Adapting an Outpatient Psychiatric Clinic to Telehealth During the COVID-19 Pandemic: A Practice Perspective.

As the demand for telepsychiatry increases during the COVID-19 pandemic, the strengths and challenges of telepsychiatry implementation must be articulated to improve clinical practices in the long term. Currently, observations within US contexts are lacking; therefore, we report on the rapid implementation of telepsychiatry and workflow experiences in a psychiatric practice based within a large health care system in southeast Texas with a national catchment area. We discuss the logistics of the implementation, including modes of communication, scheduling, coordination, and capacity; the psychological effects of web-based services, including both the loss of the physical therapeutic environment and the unique interpersonal dynamics experienced in the virtual environment; and postadoption patterns of engagement with our services and with other clinical functions affected by the rapid adaptation to telemedicine. Our art therapy group programming serves as an applied case study, demonstrating the value of a well-managed web-based program (eg, patients were receptive and well-engaged, and they appreciated the continuity of accessible service) as well as the challenges (eg, the need for backup plans and technological fallbacks, managing interruptions and telecommunication learning curves, and working around the difference in resources for art and music therapy between a well-stocked clinical setting versus clients' home spaces). We conclude from our experience that the overall strengths of telepsychiatry include receptive and well-engaged responses from patients as well as the expansion of boundaries, which provides a directly contextualized view into patients' home lives. Challenges and corresponding recommendations include the need for more careful safety planning for high-risk patients; maintaining professional boundaries in the newly informal virtual setting; designing the physical space to both frame the patient encounter and maintain work-life balance for the therapist; allowing for delays and interruptions (including an initial acclimation session); and preserving interprofessional care team collaboration when the physical locations that normally facilitate such encounters are not accessible. We believe that careful observations of the strengths and challenges of telepsychiatry during this pandemic will better inform practices that are considering telepsychiatry adoption both within pandemic contexts and more broadly thereafter.

Myrmenaphthol A, Isolated from a Hawaiian Sponge of the Genus Myrmekioderma.

Four compounds (1-4) were isolated from a Hawaiian sponge of the genus Myrmekioderma. Myrmenaphthol A (1) incorporates two unusual elements into an oxidized steroidal core: a naphthyl AB-ring system and a hydroxy group at C-2. A comparison of the experimental and predicted electronic circular dichroism (ECD) spectra of 1 assigned an S configuration to the lone stereocenter (ΔESI = 0.75; similarity factor 0.8137). Known compounds, cinanthrenol A (2), 3,4-dihydroxypregna-5,17-diene-10,2-carbolactone (3), and 3,4-dihydroxypregna-5,20-diene-10,2-carbolactone (4), were also isolated. Despite literature reports of competitive inhibition at nanomolar levels for 2, neither 2 nor the structurally related 1 showed any activity against estrogen receptors at the concentrations tested.

Cytotoxic Sesquiterpenoid Quinones and Quinols, and an 11-Membered Heterocycle, Kauamide, from the Hawaiian Marine Sponge Dactylospongia elegans.

Several known sesquiterpenoid quinones and quinols (1-9), and kauamide (10), a new polyketide-peptide containing an 11-membered heterocycle, were isolated from the extracts of the Hawaiian marine sponge Dactylospongia elegans. The planar structure of 10 was determined from spectroscopic analyses, and its relative and absolute configurations were established from density functional theory (DFT) calculations of the GIAO NMR shielding tensors, and advanced Marfey's analysis of the N-MeLeu residue, respectively. Compounds 1 and 3 showed moderate inhibition of ß-secretase 1 (BACE1), whereas 1-9 exhibited moderate to potent inhibition of growth of human glioma (U251) cells. Compounds 1-2 and 4-7 were also active against human pancreatic carcinoma (Panc-1) cells.

A Comprehensive Approach to Addressing the Burnout Crisis Among US Health Care Workers: The Houston Methodist Experience.

Health care workers experience high rates of burnout and psychiatric distress. A large health care system in the southwest United States developed a comprehensive mental health service model for employees. Services offered range from traditional benefits (eg, Employee Assistance Program), resiliency and well-being initiatives, and innovative technology solutions, to access to peer support services for professional practice issues. The latest innovation in services is a free, self-insured outpatient mental health clinic designed exclusively for health care workers and their dependents. In this article, the authors describe the development of expanded mental health programming for health care workers and discuss how this unique service model proactively reduces common barriers to the receipt of high-quality care. This approach to caring for the workforce may serve as a model for other health care organizations across the United States. By providing mental health support to employees, health care organizations are mitigating the risk of burnout and related consequences to the system.

