Pilot Study: Effect of Morton's Extension on the Subtalar Joint Forces in Subjects with Excessive Foot Pronation.

This study focuses on the assessment of the mechanical effect produced by Morton's extension as an orthopedic intervention in patients with bilateral foot pronation posture, through a variation in hindfoot and forefoot prone-supinator forces during the stance phase of gait. A quasi-experimental and transversal research was designed comparing three conditions: barefoot (A); wearing footwear with a 3 mm EVA flat insole (B); and wearing a 3 mm EVA flat insole with a 3 mm thick Morton's extension (C), with respect to the force or time relational to the maximum time of supination or pronation of the subtalar joint (STJ) using a Bertec force plate. Morton's extension did not show significant differences in the moment during the gait phase in which the maximum pronation force of the STJ is produced, nor in the magnitude of the force, although it decreased. The maximum force of supination increased significantly and was advanced in time. The use of Morton's extension seems to decrease the maximum force of pronation and increase supination of the subtalar joint. As such, it could be used to improve the biomechanical effects of foot orthoses to control excessive pronation.

Use of an innovative cuff pressure control and subglottic secretions drainage system in COVID-19 ARDS patients undergoing pronation.

We conducted a proof of concept study where Anapnoguard endotracheal tubes and its control unit were used in 15 patients with COVID-19 acute respiratory distress syndrome. Anapnoguard system provides suction, venting, rinsing of subglottic space and controls cuff pressure detecting air leakage through the cuff. Alpha-amylase and pepsin levels, as oropharyngeal and gastric microaspiration markers, were assessed from 85 tracheal aspirates in the first 72 h after connection to the system. Oropharyngeal microaspiration occurred in 47 cases (55%). Episodes of gastric microaspiration were not detected. Patient positioning, either prone or supine, did not affect alpha-amylase and pepsin concentration in tracheal secretions. Ventilator-associated pneumonia (VAP) rate was 40%. The use of the AG system provided effective cuff pressure control and subglottic secretions drainage. Despite this, no reduction in the incidence of VAP has been demonstrated, compared to data reported in the current COVID-19 literature. The value of this new technology is worth of being evaluated for the prevention of ventilator-associated respiratory tract infections.

Desenvolvimento de Competências Especializadas em Enfermagem na Área da Pessoa em Situação Crítica / Relatório de Estágio - Desenvolvimento de Competências Especializadas em Enfermagem na Área da Pessoa em Situação Crítica / Development of Specialised Competencies in Nursing in the Area of People in Critical Condition

O desenvolvimento da especialidade em Enfermagem Médica Cirúrgica na Área da Pessoa em Situação Critica compreende a aquisição de competências comuns e específicas inerentes à mesma. Os estágios realizados visam contribuir para a formação do enfermeiro especialista, fomentando a prática baseada na evidência na prestação de cuidados de enfermagem, quer pelo próprio quer pelos pares. Neste sentido foi desenvolvido uma investigação-ação no contexto de local de trabalho, na temática da pronação em doentes despertos com dificuldade respiratória. Os objetivos deste trabalho visam evidenciar as competências comuns e específicas adquiridas em Enfermagem Médico-Cirúrgica na Área da Pessoa em Situação Crítica e capacitar os enfermeiros, de um serviço de um hospital da região centro, para a tomada de decisão de pronar doentes com dificuldade respiratória. O trabalho desenvolvido tem cariz quantitativo, correlacional e prospetivo. A partir de uma revisão integrativa da literatura elaborou-se um questionário para avaliação do conhecimento dos enfermeiros sobre a técnica de pronar e um fluxograma sobre tomada de decisão. Após aplicação do fluxograma, como intervenção da técnica de pronar, constituíram-se dois grupos focais, um com enfermeiros especialistas e outro com enfermeiros generalistas. Na fase anterior à aplicação do fluxograma não se observaram a adoção de técnica de pronação. Após formação de pares observaram-se 14 casos com critérios de pronação, dos quais seis foram alvo deste posicionamento. A tomada de decisão foi efetuada por enfermeiros que frequentaram a formação (valor p <0,05), detentores de especialidade (valor p < 0,05). Conclusão: A formação de pares contribuiu para a tomada de decisão no ato de pronar doentes com dificuldade respiratória, sobretudo em enfermeiros especialistas. Abordagens complementares à formação poderão contribuir para uma maior capacitação dos enfermeiros, tais como a construção e divulgação de protocolo de tomada de decisão por meios eletrónicos e presencialmente junto dos profissionais.

