Juha M. Hijmans

Bilateral upper-limb rehabilitation after stroke using a movement-based game controller

This study aimed to determine the effectiveness of a bilateral, self-supported, upper-limb rehabilitation intervention using a movement-based game controller for people with chronic stroke. Fourteen participants received a control treatment, followed by a washout period, and then the intervention. The intervention comprised playing computer games with the CyWee Z (CyWee Group Ltd; Taipei, Taiwan), a movement-based game controller similar to the Nintendo Wii remote. The CyWee Z was incorporated into a handlebar, making bilateral exercises possible by allowing the unaffected side to support and assist the affected side. The intervention lasted for 8 to 10 sessions of 45 to 60 minutes over a period of 2.5 weeks. The Fugl-Meyer Assessment upper-limb section (FMA-UL) was used as the primary outcome. The Wolf Motor Function Test and the Disabilities of Arm, Shoulder, and Hand outcome measure were used as secondary outcomes. Postintervention, motor performance as measured by the FMA-UL was significantly improved compared with all preintervention assessments (p < 0.001), whereas no changes were found on both secondary outcomes. It can be concluded from this pilot study that upper-limb motor performance of adults with chronic stroke improves with repetitive, game-assisted, self-supported bilateral exercises.

The Effect of Reduced Somatosensation on Standing Balance: A Systematic Review

The objective of this review is to identify and review publications describing the impact of reduced somatosensation on balance. Based on knowledge of the association between specific somatosensory loss and deterioration of balance, conclusions can be made about role of somatosensation in standing balance. A systematic literature review is presented in which publications from the years 1993 through 2007 were searched in Medline and Embase. Medical Subject Headings (MESH) terms and free text words (related to balance, somatosensory loss, and lower limb) were used to perform the searches. Fifteen articles were selected for detailed review based on predetermined inclusion criteria, and three of the included articles described the effect of experimentally reduced somatosensation on balance in healthy subjects. Ten of the articles described balance in diabetic neuropathy (DN). The last two included articles described balance in Charcot-Marie-Tooth (CMT) disease type 1A (CMT1A) or type 2 (CMT2). The literature indicates that the tactile sensation is reduced in DN, CMT1A, and CMT2 and when the plantar surface of the feet was hypothermically anesthetized. Joint motion sensation seems to be impaired in patients with DN, and passive joint position sensation appears to be reduced in healthy subjects with anesthesia of ankle and foot from prolonged ischemia. This reduced somatosensation seems to have a negative effect on balance in patients with DN and CMT2; however, this appeared not to be the case in patients with CMT1A and in healthy subjects.

Effects of vibrating insoles on standing balance in diabetic neuropathy.

This study investigated the effects on standing balance of random vibrations applied to the plantar side of the feet by vibrating insoles in subjects with neuropathy and nondisabled subjects. In four different conditions (eyes open or closed and with or without an attention-demanding task [ATD]), subjects with neuropathy secondary to diabetes mellitus (n = 17) and nondisabled subjects (n = 15) stood for 60 s on vibrating insoles placed on a force plate. During each condition, the insoles were turned on for 30 s and off for 30 s (random order). The calculated balance measures were mean velocity of the center of pressure displacements and root-mean-square of the velocity of these displacements in the anteroposterior and mediolateral directions. In subjects with neuropathy, an interaction effect between vibration and an ADT was found for balance. No effects of vibration on balance were found in nondisabled subjects. Vibrating insoles improved standing balance in subjects with neuropathy only when attention was distracted. Improvement of the insoles and their activation is needed to make their implementation in daily living possible and effective.

Development of vibrating insoles

The objective of this study was to describe the development of vibrating insoles. Insoles, providing a subsensory mechanical noise signal to the plantar side of the feet, may improve balance in healthy young and older people and in patients with stroke or diabetic neuropathy. This study describes the requirements for the tactors, (tactile actuators) insole material and noise generator. A search for the components of vibrating insoles providing mechanical noise to the plantar side of the feet was performed. The mechanical noise signal should be provided by tactors built in an insole or shoe and should obtain an input signal from a noise generator and an amplifier. Possible tactors are electromechanical tactors, a piezo actuator or the VBW32 skin transducer. The Minirator MR1 of NTI, a portable MP3 player or a custom-made noise generator can provide these tactors with input. The tactors can be built in foam, silicone or cork insoles. In conclusion, a C2 electromechanical tactor, a piezo actuator or the VBW32 skin transducer, activated by a custom-made noise generator, built in a cork insole covered with a leather layer seems the ideal solution.

Running with a minimalist shoe increases plantar pressure in the forefoot region of healthy female runners

OBJECTIVES Minimalist running shoes have been proposed as an alternative to barefoot running. However, several studies have reported cases of forefoot stress fractures after switching from standard to minimalist shoes. Therefore, the aim of the current study was to investigate the differences in plantar pressure in the forefoot region between running with a minimalist shoe and running with a standard shoe in healthy female runners during overground running. DESIGN Randomized crossover design. METHODS In-shoe plantar pressure measurements were recorded from eighteen healthy female runners. Peak pressure, maximum mean pressure, pressure time integral and instant of peak pressure were assessed for seven foot areas. Force time integral, stride time, stance time, swing time, shoe comfort and landing type were assessed for both shoe types. A linear mixed model was used to analyze the data. RESULTS Peak pressure and maximum mean pressure were higher in the medial forefoot (respectively 13.5% and 7.46%), central forefoot (respectively 37.5% and 29.2%) and lateral forefoot (respectively 37.9% and 20.4%) for the minimalist shoe condition. Stance time was reduced with 3.81%. No relevant differences in shoe comfort or landing strategy were found. CONCLUSIONS Running with a minimalist shoe increased plantar pressure without a change in landing pattern. This increased pressure in the forefoot region might play a role in the occurrence of metatarsal stress fractures in runners who switched to minimalist shoes and warrants a cautious approach to transitioning to minimalist shoe use.

