Analysis of human ambulation as a chaotic time-series: with nonlinear dynamics tools.

The aim of the present study is to investigate the complexity and stability of human ambulation and the implications on robotic prostheses control systems. Fourteen healthy individuals participate in two experiments, the first group run at three different speeds. The second group ascended and descended stairs of a five-level building block at a self-selected speed. All participants completed the experiment with seven inertial measurement units wrapped around the lower body segments and waist. The data were analyzed to determine the fractal dimension, spectral entropy, and the Lyapunov exponent (LyE). Two methods were used to calculate the long-term LyE, first LyE calculated using the full size of data sets. And the embedding dimensions were calculated using Average Mutual Information (AMI) and the False Nearest Neighbor (FNN) algorithm was used to find the time delay. Besides, a second approach was developed to find long-term LyE where the time delay was based on the average period of the gait cycle using adaptive event-based window. The average values of spectral entropy are 0.538 and 0.575 for stairs ambulation and running, respectively. The degree of uncertainty and complexity increases with the ambulation speed. The short term LyEs for tibia orientation have the minimum range of variation when it comes to stairs ascent and descent. Using two-way analysis of variance we demonstrated the effect of the ambulation speed and type of ambulation on spectral entropy. Moreover, it was shown that the fractal dimension only changed significantly with ambulation speed.

The impact of mobility limitations on geriatric rehabilitation outcomes: Positive effects of resistance exercise training (RESORT).

BACKGROUND: Regaining walking ability is a key target in geriatric rehabilitation. This study evaluated the prevalence of walking ability at (pre-)admission and related clinical characteristics in a cohort of geriatric rehabilitation inpatients; in inpatients without walking ability, feasibility and effectiveness of progressive resistance exercise training (PRT) were assessed. METHODS: Inpatients within RESORT, an observational, longitudinal cohort of geriatric rehabilitation inpatients, were stratified in those with and without ability to walk independently (defined by Functional Ambulation Classification (FAC) score ≤ 2) at admission; further subdivision was performed by pre-admission walking ability. Clinical characteristics at admission, length of stay, and changes in physical and functional performance throughout admission were compared depending on (pre-)admission walking ability. Feasibility (relative number of PRT sessions given and dropout rate) and effectiveness [change in Short Physical Performance Battery, FAC, independence in (instrumental) activities of daily living (ADL/IADL)] of PRT (n = 11) in a subset of inpatients without ability to walk independently at admission (able to walk pre-admission) were investigated compared with usual care (n = 11) (LIFT-UP study). RESULTS: Out of 710 inpatients (median age 83.5 years; 58.0% female), 52.2% were not able to walk independently at admission, and 7.6% were not able to walk pre-admission. Inpatients who were not able to walk independently at admission, had a longer length of stay, higher prevalence of cognitive impairment and frailty and malnutrition risk scores, and a lower improvement in independence in (I)ADL compared with inpatients who were able to walk at both admission and pre-admission. In LIFT-UP, the relative median number of PRT sessions given compared with the protocol (twice per weekday) was 11 out of 44. There were no dropouts. PRT improved FAC (P = 0.028) and ADL (P = 0.034) compared with usual care. CONCLUSIONS: High prevalence of inpatients who are not able to walk independently and its negative impact on independence in (I)ADL during geriatric rehabilitation highlights the importance of tailored interventions such as PRT, which resulted in improvement in FAC and ADL.

Long-term outcome and predictors of neurological recovery in cervical spinal cord injury: a population-based cohort study.

This retrospective study analyzed prognostic factors for neurological improvement and ambulation in 194 adult patients (≥ 15 years) with traumatic cervical spinal cord injuries treated at the neurological SCI unit (SCIU) at the Karolinska University Hospital Stockholm, Sweden, between 2010 and 2020. The primary outcome was American spinal injury association impairment scale (AIS) improvement, with secondary focus on ambulation restoration. Results showed 41% experienced AIS improvement, with 51% regaining ambulation over a median follow-up of 3.7 years. Significant AIS improvement (p < 0.001) and reduced bladder/bowel dysfunction (p < 0.001) were noted. Multivariable analysis identified initial AIS C-D (< 0.001), central cord syndrome (p = 0.016), and C0-C3 injury (p = 0.017) as positive AIS improvement predictors, while lower extremity motor score (LEMS) (p < 0.001) and longer ICU stays (p < 0.001) were negative predictors. Patients with initial AIS C-D (p < 0.001) and higher LEMS (p < 0.001) were more likely to regain ambulation. Finally, older age was a negative prognostic factor (p = 0.003). In conclusion, initial injury severity significantly predicted neurological improvement and ambulation. Recovery was observed even in severe cases, emphasizing the importance of tailored rehabilitation for improved outcomes.