The development of the specialty in Medical Surgical Nursing in the area of Critical Care includes the acquisition of common and specific skills inherent to it. The internships aim at contributing to the training of specialist nurses, fostering evidence-based practice in the provision of nursing care, both by the nurse him/herself and his/her peers. In this sense, an action-research study was conducted in the workplace on the topic of pronation in awake patients with respiratory distress. The objectives of this study aimed to identify the common and specific skills acquired in Medical-Surgical Nursing in the area of Critical Care and to empower nurses from a service of a hospital in the central region of Portugal to make the decision to pronate patients with respiratory distress. This study has a quantitative, correlational and prospective nature. Based on an integrative literature review, a questionnaire was designed to assess nurses' knowledge about the pronation technique and a flowchart on decision-making. Após aplicação do fluxograma, como intervenção da técnica de pronar, constituíram dois grupos focais, um com enfermeiros especialistas e outro com enfermeiros geraisistas. In the phase prior to the application of the flowchart, the adoption of the pronation technique was not observed. After pair formation, 14 cases with pronation criteria were observed, of which six were subject to this positioning. Decision-making was performed by nurses who had attended the training (p value <0.05) and who had a specialty (p value < 0.05). Conclusão: A formação de pares contribuiu para a tomada de decisão no ato de pronar doentes com dificuldade respiratória, sobretudo em enfermeiros especialistas. Complementary approaches to training may contribute to nurses' greater empowerment, such as the development and dissemination of a decision-making protocol through electronic and face-to-face means among professionals.

Analysis of anthropometrics and mechanomyography signals as forearm flexion, pronation and supination torque predictors.

This study aimed to analyze anthropometrics and mechanomyography (MMG) signals as forearm flexion, pronation, and supination torque predictors. 25 young, healthy, male participants performed isometric forearm flexion, pronation, and supination tasks from 20 to 100% maximal voluntary isometric contraction (MVIC) while maintaining 90° at the elbow joint. Nine anthropometric measures were recorded, and MMG signals from the biceps brachii (BB), brachialis (BRA), and brachioradialis (BRD) muscles were digitally acquired using triaxial accelerometers. These were then correlated with torque values. Significant positive correlations were found for arm circumference (CA) and MMG root mean square (RMS) values with flexion torque. Flexion torque might be predicted using CA (r = 0.426-0.575), a pseudo for muscle size while MMGRMS (r = 0.441), an indication of muscle activation.

Design of Spiral-Cable Forearm Exoskeleton to Assist Supination for Hemiparetic Stroke Subjects.

We present the development of a cable-based passive forearm exoskeleton that is designed to assist supination for hemiparetic stroke survivors. Our device uniquely provides torque sufficient for counteracting spasticity within a below-elbow apparatus. The mechanism consists of a spiral single-tendon routing embedded in a rigid forearm brace and terminated at the hand and upper-forearm. A spool with an internal releasable-ratchet mechanism allows the user to manually retract the tendon and rotate the hand to counteract involuntary pronation synergies due to stroke. We characterize the mechanism with benchtop testing and five healthy subjects, and perform a preliminary assessment of the exoskeleton with a single chronic stroke subject having minimal supination ability. The mechanism can be integrated into an existing active hand-opening orthosis to enable supination support during grasping tasks, and also allows for a future actuated supination strategy.

The influence of sagittal deformity of the distal radius on pronosupination: a cadaver study.

We performed a cadaver study using seven fresh-frozen adult upper limbs to assess the impact of increasingly larger distal radial deformity in the sagittal plane on the range of motion in pronation/supination. Three palmar (20°, 30° and 40° angulations) and three dorsal (10°, 20° and 30° angulations) tilt deformities, without any radial shortening, were simulated by performing a radial osteotomy and using custom-made three-dimensional-printed anterior plates. We measured the maximum unconstrained pronation and supination before the osteotomy and after each induced deformation. There was a decrease in the median pronation and supination values for all palmar and dorsal tilt deformities. The pronation range was more impaired than the supination range, and dorsal tilt deformities caused the greatest loss in forearm rotation. Our results suggest that forearm rotation in both pronation and supination is reduced as soon as 10° to 20° distal radial deformity occurs in the palmar or dorsal direction.

