Developing, Implementing, and Applying Novel Techniques During Systematic Reviews of Primary Space Medicine Data.

BACKGROUND: The Aerospace Medicine Systematic Review Group was set up in 2016 to facilitate high quality and transparent synthesis of primary data to enable evidence-based practice. The group identified many research methods specific to space medicine that need consideration for systematic review methods. The group has developed space medicine specific methods to address this and trialed usage of these methods across seven published systematic reviews. This paper outlines evolution of space medicine synthesis methods and discussion of their initial application.METHODS: Space medicine systematic review guidance has been developed for protocol planning, quantitative and qualitative synthesis, sourcing gray data, and assessing quality and transferability of space medicine human spaceflight simulation study environments.RESULTS: Decision algorithms for guidance and tool usage were created based on usage. Six reviews used quantitative methods in which no meta-analyses were possible due to lack of controlled trials or reporting issues. All reviews scored the quality and transferability of space simulation environments. One review was qualitative. Several research gaps were identified.CONCLUSION: Successful use of the developed methods demonstrates usability and initial validity. The current space medicine evidence base resulting in no meta-analyses being possible shows the need for standardized guidance on how to synthesize data in this field. It also provides evidence to call for increasing use of controlled trials, standardizing outcome measures, and improving minimum reporting standards. Space medicine is a unique field of medical research that requires specific systematic review methods.Winnard A, Caplan N, Bruce-Martin C, Swain P, Velho R, Meroni R, Wotring V, Damann V, Weber T, Evetts S, Laws J. Developing, implementing, and applying novel techniques during systematic reviews of primary space medicine data. Aerosp Med Hum Perform. 2021; 92(8):681688.

Trunk muscle activation during movement with a new exercise device for lumbo-pelvic reconditioning.

Gravitational unloading leads to adaptations of the human body, including the spine and its adjacent structures, making it more vulnerable to injury and pain. The Functional Re-adaptive Exercise Device (FRED) has been developed to activate the deep spinal muscles, lumbar multifidus (LM) and transversus abdominis (TrA), that provide inter-segmental control and spinal protection. The FRED provides an unstable base of support and combines weight bearing in up-right posture with side alternating, elliptical leg movements, without any resistance to movement. The present study investigated the activation of LM, TrA, obliquus externus (OE), obliquus internus (OI), abdominis, and erector spinae (ES) during FRED exercise using intramuscular fine-wire and surface EMG Nine healthy male volunteers (27 ± 5 years) have been recruited for the study. FRED exercise was compared with treadmill walking. It was confirmed that LM and TrA were continually active during FRED exercise. Compared with walking, FRED exercise resulted in similar mean activation of LM and TrA, less activation of OE, OI, ES, and greater variability of lumbo-pelvic muscle activation patterns between individual FRED/gait cycles. These data suggest that FRED continuously engages LM and TrA, and therefore, has the potential as a stationary exercise device to train these muscles.

Exercise in space: the European Space Agency approach to in-flight exercise countermeasures for long-duration missions on ISS.

BACKGROUND: To counteract microgravity (µG)-induced adaptation, European Space Agency (ESA) astronauts on long-duration missions (LDMs) to the International Space Station (ISS) perform a daily physical exercise countermeasure program. Since the first ESA crewmember completed an LDM in 2006, the ESA countermeasure program has strived to provide efficient protection against decreases in body mass, muscle strength, bone mass, and aerobic capacity within the operational constraints of the ISS environment and the changing availability of on-board exercise devices. The purpose of this paper is to provide a description of ESA's individualised approach to in-flight exercise countermeasures and an up-to-date picture of how exercise is used to counteract physiological changes resulting from µG-induced adaptation. Changes in the absolute workload for resistive exercise, treadmill running and cycle ergometry throughout ESA's eight LDMs are also presented, and aspects of pre-flight physical preparation and post-flight reconditioning outlined. RESULTS: With the introduction of the advanced resistive exercise device (ARED) in 2009, the relative contribution of resistance exercise to total in-flight exercise increased (33-46 %), whilst treadmill running (42-33 %) and cycle ergometry (26-20 %) decreased. All eight ESA crewmembers increased their in-flight absolute workload during their LDMs for resistance exercise and treadmill running (running speed and vertical loading through the harness), while cycle ergometer workload was unchanged across missions. CONCLUSION: Increased or unchanged absolute exercise workloads in-flight would appear contradictory to typical post-flight reductions in muscle mass and strength, and cardiovascular capacity following LDMs. However, increased absolute in-flight workloads are not directly linked to changes in exercise capacity as they likely also reflect the planned, conservative loading early in the mission to allow adaption to µG exercise, including personal comfort issues with novel exercise hardware (e.g. the treadmill harness). Inconsistency in hardware and individualised support concepts across time limit the comparability of results from different crewmembers, and questions regarding the difference between cycling and running in µG versus identical exercise here on Earth, and other factors that might influence in-flight exercise performance, still require further investigation.

