Evidence-informed and consensus-based statements about SAFEty of Physical Agent Modalities Practice in physiotherapy and rehabilitation medicine (SAFE PAMP): a national Delphi of healthcare scientific societies.

OBJECTIVE: A shared consensus on the safety about physical agent modalities (PAMs) practice in physiotherapy and rehabilitation is lacking. We aimed to develop evidence-informed and consensus-based statements about the safety of PAMs. STUDY DESIGN AND SETTING: A RAND-modified Delphi Rounds' survey was used to reach a consensus. We established a steering committee of the Italian Association of Physiotherapy (Associazione Italiana di Fisioterapia) to identify areas and questions for developing statements about the safety of the most commonly used PAMs in physiotherapy and rehabilitation. We invited 28 National Scientific and Technical Societies, including forensics and lay members, as a multidisciplinary and multiprofessional panel of experts to evaluate the nine proposed statements and formulate additional inputs. The level of agreement was measured using a 9-point Likert scale, with consensus in the Delphi Rounds assessed using the rating proportion with a threshold of 75%. RESULTS: Overall, 17 (61%) out of 28 scientific and technical societies participated, involving their most representative members. The panel of experts mainly consisted of clinicians (88%) with expertise in musculoskeletal (47%), pelvic floor (24%), neurological (18%) and lymphatic (6%) disorders with a median experience of 30 years (IQR=17-36). Two Delphi rounds were necessary to reach a consensus. The final approved criteria list comprised nine statements about the safety of nine PAMs (ie, electrical stimulation neuromodulation, extracorporeal shock wave therapy, laser therapy, electromagnetic therapy, diathermy, hot thermal agents, cryotherapy and therapeutic ultrasound) in adult patients with a general note about populations subgroups. CONCLUSIONS: The resulting consensus-based statements inform patients, healthcare professionals and policy-makers regarding the safe application of PAMs in physiotherapy and rehabilitation practice. Future research is needed to extend this consensus on paediatric and frail populations, such as immunocompromised patients.

Enhanced solute transport and steady mechanical stimulation in a novel dynamic perifusion bioreactor increase the efficiency of the in vitro culture of ovarian cortical tissue strips.

Introduction: We report the development and preliminary evaluation of a novel dynamic bioreactor to culture ovarian cortical tissue strips that leverages tissue response to enhanced oxygen transport and adequate mechanical stimulation. In vitro multistep ovarian tissue static culture followed by mature oocyte generation, fertilization, and embryo transfer promises to use the reserve of dormant follicles. Unfortunately, static in vitro culture of ovarian tissue does not promote development of primordial to secondary follicles or sustain follicle viability and thereby limits the number of obtainable mature oocytes. Enhancing oxygen transport to and exerting mechanical stimulation on ovarian tissue in a dynamic bioreactor may more closely mimic the physiological microenvironment and thus promote follicle activation, development, and viability. Materials and Methods: The most transport-effective dynamic bioreactor design was modified using 3D models of medium and oxygen transport to maximize strip perifusion and apply tissue fluid dynamic shear stresses and direct compressive strains to elicit tissue response. Prototypes of the final bioreactor design were manufactured with materials of varying cytocompatibility and assessed by testing the effect of leachables on sperm motility. Effectiveness of the bioreactor culture was characterized against static controls by culturing fresh bovine ovarian tissue strips for 7 days at 4.8 × 10-5 m/s medium filtration flux in air at -15% maximal total compressive strain and by assessing follicle development, health, and viability. Results and Conclusions: Culture in dynamic bioreactors promoted effective oxygen transport to tissues and stimulated tissues with strains and fluid dynamic shear stresses that, although non-uniform, significantly influenced tissue metabolism. Tissue strip culture in bioreactors made of cytocompatible polypropylene preserved follicle viability and promoted follicle development better than static culture, less so in bioreactors made of cytotoxic ABS-like resin.

Impact of prepubertal bovine ovarian tissue pre-freeze holding duration on follicle quality.

