Agricultural education in Africa using YouTube multilingual animations: A retrospective feasibility study assessing costs to reach language-diverse populations.

There is a critical need for widespread information dissemination of agricultural best practices in Africa. Literacy, language and resource barriers often impede such information dissemination. Culturally and linguistically localized, computer-animated training videos placed on YouTube and promoted through paid advertising is a potential tool to help overcome these barriers. The goal of this study is to assess the feasibility of reaching language-diverse populations in Africa using this new type of information dissemination channel. As a case study, cost estimates were obtained for YouTube ad campaigns of a video to prevent post-harvest loss through safe food storage using sanitized jerrycan containers. Seventy-three video variants were created for the most common 16 languages in Ghana, 35 languages in Kenya, and 22 languages in Nigeria. Using these videos, campaigns were deployed country wide or focused on zones of influence that represent economically underdeveloped regions known to produce beans suitable for jerrycan storage. Using data collected from YouTube ad campaigns, language-specific models were created for each country to estimate how many viewers could be reached per US dollar spent. Separate models were created to estimate the number of viewers who watched 25% and 75% of the video (most of video without end credits), reflecting different levels of engagement. For language campaigns with both country wide and zone of influence areas of deployment, separate region-specific models were created. Models showed that the estimated number of viewers per dollar spent varied considerably amongst countries and languages. On average, the expected number of viewers per dollar spent were 1.8 (Range = 0.2-7.3) for 25% watched and 0.8 (Range = 0.1-3.2) for 75% watched in Ghana, 1.2 (0.2-4.8) for 25% watched and 0.5 (Range = 0.1-2.0) for 75% watched in Kenya, and 0.4 (Range = 0.2-1.3) for 25% watched and 0.2 (Range = 0.1-0.5) for 75% watched in Nigeria. English versions of the video were the most cost-effective in reaching viewers in Ghana and Nigeria. In Kenya, English language campaigns ranked 28 (country wide) and 36 (zones of influence) out of 37 analyzed campaigns. Results also showed that many local language campaigns performed well, opening the possibility that targeted knowledge dissemination on topics of importance to local populations, is potentially cost effective. In addition, such targeted information dissemination appears feasible, even during regional and global crises when in-person training may not be possible. In summary, leveraging multilingual computer-animations and digital platforms such as YouTube shows promise for conducting large-scale agricultural education campaigns. The findings of the current study provides the justification to pursue a more rigorous prospective study to verify the efficacy of knowledge exchange and societal impact through this form of information dissemination channel.

The effects of osteopathic manipulative treatment on pain and disability in patients with chronic low back pain: a single-blinded randomized controlled trial.

CONTEXT: The evidence for the efficacy of osteopathic manipulative treatment (OMT) in the management of low back pain (LBP) is considered weak by systematic reviews, because it is generally based on low-quality studies. Consequently, there is a need for more randomized controlled trials (RCTs) with a low risk of bias. OBJECTIVES: The objective of this study is to evaluate the efficacy of an OMT intervention for reducing pain and disability in patients with chronic LBP. METHODS: A single-blinded, crossover, RCT was conducted at a university-based health system. Participants were adults, 21-65 years old, with nonspecific LBP. Eligible participants (n=80) were randomized to two trial arms: an immediate OMT intervention group and a delayed OMT (waiting period) group. The intervention consisted of three to four OMT sessions over 4-6 weeks, after which the participants switched (crossed-over) groups. The primary clinical outcomes were average pain, current pain, Patient-Reported Outcomes Measurement Information System (PROMIS) 29 v1.0 pain interference and physical function, and modified Oswestry Disability Index (ODI). Secondary outcomes included the remaining PROMIS health domains and the Fear Avoidance Beliefs Questionnaire (FABQ). These measures were taken at baseline (T0), after one OMT session (T1), at the crossover point (T2), and at the end of the trial (T3). Due to the carryover effects of OMT intervention, only the outcomes obtained prior to T2 were evaluated utilizing mixed-effects models and after adjusting for baseline values. RESULTS: Totals of 35 and 36 participants with chronic LBP were available for the analysis at T1 in the immediate OMT and waiting period groups, respectively, whereas 31 and 33 participants were available for the analysis at T2 in the immediate OMT and waiting period groups, respectively. After one session of OMT (T1), the analysis showed a significant reduction in the secondary outcomes of sleep disturbance and anxiety compared to the waiting period group. Following the entire intervention period (T2), the immediate OMT group demonstrated a significantly better average pain outcome. The effect size was a 0.8 standard deviation (SD), rendering the reduction in pain clinically significant. Further, the improvement in anxiety remained statistically significant. No study-related serious adverse events (AEs) were reported. CONCLUSIONS: OMT intervention is safe and effective in reducing pain along with improving sleep and anxiety profiles in patients with chronic LBP.

