Lessons from the pandemic era: do we need new strategies to improve conservative treatment adherence in adolescent idiopathic scoliosis? A retrospective analysis.

This study aims to examine whether the COVID-19 pandemic affected the adherence to conservative AIS treatment. Adolescent Idiopathic Scoliosis (AIS) is characterized by a lateral curvature of the spine of at least 10 degrees. Compliance rates in conservative treatments are influenced by various factors. From a database of AIS patients, we selected 30 AIS patients who were assessed before, during, and after the COVID-19 pandemic. Data regarding Cobb's angle, brace prescription, prescribed brace wear time, brace wear compliance, and time dedicated to sports activities were collected over a six-year period from January 2018 to December 2023, divided into three 2-year time periods (before, during, and after COVID-19). There was an increased percentage of AIS patients prescribed with a brace during the pandemic. However, no significant differences in Cobb's angle were observed. Additionally, the prescribed wear time showed a significant decrease from the pre-COVID period to the post-COVID period (p-value = 0.03). Wear compliance exhibited a decreasing trend from pre- to during- and post-COVID-19 periods without reaching statistically significant differences, and the time dedicated to sports statistically significantly decreased. These differences were statistically significant when comparing the pre- vs. post- and pre- vs. during-COVID-19 periods (p-values 0.01, 0.04, respectively). Our study highlights changes in AIS conservative treatment during and after the COVID-19 pandemic. The increase in the number of patients prescribed with a brace during the pandemic, although not supported by an increase in Cobb's angle, may be attributed to the concerns about regular monitoring during the reduction of rehabilitation services. The observed decreases in brace compliance and involvement in sport activities, which persisted even in the post-pandemic period, emphasizes the lasting impact of the pandemic on AIS management, necessitating innovative approaches to address these ongoing concerns.

Neurophysiological, balance and motion evidence in adolescent idiopathic scoliosis: A systematic review.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is a spinal deformity that affects approximately 4% of the world's population. Several hypotheses regarding the etiology of AIS have been investigated. In the last decades, impaired visual-spatial perception, alterations in spatial body orientation and sensory integration deficits have been documented. OBJECTIVE: We aimed to summarize the neurophysiological, balance, and motion evidence related to AIS published in the last fifteen years, between January 2008 and April 2023. Both observational and interventional studies were considered. Only studies using quantitative assessment methods, such as electroencephalography (EEG), electromyography (EMG), magnetic resonance imaging (MRI), somatosensory evoked potentials, force platform, or motion capture, were included. METHODS: 1250 eligible records identified from online database searching were filtered by duplicate removal, title and abstract screening, and qualitative analysis. 61 articles met the inclusion criteria (i.e., Cobb range 10°-35°, age range 10-18 years) and were summarized. RESULTS: We found significant evidence of impaired standing balance in individuals with AIS who greatly rely on visual and proprioceptive information to stay upright. EMG studies frequently reported an increased activity on the convex side of the intrinsic spinae muscles. EEG data show increased delta and theta power, higher alpha peak frequencies, and significant suppression in the alpha and beta bands in subjects with AIS during standing tasks. MRI studies report changes in white matter structures, differences in the vestibular system, and abnormal cortical activations over motor-related areas in subjects with AIS. Bracing appears to be an effective treatment for AIS, leading to improvements in static balance and gait. Methodological issues prevent reliable conclusions about the effects of other treatment options. CONCLUSIONS: This review underscores the importance of quantitative assessment methods to explore the etiology and pathophysiology of AIS. Further research is needed to measure the impact of physical therapy and orthotic treatments on the neurophysiological mechanisms of the disease.

