Therapists and patients perceptions of a mixed reality system designed to improve trunk control and upper extremity function.

A prototype system aimed at improving arm function and trunk control after stroke has been developed that combines mixed-reality (MR) feedback with a mobile seat system (Holoreach). The purpose of this study was to assess the usability of Holoreach in a rehabilitation setting from both the patient and therapist perspective. Ten therapists (eight physiotherapists and two occupational therapists) used the device in their regular therapy programs for fifteen stroke patients with trunk control issues. Each patient received four individual therapy sessions with the device performed under the supervision of the therapist. Therapists and patients kept therapy diaries and used customized questionnaires. At the end of the study two focus groups were conducted to further assess usability. Generally, the prototype system is suitable for training trunk and arm control. The therapists expressed overall positive views on the impact of Holoreach. They characterized it as new, motivating, fresh, joyful, interesting, and exciting. All therapists and 80% of the patients agreed with the statement that training with Holoreach is beneficial for rehabilitation. Nonetheless, improvements are required in the hardware and software, and design. The prototype system contributes at various levels to the rapidly evolving advances in neurorehabilitation, particularly regarding the practical aspect of exercise delivery.

Usability of a visual feedback system to assess and improve movement disorders related to neck pain: Perceptions of physical therapists and patients.

A prototype visual feedback system has been developed to assess and improve movement disorders related to neck pain. The aim of this study was to assess the usability of the prototype in a rehabilitation setting. Twelve physical therapists integrated the device into their regular therapy programs for 24 neck pain patients with movement disorders. Each patient performed three individual therapy sessions with the device under physical therapist supervision. Usability was assessed by the physical therapists and patients using therapy diaries, the System Usability Scale, and focus group or personal interviews. Based on an overall usability rating of marginally acceptable, the visual feedback system was generally found to be a device with the potential to assess and train neck pain patients but needs improvement. To become a useful adjunct to regular physical therapy, improvements in the hardware and software, and further system developments are required.

A novel assistive therapy chair to improve trunk control during neurorehabilitation: Perceptions of physical therapists and patients.

A prototype assistive therapy chair (T-Chair) that induces exercise stimuli to improve trunk control and standing and walking early after stroke has been developed. The aim of this study was to assess its usability in a rehabilitation setting. Eleven physical therapists (PTs) integrated the T-Chair into the therapy programs of 15 patients post stroke. Each patient performed on average four individual therapy sessions on the T-Chair under the PTs' supervision. Usability was assessed using questionnaires, therapy diaries and focus group interviews with PTs'. Among PTs', 64% had generally a positive view on the T-Chair. Physical therapists recognized the potential for unsupervised therapy. Generally, patients reacted positively and enjoyed training. The T-Chair has the potential to become an adequate training tool for patients with an intermediate trunk control after stroke. Further development and usability testing are required to provide a therapeutic device allowing for an intensive therapy early post stroke.

Efficacy of six months neuromuscular exercise on lumbar movement variability - A randomized controlled trial.

INTRODUCTION: Lumbar movement variability during heavy, repetitive work may be a protective mechanism to diminish the progression of lumbar disorders and maintain neuromuscular functional integrity. The effect of neuromuscular exercise (NME) on the variability of lumbar movement is still to be determined. METHODS: A randomised controlled trial was conducted on a population of nursing personnel with subacute LBP. Following randomization, the NME group participants completed an NME program of six months duration. The participants in the control group only attended the assessment sessions. The outcomes were assessed at: baseline; after six months intervention; 12 months. The primary outcome was lumbar movement variability based on angular displacement and velocity. RESULTS: A positive treatment effect on lumbar movement variability was seen after six months of NME intervention. Angular displacement improved, and angular velocity remained constant. At the 12-month follow up, however, the effect faded in the NME group. Lumbar movement variability worsened in the control group over all time periods. CONCLUSION: NME may improve lumbar movement variability in the short term and may indicate improved neuromuscular functional integrity. The design of an optimal NME program to achieve long-term improvement in lumbar movement variability is a subject worthy of further research.

