The pressure time integral: An underused, clinically significant parameter as a determinant of neuropathic ulceration in diabetes.

BACKGROUND: The purpose of this study was to evaluate plantar pressure dynamics in the occurrence of active diabetic neuropathic ulceration (DNU) and any changes in loadings occurring in individuals with a history of diabetic neuropathic ulceration (DHNU). Since current gold standard offloading strategies are not producing desirable healing outcomes and optimum ulcer prevention, this study aimed to better understand the effect of diabetic peripheral neuropathy (DPN) and ulceration on mean peak plantar pressure (MPPP) and pressure-time integral (PTI) changes. RESEARCH QUESTION: Is there a redistribution of plantar pressure during gait in the presence of active and history of diabetic neuropathic ulceration? METHODS: A prospective, cross-sectional study was conducted, in which, eighty adult participants were divided into four groups, namely, the DM, DPN, DNU and DHNU groups. Participants were instructed to walk barefoot over a Tekscan HR Mat™ at self-selected speed. MPPP and PTI data were analysed under five forefoot anatomical landmarks and compared between individuals with and without active neuropathic ulceration. RESULTS: Minimal MPPP significant changes were observed between ulcerated and non-ulcerated groups, however, PTI values were significantly increased in the ulcerated groups under all plantar ulceration regions. No significant plantar pressure differences were observed between the DNU and DHNU groups. Logistic regression tests demonstrated that as PTIs under the hallux increase, the likelihood of an individual living with DPN developing ulceration increases. SIGNIFICANCE: A significant increase in PTI values in the presence of ulceration highlights the importance of evaluating the duration of loads under forefoot regions during gait rather than just focusing on the magnitude of pressures during ulcer management and prevention. Moreover, results show that PTI values remain high in the presence of a history of neuropathic ulceration, possibly demonstrating the value of PTI as a clinical tool over MPPP in the assessment of the high-risk diabetic foot.

The Burden of Type 1 and Type 2 Diabetes Among Adolescents and Young Adults in 24 Western European Countries, 1990-2019: Results From the Global Burden of Disease Study 2019.

Objectives: As little is known about the burden of type 1 (T1DM) and type 2 diabetes (T2DM) in adolescents in Western Europe (WE), we aimed to explore their epidemiology among 10-24 year-olds. Methods: Estimates were retrieved from the Global Burden of Diseases Study (GBD) 2019. We reported counts, rates per 100,000 population, and percentage changes from 1990 to 2019 for prevalence, incidence and years lived with disability (YLDs) of T1DM and T2DM, and the burden of T2DM in YLDs attributable to high body mass index (HBMI), for 24 WE countries. Results: In 2019, prevalence and disability estimates were higher for T1DM than T2DM among 10-24 years old adolescents in WE. However, T2DM showed a greater increase in prevalence and disability than T1DM in the 30 years observation period in all WE countries. Prevalence increased with age, while only minor differences were observed between sexes. Conclusion: Our findings highlight the substantial burden posed by DM in WE among adolescents. Health system responses are needed for transition services, data collection systems, education, and obesity prevention.

Kinematic differences in the presentation of recurrent congenital talipes equinovarus (clubfoot).

BACKGROUND: The tibialis anterior tendon transfer (TATT) is the suggested surgical intervention in the Ponseti method for treatment of dynamic recurrent congenital talipes equinovarus (clubfoot) presenting as hindfoot varus and forefoot supination during the swing phase of gait. The indication for surgery, however, is typically based on visual assessment, which does not sufficiently examine the variability of foot motion in this cohort. RESEARCH QUESTION: The aim of this research was to determine whether subgroups, based on foot model kinematics, existed within a clubfoot cohort being considered for TATT surgery. METHODS: Sixteen children with recurrent clubfoot that had been previously treated with the Ponseti method and were being considered for tendon transfer surgery were prospectively recruited for this study and were required to attend a pre-surgery data collection session at the Queensland Children's Motion Analysis Service (QCMAS). Data collected included standard Plug-in-Gait (PiG) kinematics and kinetics, Oxford Foot Model (OFM) foot kinematics, and regional plantar loads based on anatomical masking using the integrated kinematic-pressure method. RESULTS: Results of this study identified two clear subgroups within the cohort. One group presented with increased hindfoot inversion across 91 % of the gait cycle. The second group presented with increased hindfoot adduction across 100 % of the gait cycle. Hindfoot adduction was statistically significantly different between the two groups. SIGNIFICANCE: The identification of these two groups propose a need for further classification of deformity within this cohort and query the appropriateness of this surgical intervention for both presentations.

