Biomechanical Load of Neck and Lumbar Joints in Open-Surgery Training.

The prevalence of musculoskeletal symptoms (MSS) like neck and back pain is high among open-surgery surgeons. Prolonged working in the same posture and unfavourable postures are biomechanical risk factors for developing MSS. Ergonomic devices such as exoskeletons are possible solutions that can reduce muscle and joint load. To design effective exoskeletons for surgeons, one needs to quantify which neck and trunk postures are seen and how much support during actual surgery is required. Hence, this study aimed to establish the biomechanical profile of neck and trunk postures and neck and lumbar joint loads during open surgery (training). Eight surgical trainees volunteered to participate in this research. Neck and trunk segment orientations were recorded using an inertial measurement unit (IMU) system during open surgery (training). Neck and lumbar joint kinematics, joint moments and compression forces were computed using OpenSim modelling software and a musculoskeletal model. Histograms were used to illustrate the joint angle and load distribution of the neck and lumbar joints over time. During open surgery, the neck flexion angle was 71.6% of the total duration in the range of 10~40 degrees, and lumbar flexion was 68.9% of the duration in the range of 10~30 degrees. The normalized neck and lumbar flexion moments were 53.8% and 35.5% of the time in the range of 0.04~0.06 Nm/kg and 0.4~0.6 Nm/kg, respectively. Furthermore, the neck and lumbar compression forces were 32.9% and 38.2% of the time in the range of 2.0~2.5 N/kg and 15~20 N/kg, respectively. In contrast to exoskeletons used for heavy lifting tasks, exoskeletons designed for surgeons exhibit lower support torque requirements while additional degrees of freedom (DOF) are needed to accommodate combinations of neck and trunk postures.

Effect of painful Ledderhose disease on dynamic plantar foot pressure distribution during walking: a case-control study.

BACKGROUND: Plantar pressure distribution during walking in patients with painful Ledderhose disease is unknown. RESEARCH QUESTION: Do patients with painful Ledderhose disease have an altered plantar pressure distribution during walking compared to individuals without foot pathologies? It was hypothesized that plantar pressure is shifted away from the painful nodules. METHODS: Pedobarography data of 41 patients with painful Ledderhose disease (cases, mean age: 54.2 ± 10.4 years) was collected and compared to pedobarography data from 41 individuals without foot pathologies (controls, mean age: 21.7 ± 2.0 years). Peak Pressure (PP), Maximum Mean Pressure (MMP) and Force-Time Integral (FTI) were calculated for eight regions (heel, medial midfoot, lateral midfoot, medial forefoot, central forefoot, lateral forefoot, hallux and other toes) under the soles of the feet. Differences between cases and controls were calculated and analysed by means of linear (mixed models) regression. RESULTS: Proportional differences in PP, MMP and FTI showed increased values for the cases compared to the controls, especially in the heel, hallux and other toes regions, and decreased values in the medial- and lateral midfoot regions. In naïve regression analysis, being a patient was a predictor for increased- and decreased values for PP, MMP and FTI for several regions. When dependencies in the data were taken into account with linear mixed-model regression analysis, the increased- and decreased values for the patients were most prevalent for FTI at the heel, medial midfoot, hallux and other toes regions. SIGNIFICANCE: In patients with painful Ledderhose disease, during walking, a shift of pressure was found towards the proximal and distal foot regions, while offloading the midfoot regions.

Pilot Validation Study of Inertial Measurement Units and Markerless Methods for 3D Neck and Trunk Kinematics during a Simulated Surgery Task.

Surgeons are at high risk for developing musculoskeletal symptoms (MSS), like neck and back pain. Quantitative analysis of 3D neck and trunk movements during surgery can help to develop preventive devices such as exoskeletons. Inertial Measurement Units (IMU) and markerless motion capture methods are allowed in the operating room (OR) and are a good alternative for bulky optoelectronic systems. We aim to validate IMU and markerless methods against an optoelectronic system during a simulated surgery task. Intraclass correlation coefficient (ICC (2,1)), root mean square error (RMSE), range of motion (ROM) difference and Bland-Altman plots were used for evaluating both methods. The IMU-based motion analysis showed good-to-excellent (ICC 0.80-0.97) agreement with the gold standard within 2.3 to 3.9 degrees RMSE accuracy during simulated surgery tasks. The markerless method shows 5.5 to 8.7 degrees RMSE accuracy (ICC 0.31-0.70). Therefore, the IMU method is recommended over the markerless motion capture.

HoMEcare aRm rehabiLItatioN (MERLIN): preliminary evidence of long term effects of telerehabilitation using an unactuated training device on upper limb function after stroke.