Determination of a sagittal plane axis of rotation for a dynamic office chair.

OBJECTIVE: This study investigated the location of the axis of rotation in sagittal plane movement of the spine in a free sitting condition to adjust the kinematics of a mobile seat for a dynamic chair. BACKGROUND: Dynamic office chairs are designed to avoid continuous isometric muscle activity, and to facilitate increased mobility of the back during sitting. However, these chairs incorporate increased upper body movement which could distract office workers from the performance of their tasks. A chair with an axis of rotation above the seat would facilitate a stable upper back during movements of the lower back. The selection of a natural kinematic pattern is of high importance in order to match the properties of the spine. METHOD: Twenty-one participants performed four cycles of flexion and extension of the spine during an upper arm hang on parallel bars. The location of the axis of rotation relative to the seat was estimated using infrared cameras and reflective skin markers. RESULTS: The median axis of rotation across all participants was located 36 cm above the seat for the complete movement and 39 cm for both the flexion and extension phases, each with an interquartile range of 20 cm. CONCLUSION: There was no significant effect of the movement direction on the location of the axis of rotation and only a weak, non-significant correlation between body height and the location of the axis of rotation. Individual movement patterns explained the majority of the variance. APPLICATION: The axis of rotation for a spinal flexion/extension movement is located above the seat. The recommended radius for a guide rail of a mobile seat is between 36 cm and 39 cm.

The effect of muscle fatigue and low back pain on lumbar movement variability and complexity.

INTRODUCTION: Changes in movement variability and complexity may reflect an adaptation strategy to fatigue. One unresolved question is whether this adaptation is hampered by the presence of low back pain (LBP). This study investigated if changes in movement variability and complexity after fatigue are influenced by the presence of LBP. It is hypothesised that pain free people and people suffering from LBP differ in their response to fatigue. METHODS: The effect of an isometric endurance test on lumbar movement was tested in 27 pain free participants and 59 participants suffering from LBP. Movement variability and complexity were quantified with %determinism and sample entropy of lumbar angular displacement and velocity. Generalized linear models were fitted for each outcome. Bayesian estimation of the group-fatigue effect with 95% highest posterior density intervals (95%HPDI) was performed. RESULTS: After fatiguing %determinism decreased and sample entropy increased in the pain free group, compared to the LBP group. The corresponding group-fatigue effects were 3.7 (95%HPDI: 2.3-7.1) and -1.4 (95%HPDI: -2.7 to -0.1). These effects manifested in angular velocity, but not in angular displacement. DISCUSSION: The effects indicate that pain free participants showed more complex and less predictable lumbar movement with a lower degree of structure in its variability following fatigue while participants suffering from LBP did not. This may be physiological responses to avoid overload of fatigued tissue, increase endurance, or a consequence of reduced movement control caused by fatigue.

A test of reactive scope: Reducing reactive scope causes delayed wound healing.

Reactive scope predicts that all animals have an adaptive ability to respond to stressors in their environment, termed reactive homeostasis, and that only when an animal's response to stressful stimuli exceeds a certain threshold (homeostatic overload) will stress have pathological effects. While this framework has successfully helped interpret effects of stressors on wildlife, no study has designed an experiment to directly test this framework. This study was designed to expose house sparrows (Passer domesticus) to treatments that would result in varying ranges of reactive homeostasis during chronic stress, which based on the reactive scope model should cause birds with the lowest reactive homeostasis range to exhibit signs of pathology during a subsequent challenge. To modulate the reactive homeostasis range, we altered allostatic load of birds by exposing them to chronic stress while either elevating, blocking, or not manipulating corticosterone. After concluding chronic stress treatments, birds were exposed to the subsequent challenge of a superficial wound. Individuals treated with corticosterone during chronic stress (high allostatic load) experienced the most pathology, including both weight loss and slower wound healing. Unmanipulated birds (medium allostatic load) also experienced weight loss but had normal healing rates, while birds with blocked corticosterone (low allostatic load) had minimal weight loss and normal healing rates. Our results indicate that increased allostatic load reduces the reactive homeostasis range, thereby causing individuals to cross the homeostatic overload threshold sooner, and thus support the reactive scope framework.

