Identifying and Overcoming the Barriers to Virtual Electromyography Assessments: A Scoping Review.

Introduction: Electromyography (EMG) assessments have been conducted virtually more frequently in recent years, leading researchers to explore the barriers to EMG assessments in a telehealth setting and how to overcome them. Methods: A scoping review was conducted according to the methodology described by Arksey and O'Malley. A comprehensive search using controlled vocabulary and keywords for two concepts, EMG and telehealth, was conducted using Medline and EMBASE on February 7, 2022. Two independent reviewers screened titles, abstracts, and full-text articles. Two reviewers also extracted the data and described the findings in a descriptive analysis. Results: A total of 248 articles were screened during the abstract and title review, of which 64 full texts were screened for eligibility. Of these, 15 publications met the inclusion criteria. Most articles were published in 2018 or later (66.7%). The most frequently mentioned barrier to conducting a virtual EMG assessment was poor data and signal transmission (53.3%). Another frequently mentioned barrier was poor patient usability (33.3%). Solutions most frequently reported related to patient usability (33.3%). These included interactive instructions and video chat to monitor and provide the patient with technical support. Conclusion: The last 4 years have seen an increase in articles published on EMGs' use in telehealth to monitor or diagnose patients. Further research is required to determine if the proposed solutions have improved clinical outcomes for the patient.

Development of Pressure Sensors to Help Support Community Lymphedema Monitoring: A Scoping Review.

Breast cancer-related lymphedema is a condition occurring after a partial or full mastectomy, where there is a buildup of interstitial fluid in the body, particularly in the upper limb. There is a lack of at-home sensors that can help monitor the progression of lymphedema. The purpose of this scoping review is to gather relevant information on sensors for remote lymphedema monitoring. A literature search of Medline, PubMed, Scopus, Web of Science, and BMC databases yielded 96 studies. A total of six studies were selected for data extraction. Data were extracted from each study and organized into tables for analysis. A total of six different devices were mentioned in the six studies included in the scoping review, divided into wearable and nonwearable sensors. Nonwearable sensors were more likely to be adaptable for remote sensing as they were further along in development and commercially available on the market. Nonwearable sensors are more developed than wearable sensors for the purpose of remote lymphedema monitoring. This review advocates further development and validation of sensors for lymphedema management, particularly for remote monitoring and health assessments.

Assessment of remote ischemic conditioning delivery with optical sensor in acute ischemic stroke: Randomised clinical trial protocol.

BACKGROUND: Remote ischemic conditioning (RIC) is delivered by a blood pressure cuff over the limb, raising pressure 50 mmHg above the systolic blood pressure, to a maximum of 200 mmHg. The cuff is inflated for five minutes and then deflated for five minutes in a sequential ischemia-reperfusion cycle 4-5 times per session. Elevated pressure in the limb may be associated with discomfort and consequently reduced compliance. Continuous assessment of relative blood concentration and oxygenation with a tissue reflectance spectroscopy (a type of optical sensor device) placed over the forearm during the RIC sessions of the arm will allow us to observe the effect of inflation and deflation of the pressure cuff. We hypothesize, in patients with acute ischemic stroke (AIS) and small vessel disease, RIC delivered together with a tissue reflectance sensor will be feasible. METHODS: The study is a prospective, single-center, randomized control trial testing the feasibility of the device. Patients with AIS within 7 days from symptoms onset; who also have small vessel disease will be randomized 2:1 to intervention or sham control arms. All patients randomized to the intervention arm will receive 5 cycles of ischemia/reperfusion in the non-paralyzed upper limb with a tissue reflectance sensor and patients in the sham control arm will receive pressure by keeping the cuff pressure at 30 mmHg for 5 minutes. A total of 51 patients will be randomized, 17 in the sham control arm and 34 in the intervention arm. The primary outcome measure will be the feasibility of RIC delivered for 7 days or at the time of discharge. The secondary device-related outcome measures are fidelity of RIC delivery and the completion rate of intervention. The secondary clinical outcome includes a modified Rankin scale, recurrent stroke and cognitive assessment at 90 days. DISCUSSION: RIC delivery together with a tissue reflectance sensor will allow insight into the blood concentration and blood oxygenation changes in the skin. This will allow individualized delivery of the RIC and improve compliance. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05408130, June 7, 2022.

Technologies measuring manual wheelchair propulsion metrics: a scoping review.