Ovarian tissue cryopreservation prior to gonadotoxic treatment is the only recommended option for fertility preservation in prepubertal girls. Due to the technical complexity of this technique, limited number of centres across the world are equipped to offer the facility. Hence, the retrieved ovarian tissue needs to be maintained at hypothermic temperature (4 °C) for long time during shipment. The time taken between tissue retrieval and cryopreservation could influence the functionality of cells during fertility restoration. This study explored the tissue integrity and follicle quality of ovarian cortical slices subjected to pre-freeze holding for various time durations in vitro. Prepubertal bovine ovarian tissue from < 12 months old animals were handled at hypothermic holding (4 °C) for 0, 24, 48 and 72 h. The tissues were assessed for follicle viability through confocal analysis of live-dead labelled samples, and follicle quality and tissue integrity through histology. Results have shown that follicle viability, and overall follicle quality were not significantly affected at the end of 72 h hypothermic holding. Though, the observation reassures extended hypothermic holding prior to freezing, findings need to be validated in human tissue prior to use in clinical fertility preservation programs.

Dynamic in vitro culture of bovine and human ovarian tissue enhances follicle progression and health.

In vitro ovarian cortical tissue culture, followed by culture of isolated secondary follicles, is a promising future option for production of mature oocytes. Although efforts have been made to improve the culture outcome by changing the medium composition, so far, most studies used static culture systems. Here we describe the outcome of 7 days cultures of bovine and human ovarian cortical tissue in a dynamic system using a novel perifusion bioreactor in comparison to static culture in conventional and/or gas permeable dishes. Findings show that dynamic culture significantly improves follicle quality and viability, percentage and health of secondary follicles, overall tissue health, and steroid secretion in both species. Model predictions suggest that such amelioration can be mediated by an enhanced oxygen availability and/or by fluid-mechanical shear stresses and solid compressive strains exerted on the tissue.

Protective effects of a SIRT1 inhibitor on primordial follicle activation and growth induced by cyclophosphamide: insights from a bovine in vitro folliculogenesis system.

PURPOSE: Although oncological advances have improved survival rates of female cancer patients, they often suffer a reduced fertility due to treatment side effects. In the present study, we evaluated the potential fertoprotective effects of the specific inhibitor of SIRT1, EX-527, on the gonadotoxic action exerted by cyclophosphamide (CPM) on loss of primordial follicles (PFs). METHODS: The effects of the CPM metabolite phosphoramide mustard (PM) on follicle activation, growth and viability and the protective action of EX-527 against PM effects were evaluated on bovine ovarian cortical strips in vitro cultured for 1 or 6 days. To understand whether PFs exposed to PM plus EX-527 were able to activate and grow to the secondary stage after suspension of the treatment, strips cultured for 3 days in PM plus EX-527 for 3 days were transferred to plain medium until day 6. Follicle growth and health were evaluated through histology and viability assay at a confocal microscope. In order to investigate the molecular pathways underlying the ovarian response to PM in the presence of EX-527, we analysed the protein level of SIRT1, HuR, PARP1 and SOD2 after 1 day of in vitro culture. RESULTS: We found that (1) PM, the main CPM active metabolite, promotes PF activation; (2) the ovarian stress response induced by PM includes a SIRT1-dependent pathway; and (3) EX-527 reduces PF activation and growth induced by PM. CONCLUSION: SIRT1 can represent a candidate molecule to be targeted to protect ovarian follicles from alkylating agents and EX-527 could represent a potential fertoprotective agent for cancer patients.

Up-Down Chair: A novel mechatronic device to assess otolith function in patients with vestibular disorders.

