A Serious Game for the Assessment of Visuomotor Adaptation Capabilities during Locomotion Tasks Employing an Embodied Avatar in Virtual Reality.

The study of visuomotor adaptation (VMA) capabilities has been encompassed in various experimental protocols aimed at investigating human motor control strategies and/or cognitive functions. VMA-oriented frameworks can have clinical applications, primarily in the investigation and assessment of neuromotor impairments caused by conditions such as Parkinson's disease or post-stroke, which affect the lives of tens of thousands of people worldwide. Therefore, they can enhance the understanding of the specific mechanisms of such neuromotor disorders, thus being a potential biomarker for recovery, with the aim of being integrated with conventional rehabilitative programs. Virtual Reality (VR) can be entailed in a framework targeting VMA since it allows the development of visual perturbations in a more customizable and realistic way. Moreover, as has been demonstrated in previous works, a serious game (SG) can further increase engagement thanks to the use of full-body embodied avatars. Most studies implementing VMA frameworks have focused on upper limb tasks and have utilized a cursor as visual feedback for the user. Hence, there is a paucity in the literature about VMA-oriented frameworks targeting locomotion tasks. In this article, the authors present the design, development, and testing of an SG-based framework that addresses VMA in a locomotion activity by controlling a full-body moving avatar in a custom VR environment. This workflow includes a set of metrics to quantitatively assess the participants' performance. Thirteen healthy children were recruited to evaluate the framework. Several quantitative comparisons and analyses were run to validate the different types of introduced visuomotor perturbations and to evaluate the ability of the proposed metrics to describe the difficulty caused by such perturbations. During the experimental sessions, it emerged that the system is safe, easy to use, and practical in a clinical setting. Despite the limited sample size, which represents the main limitation of the study and can be compensated for with future recruitment, the authors claim the potential of this framework as a useful instrument for quantitatively assessing either motor or cognitive impairments. The proposed feature-based approach gives several objective parameters as additional biomarkers that can integrate the conventional clinical scores. Future studies might investigate the relation between the proposed biomarkers and the clinical scores for specific disorders such as Parkinson's disease and cerebral palsy.

Consensus Paper: Ataxic Gait.

The aim of this consensus paper is to discuss the roles of the cerebellum in human gait, as well as its assessment and therapy. Cerebellar vermis is critical for postural control. The cerebellum ensures the mapping of sensory information into temporally relevant motor commands. Mental imagery of gait involves intrinsically connected fronto-parietal networks comprising the cerebellum. Muscular activities in cerebellar patients show impaired timing of discharges, affecting the patterning of the synergies subserving locomotion. Ataxia of stance/gait is amongst the first cerebellar deficits in cerebellar disorders such as degenerative ataxias and is a disabling symptom with a high risk of falls. Prolonged discharges and increased muscle coactivation may be related to compensatory mechanisms and enhanced body sway, respectively. Essential tremor is frequently associated with mild gait ataxia. There is growing evidence for an important role of the cerebellar cortex in the pathogenesis of essential tremor. In multiple sclerosis, balance and gait are affected due to cerebellar and spinal cord involvement, as a result of disseminated demyelination and neurodegeneration impairing proprioception. In orthostatic tremor, patients often show mild-to-moderate limb and gait ataxia. The tremor generator is likely located in the posterior fossa. Tandem gait is impaired in the early stages of cerebellar disorders and may be particularly useful in the evaluation of pre-ataxic stages of progressive ataxias. Impaired inter-joint coordination and enhanced variability of gait temporal and kinetic parameters can be grasped by wearable devices such as accelerometers. Kinect is a promising low cost technology to obtain reliable measurements and remote assessments of gait. Deep learning methods are being developed in order to help clinicians in the diagnosis and decision-making process. Locomotor adaptation is impaired in cerebellar patients. Coordinative training aims to improve the coordinative strategy and foot placements across strides, cerebellar patients benefiting from intense rehabilitation therapies. Robotic training is a promising approach to complement conventional rehabilitation and neuromodulation of the cerebellum. Wearable dynamic orthoses represent a potential aid to assist gait. The panel of experts agree that the understanding of the cerebellar contribution to gait control will lead to a better management of cerebellar ataxias in general and will likely contribute to use gait parameters as robust biomarkers of future clinical trials.