A theoretical investigation of the relative stability of hydrated glycine and methylcarbamic acid--from water clusters to interstellar ices.

We have theoretically investigated how the low-energy conformers of the neutral and the zwitterionic forms of glycine as well as methylcarbamic acid are stabilized by the presence water. The MP2/6-311++G(d,p) method was utilized to conduct calculations on glycine and methylcarbamic acid in both isolated clusters and in clusters embedded in the conductor-like polarizable continuum model (C-PCM), where the clusters explicitly contain between one and ten water molecules. The neutral forms of glycine and methylcarbamic acid were found to have similar hydration energies, whereas the neutral methylcarbamic acid was determined to be approximately 32 kJ mol(-1) more stable than the neutral glycine in the isolated clusters and 30 kJ mol(-1) more stable in the C-PCM embedded clusters. Both the number and strength of the hydrogen bonding interactions between water and the zwitterions drive the stability. This lowers the relative energy of the glycine zwitterion from 50 kJ mol(-1) above neutral glycine, when there are two water molecules in the clusters to 11 kJ mol(-1) below for the clusters containing ten water molecules. For the methylcarbamic acid clusters with two water molecules, the zwitterion is 51 kJ mol(-1) higher in energy than the neutral form, but it remains 13 kJ mol(-1) above the neutral methylcarbamic acid in the clusters containing ten water molecules. When the bulk water environment is simulated by the C-PCM calculations, we find both the methylcarbamic acid and glycine zwitterionic forms have similar energies at 20 kJ mol(-1) above the neutral methylcarbamic acid energy and 10 kJ mol(-1) lower than the neutral glycine energy. Although neither methylcarbamic acid nor glycine have been detected in the interstellar medium yet, our findings indicate that methylcarbamic acid is the more stable product from methylamine and carbon dioxide reactions in a water ice. This suggests that methylcarbamic acid likely plays a role in the intermediate steps if glycine is formed in the interstellar medium.

Theoretical exploration of hydrogen loss from Al3H9.

The Al(3)H(9) and Al(3)H(7) potential energy surfaces were explored using quantum chemistry calculations to investigate the H(2) loss mechanism from Al(3)H(9), which provide new insights into hydrogen production from bulk alane, [AlH(3)](x), a possible energy storage material. We present results of B3LYP/6-311++G(d,p) calculations for the various Al(3)H(9) and Al(3)H(7) optimized local minima and transition state structures along with some reaction pathways for their interconversion. We find the energy for Al(3)H(9) decomposition into Al(2)H(6) and AlH(3) is slightly lower than that for H(2) loss and Al(3)H(7) formation, but the calculations show that H(2) loss from Al(3)H(9) is a lower energy process than for losing hydrogen from either Al(2)H(6) or AlH(3). We found four transition state structures and reaction pathways for Al(3)H(9) → Al(3)H(7) + H(2), where the lowest energy activation barrier is around 25-73 kJ/mol greater than the experimental value for H(2) loss from bulk alane. Intrinsic reaction coordinate calculations show that the H(2) loss pathway involves considerable rearrangement of the H atom positions around a single Al center. Three of the pathways start with the formation of an AlH(3) moiety, which then enables a terminal H on the AlH(3) to get within 1.1 to 1.2 Šof a nearby bridging H atom. The bridging and terminal H atoms eventually combine to form H(2) and leave Al(3)H(9). One implication of these H(2) loss reaction pathways is that, since the H atoms in bulk alanes are all at bridging positions, if a similar H(2) loss mechanism were to apply to bulk alane, then H(2) loss would most likely occur on the bulk alane surface or at a defect site where there should be more terminal H atoms available for reaction with nearby bridging H atoms.

Developing a paediatric healthcare research network: key learnings from the 'starworks' child prosthetics project.

The context of child prosthetics is a complex and important area for research and innovation. Yet, like many areas of paediatric medical technology development, there are several barriers to innovating specifically for the unique needs of children (i.e., a relatively small patient population or 'market'). As such, much child prosthetics technology is developed from the downsizing of adult prosthetics, leading to suboptimal outcomes for children and young people. Since 2016, the Starworks Child Prosthetics Research Network has been exploring this space, bringing children and their families together with key opinion leaders from the NHS, clinical Academia and leading National Research Centres with capabilities in child prosthetics with the aim of increasing research across the system. Above all else, Starworks is centred on the needs of children and their families, ensuring they have an equal voice in driving the ongoing research agenda. This article will share key learnings from the creation and development of the Starworks Network that may be applicable and/or adaptable across a wider paediatric medical technology research and innovation landscape. In particular it will discuss how it addressed three key aims of; (1) Addressing child-specific issues; (2) Building a sustainable network; and (3) Fostering impactful innovation.