This paper describes a novel mechatronic platform, named "Up-Down Chair" (UDC), aimed at investigating otolith function in patients with vestibular disorders. The UDC was designed to provide a wide range of repeatable and controllable vertical oscillations of the head whose kinematic features match those encountered during daily activities. The following parameters were assessed to characterize the performance of the UDC: accordance between expected and measured kinematics in both loaded and unloaded conditions; Dynamic Visual Acuity (DVA) of a group of 15 healthy subjects who were asked to identify a set of Snellen optotypes while being repeatedly moved at different perturbation intensities. Results revealed a good agreement between expected and measured kinematic patterns, and excellent reliability of DVA assessed across enrolled participants. In addition, we observed that the proposed paradigm was effective in inducing oscillopsia in enrolled subjects and that the frequency of the oscillation significantly induced blurred vision during the experimental tests. The UDC appears to be usable as a complementary vestibular clinical test to investigate the effects of therapeutic treatments while applying a wide range of physiological stimuli compatible with those encountered during daily activities.

Prior-to- and Post-Impact Fall Detection Using Inertial and Barometric Altimeter Measurements.

This paper investigates a fall detection system based on the integration of an inertial measurement unit with a barometric altimeter (BIMU). The vertical motion of the body part the BIMU was attached to was monitored on-line using a method that delivered drift-free estimates of the vertical velocity and estimates of the height change from the floor. The experimental study included activities of daily living of seven types and falls of five types, simulated by a cohort of 25 young healthy adults. The downward vertical velocity was thresholded at 1.38 m/s, yielding 80% sensitivity (SE), 100% specificity (SP) and a mean prior-to-impact time of 157 ms (range 40-300 ms). The soft falls, i.e., those with downward vertical velocity above 0.55 m/s and below 1.38 m/s were analyzed post-impact. Six fall detection methods, tuned to achieve 100% SE, were considered to include features of impact, change of posture and height, singularly or in association with one another. No single feature allowed for 100% SP. The detection accuracy marginally improved when the height change was considered in association with either the impact or the change of posture; the post-impact fall detection method that analyzed the impact and the change of posture together achieved 100% SP.

A real-time research platform to study vestibular implants with gyroscopic inputs in vestibular deficient subjects.

Researchers have succeeded in partly restoring damaged vestibular functionality in several animal models. Recently, acute interventions have also been demonstrated in human patients. Our previous work on a vestibular implant for humans used predefined stimulation patterns; here we present a research tool that facilitates motion-modulated stimulation. This requires a system that can process gyroscope measurements and send stimulation parameters to a hybrid vestibular-cochlear implant in real-time. To match natural vestibular latencies, the time from sensor input to stimulation output should not exceed 6.5 ms. We describe a system based on National Instrument's CompactRIO platform that can meet this requirement and also offers floating point precision for advanced transfer functions. It is designed for acute clinical interventions, and is sufficiently powerful and flexible to serve as a development platform for evaluating prosthetic control strategies. Amplitude and pulse frequency modulation to predetermined functions or sensor inputs have been validated. The system has been connected to human patients, who each have received a modified MED-EL cochlear implant for vestibular stimulation, and patient tests are ongoing.

A sensor fusion method for tracking vertical velocity and height based on inertial and barometric altimeter measurements.

A sensor fusion method was developed for vertical channel stabilization by fusing inertial measurements from an Inertial Measurement Unit (IMU) and pressure altitude measurements from a barometric altimeter integrated in the same device (baro-IMU). An Extended Kalman Filter (EKF) estimated the quaternion from the sensor frame to the navigation frame; the sensed specific force was rotated into the navigation frame and compensated for gravity, yielding the vertical linear acceleration; finally, a complementary filter driven by the vertical linear acceleration and the measured pressure altitude produced estimates of height and vertical velocity. A method was also developed to condition the measured pressure altitude using a whitening filter, which helped to remove the short-term correlation due to environment-dependent pressure changes from raw pressure altitude. The sensor fusion method was implemented to work on-line using data from a wireless baro-IMU and tested for the capability of tracking low-frequency small-amplitude vertical human-like motions that can be critical for stand-alone inertial sensor measurements. Validation tests were performed in different experimental conditions, namely no motion, free-fall motion, forced circular motion and squatting. Accurate on-line tracking of height and vertical velocity was achieved, giving confidence to the use of the sensor fusion method for tracking typical vertical human motions: velocity Root Mean Square Error (RMSE) was in the range 0.04-0.24 m/s; height RMSE was in the range 5-68 cm, with statistically significant performance gains when the whitening filter was used by the sensor fusion method to track relatively high-frequency vertical motions.

