Biofeedback can reduce foot pressure to a safe level and without causing new at-risk zones in patients with diabetes and peripheral neuropathy.

BACKGROUND: Plantar pressure reduction is mandatory for diabetic foot ulcer healing. Our aim was to evaluate the impact of a new walking strategy learned by biofeedback on plantar pressure distribution under both feet in patients with diabetic peripheral neuropathy. METHODS: Terminally augmented biofeedback has been used for foot off-loading training in 21 patients with diabetic peripheral sensory neuropathy. The biofeedback technique was based on a subjective estimation of performance and objective visual feedback following walking sequences. The patient was considered to have learned a new walking strategy as soon as the peak plantar pressure (PPP) under the previously defined at-risk zone was within a range of 40-80% of baseline PPP in 70% of the totality of steps and during three consecutive walking sequences. The PPP was measured by a portable in-shoe foot pressure measurement system (PEDAR(®)) at baseline (T0), directly after learning (T1) and at 10-day retention test (T2). RESULTS: The PPP under at-risk zones decreased significantly at T1 (165 ± 9 kPa, p < 0.0001) and T2 (167 ± 11, p = 0.001), as compared with T0 (242 ± 12 kPa) without any increase of the PPP elsewhere. At the contralateral foot (not concerned by off-loading), the PPP was slightly higher under the lateral midfoot at T1 (68 ± 8 kPa, p = 0.01) and T2 (65 ± 8 kPa, p = 0.01), as compared with T0 (58 ± 6 kPa). CONCLUSIONS: The foot off-loading by biofeedback leads to a safe and regular plantar pressure distribution without inducing any new 'at-risk' area under both feet.

Association between biological markers of sickle cell disease and cognitive functioning amongst Cameroonian children.

BACKGROUND: Some of the major complications of sickle cell disease (SCD) occur in the brain and apart from overt stroke, patients also present with cognitive impairments. We sought to evaluate the prevalence of cognitive deficits as well as their biological predicting factors in young SCD patients in Cameroon. METHODS: The cognitive performances of Cameroonian SCD young patients were evaluated using a neuropsychological test battery assessing four domains of cognitive functioning (executive functions, attention, memory, and sensory-motor skills) previously adapted and normalized on healthy subjects in Yaoundé. FINDINGS: Up to 37.5% of the 96 SCD patients aged 6 to 24 years (M = 13.5, SD = 4.9) had mild-to-severe cognitive deficits. The cognitive deficits tend to increase with age. There was a significant effect of SCD on executive functions and attention, whereas SCD patients performed as well as controls on memory and sensory-motor skills tests. Structural equation models showed a significant association between (a) severe anemia and lower executive functioning, (b) low fetal hemoglobin levels and lower executive functioning and attention, (c) history of cerebrovascular accidents and lower performances in executive functioning, sensory-motor skills, and memory, (d) pathological electroencephalogram and lower attention, and (e) abnormal Transcranial Doppler and lower memory. CONCLUSION: SCD patients in Cameroon presented a very high prevalence of cognitive deficits, with a specific impairment of executive functions and attention. Routine neuropsychological evaluation for early detection of cognitive deficits in SCD patients could represent a cost-effective tool to implement in resource-limited contexts such as in sub-Saharan Africa.

Activation and inhibition of bimanual movements in school-aged children.

The development of motor activation and inhibition was compared in 6-to-12 year-olds. Children had to initiate or stop the externally paced movements of one hand, while maintaining that of the other hand. The time needed to perform the switching task (RT) and the spatio-temporal variables show different age-related evolutions depending on the coordination pattern (in- or anti-phase) and the type of transition (activation, selective inhibition, non selective inhibition) required. In the anti-phase mode, activation perturbs the younger subjects' responses while temporal and spatial stabilities transiently decrease around 9 years when activating in the in-phase mode. Aged-related changes differed between inhibition and activation in the anti-phase mode, suggesting either the involvement of distinct neural networks or the existence of a single network that is reorganized. In contrast, stopping or adding one hand in the in-phase mode shows similar aged-related improvement. We suggest that selectively stopping or activating one arm during symmetrical coordination rely on the two faces of a common processing in which activation could be the release of inhibition.

Biofeedback for foot offloading in diabetic patients with peripheral neuropathy.

