Gait transitions in simulated reduced gravity.

Gravity has a strong effect on gait and the speed of gait transitions. A gait has been defined as a pattern of locomotion that changes discontinuously at the transition to another gait. On Earth, during gradual speed changes, humans exhibit a sudden discontinuous switch from walking to running at a specific speed. To study the effects of altered gravity on both the stance and swing legs, we developed a novel unloading exoskeleton that allows a person to step in simulated reduced gravity by tilting the body relative to the vertical. Using different simulation techniques, we confirmed that at lower gravity levels the transition speed is slower (in accordance with the previously reported Froude number ∼0.5). Surprisingly, however, we found that at lower levels of simulated gravity the transition between walking and running was generally gradual, without any noticeable abrupt change in gait parameters. This was associated with a significant prolongation of the swing phase, whose duration became virtually equal to that of stance in the vicinity of the walk-run transition speed, and with a gradual shift from inverted-pendulum gait (walking) to bouncing gait (running).

Methodological issues in monitoring health services and outcomes for stroke survivors: a case study.

BACKGROUND: Obtaining comprehensive health outcomes and health services utilization data on stroke patients has been difficult. This research grew out of a memorandum of understanding between the NIH and the ISS (its Italian equivalent) to foster collaborative research on rehabilitation. OBJECTIVE: The purpose of this study was to pilot a methodology using administrative data to monitor and improve health outcomes for stroke survivors in Tuscany. METHODS: This study used qualitative and quantitative methods to study health resources available to and utilized by stroke survivors during the first 12 months post-stroke in two Italian health authorities (AUSL10 and 11). Mortality rates were used as an outcome measure. RESULTS: Number of inpatient days, number of prescriptions, and prescription costs were significantly higher for patients in AUSL 10 compared to AUSL 11. There was no significant difference between mortality rates. CONCLUSION: Using administrative data to monitor process and outcomes for chronic stroke has the potential to save money and improve outcomes. However, measures of functional impairment and more sensitive outcome measures than mortality are important. Additional recommendations for enhanced data collection and reporting are discussed.

Measurement of physical quantities in upper-limb tele-rehabilitation.

A total of 50 patients (affected by traumatic brain injury, stroke or multiple sclerosis) were treated for one month using a rehabilitation protocol. Rehabilitation could be monitored using a Portable Unit (PU) which could be installed in a patient's home allowing the measurement of kinetic and kinematic variables during exercise. In a preliminary analysis, the variables related to four rehabilitation exercises were examined for two patients at baseline and at the end of the one-month treatment. The exercises involved movement of checkers, a pencil, a jar and a key. The results suggest that, even if the overall duration of exercise execution is an important aspect of the rehabilitation process, other variables acquired by the PU might deliver useful information for assessing the patient's status. In order to integrate such variables into the assessment process, further studies are needed to investigate their eventual correlation with traditional rehabilitation scales and variables.

Community-based adaptive physical activity program for chronic stroke: feasibility, safety, and efficacy of the Empoli model.

OBJECTIVE: To determine whether Adaptive Physical Activity (APA-stroke), a community-based exercise program for participants with hemiparetic stroke, improves function in the community. METHODS: Nonrandomized controlled study in Tuscany, Italy, of participants with mild to moderate hemiparesis at least 9 months after stroke. Forty-nine participants in a geographic health authority (Empoli) were offered APA-stroke (40 completed the study). Forty-four control participants in neighboring health authorities (Florence and Pisa) received usual care (38 completed the study). The APA intervention was a community-based progressive group exercise regimen that included walking, strength, and balance training for 1 hour, thrice a week, in local gyms, supervised by gym instructors. No serious adverse clinical events occurred during the exercise intervention. Outcome measures included the following: 6-month change in gait velocity (6-Minute Timed Walk), Short Physical Performance Battery (SPPB), Berg Balance Scale, Stroke Impact Scale (SIS), Barthel Index, Hamilton Rating Scale for Depression, and Index of Caregivers Strain. RESULTS: After 6 months, the intervention group improved whereas controls declined in gait velocity, balance, SPPB, and SIS social participation domains. These between-group comparisons were statistically significant at P<.00015. Individuals with depressive symptoms at baseline improved whereas controls were unchanged (P<.003). Oral glucose tolerance tests were performed on a subset of participants in the intervention group. For these individuals, insulin secretion declined 29% after 6 months (P=.01). CONCLUSION: APA-stroke appears to be safe, feasible, and efficacious in a community setting.

A web based health technology assessment in tele-echocardiography: the experience within an Italian project.