The Impact of Increased Body Mass Index on Patient Outcomes and Complications in Microsurgical Lower Extremity Reconstruction.

BACKGROUND: Elevated body mass index (BMI) is a known perioperative risk factor for complications such as delayed wound healing and infection. However, there is a gap in understanding how elevated BMI impacts outcomes after posttraumatic lower extremity (LE) microvascular reconstruction. METHODS: A retrospective review was performed at a level 1 trauma center between 2007 and 2022 of patients who underwent posttraumatic microvascular LE reconstruction. Demographics, flap/wound details, complications, and outcomes were recorded. Patients were stratified into BMI Center for Disease Control categories. RESULTS: A total of 398 patients were included with an average BMI of 28.2 ± 5.8. Nearly half (45%) of LE defects were located in the distal third of the leg, 27.5% in the middle third, and 34.4% in the proximal third. Most reconstructions utilized muscle-containing flaps (74.4%) compared with fasciocutaneous flaps (16.8%). Surgical approaches included free flaps (47.6%) and local flaps (52.5%). Class III obese patients were significantly more likely to be nonambulatory than nonobese patients (OR: 4.10, 95% CI 1.10-15.2, p = 0.035). At final follow-up, 30.1% of patients with Class III obesity were ambulatory, requiring either wheelchairs (42.3%) or assistance devices (26.9%). There were no significant differences in complication rates based on obesity status (0.704). The average follow-up time for the entire cohort was 5.8 years. CONCLUSIONS: BMI is critical for patient care and surgical decision-making in LE reconstruction. Further research is warranted to optimize outcomes for higher BMI patients, thereby potentially reducing the burden of postoperative complications and enhancing overall patient recovery.

Effect of a soft exosuit on daily life gait performance in people with incomplete spinal cord injury: study protocol for a randomized controlled trial.

BACKGROUND: People with incomplete spinal cord injury (iSCI) often have gait impairments that negatively affect daily life gait performance (i.e., ambulation in the home and community setting) and quality of life. They may benefit from light-weight lower extremity exosuits that assist in walking, such as the Myosuit (MyoSwiss AG, Zurich, Switzerland). A previous pilot study showed that participants with various gait disorders increased their gait speed with the Myosuit in a standardized environment. However, the effect of a soft exosuit on daily life gait performance in people with iSCI has not yet been evaluated. OBJECTIVE: The primary study objective is to test the effect of a soft exosuit (Myosuit) on daily life gait performance in people with iSCI. Second, the effect of Myosuit use on gait capacity and the usability of the Myosuit in the home and community setting will be investigated. Finally, short-term impact on both costs and effects will be evaluated. METHODS: This is a two-armed, open label, randomized controlled trial (RCT). Participants will be randomized (1:1) to the intervention group (receiving the Myosuit program) or control group (initially receiving the conventional program). Thirty-four people with chronic iSCI will be included. The Myosuit program consists of five gait training sessions with the Myosuit at the Sint Maartenskliniek. Thereafter, participants will have access to the Myosuit for home use during 6 weeks. The conventional program consists of four gait training sessions, followed by a 6-week home period. After completing the conventional program, participants in the control group will subsequently receive the Myosuit program. The primary outcome is walking time per day as assessed with an activity monitor at baseline and during the first, third, and sixth week of the home periods. Secondary outcomes are gait capacity (10MWT, 6MWT, and SCI-FAP), usability (D-SUS and D-QUEST questionnaires), and costs and effects (EQ-5D-5L). DISCUSSION: This is the first RCT to investigate the effect of the Myosuit on daily life gait performance in people with iSCI. TRIAL REGISTRATION: Clinicaltrials.gov NCT05605912. Registered on November 2, 2022.

The Impact of Postural and Anthropometric Properties of Foot and Ankle on Physical Performance and Ambulation of Patients with Duchenne Muscular Dystrophy.

