Translating guidelines to practice: a training session about cancer-related fatigue.

Background: Cancer-related fatigue (crf) is the highest unmet need in cancer survivors. The Canadian Association of Psychosocial Oncology (capo) has developed guidelines for screening, assessment, and intervention in crf; however, those guidelines are not consistently applied in practice because of patient, health care provider (hcp), and systemic barriers. Notably, previous studies have identified a lack of knowledge of crf guidelines as an impediment to implementation. Methods: In this pilot study, we tested the preliminary outcomes, acceptability, and feasibility of a training session and a knowledge translation (kt) tool designed to increase knowledge of the capo crf guidelines among hcps and community support providers (csps). A one-time in-person training session was offered to a diverse sample of hcps and csps (n = 18). Outcomes (that is, knowledge of the capo crf guidelines, and intentions and self-efficacy to apply guidelines in practice) were assessed before and after training. Acceptability and feasibility were also assessed after training to guide future testing and implementation of the training. Results: After training, participants reported increased knowledge of the capo crf guidelines and greater self-efficacy and intent to apply guidelines in practice. Participant satisfaction with the training session and the kt tool was high, and recruitment time, participation, and retention rates indicated that the training was acceptable and feasible. Conclusions: The provided training is both acceptable to hcps and csps and feasible. It could increase knowledge of the capo crf guidelines and participant intentions and self-efficacy to implement evidence-based recommendations. Future studies should investigate actual changes in practice and how to optimize follow-up assessments. To promote practice uptake, kt strategies should be paired with guideline development.

Non-vitamin K antagonist oral anticoagulants (NOACs) for thromboembolic prevention, are they safe in congenital heart disease? Results of a worldwide study.

BACKGROUND: Current guidelines consider vitamin K antagonists (VKA) the oral anticoagulant agents of choice in adults with atrial arrhythmias (AA) and moderate or complex forms of congenital heart disease, significant valvular lesions, or bioprosthetic valves, pending safety data on non-VKA oral anticoagulants (NOACs). Therefore, the international NOTE registry was initiated to assess safety, change in adherence and quality of life (QoL) associated with NOACs in adults with congenital heart disease (ACHD). METHODS: An international multicenter prospective study of NOACs in ACHD was established. Follow-up occurred at 6 months and yearly thereafter. Primary endpoints were thromboembolism and major bleeding. Secondary endpoints included minor bleeding, change in therapy adherence (≥80% medication refill rate, ≥6 out of 8 on Morisky-8 questionnaire) and QoL (SF-36 questionnaire). RESULTS: In total, 530 ACHD patients (mean age 47 SD 15 years; 55% male) with predominantly moderate or complex defects (85%), significant valvular lesions (46%) and/or bioprosthetic valves (11%) using NOACs (rivaroxaban 43%; apixaban 39%; dabigatran 12%; edoxaban 7%) were enrolled. The most common indication was AA (91%). Over a median follow-up of 1.0 [IQR 0.0-2.0] year, thromboembolic event rate was 1.0% [95%CI 0.4-2.0] (n = 6) per year, with 1.1% [95%CI 0.5-2.2] (n = 7) annualized rate of major bleeding and 6.3% [95%CI 4.5-8.5] (n = 37) annualized rate of minor bleeding. Adherence was sufficient during 2 years follow-up in 80-93% of patients. At 1-year follow-up, among the subset of previous VKA-users who completed the survey (n = 33), QoL improved in 6 out of 8 domains (p ≪ 0.05). CONCLUSIONS: Initial results from our worldwide prospective study suggest that NOACs are safe and may be effective for thromboembolic prevention in adults with heterogeneous forms of congenital heart disease.

Cardiac performance assessment during cardiopulmonary exercise test can improve the management of children with repaired congenital heart disease.