Experimental protocol to investigate cortical, muscular and body representation alterations in adolescents with idiopathic scoliosis.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis. AIS is a three-dimensional morphological spinal deformity that affects approximately 1-3% of adolescents. Not all factors related to the etiology of AIS have yet been identified. OBJECTIVE: The primary aim of this experimental protocol is to quantitatively investigate alterations in body representation in AIS, and to quantitatively and objectively track the changes in body sensorimotor representation due to treatment. METHODS: Adolescent girls with a confirmed diagnosis of mild (Cobb angle: 10°-20°) or moderate (21°-35°) scoliosis as well as age and sex-matched controls will be recruited. Participants will be asked to perform a 6-min upright standing and two tasks-named target reaching and forearm bisection task. Eventually, subjects will fill in a self-report questionnaire and a computer-based test to assess body image. This evaluation will be repeated after 6 and 12 months of treatment (i.e., partial or full-time brace and physiotherapy corrective postural exercises). RESULTS: We expect that theta brain rhythm in the central brain areas, alpha brain rhythm lateralization and body representation will change over time depending on treatment and scoliosis progression as a compensatory strategy to overcome a sensorimotor dysfunction. We also expect asymmetric activation of the trunk muscle during reaching tasks and decreased postural stability in AIS. CONCLUSIONS: Quantitatively assess the body representation at different time points during AIS treatment may provide new insights on the pathophysiology and etiology of scoliosis.

Ability-Based Methods for Personalized Keyboard Generation.

This study introduces an ability-based method for personalized keyboard generation, wherein an individual's own movement and human-computer interaction data are used to automatically compute a personalized virtual keyboard layout. Our approach integrates a multidirectional point-select task to characterize cursor control over time, distance, and direction. The characterization is automatically employed to develop a computationally efficient keyboard layout that prioritizes each user's movement abilities through capturing directional constraints and preferences. We evaluated our approach in a study involving 16 participants using inertial sensing and facial electromyography as an access method, resulting in significantly increased communication rates using the personalized keyboard (52.0 bits/min) when compared to a generically optimized keyboard (47.9 bits/min). Our results demonstrate the ability to effectively characterize an individual's movement abilities to design a personalized keyboard for improved communication. This work underscores the importance of integrating a user's motor abilities when designing virtual interfaces.

Ability-based Keyboards for Augmentative and Alternative Communication: Understanding How Individuals' Movement Patterns Translate to More Efficient Keyboards: Methods to Generate Keyboards Tailored to User-specific Motor Abilities.

This study presents the evaluation of ability-based methods extended to keyboard generation for alternative communication in people with dexterity impairments due to motor disabilities. Our approach characterizes user-specific cursor control abilities from a multidirectional point-select task to configure letters on a virtual keyboard based on estimated time, distance, and direction of movement. These methods were evaluated in three individuals with motor disabilities against a generically optimized keyboard and the ubiquitous QWERTY keyboard. We highlight key observations relating to the heterogeneity of the manifestation of motor disabilities, perceived importance of communication technology, and quantitative improvements in communication performance when characterizing an individual's movement abilities to design personalized AAC interfaces.

On the reliability and validity of central fatigue determination.

Physical performance fatigue can be ascribed to both peripheral and central components. Central fatigue, however, is an elusive entity, consisting of cognitive/sensory component and presumably also a neuro-physiological component that are difficult to tease apart and assess independently of each other. The most widely accepted method for the assessment of central fatigue is based on the premise that decreasing volitional muscle activation (VA), as determined by the interpolated twitch technique (ITT) in fatiguing muscles, reflects increasing central fatigue. Suffering its own shortcomings, the validity of VA determination under fatigued conditions has never been proven and is only assumed. This review presents evidence that questions ITT's reliability and validity in reflecting VA in the fatiguing muscle and, consequently, VA's validity for central fatigue assessment. Specifically highlighted is the paradox of children and endurance athletes, who share striking endurance characteristics, being claimed as more centrally fatigable than untrained adults. Further research and new directions are needed for confirming and quantifying central fatigue and teasing apart its psychologic and neuromotor components.

Surface Electromyography-Based Recognition, Synthesis, and Perception of Prosodic Subvocal Speech.

