-condition in LOPES II the lateral pelvic displacement was significantly greater (105.6 ± 0 .5 mm) than during the PC-condition (10.8 ± 0 .7 mm; p < 0.001). Analysis of the first five steps of overground walking immediately following PC-condition showed significantly smaller lateral displacements of the pelvis (32.3 ± 12.0 mm) compared to PS-condition (40.1 ± 9 .8 mm; p < 0.01). During the first five steps, step width was significantly smaller after PC-condition (0.17 ± 0. 04 m) compared to PS-condition (0.20 ± 0.04 m; p = 0.01) and baseline (0.19 ± 0. 03 m; p = 0.01). Lateral displacement of the pelvis and step width post training returned to baseline levels within 10 steps. PC- nor PS-condition affected kinematics, gait velocity, cadence, stride length or stance time. CONCLUSIONS: In healthy subjects, robot-assisted gait training with pelvic constraint had immediate negative after-effects on the overground walking pattern, as compared to robot-assisted gait training with pelvic support. Gait training including support of the lateral displacement of the pelvis better resembles the natural gait pattern. It remains to be identified whether pelvic support during robot-assisted gait training is superior to pelvic constraint to promote gait recovery in individuals with neurological disorders.

Development of the Drooling Infants and Preschoolers Scale (DRIPS) and reference charts for monitoring saliva control in children aged 0-4 years.

OBJECTIVES: To develop and validate a parent questionnaire to quantify drooling severity and frequency in young children (the Drooling Infants and Preschoolers Scale - the DRIPS). To investigate development of saliva control in typically developing young children in the age of 0-4 years. To construct sex-specific reference charts presenting percentile curves for drooling plotted for age to monitor the development of saliva control in infancy and preschool age. STUDY DESIGN: The DRIPS was developed consisting of 20 items to identify severity and frequency of drooling during meaningful daily activities. Factor analysis was performed to test construct validity. A piecewise logistic regression was followed by a piecewise linear regression to construct sex-specific reference charts. RESULTS: We obtained 652 completed questionnaires from parents of typically developing children. The factor analysis revealed four discriminating components: drooling during Activities, Feeding, Non nutritive sucking, and Sleep. To illustrate the development of saliva control, eight sex-specific reference curves were constructed to plot the scores of the DRIPS by age group, at the 15th, 50th, 85th and 97th percentile. About 3-15% of the preschoolers in our cohort did not acquire full saliva control at the age of 4 years. CONCLUSIONS: With the DRIPS it is possible to validly compare and visualize the development of saliva control in an individual infant or preschooler and allow clinicians to timely initiate individually targeted interventions if children outperform.

European core curriculum in neurorehabilitation.

To date, medical education lacks Europe-wide standards on neurorehabilitation. To address this, the European Federation of NeuroRehabilitation Societies (EFNR) here proposes a postgraduate neurorehabilitation training scheme. In particular, the European medical core curriculum in neurorehabilitation should include a two-year residency in a neurorehabilitation setting where trainees can gain practical experience. Furthermore, it should comprise six modules of classroom training organized as weekend seminars or summer/winter schools. In conclusion, after defining the European medical core curriculum in neurorehabilitation, the next activities of the EFNR will be to try and reach the largest possible consensus on its content among all national societies across Europe in order to further validate it and try to extend it to the other, non-medical, professionals on the neurorehabilitation team in line with their core curricula defined by each professional association.

Expression and function of the Scn5a-encoded voltage-gated sodium channel NaV 1.5 in the rat jejunum.

