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Idiopathic normal pressure hydrocephalus (iNPH) is a neurological disorder affecting older adults for which symptoms may improve following shunting; however, the criteria for surgical referral remain unclear. While most studies rely on fixed cut-off scores for cognitive and gait tests, the present study examined decision-making based on clinical judgment to identify which factors influence referral. A secondary objective was to compare pre- and post-CSF tap test (CSF-TT) changes between the shunt and no shunt groups.
Methods:
This retrospective study included 175 patients assessed at CHU de Québec – Hôpital de l’Enfant-Jésus. Based on a combination of objective test results and clinical judgment, patients were categorized as referred (n = 119) or not referred (n = 56) for shunt surgery. Logistic regression identified the variables influencing referral decisions. Mixed-effects ANOVA models for repeated measures were conducted to compare pre- and post-CSF-TT changes in gait and cognitive performance between shunt and no shunt groups.
Results:
Three change indices significantly predicted referral: the 10-Meter Walk Test (normal pace), the Trail Making Test Condition 5 and the Berg Balance Scale. Higher education positively influenced referral. While most gait and balance measures showed significant improvement following CSF-TT, cognitive tests appeared less responsive to the procedure.
Conclusion:
Although this study employed a clinically grounded approach based on clinical judgment rather than fixed thresholds, the findings align with prior literature identifying gait and balance as robust indicators. This study reinforces the need to shift from rigid threshold-based criteria toward individualized, clinically grounded decision-making models that can better capture the heterogeneity of iNPH presentations.
System uncertainty remains a challenge for effective control of lower extremity exoskeletons, particularly in clinical populations. Adaptive control offers a potential solution by accounting for unknown system characteristics in real time. Here, we introduce the use of Gaussian-based adaptive control (GBAC) in a two-degree-of-freedom (DOF) exoskeleton for an angular position tracking task in the presence of system uncertainty. The mathematical derivation of the implicitly non-Lyapunov adaptation law is presented using Lagrangian mechanics, including a Gaussian kernel regressor and its stable convergence. We then evaluate GBAC performance in a 2-DOF simulation compared with a previously developed robust adaptive backstepping algorithm, Lyapunov-stable Slotine–Li control, and a proportional-integral-derivative (PID) controller. We additionally complete 1-DOF simulations to evaluate the effects of external disturbance and parameter uncertainty on controller performance. Finally, we evaluate GBAC experimentally in our existing 1-DOF knee exoskeleton along with Slotine–Li and PID controllers. The simulation results demonstrate the improved tracking performance and faster convergence of GBAC, especially in the presence of an external disturbance and uncertainty introduced by extra segment length and mass. The experimental results demonstrate similar performance, wherein GBAC and Slotine–Li provide stable tracking in the presence of unmodeled system dynamics; however, convergence time was faster and tracking error was lower for GBAC. Collectively, these results demonstrate that GBAC is an effective adaptive controller in the presence of system uncertainty and therefore warrants further development and investigation for use in flexible joint exoskeleton systems, particularly those designed for pediatric and/or clinical populations that have inherently high uncertainty.
Idiopathic normal pressure hydrocephalus (iNPH) is characterized by gait disturbances, cognitive impairment and urinary dysfunction. Early diagnosis is essential to ensure timely shunt treatment. However, patient identification remains challenging due to limited studies, mostly from Asia and Europe, which restrict generalizability to other geographic areas. Moreover, demographic factors (age, sex, education) influence cognitive and gait performance in other neurological conditions, but their impact on iNPH remains unclear. This study aimed to characterize the demographic, vascular, cognitive and gait profiles of iNPH patients in Eastern Quebec (Canada) and determine how demographic factors influence performance outcomes.
Methods:
A retrospective chart review was conducted on 175 patients diagnosed with probable iNPH at a specialized neurology center in Eastern Quebec. Demographic data, vascular risk factors and cognitive and gait outcomes were extracted from medical records. Descriptive statistics were used to characterize the sample, and multiple linear regressions assessed the effect of demographic factors on performance outcomes.
Results:
The cohort had a mean age of 73.9 years and a mean education level of 11.9 years. Age and education significantly predicted over half of the cognitive test results, while age was the only significant predictor of gait. Hypertension (58%) and hyperlipidemia (47%) were more prevalent than diabetes (26%), differing from previous studies where diabetes was the second most reported vascular risk factor after hypertension.
Conclusions:
Clinical heterogeneity characterizes iNPH patients in Eastern Quebec. Differences in the prevalence of vascular risk factors compared to previous studies may reflect geographic variability in the clinical presentation of this condition.