Purpose This study aimed to evaluate a novel communication system designed to translate surface electromyographic (sEMG) signals from articulatory muscles into speech using a personalized, digital voice. The system was evaluated for word recognition, prosodic classification, and listener perception of synthesized speech. Method sEMG signals were recorded from the face and neck as speakers with (n = 4) and without (n = 4) laryngectomy subvocally recited (silently mouthed) a speech corpus comprising 750 phrases (150 phrases with variable phrase-level stress). Corpus tokens were then translated into speech via personalized voice synthesis (n = 8 synthetic voices) and compared against phrases produced by each speaker when using their typical mode of communication (n = 4 natural voices, n = 4 electrolaryngeal [EL] voices). Naïve listeners (n = 12) evaluated synthetic, natural, and EL speech for acceptability and intelligibility in a visual sort-and-rate task, as well as phrasal stress discriminability via a classification mechanism. Results Recorded sEMG signals were processed to translate sEMG muscle activity into lexical content and categorize variations in phrase-level stress, achieving a mean accuracy of 96.3% (SD = 3.10%) and 91.2% (SD = 4.46%), respectively. Synthetic speech was significantly higher in acceptability and intelligibility than EL speech, also leading to greater phrasal stress classification accuracy, whereas natural speech was rated as the most acceptable and intelligible, with the greatest phrasal stress classification accuracy. Conclusion This proof-of-concept study establishes the feasibility of using subvocal sEMG-based alternative communication not only for lexical recognition but also for prosodic communication in healthy individuals, as well as those living with vocal impairments and residual articulatory function. Supplemental Material https://doi.org/10.23641/asha.14558481.

Motor unit drive: a neural interface for real-time upper limb prosthetic control.

OBJECTIVE: Modern prosthetic limbs have made strident gains in recent years, incorporating terminal electromechanical devices that are capable of mimicking the human hand. However, access to these advanced control capabilities has been prevented by fundamental limitations of amplitude-based myoelectric neural interfaces, which have remained virtually unchanged for over four decades. Consequently, nearly 23% of adults and 32% of children with major traumatic or congenital upper-limb loss abandon regular use of their myoelectric prosthesis. To address this healthcare need, we have developed a noninvasive neural interface technology that maps natural motor unit increments of neural control and force into biomechanically informed signals for improved prosthetic control. APPROACH: Our technology, referred to as motor unit drive (MU Drive), utilizes real-time machine learning algorithms for directly measuring motor unit firings from surface electromyographic signals recorded from residual muscles of an amputated or congenitally missing limb. The extracted firings are transformed into biomechanically informed signals based on the force generating properties of individual motor units to provide a control source that represents the intended movement. MAIN RESULTS: We evaluated the characteristics of the MU Drive control signals and compared them to conventional amplitude-based myoelectric signals in healthy subjects as well as subjects with congenital or traumatic trans-radial limb-loss. Our analysis established a vital proof-of-concept: MU Drive provides a more responsive real-time signal with improved smoothness and more faithful replication of intended limb movement that overcomes the trade-off between performance and latency inherent to amplitude-based myoelectric methods. SIGNIFICANCE: MU Drive is the first neural interface for prosthetic control that provides noninvasive real-time access to the natural motor control mechanisms of the human nervous system. This new neural interface holds promise for improving prosthetic function by achieving advanced control that better reflects the user intent. Beyond the immediate advantages in the field of prosthetics, MU Drive provides an innovative alternative for advancing the control of exoskeletons, assistive devices, and other robotic rehabilitation applications.

Contribution from motor unit firing adaptations and muscle coactivation during fatigue.

The control of motor unit firing behavior during fatigue is still debated in the literature. Most studies agree that the central nervous system increases the excitation to the motoneuron pool to compensate for decreased force contributions of individual motor units and sustain muscle force output during fatigue. However, some studies claim that motor units may decrease their firing rates despite increased excitation, contradicting the direct relationship between firing rates and excitation that governs the voluntary control of motor units. To investigate whether the control of motor units in fact changes with fatigue, we measured motor unit firing behavior during repeated contractions of the first dorsal interosseous (FDI) muscle while concurrently monitoring the activation of surrounding muscles, including the flexor carpi radialis, extensor carpi radialis, and pronator teres. Across all subjects, we observed an overall increase in FDI activation and motor unit firing rates by the end of the fatigue task. However, in some subjects we observed increases in FDI activation and motor unit firing rates only during the initial phase of the fatigue task, followed by subsequent decreases during the late phase of the fatigue task while the coactivation of surrounding muscles increased. These findings indicate that the strategy for sustaining force output may occasionally change, leading to increases in the relative activation of surrounding muscles while the excitation to the fatiguing muscle decreases. Importantly, irrespective of changes in the strategy for sustaining force output, the control properties regulating motor unit firing behavior remain unchanged during fatigue. NEW & NOTEWORTHY This work addresses sources of debate surrounding the manner in which motor unit firing behavior is controlled during fatigue. We found that decreases in the motor unit firing rates of the fatiguing muscle may occasionally be observed when the contribution of coactive muscles increases. Despite changes in the strategy employed to sustain the force output, the underlying control properties regulating motor unit firing behavior remain unchanged during muscle fatigue.