BACKGROUND: Abnormal foot anthropometry and posture of patients with Duchenne Muscular Dystrophy (DMD) can be considered as possible risk factors for performance and ambulation. It was aimed to examine the effects of foot posture and anthropometric characteristics, which deteriorated from the early period, on ambulation and performance of patients with DMD. METHODS: The foot arch height (FAH), the metatarsal width (MW), subtalar pronation angle, and ankle limitation degree (ALD) were evaluated to determine the foot anthropometric characteristics of the patients. Foot Posture Index-6 (FPI-6) was used to evaluate foot posture. The performance of the patients was determined by the 6-minute walk test (6MWT), the 10-meter walk test (10MWT), and ascend/descend a standard 4-step test, and the ambulation was determined by the North Star Ambulatory Assessment (NSAA). Spearman's correlation coefficient was calculated to assess the relationship between foot anthropometric characteristics and posture, and performance and ambulation. RESULTS: The sample consisted of 48 patients with DMD aged 5.5 to 12 years. Both of the right and left foot FPI-6 scores were associated with all parameters, except descending 4-step. The left FAH was associated with 6MWT and NSAA, and the left MW was associated with 6MWT. The ALD of right foot was associated with 6MWT, ascending/descending 4 steps, and NSAA, and left ankle limitation was associated with NSAA (p<0.05). There was no relationship between other parameters. CONCLUSIONS: These findings suggest that postural disorders in the foot and ankle may contribute to the decrease in performance and ambulation in patients with DMD.

The Recovered Independent Ambulation Rate and Prognostic Factors of Non-ambulatory Patients After Metastatic Spinal Cord Compression Surgery.

PURPOSE: Surgery could regain the ability to walk even in non-ambulatory patients with spinal cord compression due to metastatic spine disease. However, many patients cannot reach the stage of independent ambulation because most are at an advanced disease stage. This study investigated the regained independent ambulation rate after surgery and prognostic factors for independent ambulation after metastatic spinal cord compression surgery. METHODS: In a retrospective cohort study, 38 non-ambulatory patients with spinal metastases at the cervical or thoracic lesions, who underwent surgery, were included. All surgeries were performed using laminectomy and posterior fixation. Recovery rates of independent ambulation and its prognostic factors were examined. Independent ambulation was defined as the use of a walking aid without wheelchair requirement. Factors, including age, tumor type, visceral organ metastasis, past systematic cancer therapy, neurological grade, the time from leg-symptom onset to non-ambulatory stage, and the time from non-ambulatory stage to surgery, were investigated. RESULTS: The regained independent ambulation rate was 18% (7/38). Compared to non-ambulatory patients, those who regained independent ambulation were more likely to have less past systematic therapy (14% [1/7] vs. 74% [23/31], P=0.003) and slow paralysis progression (over seven days from leg-symptom onset to non-ambulatory stage) (86% [6/7] vs. 23% [7/31], P=0.002). CONCLUSIONS: Recovery to independent ambulation in non-ambulatory patients with metastatic spinal cord compression was poor, even if surgery was performed. Absence of past systematic therapy and slow paralysis progression were favorable factors for regaining independent ambulation.

Virtual Reality Strategies for Promoting Mobility in the Intensive Care Unit: A Case Report.

Prolonged bed rest is a known contributor to muscle atrophy, weakness, and deconditioning. Early active mobilization protocols aim to combat acquired weakness and loss of function in patients in the intensive care unit. Despite these benefits, mobilization of patients in the intensive care unit remains a challenge, most notably for patients with limited ability to get out of bed because of invasive devices and prolonged hospitalization. Virtual reality has gained favor for use in critical care to mitigate patients' stress, pain, and anxiety and to provide distraction and socialization. This case report demonstrates a novel application of virtual reality and the ease with which virtual reality can be used to facilitate early mobility and activity progression in the critically ill.

Bilateral hip stability variation in the functional ambulation and kinetic parameters after total hip arthroplasty during leveled walking.