BACKGROUND: Children with repaired congenital heart disease (CHD) have impaired maximal aerobic capacity (VO2max). Determining the causes of their VO2max alteration remains challenging. Cardiac output measure using thoracic impedancemetry during cardiopulmonary exercise tests (CPET) can help to understand the determinants of VO2max in children with open-heart repaired CHD. METHOD: We analyzed CPET in 77 children with repaired CHD. Among them, 55 patients had residual lesions. Patients with repaired CHD were compared with 44 age-matched healthy individuals. Maximal oxygen content brought to capillaries (QO2max) and oxygen muscle diffusion capacity (DO2) were assessed using cardiac output measure, Fick principle and simplified Fick law. RESULTS: In the 55 patients with residual lesion, VO2max, QO2max and DO2 were lower than those of controls (76.1 vs 86% of theoretical value, p < 0.01; 2.15 vs 2.81 L/mn, p < 0.001; 24.7 vs 28.8 ml/min/mmHg, p < 0.05). Decrease in QO2max was due to both impaired stroke volume and chronotropic insufficiency (48 vs 53 ml/m2 and p < 0.05; 171 vs 185/min p < 0.001). Patients without residual lesion (22/77) had normal VO2max with lower maximal heart rate compensated by higher SV (p < 0.05). CONCLUSION: Aerobic capacity was normal in children without residual lesions after CHD repair. Patients with residual lesion have impaired VO2max due to both lower central and peripheral determinants. Measuring cardiac performance during CPET allowed a better selection of patients with altered cardiac reserve that can benefit from residual lesion treatment and find the good timing for intervention. Detection of peripheral deconditioning can lead to a rehabilitation program.

Timing of insulin basal rate reduction to reduce hypoglycemia during late post-prandial exercise in adults with type 1 diabetes using insulin pump therapy: A randomized crossover trial.

AIMS: To compare the efficacy of three timings to decrease basal insulin infusion rate to reduce exercise-induced hypoglycaemia in patients with type 1 diabetes (T1D) using pump therapy. METHODS: A single-blinded, randomized, 3-way crossover study in 22 adults that had T1D > 1 year and using insulin pump > 3 months (age, 40 ± 15 years; HbA1c, 56.3 ± 10.2 mmol/mol). Participants practiced three 45-min exercise sessions (ergocyle) at 60% VO2peak 3 hours after lunch comparing an 80% reduction of basal insulin applied 40 minutes before (T-40), 20 minutes before (T-20) or at exercise onset (T0). RESULTS: No significant difference was observed for percentage of time spent < 4.0 mmol/L (T-40: 16 ± 25%; T-20: 26 ± 27%; T0: 24 ± 29%) (main outcome) and time spent in target range 4.0-10.0 mmol/L (T-40: 63 ± 37%; T-20: 66 ± 25%; T0: 65 ± 31%). With T-40 strategy, although not significant, starting blood glucose (BG) was higher (T-40: 8.6 ± 3.6 mmol/L; T-20: 7.4 ± 2.5 mmol/L ; T0: 7.4 ± 2.7 mmol/L), fewer patients needed extra carbohydrates consumption prior to exercise for BG < 5.0 mmol/L (T-40: n = 3; T-20: n = 5; T0: n = 6) as well as during exercise for BG < 3.3 mmol/L [T-40: n = 6 (27%); T-20: n = 12 (55%); T0: n = 11 (50%)] while time to first hypoglycaemic episode was delayed (T-40: 28 ± 14 min; T-20: 24 ± 10 min; T0: 22 ± 11 min). CONCLUSION: Decreasing basal insulin infusion rate by 80% up to 40 minutes before exercise onset is insufficient to reduce exercise-induced hypoglycaemia.

Association of aerobic fitness level with exercise-induced hypoglycaemia in Type 1 diabetes.