The effects of a sleeve knee brace during stair negotiation in patients with symptomatic patellofemoral osteoarthritis.

BACKGROUND: The patellofemoral joint is an important source of pain in knee osteoarthritis. Most biomechanical research in knee osteoarthritis has focused on the tibiofemoral joint during level walking. It is unknown what happens during stair negotiation in patients with patellofemoral joint osteoarthritis, a task commonly increasing pain. Conservative therapy for patellofemoral joint osteoarthritis includes the use of a sleeve knee brace. We aimed to examine the effect of a sleeve knee brace on knee biomechanics during stair negotiation in patellofemoral joint osteoarthritis patients. METHODS: 30 patellofemoral joint osteoarthritis patients (40-70 years) ascended and descended an instrumented staircase with force plates under two conditions - wearing a Lycra flexible knee support (Bioskin Patellar Tracking Q Brace) and no brace (control condition). Knee joint kinematics (VICON) and kinetics were recorded. FINDINGS: During stair ascent, at the knee, the brace significantly reduced the maximal flexion angle (2.70, P = 0.002), maximal adduction angle (2.00, P = 0.044), total sagittal range of motion (2.00, P = 0.008), total frontal range of motion (1.70, P = 0.023) and sagittal peak extension moment (0.05 Nm/kg, P = 0.043) compared to control. During stair descent, at the knee, the brace significantly reduced the maximal flexion angle (1.80, P = 0.039) and total sagittal range of motion (1.50, P = 0.045) compared to control. INTERPRETATION: The small changes in knee joint biomechanics during stair negotiation observed in our study need to be investigated further to help explain mechanisms behind the potential benefits of a sleeve knee brace for painful patellofemoral joint osteoarthritis.

Inflammatory biomarker signatures in post-surgical drain fluid may detect anastomotic leaks within 48 hours of colorectal resection.

BACKGROUND: The optimal treatment of colorectal cancer is surgical resection and primary anastomosis. Anastomotic leak can affect up to 20% of patients and creates significant morbidity and mortality. Current diagnosis of a leak is based on clinical suspicion and subsequent radiology. Peritoneal biomarkers have shown diagnostic utility in other conditions and could be useful in providing earlier diagnosis. This pilot study was designed to assess the practical utility of peritoneal biomarkers after abdominal surgery utilising an automated immunoassay system in routine use for quantifying cytokines. METHODS: Patients undergoing an anterior resection for a rectal cancer diagnosis were recruited at University Hospital of Wales, Cardiff between June 2019 and June 2021. A peritoneal drain was placed in the proximity of the anastomosis during surgery, and peritoneal fluid was collected at days 1 to 3 post-operatively, and analysed using the Siemens IMMULITE platform for interleukin (IL)-1ß, IL-6, IL-10, CXCL8, tumour necrosis factor alpha (TNFα) and C-reactive protein (CRP). RESULTS: A total of 42 patients were recruited (22M:20F, median age 65). Anastomotic leak was detected in four patients and a further five patients had other intra-abdominal complications. The IMMULITE platform was able to provide robust and reliable results from the analysis of the peritoneal fluid. A metric based on the combination of peritoneal IL-6 and CRP levels was able to accurately diagnose three anastomotic leaks, whilst correctly classifying all negative control patients including those with other complications. CONCLUSIONS: This pilot study demonstrates that a simple immune signature in surgical drain fluid could accurately diagnose an anastomotic leak at 48 h postoperatively using instrumentation that is already widely available in hospital clinical laboratories.