Objectives: This study determines gender variation, comparing the significance level between men and women related to functional ambulation characteristics after hip arthroplasty. The study focuses on the broader female pelvis and how it affects the rehabilitation regimen following total hip arthroplasty. Materials and Methods: In this cross-sectional study, 20 cases of right hip arthroplasty were divided into 10 male and 10 female cases, aged 40-65 years. The functional ambulation parameters (walking cadence, gait speed, stride length, and gait cycle time) were acquired from the GAITRite device, as well as kinematic values for hip frontal plane displacement and kinetic parameters for ground response force in the medial-lateral direction. Results: An independent t-test showed a significant difference in the kinematic parameter variables for the anterior superior iliac spine, more significant trochanter displacement, and hip abduction angle between the operated and non-operated limbs for each group separately. Regarding the functional ambulation parameters, there was a significant difference in the walking cadence between the operated and non-operated limbs of both male and female groups. Moreover, the output variables of ground reaction force measures revealed significant differences between their operated and non-operated limbs. The linear regression model used was consistent with the current results, demonstrating a weak negative correlation between the abduction angle of the operated hip and gait speed for both male and female groups. Conclusion: Based on the findings, we draw the conclusion that improving a rehabilitated physical therapy program for the abductors of both male and female patients' operated and non-operated limbs is essential for normalizing the ground reaction force value, avoiding focus on the operated hip, and reducing the amount of time that the operated hip's abductors must perform. This involves exposing the surgically repaired limb to the risk of post-operative displacement or dislocation, particularly in female patients.

Recommendations for clinical decision-making when offering exoskeletons for community use in individuals with spinal cord injury.

Approved in 2014 by the Food and Drug Administration (FDA) for use with a trained companion, personal powered exoskeletons (PPE) for individuals with spinal cord injury (SCI) provide an opportunity for the appropriate candidate to ambulate in their home and community. As an adjunct to wheeled mobility, PPE use allows those individuals who desire to ambulate the opportunity to experience the potential physiological and psychosocial benefits of assisted walking outside of a rehabilitation setting. There exists, however, a knowledge gap for clinicians regarding appropriate candidate selection for use, as well as who might benefit from ambulating with a PPE. The purpose of this paper is to provide guidance for clinicians working with individuals living with SCI by outlining an expert consensus for a PPE decision-making algorithm, as well as a discussion of potential physiological and psychosocial benefits from PPE use based on early evidence in publication.

Independent Walking Disability After Fragility Hip Fractures: A Prognostic Factors Analysis.

Introduction: Up to one-third of patients with fragility hip fractures are totally dependent in the year following the injury which leads to later morbidity and mortality. Understanding the related factors that affect patients' ambulation helps health care providers prepare for the treatment plans to improve their functional outcomes. This study aimed to evaluate the factors associated with independent walking disability in the early postoperative period after fragility hip fractures. Material and methods: This retrospective cohort study involved 394 patients with fragility hip fractures with either intertrochanteric, subtrochanteric, or femoral neck fractures from January 2018 to June 2023. The related factors including preoperative demographics, perioperative, and postoperative factors, were collected and analyzed. The endpoint was the independent walking disability of patients at 6 weeks after surgery. Results: 110 patients (27.9%) were disabled, whereas 284 patients (72.1%) could walk independently at postoperative 6 weeks. The multivariable risk ratio regression analysis showed that patients with age ≥80 years (RR 1.65; 95% CI 1.21-2.25; P = 0.001), pre-fracture walking with the gait aid (RR 2.03; 95% CI 1.53-2.69; P < 0.001), having ≥2 underlying comorbidities (RR 1.63; 95% CI 1.19-2.23; P = 0.002), preoperative hypoalbuminemia (RR 1.74; 95% CI 1.32-2.29; P < 0.001), and presence of the postoperative medical complication (RR 2.04; 95% CI 1.37-3.02; P < 0.001) were significantly associated with independent walking disability at the early postoperative period of 6 weeks. Conclusions: Post-hip fracture surgery patients with the presence of postoperative medical complication have the highest risk of independent walking disability. Health care providers should concentrate on high-risk patients, correct the modifiable factors, and minimize any postoperative complications to improve functional recovery and decrease morbidity related to non-ambulation after fragility hip fractures.

Rehabilitation after surgery for hip fracture - the impact of prompt, frequent and mobilisation-focused physiotherapy on discharge outcomes: an observational cohort study.