Self-reported compliance with drug therapy during the first SARS-CoV-2 Italian lockdown in patients with respiratory disease.

BACKGROUND: Low compliance with drug therapy in patients with chronic respiratory diseases was a well-known issue even before the coronavirus pandemic, but its causes are not yet fully defined. OBJECTIVE: To verify the adherence to drug therapy in patients with respiratory disease during the COVID-19 pandemic. METHODS: From June to September 2020, about 700 patients of the Forlanini Hospital who had been unmonitored during the March-May 2020 lockdown in Italy received a questionnaire during the pneumological check-up based on self-reported information on compliance with therapy during lockdown. RESULTS: 284 out of the 418 returned questionnaires could be used in this study: 179 patients (63.0%) responded positively to the continuation of therapy, 18 (6.3%) reduced the dosage of their medication and 82 (28.9%) interrupted the therapy. CONCLUSIONS: The low percentage of patients that reduced their drug dosage may be due to an increased awareness of drug treatment benefits, and may also be ascribed to the Government healthcare strategy during lockdown.

The effect of induced joint restriction on plantar pressure during gait - a pilot study.

BACKGROUND: The aim of this study was to analyse the effect of induced lower limb joint restriction on plantar pressures during gait. Focusing on restricting a single joint, without the effect of other co-morbidities, would provide better understanding as to the resultant plantar loadings during gait, which would be especially beneficial in patients requiring offloading procedures. RESEARCH QUESTION: Does induced lower limb joint restriction affect plantar pressure distribution during gait? METHODS: A prospective, quasi-experimental study was conducted, recruiting ten healthy, adult participants who were instructed to walk barefoot over a Tekscan HR Mat™. This procedure was repeated after separately inducing restriction of the hip, knee and ankle joints. Mean peak plantar pressure (MPP) and pressure-time integral (PTI) data were analysed to compare between unrestricted and restricted data. RESULTS: Significant plantar pressure changes were observed in the heel and first metatarsal regions. Rearfoot PTIs were increased with restriction of the contralateral hip (left p <0.001) (right p =0.02) and knee joints (left p =0.01) (right p =0.04). Both MPPs (left p =0.01; right p =0.01) and PTIs (left p =0.004; right p =0.03) were increased in the first metatarsal when restricting the hip joint of the same limb. MPP was decreased in the left first metatarsal with induced knee (left p =0.01; right p =0.04) and ankle (left and right p <0.001) joint restriction. Finally, MPP was decreased in the right first metatarsal with knee (left and right p =0.01) and ankle (left p =0.04; right p =0.01) joint restriction. SIGNIFICANCE: Limited joint mobility may have a direct effect on plantar pressure, particularly with restriction in the hip and knee joints, hence careful attention should be given especially in patients with conditions involving plantar loadings. Results in this study also show that PTI changes during gait should be equally evaluated clinically along with peak plantar pressure analysis.

Experimental study protocol of the project "MOtor function and VItamin D: Toolkit for motor performance and risk Assessment (MOVIDA)".