Assessing Respiratory Activity by Using IMUs: Modeling and Validation.

This study aimed to explore novel inertial measurement unit (IMU)-based strategies to estimate respiratory parameters in healthy adults lying on a bed while breathing normally. During the experimental sessions, the kinematics of the chest wall were contemporaneously collected through both a network of 9 IMUs and a set of 45 uniformly distributed reflective markers. All inertial kinematics were analyzed to identify a minimum set of signals and IMUs whose linear combination best matched the tidal volume measured by optoelectronic plethysmography. The resulting models were finally tuned and validated through a leave-one-out cross-validation approach to assess the extent to which they could accurately estimate a set of respiratory parameters related to three trunk compartments. The adopted methodological approach allowed us to identify two different models. The first, referred to as Model 1, relies on the 3D acceleration measured by three IMUs located on the abdominal compartment and on the lower costal margin. The second, referred to as Model 2, relies on only one component of the acceleration measured by two IMUs located on the abdominal compartment. Both models can accurately estimate the respiratory rate (relative error < 1.5%). Conversely, the duration of the respiratory phases and the tidal volume can be more accurately assessed by Model 2 (relative error < 5%) and Model 1 (relative error < 5%), respectively. We further discuss possible approaches to overcome limitations and improve the overall accuracy of the proposed approach.

Flipping food during grilling tasks, a dataset of utensils kinematics and dynamics, food pose and subject gaze.

This paper presents a multivariate dataset of 2866 food flipping movements, performed by 4 chefs and 5 home cooks, with different grilled food and two utensils (spatula and tweezers). The 3D trajectories of strategic points in the utensils were tracked using optoelectronic motion capture. The pinching force of the tweezers, the bending force and torsion torque of the spatula were also recorded, as well as videos and the subject gaze. These data were collected using a custom experimental setup that allowed the execution of flipping movements with freshly cooked food, without having the sensors near the dangerous cooking area. Complementary, the 2D position of food was computed from the videos. The action of flipping food is, indeed, gaining the attention of both researchers and manufacturers of foodservice technology. The reported dataset contains valuable measurements (1) to characterize and model flipping movements as performed by humans, (2) to develop bio-inspired methods to control a cooking robot, or (3) to study new algorithms for human actions recognition.

Survey of transfemoral amputee experience and priorities for the user-centered design of powered robotic transfemoral prostheses.

BACKGROUND: Transfemoral amputees experience a complex host of physical, psychological, and social challenges, compounded by the functional limitations of current transfemoral prostheses. However, the specific relationships between human factors and prosthesis design and performance characteristics have not yet been adequately investigated. The present study aims to address this knowledge gap. METHODS: A comprehensive single-cohort survey of 114 unilateral transfemoral amputees addressed a broad range of demographic and clinical characteristics, functional autonomy, satisfaction and attitudes towards their current prostheses, and design priorities for an ideal transfemoral prosthesis, including the possibility of active assistance from a robotic knee unit. The survey was custom-developed based on several standard questionnaires used to assess motor abilities and autonomy in activities of daily living, prosthesis satisfaction, and quality of life in lower-limb amputees. Survey data were analyzed to compare the experience (including autonomy and satisfaction) and design priorities of users of transfemoral prostheses with versus without microprocessor-controlled knee units (MPKs and NMPKs, respectively), with a subsequent analyses of cross-category correlation, principal component analysis (PCA), cost-sensitivity segmentation, and unsupervised K-means clustering applied within the most cost-sensitive participants, to identify functional groupings of users with respect to their design priorities. RESULTS: The cohort featured predominantly younger (< 50 years) traumatic male amputees with respect to the general transfemoral amputee population, with pronounced differences in age distribution and amputation etiology (traumatic vs. non-traumatic) between MPK and NMPK groups. These differences were further reflected in user experience, with MPK users reporting significantly greater overall functional autonomy, satisfaction, and sense of prosthesis ownership than those with NMPKs, in conjunction with a decreased incidence of instability and falls. Across all participants, the leading functional priorities for an ideal transfemoral prosthesis were overall stability, adaptability to variable walking velocity, and lifestyle-related functionality, while the highest-prioritized general characteristics were reliability, comfort, and weight, with highly variable prioritization of cost according to reimbursement status. PCA and user clustering analyses revealed the possibility for functionally relevant groupings of prosthesis features and users, based on their differential prioritization of these features-with implications towards prosthesis design tradeoffs. CONCLUSIONS: This study's findings support the understanding that when appropriately prescribed according to patient characteristics and needs in the context of a proactive rehabilitation program, advanced transfemoral prostheses promote patient mobility, autonomy, and overall health. Survey data indicate overall stability, modularity, and versatility as key design priorities for the continued development of transfemoral prosthesis technology. Finally, observed associations between prosthesis type, user experience, and attitudes concerning prosthesis ownership suggest both that prosthesis characteristics influence device acceptance and functional outcomes, and that psychosocial factors should be specifically and proactively addressed during the rehabilitation process.

