Claudia Giacomozzi

Feasibility of a home-based telerehabilitation system compared to usual care: arm/hand function in patients with stroke, traumatic brain injury and multiple sclerosis

We conducted a randomized controlled multicentre trial to investigate the feasibility of a telerehabilitation intervention for arm/hand function (the Home Care Activity Desk [HCAD] training) in a home setting. Usual care was compared to HCAD training. The hypothesis was that the clinical outcomes of the HCAD intervention would be at least the same as those measured after a period of usual care for patients with stroke, traumatic brain injury (TBI) and multiple sclerosis (MS) with respect to their arm/hand function. Eighty-one patients with affected arm/hand function resulting from either stroke, MS or TBI were recruited in Italy, Spain and Belgium; 11 were lost during follow-up (14%). The outcome measures were the Action Research Arm Test (ARAT) and the Nine Hole Peg Test (NHPT). There were no significant differences between the two groups on the outcome measures (ARAT and NHPT); in both groups, patients maintained or even improved their arm/hand function. The HCAD training was found to be as feasible as usual care in terms of clinical outcomes, and both therapists and patients were satisfied with the HCAD intervention. A telerehabilitation intervention using HCAD may increase the efficiency of care.

Appropriateness of plantar pressure measurement devices: A comparative technical assessment

Accurate plantar pressure measurements are mandatory in both clinical and research contexts. Differences in accuracy, precision and reliability of the available devices have prevented so far the onset of standardization processes or the definition of reliable reference datasets. In order to comparatively assess the appropriateness of the most used pressure measurement devices (PMD) on-the-market, in 2006 the Institute the author is working for approved a two-year scientific project aimed to design, validate and implement dedicated testing methods for both in-factory and on-the field assessment. A first testing phase was also performed which finished in December 2008. Five commercial PMDs using different technologies-resistive, elastomer-based capacitive, air-based capacitive-were assessed and compared with respect to absolute pressure measurements, hysteresis, creep and COP estimation. The static and dynamic pressure tests showed very high accuracy of capacitive, elastomer-based technology (RMSE<0.5%), and quite a good performance of capacitive, air-based technology (RMSE<5%). High accuracy was also found for the resistive technology by TEKSCAN (RMSE<2.5%), even though a complex ad hoc calibration was necessary.

Integrated pressure-force-kinematics measuring system for the characterisation of plantar foot loading during locomotion

Plantar pressure, ground reaction force and body-segment kinematics measurements are largely used in gait analysis to characterise normal and abnormal function of the human foot. The combination of all these data together provides a more exhaustive, detailed and accurate view of foot loading during activities than traditional measurement systems alone do. A prototype system is presented that integrates a pressure platform, a force platform and a 3D anatomical tracking system to acquire combined information about foot function and loading. A stereophotogrammetric system and an anatomically based protocol for foot segment kinematics is included in a previously devised piezo-dynamometric system that combines pressure and force measurements. Experimental validation tests are carried out to check for both spatial and time synchronisation. Misalignment of the three systems is found to be within 6.0, 5.0 and 1.5mm for the stereophotogrammetric system, force platform and pressure platform, respectively. The combination of position and pressure data allows for a more accurate selection of plantar foot subareas on the footprint. Measurements are also taken on five healthy volunteers during level walking to verify the feasibility of the overall experimental protocol. Four main subareas are defined and identified, and the relevant vertical and shear force data are computed. The integrated system is effective when there is a need for loading measurements in specific plantar foot subareas. This is attractive both in clinical assessment and in biomechanics research.

Muscle performance and ankle joint mobility in long-term patients with diabetes

BackgroundLong-term patients with diabetes and peripheral neuropathy show altered foot biomechanics and abnormal foot loading. This study aimed at assessing muscle performance and ankle mobility in such patients under controlled conditions.MethodsForty six long-term diabetes patients with (DN) and without (D) peripheral neuropathy, and 21 controls (C) were examined. Lower leg muscle performance and ankle mobility were assessed by means of a dedicated equipment, with the patient seated and the examined limb unloaded. 3D active ranges of motion and moments of force were recorded, the latter during maximal isometric contractions, with the foot blocked in different positions.ResultsAll patients showed reduced ankle mobility. In the sagittal and transversal planes reduction vs C was 11% and 20% for D, 20% and 21% for DN, respectively.Dorsal-flexing moments were significantly reduced in all patients and foot positions, the highest reduction being 28% for D and 37% for DN. Reductions of plantar-flexing moments were in the range 12–15% for D (only with the foot blocked in neutral and in dorsal-flexed position), and in the range 10–24% for DN. In all patients, reductions in the frontal and transversal planes ranged 14–41%.ConclusionThe investigation revealed ankle functional impairments in patients with diabetes, with or without neuropathy, thus suggesting that other mechanisms besides neuropathy might contribute to alter foot-ankle biomechanics. Such impairments may then play a role in the development of abnormal gait and in the onset of plantar ulcers.