BACKGROUND: The SCN5A-encoded voltage-gated sodium channel NaV 1.5 is expressed in human jejunum and colon. Mutations in NaV 1.5 are associated with gastrointestinal motility disorders. The rat gastrointestinal tract expresses voltage-gated sodium channels, but their molecular identity and role in rat gastrointestinal electrophysiology are unknown. METHODS: The presence and distribution of Scn5a-encoded NaV 1.5 was examined by PCR, Western blotting and immunohistochemistry in rat jejunum. Freshly dissociated smooth muscle cells were examined by whole cell electrophysiology. Zinc finger nuclease was used to target Scn5a in rats. Lentiviral-mediated transduction with shRNA was used to target Scn5a in rat jejunum smooth muscle organotypic cultures. Organotypic cultures were examined by sharp electrode electrophysiology and RT-PCR. KEY RESULTS: We found NaV 1.5 in rat jejunum and colon smooth muscle by Western blot. Immunohistochemistry using two other antibodies of different portions of NaV 1.5 revealed the presence of the ion channel in rat jejunum. Whole cell voltage-clamp in dissociated smooth muscle cells from rat jejunum showed fast activating and inactivating voltage-dependent inward current that was eliminated by Na(+) replacement by NMDG(+) . Constitutive rat Scn5a knockout resulted in death in utero. NaV 1.5 shRNA delivered by lentivirus into rat jejunum smooth muscle organotypic culture resulted in 57% loss of Scn5a mRNA and several significant changes in slow waves, namely 40% decrease in peak amplitude, 30% decrease in half-width, and 7 mV hyperpolarization of the membrane potential at peak amplitude. CONCLUSIONS & INFERENCES: Scn5a-encoded NaV 1.5 is expressed in rat gastrointestinal smooth muscle and it contributes to smooth muscle electrophysiology.

An economic evaluation of an augmented cognitive behavioural intervention vs. computerized cognitive training for post-stroke depressive symptoms.

BACKGROUND: Stroke survivors encounter emotional problems in the chronic phase after stroke. Post-stroke depressive symptoms have major impact on health-related quality of life (HRQol) and lead to increased hospitalization and therefore substantial healthcare costs. We present a cost-effectiveness and cost-utility evaluation of a cognitive behavioural therapy augmented with occupational and movement therapy to support patients with a stroke with depressive symptoms in goal-setting and goal attainment (augmented CBT) in comparison with a computerized cognitive training program (CogniPlus) as a control intervention. METHODS: A trial-based economic evaluation was conducted from a societal perspective with a time horizon of 12 months. Stroke patients (aged 18+ years) with signs of depression (Hospital Anxiety and Depression Scale (HADS) - subscale depression > 7) were eligible to participate. Primary outcomes were the HADS and Quality Adjusted Life Years (QALYs) based on the three-level five-dimensional EuroQol (EQ-5D-3 L). Missing data were handled through mean imputation (costs) and multiple imputation (HADS and EuroQol), and costs were bootstrapped. Sensitivity analyses were performed to test robustness of baseline assumptions. RESULTS: Sixty-one patients were included. The average total societal costs were not significantly different between the control group (€9,998.3) and the augmented CBT group (€8,063.7), with a 95 % confidence interval (-5,284, 1,796). The augmented CBT intervention was less costly and less effective from a societal perspective on the HADS, and less costly and slightly more effective in QALYs, in comparison with the control treatment. The cost-effectiveness and cost-utility analyses provided greater effects and fewer costs for the augmented CBT group, and fewer effects and costs for the HADS. Based on a willingness to pay (WTP) level of €40,000 per QALY, the augmented CBT intervention had a 76 % chance of being cost-effective. Sensitivity analyses showed robustness of results. CONCLUSION: The stroke-specific augmented CBT intervention did not show convincing cost-effectiveness results. In addition to other literature, this study provided new insights into the potential cost-effectiveness of an adjusted cognitive behavioural therapy intervention. However, as our study showed a 76 % chance of being cost-effective for one outcome measure (QALY) and did not provide convincing cost-effectiveness results on the HADS we recommend further research in a larger population.

Dynamic stability during level walking and obstacle crossing in persons with facioscapulohumeral muscular dystrophy.