[Imaging and Laboratory Diagnostics for Tuberculosis]. / Bildgebung und Labordiagnostik bei Tuberkulose.

Diagnosis of tuberculosis (TB) is difficult, since symptoms are often very unspecific or lacking. However active, prompt and accurate diagnosis is the key element in the public health response to tuberculosis and the cornerstone of tuberculosis control. Different diagnostic methods for an assured diagnosis of TB are necessary. Chest radiography is a useful keystone to identify tuberculosis, but diagnosis of tuberculosis cannot be established by radiography alone. CT scanning is used in patients without pathological chest radiography but clinically suspected active TB and to differentiate TB from other diseases. Radiological appearance is primarily determined by the immune status of patients and caverns and disseminated disease foci are often observed. Laboratory diagnostic methods include microscopic identification of acid-fast mycobacteria from any body fluid (especially sputum), as well as isolation and characterisation of mycobacteria in culture. It is then possible to type the pathogens by the shape of their colony, their growth behavior and their biochemical characteristics. These methods are regarded as the gold standard in diagnosis of active TB. In patients who are highly suspected of having TB, but whose sputum specimens tested negative for mycobacteria, a nucleic acid amplification test is additionally performed. Moreover, sensitivity testing with first and second line antitubercular drugs is applied as standard. Laboratory diagnostic testing of cellular immunity against pathogenic mycobacteria employs the tuberculin skin test (TST, Mantoux tuberculin test) or the more specific interferon γ test to determine γ interferon released by T lymphocytes stimulated in vitro. The new ELISA and ELISPOT procedures exhibit higher test specificity and less cross reactivity to NTM (non-tuberculosis mycobacteria), are independent of BCG-vaccination status and correlate better with the degree of exposure than does the TST.

Maternal and neonatal outcomes in obese women who lose weight during pregnancy.

OBJECTIVE: To evaluate neonatal and maternal outcomes in obese pregnant women whose weight gain differed from the Institute of Medicine (IOM) recommendations. STUDY DESIGN: Maternal and neonatal outcomes associated with weight change in pregnancy were retrospectively investigated in women with obesity (body mass index (BMI) ⩾30 kg m(-2); N=10734) who gave birth at 12 hospitals. Using a 1:1:1:1 design (n=778 matched groups), we matched women with obesity who lost, maintained, gained appropriate (IOM recommended) and gained excessive weight during pregnancy by gestational age at delivery, maternal age, race/ethnicity, prepregnancy BMI, chronic hypertension, pregestational diabetes and smoking status. Regression techniques were used to adjust for confounders and compare outcomes across weight change categories. RESULT: Compared with IOM recommendations, weight loss was associated with twofold greater odds of low birth weight infants and a mean decrease in estimated blood loss of 30 ml; excessive weight gain was associated with doubled odds of gestational hypertension or preeclampsia, fourfold greater odds of macrosomia and a mean decrease in 5-min APGAR of 0.09. From lost to excessively gained weight, the odds of cesarean delivery increased 1.4 times and mean infant birth weight increased by 197 g. In contrast, the odds of small-for-gestational age were 1.8 times greater for women who lost than gained excessive weight. CONCLUSION: Weight loss in obese pregnant women is associated with increased risk for low birth weight neonates but significantly decreased or maintained risk for other maternal and neonatal morbidities, as compared with appropriate or excessive weight gain. This study supports re-evaluation of the current IOM guidelines for women with obesity.

Prediction of future falls in a community dwelling older adult population using instrumented balance and gait analysis.