Due to major advances in the information technology, telemedicine applications are ready for a widespread use. Nonetheless, to allow their diffusion in National Health Care Systems (NHCSs) specific methodologies of health technology assessment (HTA) should be used to assess the standardization, the overall quality, the interoperability, the addressing to legal, economic and cost benefit aspects. One of the limits to the diffusion of the digital tele-echocardiography (T-E) applications in the NHCS lacking of a specific methodology for the HTA. In the present study, a solution offering a structured HTA of T-E products was designed. The methodology assured also the definition of standardized quality levels for the application. The first level represents the minimum level of acceptance; the other levels are accessory levels useful for a more accurate assessment of the product. The methodology showed to be useful to rationalize the process of standardization and has received a high degree of acceptance by the subjects involved in the study.

A novel, user-friendly step counter for home telemonitoring of physical activity.

Step counting is an important index of motion in telemonitoring. We have developed a wearable system based on a device with a force-sensing resistor. This is affixed at the calf gastrocnemius level to monitor the muscular expansion related to the gait. The gastrocnemius expansion measurement unit (GEMU) was tested on three subjects at Level 2 of the Tinetti test of unbalance, who performed five repetitions of 100 steps at two different speeds (normal and slow). The mean error was less than 0.5%. The GEMU also performed better than an accelerometer unit, which is normally considered to be the best solution for this disability. The system can be integrated into a routine home-care application based on a GSM home-care unit.

A home-care system for the telemonitoring and telerehabilitation of the hand incorporating interactive biofeedback.

We have designed and constructed force measurement equipment to assess hand-finger function in pressing tasks. The equipment was used for monitoring the follow-up of five hand-transplanted subjects. Interactive software was integrated into the instrument to monitor the functionality of the hand and fingers during exercises in realtime. The interactive software included biofeedback to provide realtime quantitative responses for the patient and the therapist. Acceptance of the system was investigated with patients and therapists: the system was found to be user-friendly and effective; it was practical both for patients and therapists. The system could be used in a telerehabilitation centre or in a patient's home.

Muscle performance and ankle joint mobility in long-term patients with diabetes.

BACKGROUND: Long-term patients with diabetes and peripheral neuropathy show altered foot biomechanics and abnormal foot loading. This study aimed at assessing muscle performance and ankle mobility in such patients under controlled conditions. METHODS: Forty six long-term diabetes patients with (DN) and without (D) peripheral neuropathy, and 21 controls (C) were examined. Lower leg muscle performance and ankle mobility were assessed by means of a dedicated equipment, with the patient seated and the examined limb unloaded. 3D active ranges of motion and moments of force were recorded, the latter during maximal isometric contractions, with the foot blocked in different positions. RESULTS: All patients showed reduced ankle mobility. In the sagittal and transversal planes reduction vs C was 11% and 20% for D, 20% and 21% for DN, respectively.Dorsal-flexing moments were significantly reduced in all patients and foot positions, the highest reduction being 28% for D and 37% for DN. Reductions of plantar-flexing moments were in the range 12-15% for D (only with the foot blocked in neutral and in dorsal-flexed position), and in the range 10-24% for DN. In all patients, reductions in the frontal and transversal planes ranged 14-41%. CONCLUSION: The investigation revealed ankle functional impairments in patients with diabetes, with or without neuropathy, thus suggesting that other mechanisms besides neuropathy might contribute to alter foot-ankle biomechanics. Such impairments may then play a role in the development of abnormal gait and in the onset of plantar ulcers.

Tele-rehabilitation: present and future.

SUMMARY: During the last decade we assisted to relevant progress in rehabilitation studies and in technological development. From the combination of these issues rises the tele-rehabilitation--a subfield of telemedicine consisting of a system to control rehabilitation "at distance"--as an actual possibility of application and a promising development in the future. The present paper offers a short review of the state of the art in the field of tele-rehabilitation, with a special focus on upper limb tele-rehabilitation. The experience is also briefly reported of the preliminary application of the H-CAD (home care activity desk) system and the HELLODOC (Healthcare service linking tele-rehabilitation to disabled people and clinicians) tele-rehabilitation service, conducted by the authors within two European projects in the period 2003-2005 and 2005-2007 respectively.

Technical assessment of the HELLODOC service.

SUMMARY: A technical assessment activity has been conducted by Istituto Superiore di Sanità (ISS) in the European project HELLODOC (Healthcare service linking tele-rehabilitation to disabled people and clinicians) for evaluating the tele-rehabilitation service. The activity was mainly focussed on architectural aspects and a step by step monitoring of the service. It was mainly related to the following aspects: service implementation, service performances, service integration and fault management. The technical assessment analysis demonstrated that the service worked in a quite satisfactory way, also considering the pioneering aspect of the project; the set of malfunctioning occurred, which had a low impact on the service continuity, are typical of a post-debug phase.

