Jan Andrysek

Active Video Game Play in Children With Cerebral Palsy: Potential for Physical Activity Promotion and Rehabilitation Therapies

OBJECTIVE To evaluate the potential of active video game (AVG) play for physical activity promotion and rehabilitation therapies in children with cerebral palsy (CP) through a quantitative exploration of energy expenditure, muscle activation, and quality of movement. DESIGN Single-group, experimental study. SETTING Human movement laboratory in an urban rehabilitation hospital. PARTICIPANTS Children (N=17; mean age ± SD, 9.43±1.51y) with CP. INTERVENTION Participants played 4 AVGs (bowling, tennis, boxing, and a dance game). MAIN OUTCOME MEASURES Energy expenditure via a portable cardiopulmonary testing unit; upper limb muscle activations via single differential surface electrodes; upper limb kinematics via an optical motion capture system; and self-reported enjoyment via the Physical Activity Enjoyment Scale (PACES). RESULTS Moderate levels of physical activity were achieved during the dance (metabolic equivalent for task [MET]=3.20±1.04) and boxing (MET=3.36±1.50) games. Muscle activations did not exceed maximum voluntary exertions and were greatest for the boxing AVG and for the wrist extensor bundle. Angular velocities and accelerations were significantly larger in the dominant arm than in the hemiplegic arm during bilateral play. A high level of enjoyment was reported on the PACES (4.5±0.3 out of 5). CONCLUSIONS AVG play via a low-cost, commercially available system can offer an enjoyable opportunity for light to moderate physical activity in children with CP. While all games may encourage motor learning to some extent, AVGs can be strategically selected to address specific therapeutic goals (eg, targeted joints, bilateral limb use). Future research is needed to address the challenge of individual variability in movement patterns/play styles. Likewise, further study exploring home use of AVGs for physical activity promotion and rehabilitation therapies, and its functional outcomes, is warranted.

Lower-limb prosthetic technologies in the developing world: A review of literature from 1994–2010

In the mid-1990s, a number of key publications and meetings of experts identified major technical issues associated with prosthetic technologies intended for developing countries. These included inadequate durability of prosthetic feet, poor socket quality and prosthetic fit, improper alignment of prostheses, and inferior function of components. To examine the progress that has been made since then in addressing these issues, a comprehensive review of literature was performed. In total, 106 articles were selected and included in the review. The review examined prosthetic technologies categorized into feet and ankles, knees, sockets and suspension, and matehals, structures, and alignment methods. Moreover, publications were categorized as technical development, clinical (lab-based) testing, or clinical field testing studies. The results reveal important work that has been carried out to develop and implement standardized outcome measures during field testing, allowing various existing prosthetic technologies to be evaluated in terms of their use, function, durability, and other factors. Progress has also been made toward addressing the aforementioned limitations of prosthetic technologies, however, more research and development is required. This includes improving the durability of the external cosmetic features of prosthetic feet, developing more functional prosthetic knee joints, and simplifying fabrication techniques to further improve outcomes associated with socket fit and prosthetic alignment. Research and development collaborations between developed and developing countries, and the dissemination of ongoing research, development, and evaluation activities are essential to the advancement of prosthetic technologies in these regions.

Assessment of the postural control strategies used to play two Wii Fit™ videogames

The Nintendo Wii Fit™ may provide an affordable alternative to traditional biofeedback or virtual reality systems for retraining or improving motor function in populations with impaired balance. The purpose of this study was to evaluate postural control strategies healthy individuals use to play Wii Fit™ videogames. Sixteen young adults played 10 trials of Ski Slalom and Soccer Heading respectively. Centre of pressure (COP) excursion and three-dimensional movement data were acquired to determine variability in medial-lateral COP sway and shoulder-pelvic movement. While there was no difference in medial-lateral COP variability between games during trial 1, there was a significant difference after 10 trials. COP sway increased (59-75 mm) for Soccer Heading while it decreased (67-33 mm) for Ski Slalom from trial 1 to trial 10. During Ski Slalom participants demonstrated decreased shoulder and pelvic movement combined with increased pelvic-shoulder coupling. Conversely, participants demonstrated greater initial shoulder tilt when playing Soccer Heading, with no reduction in pelvic rotation and tilt. Participants decreased pelvic and trunk movements when skiing, suggesting a greater contribution of lower extremity control while they primarily used a trunk strategy to play Soccer Heading.