Musculoskeletal injuries, a public health priority also in the military context, are ascribed to several risk factors, including: increased reaction forces; low/reduced muscle strength, endurance, body mass, Vitamin D level, and bone density; inadequate lifestyles and environment. The MOVIDA Project-funded by the Italian Ministry of Defence-aims at developing a transportable toolkit (assessment instrumentation, assessment protocols and reference/risk thresholds) which integrates motor function assessment with biological, environmental and behavioural factors to help characterizing the risk of stress fracture, stress injury or muscle fatigue due to mechanical overload. The MOVIDA study has been designed following the STROBE guidelines for observational cross-sectional studies addressing healthy adults, both militaries and civilians, with varying levels of physical fitness (sedentary people, recreational athletes, and competitive athletes). The protocol of the study has been designed and validated and is hereby reported. It allows to collect and analyse anamnestic, diagnostic and lifestyle-related data, environmental parameters, and functional parameters measured through portable and wearable instrumentation during adapted 6 minutes walking test. The t-test, one and two-way ANOVA with post-hoc corrections, and ANCOVA tests will be used to investigate relevant differences among the groups with respect to biomechanical parameters; non-parametric statistics will be rather used for non-normal continuous variables and for quantitative discrete variables. Generalized linear models will be used to account for risk and confounding factors.

Plantar load transfer in children: a descriptive study with two pathological case studies.

BACKGROUND: Typical gait is often considered to be highly symmetrical, with gait asymmetries typically associated with pathological gait. Whilst gait symmetry is often expressed in symmetry ratios, measures of symmetry do not provide insight into how these asymmetries affect gait variables. To fully understand changes caused by gait asymmetry, we must first develop a normative database for comparison. Therefore, the aim of this study was to describe normative reference values of regional plantar load and present comparisons with two pathological case studies. METHODS: A descriptive study of the load transfer of plantar pressures in typically developed children was conducted to develop a baseline for comparison of the effects of gait asymmetry in paediatric clinical populations. Plantar load and 3D kinematic data was collected for 17 typically developed participants with a mean age of 9.4 ± 4.0 years. Two case studies were also included; a 10-year-old male with clubfoot and an 8-year-old female with a flatfoot deformity. Data was analysed using a kinematics-pressure integration technique for anatomical masking into 5 regions of interest; medial and lateral forefoot, midfoot, and medial and lateral hindfoot. RESULTS: Clear differences between the two case studies and the typical dataset were seen for the load transfer phase of gait. For case study one, lateral bias was seen in the forefoot of the trailing foot across all variables, as well as increases in contact area, force and mean pressure in the lateral hindfoot of the leading foot. For case study two, the forefoot of the trailing foot produced results very similar to the typical dataset across all variables. In the hindfoot of the leading foot, medial bias presents most notably in the force and mean pressure graphs. CONCLUSIONS: This study highlights the clinical significance of the load transfer phase of gait, providing meaningful information for intervention planning.

Overuse-Related Injuries of the Musculoskeletal System: Systematic Review and Quantitative Synthesis of Injuries, Locations, Risk Factors and Assessment Techniques.

Overuse-related musculoskeletal injuries mostly affect athletes, especially if involved in preseason conditioning, and military populations; they may also occur, however, when pathological or biological conditions render the musculoskeletal system inadequate to cope with a mechanical load, even if moderate. Within the MOVIDA (Motor function and Vitamin D: toolkit for risk Assessment and prediction) Project, funded by the Italian Ministry of Defence, a systematic review of the literature was conducted to support the development of a transportable toolkit (instrumentation, protocols and reference/risk thresholds) to help characterize the risk of overuse-related musculoskeletal injury. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach was used to analyze Review papers indexed in PubMed and published in the period 2010 to 2020. The search focused on stress (overuse) fracture or injuries, and muscle fatigue in the lower limbs in association with functional (biomechanical) or biological biomarkers. A total of 225 Review papers were retrieved: 115 were found eligible for full text analysis and led to another 141 research papers derived from a second-level search. A total of 183 papers were finally chosen for analysis: 74 were classified as introductory to the topics, 109 were analyzed in depth. Qualitative and, wherever possible, quantitative syntheses were carried out with respect to the literature review process and quality, injury epidemiology (type and location of injuries, and investigated populations), risk factors, assessment techniques and assessment protocols.

Correlations between weight-bearing 3D bone architecture and dynamic plantar pressure measurements in the diabetic foot.

