A finite element analysis of load distribution during donning and orthostatic posture in the ITOP hybrid subischial socket.

INTRODUCTION: Pressure and shear stresses applied to the stump of a transfemoral amputee wearing a newly designed prosthetic socket have been analyzed by a finite element modeling approach. METHODS: The new socket was developed by the Istituto Tecnico Ortopedico Preneste, and it was named the "hybrid subischial socket." This work aimed at understanding the loads' distribution on the stump surface in 2 operative conditions: at the end of the wearing phase and during the orthostatic posture. The model of the stump was composed of 4 different materials: the femoral bone, the muscle tissue, the fat, and the skin layers. Except for the bone (rigid), the biological tissues were modeled as Neo-Hookean, and their mechanical properties were taken from the literature. The socket was composed of a containment frame, made of carbon fiber composite material, a shell made of flexible silicone, and a liner made of hyperelastic silicone. RESULTS: The results of our simulation show that the main support areas are located in a proper position, in agreement with the ideal principles of this prosthetic design, and the maximum pressures are well below the pain threshold reported in the literature for the same contact areas. CONCLUSIONS: We can conclude that although the upper rim of the socket is well below the ischiatic area, the new socket design allows for a safe and comfortable support of the body weight. This is in agreement with the evidence of a good functionality and acceptance of this prosthetics gathered in the many real applications.

Gait initiation in progressive supranuclear palsy: brain metabolic correlates.

The initiation of gait is a highly challenging task for the balance control system, and can be used to investigate the neural control of upright posture maintenance during whole-body movement. Gait initiation is a centrally-mediated motion achieved in a principled, controlled manner, including predictive mechanisms (anticipatory postural adjustments, APA) that destabilize the antigravitary postural set of body segments for the execution of functionally-optimized stepping. Progressive supranuclear palsy (PSP) is a neurodegenerative disease characterized by early impairment of balance and frequent falls. The neural correlates of postural imbalance and falls in PSP are largely unknown. We biomechanically assessed the APA at gait initiation (imbalance, unloading, and stepping phases) of 26 patients with PSP and 14 age-matched healthy controls. Fourteen of 26 enrolled patients were able to perform valid gait initiation trials. The influence of anthropometric and base-of-support measurements on the biomechanical outcome variables was assessed and removed. Biomechanical data were correlated with clinical findings and, in 11 patients, with brain metabolic abnormalities measured using positron emission tomography and 2-deoxy-2-[18F]fluoro-D-glucose. Patients with PSP showed impaired modulation of the center of pressure displacement for a proper setting of the center of mass momentum and subsequent efficient stepping. Biomechanical measurements correlated with "Limb motor" and "Gait and midline" subscores of the Progressive Supranuclear Palsy Rating Scale. Decreased regional glucose uptake in the caudate nucleus correlated with impaired APA programming. Hypometabolism of the caudate nucleus, supplementary motor area, cingulate cortex, thalamus, and midbrain was associated with specific biomechanical resultants of APA. Our findings show that postural instability at gait initiation in patients with PSP correlates with deficient APA production, and is associated with multiple and distinctive dysfunctioning of different areas of the supraspinal locomotor network. Objective biomechanical measures can help to understand fall-related pathophysiological mechanisms and to better monitor disease progression and new interventions.

Gait Initiation in Parkinson's Disease: Impact of Dopamine Depletion and Initial Stance Condition.

Postural instability, in particular at gait initiation (GI), and resulting falls are a major determinant of poor quality of life in subjects with Parkinson's disease (PD). Still, the contribution of the basal ganglia and dopamine on the feedforward postural control associated with this motor task is poorly known. In addition, the influence of anthropometric measures (AM) and initial stance condition on GI has never been consistently assessed. The biomechanical resultants of anticipatory postural adjustments contributing to GI [imbalance (IMB), unloading (UNL), and stepping phase) were studied in 26 unmedicated subjects with idiopathic PD and in 27 healthy subjects. A subset of 13 patients was analyzed under standardized medication conditions and the striatal dopaminergic innervation was studied in 22 patients using FP-CIT and SPECT. People with PD showed a significant reduction in center of pressure (CoP) displacement and velocity during the IMB phase, reduced first step length and velocity, and decreased velocity and acceleration of the center of mass (CoM) at toe off of the stance foot. All these measurements correlated with the dopaminergic innervation of the putamen and substantially improved with levodopa. These results were not influenced by anthropometric parameters or by the initial stance condition. In contrast, most of the measurements of the UNL phase were influenced by the foot placement and did not correlate with putaminal dopaminergic innervation. Our results suggest a significant role of dopamine and the putamen particularly in the elaboration of the IMB phase of anticipatory postural adjustments and in the execution of the first step. The basal ganglia circuitry may contribute to defining the optimal referent body configuration for a proper initiation of gait and possibly gait adaptation to the environment.