Positive Stimulation for Medically Sedated Patients: A Music Therapy Intervention to Treat Sedation-Related Delirium in Critical Care.

Sedation is an essential component of treatment for some patients admitted to the ICU, but it carries a risk of sedation-related delirium. Sedation-related delirium is associated with higher mortality and increased length of stay, but pharmacologic treatments for delirium can lead to oversedation or other adverse effects. Therefore, nonpharmacologic treatments are recommended in the literature; however, these recommendations are quite general and do not provide structured interventions. To establish a structured nonpharmacologic intervention that could improve indications of delirium after sedation, we combined evidence-based interventions including recordings of sensory-rich stories told by the patient's family and patient-specific music into our novel positive stimulation for medically sedated patients (PSMSP) protocol. The positive listening stimulation playlist organized by a board-certified music therapist (MT-BC) within the PSMSP protocol can be used in carefully monitored sessions with the MT-BC potentially to decrease agitation and stabilize arousal, as well as being played by nursing staff throughout the patient's recovery from sedation. Further controlled studies will be necessary, but the PSMSP protocol has the potential to reduce agitation and increase arousal during listening, as highlighted by the case of a patient recovering from sedation during treatment for COVID-19 pneumonia. It is important for the entire critical care team to be aware of nonpharmacologic treatments like PSMSP that are available for delirium mitigation so that, where applicable, these therapies can be incorporated into the patient's treatment regimen.

Effects of a modified passive socket system on short-term changes in residuum volume and comfort: A preliminary study in transtibial amputees.

BACKGROUND: Changes in residuum volume are a common problem in lower-limb amputees during prosthesis usage, and can lead to poor suspension, impaired gait, and tissue damage. Residuum volume can be affected by the in-socket air pressure, which will influence fluid flow in and around the residuum. The use of "active" pumps to reduce air pressure has been shown to conserve the residuum volume, but these are expensive and unlikely to be widely available. An alternative, passive approach, based on Boyles' law, is to introduce a larger distal void volume at the end of the socket and hence reduce the change in pressure for a given change in volume. OBJECTIVES: To compare the performance across three test conditions (passive-conventional, with standard distal void; passive-with increased distal void; and active system) in terms of residuum volume changes and comfort. STUDY DESIGN: Repeated-measures experiment under three test conditions. METHODS: Five transtibial amputee participants (three males and two females), aged between 27 and 67 years, and of mobility grade K2 or K3, were fitted with a bespoke test prosthesis that was adapted to include the three test conditions. Residuum volume was measured before and after walking under each test condition (presented in a random order). Comfort was also assessed after walking with each test condition. RESULTS: The reduction in residuum volume, relative to the baseline volume, was higher for the conventional passive system (4.2% ± 2.8%) compared with the modified passive (1.4% ± 1.4%) and active (1.6% ± 1.1%) systems. CONCLUSION: The use of a passive suspension system with an increased distal void within the socket may help to stabilize the residuum volume during prosthesis usage.

Functional Rehabilitation: An Integrated Treatment Model for Patients With Complex Physical and Psychiatric Conditions.

The health care delivery system in the United States, structured to provide single-disease care, presents unique challenges for patients with complex physical and psychiatric comorbidities. Patients in these populations are often referred to multiple specialty clinics, encounter little continuity of care or collaboration among their providers, incur high health care costs, and experience poor treatment outcomes. Given these barriers, questions remain about the extent to which siloed and fragmented care, as opposed to the complex nature of the illnesses themselves, contribute to poor outcomes. If given the opportunity to receive well-integrated, consistent, and personalized care, can patients with historically difficult-to-treat comorbid medical and mental illnesses make progress? This article describes an innovative model of care called functional rehabilitation that is designed to address existing barriers in treatment. The functional rehabilitation program seeks to disrupt the escalating effects of interacting comorbidities by offering highly collaborative treatment from a small team of clinicians, personalized interventions using a shared decision-making framework, multipronged treatment options, colocation in a large hospital system, and significant 1:1 time with patients. The article includes a case example with longitudinal outcome data that illustrates how progress can be made with appropriate programmatic supports. Future research should examine the cost-effectiveness of this model of care.