BACKGROUND: Measurements of plantar loading reveal foot-to-floor interaction during activity, but information on bone architecture cannot be derived. Recently, cone-beam computer tomography (CBCT) has given visual access to skeletal structures in weight-bearing. The combination of the two measures has the potential to improve clinical understanding and prevention of diabetic foot ulcers. This study explores the correlations between static 3D bone alignment and dynamic plantar loading. METHODS: Sixteen patients with diabetes were enrolled (group ALL): 15 type 1 with (N, 7) and without (D, 8) diabetic neuropathy, and 1 with latent autoimmune diabetes. CBCT foot scans were taken in single-leg upright posture. 3D bone models were obtained by image segmentation and aligned in a foot anatomical reference frame. Absolute inclination and relative orientation angles and heights of the bones were calculated. Pressure patterns were also acquired during barefoot level walking at self-selected speed, from which regional peak pressure and absolute and normalised pressure-time integral were worked out at hallux and at first, central and fifth metatarsals (LOAD variables) as averaged over five trials. Correlations with 3D alignments were searched also with arch index, contact time, age, BMI, years of disease and a neuropathy-related variable. RESULTS: Lateral and 3D angles showed the highest percentage of significant (p < 0.05) correlations with LOAD. These were weak-to-moderate in the ALL group, moderate-to-strong in N and D. LOAD under the central metatarsals showed moderate-to-strong correlation with plantarflexion of the 2nd and 3rd phalanxes in ALL and N. LOAD at the hallux increased with plantarflexion at the 3rd phalanx in ALL, at 1st phalanx in N and at 5th phalanx in D. Arch index correlated with 1st phalanx plantarflexion in ALL and D; contact time showed strong correlation with 2nd and 3rd metatarsals and with 4th phalanx dorsiflexion in D. CONCLUSION: These preliminary original measures reveal that alteration of plantar dynamic loading patterns can be accounted for peculiar structural changes of foot bones. Load under the central metatarsal heads were correlated more with inclination of the corresponding phalanxes than metatarsals. Further analyses shall detect to which extent variables play a role in the many group-specific correlations.

The Perceived Health Status from Young Adults to Elderly: Results of the MEHM Questionnaire within the CUORE Project Survey 2008-2012.

Improving healthy life years requires an effective understanding and management of the process of healthy ageing. Assessing the perceived health status and its determinants is a relevant step in this process. This study explored the potentialities of the Minimum European Health Module (MEHM) to cope with this critical issue. Investigation was conducted on 4798 Italian residents (49.7% women, aged 35-79 years), participating in the CUORE Project Health Examination Survey 2008-2012. The three MEHM questions-perceived health status, chronic morbidity and activity limitations-were examined also in association with living context, seasonality, marital status and level of education. A higher prevalence of health status negative perception was associated with older age (9% and 24% respectively in men and women aged 35-44 years; 46% and 61% respectively in men and women aged 75-79 years). In women, this negative perception was higher than in men in any age group, and reached 50% in the 65-69 age group, 10 years earlier than in men. For both sexes, the level of education had a strong impact on this negative perception (odds ratio 2.32 and 2.72 in men and women respectively), while "living alone" played a greater impact in women than in men. MEHM activity limitations subscale was as much as 30% higher for questionnaires answered during the hottest months. This study identified potential predictors of perceived health status in adults aged 35-79 years, which can be used to target interventions aimed at improving self-perceived health status.

Weight-bearing CT Technology in Musculoskeletal Pathologies of the Lower Limbs: Techniques, Initial Applications, and Preliminary Combinations with Gait-Analysis Measurements at the Istituto Ortopedico Rizzoli.

Musculoskeletal radiology has been mostly limited by the option between imaging under load but in two dimensions (i.e., radiographs) and three-dimensional (3D) scans but in unloaded conditions (i.e., computed tomography [CT] and magnetic resonance imaging in a supine position). Cone-beam technology is now also a way to image the extremities with 3D and weight-bearing CT. This article discusses the initial experience over a few studies in progress at an orthopaedic center. The custom design of total ankle replacements, the patellofemoral alignment after medial ligament reconstruction, the overall architecture of the foot bones in the diabetic foot, and the radiographic assessment of the rearfoot after subtalar fusion for correction of severe flat foot have all taken advantage of the 3D and weight-bearing feature of relevant CT scans. To further support these novel assessments, techniques have been developed to obtain 3D models of the bones from the scans and to merge these with state-of-the-art gait analyses.