Dramatically increased accessibility and decreased cost-per-person impacts are needed for scaling IPM in Africa.

While traditional scaling for integrated pest management (IPM) in Africa requires the movement of expert trainers from village to village, these efforts are often costly, time-inefficient, hampered by distance, and became impossible under COVID-19's movement restrictions (despite tremendously increased public need for IPM-scaling knowledge). One solution to this dilemma is IPM-scaling, usable by a diversity of development actors expending limited or few resources, to deliver critical information to large numbers of people with systems-approach information and communication technologies. This paper describes one such systems-approach scaling platform, Scientific Animations Without Borders, which effectively elicited end-user solution-adoption and decreased unit costs over increasing scales in three African countries during COVID-19. How to scale game-changing IPM insights 'off the shelf' and 'into people's hands in the field' is also discussed.

Large-scale rollout of extension training in Bangladesh: Challenges and opportunities for gender-inclusive participation.

Despite the recognized importance of women's participation in agricultural extension services, research continues to show inequalities in women's participation. Emerging capacities for conducting large-scale extension training using information and communication technologies (ICTs) now afford opportunities for generating the rich datasets needed to analyze situational factors that affect women's participation. Data was recorded from 1,070 video-based agricultural extension training events (131,073 farmers) in four Administrative Divisions of Bangladesh (Rangpur, Dhaka, Khulna, and Rajshahi). The study analyzed the effect of gender of the trainer, time of the day, day of the week, month of the year, Bangladesh Administrative Division, and venue type on (1) the expected number of extension event attendees and (2) the odds of females attending the event conditioned on the total number of attendees. The study revealed strong gender specific training preferences. Several factors that increased total participation, decreased female attendance (e.g., male-led training event held after 3:30 pm in Rangpur). These findings highlight the dilemma faced by extension trainers seeking to maximize attendance at training events while avoiding exacerbating gender inequalities. The study concludes with a discussion of ways to mitigate gender exclusion in extension training by extending data collection processes, incorporating machine learning to understand gender preferences, and applying optimization theory to increase total participation while concurrently improving gender inclusivity.

The effects of osteopathic manipulative treatment on pain and disability in patients with chronic neck pain: A single-blinded randomized controlled trial.

BACKGROUND: Neck pain (NP) affects up to 70% of individuals at some point in their lives. Systematic reviews indicate that manual treatments can be moderately effective in the management of chronic, nonspecific NP. However, there is a paucity of studies specifically evaluating the efficacy of osteopathic manipulative treatment (OMT). OBJECTIVE: To evaluate the efficacy of OMT in reducing pain and disability in patients with chronic NP. DESIGN: Single-blinded, cross-over, randomized-controlled trial. SETTING: University-based, osteopathic manipulative medicine outpatient clinic. PARTICIPANTS: Ninety-seven participants, 21 to 65 years of age, with chronic, nonspecific NP. INTERVENTIONS: Participants were randomized to two trial arms: immediate OMT intervention or waiting period first. The intervention consisted of three to four OMT sessions over 4 to 6 weeks, after which the participants switched groups. MAIN OUTCOME MEASURES: Primary outcome measures were pain intensity (average and current) on the numerical rating scale and Neck Disability Index. Secondary outcomes included Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) health domains and Fear Avoidance Beliefs Questionnaire. Outcomes obtained prior to the cross-over allocation were evaluated using general linear models and after adjusting for baseline values. RESULTS: A total of 38 and 37 participants were available for the analysis in the OMT and waiting period groups, respectively. The results showed significantly better primary outcomes in the immediate OMT group for reductions in average pain (-1.02, 95% confidence interval [CI] -1.72, -0.32; p = .005), current pain (-1.02, 95% CI -1.75, -0.30; p = .006), disability (-5.30%, 95% CI -9.2%, -1.3%; p = .010) and improved secondary outcomes (PROMIS) related to sleep (-3.25, 95% CI -6.95, -1.54; p = .003), fatigue (-3.26, 95% CI -6.04, -0.48; p = .022), and depression (-2.59, 95% CI -4.73, -0.45; p = .018). The effect sizes were in the clinically meaningful range between 0.5 and 1 standard deviation. No study-related serious adverse events were reported. CONCLUSIONS: OMT is relatively safe and effective in reducing pain and disability along with improving sleep, fatigue, and depression in patients with chronic NP immediately following treatment delivered over approximately 4 to 6 weeks.