A theoretical investigation of the low energy conformers of the isomers glycine and methylcarbamic acid and their role in the interstellar medium.

We have theoretically investigated the low energy conformers of neutral glycine (NH(2)CH(2)COOH) and its isomer methylcarbamic acid (CH(3)NHCOOH) in the gas phase. A total of 16 different levels of the theory, including CCSD(T), MP2 and B3LYP methods with various Pople and Dunning type basis sets with and without polarization and diffuse functions were used. We found eight low energy glycine conformers, where the heavy atoms in three have a planar backbone, and four low energy methylcarbamic acid conformers all with non-planar backbones. Interestingly at all levels of theory, we found that the most stable methylcarbamic acid conformer is significantly lower in energy than the lowest energy glycine conformer. The MP2 level and single point CCSD(T) calculations show the lowest energy methylcarbamic acid conformer to be between 31 to 37 kJ mol(-1) lower in energy than the lowest energy glycine conformer. These calculations suggest that methylcarbamic acid might serve as a precursor to glycine formation in the Interstellar Medium (ISM). We also report the theoretical harmonic vibrational frequencies, infrared intensities, moment of inertia, rotational constants and dipole moments for all of the conformers. In order to understand how glycine or methylcarbamic acid might be formed in the ISM, larger calculations which model glycine or its isomer interacting with several surrounding molecules, such as water, are needed. We demonstrate that B3LYP method should provide a reliable and computationally practical approach to modeling these larger systems.

A computational study on the structures of methylamine-carbon dioxide-water clusters: evidence for the barrier free formation of the methylcarbamic acid zwitterion (CH3NH2+COO-) in interstellar water ices.

We investigated theoretically the interaction between methylamine (CH(3)NH(2)) and carbon dioxide (CO(2)) in the presence of water (H(2)O) molecules thus simulating the geometries of various methylamine-carbon dioxide complexes (CH(3)NH(2)/CO(2)) relevant to the chemical processing of icy grains in the interstellar medium (ISM). Two approaches were followed. In the amorphous water phase approach, structures of methylamine-carbon dioxide-water [CH(3)NH(2)/CO(2)/(H(2)O)(n)] clusters (n = 0-20) were studied using density functional theory (DFT). In the crystalline water approach, we simulated methylamine and carbon dioxide interactions on a fragment of the crystalline water ice surface in the presence of additional water molecules in the CH(3)NH(2)/CO(2) environment using DFT and effective fragment potentials (EFP). Both the geometry optimization and vibrational frequency analysis results obtained from these two approaches suggested that the surrounding water molecules which form hydrogen bonds with the CH(3)NH(2)/CO(2) complex draw the carbon dioxide closer to the methylamine. This enables, when two or more water molecules are present, an electron transfer from methylamine to carbon dioxide to form the methylcarbamic acid zwitterion, CH(3)NH(2)(+)CO(2)(-), in which the carbon dioxide is bent. Our calculations show that the zwitterion is formed without involving any electronic excitation on the ground state surface; this structure is only stable in the presence of water, i.e. in a methyl amine-carbon dioxide-water ice. Notably, in the vibrational frequency calculations on the methylcarbamic acid zwitterion and two water molecules we find the carbon dioxide asymmetric stretch is drastically red shifted by 435 cm(-1) to 1989 cm(-1) and the carbon dioxide symmetric stretch becomes strongly infrared active. We discuss how the methylcarbamic acid zwitterion CH(3)NH(2)(+)CO(2)(-) might be experimentally and astronomically identified by its asymmetric CO(2) stretching mode using infrared spectroscopy.

Remote creation of clinical-standard myoelectric trans-radial bypass sockets during COVID-19.

To enable the progression of research during the COVID-19 lockdown, a novel remote method of creating clinical standard trans-radial bypass sockets was devised as a collaboration between an engineering team and a clinical research group. The engineering team recruited two able-bodied participants, marked areas of interest on the participant's limb and captured limb geometry and electrode sites with a high definition optical scanner. The resulting 3D scan was modified to make electrode sites and areas of interest recessed and tactile. Models were 3D printed to scale and posted to the clinical team to manufacture the sockets. A modified lamination process was used, comprising plaster casting and rectifiying the model by hand. The recessed areas of the 3D printed model were used to guide the process. The bypass sockets were returned to the engineering team for testing. A simple electromyography (EMG) tracking task was performed using clinical electrodes to validate the skin-electrode contact and alignment. This paper demonstrates a validated method for remotely creating transradial bypass sockets. There is potential to extrapolate this method to standard socket fittings with further research.