Ulcer-risk classification and plantar pressure distribution in patients with diabetic polyneuropathy: exploring the factors that can lead to foot ulceration.

Plantar pressure is critical in the onset of neuropathic foot ulcers. However, risk classifications do not consider it as a stratification parameter. Whether plantar pressure distribution affects ulcer-risk was investigated. Patients from a research study (n. 134) and from a clinical environment (n. 83) were classified into ulcer-risk groups according to the International Working Group on the Diabetic Foot guidelines. Pressure distribution was acquired during gait (Pedar-X System), and assessed for hindfoot, midfoot, forefoot and toes (1way- and 2way-ANOVAs, p < 0.05). Pressure distribution changed with polyneuropathy even in the low-risk groups: median p = 0.048 (0.001-0.223). Risk classification correlated poorly with pressure distribution: median p = 0.686 (0.374-0.828). BMI, age and walking speed influenced most parameters and rendered the studies almost impossible to compare (2-way ANOVA factor A > 0.05). Pressure-time integral, the only comparable parameter between the two studies, may increase the predictive capacity of ulcer-risk stratification models.

Understanding Seasonal Changes to Improve Good Practices in Livestock Management.

Background and Aim: Food quality control techniques based on process control methods are increasingly adopted in livestock production systems to fulfill increasing market's expectations toward competitiveness and issues linked to One Health pillars (environment, animal, and human health). Control Charts allow monitoring and systematic investigation of sources of variability in dairy production parameters. These parameters, however, may be affected by seasonal variations that render impractical, biased or ineffective the use statistical control charts. A possible approach to this problem is to adapt seasonal adjustment methods used for the analysis of economic and demographic seasonal time series. The aim of the present work is to evaluate a seasonal decomposition technique called X-11 on milk parameters routinely collected also in small farms (fat, protein, and lactose content, solids-not-fat, freezing point, somatic cell count, total bacterial count) and to test the efficacy of different seasonal removal methods to improve the effectiveness of statistical control charting. Method: Data collection was carried out for 3 years on routinely monitored bulk tank milk parameters of a small farm. Seasonality presence was statistically assessed on milk parameters and, for those parameters showing seasonality, control charts for individuals were applied on raw data, on X-11 seasonally adjusted data, and on data smoothed with a symmetric moving average filter. Correlation of seasonally influenced parameters with daily mean temperature was investigated. Results: Presence of seasonality in milk parameters was statistically assessed for fat, protein, and solids-non-fat components. The X-11 seasonally-adjusted control charts showed a reduced number of violations (false alarms) with respect to non-seasonally adjusted control chart (from 5 to 1 violation for fat, from 17 to 1 violation for protein, and from 9 to none violation for solids-non-fat.). This result was achieved despite stricter control chart limits: with respect to raw data charts, the interval of control chart allowed variation (UCL-LCL) was reduced by 43% for fat, by 33.1% for protein, and by 14.3% for solids-not-fat. Conclusions: X-11 deseasonalization of routinely collected milk parameters was found to be an effective method to improve control chart application effectiveness in farms and milk collecting centers.

Textured insoles affect the plantar pressure distribution while elite rowers perform on an indoor rowing machine.

INTRODUCTION: During rowing, foot positioning on the foot stretcher is critical to optimise muscle force transmission and boat propulsion. Following the beneficial effects of textured insoles on gait and balance, this study aims at investigating whether passive stimulation of foot mechanoreceptors induced by these insoles may contribute to improving foot loading pattern and symmetry during indoor rowing. METHODS: Eleven elite rowers were assessed during controlled training on a standard rowing machine while wearing control, low-density or high-density textured insoles. Plantar pressure and knee and trunk kinematics were measured; performance data were recorded from the machine. Insole effect on kinematic parameters, peak and average values of foot force, contact area and position of centre of pressure was assessed with ANOVA and Bonferroni correction for pair-wise comparisons. RESULTS: A main effect was observed for force and contact area, with the high-density insoles providing greatest values (P<0.035). No interaction was observed between side and insole (P>0.190), even though symmetry was higher with high-density insoles. Kinematics (P = 0.800) and rowing performance were not affected by insole type; a consistent though not statistically significant increase in mean travelled distance was observed for denser insoles (P>0.21). CONCLUSION: The high-density textured insoles affected foot loading distribution during indoor rowing. Rowers applied greater foot force and over a greater foot stretcher area with the high-density than the low-density and control insoles. These findings and the methodology applied may be relevant for the understanding and monitoring of rowing performance.