The aim of this review is to investigate existing and developing technologies assessing metrics of manual wheelchair propulsion. A scoping review of scientific and gray literature was performed. Five databases were searched - Medline, Scopus, CINAHL, Institute of Electrical and Electronics Engineers (IEEE), and Embase. The 38 retained articles identified 27 devices categorized into accelerometers, wheelchair-mounted devices, instrumented wheels, and wearables. The devices included in this review can be used by manual wheelchair users to monitor propulsion effort and activity goals, by clinicians to assess rehabilitation programs, and to inform and guide future research. The findings support a need for further research into the development of custom algorithms for manual wheelchair user populations as well as further validation in broader free-living environments with equitable participant populations.

The Effect of Fatigue on Wheelchair Users' Upper Limb Muscle Coordination Patterns in Time-Frequency and Principal Component Analysis.

An assessment of shoulder muscle coordination patterns is important to gain insight into muscle fatigue during wheelchair propulsion. The objective of the present study was to quantify muscle coordination changes over time during fatiguing wheelchair propulsion, as the muscles go through distinct levels of fatigue, a) non-fatigued, b) transiting to fatigue and c) fatigued to exhaustion. We recorded surface electromyography (sEMG) signals of the anterior deltoid (AD), middle deltoid (MD), posterior deltoid (PD), infraspinatus (IS), upper trapezius (UT), sternal head of the pectoralis major (PM), biceps brachii (BB), and triceps brachii (TB) during a wheelchair incremental exercise test. Nine wheelchair users with a diagnosis of spina bifida or T6-T12 spinal cord injury volunteered for the study. Oxygen uptake and SmartWheel kinetic parameters were also recorded during the test. EMG signals were processed by wavelet and principal component analysis (PCA), allowing for an assessment of how wheelchair users modify their muscle coordination patterns over time. Analyses of covariance (ANCOVA) were conducted to identify the main effect of fatigue levels on muscle coordination patterns by controlling for the effect of increased workload as covariate. A significant effect of fatigue levels on the PC1 and PC3 loading scores was found after controlling for the effect of increasing workloads (with both cases). In addition, PC3 reflects the most dominant fatigue effect on muscle coordination patterns which are not affected by increased ergometer workload. PC3 indicates muscle imbalance when muscles are fully fatigued and muscle co-contraction when muscles are beginning to fatigue. We conclude that fatigue-related changes in neuromuscular activity during wheelchair propulsion contribute to muscle imbalance and reflect a strategy of stiffening the shoulder joint.

Balancing Access with Technology: Comparing In-Person and Telerehabilitation Berg Balance Scale Scores among Stroke Survivors.

Purpose: Stroke survivors living in rural and remote communities experience challenges in accessing specialized rehabilitation services. Access to balance assessment after stroke is an essential aspect of the physiotherapy assessment. Telerehabilitation (TRH) can eliminate access disparities; however, adoption into practice has been limited. Our primary objective was to examine agreement between Berg Balance Scale (BBS) scores obtained through TRH and those obtained through traditional in-person assessment of community-dwelling individuals with stroke. Method: Two raters administered the BBS to 20 community-dwelling individuals with stroke, using both TRH and traditional in-person approaches. The order of assessments and rater assignment was randomized. Interrater reliability between the methods was assessed using Krippendorff's α reliability estimate. A survey was then administered to examine the participants' perceptions of the two means of assessment. Results: Excellent interrater agreement was found between TRH and in-person assessment (κ = 0.97; 95% CI: 0.96, 0.99), and responses regarding patients' perceived hearing and understanding of instructions as well as perceived safety were comparable. In addition, the vast majority of participants agreed or strongly agreed that they would use TRH for future physiotherapy sessions. Conclusions: The results of this study support administration of the BBS using TRH technology; this could improve access to balance assessment for stroke survivors in rural and remote communities.