Stability threshold during seated balancing is sensitive to low back pain and safe to assess.

Challenging trunk neuromuscular control maximally using a seated balancing task is useful for unmasking impairments that may go unnoticed with traditional postural sway measures and appears to be safe to assess in healthy individuals. This study investigates whether the stability threshold, reflecting the upper limits in trunk neuromuscular control, is sensitive to pain and disability and is safe to assess in low back pain (LBP) patients. Seventy-nine subjects with non-specific LBP balanced on a robotic seat while rotational stiffness was gradually reduced. The critical rotational stiffness, KCrit, that marked the transition between stable and unstable balance was used to quantify the individual's stability threshold. The effects of current pain, 7-day average pain, and disability on KCrit were assessed, while controlling for age, sex, height, and weight. Adverse events (AEs) recorded at the end of the testing session were used to assess safety. Current pain and 7-day average pain were strongly associated with KCrit (current pain p < 0.001, 7-day pain p = 0.023), reflecting that people experiencing more pain have poorer trunk neuromuscular control. There was no evidence that disability was associated with KCrit, although the limited range in disability scores in subjects may have impacted the analysis. AEs were reported in 13 out of 79 total sessions (AE Severity: 12 mild, 1 moderate; AE Relatedness: 1 possibly, 11 probably, 1 definitely-related to the study). Stability threshold is sensitive to pain and appears safe to assess in people with LBP, suggesting it could be useful for identifying trunk neuromuscular impairments and guiding rehabilitation.

Impact of a defunctioning ileostomy and time to stoma closure on bowel function after low anterior resection for rectal cancer: a systematic review and meta-analysis.

BACKGROUND: Impaired bowel function after low anterior resection (LAR) for rectal cancer is a frequent problem with a major impact on quality of life. The aim of this study was to assess the impact of a defunctioning ileostomy, and time to ileostomy closure on bowel function after LAR for rectal cancer. METHODS: We performed a systematic review based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Comprehensive literature searches were conducted using PubMed, Embase and Cochrane databases for articles published from 1989 up to August 2019. Analysis was performed using Review Manager (version 5.3) using a random-effects model. RESULTS: The search yielded 11 studies (1400 patients) that reported on functional outcome after LAR with at least 1 year follow-up, except for one study. Five scales were used: the Low Anterior Resection Syndrome (LARS) score, the Wexner score, the Memorial Sloan Kettering Cancer Centre Bowel Function Instrument, the Fecal Incontinence Quality of Life scale, and the Hallbook questionnaire. Based on seven studies, major LARS occurred more often in the ileostomy group (OR 2.84, 95% CI, 1.70-4.75, p < 0.0001: I2 = 60%, X2 = 0.02). Based on six studies, a longer time to stoma closure increased the risk of major LARS with a mean difference in time to closure of 2.39 months (95% CI, 1.28-3.51, p < 0.0001: I2 = 21%, X2 = 0.28) in the major vs. no LARS group. Other scoring systems could not be pooled, but presence of an ileostomy predicted poorer bowel function except with the Hallbook questionnaire. CONCLUSIONS: The risk of developing major LARS seems higher with a defunctioning ileostomy. A prolonged time to ileostomy closure seems to reinforce the negative effect on bowel function; therefore, early reversal should be an important part of the patient pathway.

Where have all the appendicectomies gone?