Assessing the Tidal Volume through Wearables: A Scoping Review.

The assessment of respiratory activity based on wearable devices is becoming an area of growing interest due to the wide range of available sensors. Accordingly, this scoping review aims to identify research evidence supporting the use of wearable devices to monitor the tidal volume during both daily activities and clinical settings. A screening of the literature (Pubmed, Scopus, and Web of Science) was carried out in December 2020 to collect studies: i. comparing one or more methodological approaches for the assessment of tidal volume with the outcome of a state-of-the-art measurement device (i.e., spirometry or optoelectronic plethysmography); ii. dealing with technological solutions designed to be exploited in wearable devices. From the initial 1031 documents, only 36 citations met the eligibility criteria. These studies highlighted that the tidal volume can be estimated by using different technologies ranging from IMUs to strain sensors (e.g., resistive, capacitive, inductive, electromagnetic, and optical) or acoustic sensors. Noticeably, the relative volumetric error of these solutions during quasi-static tasks (e.g., resting and sitting) is typically ≥10% but it deteriorates during dynamic motor tasks (e.g., walking). As such, additional efforts are required to improve the performance of these devices and to identify possible applications based on their accuracy and reliability.

Residual limb volume fluctuations in transfemoral amputees.

This study constitutes the first attempt to systematically quantify residual limb volume fluctuations in transfemoral amputees. The study was carried out on 24 amputees to investigate variations due to prosthesis doffing, physical activity, and testing time. A proper experimental set-up was designed, including a 3D optical scanner to improve precision and acceptability by amputees. The first test session aimed at measuring residual limb volume at 7 time-points, with 10 min intervals, after prosthesis doffing. This allowed for evaluating the time required for volume stabilization after prosthesis removal, for each amputee. In subsequent sessions, 16 residual limb scans in a day for each amputee were captured to evaluate volume fluctuations due to prosthesis removal and physical activity, in two times per day (morning and afternoon). These measurements were repeated in three different days, a week apart from each other, for a total of 48 scans for each amputee. Volume fluctuations over time after prosthesis doffing showed a two-term decay exponential trend (R2 = 0.97), with the highest variation in the initial 10 min and an average stabilization time of 30 min. A statistically significant increase in residual limb volume following both prosthesis removal and physical activity was verified. No differences were observed between measures collected in the morning and in the afternoon.Clinical Trials.gov ID: NCT04709367.

Effects of gait rehabilitation on motor coordination in stroke survivors: an UCM-based approach.