Objectif : les survivants d'un accident vasculaire cérébral (AVC) qui vivent en région rurale ou éloignée éprouvent de la difficulté à accéder à des services de réadaptation spécialisés. L'accès à une évaluation de l'équilibre après un AVC est un aspect essentiel de l'évaluation physiothérapique. La téléréadaptation peut éliminer les disparités d'accès, mais sa mise en pratique est limitée. Les chercheurs se sont donné comme objectif principal d'examiner la concordance entre les scores de l'échelle d'évaluation de l'équilibre de Berg (ÉÉÉB) obtenus par transmission vidéo grâce à la téléréadaptation et ceux obtenus par les évaluations physiques habituelles chez des personnes victimes d'un AVC habitant dans la communauté. Méthodologie : deux évaluateurs ont mesuré le score de la BBS chez 20 personnes ayant subi un AVC habitant dans la communauté, à la fois par la téléréadaptation et par l'approche physique habituelle. Ils ont établi l'ordre d'évaluation et l'affectation des évaluateurs au hasard, ont déterminé la fiabilité interévaluateur des deux méthodes au moyen du coefficient alpha de Krippendorff et ont ensuite réalisé un sondage pour connaître les perceptions de participants à l'égard des deux évaluations. Résultats : les chercheurs ont constaté une excellente concordance interévaluateur entre la téléréadaptation et l'évaluation physique (κ = 0,97; IC à 95 % : 0,96, 0,99), et les patients ont entendu et compris les directives et se sont sentis en sécurité selon un ordre de perception comparable. De plus, la grande majorité d'entre eux ont convenu ou fortement convenu qu'ils utiliseraient la vidéoconférence pour leurs futures séances de physiothérapie. Conclusion : les résultats de cette étude appuient l'utilisation de l'ÉÉÉB en téléréadaptation, ce qui pourrait améliorer l'accès des survivants d'un AVC qui vivent en région rurale ou éloignée à l'évaluation de l'équilibre.

Motion sickness and sense of presence in a virtual reality environment developed for manual wheelchair users, with three different approaches.

Visually Induced Motion Sickness (VIMS) is a bothersome and sometimes unsafe experience, frequently experienced in Virtual Reality (VR) environments. In this study, the effect of up to four training sessions to decrease VIMS in the VR environment to a minimal level was tested and verified through explicit declarations of all 14 healthy participants that were recruited in this study. Additionally, the Motion Sickness Assessment Questionnaire (MSAQ) was used at the end of each training session to measure responses to different aspects of VIMS. Total, gastrointestinal, and central motion sickness were shown to decrease significantly by the last training session, compared to the first one. After acclimatizing to motion sickness, participants' sense of presence and the level of their motion sickness in the VR environment were assessed while actuating three novel and sophisticated VR systems. They performed up to four trials of the Illinois agility test in the VR systems and the real world, then completed MSAQ and Igroup Presence Questionnaire (IPQ) at the end of each session. Following acclimatization, the three VR systems generated relatively little motion sickness and high virtual presence scores, with no statistically meaningful difference among them for either MSAQ or IPQ. Also, it was shown that presence has a significant negative correlation with VIMS.

Investigating the test-retest reliability of Illinois Agility Test for wheelchair users.

The Illinois Agility Test (IAT) is a standard agility course used to assess and train able-bodied athletes as well as wheelchair-sport athletes and rehabilitation of wheelchair users. It has been shown to be a reliable and valid tool to assess the able-bodied population, but the reliability of this test for assessing wheelchair propulsion has never been shown. The purpose of this study is to investigate the test-retest reliability of IAT to assess wheelchair propulsion. In this paper, the test-retest reliability of using IAT for wheelchair users is found for peak and average velocity, acceleration, tangential and total force of the push, each for the left and the right wheel. Each of these variables was found for thirty-two decisive points throughout the IAT path. The Intra-class Correlation Coefficient (ICC) was found to be very strong for 15 out of 16 variables. The average ICC was 89% and the average 95% confidence interval was [44% 96%]. In addition, thirty-seven other significant propulsion parameters were found that are clinically important, such as the number of pushes participants take to go around cones on the right, relative to turning around the cones on the left. Also, all thirty-seven variables were compared between the two sessions using four separate MANOVAs; the results showed no significant difference between IAT performed in the two sessions which were at least one week apart. This, in turn, backs the reliability of IAT for wheelchair users. These results are sufficient evidence to show that IAT is a reliable tool to test wheelchair agility for fifteen variables tested for non-wheelchair users. Since experienced wheelchair users are much more consistent in wheelchair propulsion compared to non-wheelchair-users, the results of this study show that IAT can be used as a reliable tool to assess and train wheelchair users, both for clinical and athletic applications.

Virtual Trauma-Focused Therapy for Military Members, Veterans, and Public Safety Personnel With Posttraumatic Stress Injury: Systematic Scoping Review.