INTRODUCTION: The COVID-19 pandemic stimulated a national lockdown in the UK. The public were advised to avoid unnecessary hospital attendances and health professionals were advised to avoid aerosol-generating procedures wherever possible. The authors hypothesised that these measures would result in a reduction in the number of patients presenting to hospital with acute appendicitis and alter treatment choices. METHODS: A multicentred, prospective observational study was undertaken during April 2020 to identify adults treated for acute appendicitis. Searches of operative and radiological records were performed to identify patients treated during April 2018 and April 2019 for comparison. RESULTS: A total of 190 patients were treated for acute appendicitis pre-lockdown compared with 64 patients treated during lockdown. Patients treated during the pandemic were more likely to have a higher American Society of Anesthesiology (ASA) score (p = 0.049) and to have delayed their presentation to hospital (2 versus 3 days, p = 0.03). During the lockdown, the use of computed tomography (CT) increased from 36.3% to 85.9% (p < 0.001), the use of an antibiotic-only approach increased from 6.2% to 40.6% (p < 0.001) and the rate of laparoscopic appendicectomy reduced from 85.3% to 17.2% (p < 0.001). The negative appendicectomy rate decreased from 21.7% to 7.1% during lockdown (p < 0.001). CONCLUSIONS: The COVID-19 lockdown was associated with a decreased incidence of acute appendicitis and a significant shift in the management approach. The increased use of CT allows the identification of simple appendicitis for conservative treatment and decreases the negative appendicectomy rate.

Correlates of self-rated health in people with diabetic peripheral neuropathy: a longitudinal study.

AIM: Self-rated health, a measure of self-reported general health, is a robust predictor of morbidity and mortality in various populations, including persons with diabetes. This study examines correlates of self-rated health in adults with diabetic peripheral neuropathy (DPN). METHODS: Participants recruited from the UK and USA (n = 295; mean (± sd) age: 61.5 ± 10.7 years; 69% male; 71% type 2 diabetes) rated their health at baseline and 18 months. DPN severity was assessed using the neuropathy disability score and the vibration perception threshold. Validated self-report measures assessed neuroticism, DPN-symptoms of pain, unsteadiness and reduced sensation in feet, DPN-related limitations in daily activities, DPN-specific emotional distress and symptoms of depression. RESULTS: In the fully adjusted baseline model, younger age, presence of cardiovascular disease and higher depression symptom scores showed likely clinically meaningful independent associations with worse health ratings. Being at the UK study site and presence of nephropathy indicated potentially meaningful independent associations with lower baseline health ratings. These predictors were largely consistent in their association with health ratings at 18 months. CONCLUSION: Results identify independent correlates of health ratings among adults with DPN. Future research should investigate the clinical implications of associations and examine changes in these variables over time and potential effects on changes in health perceptions. If these associations reflect causal pathways, our results may guide interventions to target issues that are likely to have an impact on subjectively experienced health as an important patient-reported outcome in DPN care.

Physical function in UK adults with osteogenesis imperfecta: a cross-sectional analysis of the RUDY study.

We describe the physical function in adults with osteogenesis imperfecta (OI) and explored clinical and non-clinical factors related to its impairment. Our data showed that physical dysfunction is a common feature of adults with OI, varying by OI severity, and mediated by the presence and quality of pain and fatigue symptoms. INTRODUCTION: There is a paucity of data describing physical function in adults with osteogenesis imperfecta (OI). We investigated the effects of OI and its severity on physical function and explored the relationship between physical function and number of fractures and symptomatology. METHODS: Adults with OI of different types were recruited from the RUDY study, an ongoing UK-based prospective cohort study. Participants completed demographic and clinical questions and questionnaires. These assessed physical function (SF-36), mobility (EQ-5D-5L and NEADL), fatigue (FACIT-F), and pain (SF-MQ-2). Scores were compared using parametric or non-parametric statistical analyses, whereas correlations between outcomes were examined using univariate and multivariate regression analysis. RESULTS: Seventy-eight adults with OI aged 43.5 ± 14.5 years were enrolled (type I, 32; type III, 11; type IV, 10; unknown type, 26). Physical function (PCS, SF-36) was significantly lower in all participants than normative values (p < 0.001) and in type III than type I (p = 0.008). Mobility was significantly different across the types (EQ-5D-EL, p = 0.007; NEADL, p < 0.001), with type III having more severe problems, followed by types IV, unknown, and I. Physical function was associated with OI type (r = 0.26; p = 0.021), presence and quality of pain (r = - 0.57; p < 0.0001), and fatigue (r = - 0.51; p < 0.0001). Multivariate analysis revealed that physical function correlated independently with age, OI type, fatigue, and non-neuropathic pain. CONCLUSIONS: Individuals with OI display a marked deterioration in physical function during adulthood. This impairment varies in severity according to the OI phenotype and is associated with the presence of non-neuropathic pain and fatigue.