Cerebellar ataxias are a heterogeneous group of disorders clinically manifest as impaired coordination during a voluntary motor task resulting from cortico-cerebellar brain network dysfunction, resulting in multiple motor systems including speech, upper limb dexterous movement and gait. Objective assessment of these dysfunctional motor domains provides vital clues in assessing the underlying pathophysiology.
Methods:
In this study, speech, upper limb kinematics and gait were studied using acoustic software (Praat), upper limb robot (KINARM) and gait carpet (Zeno Walkway with PKMAS). Clinical assessment was conducted using the Scale for the Assessment and Rating of Ataxia (SARA).
Results:
In speech analysis, ataxia patients had slower and variable ‘tuh’ syllable repetition performance than healthy controls. In KINARM reaching tasks, ataxia patients displayed less accuracy and efficacy as measured by endpoint error (EE) and mean perpendicular error, along with slower mean and peak velocity of arm movements, prolonged reaction time and increased inter-trial variability. Moreover, there were more EEs while applying load during arm movement. Gait analysis revealed reduced cadence, reduced stride velocity, reduced step length, longer time in the double support phase and increased variability of step length, stride velocity, double support percentage and gait cycle time.
Conclusion:
The study highlights the critical role played by the cerebellum during movement execution and has paved the way for more comprehensive future studies on degenerative cerebellar ataxia, incorporating kinematic measurements in multiple motor domains.
The muscular restructuring and loss of function that occurs during a transfemoral amputation surgery has a great impact on the gait and mobility of the individual. The hip of the residual limb adopts a number of functional roles that would previously be controlled by lower joints. In the absence of active plantar flexors, swing initiation must be achieved through an increased hip flexion moment. The high activity of the residual limb is a major contributor to the discomfort and fatigue experienced by individuals with transfemoral amputations during walking. In other patient populations, both passive and active hip exosuits have been shown to positively affect gait mechanics. We believe an exosuit configured to aid with hip flexion could be well applied to individuals with transfemoral amputation. In this article, we model the effects of such a device during whole-body, subject-specific kinematic simulations of level ground walking. The device is simulated for 18 individuals of K2 and K3 Medicare functional classification levels. A user-specific device profile is generated via a three-axis moment-matching optimization using an interior-point algorithm. We employ two related cost functions that reflect an active and passive form of the device. We hypothesized that the optimal device configuration would be highly variable across subjects but that variance within mobility groups would be lower. From the results, we partially accept this hypothesis, as some parameters had high variance across subjects. However, variance did not consistently trend down when dividing into mobility groups, highlighting the need for user-specific design.
Commonly, quantitative gait analysis post-stroke is performed in fully equipped laboratories housing costly technologies for quantitative evaluation of a patient’s movement capacity. Combining such technologies with an electromyography (EMG)-driven musculoskeletal model can estimate muscle force properties non-invasively, offering clinicians insights into motor impairment mechanisms. However, lab-constrained areas and time-demanding sensor setup and data processing limit the practicality of these technologies in routine clinical care. We presented wearable technology featuring a multi-channel EMG-sensorized garment and an automated muscle localization technique. This allows unsupervised computation of muscle-specific activations, combined with five inertial measurement units (IMUs) for assessing joint kinematics and kinetics during various walking speeds. Finally, the wearable system was combined with a person-specific EMG-driven musculoskeletal model (referred to as human digital twins), enabling the quantitative assessment of movement capacity at a muscle-tendon level. This human digital twin facilitates the estimation of ankle dorsi-plantar flexion torque resulting from individual muscle-tendon forces. Results demonstrate the wearable technology’s capability to extract joint kinematics and kinetics. When combined with EMG signals to drive a musculoskeletal model, it yields reasonable estimates of ankle dorsi-plantar flexion torques (R2 = 0.65 ± 0.21) across different walking speeds for post-stroke individuals. Notably, EMG signals revealing an individual’s control strategy compensate for inaccuracies in IMU-derived kinetics and kinematics when input into a musculoskeletal model. Our proposed wearable technology holds promise for estimating muscle kinetics and resulting joint torque in time-limited and space-constrained environments. It represents a crucial step toward translating human movement biomechanics outside of controlled lab environments for effective motor impairment monitoring.