Where Failure Is Not an Option -Personalized Medicine in Astronauts.

Drug safety and efficacy are highly variable among patients. Most patients will experience the desired drug effect, but some may suffer from adverse drug reactions or gain no benefit. Pharmacogenetic testing serves as a pre-treatment diagnostic option in situations where failure or adverse events should be avoided at all costs. One such situation is human space flight. On the international space station (ISS), a list of drugs is available to cover typical emergency settings, as well as the long-term treatment of common conditions for the use in self-medicating common ailments developing over a definite period. Here, we scrutinized the list of the 78 drugs permanently available at the ISS (year 2014) to determine the extent to which their metabolism may be affected by genetic polymorphisms, potentially requiring genotype-specific dosing or choice of an alternative drug. The purpose of this analysis was to estimate the potential benefit of pharmacogenetic diagnostics in astronauts to prevent therapy failure or side effects.

Reliability of a new test battery for fitness assessment of the European Astronaut corps.

BACKGROUND: To optimise health for space missions, European astronauts follow specific conditioning programs before, during and after their flights. To evaluate the effectiveness of these programs, the European Space Agency conducts an Astronaut Fitness Assessment (AFA), but the test-retest reliability of elements within it remains unexamined. The reliability study described here presents a scientific basis for implementing the AFA, but also highlights challenges faced by operational teams supporting humans in such unique environments, especially with respect to health and fitness monitoring of crew members travelling not only into space, but also across the world. The AFA tests assessed parameters known to be affected by prolonged exposure to microgravity: aerobic capacity (VO2max), muscular strength (one repetition max, 1 RM) and power (vertical jumps), core stability, flexibility and balance. Intraclass correlation coefficients (ICC3.1), standard error of measurement and coefficient of variation were used to assess relative and absolute test-retest reliability. RESULTS: Squat and bench 1 RM (ICC3.1 = 0.94-0.99), hip flexion (ICC3.1 = 0.99) and left and right handgrip strength (ICC3.1 = 0.95 and 0.97), showed the highest test-retest reliability, followed by VO2max (ICC3.1 = 0.91), core strength (ICC3.1 = 0.78-0.89), hip extension (ICC3.1 = 0.63), the countermeasure (ICC3.1 = 0.76) and squat (ICC3.1 = 0.63) jumps, and single right- and left-leg jump height (ICC3.1 = 0.51 and 0.14). For balance, relative reliability ranged from ICC3.1 = 0.78 for path length (two legs, head tilted back, eyes open) to ICC3.1 = 0.04 for average rotation velocity (one leg, eyes closed). CONCLUSIONS: In a small sample (n = 8) of young, healthy individuals, the AFA battery of tests demonstrated acceptable test-retest reliability for most parameters except some balance and single-leg jump tasks. These findings suggest that, for the application with astronauts, most AFA tests appear appropriate to be maintained in the test battery, but that some elements may be unreliable, and require either modification (duration, selection of task) or removal (single-leg jump, balance test on sphere) from the battery. The test battery is mobile and universally applicable for occupational and general fitness assessment by its comprehensive composition of tests covering many systems involved in whole body movement.

Post space mission lumbo-pelvic neuromuscular reconditioning: a European perspective.

Long-duration exposure to the space environment causes physical adaptations that are deleterious to optimal functioning on Earth. Post-mission rehabilitation traditionally concentrates on regaining general muscle strength, neuromuscular control, and lumbo-pelvic stability. A particular problem is muscle imbalance caused by the hypertrophy of the flexor and atrophy of the extensor and local lumbo-pelvic muscles, increasing the risk of post-mission injury. A method currently used in European human spaceflight to aid post-mission recovery involves a motor control approach, focusing initially on teaching voluntary contraction of specific lumbo-pelvic muscles and optimizing spinal position, progressing to functional retraining in weight bearing positions. An alternative approach would be to use a Functional Readaptive Exercise Device to appropriately recruit this musculature, thus complementing current rehabilitation programs. Advances in post-mission recovery of this nature may both improve astronaut healthcare and aid terrestrial healthcare through more effective treatment of low back pain and accelerated post bed rest rehabilitation.