BACKGROUND: The role of instrumented balance and gait assessment when screening for prospective fallers is currently a topic of controversial discussion. OBJECTIVES: This study analyzed the association between variables derived from static posturography, instrumented gait analysis and clinical assessments with the occurrence of prospective falls in a sample of community dwelling older people. METHODS: In this study 84 older people were analyzed. Based on a prospective occurrence of falls, participants were categorized into fallers and non-fallers. Variables derived from clinical assessments, static posturography and instrumented gait analysis were evaluated with respect to the association with the occurrence of prospective falls using a forward stepwise, binary, logistic regression procedure. RESULTS: Fallers displayed a significantly shorter single support time during walking while counting backwards, increased mediolateral to anteroposterior sway amplitude ratio, increased fast mediolateral oscillations and a larger coefficient (Coeff) of sway direction during various static posturography tests. Previous falls were insignificantly associated with the occurrence of prospective falls. CONCLUSION: Variables derived from posturography and instrumented gait analysis showed significant associations with the occurrence of prospective falls in a sample of community dwelling older adults.

Pain intensity attenuates movement control of the lumbar spine in low back pain.

INTRODUCTION: Pain intensity attenuates muscular activity, proprioception, and tactile acuity, with consequent changes of joint kinematics. People suffering from low back pain (LBP) frequently show movement control impairments of the lumbar spine in sagittal plane. This cross-sectional, observational study investigated if the intensity of LBP attenuates lumbar movement control. The hypothesis was that lumbar movement control becomes more limited with increased pain intensity. METHODS: The effect of LBP intensity, measured with a numeric rating scale (NRS), on lumbar movement control was tested using three movement control tests. The lumbar range of motion (ROM), the ratio of lumbar and hip ROM as indicators of direction specific movement control, and the recurrence and determinism of repetitive lumbar movement patterns were assessed in ninety-four persons suffering from LBP of different intensity and measured with an inertial measurement unit system. Generalized linear models were fitted for each outcome. RESULTS: Lumbar ROM (+ 0.03°, p = 0.24) and ratio of lumbar and hip ROM (0.01, p = 0.84) were unaffected by LBP intensity. Each one point increase on the NRS resulted in a decrease of recurrence and determinism of lumbar movement patterns (-3.11 to -0.06, p ⩽ 0.05). DISCUSSION: Our results indicate changes in movement control in people suffering from LBP. Whether decreased recurrence and determinism of lumbar movement patterns are intensifiers of LBP intensity or a consequence thereof should be addressed in a future prospective study.

Concurrent validity and reliability of a novel wireless inertial measurement system to assess trunk movement.

INTRODUCTION: Assessment of movement dysfunctions commonly comprises trunk range of motion (ROM), movement or control impairment (MCI), repetitive movements (RM), and reposition error (RE). Inertial measurement unit (IMU)-systems could be used to quantify these movement dysfunctions in clinical settings. The aim of this study was to evaluate a novel IMU-system when assessing movement dysfunctions in terms of concurrent validity and reliability. METHODS: The concurrent validity of the IMU-system was tested against an optoelectronic system with 22 participants. The reliability of 14 movement dysfunction tests were analysed using generalizability theory and coefficient of variation, measuring 24 participants in seven trials on two days. RESULTS: The IMU-system provided valid estimates of trunk movement in the primary movement direction when compared to the optoelectronic system. Reliability varied across tests and variables. On average, ROM and RM were more reliable, compared to MCI and RE tests. DISCUSSION: When compared to the optoelectronic system, the IMU-system is valid for estimates of trunk movement in the primary movement direction. Four ROM, two MCI, one RM, and one RE test were identified as reliable and should be studied further for inter-subject comparisons and monitoring changes after an intervention.