PURPOSE: To determine the relationship between three postoperative physiotherapy activities (time to first postoperative walk, activity on the day after surgery, and physiotherapy frequency), and the outcomes of hospital length of stay (LOS) and discharge destination after hip fracture. METHODS: A cohort study was conducted on 437 hip fracture surgery patients aged ≥ 50 years across 36 participating hospitals from the Australian and New Zealand Hip Fracture Registry Acute Rehabilitation Sprint Audit during June 2022. Study outcomes included hospital LOS and discharge destination. Generalised linear and logistic regressions were used respectively, adjusted for potential confounders. RESULTS: Of 437 patients, 62% were female, 56% were aged ≥ 85 years, 23% were previously living in a residential aged care facility, 48% usually walked with a gait aid, and 38% were cognitively impaired prior to their injury. The median acute and total LOS were 8 (IQR 5-13) and 20 (IQR 8-38) days. Approximately 71% (n = 179/251) of patients originally living in private residence returned home and 29% (n = 72/251) were discharged to a residential aged care facility. Previously mobile patients had a higher total LOS if they walked day 2-3 (10.3 days; 95% CI 3.2, 17.4) or transferred with a mechanical lifter or did not get out of bed day 1 (7.6 days; 95% CI 0.6, 14.6) compared to those who walked day 1 postoperatively. Previously mobile patients from private residence had a reduced odds of return to private residence if they walked day 2-3 (OR 0.38; 95% CI 0.17, 0.87), day 4 + (OR 0.38; 95% CI 0.15, 0.96), or if they only sat, stood or stepped on the spot day 1 (OR 0.29; 95% CI 0.13, 0.62) when compared to those who walked day 1 postoperatively. Among patients from private residence, each additional physiotherapy session per day was associated with a -2.2 (95% CI -3.3, -1.0) day shorter acute LOS, and an increased log odds of return to private residence (OR 1.76; 95% CI 1.02, 3.02). CONCLUSION: Hip fracture patients who walked earlier, were more active day 1 postoperatively, and/or received a higher number of physiotherapy sessions were more likely to return home after a shorter LOS.

Ambulatory status and related factors in patients with spinal cord ischemia due to aortic aneurysm.

BACKGROUND: Spinal cord ischemia (SCI) is a serious complication that can occur at the onset of aortic aneurysm (AA) or after AA surgery. SCI impairs ambulation in patients. However, there is a lack of evidence regarding ambulatory status and its associated factors. OBJECTIVES: To identify the ambulatory status of patients with SCI due to AA and/or AA surgery and sociodemographic and clinical characteristics factors associated with ambulatory status. METHODS: A descriptive study using a retrospective medical record data was undertaken. Data were collected from the electronic health records of SCI patients resulting from AA or who underwent surgical intervention for AA from January 2009 through December 2021. We analyzed the data to determine the ambulatory status before discharge. The demographic and clinical characteristics of the patients were investigated using chi-square and Fisher's exact tests to identify factors associated with ambulatory status. RESULTS: Among the 4,142 patients diagnosed with AA, 30 developed SCI. Of these 30 AA patients with SCI, 63.3 % were male. The median age was 70 years, ranging from 39 to 89 years. Six had SCI at the time of AA diagnosis. Among the subset of 2,994 patients who underwent aortic surgery, 24 developed SCI postoperatively. At discharge, two-thirds of the SCI patients with AA were unable to ambulate, and almost half were bedridden. The factors associated with ambulatory status were length of stay, neurogenic bladder, and pressure ulcers. CONCLUSIONS: Most patients with SCI due to AA and/or AA surgery are unable to walk before discharge. Length of stay, neurogenic bladder, and pressure ulcers were associated with poor ambulatory status. Older adults and those with medical comorbidities and complications are at particularly high risk for impaired ambulation.

The Effect of Intravenous Tranexamic Acid on Perioperative Blood Loss, Transfusion Requirements, Verticalization, and Ambulation in Total Knee Arthroplasty: A Randomized Double-Blind Study.

Background and Objectives: Total knee arthroplasty (TKA) is sometimes associated with significant perioperative bleeding. The aim of this study was to determine the efficacy of tranexamic acid (TXA) in reducing perioperative blood loss in patients undergoing primary TKA. The secondary objectives were to assess the efficacy of TXA in reducing the need for blood transfusion in these patients and to determine its effect on verticalization and ambulation after TKA. Materials and Methods: This study included 96 patients who were randomly assigned to two groups, each containing 48 patients. The study group received intravenous TXA at two time points: immediately after the induction with doses of 15 mg/kg and 10 mg/kg 15 min before the release of the pneumatic tourniquet. The control group received an equivalent volume of 0.9% saline solution via the same route. Results: TXA markedly reduced (Z = -6.512, p < 0.001) the total perioperative blood loss from 892.56 ± 324.46 mL, median 800 mL, interquartile range (IQR) 530 mL in the control group, to 411.96 ± 172.74 mL, median 375 mL, IQR 200 mL, in the TXA group. In the TXA group, only 5 (10.4%) patients received a transfusion, while in the control group, 22 (45.83%) received it (χ2 = 15.536, p = 0.001). Patients in the study group stood (χ2 = 21.162, p < 0.001) and ambulated earlier postoperatively, compared to the control group (χ2 = 26.274, p < 0.001). Patients who received TXA had a better overall postoperative functional recovery. There was a statistically significant difference in all the above results. Conclusions: TXA is an effective drug for reducing the incidence of perioperative bleeding, decreasing transfusion rates, and indirectly improving postoperative functional recovery in patients undergoing primary TKA.