BACKGROUND: While short term effects on upper limb function of stroke patients after training with robotic devices have been studied extensively, long term effects are often not addressed. HoMEcare aRm rehabiLItatioN (MERLIN) is a combination of an unactuated training device using serious games and a telerehabilitation platform in the patient's home situation. Short term effects showed that upper limb function improved after training with MERLIN. The aim was to determine long term effects on upper limb function and quality of life. METHODS: Six months after cessation of the 6 week MERLIN training program, the upper limb function and quality of life of 11 chronic stroke patients were assessed. Upper limb function was measured using the Wolf Motor Function Test (WMFT), Action Research Arm Test (ARAT) and Fugl-Meyer Assessment-Upper Extremity (FMA-UE). EuroQoL-5D (EQ-5D) was used to measure quality of life. RESULTS: The WMFT, ARAT and EQ-5D did not show significant differences 6 months after the training period compared to directly after training. At 6 months follow-up, FMA-UE results were significantly better than at baseline. Time plots showed a decreasing trend in all tests. CONCLUSION: Training effects were still present at 6 months follow-up, since arm function seemed similar to directly after training and FMA-UE results were better than at baseline. However, because of the decreasing trend shown in all tests, it is questionable if improvements will be maintained longer than 6 months. Due to the sample size and study design, results should be interpreted with caution. Trial registration This study is registered at the Netherlands Trial Register (NL7535). Registered 18-02-2019, https://www.trialregister.nl/trial/7535.

Pre-operative rehabilitation in lower-limb amputation patients and its effect on post-operative outcomes.

Major lower-limb amputation (LLA) is a life-changing event associated with poor post-operative physical and psychological functioning and decreased quality of life. The general physical condition of most LLA patients prior to surgery is already significantly deteriorated due to chronic peripheral vascular disease often in combination with diabetes. Pre-operative rehabilitation (also called 'pre-rehabilitation') is an increasingly common strategy used in multiple patient populations to improve patients' physical and mental condition prior to surgery, thus aiming at improving the post-operative patient outcomes. Given the positive effects of post-surgical outcomes in many patient populations, we hypothesize that pre-operative rehabilitation will improve post-operative outcomes after LLA. To test this hypothesis, a literature search of PubMed, EMBASE, EBSCOhost, Web of Science and ScienceDirect was performed to identify studies that investigated the impact of a pre-operative rehabilitation therapy on post-operative outcomes such as length of hospital stay, mobility, physical functioning, and health related quality of life. No time restrictions were applied to the search. Only articles published in English were included in the selection. Two studies satisfied the eligibility criteria for inclusion in the review, one qualitative and one quantitative study. The quantitative study reported a beneficial effect of pre-rehabilitation, resulting in post-operative mobility (at least indoor ambulation) in 63% of the included LLA patients. There is a need for prospective clinical studies examining the effect of pre-rehabilitation on post-operative outcomes to be able to confirm or reject our hypothesis. Although the hypothesis seems plausible, evidence is lacking to support our hypothesis that pre-operative rehabilitation will improve post-operative outcomes in patients with LLA. The qualitative study indicated that integrating pre-rehabilitation in the care for LLA patients seems to be limited to a selected group of dysvascular patients, but at this stage cannot be advised based on current evidence even in this subgroup. Further research is needed to clarify whether such an intervention prior to amputation would be a useful and effective tool for optimizing post-operative outcomes in LLA patients.

Pre-operative rehabilitation for dysvascular lower-limb amputee patients: A focus group study involving medical professionals.

BACKGROUND: Major lower-limb amputation (LLA) predisposes patients post-operatively to a significant decline in daily-life functioning. The physical condition of amputee patients prior to surgery is significantly deteriorated due to chronic peripheral vascular disease (PVD) and diabetes, which accounts for the majority of LLAs in the adult population. A common strategy called pre-rehabilitation has been used in multiple patient populations to prepare the patient for undergoing a surgical event and to improve post-operative patient outcomes. Pre-rehabilitation might enhance the outcome of dysvascular LLA patients and reduce the high post-operative mortality rates. However, experience of experts with pre-rehabilitation and feasibility of a pre-rehabilitation program in this group remains unknown. OBJECTIVE: To investigate the experiences of medical professionals and researchers in the field of LLA with the use of pre-rehabilitation in general and in particular PVD patients. Additionally, the study examines their opinions regarding need for and feasibility of a pre-rehabilitation program for dysvascular patients at risk for an LLA. METHODS: Two explorative focus group discussions were organized with in total 16 experts in the field of treatment and research of LLA. Transcribed data were coded using the Atlas.ti software package. Thematic analysis with inductive approach was opted to arrange and interpret codes. RESULTS: The experiences of the experts with pre-rehabilitation in dysvascular patients were scarce. The experts described dysvascular patients at risk for an LLA as a difficult group for pre-rehabilitation due to short time window prior to surgery, older age, multiple co-morbidities and lack of motivation for behavioral change. The experts concluded that a pre-rehabilitation program should focus on patients who have sufficient time in advance before the amputation for pre-rehabilitation and who are motivated to participate. CONCLUSION: Although in general the effects of pre-rehabilitation are promising, pre-operative rehabilitation in dysvascular patients at risk for an LLA seems not feasible. Future research could focus on a better monitoring of dysvascular patients and the development of pre-rehabilitation in subgroups of younger dysvascular LLA patients.