[Efficacy and sustainability of a smoking prevention program for pupils--"ohnekippe"]. / Wirksamkeit und Nachhaltigkeit eines Raucher-präventionsprogramm für Schüler--"ohnekippe"

BACKGROUND: Since 2000 the Thoraxklinik Heidelberg offers the primary smoking prevention program "ohnekippe" for children aged 12-14 years. This program was scientifically evaluated to test its efficacy and sustainability. METHODS: All pupils participating in this prevention program (n=1427) were asked to complete a written survey regarding their smoking behaviour at the time of intervention (baseline) and after one year. A control group (n=1412) without intervention from comparable schools and grades were questioned in parallel. Afterwards the program was modified with active involvement of schools and then data regarding smoking prevalence of young people were compared based on the microcensus 2005 and 2009. RESULTS: 187 (13,4 %) pupils in the intervention and 215 (15,4 %) pupils in the control group were smokers at baseline. One year after, the number of regular and occasional smokers had increased from 11.2 % to 21.2 % in both groups without significant differences. Besides age and initial smoking status the "peer group" had important influence on smoking behaviour of young people. After modifying the program the number of smoking young people in the catchment area of "ohnekippe" has decreased significantly (7.8 %). Overall smoking prevalence in this age group was much lower (11,8 %) than in the rest of Baden-Württemberg (16.0 %) and of Germany (17.5 %). CONCLUSION: Smoking prevention programs for young people can be effective if they are appropriately designed. Not only one prevention event, but intensive preparation and follow-up in schools as well as involvement of the "peer group" is essential for a successful intervention. After appropriate modification the smoking prevention program "ohnekippe" shows highly promising success.

Double-stranded RNA induces molecular and inflammatory signatures that are directly relevant to COPD.

Polyinosinic:polycytidylic acid (poly I:C) is a synthetic analogue of double-stranded (ds)RNA, a molecular pattern associated with viral infections, that is used to exacerbate inflammation in lung injury models. Despite its frequent use, there are no detailed studies of the responses elicited by a single topical administration of poly I:C to the lungs of mice. Our data provides the first demonstration that the molecular responses in the airways induced by poly I:C correlate to those observed in the lungs of chronic obstructive pulmonary disease (COPD) patients. These expression data also revealed three distinct phases of response to poly I:C, consistent with the changing inflammatory cell infiltrate in the airways. Poly I:C induced increased numbers of neutrophils and natural killer cells in the airways, which were blocked by CXCR2 and CCR5 antagonists, respectively. Using gene set variation analysis on representative clinical data sets, gene sets defined by poly I:C-induced differentially expressed genes were enriched in the molecular profiles of COPD but not idiopathic pulmonary fibrosis patients. Collectively, these data represent a new approach for validating the clinical relevance of preclinical animal models and demonstrate that a dual CXCR2/CCR5 antagonist may be an effective treatment for COPD patients.

Mechanisms of clearance of nontypeable Haemophilus influenzae from cigarette smoke-exposed mouse lungs.

Inflammation is prevalent in all stages of chronic obstructive pulmonary disease, and, furthermore, individuals undergo periods of exacerbation, during which pulmonary inflammation increases, often a result of bacterial infection. The present study investigates the in vivo consequences of cigarette smoke exposure on bacterial challenge with nontypeable Haemophilus influenzae (NTHi). BALB/c and C57 black 6 (C57BL/6) mice were exposed to cigarette smoke once or twice daily for a total period of 8 weeks. Exacerbated inflammation was observed in cigarette smoke-exposed compared to room-air-exposed mice following challenge with live or heat-inactivated NTHi. Accelerated clearance of live NTHi from cigarette smoke-exposed mice was independent of the establishment of chronic inflammation or direct toxic effects of cigarette smoke components on bacteria. Mechanistically, a cell-free factor in the bronchoalveolar lavage fluid contributed to accelerated clearance following passive transfer to naive mice. Further investigation demonstrated increased titres of immunoglobulin A in the bronchoalveolar lavage fluid, but not the blood, of cigarette smoke-exposed mice, including increased titres of NTHi-specific immunoglobulin A, whereas heavy chain joining element (J(H))(-/-) B-cell-deficient cigarette smoke-exposed mice did not demonstrate decreased bacterial burden following challenge. The present results demonstrate that cigarette smoke exposure results in exacerbated inflammation following challenge with NTHi, as well as increased titres of antibodies that contribute to bacterial clearance.