Single-session reliability of discrete gait parameters in ambulatory children with cerebral palsy based on GMFCS level.

The single-session reliability of 28 discrete spatiotemporal and kinematic variables was evaluated from computerized gait analysis (CGA) in 33 ambulatory children with cerebral palsy (CP), subcategorized according to Gross Motor Function Classification System (GMFCS) Levels I (n=11), II (n=12) and III (n=10). Nineteen boys and 14 girls participated, mean age=8 years 1 month (S.D.=3 years 0 month). Intraclass correlation coefficients (ICCs) estimated reliability, and the number of strides required to obtain an ICC of at least 0.90 was determined. The reliability of discrete gait parameters was dependent upon GMFCS level, with children in GMFCS Level I exhibiting the highest reliability (ICC range=0.70-0.96). GMFCS Levels II and III had lower levels of reliability with ICC values varying from 0.54 to 0.95 and 0.45 to 0.98, respectively. With the exclusion of pelvis range of motion (ROM), an average of four strides provided a reliability estimate of at least 0.90 for GMFCS Level I, while six strides were needed for children in Levels II and III. On the basis of the intrasession reliability results from the present study, further work is recommended to examine the test-retest reliability of these gait parameters in children with CP.

Test-Retest Reliability of Discrete Gait Parameters in Children With Cerebral Palsy

OBJECTIVES To examine the test-retest reliability of discrete gait parameters in children with cerebral palsy (CP) in Gross Motor Function Classification System (GMFCS) levels I, II, and III; to calculate the measurement error between testing sessions of these parameters in the total sample and within GMFCS subgroups using the standard error of measurement; and to evaluate the minimal detectable change (MDC) to identify discrete gait parameters that are most sensitive to change in children with CP. DESIGN Test-retest reliability study. SETTING Rehabilitation facility with human movement laboratory. PARTICIPANTS Ambulatory children with CP (N=28). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Intraclass correlation coefficients (ICCs), standard error of measurement, and MDC of discrete gait parameters. RESULTS Parameters measured in the sagittal plane and temporal-spatial parameters were highly reliable across all GMFCS levels (ICC range, .84-.97), while test-retest reliability in the frontal and transverse planes varied from poor to excellent (ICC range, .46-.91). Using MDC as a guide, hip and pelvis parameters in the transverse and frontal planes were least responsive for GMFCS levels I and III (MDC ranges, 8.3 degrees -18.0 degrees and 2.7 degrees -23.4 degrees , respectively), whereas ankle kinematics were the least responsive for level II (MDC range, 8.2 degrees -11.9 degrees ). Reliability was dependent on mobility level, with children in GMFCS level III exhibiting greater test-retest variability overall. CONCLUSIONS Our findings suggest that select discrete gait parameters measured using computerized gait analysis are reliable and potentially responsive measures of performance and can be used as outcome measures in intervention studies.

Design characteristics of pediatric prosthetic knees

We examined whether pediatric prosthetic single-axis knees can theoretically provide the beneficial functional characteristics of polycentric knees and the design considerations needed to realize this. Five children and their parents provided subjective opinions of the relative importance of functional requirements (FRs) for the knee. FRs related to comfort, fatigue, stability, and falling were found to be of high importance, while sitting appearance and adequate knee flexion were of lower importance. Relationships were drawn between these FRs and deductions were made regarding the importance of associated design parameters. Stance-phase control was rated to be of greatest importance followed by toe clearance. Models were developed for five knees including four- and six-bar knees, corresponding to two commercially available components, and for three configurations of a single-axis knee. Stance-phase control, specifically stability after heel-strike and swing-phase initiation at push-off, and toe clearance were simulated. The results suggest that a single-axis knee design incorporating stance-phase control will mutually satisfy the identified set of highly and moderately important FRs.

Design and quantitative evaluation of a stance-phase controlled prosthetic knee joint for children

The aims of this study were to demonstrate a theoretical basis for the design of a stance-phase controlled paediatric prosthetic knee joint, clinically test prototypes of the knee, and use a questionnaire to evaluate its efficacy. Biomechanical models were used to analyze the stance-phase control characteristics of the proposed knee, and those of three other commonly prescribed paediatric knee joint mechanisms, which were also the conventional knee joints used by the six participants of this study (mean age 10.8 years). A questionnaire pertaining to stance-phase control was designed and administered twice to each child; once for the evaluation of the prototype knee joint and once for the conventional knee joint. Stance-phase modeling results indicated decreased zones of instability for the new knee as compared to other paediatric knee joints. Questionnaire results revealed a decrease in the frequency of falls with the prototype compared to other knees, especially in highly active children. The children also reported worrying less about the knee collapsing during walking. No differences were evident for stance-phase stability during running, walking on uneven terrain, ambulating up and down stairs and inclines, fatigue, and types of activities performed.