BACKGROUND: A necessary shift from in-person to remote delivery of psychotherapy (eg, teletherapy, eHealth, videoconferencing) has occurred because of the COVID-19 pandemic. A corollary benefit is a potential fit in terms of the need for equitable and timely access to mental health services in remote and rural locations. Owing to COVID-19, there may be an increase in the demand for timely, virtual delivery of services among trauma-affected populations, including public safety personnel (PSP; eg, paramedics, police, fire, correctional officers), military members, and veterans. There is a lack of evidence on the question of whether digital delivery of trauma-therapies for military members, veterans, and PSP leads to similar outcomes to in-person delivery. Information on barriers and facilitators and recommendations regarding digital-delivery is also scarce. OBJECTIVE: This study aims to evaluate the scope and quality of peer-reviewed literature on psychotherapeutic digital health interventions delivered remotely to military members, veterans, and PSP and synthesize the knowledge of needs, gaps, barriers to, and facilitators for virtual assessment of and virtual interventions for posttraumatic stress injury. METHODS: Relevant studies were identified using MEDLINE (Medical Literature Analysis and Retrieval System Online), EMBASE (Excerpta Medica dataBASE), APA (American Psychological Association) PsycINFO, CINAHL (Cumulative Index of Nursing and Allied Health Literature) Plus with Full Text, and Military & Government Collection. For collation, analysis, summarizing, and reporting of results, we used the CASP (Critical Skills Appraisal Program) qualitative checklist, PEDro (Physiotherapy Evidence Database) scale, level of evidence hierarchy, PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews), and narrative synthesis. RESULTS: A total of 38 studies were included in this review. Evidence for the effectiveness of digital delivery of prolonged exposure therapy, cognitive processing therapy, behavioral activation treatment with therapeutic exposure to military members, veterans, and PSP was rated level 1a, whereas evidence for cognitive behavioral therapy was conflicting. The narrative synthesis indicated that virtual delivery of these therapies can be as effective as in-person delivery but may reduce stigma and cost while increasing access to therapy. Issues of risk, safety, potential harm (ie, suicidality, enabling avoidance), privacy, security, and the match among the therapist, modality, and patient warrant further consideration. There is a lack of studies on the influences of gender, racial, and cultural factors that may result in differential outcomes, preferences, and/or needs. An investigation into other therapies that may be suitable for digital delivery is needed. CONCLUSIONS: Digital delivery of trauma therapies for military members, veterans, and PSP is a critical area for further research. Although promising evidence exists regarding the effectiveness of digital health within these populations, many questions remain, and a cautious approach to more widespread implementation is warranted.

Wheelchair propulsion fatigue thresholds in electromyographic and ventilatory testing.

STUDY DESIGN: Qualitative study. OBJECTIVE: The objective of the present study are physiological processes occurring when the intensity of manual wheelchair propulsion approaches levels causing muscular fatigue. In particular, we set out to (1) detect the electromyographic (EMG) and ventilatory fatigue threshold during a single wheelchair incremental test, (2) examine the relationship between EMG threshold (EMGT) and ventilatory threshold (VT), and (3) detect the EMG threshold differences between the propulsive and recovery muscle synergies. SETTING: Biomechanics laboratory at the University of Alberta, Canada. METHODS: Oxygen uptake and EMG signals from ten wheelchair users (seven males and three females) were recorded as they were each performing an incremental propulsion bout in their own wheelchairs on a wheelchair ergometer. The V-slope method was used to identify the VT, and the EMGT of each of the eight muscles (anterior deltoid, middle deltoid, posterior deltoid, infraspinatus, upper trapezius, sternal head of pectoralis major, biceps brachii, and triceps brachii) was determined using the bisegmental linear regression method. RESULTS: For each participant, we were able to determine the EMGT and VT from a single incremental wheelchair propulsion bout. EMGT stands in good agreement with VT, and there was a high similarity in EMGT between push and recovery muscles (intraclass correlation coefficient = 0.91). CONCLUSION: The EMG fatigue threshold method can serve as a valid and reliable tool for identifying the onset of muscular fatigue during wheelchair propulsion, thus providing a foundation for automated muscle fatigue detection/prediction in wearable technology.

Investigating the Reliability and Validity of Three Novel Virtual Reality Environments With Different Approaches to Simulate Wheelchair Maneuvers.