Post-stroke locomotion is usually characterized by asymmetrical gait patterns, compensatory movements of trunk and nonparetic limb, altered motor coordination, and wide inter-stride variability. This pilot study was designed to test a twofold hypothesis: post-stroke survivors can exploit the redundancy of the segmental angles to stabilize the 3D footpath trajectory during the swing phase, in accordance with the Uncontrolled Manifold (UCM) theory; an intense rehabilitative treatment improves both motor performance and outcomes of the UCM analysis. Ten stroke survivors underwent two evaluation sessions, before and after a conventional multidisciplinary intensive rehabilitation program, encompassing clinical tests and gait analysis, both overground and on treadmill. In addition, the UCM analysis was implemented to investigate whether variance of segmental angles is structured to minimize the inter-stride variability of the 3D footpath during the swing phase of treadmill locomotion. Both clinical and spatio-temporal parameters improved after the treatment, even if the statistical significance was reached for a limited set of them. The UCM analysis suggested that post-stroke survivors exploit the redundancy of lower limbs segmental angles mainly during the late swing, without significant differences between affected and unaffected sides. Thereafter, the main significant effects of the rehabilitative treatment consisted in strengthening the synergistic organization of the redundant segmental angles involving a more accurate control of the 3D footpath. Concluding, the UCM theory can be a promising tool to appraise the effects of a specific rehabilitative protocol on motor coordination in post-stroke survivors.

Repeated exposure to tripping like perturbations elicits more precise control and lower toe clearance of the swinging foot during steady walking.

Controlling minimum toe clearance (MTC) is considered an important factor in preventing tripping. In the current study, we investigated modifications of neuro-muscular control underlying toe clearance during steady locomotion induced by repeated exposure to tripping-like perturbations of the right swing foot. Fourteen healthy young adults (mean age 26.4 ± 3.1 years) participated in the study. The experimental protocol consisted of three identical trials, each involving three phases: steady walking (baseline), perturbation, and steady walking (post-perturbation). During the perturbation, participants experienced 30 tripping-like perturbations at unexpected timing delivered by a custom-made mechatronic perturbation device. The temporal parameters (cadence and stance phase%), mean, and standard deviation of MTC were computed across approximately 90 strides collected during both baseline and post-perturbation phases, for all trials. The effects of trial (three levels), phase (two levels: baseline and post-perturbation) and foot (two levels: right and left) on the outcome variables were analyzed using a three-way repeated measures analysis of variance. The results revealed that exposure to repeated trip-like perturbations modified MTC toward more precise control and lower toe clearance of the swinging foot, which appeared to reflect both the expectation of potential forthcoming perturbations and a quicker compensatory response in cases of a lack of balance. Moreover, locomotion control enabled subjects to maintain symmetric rhythmic features during post-perturbation steady walking. Finally, the effects of exposure to perturbation quickly disappeared among consecutive trials.

Uncontrolled manifold analysis of the effects of a perturbation-based training on the organization of leg joint variance in cerebellar ataxia.

Walking patterns of persons affected by cerebellar ataxia (CA) are characterized by wide stride-to-stride variability ascribable to: the background pathology-related sensory-motor noise; the motor redundancy, i.e., an excess of elemental degrees of freedom that overcomes the number of variables underlying a specific task performance. In this study, we first tested the hypothesis that healthy and, especially, CA subjects can effectively exploit solutions in the domain of segmental angles to stabilize the position of either the foot or the pelvis (task performance) across heel strikes, in accordance with the uncontrolled manifold (UCM) theory. Next, we verified whether a specific perturbation-based training allows CA subjects to further take advantage of this coordination mechanism to better cope with their inherent pathology-related variability. Results always rejected the hypothesis of pelvis stabilization whereas supported the idea that the foot position is stabilized across heel strikes by a synergic covariation of elevation and azimuth angles of lower limb segments in CA subjects only. In addition, it was observed that the perturbation-based training involves a decreasing trend in the variance component orthogonal to the UCM in both groups, reflecting an improved accuracy of the foot control. Concluding, CA subjects can effectively structure the wide amount of pathology-related sensory-motor noise to stabilize specific task performance, such as the foot position across heel strikes. Moreover, the promising effects of the proposed perturbation-based training paradigm are expected to improve the coordinative strategy underlying the stabilization of the foot position across strides, thus ameliorating balance control during treadmill locomotion.