Early ambulation after total knee arthroplasty: a retrospective single-center study.

PURPOSE: Early ambulation is an important step in accelerating post-joint replacement surgery recovery. However, there is limited research on populations who are unable to walk immediately after the operation. The purpose of this study was to determine the factors influencing postoperative ambulation in total knee arthroplasty (TKA) patients. METHODS: Primary TKA patients were included in this retrospective study. All patients were divided into two groups. Patients who began walking within 24 h were categorized as the early ambulation group, while patients who began walking after 24 h were classified as the late ambulation group. Recorded demographic data included age, gender, body mass index (BMI), clinical diagnosis, and comorbidities. Hematological parameters potentially affecting patients' preoperative physical condition were also documented. Additionally, intraoperative metrics such as surgical time, surgical side, tourniquet time, intraoperative blood loss, the placement of drains, and prosthetic model were recorded. RESULTS: A total of 453 patients (79.0% female, 21.0% male) were included in this study. The average age of all patients was 68.5±7.9 years, ranging from 36 to 87 years, with an average BMI of 27.2±9.9 kg/ m 2 . The mean postoperative ambulation time was 1.6 days, with a range of 0-4 days. In univariate group comparisons, an increase in postoperative time to ambulation was significantly associated with a history of heart disease ( P < 0.001 ), stroke history ( P = 0.003 ), and prior surgeries ( P = 0.003 ). Patients who delayed ambulation also exhibited significantly higher coagulation-related parameters including PT ( P < 0.001 ), APTT ( P = 0.002 ), TT ( P = 0.039 ) before surgery compared to those who mobilized early. Furthermore, prolonged surgical time ( P = 0.030 ), increased intraoperative blood loss ( P < 0.001 ), and the placement of intraoperative drains ( P < 0.001 ) also significantly extended the time to postoperative ambulation. However, after multivariate logistic regression analysis, only PT (OR 1.86, 95% CI 1.32 - 2.61, P < 0.001 ), TT (OR 1.30, 95% CI 1.09 - 1.55, P = 0.004 ) intraoperative blood loss (OR 1.01, 95% CI 1.00 - 1.01, P = 0.008 ) and the placement of intraoperative drains (OR 11.39, 95% CI 6.59 - 19.69, P < 0.001 ) were identified as predictive factors for late ambulation in patients after TKA. CONCLUSION: In this study, preoperative coagulation function, intraoperative blood loss and the placement of intraoperative drains were factors contributing to delay ambulation time. Therefore, it is believed that properly improving preoperative coagulation function, effective intraoperative hemostasis, and reducing the placement of drains have a positive impact on early postoperative ambulation in patients undergoing TKA.

A Culture of Early Mobilization in Adult Intensive Care Units: Perspective and Competency of Physicians.

BACKGROUND: Early mobility (EM) is vital in the intensive care unit (ICU) to counteract immobility-related effects. A multidisciplinary approach is key, as it requires precise initiation knowledge. However, physicians' understanding of EM in adult ICU settings remains unexplored. This study was conducted to investigate the knowledge and clinical competency of physicians working in adult ICUs toward EM. METHODS: This cross-sectional study enrolled 236 physicians to assess their knowledge of EM. A rigorously designed survey comprising 30 questions across the demographic, theoretical, and clinical domains was employed. The criteria for knowledge and competency were aligned with the minimum passing score (70%) stipulated for physician licensure by the medical regulatory authority in Saudi Arabia. RESULTS: Nearly 40% of the respondents had more than 5 years of experience. One-third of the respondents received theoretical knowledge about EM as part of their residency training, and only 4% of the respondents attended formal courses to enhance their knowledge. Almost all the respondents (95%) stated their awareness of EM benefits and its indications and contraindications and considered it safe to mobilize patients on mechanical ventilators. However, 62.3% of the respondents did not support EM for critically ill patients on mechanical ventilators until weaning. In contrast, 51.7% of respondents advised EM for agitated patients with RASS > 2. Only 113 (47.9%) physicians were competent in determining the suitability of ICU patients for EM. For critically ill patients who should be mobilized, nearly 60% of physicians refused to initiate EM. CONCLUSIONS: This study underscores insufficient practical knowledge of ICU physicians about EM criteria, which leads to suboptimal decisions, particularly in complex ICU cases. These findings emphasize the need for enhanced training and education of physicians working in adult ICU settings to optimize patient care and outcomes in critical care settings.