Priorities in lower limb prosthetic service delivery based on an international survey of prosthetists in low- and high-income countries

Background: Prosthetic services, including the provision of an appropriate prosthesis, are a crucial part of the rehabilitation process for individuals with lower limb amputations. However, globally there exist unique challenges in the delivery of prosthetic services that are limiting rehabilitation outcomes and consequently the well-being and socio-economic status of individuals with lower limb amputations. Objectives: The objective of this work was to explore the issues related to the provision of appropriate prosthetic technologies and to compare these across different economies of the world. Study design: Cross-sectional survey. Methods: An online survey was developed and distributed to prosthetic practitioners providing services in countries around the world. An open-coding thematic content analysis procedure was applied to extract key themes from the data. Results: The response codes defined three overall themes of lower limb prosthetic delivery, and several key differences between higher and lower income countries emerged. Namely, a higher emphasis on part/material availability, practitioner training and durability in lower income countries was found. High costs were an issue raised by practitioners in all countries. Conclusion: Practitioners around the world share many of the same concerns; however, some lower income countries face important and pressing issues that limit their ability to provide adequate prosthetic services. Clinical relevance This work highlights the most crucial service and technology-related needs, as perceived by trained prosthetic practitioners, of populations requiring lower limb prosthetic treatment around the world. Additionally, the results may be used to prioritize prosthetic-related health-care initiatives led by other researchers, governments and organizations working to improve services internationally.

Mobility function of a prosthetic knee joint with an automatic stance phase lock

Background: There is a need for a prosthetic knee joint design that is technologically and functionally appropriate for use in developing countries. Objectives: To develop and clinically evaluate a new type of stance phase controlled prosthetic knee joint that provides stance phase stability without inhibiting swing phase flexion. Study design: A crossover repeated measures study design comparing the new knee joint to the participants conventional low- or high-end prosthetic knee joint. Methods: The new knee joint was fitted to fourteen individuals aged 15 to 67 years with unilateral lower limb amputations. Walk tests were performed to measure walking speed. Energy expenditure was estimated using the physiological cost index (PCI). Results: Walking speeds with the new knee joint were on average 0.14 m/s faster than conventional low-end knees (p < 0.0001), but 0.07 m/s slower than conventional high-end prosthetic knees (p = 0.008). The PCI was similar across all three knee joint technologies (p = 0.276). Conclusions: Mobility function with the new knee joint, in terms of walking speed, was more closely matched to high-end than low-end prosthetic knee joints. Therefore, given its relatively simple design, the new stance phase control mechanism may offer a functional and cost effective solution for active transfemoral amputees. Clinical relevance This paper describes a new type of prosthetic knee joint mechanism that is intended to be cost-effective while providing high-level stance phase function to active individuals with a transfemoral amputation. Initial clinical testing suggests that the new knee joint may have some functional advantages over existing technologies in this category.

Factors influencing evidence-based practice in prosthetics and orthotics.

Background: The importance of evidence-based practice is being recognized across a broad range of healthcare disciplines as a means for improving patient outcomes and also efficiently managing healthcare resources. Objective: The objective of this work was to obtain information from clinicians about the underlying barriers and facilitators relating to evidence-based practice in prosthetics and orthotics. Study design: Cross sectional survey. Methods: An internet survey was developed and distributed to 300 prosthetists and orthotists currently practicing in Canada. Results: A principal component factor analysis of the survey results revealed ten primary factors affecting evidence-based practice. These include time constraints, workload and system demands, limited relevant evidence from research, and gaps in skills and knowledge required to perform evidence-based practice. Conclusions: Clinicians value research as a means of improving clinical practice, but they are faced with a number of practical barriers in performing evidence-based practice. Clinical relevance This study provides empirical data about the underlying barriers and facilitators relating to evidence-based practice in prosthetics and orthotics. Such data are essential in order to inform those involved in improving existing clinical practices, including educators, professional organizations, and governing bodies.