Mechanical Energy Recovery during Walking in Patients with Parkinson Disease.

The mechanisms of mechanical energy recovery during gait have been thoroughly investigated in healthy subjects, but never described in patients with Parkinson disease (PD). The aim of this study was to investigate whether such mechanisms are preserved in PD patients despite an altered pattern of locomotion. We consecutively enrolled 23 PD patients (mean age 64±9 years) with bilateral symptoms (H&Y ≥II) if able to walk unassisted in medication-off condition (overnight suspension of all dopaminergic drugs). Ten healthy subjects (mean age 62±3 years) walked both at their 'preferred' and 'slow' speeds, to match the whole range of PD velocities. Kinematic data were recorded by means of an optoelectronic motion analyzer. For each stride we computed spatio-temporal parameters, time-course and range of motion (ROM) of hip, knee and ankle joint angles. We also measured kinetic (Wk), potential (Wp), total (WtotCM) energy variations and the energy recovery index (ER). Along with PD progression, we found a significant correlation of WtotCM and Wp with knee ROM and in particular with knee extension in terminal stance phase. Wk and ER were instead mainly related to gait velocity. In PD subjects, the reduction of knee ROM significantly diminished both Wp and WtotCM. Rehabilitation treatments should possibly integrate passive and active mobilization of knee to prevent a reduction of gait-related energetic components.

A dynamic multibody model of the physiological knee to predict internal loads during movement in gravitational field.

Obtaining tibio-femoral (TF) contact forces, ligament deformations and loads during daily life motor tasks would be useful to better understand the aetiopathogenesis of knee joint diseases or the effects of ligament reconstruction and knee arthroplasty. However, methods to obtain this information are either too simplified or too computationally demanding to be used for clinical application. A multibody dynamic model of the lower limb reproducing knee joint contact surfaces and ligaments was developed on the basis of magnetic resonance imaging. Several clinically relevant conditions were simulated, including resistance to hyperextension, varus-valgus stability, anterior-posterior drawer, loaded squat movement. Quadriceps force, ligament deformations and loads, and TF contact forces were computed. During anterior drawer test the anterior cruciate ligament (ACL) was maximally loaded when the knee was extended (392 N) while the posterior cruciate ligament (PCL) was much more stressed during posterior drawer when the knee was flexed (319 N). The simulated loaded squat revealed that the anterior fibres of ACL become inactive after 60° of flexion in conjunction with PCL anterior bundle activation, while most components of the collateral ligaments exhibit limited length changes. Maximum quadriceps and TF forces achieved 3.2 and 4.2 body weight, respectively. The possibility to easily manage model parameters and the low computational cost of each simulation represent key points of the present project. The obtained results are consistent with in vivo measurements, suggesting that the model can be used to simulate complex and clinically relevant exercises.

Processing of surface EMG through pattern recognition techniques aimed at classifying shoulder joint movements.

Artificial arms for shoulder disarticulation need a high number of degrees of freedom to be controlled. In order to control a prosthetic shoulder joint, an intention detection system based on surface electromyography (sEMG) pattern recognition methods was proposed and experimentally investigated. Signals from eight trunk muscles that are generally preserved after shoulder disarticulation were recorded from a group of eight normal subjects in nine shoulder positions. After data segmentation, four different features were extracted (sample entropy, cepstral coefficients of the 4th order, root mean square and waveform length) and classified by means of linear discriminant analysis. The classification accuracy was 92.1% and this performance reached 97.9% after reducing the positions considered to five classes. To reduce the computational cost, the two channels with the least discriminating information were neglected yielding to a classification accuracy diminished by just 4.08%.

Influence of an eccentric load added at the back of the head on head-neck posture.

A biomechanical study of the head-neck complex in seated subjects was conducted to verify whether a slight load, applied at the back of the head, could beneficially affect the head-neck posture, one of the factors of postural neck pain. An eccentric load of 0.5 kg was applied to the subjects' head by means of a special cap. A group of asymptomatic subjects (n=10, 28.9±12.1 yrs), and a group of subjects that had experienced mild, occasional neck pain (n=10, 39.6±18.4 yrs) were compared. They were analyzed while maintaining a still posture that was periodically perturbed to avoid habituation. A 3D motion analyzer and reflective markers placed over the head, the neck and the trunk, were used to compute head inclination and translation and head/neck flexion angle in different conditions: before, during and after having had the load applied for 15 min. Although the moment induced by the load was extensor, a forward-oriented movement of the head was observed in both groups. However, the forward displacement, in relation to the initial position, was smaller in the mild neck pain group than in the asymptomatic group (5.7±4.7 mm vs. 8.9±5.5 mm, P<0.05 and 2.6±5.9 mm vs. 11.0±9.0 mm after 15 min, P<0.05). After removing the load, the mild neck pain subjects assumed a retracted position (-3.8±2.7 mm) while the asymptomatic subjects stayed protracted (+3.5±5.1 mm, P<0.01). These unexpected findings suggest that a slight load added to the head can influence the postural control mechanisms and, in symptomatic subjects, lead to a new strategy aimed at a reduction of the neck extensor muscle contraction.