Tele-rehabilitation and e-learning: the HELLODOC educational experience.

SUMMARY: A web-based learning activity in the field of tele-rehabilitation was conducted by Istituto Superiore di Sanità (ISS), the Italian National Institute of Health, within the EU project HELLODOC. The activity aimed at training professionals to effectively manage the tele-rehabilitation service. ISS adapted the Moodle e-learning platform and implemented the problem-based learning (PBL) methodology. One clinical and one technical module were prepared by using traditional learning sources as well as interactive tools. Each module included 4 units; each unit was based on a 5-days cycle. The courses remained open from January to October 2006. Fifty percent of the registered students attended the courses. Traditional and interactive learning resources were equally used. Overall feedback was positive, unless for the amount of time requested for the study and the lack of an official certificate of attendance. Both modules are now in the process of being revised, improved and generalised, in order to be integrated into the ISS Rehabilitation website.

Clinical assessment of the HELLODOC tele-rehabilitation service.

SUMMARY: Within the EU project HELLODOC, the clinical effectiveness was investigated of the home care activity desk (H-CAD). Eighty-one patients with chronic stroke, traumatic brain injury (TBI) and multiple sclerosis (MS) were recruited; 50 out of 81 received 1 month of H-CAD intervention, with one training session a day lasting 30 minutes for 5 days a week. The overall satisfaction of both patients and therapists was high. The Action Research Arm (ARA) and the Nine Hole Peg Test (NHPT) were used as main outcome measures. They proved the H-CAD system to be at least as effective as usual care. Maybe due to limited length and intensity of treatment, during the training month subjects improved on the individual H-CAD exercises but, as in the usual care group, the arm/hand function remained at the same level.

Adaptive physical activity improves mobility function and quality of life in chronic hemiparesis.

This study investigated the effects of an adaptive physical activity (APA) program on mobility function and quality of life (QOL) in chronic stroke patients. Twenty subjects with chronic hemiparesis completed a 2-month, combined group, class-home exercise regimen that emphasized mobility training. APA improved Berg Balance Scale scores (35 +/- 2 vs 45 +/- 2, p = 0.001), 6-minute walk distances (114 +/- 15 vs 142 +/- 7 m, p < 0.001), and Short Physical Performance Battery scores (3.2 +/- 0.4 vs 5.2 +/- 0.6, p < 0.001). Barthel Index scores increased (75 +/- 4 vs 84 +/- 4, p < 0.001), but Lawton scores were unchanged. Geriatric Depression Scale (p < 0.01) and Stroke Impact Scale (SIS), Mobility, Participation, and Recovery improved with APA (p < 0.03). APA has the potential to improve gait, balance, and basic but not instrumental activities of daily living profiles in individuals with chronic stroke. Improved depression and SIS scores suggest APA improves stroke-specific outcomes related to QOL.

New neural network classifier of fall-risk based on the Mahalanobis distance and kinematic parameters assessed by a wearable device.

Fall prevention lacks easy, quantitative and wearable methods for the classification of fall-risk (FR). Efforts must be thus devoted to the choice of an ad hoc classifier both to reduce the size of the sample used to train the classifier and to improve performances. A new methodology that uses a neural network (NN) and a wearable device are hereby proposed for this purpose. The NN uses kinematic parameters assessed by a wearable device with accelerometers and rate gyroscopes during a posturography protocol. The training of the NN was based on the Mahalanobis distance and was carried out on two groups of 30 elderly subjects with varying fall-risk Tinetti scores. The validation was done on two groups of 100 subjects with different fall-risk Tinetti scores and showed that, both in terms of specificity and sensitivity, the NN performed better than other classifiers (naive Bayes, Bayes net, multilayer perceptron, support vector machines, statistical classifiers). In particular, (i) the proposed NN methodology improved the specificity and sensitivity by a mean of 3% when compared to the statistical classifier based on the Mahalanobis distance (SCMD) described in Giansanti (2006 Physiol. Meas. 27 1081-90); (ii) the assessed specificity was 97%, the assessed sensitivity was 98% and the area under receiver operator characteristics was 0.965.

Health technology assessment of a homecare device for telemonitoring and telerehabilitation for patients after hand transplantation.