Complicações cutâneas da hospitalização por COVID-19 relacionadas à pronação / skin complications of hospitalization for COVID-19 related to pronation

Contexto: A pandemia da doença do coronavírus (COVID-19) revelou uma miríade de manifestações sistêmicas e cutâneas possivelmente relacionadas à infecção por síndrome respiratória aguda grave ocasionada pelo coronavírus (SARS-CoV-2). O comprometimento pulmonar é a causa mais frequente de hospitalização e a progressão para síndrome respiratória aguda grave geralmente requer tratamento com ventilação mecânica na posição pronada. Períodos prolongados e repetidos de pronação aumentam o risco de complicações, incluindo úlcera de pressão, cegueira e neuropatia periférica. Descrição do caso: Relatamos três casos de complicações cutâneas relacionadas à ventilação em pronação avaliadas durante interconsultas no maior hospital terciário universitário da América Latina, e salientamos potenciais causas e medidas de prevenção. Discussão: Complicações da ventilação em pronação para tratamento da COVID-19 são provavelmente resultantes da interação entre múltiplos fatores, dentre os quais as condições clínicas do paciente, períodos prolongados na posição pronada e limitações para mudanças de decúbito. Conclusões: Medidas de prevenção para complicações da pronação e diagnóstico precoce são fundamentais para evitar aumento da morbidade e sequelas graves e irreversíveis associadas à COVID-19.

Sensor Verification and Analytical Validation of Algorithms to Measure Gait and Balance and Pronation/Supination in Healthy Volunteers.

Numerous studies have sought to demonstrate the utility of digital measures of motor function in Parkinson's disease. Frameworks, such as V3, document digital measure development: technical verification, analytical and clinical validation. We present the results of a study to (1) technically verify accelerometers in an Apple iPhone 8 Plus and ActiGraph GT9X versus an oscillating table and (2) analytically validate software tasks for walking and pronation/supination on the iPhone plus passively detect walking measures with the ActiGraph in healthy volunteers versus human raters. In technical verification, 99.4% of iPhone and 91% of ActiGraph tests show good or excellent agreement versus the oscillating table as the gold standard. For the iPhone software task and algorithms, intraclass correlation coefficients (ICCs) > 0.75 are achieved versus the human raters for measures when walking distance is >10 s and pronation/supination when the arm is rotated more than two times. Passively detected walking start and end time was accurate to approx. 1 s and walking measures were accurate to one unit, e.g., one step. The results suggest that the Apple iPhone and ActiGraph GT9X accelerometers are fit for purpose and that task and passively collected measures are sufficiently analytically valid to assess usability and clinical validity in Parkinson's patients.

[Malleolar Fractures - Indication for Nonoperative and Operative Treatment]. / Malleolarfrakturen.

Malleolar Fractures - Indication for Nonoperative and Operative Treatment Abstract. In order to understand the trauma mechanism and the expected pattern of injury, malleolar fractures can be classified according to Lauge-Hansen [1]. For isolated lateral malleolar fractures, the Weber classification is also frequently used [2]. For most Weber A fractures and 80% of Weber B fractures conservative treatment is indicated. In all isolated Weber B fractures a supination-external rotation (SER) injury has to be distinguished from a pronation-abduction (PA) injury according to the Lauge-Hansen classification. In SER fractures, stability should be assessed by a gravity stress and a weightbearing radiograph. If the fracture is stable, it can be treated nonoperatively. We recommend surgical treatment for unstable Weber B SER injuries, Weber B PA injuries, and Weber C fractures.

Biomechanical assessment of the central band of the interosseous membrane using shear wave elastography: reliability and reproducibility.

The interosseous membrane of the forearm is an essential structure for the stability of the forearm skeleton, the most important part being the central band. The purpose of this study was to determine if shear wave elastography, a non-invasive ultrasound technique, can be used to measure shear wave speed in the central band and quantify stiffness. Fifteen healthy adult subjects were included (30 forearms). The participants forearms were positioned on an articulated plate, with their hand in neutral, pronated and then supinated positions of 30°, 60° and 90°. The shear wave speed was highest in 90° pronation (4.4 m/s (SD 0.3)) and 90° supination (4.4 m/s (SD 0.27)) indicating maximum stiffness in these positions. Its minimum value was in the neutral position, and either in 30° pronation or supination (3.5 m/s (SD 0.3)). Intra- and interobserver agreement was excellent, regardless of probe positioning or forearm mobilization. This study presents a reliable shear wave elastography measurement protocol to describe the physiological function of the central band of the interosseous membrane in healthy adults.Level of evidence: IV.

A Kinematic Information Acquisition Model That Uses Digital Signals from an Inertial and Magnetic Motion Capture System.