Anatomical masking of pressure footprints based on the Oxford Foot Model: validation and clinical relevance.

Plantar pressure analysis is widely used in the assessment of foot function. In order to assess regional loading, a mask is applied to the footprint to sub-divide it into regions of interest (ROIs). The most common masking method is based on geometric features of the footprint (GM). Footprint masking based on anatomical landmarks of the foot has been implemented more recently, and involves the integration of a 3D motion capture system, plantar pressure measurement device, and a multi-segment foot model. However, thorough validation of anatomical masking (AM) using pathological footprints has not yet been presented. In the present study, an AM method based on the Oxford Foot Model (OFM) was compared to an equivalent GM. Pressure footprints from 20 young healthy subjects (HG) and 20 patients with clubfoot (CF) were anatomically divided into 5 ROIs using a subset of the OFM markers. The same foot regions were also identified by using a standard GM method. Comparisons of intra-subject coefficient of variation (CV) showed that the OFM-based AM was at least as reliable as the GM for all investigated pressure parameters in all foot regions. Clinical relevance of AM was investigated by comparing footprints from HG and CF groups. Contact time, maximum force, force-time integral and contact area proved to be sensitive parameters that were able to distinguish HG and CF groups, using both AM and GM methods However, the AM method revealed statistically significant differences between groups in 75% of measured variables, compared to 62% using a standard GM method, indicating that the AM method is more sensitive for revealing differences between groups.

Scoping review of outcome measures used in telerehabilitation and virtual reality for post-stroke rehabilitation.

Introduction Despite the increased interest in telerehabilitation (TR), virtual reality (VR) and outcome measures for stroke rehabilitation, surprisingly little research has been done to map and identify the most common outcome measures used in TR. For this review, we conducted a systematic search of the literature that reports outcome measures used in TR or VR for stroke rehabilitation. Our specific objectives included: 1) to identify the outcome measures used in TR and VR studies; and 2) to describe which parts of the International Classification of Functioning are measured in the studies. Methods We conducted a comprehensive search of relevant electronic databases (e.g. PubMed, the Cumulative Index to Nursing and Allied Health Literature, Embase, PSYCOINFO, The Cochrane Central Register of Controlled Trial and the Physiotherapy Evidence Database). The scoping review included all study designs. Two reviewers conducted pilot testing of the data extraction forms and independently screened all the studies and extracted the data. Disagreements about inclusion or exclusion were resolved by consensus or by consulting a third reviewer. Results In total, 28 studies were included in this scoping review. The results were synthesized and reported considering the implications of the findings within the clinical practice and policy context. Discussion This scoping review identified a wide range of outcome measures used in VR and TR studies and helped identify gaps in current use of outcome measures in the literature. The review also informs researchers and end users (i.e. clinicians, policymakers and researchers) regarding the most appropriate outcome measures for TR or VR.

Health software: a new CEI Guide for software management in medical environment.

INTRODUCTION: The increasing spread of software components in the healthcare context renders explanatory guides relevant and mandatory to interpret laws and standards, and to support safe management of software products in healthcare. METHODOLOGY: In 2012 a working group has been settled for the above purposes at Italian Electrotechnical Committee (CEI), made of experts from Italian National Institute of Health (ISS), representatives of industry, and representatives of the healthcare organizations. RESULTS: As a first outcome of the group activity, Guide CEI 62-237 was published in February 2015. The Guide incorporates an innovative approach based on the proper contextualization of software products, either medical devices or not, to the specific healthcare scenario, and addresses the risk management of IT systems. CONCLUSIONS: The Guide provides operators and manufacturers with an interpretative support with many detailed examples to facilitate the proper contextualization and management of health software, in compliance with related European and international regulations and standards.