AIM: To determine the impact of physical fitness level on hypoglycaemia risk during exercise in people with Type 1 diabetes. METHODS: A total of 44 patients [34 adults (aged 22-70 years) and 10 adolescents (aged 12-18 years)] with Type 1 diabetes, treated with insulin pump therapy, underwent a standardized exercise session. Cardiorespiratory fitness (maximum oxygen uptake) was measured and classified, based on established norms for age and sex, into either poor (< 25th percentile) or good fitness level (> 25th percentile). Plasma glucose levels were measured every 10 min, each patient performed physical activity at 60% maximum oxygen uptake either on a treadmill for 1 h or on a bicycle for 30 min. Frequency of hypoglycaemia (plasma glucose < 4 mmol/l) and decline in plasma glucose levels during exercise were assessed. RESULTS: In all, 23 patients had a good exercise fitness level. Hypoglycaemic events occurred in 17/23 patients (74.0%) in the good fitness level group compared with 8/21 patients (38.0%) in the poor fitness level group (P = 0.02). Both groups had similar pre-exercise plasma glucose levels. The plasma glucose values during exercise in the good fitness level group compared with the poor fitness level group were: plasma glucose nadir 3.9 ± 1.6 vs 5.5 ± 2.4 mmol/l (P = 0.01) and plasma glucose change -4.6 ± 3.4 vs. -2.1 ± 3.1 mmol/l (P = 0.01). The correlation between the plasma glucose nadir and maximum oxygen uptake was r = -0.38 (P = 0.01). CONCLUSIONS: Patients with good fitness level seem to be more prone to hypoglycaemia during exercise. This could be the result of better insulin sensitivity and the fact that they tend to exercise at greater work thresholds. These results are a step toward a better understanding of the association between physical fitness and exercise-induced hypoglycaemia.

Efficacy of dual-hormone artificial pancreas to alleviate the carbohydrate-counting burden of type 1 diabetes: A randomized crossover trial.

AIM: Carbohydrate-counting is a complex task for many patients with type 1 diabetes. This study examined whether an artificial pancreas, delivering insulin and glucagon based on glucose sensor readings, could alleviate the burden of carbohydrate-counting without degrading glucose control. METHODS: Twelve adults were recruited into a randomized, three-way, crossover trial (ClinicalTrials.gov identifier No. NCT01930097). Participants were admitted on three occasions from 7AM to 9PM and consumed a low-carbohydrate breakfast (women: 30g; men: 50g), a medium-carbohydrate dinner (women: 50g; men: 70g) and a high-carbohydrate lunch (women: 90g; men: 120g). At each visit, glucose levels were randomly regulated by: (1) conventional pump therapy; (2) an artificial pancreas (AP) accompanied by prandial boluses, matching the meal's carbohydrate content based on insulin-to-carbohydrate ratios (AP with carbohydrate-counting); or (3) an AP accompanied by prandial boluses based on qualitative categorization (regular or large) of meal size (AP without carbohydrate-counting). RESULTS: The AP without carbohydrate-counting achieved similar incremental AUC values compared with carbohydrate-counting after the low- (P=0.54) and medium- (P=0.38) carbohydrate meals, but yielded higher post-meal excursions after the high-carbohydrate meal (P=0.004). The AP with and without carbohydrate-counting yielded similar mean glucose levels (8.2±2.1mmol/L vs. 8.4±1.7mmol/L; P=0.52), and both strategies resulted in lower mean glucose compared with conventional pump therapy (9.6±2.0mmol/L; P=0.02 and P=0.03, respectively). CONCLUSION: The AP with qualitative categorization of meal size could alleviate the burden of carbohydrate-counting without compromising glucose control, although more categories of meal sizes are probably needed to effectively control higher-carbohydrate meals.

Lengthy cold ischemia time is a modifiable risk factor associated with low glomerular filtration rates in expanded criteria donor kidney transplant recipients.