AIMS: The reduction of high plantar pressure in diabetic patients with peripheral neuropathy is mandatory for prevention of foot ulcers and amputations. We used a new biofeedback-based method to reduce the plantar pressure at an at-risk area of foot in diabetic patients with peripheral neuropathy. METHODS: Thirteen diabetic patients (age 60.8 +/- 12.3 years, body mass index 29.0 +/- 5.0 kg/m(2)) with peripheral neuropathy of the lower limbs were studied. Patients with memory impairment were excluded. The portable in-shoe foot pressure measurement system (PEDAR) was used for foot offloading training by biofeedback. The learning procedure consisted in sequences of walking (10 steps), each followed by a subjective estimation of performance and objective feedback. The goal was to achieve three consecutive walking cycles of 10 steps, with a minimum of seven steps inside the range of 40-80% of the baseline peak plantar pressure. The peak plantar pressure was assessed during the learning period and at retention tests. RESULTS: A significant difference in peak plantar pressure was recorded between the beginning and the end of the learning period (when the target for plantar pressure was achieved) (262 +/- 70 vs. 191 +/- 53 kPa; P = 0.002). The statistically significant difference between the beginning of learning and all retention tests persisted, even at the 10-day follow-up. CONCLUSIONS: Terminal augmented feedback training may positively affect motor learning in diabetic patients with peripheral neuropathy and could possibly lead to suitable foot offloading. Additional research is needed to confirm the maintenance of offloading in the long term.

Neuropsychology in Cameroon: first normative data for cognitive tests among school-aged children.

INTRODUCTION: Very few normative data on psychometric tests are available in sub-Saharan African countries, in spite of the obvious needs and potential benefits from psychological and neuropsychological examination in these contexts. The goal of the ongoing overall project is to assess the cognitive functioning of Cameroonian school-aged children suffering from Sickle Cell Disease. For this purpose, normative data on psychometric tests adapted to the Cameroonian cultural context had to first be established. METHOD: 125 "healthy" school-aged Cameroonian children were recruited from public schools in the city of Yaounde and were given a battery of 14 cognitive tests assessing executive functions and memory. Criteria for tests inclusions were: simplicity of administration, few verbal demand, and broad cross-cultural applicability. Results allow concluding that the battery is appropriate for neuropsychological evaluation in Cameroon, with the exception of the Block Design test (WISC-IV) and a Verbal Phonemic Fluency test. A factor analysis shows a division of the tests in a four-factors model that is very consistent with the expected measures of the tests. Effects of gender, age, and education are also discussed. CONCLUSION: this study is the first to report normative data on neuropsychological tests among children in Cameroon and constitutes an initial step for the advancement of neuropsychology in this country in particular and in sub-Saharan Africa in general. The battery is currently used in Cameroon with children suffering from Sickle Cell Disease as an aid to detect cerebrovascular complications.

Representation of anatomical constraints in motor imagery: mental rotation of a body segment.

Classically, the mental rotation paradigm has shown that when subjects are asked to judge whether objects that differ in orientation are spatially congruent, reaction times increase with angular discrepancy, although some reports have shown that this is not always the case. Would similar results be obtained with realistic figures of body segments? In this work, the mental rotation of a hand attached to its forearm and arm in anatomically possible and impossible starting positions is compared with the mental rotation of a hammer. The main results show that reaction times increase monotonically with the angle of discrepancy for both stimuli and that the speed of rotation is higher for anatomically possible orientations in the case of the hand. Thus, mental rotation of body segments follows the same empirical rules as objects of another nature, and biomechanical constraints imposed to the motility of these segments can be considered as attributes of the mental representation.

Alpha band power changes in unimanual and bimanual sequential movements, and during motor transitions.

OBJECTIVE: To investigate the cortical activation during execution of unimanual and bimanual synchronous and asynchronous finger sequences, as well as during transitions between those sequences. METHODS: Task-related power (TRPow) analysis of multichannel surface EEG was used to examine the regional oscillatory brain activity in the lower (7.8-9.8 Hz) and upper (10.8-11.8 Hz) alpha band. Unimanual to bimanual, bimanual to unimanual, and unimanual to unimanual transitions, prompted by visual cues, were studied in 10 right handed subjects. RESULTS: (1) Execution of unimanual and bimanual movements was accompanied by a bilateral activation over the central regions. (2) The 7.8-9.8 Hz TRPow decrease was more prominent for left and bimanual movements, suggesting sensitivity of the lower alpha band to task difficulty. (3) No difference in alpha oscillatory activity was found between bimanual synchronous and asynchronous sequences. (4) Transitions between motor sequences were invariably accompanied by a mesioparietal TRPow decrease in the lower alpha band. (5) This mesioparietal activation was contingent to the change of motor program, and could not be accounted for by the change of visual cue, or related attentional processes. CONCLUSION: The 7.8-9.8 Hz mesioparietal activation most likely reflects a posterior parietal motor command initiating transition between motor programs.

Visually induced activity in human frontal motor areas during simple visuomotor performance.

Visuomotor tasks elicit neuronal activity in primate motor areas at relatively short latencies. Although this early activity embodies features of visual responses (short latency, stimulus-dependency), its sensory nature has been questioned. We investigated neural correlates of visuomotor performance in human motor areas using scalp and intracranial event-related potential measures. A simple visuomanual reaction-time task evoked early potentials at 133-145 ms post-stimulus which occurred much earlier than the motor potentials of the same region. The amplitude of the early potentials covaried with stimulus location and was independent of parameters of the motor response. Because of their timing, stimulus-dependency and characteristics of our behavioral task, the early potentials are suggested to reflect neuronal responses of sensory nature rather than processing related to pure motor aspects of the task.