Patient perspectives on participation in exercise-based rehabilitation for Achilles tendinopathy: A qualitative study.

BACKGROUND: Achilles tendinopathy (AT) is common, and can be traumatic or insidious in onset and short-lasting or persistent in nature. Factors influencing the experience of pain are poorly understood; little is known about mechanisms driving pain and the response (or lack of) to rehabilitation. Despite this, there is a growing body of evidence supporting the use of exercise to manage AT. Interestingly, variation in exercise approach does not appear to significantly impact outcome. Patients' perceptions of factors related to rehabilitation that may influence outcome could provide a valuable addition to help guide future research and practice. OBJECTIVES: The aim of this study is to gain an insight into patients' experiences of participating in an exercise-based rehabilitation programme for AT. METHOD: A qualitative interpretive description design. Data generated from semi-structured interviews were analysed thematically using the guidelines set out by Braun and Clarke. FINDINGS: This is the first study to use a qualitative method of inquiry to gain data on the experiences of people undertaking exercise-based rehabilitation for AT. The four major themes that were identified from the data were: (1) 'understanding the impact' (2) 'expectations' (3) 'what matters' and (4) 'the burden of exercise'. CONCLUSIONS: Given the uncertainty surrounding the mechanisms of effect of our treatments, the insights provide a platform from which researchers and clinicians can consider further in the management of people with Achilles tendinopathy. Specifically, it has highlighted that patients value a flexible, supportive approach embracing the biopsychosocial impact of AT on the individual.

Evaluating Reachable Workspace and User Control Over Prehensor Aperture for a Body-Powered Prosthesis.

Using a shoulder harness and control cable, a person can control the opening and closing of a body-powered prosthesis prehensor. In many setups the cable does not pass adjacent to the shoulder joint center allowing shoulder flexion on the prosthetic side to be used for prehensor control. However, this makes cable setup a difficult compromise as prosthesis control is dependent on arm posture; too short and the space within which a person can reach may be unduly restricted, too long and the user may not be able to move their shoulder sufficiently to take up the inevitable slack at some postures and hence have no control over prehensor movement. Despite the fundamental importance of reachable workspace to users, to date there have been no studies in prosthetics on this aspect. Here, a methodology is presented to quantify the reduction in the reachable volume due to the harness, and to record the range-of-motion of the prehensor at a series of locations within the reachable workspace. Ten anatomically intact participants were assessed using a body-powered prosthesis simulator. Data was collected using a 3D motion capture system and an electronic goniometer. The harnessed reachable workspace was 38-85% the size of the unharnessed volume with participants struggling to reach across the body and above the head. Across all arm postures assessed, participants were only able to achieve full prehensor range-of-motion in 9%. The methodologies presented could be used to evaluate future designs of both body-powered and myoelectric prostheses.

Is our bTB policy one of the worst attempts to control a major notifiable disease ever seen?

A group of experienced vets argue that the lack of control of endemically TB-infected communities of badgers has resulted in a bovine TB dilemma that is worse now than it was 50 years ago.

The effect of a semi-rigid thoracolumbosacral orthosis (TLSO) on foot pressure in elderly subjects presenting with spinal hyperkyphosis.

Purpose: The ageing process can be accompanied by a degeneration of the spine and increase the risk of thoracic hyperkyphosis (excessive spinal forward curvature) amongst elderly people. This condition can in turn impair mobility, reduce balance, and increase the risk of falling and mortality in affected individuals. The use of corrective orthotic bracing has been shown to improve spinal posture, and increase stability and balance amongst the elderly. However, there is little evidence that evaluates the use of corrective braces on foot pressure changes in these subjects.Methods: In this study, we evaluated the use of a thoracolumbosacral orthosis (TLSO) on 19 subjects over 60 years old who presented with hyperkyphosis. We measured foot pressure using the Pedar-X system before (without brace) and after (with brace) immediate using a TLSO in both static (quite standing) and dynamic (walking on a 5 meters freeway) scenarios.Results: The results demonstrated that using a TLSO immediately decreases forefoot pressures in stasis, and around the first metatarsal, as well as pressures relating to the second to fifth metatarsals under dynamic conditions. Hindfoot pressures were increased, but not significantly.Conclusion: This study showed that using a TLSO can be beneficial for elderly people with hyperkyphosis.Implications for rehabilitationThe ageing process can be accompanied by a degeneration of the spine and increase the risk of thoracic hyperkyphosis.The use of corrective orthotic bracing has been shown to improve spinal posture, and increase stability and balance amongst the elderly.Using a TLSO decreases forefoot pressures in stasis, and around the first metatarsal, as well as pressures relating to the second to fifth metatarsals under dynamic conditions.