Fitness, blood, and urine measurements from the 2009 European astronaut selection medical examination.

INTRODUCTION: The European Space Agency conducted an astronaut selection campaign in 2008-09 which attracted over 8000 applicants. Of those, 45 made the final assessment stage: the medical examination (MEX). This retrospective, observational study reports exercise and fitness data, lipid profiles and other results of interest from the blood and urine samples of this niche subpopulation. METHODS: All the applicants that reached the MEX completed a Bruce protocol test and a standard blood draw (12 h of fasting, water intake was ad libitum) was collected together with a 24-h urine collection. All the results were compared to either a comparative population or reference range. RESULTS: The applicants had comparable fitness levels to the 90th percentile of their age group. The lipid profiles were observed to be within the 'optimal' or 'desirable' ranges. Bilirubin and creatinine clearance were measured at 1.2 (+/- 0.40) mg x dl(-1) and 131.0 (+/- 25.81) ml x min(-1), respectively, and both were shown to be significantly higher than their respective normative ranges, while urinary creatinine (0.65 (+/- 0.19) g x L(-1)) was significantly lower than the reference range. DISCUSSION: Overall, the results from the Bruce protocol and lipid profile show that the final round applicants were in good health and physically active. The most likely cause of the elevated bilirubin and creatinine levels was 'last-minute' exercise conducted by the final round applicants before the MEX and the low levels of urinary creatinine may be attributed to drinking high quantities of water with an associated hypovolemia, diluting the urine.

The effects of rehabilitation on the muscles of the trunk following prolonged bed rest.

Microgravity and inactivity due to prolonged bed rest have been shown to result in atrophy of spinal extensor muscles such as the multifidus, and either no atrophy or hypertrophy of flexor muscles such as the abdominal group and psoas muscle. These effects are long-lasting after bed rest and the potential effects of rehabilitation are unknown. This two-group intervention study aimed to investigate the effects of two rehabilitation programs on the recovery of lumbo-pelvic musculature following prolonged bed rest. 24 subjects underwent 60 days of head down tilt bed rest as part of the 2nd Berlin BedRest Study (BBR2-2). After bed rest, they underwent one of two exercise programs, trunk flexor and general strength (TFS) training or specific motor control (SMC) training. Magnetic resonance imaging of the lumbo-pelvic region was conducted at the start and end of bed rest and during the recovery period (14 and 90 days after re-ambulation). Cross-sectional areas (CSAs) of the multifidus, psoas, lumbar erector spinae and quadratus lumborum muscles were measured from L1 to L5. Morphological changes including disc volume, spinal length, lordosis angle and disc height were also measured. Both exercise programs restored the multifidus muscle to pre-bed-rest size, but further increases in psoas muscle size were seen in the TFS group up to 14 days after bed rest. There was no significant difference in the number of low back pain reports for the two rehabilitation groups (p=.59). The TFS program resulted in greater decreases in disc volume and anterior disc height. The SMC training program may be preferable to TFS training after bed rest as it restored the CSA of the multifidus muscle without generating potentially harmful compressive forces through the spine.

International Space Station medical standards and certification for space flight participants.

INTRODUCTION: The medical community of the International Space Station (ISS) has developed joint medical standards and evaluation requirements for Space Flight Participants ("space tourists") which are used by the ISS medical certification board to determine medical eligibility of individuals other than professional astronauts (cosmonauts) for short-duration space flight to the ISS. These individuals are generally fare-paying passengers without operational responsibilities. MATERIAL AND CONTEXT: By means of this publication, the medical standards and evaluation requirements for the ISS Space Flight Participants are offered to the aerospace medicine and commercial spaceflight communities for reference purposes. It is emphasized that the criteria applied to the ISS spaceflight participant candidates are substantially less stringent than those for professional astronauts and/or crewmembers of visiting and long-duration missions to the ISS. CONCLUSIONS: These medical standards are released by the government space agencies to facilitate the development of robust medical screening and medical risk assessment approaches in the context of the evolving commercial human spaceflight industry.