Wheelchair manoeuvring has received little attention in the literature despite its importance in mobility and performing activities of daily living and its role in developing secondary injuries for wheelchair users. The focus in this paper was technology development with iterative and proof-of-concept testing. Three versions of a wheelchair simulator that were designed and developed for simulating curvilinear wheelchair propulsion in virtual reality were tested for their validity and reliability. The wheelchair simulators comprise a sophisticated wheelchair ergometer in an immersive virtual reality environment and are developed for manual wheelchair propulsion. These simulators all replicate inertia in translation, in addition to taking three approaches for simulating turning. The three systems were then tested and compared with the real world to see how reliable and valid they are; 15 healthy participants were recruited to perform the Illinois Agility Test (IAT) in two sessions that were at least one week apart. The intraclass correlation coefficient and the Pearson correlation coefficient were found for 16 variables to find the test-retest reliability and convergent construct validity of the systems, respectively. Overall, the three systems showed good validity and reliability with the VR_system 2 (mechanical compensation for rotational inertia) having the best scores and the VR_system 3 (software compensation for rotational inertia) having the lowest scores. Also, it was observed that performing IAT in the real world needed fewer pushes and often accompanied more negative pushes. Participants also used longer strokes in the real world compared to virtual reality environment.

Blood perfusion changes during sacral nerve root stimulation versus surface gluteus electrical stimulation on in seated spinal cord injury.

The objective of this article is to examine dynamic changes of ischial blood perfusion during sacral nerve root stimulation against surface functional electrical stimulation (FES). Fourteen adults with suprasacral spinal cord injury (SCI) were recruited. The gluteal maximus was activated by surface FES or stimulating sacral nerve roots by functional magnetic stimulation (FMS) or a sacral anterior root stimulator implant (SARS). Ischial skin index of hemoglobin (IHB) and oxygenation (IOX) was measured.Skin blood perfusion was significantly higher during FMS than the baseline (IHB 1.05 ± 0.21 before vs.1.08 ± 0.02 during stimulation, p = 0.03; IOX 0.18 ± 0.21 before vs. 0.46 ± 0.30, p = 0.01 during stimulation). Similarly, when using the SARS implant, we also observed blood perfusion significantly increased (IHB 1.01 ± 0.02 before vs.1.07 ± 0.02 during stimulation, p = 0.003; IOX 0.79 ± 0.81 before vs. 2.2 ± 1.21 during stimulation, p = 0.036). Among four participants who completed both the FMS and FES studies, the magnitude of increase in both parameters was significantly higher during FMS. This study demonstrates sacral nerve root stimulation confer better benefit on blood perfusion than applying traditional FES in SCI population.

The Effect of Manual Wheelchair Propulsion Speed on Users' Shoulder Muscle Coordination Patterns in Time-Frequency and Principal Component Analysis.

A rehabilitation program for wheelchair users should be based on a thorough understanding of shoulder muscle coordination patterns. The objective of the study was to quantify the extent to which the muscle electromyographic (EMG) patterns vary with propulsion speed. A total of 11 wheelchair-dependent participants with a diagnosis of spina bifida or T6-T12 spinal cord injury volunteered for the study. Each participant performed a series of wheelchair propulsion bouts at 1m/s, 1.3 m/s, and 1.6m/s. EMG signals of 8 shoulder muscles as well as the physiological and kinetic variables were recorded. Propulsion at 1.6m/s generated significantly higher EMG intensities in biceps brachii, anterior deltoid, pectoralis major, and middle deltoid than at 1m/s and 1.3m/s. The combined wavelet and principal component analysis showed that the faster propulsion speed requires higher push muscle activity in the early push phase and in the phase transitions between alternating push and recovery. Training to strengthen the shoulder flexors to achieve smoother phase transitions could improve rehabilitation outcomes by increasing functional speed while lessening shoulder strain.

Development of Three Versions of a Wheelchair Ergometer for Curvilinear Manual Wheelchair Propulsion Using Virtual Reality.