The human nervous system contains more than 100 billion neurons. Each has a unique function enabling taste, smell, touch, sight, hearing, movement, respiration, cognition, and much more. In the setting of a neurologic emergency, patients may lose these unique capacities. It is the emergency physician’s responsibility to complete a neurologic history and examination to determine the type of deficit and the neuroanatomical location of the abnormality
Increased intraindividual variability (IIV) in behavioral and cognitive performance is a risk factor for adverse outcomes but research concerning hemodynamic signal IIV is limited. Cortical thinning occurs during aging and is associated with cognitive decline. Dual-task walking (DTW) performance in older adults has been related to cognition and neural integrity. We examined the hypothesis that reduced cortical thickness would be associated with greater increases in IIV in prefrontal cortex oxygenated hemoglobin (HbO2) from single tasks to DTW in healthy older adults while adjusting for behavioral performance.
Method:
Participants were 55 healthy community-dwelling older adults (mean age = 74.84, standard deviation (SD) = 4.97). Structural MRI was used to quantify cortical thickness. Functional near-infrared spectroscopy (fNIRS) was used to assess changes in prefrontal cortex HbO2 during walking. HbO2 IIV was operationalized as the SD of HbO2 observations assessed during the first 30 seconds of each task. Linear mixed models were used to examine the moderation effect of cortical thickness throughout the cortex on HbO2 IIV across task conditions.
Results:
Analyses revealed that thinner cortex in several regions was associated with greater increases in HbO2 IIV from the single tasks to DTW (ps < .02).
Conclusions:
Consistent with neural inefficiency, reduced cortical thickness in the PFC and throughout the cerebral cortex was associated with increases in HbO2 IIV from the single tasks to DTW without behavioral benefit. Reduced cortical thickness and greater IIV of prefrontal cortex HbO2 during DTW may be further investigated as risk factors for developing mobility impairments in aging.
The biological ankle dorsiflexes several degrees during swing to provide adequate clearance between the foot and ground, but conventional energy storage and return (ESR) prosthetic feet remain in their neutral position, increasing the risk of toe scuffs and tripping. We present a new prosthetic ankle intended to reduce fall risk by dorsiflexing the ankle joint during swing, thereby increasing the minimum clearance between the foot and ground. Unlike previous approaches to providing swing dorsiflexion such as powered ankles or hydraulic systems with dissipative yielding in stance, our ankle device features a spring-loaded linkage that adopts a neutral angle during stance, allowing ESR, but adopts a dorsiflexed angle during swing. The ankle unit was designed, fabricated, and assessed in level ground walking trials on a unilateral transtibial prosthesis user to experimentally validate its stance and swing phase behaviors. The assessment consisted of three conditions: the ankle in an operational configuration, the ankle in a locked configuration (unable to dorsiflex), and the subject’s daily use ESR prosthesis. When the ankle was operational, minimum foot clearance (MFC) increased by 13 mm relative to the locked configuration and 15 mm relative to his daily use prosthesis. Stance phase energy return was not significantly impacted in the operational configuration. The increase in MFC provided by the passive dorsiflexing ankle prosthesis may be sufficient to decrease the rate of falls experienced by prosthesis users in the real world.
In today’s world, in order to increase the movement abilities of amputees, different types of passive prostheses are used according to the level of the person’s disability. Although these types of prostheses increase a person’s mobility; however, they still have a limited ability to help the amputee walk normally on uneven terrain, as there is no net stimulus input power for the target joint. These limitations have led to the growth of the use of active prostheses in recent years, which has led to a variety of prosthetic designs. The purpose of this research is, first of all, to provide a suitable design and control of active transtibial prosthesis close to the performance of lost limb of a healthy person, and second and more importantly, to develop a 7-link inverse dynamic model of human gait and use it to analyze of an amputee gait with the designed prosthesis. Winter’s reference data are used in the entire process of design and simulation of prosthesis performance. Also, it is assumed that the amputation occurred in only one leg of the person. Based on the obtained results, when an amputee with 57 kg weight and 1.55 cm height wears an active prosthesis designed with 0.5 kg extra weight, the amount of metabolic cost of amputee in the swing phase increases by about 20%. By using this obtained model, it will be possible to optimize different prosthesis designs for people with different weight and height conditions.
This study compares various morphometric features of two strains of broilers, selected and ‘relaxed’ (ie random-bred), raised under two feeding regimes, ad-libitum-fed and restricted-fed. We consider the possible consequences of the different body shapes on the musculoskeletal system. The ad-libitum-fed selected birds reached heavier bodyweights at younger ages, had wider girths, and developed large amounts of breast muscle which probably displaced their centre of gravity cranially. At cull weight, they had shorter legs than birds in the other groups and greater thigh-muscle masses; therefore, greater forces would have to be exerted by shorter lever arms in order to move the body. The tarsometatarsi were broader, providing increased resistance to greater loads, but the bones had a lower calcium and phosphorus content, which would theoretically make them weaker. Many of these morphological changes are likely to have detrimental effects on the musculoskeletal system and therefore compromise the walking ability and welfare of the birds.