Sequential pointing in children and adults.

The development of visuomotor control in sequential pointing was investigated in 6- to 10-year-old children and in adults. In 3 experiments we manipulated task difficulty by changing the number, the size, and the spacing of the targets in the sequences. In Experiment 4, only 1 movement was required; we varied independently the distance between targets and the distance of the starting point from the participant's body. Children's temporal and spatial parameters of the motor sequences showed large age-dependent trends, but did not reach the adult values. Comparison of performance across levels of difficulty and ages suggests that motor development is not a uniform fine-tuning of stable strategies. Instead, we argue that each stage of development is best characterized by the set of strategic components potentially available at that stage, and by the (age-dependent) rules for the selection of components in a given context.

Evidence for interhemispheric motor-level transfer in a simple reaction time task: an EEG study.

Simple visuomanual reaction time tasks require interhemispheric communication when stimuli are presented in the hemifield opposite the responding hand. Although confirmed in many studies, it is still a matter of debate when, at what functional level and at what site this interhemispheric transfer takes place. To address these questions, we recorded event-related potentials (ERPs) in 12 healthy subjects performing such a task and analyzed the data using techniques based on topographic ERP map characteristics. A method which has proved useful for associating ERP map configurations of different time periods with functional states of the brain was supplemented by a source localization procedure. The results suggest that transfer occurs late in time, on a functional motor level and at frontal sites, at least for left-to-right interhemispheric direction of transfer.

Visuo-manual aiming movements in 6- to 10-year-Old children: evidence for an asymmetric and asynchronous development of information processes.

Sixty children from 6 to 10 years old participated in an open-loop visuo-manual aiming task (Experiment 1). They were asked to point as fast and accurately as possible toward lateralized visual targets. Responses were wrist flexion-extension movements. Results showed non-monotonic changes with age of constant error, reaction time, and movement time. Constant error for targets presented in the right visual field increased between 6 and 8 years and decreased afterward. Reaction time and movement time decreased with age except at 8 years where they tended to increase. The same subjects participated in two control tasks. One task was designed to test the spatial localization of the lateralized visual targets (Experiment 2). Results showed that subjects localized very accurately the targets at all ages. The second control task was designed to test simple reaction time to the same visual stimuli used in the previous tasks (Experiment 3). Results indicate that reaction time decreased linearly with age when no spatial processing is required for the production of the response. The results of the three experiments showed different developmental functions according to the processes involved in each task. Moreover, they suggest that the conversion from visual to motor coordinates undergo a qualitative change at 8 years of age, and that the prevailing process of this conversion is located in the left cerebral hemisphere.

Effects of lexicality and trigram frequency on handwriting production in children and adults.

Recent studies of handwriting have shown that linguistic variables, such as phonology or lexicality, influence various aspects of the production of letter sequences. Following a previous experiment, in which a facilitation effect of words over pseudowords has been documented both in children and in adults, an experiment is reported concerning the effect of lexicality and of trigram frequency on handwriting production at different levels of handwriting mastery. In this experiment, 8- to 12-year-old children and adults were asked to write words, pseudowords ending with a frequent trigram, and pseudowords ending with a nonfrequent trigram. Results show that in adults there is a facilitation effect of words over pseudowords and of frequent trigrams over nonfrequent trigrams. In children, no clear effect of lexicality or trigram frequency could be observed. Developmental trends show that major changes in children's handwriting occur between 8 and 10 years, whereas only minor modifications are observed between 10 and 12 years.

The relationship between motor function and cognition in the developmental perspective.

The relationships between motor functions and cognitive functions in the normal human subject are discussed from three points of view: a priori analysis of the operations involved in the production and control of movement; synchronic experimental data; diachronic experimental data. This evidence is adduced in support of the view that motor function is a cognitive function, a view that runs strongly counter to the concepts at present dominating the domain of motor behavior research. According to the current concepts motor function is almost independent of cognition, except in so far as concerns the ideational aspects preceding motor performance and defining the most general logical characteristics of movement. The theoretical and methodological interest of taking the developmental perspective into account in the study of motor function is emphasized.

Motor strategies in lifting movements: a comparison of adult and child performance.

The experiment compares the performances of children six to nine years old and adults in a simple, monoarticular lifting task. Overt behaviors, as described by the kinematic features of the movement, do not differ qualitatively in the two groups. The patterns of motor commands, as expressed by the electromyographic recordings, are however strikingly different. Adults plan the movement with a careful balance between agonist muscle activity and passive, viscoelastic forces, whereas children use both agonist and antagonist active forces. It is argued that the motor strategy adopted by adults depends upon an internal representation of the properties of the motor system and of the size/weight covariation in natural objects, and that this representation is not yet fully developed at nine years of age.