Online decoding of hidden Markov models for gait event detection using foot-mounted gyroscopes.

In this paper, we present an approach to the online implementation of a gait event detector based on machine learning algorithms. Gait events were detected using a uniaxial gyro that measured the foot instep angular velocity in the sagittal plane to feed a four-state left-right hidden Markov model (HMM). The short-time Viterbi algorithm was used to overcome the limitation of the standard Viterbi algorithm, which does not allow the online decoding of hidden state sequences. Supervised learning of the HMM structure and validation with the leave-one-subject-out validation method were performed using treadmill gait reference data from an optical motion capture system. The four gait events were foot strike, flat foot (FF), heel off (HO), and toe off. The accuracy ranged, on average, from 45 ms (early detection, FF) to 35 ms (late detection, HO); the latency of detection was less than 100 ms for all gait events but the HO, where the probability that it was greater than 100 ms was 25%. Overground walking tests of the HMM-based gait event detector were also successfully performed.

A stochastic approach to noise modeling for barometric altimeters.

The question whether barometric altimeters can be applied to accurately track human motions is still debated, since their measurement performance are rather poor due to either coarse resolution or drifting behavior problems. As a step toward accurate short-time tracking of changes in height (up to few minutes), we develop a stochastic model that attempts to capture some statistical properties of the barometric altimeter noise. The barometric altimeter noise is decomposed in three components with different physical origin and properties: a deterministic time-varying mean, mainly correlated with global environment changes, and a first-order Gauss-Markov (GM) random process, mainly accounting for short-term, local environment changes, the effects of which are prominent, respectively, for long-time and short-time motion tracking; an uncorrelated random process, mainly due to wideband electronic noise, including quantization noise. Autoregressive-moving average (ARMA) system identification techniques are used to capture the correlation structure of the piecewise stationary GM component, and to estimate its standard deviation, together with the standard deviation of the uncorrelated component. M-point moving average filters used alone or in combination with whitening filters learnt from ARMA model parameters are further tested in few dynamic motion experiments and discussed for their capability of short-time tracking small-amplitude, low-frequency motions.

Design and evaluation of a new mechatronic platform for assessment and prevention of fall risks.

BACKGROUND: Studying the responses in human behaviour to external perturbations during daily motor tasks is of key importance for understanding mechanisms of balance control and for investigating the functional response of targeted subjects. Experimental platforms as far developed entail a low number of perturbations and, only in few cases, have been designed to measure variables used at run time to trigger events during a certain motor task. METHODS: This work introduces a new mechatronic device, named SENLY, that provides balance perturbations while subjects carry out daily motor tasks (e.g., walking, upright stance). SENLY mainly consists of two independently-controlled treadmills that destabilize balance by suddenly perturbing belts movements in the horizontal plane. It is also provided with force sensors, which can be used at run time to estimate the ground reaction forces and identify events along the gait cycle in order to trigger the platform perturbation. The paper also describes the customized procedures adopted to calibrate the platform and the first testing trials aimed at evaluating its performance. RESULTS: SENLY allows to measure both vertical ground reaction forces and their related location more precisely and more accurately than other platforms of the same size. Moreover, the platform kinematic and kinetic performance meets all required specifications, with a negligible influence of the instrumental noise. CONCLUSION: A new perturbing platform able to reproduce different slipping paradigms while measuring GRFs at run time in order to enable the asynchronous triggering during the gait cycle was designed and developed. Calibration procedures and pilot tests show that SENLY allows to suitably estimate dynamical features of the load and to standardize experimental sessions, improving the efficacy of functional analysis.