Ambulatory Assessment of the Dynamic Margin of Stability Using an Inertial Sensor Network.

Loss of stability is a precursor to falling and therefore represents a leading cause of injury, especially in fragile people. Thus, dynamic stability during activities of daily living (ADLs) needs to be considered to assess balance control and fall risk. The dynamic margin of stability (MOS) is often used as an indicator of how the body center of mass is located and moves relative to the base of support. In this work, we propose a magneto-inertial measurement unit (MIMU)-based method to assess the MOS of a gait. Six young healthy subjects were asked to walk on a treadmill at different velocities while wearing MIMUs on their lower limbs and pelvis. We then assessed the MOS by computing the lower body displacement with respect to the leading inverse kinematics approach. The results were compared with those obtained using a camera-based system in terms of root mean square deviation (RMSD) and correlation coefficient (ρ). We obtained a RMSD of ≤1.80 cm and ρ ≥ 0.85 for each walking velocity. The findings revealed that our method is comparable to camera-based systems in terms of accuracy, suggesting that it may represent a strategy to assess stability during ADLs in unstructured environments.

Pre-Impact Detection Algorithm to Identify Tripping Events Using Wearable Sensors.

This study aimed to investigate the performance of an updated version of our pre-impact detection algorithm parsing out the output of a set of Inertial Measurement Units (IMUs) placed on lower limbs and designed to recognize signs of lack of balance due to tripping. Eight young subjects were asked to manage tripping events while walking on a treadmill. An adaptive threshold-based algorithm, relying on a pool of adaptive oscillators, was tuned to identify abrupt kinematics modifications during tripping. Inputs of the algorithm were the elevation angles of lower limb segments, as estimated by IMUs located on thighs, shanks and feet. The results showed that the proposed algorithm can identify a lack of balance in about 0.37 ± 0.11 s after the onset of the perturbation, with a low percentage of false alarms (<10%), by using only data related to the perturbed shank. The proposed algorithm can hence be considered a multi-purpose tool to identify different perturbations (i.e., slippage and tripping). In this respect, it can be implemented for different wearable applications (e.g., smart garments or wearable robots) and adopted during daily life activities to enable on-demand injury prevention systems prior to fall impacts.

Effects of repeated waist-pull perturbations on gait stability in subjects with cerebellar ataxia.

BACKGROUND: Damage to the cerebellum can affect neural structures involved in locomotion, causing gait and balance disorders. However, the integrity of cerebellum does not seem to be critical in managing sudden and unexpected environmental changes such as disturbances during walking. The cerebellum also plays a functional role in motor learning. Only a few effective therapies exist for individuals with cerebellar ataxia. With these in mind, we aimed at investigating: (1) corrective response of participants with cerebellar ataxia (CA) to unexpected gait perturbations; and (2) the effectiveness of a perturbation-based training to improve their dynamic stability during balance recovery responses and steady walking. Specifically, we hypothesized that: (1) CA group can show a corrective behavior similar to that of a healthy control group; (2) the exposure to a perturbation-based treatment can exploit residual learning capability, thus improving their dynamic stability during balance recovery responses and steady locomotion. METHODS: Ten participants with cerebellar ataxia and eight age-matched healthy adults were exposed to a single perturbation-based training session. The Active Tethered Pelvic Assist Device applied unexpected waist-pull perturbations while participants walked on a treadmill. Spatio-temporal parameters and dynamic stability were determined during corrective responses and steady locomotion, before and after the training. The ANalysis Of VAriance was the main statistical test used to assess the effects of group (healthy vs CA) and training (baseline vs post) on spatio-temporal parameters of the gait and margin of stability. RESULTS: Data analysis revealed that individuals with cerebellar ataxia behaved differently from healthy volunteers: (1) they retained a wider base of support during corrective responses and steady gait both before and after the training; (2) due to the training, patients improved their anterior-posterior margin of stability during steady walking only. CONCLUSIONS: Our results revealed that participants with cerebellar ataxia could still rely on their learning capability to modify the gait towards a safer behavior. However, they could not take advantage from their residual learning capability while managing sudden and unexpected perturbations. Accordingly, the proposed training paradigm can be considered as a promising approach to improve balance control during steady walking in these individuals.