Telemedicine in palliative care: a review of systematic reviews.

AIMS: To evaluate the quality of systematic reviews on telemedicine applications in palliative care. METHODS: A structured literature review was conducted to identify systematic reviews dealing with telemedicine in palliative care; the AMSTAR (Assessment of Multiple Systematic Reviews) checklist was used to appraise the evidence related to the systematic reviews. RESULTS: 405 records were initially identified; of these 14 were eligible for full-text analysis. In summary, the research strategy allowed the identification of 6 reviews to be included which showed a medium quality (AMSTAR score in between 4 and 7). All the included systematic reviews considered telemedicine applications as a feasible means to be used in palliative care; however, the positive findings are counterbalanced by several critical issues mainly related to the evidence from the primary studies included in each single review. CONCLUSIONS: Results of this first attempt to appraise the evidence in the field of telemedicine applications in palliative care highlighted that there is still limited evidence related to this approach. Strengths and weaknesses that impact on the general quality of the reviews were identified and relevant points to be taken into account for future research were suggested.

Multiple linear regression approach for the analysis of the relationships between joints mobility and regional pressure-based parameters in the normal-arched foot.

Plantar load can be considered as a measure of the foot ability to transmit forces at the foot/ground, or foot/footwear interface during ambulatory activities via the lower limb kinematic chain. While morphological and functional measures have been shown to be correlated with plantar load, no exhaustive data are currently available on the possible relationships between range of motion of foot joints and plantar load regional parameters. Joints' kinematics from a validated multi-segmental foot model were recorded together with plantar pressure parameters in 21 normal-arched healthy subjects during three barefoot walking trials. Plantar pressure maps were divided into six anatomically-based regions of interest associated to corresponding foot segments. A stepwise multiple regression analysis was performed to determine the relationships between pressure-based parameters, joints range of motion and normalized walking speed (speed/subject height). Sagittal- and frontal-plane joint motion were those most correlated to plantar load. Foot joints' range of motion and normalized walking speed explained between 6% and 43% of the model variance (adjusted R2) for pressure-based parameters. In general, those joints' presenting lower mobility during stance were associated to lower vertical force at forefoot and to larger mean and peak pressure at hindfoot and forefoot. Normalized walking speed was always positively correlated to mean and peak pressure at hindfoot and forefoot. While a large variance in plantar pressure data is still not accounted for by the present models, this study provides statistical corroboration of the close relationship between joint mobility and plantar pressure during stance in the normal healthy foot.

Outcome Measures in Tele-Rehabilitation and Virtual Reality for Stroke Survivors: Protocol for a Scoping Review.

UNLABELLED: Despite the increased interest about tele-rehabilitation, virtual reality and outcome measures for stroke rehabilitation, surprisingly little research has been done to map and summarize the most common outcome measures used in tele-rehabilitation. For this review, we propose to conduct a systematic search of the literature that reports outcome measures used in tele-rehabilitation or virtual reality for stroke rehabilitation. Specific objectives include: 1) to identify the outcome measures used in tele-rehabilitation studies; 2) to describe the psychometric properties of the outcome measures in the included studies; 3) to describe which parts of the International Classification of Functioning are measured in the studies. METHODS: we will conduct a comprehensive search of relevant electronic databases (e.g., PUBMED, CINAHL, EMBASE, PSYCOINFO, Cochrane Central Register of Controlled Trial and PEDRO). The scoping review will include all study designs. Two reviewers will pilot-test the data extraction forms and will independently screen all the studies and extract the data. Disagreements about inclusion or exclusion will be resolved by consensus or by consulting a third reviewer. The results will be synthesized and reported considering the implications of the findings within the clinical practice and policy context. Dissemination: we anticipate that this scoping review will contribute to inform researchers and end-users (ie, clinicians and policy-makers), regarding the most appropriate outcome measures for tele-rehabilitation or virtual reality as well as help to identify gaps in current measures. Results will be disseminated through reports and open access journals, conference presentations, as well as newsletters, podcasts and meetings targeting all the relevant stakeholders.