Pattern of abnormal tangential forces in the diabetic neuropathic foot.

OBJECTIVES The role of tangential stress in neuropathic foot ulceration is yet unknown. The aim of this study was to investigate the tangential forces developed during gait by the whole foot and by selected subareas of it, namely the heel, the metatarsals and the hallux. METHODS 61 diabetic patients have been evaluated: 27 without neuropathy, 19 with neuropathy and 15 with previous neuropathic ulcer. The patients were compared with 21 healthy volunteers. A piezo-dynamometric platform was used to measure the three components of the ground reaction force under the total foot and the selected subareas. RESULTS A significant reduction was observed for the forward peak and the backward peak of the anteroposterior ground reaction force component measured under the whole foot. Patients with previous neuropathic ulcer showed a significant increase of the mediolateral stress under the metatarsals. CONCLUSIONS Tangential stress is altered in diabetic neuropathic patients; the increased mediolateral component suggests that tangential stress could have a role in the high risk of recurrence observed in patients with previous ulceration. RELEVANCE To assess the effectiveness of a non-invasive methodology for the estimation and the monitoring of significant alterations of the tangential stress with the increase of neuropathy.

Spatial-temporal parameters of gait: reference data and a statistical method for normality assessment

Spatial and temporal parameters of gait are of recognised clinical relevance in the assessment of motor pathologies, because they normally occur in established combinations which can be altered by pathologies. The data collected from 596 healthy subjects have been used to establish relationships among these parameters and a procedure to estimate deviation from normality based on the comparison between measured values and values estimated by exploiting these relationships. The applied multiple linear regression method (MLRM) was preliminarily validated by comparing its outputs with those of corresponding equations found in the literature, and by applying it to a control group of 12 healthy subjects.

Multistep pressure platform as a stand-alone system for gait assessment

THE MEASUREMENT of the mechanical quantities that describe human gait is approached with different instruments according to the desired accuracy and completeness of the data set. Complex measurement systems, such those based on 3-D optoelectronic instruments for body landmark tracking, are adequately exploited at only a few prominent clinical centres (GAGE, 1993; PERRY et al., 1993; SUTHERLAND and DAVIDS, 1993). Simpler systems have gained wider clinical acceptance. Among these, pressure insoles and pressure platforms (LORD, 1981; LORD et al., 1986; MITTLMEIER et al., 1991) are easy to use, and the results are readily interpreted without the need of complex analysis. Commercial versions of such systems are also available (HENNIG and NICOL, 1978). Regardless of the technology used, these devices are based on a matrix of sensors that detect the vertical component of the force, or equivalently the mean value of the pressure acting on the sensor area. Pressure platforms measure local pressure between the foot and the floor with spatial resolution given by the intersensor distance, whereas force platforms measure the vector in the space of the resultant ground reaction force. Pressure platforms (CAVANAGH and MICHIYOSHI, 1980; SIMK_rN and STOKES, 1982) usually have a small sensitive area sufficient to sustain only one foot. A consequent disadvantage is that the subjects walking is unnatural and parameters of the whole walking cycle, related to both feet simultaneously, cannot be measured. The ambulatory monitoring of gait, which entails the analysis of a large number of steps, has been performed with a few discrete transducers attached to the sole of the foot or the shoe (SOAMES et al., 1982; HENNIG et al., 1982; GROSS and BUNCH, 1988), or with insoles (PERUCHON et al., 1989; ZHU et al., 1991). Insoles have higher precision and spatial resolution than transducers. With both kinds of device it is possible to measure the stance of both feet simultaneously, and therefore the temporal parameters of the whole gait cycle, but spatial parameters cannot be measured as they require knowledge of the relative position of one foot with respect to the other. Measuring walkways (CROUSE et al., 1987; HIROKAWA and MATSUMURA, 1989; HmOKAWA, 1989; REILLY, 1991) have been constructed with the aim of analysing only the spatialtemporal parameters of gait during the whole walking cycle; they usually consist of conductive grids spaced 1 cm along both directions, and therefore they can detect only foot-floor contact. The platform proposed here is the final version of a device partially outlined previously (Lo VERDE et al., 1991). It has been conceived as a clinical system for basic gait analysis, in which simplicity of use and a thorough analysis have been satisfactorily combined. The wide size of the platform allows us to detect at least three successive footprints, and therefore it is particularly suitable for the measurement of the spatial and temporal quantities of gait. A consistent software package has been developed to compute gait parameters of potential clinical interest.

