Feedback control of heart rate during robotics-assisted tilt table exercise in patients after stroke: a clinical feasibility study.

BACKGROUND: Patients with neurological disorders including stroke use rehabilitation to improve cognitive abilities, to regain motor function and to reduce the risk of further complications. Robotics-assisted tilt table technology has been developed to provide early mobilisation and to automate therapy involving the lower limbs. The aim of this study was to evaluate the feasibility of employing a feedback control system for heart rate (HR) during robotics-assisted tilt table exercise in patients after a stroke. METHODS: This feasibility study was designed as a case series with 12 patients ( n = 12 ) with no restriction on the time post-stroke or on the degree of post-stroke impairment severity. A robotics-assisted tilt table was augmented with force sensors, a work rate estimation algorithm, and a biofeedback screen that facilitated volitional control of a target work rate. Dynamic models of HR response to changes in target work rate were estimated in system identification tests; nominal models were used to calculate the parameters of feedback controllers designed to give a specified closed-loop bandwidth; and the accuracy of HR control was assessed quantitatively in feedback control tests. RESULTS: Feedback control tests were successfully conducted in all 12 patients. Dynamic models of heart rate response to imposed work rate were estimated with a mean root-mean-square (RMS) model error of 2.16 beats per minute (bpm), while highly accurate feedback control of heart rate was achieved with a mean RMS tracking error (RMSE) of 2.00 bpm. Control accuracy, i.e. RMSE, was found to be strongly correlated with the magnitude of heart rate variability (HRV): patients with a low magnitude of HRV had low RMSE, i.e. more accurate HR control performance, and vice versa. CONCLUSIONS: Feedback control of heart rate during robotics-assisted tilt table exercise was found to be feasible. Future work should investigate robustness aspects of the feedback control system. Modifications to the exercise modality, or alternative modalities, should be explored that allow higher levels of work rate and heart rate intensity to be achieved.

Diurnal variation of heart rate variability in individuals with spinal cord injury.

BACKGROUND: Heart rate variability (HRV) may provide objective information about cardiogenic autonomic balance in individuals with spinal cord injury (SCI). The aim of this study was to characterize the diurnal variation of HRV in individuals with SCI at lesion level T6 and above and lesion level below T6. METHODS: This was a retrospective analysis of a prior cross-sectional study. Individuals with chronic SCI underwent 24 h recording of the time between consecutive R waves (RR interval) to derive parameters of HRV as follows: standard deviation of all normal-to-normal R-R intervals (SDNN) and square root of the mean of the squared differences between successive R-R intervals (RMSSD) (time domain); and high frequency power (HF), low-frequency power (LF), very low frequency power (VLF), ultra-low frequency power (ULF) and total power (TP) (frequency domain). Changes in the magnitude of HRV outcomes over the 24 h period were investigated using a novel multi-component cosinor model constrained to the form of a three-harmonic Fourier series. RESULTS: Participants were grouped as lesion level T6 and above (n = 22) or below T6 (n = 36). Most of them were male (n = 40, 69%) and the median age (interquartile range) was 50.5 (28) years. Both groups exhibited similar diurnal patterns in most HRV metrics. The lowest values occurred in the late afternoon (4-6 pm) and gradually increased, peaking around midnight to early morning (1-6 am). Exceptions included RMSSD, which peaked before midnight, and ULF, which showed a double peak pattern that peaked from 11 am to 1 pm and 4-6 am in participants with lesion level at T6 and above. The HRV values in participants with lesion level T6 and above were generally lower than participants with lesion level below T6, except for peak values of RMSSD, HF and LF. CONCLUSION: This study demonstrated substantial diurnal variation of HRV in participants with SCI in both groups of participants. In clinical and research settings, diurnal variations in HRV must be taken into consideration.

Reliability of five-minute vs. one-hour heart rate variability metrics in individuals with spinal cord injury.

Background: A previous study showed low reliability of 1-h HRV outcomes in participants with spinal cord injury (SCI), but it was not certain whether the low reliability was due to the unrestricted activity of participants. We aimed to investigate test-retest reliability of HRV metrics in individuals with SCI using a 1-h measurement in a supine position. Methods: Individuals with SCI underwent two sessions of 1-h recording of the time between consecutive R waves (RR-intervals) in a supine position. HRV outcomes were obtained from a single 5-min data segment and for the full 1-h recording. HRV parameters of interest were: standard deviation of all normal-to-normal R-R intervals (SDNN) and square root of the mean of the squared differences between successive R-R intervals (RMSSD) (time domain); and high frequency power (HF), low frequency power (LF), very low frequency power (VLF), ultra-low frequency power (ULF) and total power (TP) (frequency domain). Relative reliability was assessed by intraclass correlation coefficient (ICC). Absolute reliability was assessed by coefficient of variation (CV) and Bland-Altman limits of agreement (LoA). Results: Data from 37 individuals (14 with tetraplegia and 23 with paraplegia) were included. Relative reliability was higher for the 1-h (ICCs ranged from 0.13-0.71) than for the 5-min duration (ICCs ranged from 0.06-0.50) in the overall SCI group for all HRV metrics. Participants with tetraplegia had lower relative reliability compared to participants with paraplegia in all HRV metrics for the 5-min duration (ICCs ranged from -0.01-0.34 vs. 0.21-0.57). For the 1-h duration, participants with paraplegia showed higher relative reliability than participants with tetraplegia in all HRV metrics (ICCs ranged from 0.18-0.79 vs. 0.07-0.54) except TP (ICC 0.69 vs. 0.82). In terms of absolute reliability, the CVs and LoAs for the 1-h duration were better than for the 5-min duration. In general, time domain metrics showed better reliability than frequency domain metrics for both durations in participants with tetraplegia and paraplegia. The lowest CV and narrowest 95% LoA were found for SDNN in 5-min and 1-h durations overall and in both lesion levels. Conclusions: The supine position did not provide better reliability compared to unrestricted activity in participants with SCI. HRV analysis using a 5-min duration is of limited value in SCI due to poor reliability. For the 1-h analysis duration, interpretation of the reliability of HRV varies according to lesion level: it is recommended to take lesion level into account when interpreting reliability measures.