Cortical reactive balance responses to unexpected slippages while walking: a pilot study.

Understanding how the human brain cortex behaves when the dynamical balance is unexpectedly challenged can be useful to enable fall prevention strategies during daily activities. In this respect, we designed and tested a novel methodological approach to early detect modifications of the scalp-level signals when steady walking is perturbed. Four young adults were asked to manage unexpected bilateral slippages while steadily walking at their self-selected speed. Lower limb kinematics, electromyographic (EMG) and electroencephalographic (EEG; 13 channels from motor and sensory-motor cortex areas) signals were synchronously recorded. EMG signals from Vastus Medialis (both sides) were used to trigger the analysis of the EEG before and after the perturbation onset. Cortical activity was then assessed and compared pre vs. post perturbation. Specifically, for each gait cycle, the rate of variation of the EEG power spectrum density, named m, was used to describe the cortical responsiveness in five bands of interests: ϑ (4-7 Hz), α (8-12 Hz), ß I, ß II, ß III rhythms (13-15, 15-20, 18-28 Hz). Results revealed a sharp increment of m early after the onset of the perturbation (perturbed step) compared to steady locomotion, for all rhythms. This cortical behavior disappeared during the recovery step. This study promisingly supports the evidence that the proposed approach can distinguish between steady walking and early reactive balance recovery, paving the way for the EEG-based monitoring of the fall risk during daily activities.

Uncontrolled manifold hypothesis: Organization of leg joint variance in humans while walking in a wide range of speeds.

This study aimed at investigating the organization of joint angle variability during walking by using the uncontrolled manifold (UCM) theory. We tested two hypotheses: i. the coordinative mechanism underlying joint angle variance during the stance phase is compatible with a kinematic synergy that stabilizes the centre of mass (CoM) position; ii. the walking speed affects the variance components onto and orthogonal to the UCM. Eight healthy subjects (26.0±2.0years old) steadily walked on a treadmill at five normalised speeds (from 0.62±0.03m/s to 1.15±0.07m/s). Joint angles and foot orientation, and components of the CoM position were, respectively, used as elemental variables and task performance for the UCM implementation. The effect of speed, time events, and variance components on the distribution of data variance in the space of joint angles was analyzed by the ANOVA test. Results corroborated the hypothesis that the variance of elemental variables is structured in order to minimize the stride-to-stride variability of the CoM position, at all speeds. Noticeably, both variance components increase during the propulsive phase, albeit that parallel to the UCM was always grater than the orthogonal one. Accordingly, the observed kinematic synergy is supposed to contribute to accomplishing an efficient transition between two steps. Results also revealed that the walking speed does not affect the partitioning of elemental variables-related variance onto and orthogonal to the UCM. Accordingly, the organization of leg joint variance underlying the stabilization of CoM position remains almost unaltered across speeds.

Aging does not affect the intralimb coordination elicited by slip-like perturbation of different intensities.