The mechanisms of adaptation for muscle fascicle length changes with exercise: Implications for spastic muscle.

We are proposing optimal training conditions that can lead to an increase in the number of serial sarcomeres (SSN) and muscle fascicle length (FL) in spastic muscles. Therapeutic interventions for increasing FL in clinical populations with neurological origin, in whom relative shortness of muscle fascicles contributed to the presentation of symptoms such as spasticity, contracture, and limited functional abilities, do not generally meet these conditions, and therefore, result in less than satisfactory outcomes. Based on a review of literature, we argue that protocols of exercise interventions that led to sarcomerogenesis, and increases in SSN and FL in healthy animal and human models satisfied three criteria: 1) all involved eccentric exercise at appropriately high velocity; 2) resulted in positive strain of muscle fascicles; and 3) momentary deactivation in the stretched muscle. Accordingly, to increase FL in spastic muscles, new exercise protocols in which the three presumed criteria are satisfied, must be developed, and long-term muscle architectural and functional adaptations to such trainings must be examined.

Quantifying trunk neuromuscular control using seated balancing and stability threshold.

Performance during seated balancing is often used to assess trunk neuromuscular control, including evaluating impairments in back pain populations. Balancing in less challenging environments allows for flexibility in control, which may not depend on health status but instead may reflect personal preferences. To make assessment less ambiguous, trunk neuromuscular control should be maximally challenged. Thirty-four healthy subjects balanced on a robotic seat capable of adjusting rotational stiffness. Subjects balanced while rotational stiffness was gradually reduced. The rotational stiffness at which subjects could no longer maintain balance, defined as critical stiffness (kCrit), was used to quantify the subjects' trunk neuromuscular control. A higher kCrit reflects poorer control, as subjects require a more stable base to balance. Subjects were tested on three days separated by 24 hours to assess test-retest reliability. Anthropometric (height and weight) and demographic (age and sex) influences on kCrit and its reliability were assessed. Height and age did not affect kCrit; whereas, being heavier (p < 0.001) and female (p = 0.042) significantly increased kCrit. Reliability was also affected by anthropometric and demographic factors, highlighting the potential problem of inflated reliability estimates from non-control related attributes. kCrit measurements appear reliable even after removing anthropometric and demographic influences, with adjusted correlations of 0.612 (95%CI: 0.433-0.766) versus unadjusted correlations of 0.880 (95%CI: 0.797-0.932). Besides assessment, trainers and therapists prescribing exercise could use the seated balance task and kCrit to precisely set difficulty level to a percentage of the subject's stability threshold to optimize improvements in trunk neuromuscular control and spine health.

Intrinsic foot muscles act to stabilise the foot when greater fluctuations in centre of pressure movement result from increased postural balance challenge.