The compensatory interaction between motor unit firing behavior and muscle force during fatigue.

Throughout the literature, different observations of motor unit firing behavior during muscle fatigue have been reported and explained with varieties of conjectures. The disagreement amongst previous studies has resulted, in part, from the limited number of available motor units and from the misleading practice of grouping motor unit data across different subjects, contractions, and force levels. To establish a more clear understanding of motor unit control during fatigue, we investigated the firing behavior of motor units from the vastus lateralis muscle of individual subjects during a fatigue protocol of repeated voluntary constant force isometric contractions. Surface electromyographic decomposition technology provided the firings of 1,890 motor unit firing trains. These data revealed that to sustain the contraction force as the muscle fatigued, the following occurred: 1) motor unit firing rates increased; 2) new motor units were recruited; and 3) motor unit recruitment thresholds decreased. Although the degree of these adaptations was subject specific, the behavior was consistent in all subjects. When we compared our empirical observations with those obtained from simulation, we found that the fatigue-induced changes in motor unit firing behavior can be explained by increasing excitation to the motoneuron pool that compensates for the fatigue-induced decrease in muscle force twitch reported in empirical studies. Yet, the fundamental motor unit control scheme remains invariant throughout the development of fatigue. These findings indicate that the central nervous system regulates motor unit firing behavior by adjusting the operating point of the excitation to the motoneuron pool to sustain the contraction force as the muscle fatigues.

Is the notion of central fatigue based on a solid foundation?

Exercise-induced muscle fatigue has been shown to be the consequence of peripheral factors that impair muscle fiber contractile mechanisms. Central factors arising within the central nervous system have also been hypothesized to induce muscle fatigue, but no direct empirical evidence that is causally associated to reduction of muscle force-generating capability has yet been reported. We developed a simulation model to investigate whether peripheral factors of muscle fatigue are sufficient to explain the muscle force behavior observed during empirical studies of fatiguing voluntary contractions, which is commonly attributed to central factors. Peripheral factors of muscle fatigue were included in the model as a time-dependent decrease in the amplitude of the motor unit force twitches. Our simulation study indicated that the force behavior commonly attributed to central fatigue could be explained solely by peripheral factors during simulated fatiguing submaximal voluntary contractions. It also revealed important flaws regarding the use of the interpolated twitch response from electrical stimulation of the muscle as a means for assessing central fatigue. Our analysis does not directly refute the concept of central fatigue. However, it raises important concerns about the manner in which it is measured and about the interpretation of the commonly accepted causes of central fatigue and questions the very need for the existence of central fatigue.

Biomechanical benefits of the Onion-Skin motor unit control scheme.

Muscle force is modulated by varying the number of active motor units and their firing rates. For the past five decades, the notion that the magnitude of the firing rates is directly related to motor unit size and recruitment threshold has been widely accepted. This construct, here named the After-hyperpolarization scheme evolved from observations in electrically stimulated cat motoneurons and from reported observations in voluntary contractions in humans. It supports the assumption that the firing rates of motor units match their mechanical properties to "optimize" force production, so that the firing rate range corresponds to that required for force-twitch fusion (tetanization) and effective graduation of muscle force. In contrast, we have shown that, at any time and force during isometric voluntary constant-force contractions in humans, the relationship between firing rate and recruitment threshold is inversely related. We refer to this construct as the Onion-Skin scheme because earlier-recruited motor units always have greater firing rates than latter-recruited ones. By applying a novel mathematical model that calculates the force produced by a muscle for the two schemes we found that the Onion-Skin scheme is more energy efficient, provides smoother muscle force at low to moderate force levels, and appears to be more conducive to evolutionary survival than the After-hyperpolarization scheme.

Transposed firing activation of motor units.