The proportion of expanded criteria donor (ECD) kidneys transplanted in North America is steadily increasing. By definition, graft survival is shorter for ECD than standard criteria donor (SCD) kidneys. Seeking to identify factors associated with low posttransplant glomerular filtration rates (GFR), we retrospectively reviewed data on 390 consecutive patients transplanted in our center from January 1999 to December 2006 including 78% SCD and 22% ECD by UNOS criteria. We analyzed donor and patient characteristics, HLA mismatches, cold ischemia time (CIT) and delayed graft function (DGF). Pulsatile perfusion was not used. The average CIT was 14.6 hours for all SCD and ECD cases. All patients received thymoglobulin, a calcineurin inhibitor, mycophenolate mofetil, and steroids. The only factor associated with low estimated GFR in the entire ECD cohort was CIT. The average CIT for the ECD group was 18.3 hours, whereas it was only 13.6 hours for those in the SCD group (P < .001). We observed that at 6 months posttransplant, those in the ECD group are 2.2 times more likely (odds ratio, 2.23; 95% confidence interval, 1.065-4.654; P = .033) to have an estimated GFR < or =50 mL/min/1.73 m(2) compared with those in the SCD group for CIT up to 18 hours. The higher odds ratio for low estimated GFR was sustained at 3 years posttransplant. In our center, a lengthy CIT was an early risk factor associated with impaired renal function. We concluded that all efforts should be made to reduce CIT.

Does limb angular motion raise limb arterial pressure?

AIM: Mechanical factors such as the muscle pump have been proposed to augment flow by several mechanisms. The potential for limb angular motion to augment local perfusion pressure (pressure = (1/2)rhor(2)omega(2), where rho is the fluid density, r the radius and omega the angular velocity) has been overlooked. We sought to test the hypothesis that limb angular motion augments limb arterial pressure. METHODS: Nine human subjects performed horizontal shoulder flexion ( approximately +/-90 degrees at 0.75 Hz for 30 s). We measured finger arterial pressure (photoplethysmography) in the moving (Trial 1) and non-moving arm (Trial 2) in separate trials along with the pressure (strain gauge) generated at the fingers within a length of water-filled tubing mounted on the moving arm in both trials. RESULTS: Arm swinging raised (P < 0.05) the mean pressure measured in the tubing by 11 +/- 2 and 14 +/- 2 mmHg (Trials 1 and 2 respectively). In response to exercise, the rise in mean finger arterial pressure in the swinging limb (18 +/- 3 mmHg, Trial 1) exceeded (P < 0.05) the rise in the resting limb (8 +/- 2 mmHg, Trial 2) by an amount similar to the 11 mmHg rise in pressure generated in the tubing in Trial 1. CONCLUSIONS: We conclude that the swinging of a limb creates centrifugal force (a biomechanical centrifuge) which imparts additional pressure to the arteries, but not the veins owing to the venous valves, which further widens the arterial-venous pressure difference.

[Transfer of cardiac catheterisation from a paediatric to an adult cardiological centre: results at 3 years]. / Transfert de l'activité de cathétérisme cardiaque d'un centre pédiatrique à un centre de cardiologie de l'adulte: trois ans d'activité

The advances of surgical and interventional treatment of congenital heart diseases have allowed a large number of patients with congenital heart disease to reach adult age. This population involves almost 0.3/1000 of total population in West Europe and North America and can be estimated around 200000 patients in France. Patients with operated Tetralogy of Fallot, benign forms of pulmonary atresia with ventricular septal defect, simple or complex transposition of the great arteries usually survive beyond childhood. These patients can need repeated interventions to treat lesions of native or reconstructed pulmonary arteries and/or aortic arch, to occlude residual shunts, to treat pulmonary incompetence. More complex heart diseases such as single ventricle, rarely allow survival until the adult age. The majority of these patients undergo heart transplant, often made difficult by multiple cardiac surgeries, anomalies of pulmonary arteries, chronic cyanosis, aorto-pulmonary shunts. Patients with relatively simple or complex congenital heart diseases need to be followed-up in specialized units, like those created more than twenty years ago in the United States, Canada, and United Kingdom. Interventional cardiac catheterisation play a major role in the management of this population. The results of 3 years of activity in a new centre treating GUCH patients are illustrated.

[Neonatal hypocalcaemic dilated myocardiopathy due to a 22q11 microdeletion]. / Myocardiopathie dilatée hypocalcémique néonatale révélatrice d'une microdélétion 22q11.