BACKGROUND: Increased postural balance challenge is associated with more fluctuations in centre of pressure movement, indicating increased interference from the postural control system. The role of intrinsic foot muscles in balance control is relatively understudied and whether such control system interference occurs at the level of these muscles is unknown. RESEARCH QUESTION: Do fewer fluctuations in intrinsic foot muscle excitation occur in response to increased postural balance challenge? METHODS: Surface EMGs were recorded using a grid of 13 × 5 channels from the plantar surface of the foot of 17 participants, who completed three balance tasks: bipedal stance; single leg stance and bipedal tip-toe. Centre of pressure (CoP) movement was calculated from simultaneously recorded force plate signals. Fluctuations in CoP and EMGs for each task were quantified using a sample entropy based metric, Entropy Halflife (EnHL). Longer EnHL indicates fewer signal fluctuations. RESULTS: The shortest EMG EnHL, 9.27 ± 3.34 ms (median ± interquartile range), occurred during bipedal stance and the longest during bipedal tip-toe 15.46 ± 11.16 ms, with 18.80 ± 8.00 ms recorded for single leg stance. Differences were statistically significant between bipedal stance and both bipedal tip-toe (p < 0.001) and single leg stance (p < 0.001). CoP EnHL for both anterior-posterior and medial-lateral movements also differed significantly between tasks (p < 0.001, both cases). However, anterior-posterior CoP EnHL was longest for bipedal stance 259.84±230.22 ms and shortest for bipedal tip-toe 146.25±73.35 ms. Medial-lateral CoP EnHL was also longest during bipedal stance 215.73±187.58 ms, but shortest for single leg stance 113.48±83.01 ms. SIGNIFICANCE: Fewer fluctuations in intrinsic foot muscle excitation occur in response to increased postural balance challenge. Fluctuations in CoP movement during balance must be predominantly driven by excitation of muscles extrinsic to the foot. Intrinsic foot muscles therefore likely play a greater role in stabilisation of the foot than balance control during the postural tasks studied.

Altered accelerator pedal control in a driving simulator in people with diabetic peripheral neuropathy.

AIM: To investigate whether the sensory-motor impairment attributable to diabetic peripheral neuropathy would affect control of the accelerator pedal during a driving simulator task. METHODS: A total of 32 active drivers, 11 with diabetic peripheral neuropathy (mean ± sd age 67±5.0 years), 10 with diabetes but no neuropathy (diabetes group; mean ± sd age 62±10 years), and 11 healthy individuals without diabetes (healthy group; mean ± sd age 60±11 years), undertook a test on a dynamometer to assess ankle plantar flexor muscle strength and ankle joint proprioception function of the right leg, in addition to a driving simulator task. The following variables were measured: maximal ankle plantar flexor muscle strength; speed of strength generation (Nm/s); and ankle joint proprioception (ankle repositioning error, degrees). In the driving simulator task, driving speed (mph), accelerator pedal signal (degrees) and the duration of specific 'loss-of-control events' (s) were measured during two drives (Drive 1, Drive 2). RESULTS: Participants with diabetic peripheral neuropathy had a lower speed of strength generation (P<0.001), lower maximal ankle plantar flexor muscle strength (P<0.001) and impaired ankle proprioception (P=0.034) compared to healthy participants. The diabetic peripheral neuropathy group drove more slowly compared with the healthy group (Drive 1 P=0.048; Drive 2 P=0.042) and showed marked differences in the use of the accelerator pedal compared to both the diabetes group (P=0.010) and the healthy group (P=0.002). Participants with diabetic peripheral neuropathy had the longest duration of loss-of-control events, but after one drive, this was greatly reduced (P=0.023). CONCLUSIONS: Muscle function, ankle proprioception and accelerator pedal control are all affected in people with diabetic peripheral neuropathy, adversely influencing driving performance, but potential for improvement with targeted practice remains possible.

Model Simulations Challenge Reductionist Research Approaches to Studying Chronic Low Back Pain.

BACKGROUND: Traditionally, low back pain (LBP) is studied using a reductionist approach, in which the factors contributing to the clinical presentation of LBP are studied in isolation to identify the primary pathology or condition linked to LBP. We argue that reductionism may not be suitable for studying LBP, considering the complex, multifactorial nature of this condition. OBJECTIVES: To quantify the likelihood of successfully subclassifying patients with LBP and effectively targeting treatment based on a single dominant factor contributing to LBP. METHODS: Both analytical and numerical simulations (Monte Carlo) of 1 million patients with LBP were performed. Several factors contributing to LBP were randomly assigned to each individual. The following outcome measures were computed, as a function of the number of factors: the percentage of individuals who could be subclassified by identifying a single factor exceeding a certain threshold, and the average reduction in LBP when treatment eliminates the largest contributing factor versus a multimodal treatment that eliminates a number of the randomly selected factors. RESULTS: With an increasing number of factors, the probability of subclassifying an individual to a subgroup based on a single factor tends toward zero. A multimodal treatment arbitrarily addressing any 2 or more factors was more effective than diagnosing and treating a single factor that maximally contributed to LBP. CONCLUSION: Results suggest that reductionism is not appropriate for subclassifying patients with LBP or for targeting treatment. The use of reductionist approaches may explain some of the challenges when creating LBP classification systems and designing effective treatment interventions. J Orthop Sports Phys Ther 2019;49(6):477-481. Epub 15 May 2019. doi:10.2519/jospt.2019.8791.