Muscles are composed of groups of muscle fibers, called motor units, each innervated by a single motoneuron originating in the spinal cord. During constant or linearly varying voluntary force contractions, motor units are activated in a hierarchical order, with the earlier-recruited motor units having greater firing rates than the later-recruited ones. We found that this normal pattern of firing activation can be altered during oscillatory contractions where the force oscillates at frequencies ≥2 Hz. During these high-frequency oscillations, the activation of the lower-threshold motor units effectively decreases and that of the higher-threshold motor units effectively increases. This transposition of firing activation provides means to activate higher-threshold motor units preferentially. Our results demonstrate that the hierarchical regulation of motor unit activation can be manipulated to activate specific motoneuron populations preferentially. This finding can be exploited to develop new forms of physical therapies and exercise programs that enhance muscle performance or that target the preferential atrophy of high-threshold motor units as a result of aging or motor disorders such as stroke and amyotrophic lateral sclerosis.

Relationship between clinical and instrumental balance assessments in chronic post-stroke hemiparesis subjects.

BACKGROUND: Stroke is often associated with balance deficits that increase the risk of falls and may lead to severe mobility disfunctions or death. The purpose of this study is to establish the relation between the outcome of instrumented posturography and of the most commonly used clinical balance tests, and investigate their role for obtaining reliable feedback on stroke patients' balance impairment. METHODS: Romberg test was performed on 20 subjects, 10 hemiplegic post-stroke subjects (SS, 69.4 ± 8.2 years old) and 10 control subjects (CS, 61.6 ± 8.6 years old), with 1 Bertec force plate. The following parameters were estimated from the centre of pressure (CoP) trajectory, which can be used to define subjects' performance during the balance task: sway area; ellipse (containing 95% of the data); mean CoP path and velocity in the anterior-posterior and medio-lateral directions. The following clinical scales and tests were administered to the subjects: Tinetti Balance test (TB); Berg Balance test (BBT); Time up and go test (TUG), Fugl-Meyer (lower limbs) (FM), Motricity Index (lower limbs), Trunk Control Test, Functional Independence Measure. Comparison between SS and CS subjects was performed by using the Student t-test. The Pearson Correlation coefficient was computed between instrumental and clinical parameters. RESULTS: Mean ± standard deviation for the balance scales scores of SS were: 12.5 ± 3.6 for TB, 42.9 ± 13.1 for BBT, 24 s and 75 cent ± 25 s and 70 cent for TUG. Correlation was found among some CoP parameters and both BBT and TUG in the eyes open and closed conditions (0.9 ≤ R ≤ 0.8). Sway area correlated only with TUG. Statistically significant differences were found between SS and CS in all CoP parameters in eyes open condition (p < 0.04); whereas in eyes closed condition only CoP path and velocity (p < 0.02) differed significantly. CONCLUSIONS: Correlation was found only among some of the clinical and instrumental balance outcomes, indicating that they might measure different aspects of balance control. Consistently with previous findings in healthy and pathological subjects, our results suggest that instrumented posturography should be recommended for use in clinical practice in addition to clinical functional tests.

Neural control of muscle force: indications from a simulation model.

We developed a model to investigate the influence of the muscle force twitch on the simulated firing behavior of motoneurons and muscle force production during voluntary isometric contractions. The input consists of an excitatory signal common to all the motor units in the pool of a muscle, consistent with the "common drive" property. Motor units respond with a hierarchically structured firing behavior wherein at any time and force, firing rates are inversely proportional to recruitment threshold, as described by the "onion skin" property. Time- and force-dependent changes in muscle force production are introduced by varying the motor unit force twitches as a function of time or by varying the number of active motor units. A force feedback adjusts the input excitation, maintaining the simulated force at a target level. The simulations replicate motor unit behavior characteristics similar to those reported in previous empirical studies of sustained contractions: 1) the initial decrease and subsequent increase of firing rates, 2) the derecruitment and recruitment of motor units throughout sustained contractions, and 3) the continual increase in the force fluctuation caused by the progressive recruitment of larger motor units. The model cautions the use of motor unit behavior at recruitment and derecruitment without consideration of changes in the muscle force generation capacity. It describes an alternative mechanism for the reserve capacity of motor units to generate extraordinary force. It supports the hypothesis that the control of motoneurons remains invariant during force-varying and sustained isometric contractions.

Hierarchical control of motor units in voluntary contractions.