Although wheelchair ergometers provide a safe and controlled environment for studying or training wheelchair users, until recently they had a major disadvantage in only being capable of simulating straight-line wheelchair propulsion. Virtual reality has helped overcome this problem and broaden the usability of wheelchair ergometers. However, for a wheelchair ergometer to be validly used in research studies, it needs to be able to simulate the biomechanics of real world wheelchair propulsion. In this paper, three versions of a wheelchair simulator were developed. They provide a sophisticated wheelchair ergometer in an immersive virtual reality environment. They are intended for manual wheelchair propulsion and all are able to simulate simple translational inertia. In addition, each of the systems reported uses a different approach to simulate wheelchair rotation and accommodate rotational inertial effects. The first system does not provide extra resistance against rotation and relies on merely linear inertia, hypothesizing that it can provide acceptable replication of biomechanics of wheelchair maneuvers. The second and third systems, however, are designed to simulate rotational inertia. System II uses mechanical compensation, and System III uses visual compensation simulating the influence that rotational inertia has on the visual perception of wheelchair movement in response to rotation at different speeds.

Users' Attitudes Towards Personal Health Records: A Cross-Sectional Pilot Study.

BACKGROUND: Prevention and management of chronic conditions is a priority for many healthcare systems. Personal health records have been suggested to facilitate implementation of chronic care programs. However, patients' attitude towards personal health records (PHRs) can significantly affect the adoption rates and use of PHRs. OBJECTIVES: to evaluate the attitude of patients with Type II diabetes towards using a PHR to manage their condition. METHODS: We used a cross-sectional exploratory pilot study. Fifty-four (54) patients used a PHR to monitor and record their blood glucose levels, diet, and activities for 30 days, and to communicate with their clinicians. At the end of the study, patients responded to a survey based on three constructs borrowed from different technology acceptance frameworks: relative advantage, job fit, and perceived usefulness. A multivariate predictive model was formed using partial least squaring technique (PLS) and the effect of each construct on the patients' attitude towards system use was evaluated. Patients also participated in a semi-structured interview. RESULTS: We found a significant positive correlation between job fit and attitude (JF → ATT = +0.318, p<0.01). There was no statistical evidence of any moderating or mediating effect of other main constructs or any of the confounding factors (i.e., age, gender, time after diagnosed) on attitude. CONCLUSION: The attitude of patients towards using PHR in management of their diabetes was positive. Their attitude was mainly influenced by the extent to which the system helped them better perform activities and self-manage their condition.

Applying ISO 16840-2 Standard to differentiate impact force dissipation characteristics of selection of commercial wheelchair cushions.

Results from applying the International Organization for Standardization (ISO) 16840-2 test method for determining the impact damping characteristics of 35 wheelchair cushions plus a high resilience (HR70) polyurethane reference foam sample are reported. The generation of impact forces when a wheelchair user either transfers onto a cushion or the wheelchair encounters rough terrain or bumps down a step can endanger the viability of tissues, especially if these forces occur repeatedly. The results demonstrate significant differences in the impact force dissipation characteristics of different cushion products but do not reliably identify differences in performance that can be attributed to descriptive information about cushion composition alone. Instead, these results demonstrate that the materials, proprietary design, and construction features of wheelchair cushions in combination dictate impact force dissipation properties. The results of a cluster analysis are used to generate a model that can be used to compare the impact damping properties obtained from the ISO 16840-2 test method with those of a range of cushions and the reference cushion. Manufacturers will therefore be able to provide users and clinicians with information about the impact force dissipation properties of the cushions that will enable them to make more informed product choices for achieving improved comfort and to protect skin integrity.

Safety and Feasibility of Intermittent Electrical Stimulation for the Prevention of Deep Tissue Injury.

Objective: To investigate the safety, feasibility, and acceptability of a novel treatment, intermittent electrical stimulation (IES), for preventing deep tissue injury (DTI) in different healthcare settings. Approach: Testing was conducted in an acute rehabilitation unit of a general hospital, a tertiary rehabilitation hospital, a long-term care facility, and homecare (HC). IES was delivered through surface electrodes placed either directly on the gluteal muscles or through mesh panels inside a specialized garment. Study participants at risk for DTI used the system for an average of 4 weeks. Outcome measures included skin reaction to long-term stimulation, demands on the caregiver, stability of induced muscle contraction, and acceptability as part of the users' daily routine. Results: A total of 48 study participants used the IES system. The system proved to be safe and feasible in all four clinical settings. No pressure ulcers were observed in any of the participants. There was no difference between the clinical settings in patient positioning, ease of finding optimal stimulation site, and patient acceptance. Although donning and doffing time was longer in the long-term care and HC settings than the acute rehabilitation unit and tertiary rehabilitation facility, time required to apply the IES system was <18 min (including data collection). The patients and caregivers did not find the application disruptive and indicated that the stimulation was acceptable as part of their daily routine in over 97% of the time. Innovation and Conclusion: We demonstrated the safety, feasibility, and acceptability of a novel method of IES to prevent DTI in a continuum of healthcare settings.