Patients with FSHD suffer from progressive skeletal muscle weakness, which is associated with an elevated fall risk. To obtain insight into fall mechanisms in this patient group, we aimed to assess dynamic stability during level walking and obstacle crossing in patients at different disease stages. Ten patients with at least some lower extremity weakness were included, of whom six were classified as moderately affected and four as mildly affected. Ten healthy controls were also included. Level walking at comfortable speed was assessed, as well as crossing a 10 cm high wooden obstacle. We assessed forward and lateral dynamic stability, as well as spatiotemporal and kinematics variables. During level walking, the moderately affected group demonstrated a lower walking speed, which was accompanied by longer step times and smaller step lengths, yet dynamic stability was unaffected. When crossing the obstacle, however, the moderately affected patients demonstrated reduced forward stability margins during the trailing step, which was accompanied by an increased toe clearance and greater trunk and hip flexion. This suggests that during level walking, the patients effectively utilized compensatory strategies for maintaining dynamic stability, but that the moderately affected group lacked the capacity to fully compensate for the greater stability demands imposed by obstacle crossing, rendering them unable to maintain optimal stability levels. The present results highlight the difficulties that FSHD patients experience in performing this common activity of daily living and may help explain their propensity to fall in the forward direction.

Gait propulsion in patients with facioscapulohumeral muscular dystrophy and ankle plantarflexor weakness.

Facioscapulohumeral muscular dystrophy is a slowly progressive hereditary disorder resulting in fatty infiltration of eventually most skeletal muscles. Weakness of trunk and leg muscles causes problems with postural balance and gait, and is associated with an increased fall risk. Although drop foot and related tripping are common problems in FSHD, gait impairments are poorly documented. The effect of ankle plantarflexor involvement on gait propulsion has never been addressed. In addition to ankle plantarflexion, gait propulsion is generated through hip flexion and hip extension. Compensatory shifts between these propulsion sources occur when specific muscles are affected. Such a shift may be expected in patients with FSHD since the calves may show early fatty infiltration, whereas iliopsoas and gluteus maximus muscles are often spared for a longer time. In the current study, magnetic resonance imaging was used to assess the percentage of unaffected calf, iliopsoas and gluteus maximus muscles. Joint powers were analyzed in 10 patients with FSHD at comfortable and maximum walking speed to determine the contribution of ankle plantarflexor, hip flexor and hip extensor power to propulsion. Associations between muscle morphology, power generation and gait speed were assessed. Based on multivariate regression analysis, ankle plantarflexor power was the only factor that uniquely contributed to the explained variance of comfortable (R(2)=80%) and maximum (R(2)=86%) walking speed. Although the iliopsoas muscles were largely unaffected, they appeared to be sub-maximally recruited. This submaximal recruitment may be related to poor trunk stability, resulting in a disproportionate effect of calf muscle affliction on gait speed in patients with FSHD.

Skeletal muscle imaging in facioscapulohumeral muscular dystrophy, pattern and asymmetry of individual muscle involvement.

To better understand postural and movement disabilities, the pattern of total body muscle fat infiltration was analyzed in a large group of patients with facioscapulohumeral muscular dystrophy. Additionally, we studied whether residual D4Z4 repeat array length adjusted for age and gender could predict the degree of muscle involvement. Total body computed tomography scans of 70 patients were used to assess the degree of fat infiltration of 42 muscles from neck to ankle level on a semi-quantitative scale. Groups of muscles that highly correlated regarding fat infiltration were identified using factor analysis. Linear regression analysis was performed using muscle fat infiltration as the dependent variable and D4Z4 repeat length and age as independent variables. A pattern of muscle fat infiltration in facioscapulohumeral muscular dystrophy could be constructed. Trunk muscles were most frequently affected. Of these, back extensors were more frequently affected than previously reported. Asymmetry in muscle involvement was seen in 45% of the muscles that were infiltrated with fat. The right-sided upper extremity showed significantly higher scores for fat infiltration compared to the left side, which could not be explained by handedness. It was possible to explain 29% of the fat infiltration based on D4Z4 repeat length, corrected for age and gender. Based on our results we conclude that frequent involvement of fat infiltration in back extensors, in addition to the abdominal muscles, emphasizes the extent of trunk involvement, which may have a profound impact on postural control even in otherwise mildly affected patients.