This study tests the hypothesis that growth rate and bodyweight affect walking ability in broilers by comparing objective measurements of the spatial and temporal gait parameters of several groups of birds. Two strains of birds were used (relaxed and selected), raised on two feeding regimes (ad-libitum and restricted), and culled at the same final bodyweight (commercial cull weight of 2.4 kg). The ad-libitum-fed selected birds walked more slowly, with lower cadences, and took shorter steps. The steps were wider, and the toes were pointed outwards, resulting in a wider walking base. They kept their feet in contact with the ground for longer periods, having longer percentage stance times, shorter percentage swing times and increased double-contact times compared to the relaxed birds. These changes serve to increase stability during walking and are a likely consequence of the morphological changes in the selected broiler — in particular, the rapid growth of breast muscle moving the centre of gravity forward, and the relatively short legs compared to their bodyweight (see Corr et al, pp 145-157, this issue). This altered gait would be very inefficient and would rapidly tire the birds, and could help to explain the low level of activity seen in the modern broiler.
In Denmark and Sweden, surveys were undertaken to estimate the prevalence of leg problems in conventional broiler production. The Danish survey included 28 Ross 208 flocks, and the Swedish survey included 15 Ross 208 and 16 Cobb flocks. Leg problems included reduced walking ability (gait), tibial dyschondroplasia (TD), varus/valgus deformations (VV) and foot-pad dermatitis (FPD). Danish Ross chicks showed a significantly higher prevalence of gait score > 0, gait score > 2 and TD, but a lower prevalence of VV, than Swedish Ross chicks. Cobb chicks showed a significantly higher prevalence of gait score > 0, gait score > 2 and TD than Swedish Ross chicks, a significantly higher prevalence of VV than Danish Ross chicks, and a significantly lower prevalence of FPD than both Danish and Swedish Ross chicks. The two genotypes of Swedish chicks showed similar relationships between body weight and probability of gait score > 0, TD and VV, indicating that the difference in prevalence of these leg problems may be due to the difference in mean body weight at slaughter age. At body weights below 2300 g, Danish chicks showed a higher probability of gait score > 2 than Swedish chicks. Furthermore, at body weights below 1900 g, Danish chicks had a higher probability of TD than Swedish chicks, whereas at body weights above 2200 g they had a lower probability of TD. This indicates that the difference in prevalence of TD between Danish and Swedish chicks was due to differences in mean body weight at slaughter age as well as housing conditions. Therefore, further studies on the risk factors in relation to management and housing conditions are required.
An animal's welfare state is intrinsically linked to its affective state. Evidence suggests that sentient, conscious animals can experience a range of affective states, such as pain, fear or boredom as well as positive affects like joy, curiosity, satiation or lust. In the behavioural assessment of animal welfare, there is increasing recognition that it is not simply which behaviours an animal engages in but also the quality of its movement. Kinematics is an approach which is being more widely applied to the behavioural assessment of animal welfare. Kinematics is a field of mechanics that describes the movement of points on a body by defining these points in a coordinate system and precisely tracking how they change in terms of space and time. A major opportunity exists for using kinematic technology to inform our understanding of the emotional state of animals. This review argues that kinematics is a useful methodology for identifying and characterising movement indicative of an animal's affective state. It demonstrates that kinematics: i) appears useful in detecting subtleties in the expression of affective states; ii) could be used in conjunction with, and add extra information to, affective tests (for example, an approach/avoidance paradigm); and iii) could potentially, eventually, be developed into an automated affective state detection system for improving the welfare of animals used in research or production. Furthering our knowledge of animal affective states using kinematics requires engagement from many areas of science outside of animal welfare, such as sports science, computer science, engineering and psychology.