Gait asymmetry of transfemoral amputees using mechanical and microprocessor-controlled prosthetic knees.

BACKGROUND: Amputees walk with an asymmetrical gait, which may lead to future musculoskeletal degenerative changes. The purpose of this study was to compare the gait asymmetry of active transfemoral amputees while using a passive mechanical knee joint or a microprocessor-controlled knee joint. METHODS: Objective 3D gait measurements were obtained in 15 subjects (12 men and 3 women; age 42, range 26-57). Research participants were longtime users of a mechanical prosthesis (mean 20 years, range 3-36 years). Joint symmetry was calculated using a novel method that includes the entire waveform throughout the gait cycle. FINDINGS: There was no significant difference in hip, knee and ankle kinematics symmetry when using the different knee prostheses. In contrast, the results demonstrated a significant improvement in lower extremity joint kinetics symmetry when using the microprocessor-controlled knee. INTERPRETATION: Use of the microprocessor-controlled knee joint resulted in improved gait symmetry. These improvements may lead to a reduction in the degenerative musculoskeletal changes often experienced by amputees.

Comparison of cartilage thickness with radiologic grade of knee osteoarthritis.

OBJECTIVE: To compare joint space width (JSW) measurements obtained from magnetic resonance imaging (MRI) with a semi-automated computer algorithm to the Kellgren and Lawrence grading of osteoarthritis (OA). MATERIALS AND METHODS: Three hundred and six patients (234 female, 72 male) with a mean age of 56.7 years (range 31-81 years) underwent MRI of their knees with a fast oblique spiral spoiled gradient (SPGR) sequence. A board-certified musculoskeletal radiologist graded the OA of all the patients in accordance with the Kellgren and Lawrence OA scale. A previously validated computer algorithm was used to determine the minimum JSW for both the tibiofemoral joint and the patellofemoral joint. An analysis of variance (ANOVA) with the Student-Newman-Kuels post-hoc test was used to determine if there were differences in JSW as a function of OA grade. RESULTS: The radiologic grade of OA was inversely associated with the JSW. In the medial compartment the JSW did not change significantly between grade 1 and grade 2, but there was a significant decrease in JSW between grade 0 (normal) and grade 1 and for each OA grade above grade 2. In the lateral compartment no statistical differences were found till grade 2, while grade 3 was found to be statistically different from the previous one. The number of patients with a grade 4 patellofemoral OA was too low for the statistical significance to be assessed. In the patellofemoral joint the JSW did not change significantly until grade 2, while a statistically significant reduction was found for both grade 3 and grade 4. CONCLUSION: This study showed that an inverse non-linear relationship exists between radiologic grade and JSW. The relationship differs for the tibiofemoral and the patellofemoral joint.

Semiautomated digital analysis of knee joint space width using MR images.

OBJECTIVE: The goal of this study was to (a) develop a semiautomated computer algorithm to measure knee joint space width (JSW) from magnetic resonance (MR) images using standard imaging techniques and (b) evaluate the reproducibility of the algorithm. DESIGN: Using a standard clinical imaging protocol, bilateral knee MR images were obtained twice within a 2-week period from 17 asymptomatic research participants. Images were analyzed to determine the variability of the measurements performed by the program compared with the variability of manual measurements. RESULTS: Measurement variability of the computer algorithm was considerably smaller than the variability of manual measurements. The average difference between two measurements of the same slice performed with the computer algorithm by the same user was 0.004 +/- 0.07 mm for the tibiofemoral joint (TF) and 0.009 +/- 0.11 mm for the patellofemoral joint (PF) compared with an average of 0.12 +/- 0.22 mm TF and 0.13 +/- 0.29 mm PF, respectively, for the manual method. Interuser variability of the computer algorithm was also considerably smaller, with an average difference of 0.004 +/- 0.1 mm TF and 0.0006 +/- 0.1 mm PF compared with 0.38 +/- 0.59 mm TF and 0.31 +/- 0.66 mm PF obtained using a manual method. The between-day reproducibility was larger but still within acceptable limits at 0.09 +/- 0.39 mm TF and 0.09 +/- 0.51 mm PF. This technique has proven consistently reproducible on a same slice base,while the reproducibility comparing different acquisitions of the same subject was larger. Longitudinal reproducibility improvement needs to be addressed through acquisition protocol improvements. CONCLUSION: A semiautomated method for measuring knee JSW from MR images has been successfully developed.