Here we report 2 cases of hypocalcemic cardiomyopathy revealing a 22q11 microdeletion syndrome. This presentation at diagnosis is rare as the cardiac phenotype is mainly made of conotruncal congenital heart defects in this condition. Cardiac failure was diagnosed during the neonatal period in the 2 cases and was associated with profound hypocalcemia. As usual, treatment with calcium and vitamin D led to the regression of the hypocalcemia and the left ventricular function was fully restored. While this circumstances are unusual, we recommend that screening for 22q11 deletion should be performed when confronted to hypocalcemic cardiomyopathy or left ventricular systolic dysfunction in conotruncal defects in neonates.

[Medical management of Marfan's syndrome and ascending aortic aneurysms in France: initial assessment]. / Prise en charge médicale du syndrome de Marfan et des anévrismes de l'aorte ascendante en France: un premier bilan.

Over the last 30 years, there has been considerable progress in the management of aneurysms of the ascending aorta whether isolated or related to Marfan's syndrome which has considerably increased the life expectancy of these patients. The aim of this study was to assess the management protocol proposed in France for this condition in order to establish recommendations. A questionnaire was sent to cardiologists, paediatric cardiologists and cardiac surgeons and also to patients diagnosed with Marfan's syndrome. Most of the 228 physicians who replied prohibited violent sporting activities and less than a quarter advised against all sports. There was a wide dispersion in the prescription of beta blockers in Marfan's syndrome as 57% proposed this treatment only in cases with dilatation of the aorta and 5% prescribed no treatment at all. On the other hand, beta blockers were widely prescribed (93%) after replacement of the ascending aorta. When poorly tolerated in adults, the most commonly prescribed option was a calcium antagonist (60%) followed by angiotensin converting enzyme inhibitors and therapeutic abstention. On the other hand, 60% of paediatric cardiologists preferred to withdraw treatment. These results were confirmed by the replies from patients with Marfan's syndrome: 58.3% were prescribed beta blockers with a higher proportion in children less than 12 years of age. This treatment was introduced late, about 7 years after diagnosis. The authors conclude that there is much disparity in the management of ascending aortic aneurysms whether or not associated with Marfan's syndrome, especially with regards the prescription of beta blockers, justifying the publication of recommendations.

Treadmill walking in incomplete spinal-cord-injured subjects: 2. Factors limiting the maximal speed.

STUDY DESIGN/METHODS: Five SCI subjects referred to the laboratory and a convenience sample of five normal volunteer individuals was selected. Stride length and frequency were measured at different walking speeds under three different conditions: preferred, highest possible and lowest possible stepping frequencies. OBJECTIVE: To determine which factors are limiting the maximal walking speed in spinal-cord-injured (SCI) individuals. SETTING: University-Based Human Gait Laboratory, Montreal, Canada. RESULTS: It is shown that maximal stride frequency was the predominant limiting factor of the maximal treadmill-walking speed in SCI subjects. These results were explained in the light of the forced hybrid mass-spring pendulum model. At all speeds, SCI subjects spent longer time in stance, swing and double support phases. The relative time spent in single support is greater at higher walking speed and the difficulty to reduce double support time is a limiting factor. CONCLUSIONS: A better understanding of the factors limiting the maximal speed in SCI subjects should help developing rehabilitation interventions oriented towards increasing the control and the capacity of walking. Rehabilitation strategies should put the emphasis on improving the capacity to produce rapid alternate rhythmical stepping movements of the lower limbs. SPONSORSHIP: Neuroscience Network of the Canadian Centre of Excellence.

A review of the adaptability and recovery of locomotion after spinal cord injury.

Spinal cord injury (SCI) is associated with multiple motor problems leading to the alteration and limited adaptation in the walking and postural behavior. This review addresses recent findings on locomotor and postural adaptations after spinal cord injury. The adaptation of the locomotor behavior to behavioral goals and external constraints constitute important functional prerequisites in the recovery of locomotion after spinal cord injury. Functional prerequisites in locomotion include coping with changes in speed, slope obstacle, weight support, interaction with walking aids, energy consumption and attentional demands. Various treatment approaches such as locomotor training using body weight support (BWS) and functional electrical stimulation (FES) will be discussed, in the context of functional prerequisites necessary in the recovery of locomotion. Understanding locomotor and postural adaptations will lead to a better appreciation of the normal and dysfunctional mechanisms, and culminate eventually in the development of appropriate rehabilitation assessment and treatment strategies.