Pressure changes under the ischial tuberosities during gluteal neuromuscular stimulation in spinal cord injury: a comparison of sacral nerve root stimulation with surface functional electrical stimulation.

OBJECTIVE: To compare the magnitude of interface pressure changes during gluteal maximus contraction by stimulating sacral nerve roots with surface electrical stimulations in patients with spinal cord injuries (SCIs). DESIGN: Pilot interventional study. SETTING: Spinal injury research laboratory. PARTICIPANTS: Adults (N=18) with suprasacral complete SCI. INTERVENTIONS: Sacral nerve root stimulation (SNRS) via a functional magnetic stimulator (FMS) or a sacral anterior root stimulator (SARS) implant; and surface functional electrical stimulation (FES). MAIN OUTCOME MEASURES: Interface pressure under the ischial tuberosity (IT) defined as peak pressure, gradient at peak pressure, and average pressure. RESULTS: With optimal FMS, a 29% average reduction of IT peak pressure was achieved during FMS (mean ± SD: 160.1±24.3mmHg at rest vs 114.7±18.0mmHg during FMS, t5=6.3, P=.002). A 30% average reduction of peak pressure during stimulation via an SARS implant (143.2±31.7mmHg at rest vs 98.5±21.5mmHg during SARS, t5=4.4, P=.007) and a 22% average decrease of IT peak pressure during FES stimulation (153.7±34.8mmHg at rest vs 120.5±26.1mmHg during FES, t5=5.3, P=.003) were obtained. In 4 participants who completed both the FMS and FES studies, the percentage of peak pressure reduction with FMS was slightly greater than with FES (mean difference, 7.8%; 95% confidence interval, 1.6%-14.0; P=.04). CONCLUSIONS: SNRS or surface FES can induce sufficient gluteus maximus contraction and significantly reduce ischial pressure. SNRS via an SARS implant may be more convenient and efficient for frequently activating the gluteus maximus.

Numerical characterization of quasi-static ultrasound elastography for the detection of deep tissue injuries.

Deep tissue injuries are subcutaneous regions of tissue breakdown associated with excessive mechanical pressure for extended period of time. These wounds are currently clinically undetectable in their early stages and result in severe burdens on not only the patients who suffer from them, but the health care system as well. The goal of this work was to numerically characterize the use of quasi-static ultrasound elastography for detecting formative and progressive deep tissue injuries. In order to numerically characterize the technique, finite-element models of sonographic B-mode imaging and tissue deformation were created. These models were fed into a local strain-estimation algorithm to determine the detection sensitivity of the technique on various parameters. Our work showed that quasi-static ultrasound elastography was able to detect and characterize deep tissue injuries over a range of lesion parameters. Simulations were validated using a physical phantom model. This work represents a step along the path to developing a clinically relevant technique for detecting and diagnosing early deep tissue injuries.

Patterns of shoulder muscle coordination vary between wheelchair propulsion techniques.

This study investigated changes in the coordination patterns of shoulder muscles and wheelchair kinetics with different propulsion techniques by comparing wheelchair users' self-selected propulsion patterns with a semicircular pattern adopted after instruction. Wheelchair kinetics data were recorded by Smart(Wheel) on an ergometer, while EMG activity of seven muscles was recorded with surface electrodes on 15 able-bodied inexperienced participants. The performance data in two sessions, first using a self-selected and then the learned semicircular pattern, were compared with a paired t-test. Muscle coordination patterns across seven muscles were analyzed by principal component analysis. The semicircular pattern was characterized by significantly lower push frequency, significantly longer push length, push duration and push distance (p < 0.05, all cases) without a significant increase in push force, when compared with the self-selected pattern. In addition, our results show that in the semicircular propulsion technique, synergistic muscles were recruited in distinct phases and displayed a clearer separation between activities in the push phase and recovery phase muscles. An instruction session in semicircular propulsion technique is recommended for the initial use of a wheelchair after an injury.