For the past five decades there has been wide acceptance of a relationship between the firing rate of motor units and the afterhyperpolarization of motoneurons. It has been promulgated that the higher-threshold, larger-soma, motoneurons fire faster than the lower-threshold, smaller-soma, motor units. This relationship was based on studies on anesthetized cats with electrically stimulated motoneurons. We questioned its applicability to motor unit control during voluntary contractions in humans. We found that during linearly force-increasing contractions, firing rates increased as exponential functions. At any time and force level, including at recruitment, the firing rate values were inversely related to the recruitment threshold of the motor unit. The time constants of the exponential functions were directly related to the recruitment threshold. From the Henneman size principle it follows that the characteristics of the firing rates are also related to the size of the soma. The "firing rate spectrum" presents a beautifully simple control scheme in which, at any given time or force, the firing rate value of earlier-recruited motor units is greater than that of later-recruited motor units. This hierarchical control scheme describes a mechanism that provides an effective economy of force generation for the earlier-recruited lower force-twitch motor units, and reduces the fatigue of later-recruited higher force-twitch motor units-both characteristics being well suited for generating and sustaining force during the fight-or-flight response.

Abnormal muscle activation during gait in diabetes patients with and without neuropathy.

The World Health Organization warns that, in 2000, as many as 33 million Europeans suffered from diabetes, approximately 15% will likely develop foot ulcers, and approximately 15-20% of these patients will face lower-extremity amputation. Changes in some gait parameters that appear to be specific in diabetes have been identified in the literature: shorter stride length, reduced walking speed, and altered lower limb and trunk mobility. The present study aimed at evaluating the role of altered muscle activity in gait alterations of diabetic subjects with and without neuropathy. This study involved 50 subjects: 10 controls (BMI 24.4 ± 2.8, age 61.2 ± 5.07), 20 diabetics (BMI 26.4 ± 2.5, age 56.53 ± 13.29) and 20 neuropathics (BMI 26.8 ± 3.4, age 61.2 ± 7.7). The electrical activity of six muscles was collected bilaterally on the lower limb during gait: gluteus medius, rectus femoris, tibialis anterior, peroneous longus, gastrocnemius lateralis, and extensor digitorum communis. Electromyographic activity was represented through linear envelopes. Time and space parameters were also evaluated by means of two Bertec force plates and a six cameras motion capture system (BTS, 60-120 Hz). At initial contact and loading response, an early peak of rectus femoris activity occurred in diabetic subjects with and without neuropathy. During midstance a delay of gastrocnemius activity was observed in diabetic non-neuropathic subjects. During terminal swing a delay of rectus femoris and gluteus medius activity was seen in diabetic non-neuropathic subjects'. The results suggest that important muscle activity deviations are present in diabetic subjects although these are not directly related to neuropathy.

Motor unit control and force fluctuation during fatigue.

During isometric contractions, the fluctuation of the force output of muscles increases as the muscle fatigues, and the contraction is sustained to exhaustion. We analyzed motor unit firing data from the vastus lateralis muscle to investigate which motor unit control parameters were associated with the increased force fluctuation. Subjects performed a sequence of isometric constant-force contractions sustained at 20% maximal force, each spaced by a 6-s rest period. The contractions were performed until the mean value of the force output could not be maintained at the desired level. Intramuscular EMG signals were detected with a quadrifilar fine-wire sensor. The EMG signals were decomposed to identify all of the firings of several motor units by using an artificial intelligence-based set of algorithms. We were able to follow the behavior of the same motor units as the endurance time progressed. The force output of the muscle was filtered to remove contributions from the tracking task. The coefficient of variation of the force was found to increase with endurance time (P < 0.001, R(2) = 0.51). We calculated the coefficient of variation of the firing rates, the synchronization of pairs of motor unit firings, the cross-correlation value of the firing rates of pairs of motor units, the cross-correlation of the firing rates of motor units and the force, and the number of motor units recruited during the contractions. Of these parameters, only the cross-correlation of the firing rates (P < 0.01, R(2) = 0.10) and the number of recruited motor units (P = 0.042, R(2) = 0.22) increased significantly with endurance time for grouped subjects. A significant increase (P < 0.001, R(2) = 0.16) in the cross-correlation of the firing rates and force was also observed. It is suggested that the increase in the cross-correlation of the firing rates is likely due to a decrease in the sensitivity of the proprioceptive feedback from the spindles.