Group II muscle afferents probably contribute to the medium latency soleus stretch reflex during walking in humans.

1. The objective of this study was to determine which afferents contribute to the medium latency response of the soleus stretch reflex resulting from an unexpected perturbation during human walking. 2. Fourteen healthy subjects walked on a treadmill at approximately 3.5 km h(-1) with the left ankle attached to a portable stretching device. The soleus stretch reflex was elicited by applying small amplitude (approximately 8 deg) dorsiflexion perturbations 200 ms after heel contact. 3. Short and medium latency responses were observed with latencies of 55 +/- 5 and 78 +/- 6 ms, respectively. The short latency response was velocity sensitive (P < 0.001), while the medium latency response was not (P = 0.725). 4. Nerve cooling increased the delay of the medium latency component to a greater extent than that of the short latency component (P < 0.005). 5. Ischaemia strongly decreased the short latency component (P = 0.004), whereas the medium latency component was unchanged (P = 0.437). 6. Two hours after the ingestion of tizanidine, an alpha(2)-adrenergic receptor agonist known to selectively depress the transmission in the group II afferent pathway, the medium latency reflex was strongly depressed (P = 0.007), whereas the short latency component was unchanged (P = 0.653). 7. An ankle block with lidocaine hydrochloride was performed to suppress the cutaneous afferents of the foot and ankle. Neither the short (P = 0.453) nor medium (P = 0.310) latency reflexes were changed. 8. Our results support the hypothesis that, during walking the medium latency component of the stretch reflex resulting from an unexpected perturbation is contributed to by group II muscle afferents.

Intrinsic and reflex stiffness in normal and spastic, spinal cord injured subjects.

Mechanical changes underlying spastic hypertonia were explored using a parallel cascade system identification technique to evaluate the relative contributions of intrinsic and reflex mechanisms to dynamic ankle stiffness in healthy subjects (controls) and spastic, spinal cord injured (SCI) patients. We examined the modulation of the gain and dynamics of these components with ankle angle for both passive and active conditions. Four main findings emerged. First, intrinsic and reflex stiffness dynamics were qualitatively similar in SCI patients and controls. Intrinsic stiffness dynamics were well modeled by a linear second-order model relating intrinsic torque to joint position, while reflex stiffness dynamics were accurately described by a linear, third-order system relating half-wave rectified velocity to reflex torque. Differences between the two groups were evident in the values of four parameters, the elastic and viscous parameters for intrinsic stiffness and the gain and first-order cut-off frequency for reflex stiffness. Second, reflex stiffness was substantially increased in SCI patients, where it generated as much as 40% of the total torque variance, compared with controls, where reflex contributions never exceeded 7%. Third, differences between SCI patients and controls depended strongly on joint position, becoming larger as the ankle was dorsiflexed. At full plantarflexion, there was no difference between SCI and control subjects; in the mid-range, reflex stiffness was abnormally high in SCI patients; at full dorsiflexion, both reflex and intrinsic stiffness were larger than normal. Fourth, differences between SCI and control subjects were smaller during the active than the passive condition, because intrinsic stiffness increased more in controls than SCI subjects; nevertheless, reflex gain remained abnormally high in SCI patients. These results elucidate the nature and origins of the mechanical abnormalities associated with hypertonia and provide a better understanding of its functional and clinical implications.

Learning needs of nurses working in Canada's First Nations communities and hospitals.