The efficacy of loading programmes for improving patient-reported outcomes in chronic midportion Achilles tendinopathy: A systematic review.

OBJECTIVE: Achilles tendinopathy is a common type of overuse condition, with isolated eccentric loading (ECL) programmes being the principal conservative treatment of choice. However, alternative protocols, involving different contraction types, have more recently been investigated. The purpose of the present review was to examine the evidence from studies comparing two or more different types of loading programmes in relation to patient-reported outcomes for people with Achilles tendinopathy. METHODS: A systematic review was undertaken, and the risk of bias of included papers were assessed using the Cochrane Risk of Bias tool. An electronic search of CINAHL, MEDLINE, Embase and SPORTDiscus was undertaken from their inception to May 2018. The eligibility criteria for selecting studies were randomized controlled or clinical controlled trials investigating two or more different loading programmes for chronic (>3 months) Achilles tendinopathy. RESULTS: Seven articles were included in the review. Low-quality evidence exists that a do-as-tolerated modification of the Alfredson programme is more effective than the standardized programme at improving function in the short term. Very-low-quality evidence suggests that ECL is superior at reducing pain levels than concentric in isolation, but no more effective at improving pain or disability than concentric-eccentric programmes. CONCLUSIONS: There is conflicting evidence regarding the superiority of ECL over other contraction types, challenging the current approach to managing Achilles tendinopathy. There is also evidence that do-as-tolerated repetition volumes are more effective at improving function in the short term compared with those recommended by the standardized Alfredson protocol.

Upper limb activity of twenty myoelectric prosthesis users and twenty healthy anatomically intact adults.

The upper limb activity of twenty unilateral upper limb myoelectric prosthesis users and twenty anatomically intact adults were recorded over a 7-day period using two wrist worn accelerometers (Actigraph, LLC). This dataset reflects the real-world activities of the participants during their normal day-to-day routines. Participants included students, working adults, and retirees recruited from across the United Kingdom. This dataset offers a potential wealth of knowledge into a poorly understood cohort. The raw unprocessed data files and the activity count data exported from the Actilife software are provided. We also provide a non-wear algorithm developed for the removal of prosthesis non-wear periods and resulting activity count data corresponding to prothesis wear periods. Finally, we have included the transposed activity diaries provided by the participants. Analysis to date has primarily involved assessment of the symmetry of upper limb activity, however, there is potential to undertake additional analysis such as understanding the differences in the way a prosthesis is used compared to an anatomical arm.

Effects of Two Different Hip-Knee-Ankle-Foot Orthoses on Postural Stability in Subjects with Spinal Cord Injury: A Pilot Study.

STUDY DESIGN: Pilot study. PURPOSE: Evaluation of two different hip-knee-ankle-foot orthoses (HKAFOs; medial linkage reciprocating gait orthosis [MLRGO] and isocentric reciprocating gait orthosis [IRGO]) using gait and postural stability analysis in four subjects with spinal cord injury (SCI). OVERVIEW OF LITERATURE: To the best of our knowledge, no study has evaluated postural stability in subjects with SCI when using MLRGO and IRGO. METHODS: The relative efficacy of each orthosis was evaluated with relevant gait parameters, and an assessment of postural stability and sway during usage was made. Each analysis was conducted following an appropriate period of training and acclimatization. The gait parameters employed in the study were walking speed, cadence, and endurance; these were recorded and analyzed using current, validated methods. Postural stability was assessed using a verified force plate measurement system, and a modified Falls Efficacy Scale (mFES) was used for the measurement of postural sway and the perceived fear of falling. RESULTS: Walking speed, cadence, and endurance increased with the use of both HKAFOs. When the two types of HKAFOs were compared, all the parameters showed a slight (but not significant) increase with the use of MLRGO compared with the use of IRGO. In contrast, there were slight but insignificant improvements in postural sway with the use of IRGO. However, although there were no significant differences between the two sets of mFES scores, there was a slightly reduced fear of falling with the use of MLRGO compared with the use of IRGO in the static standing position. CONCLUSIONS: It is noteworthy that meaningful interpretations of results can only be drawn if a larger sample is employed. This pilot study showed no significant data; however, the results indicate that the use of MLRGO is superior to that of IRGO in terms of potential improvement in the mobility and confidence levels of subjects with SCI.