[Reliability of static posturography in elderly persons]. / Reliabilität der statischen Posturografie bei älteren Personen.

BACKGROUND AND OBJECTIVE: Static posturography is used to quantify body sway. It is used to assess the balance of elderly persons who are prone to falls. There is still no general opinion concerning the reliability of force platform measurements. The aim of this study was to test the reliability of force platform parameters when measuring elderly persons. PROBANDS AND METHODS: The reliability of 11 force platform parameters was tested measuring 30 elderly persons. The following parameters were calculated: mean speed of center of pressure displacement in mm/s, length of sway in mm, sway area in mm(2), amplitudes of center of pressure movement, the axis of oscillation in degrees and the person's angles of inclination in degrees. Three measurements were taken on the same day, with a resting period of 2 min. Four different test conditions were used: normal standing and narrow stand with eyes open and eyes closed, respectively. Reliability was determined by using intraclass correlation coefficients. RESULTS: Six parameters had excellent reliability with a correlation coefficient of >0.9: mean speed of center of pressure movement during narrow stand, area of sway during narrow stand, length of sway during normal and narrow stand, and the angle of inclination in the sagittal plane during normal stand and narrow stand. The condition "narrow stand eyes closed" proved to be the most reliable test position. CONCLUSION: Six parameters proved to have excellent reliability and are recommended to be used in further investigations. Narrow stand with eyes closed should be used as the test position. The tested protocol proved to be reliable. Whether these parameters can be used to predict falls in elderly persons remains to be investigated.

The influenza virus M2 ion channel protein: probing the structure of the transmembrane domain in intact cells by using engineered disulfide cross-linking.

The influenza A virus M2 integral membrane protein is an ion channel that permits protons to enter virus particles during uncoating of virions in endosomes, and it also modulates the pH of the trans-Golgi network in virus-infected cells. M2 protein is a homo-oligomer of 97 residues with a single transmembrane (TM) domain whose residues encompass the pore region of the channel and the biologically active form of the channel is a homotetramer. To understand the structural arrangement of the TM domains, each residue of the TM domain was changed in turn to cysteine, and oxidative disulfide cross-linking used to identify residues in close proximity. Oxidative treatment of M2 protein in membranes using iodine resulted in maximum cross-linking at TM domain residues 27, 34, and 41. Oxidation of M2 protein in membranes using the catalyst Cu(II)(1,10-phenanthroline)3 resulted in cross-linking of many TM domain residues when the reaction was allowed to proceed at 37 degreesC, suggesting that rotational movements of the TM domains in the membrane can occur. However, analysis of the kinetics of disulfide-linked dimer formation showed that TM domain residues 27, 30, 34, 37, and 41 formed most rapidly. Furthermore, when oxidation was performed at 4 degreesC, maximum cross-linking occurred at TM domain residues 27, 30, 34, 37, and 41. These positions correspond to the a and d positions of a heptad repeat. Thus these biochemical data are consistent with the TM domain region of the M2 tetramer forming a four-helix bundle. Analysis of the disulfide bonds that formed when oxidation of M2 protein in membranes was performed at pH 5.2 showed greatly reduced cross-linking at TM domain residues 40, 42, and 43 than that found at pH 7.4. This pH-dependent change in cross-linking of residues toward the cytoplasmic side of the TM domain parallels with the activation of the M2 ion channel at low pH.

Stapling techniques for easy construction of an ileal J-pouch.

A technique for the extended use of GIA and EEA or ILS staplers in the easy construction of an ileal J-pouch and mucosal proctectomy has been described herein. The technique for construction of the J-pouch involves the almost exclusive multiple use of a GIA stapling device. The described mucosal proctectomy techniques use the EEA stapler for good traction and visualization for everted electrocautery suction mucosal dissection. With the use of these techniques, the integrity of the patient's tissue is preserved, suture lines are stronger, and the operating time is greatly reduced.