This paper presents a model that enables the transformation of digital signals generated by an inertial and magnetic motion capture system into kinematic information. First, the operation and data generated by the used inertial and magnetic system are described. Subsequently, the five stages of the proposed model are described, concluding with its implementation in a virtual environment to display the kinematic information. Finally, the applied tests are presented to evaluate the performance of the model through the execution of four exercises on the upper limb: flexion and extension of the elbow, and pronation and supination of the forearm. The results show a mean squared error of 3.82° in elbow flexion-extension movements and 3.46° in forearm pronation-supination movements. The results were obtained by comparing the inertial and magnetic system versus an optical motion capture system, allowing for the identification of the usability and functionality of the proposed model.

2021 ISB World Athletics Award for Biomechanics: The Subtalar Joint Maintains "Spring-Like" Function While Running in Footwear That Perturbs Foot Pronation.

Humans have the remarkable ability to run over variable terrains. During locomotion, however, humans are unstable in the mediolateral direction and this instability must be controlled actively-a goal that could be achieved in more ways than one. Walking research indicates that the subtalar joint absorbs energy in early stance and returns it in late stance, an attribute that is credited to the tibialis posterior muscle-tendon unit. The purpose of this study was to determine how humans (n = 11) adapt to mediolateral perturbations induced by custom-made 3D-printed "footwear" that either enhanced or reduced pronation of the subtalar joint (modeled as motion in 3 planes) while running (3 m/s). In all conditions, the subtalar joint absorbed energy (ie, negative mechanical work) in early stance followed by an immediate return of energy (ie, positive mechanical work) in late stance, demonstrating a "spring-like" behavior. These effects increased and decreased in footwear conditions that enhanced or reduced pronation (P ≤ .05), respectively. Of the recorded muscles, the tibialis posterior (P ≤ .05) appeared to actively change its activation in concert with the changes in joint energetics. We suggest that the "spring-like" behavior of the subtalar joint may be an inherent function that enables the lower limb to respond to mediolateral instabilities during running.

Activity-based hand-function profile in preschool children with obstetric brachial plexus palsy.

Obstetric brachial plexus palsy (OBPP) leads to various hand-function disorders. The present study aimed to determine activity-based hand function profiles in preschool children with different OBPP functional levels. 112 children aged 44-77 months were included, and grouped on the Narakas classification: group 1, Narakas type 1; group 2, type 2: and group 3, types 3 + 4. Hand function was evaluated on the Raimondi scale, stereognosis, and the elbow/forearm and wrist/finger/thumb sections of Brachial Plexus Outcome Measure (BPOM). Groups 1 and 2 successfully and comparably completed the BPOM hand activities (p > 0.05), while Group 1 had better results than Group 2 for BPOM elbow/forearm activities (p < 0.001): Group 2 had difficulty in activities involving elbow flexion, supination and pronation, whereas Group 1 had difficulty only in activities involving supination. Comparatively, Group 3 had lower scores for Raimondi scale (p < 0.001), BPOM-hand (p < 0.001), BPOM-elbow/forearm (p < 0.001) and stereognosis (p < 0.001). According to the literature, hand functions are conserved in upper-root brachial plexus injury and there is no need to evaluate them, but our results showed activity restrictions related to hand functions involving forearm rotation. In children with total plexus injury, grasp was absent and thumb function was deficient. The present showed that these restrictions can be identified by population-specific activity-based assessment.

Should Diastatic Syndesmosis be Stabilized in Advanced Pronation-External Rotation Ankle Injuries? A Retrospective Cohort Comparison.

OBJECTIVE: With or without screw stabilization for diastatic syndesmosis in advanced pronation-external rotation (PE) ankle injuries has not yet been well-determined. Both techniques were retrospectively compared to investigate the superiority of either of the two. METHODS: A retrospective cohort study was carried out. From January 1, 2008, to December 31, 2017, 81 consecutive adult patients (average, 42 years; range, 18-78 years; 44 men and 37 women) with advanced PE ankle injuries (stage 3 or 4 PE type) were treated. After malleolar fractures were internally stabilized with screws and plates, the syndesmotic stability was rechecked by external rotation and hook tests. The necessity of cortical screw insertion to stabilize diastatic syndesmosis was decided by the individual orthopaedic surgeon. Postoperatively, a short leg splint was used for 6 weeks. The syndesmotic screw was removed based on the surgeon's policy. The removal of internal fixation for malleolar fractures was required after 1 year. The outcomes of both approaches were compared clinically, and ankle function was compared using the American Orthopaedic Foot and Ankle Society (AOFAS) score. For statistical comparison, the chi-square test was used for categorical data and the Mann-Whitney U test was used for numerical data. RESULTS: Seventy-one patients (average, 40 years; range, 18-78 years; 40 men and 31 women) were followed for at least 1 year (87.7%; average, 2 years; range, 1-11 years). Group 1 (with syndesmotic stabilization) had 22 patients and Group 2 (without syndesmotic stabilization), 49 patients. The union rate in Group 1 patients was 100% (22/22), and in Group 2 patients, 91.8% (45/49; p = 0.17). One deep wound infection occurred in Group 1 patients and two in Group 2 patients. Syndesmosis re-diastasis occurred in 13.6% (3/22) of Group 1 patients and 30.6% (15/49) of Group 2 patients (p = 0.13). One syndesmotic screw broke at 6 months. Satisfactory ankle function according to the AOFAS score was noted in 86.4% (19/22) of Group 1 patients and 65.3% (32/49) of Group 2 patients (p = 0.07). CONCLUSION: Insertion of syndesmotic screws to promote ligament healing after internal fixation of malleolar fractures in advanced PE ankle injuries may be reasonable.