This study was aimed at verifying whether aging modifies intralimb coordination strategy during corrective responses elicited by unexpected slip-like perturbations delivered during steady walking on a treadmill. To this end, 10 young and 10 elderly subjects were asked to manage unexpected slippages of different intensities. We analyzed the planar covariation law of the lower limb segments, using the principal component analysis, to verify whether elevation angles of older subjects covaried along a plan before and after the perturbation. Results showed that segments related to the perturbed limbs of both younger and older people do not covary after all perturbations. Conversely, the planar covariation law of the unperturbed limb was systematically held for younger and older subjects. These results occurred despite differences in spatio-temporal and kinematic parameters being observed among groups and perturbation intensities. Overall, our analysis revealed that aging does not affect intralimb coordination during corrective responses induced by slip-like perturbation, suggesting that both younger and older subjects adopt this control strategy while managing sudden and unexpected postural transitions of increasing intensities. Accordingly, results corroborate the hypothesis that balance control emerges from a governing set of biomechanical invariants, that is, suitable control schemes (e.g., planar covariation law) shared across voluntary and corrective motor behaviors, and across different sensory contexts due to different perturbation intensities, in both younger and older subjects. In this respect, our findings provide further support to investigate the effects of specific task training programs to counteract the risk of fall.NEW & NOTEWORTHY This study was aimed at investigating how aging affects the intralimb coordination of lower limb segments, described by the planar covariation law, during unexpected slip-like perturbations of increasing intensity. Results revealed that neither the aging nor the perturbation intensity affects this coordination strategy. Accordingly, we proposed that the balance control emerges from an invariant set of control schemes shared across different sensory motor contexts and despite age-related neuromuscular adaptations.

Stability against backward balance loss: Age-related modifications following slip-like perturbations of multiple amplitudes.

Falls are one of the most serious problems in the elderly. Although previous studies clearly link the increased risk of falls with ageing, the mechanisms responsible for the modifications of reactive motor behaviours in response to external perturbations are not yet fully understood. This study investigated how the stability against backward balance loss is affected by aging and intensity of perturbations. The Margin of Stability (MoS) was estimated while eight young and eight elderly adults managed three slip-like perturbations of different intensities while walking at the same normalized speed. A compensatory step was necessary to regain stability. The forward swing phase of the trailing leg was rapidly interrupted and reversed in direction. Results have shown that ageing significantly affects the time required to select the most appropriate biomechanical response: even if the characteristic of the backward step was similar between groups, elderly subjects took more time to reverse the movement of their swinging limb, thus achieving a less efficient action to counteract the backward balance loss (lower MoS both during and at the end of the early compensatory reaction). In addition, young and elderly subjects scaled their reactions with respect to the perturbations intensity in a similar way by increasing the length of their backward step, thus revealing a context-dependent tuning of the biomechanical response that was not affected by aging. These behavioural features can be helpful in identifying the causes of increased fall risk among the elderly in order to define more suited intervention in fall prevention programs.

Scoliosis and Pectus Excavatum in Adolescents: Does the Nuss Procedure Affect the Scoliotic Curvature?

BACKGROUND: Pectus excavatum (PE) is known to be associated with adolescent idiopathic scoliosis (AIS). The correction of severe PE requires a mini-invasive procedure (MIRPE), with a metal bar positioned and left in the chest for 3 years. Adolescence seems to be the more appropriate time not only for MIRPE but also for AIS peak progression. This study was designed to answer the question whether, in adolescents, MIRPE could affect mild/moderate AIS. METHODS: We carried out a meta-analysis focused on defining the natural progression of untreated AIS. Inclusion criteria were as follows: AIS patients -age 10-18 years old -Cobb angle <40°-none treated as orthotics/electrostimulation/surgery. The expected outcome was the percentage of patients who improved, worsened, or hold steady of their condition at follow-up. Between 2008 and 2014, we followed up a cohort of 67 adolescents with severe PE treated with MIRPE, assessing whether AIS underwent a modification in the period between bar insertion and removal. RESULTS: Meta-analysis included 9 studies with 1641 AIS patients. Although heterogeneous (I(2) = 99.5%, P < .0001), the overall percentage of progression for untreated AIS was 42.5% (CI 18.2%-72.2%). In our follow-up group who underwent MIRPE, 34 out of 67 patients had concurrent AIS with a Cobb angle >10° (range 10°-45°). We demonstrated that MIRPE had a favorable effect on AIS, with a mean improvement of 1.5° (CI 0.64-2.44; P = .0011). CONCLUSION: In our PE patients with AIS, MIRPE had a beneficial effect also on the spine. From our preliminary results, it seems that MIRPE should be offered during puberty as a timely option for treating PE and stabilizing mild/moderate scoliosis progression, when concurrent.