Effects of strengthening, stretching and functional training on foot function in patients with diabetic neuropathy: results of a randomized controlled trial

BackgroundFoot musculoskeletal deficits are seldom addressed by preventive medicine despite their high prevalence in patients with diabetic polyneuropathy.AIM: To investigate the effects of strengthening, stretching, and functional training on foot rollover process during gait.MethodsA two-arm parallel-group randomized controlled trial with a blinded assessor was designed. Fifty-five patients diagnosed with diabetic polyneuropathy, 45 to 65 years-old were recruited. Exercises for foot-ankle and gait training were administered twice a week, for 12 weeks, to 26 patients assigned to the intervention group, while 29 patients assigned to control group received recommended standard medical care: pharmacological treatment for diabetes and foot care instructions. Both groups were assessed after 12 weeks, and the intervention group at follow-up (24 weeks). Primary outcomes involved foot rollover changes during gait, including peak pressure (PP). Secondary outcomes involved time-to-peak pressure (TPP) and pressure–time integral (PTI) in six foot-areas, mean center of pressure (COP) velocity, ankle kinematics and kinetics in the sagittal plane, intrinsic and extrinsic muscle function, and functional tests of foot and ankle.ResultsEven though the intervention group primary outcome (PP) showed a not statistically significant change under the six foot areas, intention-to-treat comparisons yielded softening of heel strike (delayed heel TPP, p=.03), better eccentric control of forefoot contact (decrease in ankle extensor moment, p<.01; increase in function of ankle dorsiflexion, p<.05), earlier lateral forefoot contact with respect to medial forefoot (TPP anticipation, p<.01), and increased participation of hallux (increased PP and PTI, p=.03) and toes (increase in PTI, medium effect size). A slower COP mean velocity (p=.05), and an increase in overall foot and ankle function (p<.05) were also observed. In most cases, the values returned to baseline after the follow-up (p<.05).ConclusionsIntervention discreetly changed foot rollover towards a more physiological process, supported by improved plantar pressure distribution and better functional condition of the foot ankle complex. Continuous monitoring of the foot status and patient education are necessary, and can contribute to preserving the integrity of foot muscles and joints impaired by polyneuropathy.Trial registrationClinicalTrials.gov Identifier:NCT01207284, registered in 20th September 2010.

Cluster analysis to classify gait alterations in rheumatoid arthritis using peak pressure curves

OBJECTIVE To detect gait alterations in rheumatoid arthritis (RA) patients using peak pressure curves (PPC) and normalized force curves (NFC) instead of clinical classification based on the health assessment questionnaire (HAQ). METHODS Three RA groups--30 patients each--were classified according to their HAQ score. Cluster analysis based on a k-means algorithm was applied to PPCs and NFCs in order to classify RA patients with respect to amplitude and shapes of such gait parameters. RESULTS The best gait pattern identification was obtained by clustering PPCs into three clusters. Peak pressures of the three identified patterns were 1169.5+/-99.4 kPa for cluster 1, 885.8+/-165.2 kPa for cluster 2 and 402.0+/-128.5 kPa for cluster 3 (statistically different, Students t-test, p<0.001). 41 patients were included in cluster 3, 31 in cluster 2 and only 18 patients in cluster 1. Most RA3 patients--17 out of 30--showed low peak pressures and almost normal PPCs (cluster 3). Cluster 2, which incorporated altered PPCs, was mainly formed by RA1 and RA2 patients. CONCLUSIONS PPC appears as a reliable gait parameter for a shape-based clustering algorithm. The proposed cluster analysis was proved to be reliable and the delivered classifications stable. The distribution of RA patients among the three identified PPC clusters showed only a partial agreement between clinical and functional classification, thus revealing the development of specific gait strategies related to the pathology more than to its clinical level of severity. This finding may be clinically relevant and support effective treatment of RA gait related pathologies.

Gait analysis with an integrated system for functional assessment of talocalcaneal coalition.

There is little knowledge of the functional performance of patients with talocalcaneal coalition because of the marginal quantitative information accessible using current motion-analysis and plantar pressure-measurement techniques. A novel system was developed for comprehensively measuring foot-floor interaction during the stance phase of gait that integrates instrumentation for simultaneously measuring bony segment position, ground reaction force, and plantar pressure with synchronization of spatial and temporal variables. An advanced anatomically based analysis of foot joint rotations was also applied. Tracking of numerous anatomical landmarks allowed accurate selection of three footprint subareas and reliable estimation of relevant local forces and moments. Eight patients (11 feet) with talocalcaneal coalition were analyzed. Major impairment of the rearfoot was found in nonsurgical patients, with an everted attitude, limited plantarflexion, and overloading in all three components of ground reaction force. Surgical patients showed more normal loading patterns in each footprint subarea. This measuring system allowed for accurate inspection of the effects of surgical treatment in the entire foot and at several footprint subareas. Surgical treatment of talocalcaneal coalition seems to be effective in restoring more physiologic subtalar and forefoot motion and loading patterns.