BACKGROUND: What are the learning needs of nurses providing services to Canada's First Nations Communities and Hospitals? First Nations (or Indian Band) are similar to communities except some comprise more than one geographic Native community. Aboriginal (or Native) individuals are members of the North American Indian, Inuit, or Métis peoples of Canada; those who reported being a Treaty or Registered Indian (with the Federal Government); or those who are members of an Indian Band/First Nation. METHOD: A Canada-wide survey was completed to determine the learning needs of nurses working with Canada's Aboriginal persons. RESULTS: Nurses indicated both broad and specific aspects of their clinical practice, which were important to their continuing education (CE) needs. Broad thematic areas for continuing education included the following: emergency/acute care and obstetrics/gynecology clinical skills, health and physical assessment, mental health, and prenatal and postnatal care. Specific areas nurses cited for CE included issues related to: victims of violence; non-compliant clients; substance abuse; and fetal alcohol syndrome. CONCLUSION: This study examined the learning needs of nurses working with Canada's Native people and provided a basis for comparing and contrasting CE issues of these nurses to other nurses working in remote locations around the world.

Clinical and therapeutic applications of neuromuscular stimulation: a review of current use and speculation into future developments.

In this paper we present an overview of current research into clinical and therapeutic applications of electrical neuromuscular stimulation (NMS). As this is now such a huge subject we have focused our attention on the therapeutic rather than orthotic uses of stimulation and limited the field almost exclusively to upper limb applications in hemiplegia. The evidence that NMS influences motor re-learning and how this may be measured is discussed. We have identified the following as the three most important unresolved issues: 1) an understanding of how NMS modifies the interactions within the nervous system, 2) clinical effectiveness of NMS, and 3) inexpensive, simple to insert and reliable controllable implanted systems. We discuss recent research aimed at resolving these issues and based on this we make some suggestions for future research. To resolve these issues we propose: 1) neurophysiologic research into the mechanism through which NMS interacts with the nervous system; 2) large multicenter randomized controlled trials using rigorous methodology that compare different applications of NMs; 3) continued technical development that is closely linked to clinical applications.

Inhibition of the triceps surae stretch reflex by stimulation of the deep peroneal nerve in persons with spastic stroke.

OBJECTIVE: To reduce the triceps surae stretch reflex by electrical stimulation of the deep peroneal nerve. DESIGN: Intervention study. SETTING: Research institution. PARTICIPANTS: Sample of convenience of 10 spastic stroke individuals. INTERVENTION: After the deep peroneal nerve was stimulated between 0.9 and 4 times tibialis anterior motor threshold, the triceps surae was stretched to elicit a reflex. MAIN OUTCOME MEASURE: The triceps surae stretch reflex was quantified by the amplitude of the reflex electromyography (EMG) in soleus and medial gastrocnemius muscles and mean ankle moment. Paired t test and the Wilcoxon signed rank test (p < .05) were used to evaluate the effect of conditioning stimulation. RESULTS: The soleus stretch reflex EMG was reduced significantly (p < .001) by stimulating the deep peroneal nerve to 25%+/-6% (standard error) of the unconditioned value (relaxed triceps surae). The optimal interval between stimulation and stretch was 141+/-15 msec. The velocity threshold increased significantly (p = .006) from a median value of 8 degrees per second to 33 degrees per second and the area under the stretch velocity/stretch reflex relation decreased significantly (p < .001) (soleus EMG). CONCLUSIONS: The stretch reflex of relaxed triceps surae in persons with spastic stroke can be extensively reduced by stimulating the deep peroneal nerve at several times motor threshold of the tibialis anterior.

Functional electrical stimulation-assisted walking for persons with incomplete spinal injuries: changes in the kinematics and physiological cost of overground walking.

This study was conducted to investigate the change in the kinematics and physiological cost of walking that occurs during training with functional electrical stimulation (FES)-assisted walking in persons with incomplete injuries. The main effect of FES-assisted walking was to change hip excursion and ankle dorsiflexion during swing and at foot contact, whereas training with FES-assisted walking changed the spatio-temporal parameters of walking (walking speed, cycle length and frequency as well as time in stance). The use of FES-assisted walking does not change the walking speed achieved during a 5-minute trial nor the physiological cost of walking but when combined with walking training, eight of the nine participants improved either their physiological cost index or their walking speed. It is concluded that FES-assisted walking changes the joint angular kinematic pattern of walking, but training is necessary to integrate these changes into functional gains.