Hand rehabilitation requires continuous and frequent monitoring of the functionality in order to assess therapy and/or refine it. In order to contain costs for the rehabilitation program, a telehomecare rehabilitation system is suitable. The purpose of this paper was to describe the setup and configuration of a homecare device for telemonitoring/telerehabilitation of patients who underwent hand transplant. The telehomecare device allows the assessment of dynamics and kinematics of hand function by integrating dedicated software in two components. The first was a commercial glove, the HumanGlove by Humanware (Pisa, Italy). The second was a set of instruments for the measurement of digit force using an Instrumented Keyboard and an Instrumented Mouse-Like device. The software integrating the devices is composed of two modular components. The first is to drive the devices; the second is for the data-analysis and display. The methodology was validated at the Istituto Superiore di Sanit (the Italian National Institute of Health) in the framework of an Italian National Project, funded by the Ministry of Health.

Telemonitoring and telerehabilitation of patients with Parkinson's disease: health technology assessment of a novel wearable step counter.

Step counting is an important index of motion in telemonitoring. One of the most diffused wearable systems, designed for this purpose, is the pedometer. The accuracy of commercial pedometers has been reported in the literature. Several limits have been found in many commercial systems both in healthy subjects and in people with disabilities. Furthermore, commercial pedometers lack interoperability. This paper introduces a new wearable system for step counting for telemonitoring applications. This system is based on a wearable device with a force-sensing resistor. It is affixed on the gastrocnemius muscle for monitoring muscular expansion correlated with the gait. The data exchange is assured by the XTR-434H (Aurel, FC, Italy) telemetric system. The proposed gastrocnemius expansion measurement unit (GEMU) was tested on 5 subjects with Parkinsons disease at Level 3 of the Tinetti test of unbalance. Ten repetitions of 500 steps with three different speeds (fast, slow, and normal) were performed. The mean error was <0.5%. Results also showed that GEMU performed better than an accelerometer unit (considered in the literature the best solution for this disability). The study showed that GEMU had a high performance in subjects with Parkinsons disease, causing a high degree of unbalance that confounded motion style. The next phase will be the optimization of GEMU for long-term medical applications at the patients home.

Assessment of fall-risk by means of a neural network based on parameters assessed by a wearable device during posturography.

We have investigated the use of an Artificial Neural Network (ANN) for the assessment of fall-risk (FR) in patients with different neural pathologies. The assessment integrates a clinical tool based on a wearable device (WD) with accelerometers (ACCs) and rate gyroscopes (GYROs) properly suited to identify trunk kinematic parameters that can be measured during a posturography test with different constraints. Our ANN--a Multi Layer Perceptron Neural Network with four layers and 272 neurones--shows to be able to classify patients in three well-known fall-risk levels. The training of the neural network was carried on three groups of 30 subjects with different Fall-Risk Tinetti scores. The validation of our neural network was carried out on three groups of 100 subjects with different Fall-Risk Tinetti scores and this validation demonstrated that the neural network had high specificity (> or =0.88); sensitivity (> or =0.87); area under Receiver-Operator Characteristic Curves (>0.854).

Design and construction of step counters for disable people: preliminary experience at the Italian Institute of Health.

Step counting is an important index of motion One of the most diffused wearable systems, designed for this purpose, is the pedometer. The accuracy of commercial pedometers has been tested in literature. Several limits have been found in many commercial systems both in healthy subjects and in disable people. Furthermore, commercial pedometers lack in interoperability. A new wearable system for the step counting has been introduced in this paper. The wearable system is based on a wearable device with a force sensing resistor and a band; it is affixed at the calf gastrocnemius level for the monitoring of the muscular expansion correlated to the gait. The proposed gastrocnemius expansion measurement unit (GEMU) was tested on a three subjects with the Parkinson' s disease at the Level 2 of the Tinetti test of unbalance who performed five repetition of 200 steps with three different instructions (fast, slow). The mean error was lower than 0.5%. Results also showed that GEMU performed better than an accelerometer unit (considered in literature the best solution for this disability). The study showed that GEMU had a high performance in a subject with a pathology (the Parkinson' s disease) causing a high degree of unbalance confounding the motion style and thus pedometers. The next phase will be the optimization of GEMU for long term medical applications at patients' home with the special care to the material and with a comparison to a golden standard.

Assessment of fall risk using a pneumatic pattern generator.

This paper describes the design and construction of a new equipment for the fall risk investigation. It comprehends a portable device including 3 mono-axial accelerometers and 3 rate-gyroscopes which assesses the trunk sway and provides (Giansanti et al 2005 IEEE Trans. Biomed. Eng.) and a pneumatic pressure variation pattern generator. The bench test successfully passed. Preliminary results indicates the feasibility of using the equipment as a tool for the assessment of the fall-risk.