Many animal welfare traits vary on a continuous scale but are commonly scored using an ordinal scale with few categories. The rationale behind this practice is rarely stated but appears largely based on the debatable conviction that it increases data reliability. Using 54 observers of varying levels of expertise, inter-observer reliability (IOR) and user-satisfaction were compared between a 3-point ordinal scale (OS) and a continuous modified visual analogue scale with multiple anchors (VAS) for scoring lameness in dairy cattle from video. IOR was significantly better for the VAS than for the OS. IOR increased with self-reported level of expertise for the VAS, whereas for the OS it was highest for observers with a moderate level of expertise. The mean continuous scores and the mean categorical scores were highly correlated. Three times as many observers stated a preference for the VAS (n = 27) compared to the OS (n = 9) in investigating differences in lameness between herds. Contrary to common perception, these results illustrate that it is possible for a continuous cattle lameness score to be more reliable and to have greater user acceptability than a simple categorical scale. As continuous scales are also potentially more sensitive, and produce data more amenable to algebraic processing and more powerful parametric analyses, the scepticism against their application for assessing animal welfare traits should be reconsidered.
Innovative shoe insoles, designed to enhance sensory information on the plantar surface of the feet, could help to improve walking in people with Multiple Sclerosis.
Objective:
To compare the effects of wearing textured versus smooth insoles, on measures of gait, foot sensation and patient-reported outcomes, in people with Multiple Sclerosis.
Methods:
A prospective, randomised controlled trial was conducted with concealed allocation, assessor blinding and intention-to-treat analysis. Thirty ambulant men and women with multiple sclerosis (MS) (Disease Steps rating 1–4) were randomly allocated to wear textured or smooth insoles for 12 weeks. Self-reported insole wear and falls diaries were completed over the intervention period. Laboratory assessments of spatiotemporal gait patterns, foot sensation and proprioception, and patient-reported outcomes, were performed at Weeks 0 (Baseline 1), 4 (Baseline 2) and 16 (Post-Intervention). The primary outcome was the size of the mediolateral base of support (stride/step width) when walking over even and uneven surfaces. Independent t-tests were performed on change from baseline (average of baseline measures) to post-intervention.
Results:
There were no differences in stride width between groups, when walking over the even or uneven surfaces (P ≥ 0.20) at post-intervention. There were no between-group differences for any secondary outcomes including gait (all P values > 0.23), foot sensory function (all P values ≥ 0.08) and patient-reported outcomes (all P values ≥ 0.23).
Conclusions:
In our small trial, prolonged wear of textured insoles did not appear to alter walking or foot sensation in people with MS who have limited foot sensory loss. Further investigation is needed to explore optimal insole design.
Clinical Trial Registration:
Australian and New Zealand Clinical Trials Registry (ACTRN12615000421538).
Modern rehabilitation processes for neurological patients have been widely assisted by robotic structures, with continuous research and improvements. The use of robotic assistance in rehabilitation is a consolidated technique for upper limb training sessions. However, human gait robotic rehabilitation still needs further research and development. Based on that, this paper deals with the development of a novel active body weight support (BWS) system integrated with a serious game for poststroke patients. This paper starts with a brief review of the state of the art of applied technologies for gait rehabilitation. Next, it presents the obtained mathematical model followed by multibody synthesis techniques and meta-heuristic optimization to the proposed device. The control of the structure is designed using proportional integral derivative (PID) controllers tuned with meta-heuristic optimization and associated with a suppression function to perform assist-as-needed actions. Then, the prototype is integrated with a serious game designed specifically for this application. Finally, a pilot study is conducted with the structure and healthy volunteers. The results obtained show that the mobility of the novel BWS is as expected and the proposed system potentially offers a novel tool for gait training.
In this chapter, the general system of examining the various joints in the body is described. Most joints will follow the look, feel, move system, whereas some –for example, the elbow, wrist and ankle – will be best examined using the look, move, feel system.
Other concepts such as gait, generalized laxity, assessment of power and sensory testing are included. Listed at the end of the chapter are examples of how to approach ‘difficult situations’ that the reader may face in clinical practice or in examinations.
This chapter covers clinical examination of the child through growth and development. It includes neonatal presentation to the orthopaedic surgeon, e.g. with dislocating hips or obstetric brachial plexus palsy. All joint examinations in the child are described with the differences in a child compared to an adult emphasised. Included in the chapter are rotational profile assessment, leg length assessment, assessing a child with skeletal dysplasia and how to examine a child with spina bifida.
Hip examination starts with standing the patient, then walking the patient and describing the gait. The Trendelenburg test is then performed. The patient is then asked to lie on the couch and the pelvis squared. As the hip is a deep joint, palpation does usually yield much information. Thomas test is performed, followed by range of movement of the hip. Then, leg length is assessed. Finally, if required, impingement tests are performed. Other special tests such as Phelps' test are performed if there are hip contractures. In the ‘Advanced Corner’, other less commonly performed special tests are described.