Can Biomechanics Research Lead to More Effective Treatment of Low Back Pain? A Point-Counterpoint Debate.

SYNOPSIS: Although biomechanics plays a role in the development and perhaps the persistent or recurrent nature of low back pain (LBP), whether biomechanics alone can provide the basis for intervention is debated. Biomechanics, which refers to the mechanics of the body, including its neuromuscular control, has been studied extensively in LBP. But, can gains be made in understanding LBP by research focused on this component of biology in the multifactorial biopsychosocial problem of LBP? This commentary considers whether biomechanics research has the potential to advance treatment of LBP, and how likely it is that this research will lead to better treatment strategies. A point-counterpoint format is taken to present both sides of the argument. First, the challenges faced by an approach that considers biomechanics in isolation are presented. Next, we describe 3 models that place substantial emphasis on biomechanical factors. Finally, reactions to each point are presented as a foundation for further research and clinical practice to progress understanding of the place for biomechanics in guiding treatment of LBP. J Orthop Sports Phys Ther 2019;49(6):425-436. Epub 15 May 2019. doi:10.2519/jospt.2019.8825.

Are Stability and Instability Relevant Concepts for Back Pain?

SYNOPSIS: Individuals with back pain are often diagnosed with spine instability, even though it is unclear whether the spine is susceptible to unstable behavior. The spine is a complex system with many elements that cannot be directly observed, which makes the study of spine function and direct assessment of spine instability difficult. What is known is that trunk muscle activation is adjusted to meet stability demands, which highlights that the central nervous system closely monitors threats to spine stability. The spine appears to be protected by neural coupling and mechanical coupling that prevent erroneous motor control from producing segmental instability; however, this neural and mechanical coupling could be problematic in an injured spine. Finally, instability traditionally contemplated from a mechanical and control perspective could potentially be applied to study processes involved in pain sensitization, and possibly back pain that is iatrogenic in nature. This commentary argues for a more contemporary and broadened view of stability that integrates interdisciplinary knowledge in order to capture the complexity of back pain. J Orthop Sports Phys Ther 2019;49(6):415-424. Epub 25 Apr 2019. doi:10.2519/jospt.2019.8144.

Feasibility of Incorporating Test-Retest Reliability and Model Diversity in Identification of Key Neuromuscular Pathways During Head Position Tracking.

To study the complex neuromuscular control pathways in human movement, biomechanical parametric models and system identification methods are employed. Although test-retest reliability is widely used to validate the outcomes of motor control tasks, it was not incorporated in system identification methods. This study investigates the feasibility of incorporating test-retest reliability in our previously published method of selecting sensitive parameters. We consider the selected parameters via this novel approach to be the key neuromuscular parameters, because they meet three criteria: reduced variability, improved goodness of fit, and excellent reliability. These criteria ensure that the parameter variability is below a user-defined value, the number of these parameters is maximized to enhance goodness of fit, and their test-retest reliability is above a user-defined value. We measured variability, the goodness of fit, and reliability using Fisher information matrix, variance accounted for, and intraclass correlation, respectively. We also incorporated model diversity as a fourth optional criterion to narrow down the solution space of key parameters. We applied this approach to the head position tracking tasks in axial rotation and flexion/extension. A total of forty healthy subjects performed the tasks during two visits. With variability and reliability measures ≤0.35 and ≥0.75, respectively, we selected three key parameters out of twelve with the goodness of fit >69%. The key parameters were associated with at least two neuromuscular pathways out of four modeled pathways (visual, proprioceptive, vestibular, and intrinsic), which is a measure of model diversity. Therefore, it is feasible to incorporate reliability and diversity in system identification of key neuromuscular pathways in our application.