Reducing costs and improving patient recovery through a nurse-driven centralized spinal orthoses program on a post-surgical unit: A quality improvement initiative.

Background: An external vendor providing off-the-shelf spinal orthoses to inpatients created significant costs and barriers to quality care for spinal surgery patients. A nursing leadership team initiated a quality improvement project to reduce the cost of providing off-the-shelf spinal orthoses and improve the care provided to spinal patients. Objective: To develop and evaluate a nursing-led process for providing off-the-shelf orthoses to spinal surgery patients and eliminate high costs. Design: Quality improvement project evaluated as a retrospective interrupted time-series. Setting: Post Surgery Inpatient Unit Level II Trauma Center in a United States hospital located in Florida. Participants: Vendor Program: 134 patients; Centralized Program: 155 patients. Methods: The nursing leadership team developed a centralized spinal orthoses program where the bedside nurse fitted the patient with a spinal orthosis, eliminating the need for an external orthotist. The study quantifies changes in study metrics by comparing patients identified through chart review who received care in the vendor program to those who received care in the centralized program utilizing nonparametric statistical techniques. Results: The centralized nursing-led spinal orthosis program allowed the unit to mobilize patients more quickly than patients managed under the vendor program (3.85 hr. [95 % CI: 1.27 to 7.26 hrs] reduction; p = 0.004). The overall length of stay was reduced by 0.78 days ([1.34 - 0.02 days]; p = 0.063) or 18.72 h. While the statistical test did not indicate significance, the 18.72-hour reduction in length of stay represents a potential clinically relevant finding. Evaluating patients that suffered a primary spinal injury and no complications (vendor program: 54 patients; centralized program: 86 patients) showed a similar reduction in time to mobilization (4.5 hr reduction [0.53 to 12.93 hrs]; p = 0.025), but the length of stay reduction increased to 1.02 days [0.12 to 1.97 days], a difference determined to be statistically significant (p = 0.014). Centralizing the process for providing off-the-shelf spinal orthoses reduced the cost of a thoracic-lumbar sacral orthosis by $1,483 and the price of a lumbar-sacral orthosis by $1,327. Throughout the study, the new program reduced the cost of providing spinal orthoses by $175,319. Conclusions: The results demonstrate that the nursing-led centralized spinal orthosis program positively impacted the quality of care provided to our patients while also reducing the cost of delivering the orthoses. Tweetable abstract: A nursing-led centralized spinal orthosis program reduces the cost of care while reducing time to mobilization and length of stay.

A Multi-center Cross-Sectional Assessment of Healthcare Professionals' Knowledge, Attitudes, and Practices Toward Thromboprophylaxis.