Therapeutic Effect of Tendon Bone Setting Technique and Sports Training on Joint Injury.

Purpose: In this study, we observe the therapeutic influence on tendon and bone setting technique, combined with sports training on joint injury. Methods: Using the random number method, 50 research objects with joint injuries were divided into two groups: treatment group and control group, and each group had 25 cases. The treatment group was combined with sports training with tendon and bone setting technique, and the control group was given intermediate frequency electrotherapy combined with forearm brace fixation. The scores of visual analogue scale (VAS), forearm pronation and postrotation activity, integral electromyogram (iEMG), and research object-rated wrist evaluation (PRWE) were evaluated and compared before and after treatment, and the curative effect observation (blind method was used in the evaluation process) and research object satisfaction were evaluated. Results: After the treatment, the VAS score of two groups decreased, forearm pronation and pronation activity increased, iEMG value increased, and PRWE scale score decreased (p < 0.05), and compared with the control group, the treatment group's curative effect was better (p < 0.05), and compared with the control group, treatment group's total effective rate was higher (p < 0.05). Conclusion: The method of tendon and bone setting combined with sports training could effectively reduce the pain of research objects with joint injury, improve the rotation range of the forearm, increase the recruitment of the pronator muscles, and improve the wrist function of the research objects, and the curative effect was better than that of medium frequency electrotherapy combined with forearm brace fixation.

Changes in spatiotemporal parameters, joint and CoM kinematics and leg stiffness in novice runners during a high-intensity fatigue protocol.

Even though running enjoys growing popularity, the effects of fatigue on the running kinematics of novices have rarely been studied. This is surprising, given the risk of running-related injuries when detrimental movement patterns are adopted. Therefore, the goal of the present study was to characterize the effects of fatigue induced by a high-intensity running protocol on spatiotemporal and stiffness parameters as well as on joint kinematics and center of mass (CoM) motion in novice runners. 14 participants performed a standardized treadmill familiarization and ran at 13 km/h until voluntary exhaustion. Kinematics were captured using a 3D motion capture system. Spatiotemporal and stiffness parameters as well as the range of motion (RoM) of the joints and CoM were compared by use of paired t-tests. Time series of the joint angles and CoM motion were analyzed by the statistical parametric mapping method. The results revealed that novice runners did not change spatiotemporal or stiffness parameters, but showed adaptations in joint kinematics, e.g. decreased dorsiflexion and increased pronation in the ankle joint during the swing phase. The findings of this study underline the importance of strengthening the ankle joint to prevent excessive pronation and increase its stability in novice runners.

Side-to-Side Difference of Metatarsal Rotation in Normal Individuals.

BACKGROUND: A previous study defined the normal first metatarsal pronation angle (MPA) as <16 degrees and normal α angle as <18 degrees. The primary purpose of this study was to assess the side-to-side variation in first metatarsal pronation between feet in normal individuals. METHODS: MPA and α angles were measured on standardized coronal weightbearing computed tomography slices. Pairedt tests were used to test significance of mean side-to-side differences in a population of 63 normal, asymptomatic individuals. RESULTS: The mean side-to-side difference in first metatarsal pronation was 4.3 degrees (95% CI 3.3, 5.2 degrees) for MPA and 4.9 degrees (95% CI 3.8, 6.0 degrees) for α angle. The normative range for side-to-side difference was calculated as 12 degrees for MPA and 14 degrees for α angle, as defined by 2 SDs from the mean. CONCLUSION: In a cohort of normal patients, the mean difference in first metatarsal pronation between sides was approximately 4 to 5 degrees based on MPA and α angle. However, considerable variation in differences was observed. These findings may be considered when assessing first metatarsal pronation using population-based values as it may influence thresholds for identifying pathology in an individual.