Background Venous thromboembolism (VTE) is a potentially avoidable condition that affects hospitalized patients. Risk stratification and preventative strategies have substantial evidence supporting their use, but reasons hinder widespread adoption, compliance, and success, explaining the continuation of VTE. Thromboprophylaxis consists of several measures that are frequently adopted to avoid the complications of VTE. The study evaluated knowledge, attitude, and practice toward using thromboprophylaxis by health professionals. Methods This multi-center cross-sectional study was carried out on health professionals involved in patient care working in various secondary and tertiary hospitals in the study region between October 2023 and February 2024. A previously published questionnaire was sent in the form of an online survey to the study participants. Fifteen, ten, and nine questions evaluated the participants' knowledge, attitude, and practice of thromboprophylaxis, respectively. The study followed the checklist for reporting results of the Internet E-survey (CHERRIES) guidelines. Frequency and percentages were calculated. Bi-variable and multi-variable logistic regression were carried out and presented as crude and adjusted odds ratios with corresponding 95% confidence intervals. A P-value of <0.05 was considered significant. Results Of the 219 participants, 115 (52.5%) and 104 (47.5%) were males and females. More than 50.7% were in the age group of >30 years, and the majority of the participants possessed a bachelor's (104 (47.5%)) degree. One hundred seventy-six (80.4%) of the study participants were working in government hospitals, and the majority (112 (51.1%)) were nurses. One hundred sixty-two (74% (67.63-79.65)), 175 (79.9% (73.98-85.01)) and 211 (96.3% (92.93)) had satisfactory knowledge, a positive attitude, and good practice regarding thromboprophylaxis, respectively. Regarding the facility characteristics, 196 (89.5%), 150 (68.5%), and 164 (74.9%) respondents agreed with the availability of a VTE prevention policy, VTE prevention consultants, and the availability of anticoagulants. Eighty (36.5%) participants responded with a 'not availability' of pneumatic compression devices. Of the 15 knowledge questions, the majority (124 (56.6%)) participants faulted the false statements regarding 'patients of DVT being symptomatic' and 119 (54.3%) on the statement that helping patients 'out of bed activity does not prevent VTE'. On multi-variable analysis, participants who were aware of having a VTE prevention policy and availability of anticoagulants were more knowledgeable with adjusted odds ratios of 5.39 (1.88-15.39) and 2.52 (1.12-5.63) respectively. Every practice domain received >90% approval ratings. Conclusions The study concludes that an overall satisfactory knowledge and positive attitude regarding thromboprophylaxis exists among the participants. The study proposes more training sessions on VTE prevention and orientation of health professionals on the availability of VTE policy guidelines and facility availability of resources for thromboprophylaxis.

A New Perspective to Interpret How the Vestibular Efferent System Correlates the Complexity of Routine Balance Maintenance with Management of Emergency Fall Prevention Strategies.

Bipedalism is unique among mammals. Until modern times, a fall and resulting leg fracture could be fatal. Balance maintenance after a destabilizing event requires instantaneous decision making. The vestibular system plays an essential role in this process, initiating an emergency response. The afferent otolithic neural response is the first directionally oriented information to reach the cortex, and it can then be used to initiate an appropriate protective response. Some vestibular efferent axons feed directly into type I vestibular hair cells. This allows for rapid vestibular feedback via the striated organelle (STO), which has been largely ignored in most texts. We propose that this structure is essential in emergency fall prevention, and also that the system of sensory detection and resultant motor response works by having efferent movement information simultaneously transmitted to the maculae with the movement commands. This results in the otolithic membrane positioning itself precisely for the planned movement, and any error is due to an unexpected external cause. Error is fed back via the vestibular afferent system. The efferent system causes macular otolithic membrane movement through the STO, which occurs simultaneously with the initiating motor command. As a result, no vestibular afferent activity occurs unless an error must be dealt with.

Association between delayed ambulation and increased risk of adverse events after lumbar fusion surgery in elderly patients.

PURPOSE: The relationship between delayed ambulation (DA) and postoperative adverse events (AEs) following transforaminal lumbar interbody fusion (TLIF) in elderly patients remains elusive. The aim of our study was to evaluate the effects of DA on the postoperative AEs including complications, readmission and prolonged length of hospital stay (LOS). METHODS: This was a retrospective analysis of a prospectively established database of elderly patients (aged 65 years and older) who underwent TLIF surgery. The early ambulation (EA) group was defined as patients ambulated within 48 h after surgery, whereas the delayed ambulation (DA) group was patients ambulated at a minimum of 48 h postoperatively. The DA patients were 1:1 propensity-score matched to the EA patients based on age, gender and the number of fused segments. Univariate analysis was used to compare postoperative outcomes between the two groups, and multivariate logistic regression analysis was used to identify risk factors for adverse events and DA. RESULTS: After excluding 125 patients for various reasons, 1025 patients (≤ 48 h: N = 659 and > 48 h: N = 366) were included in the final analysis. After propensity score matching, there were 326 matched patients in each group. There were no significant differences in the baseline data and the surgery-related variables between the two groups (p > 0.05). The patients in the DA group had a significant higher incidence of postoperative AEs (46.0% vs. 34.0%, p = 0.002) and longer LOS (p = 0.001). Multivariate logistic regression identified that age, operative time, diabetes, and DA were independently associated with postoperative AEs, whereas greater age, higher international normalized ratio, and intraoperative estimated blood loss were identified as independent risk factors for DA. CONCLUSIONS: Delayed ambulation was an independent risk factor for postoperative AEs after TLIF in elderly patients. Older age, increased intraoperative blood loss and worse coagulation function were associated with delayed ambulation.