Use and usability of custom-made orthopedic shoes

The goal of this study was to investigate the use of custom-made orthopedic shoes (OS) and the association between the use of OS and the most relevant aspects of their usability. Over a 6-month period, patients meeting the inclusion criteria were recruited by 12 orthopedic shoe companies scattered throughout the Netherlands and asked to complete a questionnaire composed of a pre- and post-OS section. Patients with different pathologies were included in the study (n = 339; response 67%). Mean age of the patients was 63 +/- 15 years, and 38% were male. Three months after delivery, 81% of the patients used their OS frequently (4-7 days/week), 13% occasionally (1-3 days/week), and 6% did not use their OS. Associations were found between use and all measured aspects of usability (p-values varied from <0.001 to 0.028). Patients who used their OS more often had a more positive opinion regarding all the aspects of usability. We conclude that all aspects of the usability of OS are relevant in relation to their use and should be taken into account when prescribing and evaluating OS.

Early Post-operative Mortality After Major Lower Limb Amputation: A Systematic Review of Population and Regional Based Studies

OBJECTIVE Lower limb amputation is often associated with a high risk of early post-operative mortality. Mortality rates are also increasingly being put forward as a possible benchmark for surgical performance. The primary aim of this systematic review is to investigate early post-operative mortality following a major lower limb amputation in population/regional based studies, and reported factors that might influence these mortality outcomes. METHODS Embase, PubMed, Cinahl and Psycinfo were searched for publications in any language on 30 day or in hospital mortality after major lower limb amputation in population/regional based studies. PRISMA guidelines were followed. A self developed checklist was used to assess quality and susceptibility to bias. Summary data were extracted for the percentage of the population who died; pooling of quantitative results was not possible because of methodological differences between studies. RESULTS Of the 9,082 publications identified, results were included from 21. The percentage of the population undergoing amputation who died within 30 days ranged from 7% to 22%, the in hospital equivalent was 4-20%. Transfemoral amputation and older age were found to have a higher proportion of early post-operative mortality, compared with transtibial and younger age, respectively. Other patient factors or surgical treatment choices related to increased early post-operative mortality varied between studies. CONCLUSIONS Early post-operative mortality rates vary from 4% to 22%. There are very limited data presented for patient related factors (age, comorbidities) that influence mortality. Even less is known about factors related to surgical treatment choices, being limited to amputation level. More information is needed to allow comparison across studies or for any benchmarking of acceptable mortality rates. Agreement is needed on key factors to be reported.

Foot and ankle compression improves joint position sense but not bipedal stance in older people

This study investigates the effects of foot and ankle compression on joint position sense (JPS) and balance in older people and young adults. 12 independently living healthy older persons (77-93 years) were recruited from a senior accommodation facility. 15 young adults (19-24 years) also participated. Compression was applied at the ankles and feet using medical compression hosiery. The mean velocity of the centre of pressure (CoP) displacements and the root mean square of the CoP velocity in both anteroposterior and mediolateral directions, were measured with a foot pressure plate. In older people, ankle compression was associated with an improvement of JPS towards normal values. However, a concurrent deterioration of their balance was found. In young adults compression had no effect on either JPS or balance.

Development and reproducibility of a short questionnaire to measure use and usability of custom-made orthopaedic shoes.

OBJECTIVE To develop a short and easy to use questionnaire to measure use and usability of custom-made orthopaedic shoes, and to investigate its reproducibility. DESIGN Development of the questionnaire (Monitor Orthopaedic Shoes) was based on a literature search, expert interviews, 2 expert meetings, and exploration and testing of reproducibility. The questionnaire comprises 2 parts: a pre part, measuring expectations; and a post part, measuring experiences. PATIENTS The pre part of the final version was completed twice by 37 first-time users before delivery of their orthopaedic shoes. The post part of the final version was completed twice by 39 first-time users who had worn their orthopaedic shoes for 2-4 months. RESULTS High reproducibility scores (Cohens kappa > 0.60 or intra class correlation > 0.70) were found in all but one question of both parts of the final version of the Monitor Orthopaedic Shoes questionnaire. The smallest real difference on a visual analogue scale (100 mm) ranged from 21 to 50 mm. It took patients approximately 15 minutes to complete one part. CONCLUSION Monitor Orthopaedic Shoes is a practical and reproducible questionnaire that can measure relevant aspects of use and usability of orthopaedic shoes from a patients perspective.

Rocker shoe, minimalist shoe, and standard running shoe: A comparison of running economy

OBJECTIVES Running with rocker shoes is believed to prevent lower limb injuries. However, it is not clear how running in these shoes affects the energy expenditure. The purpose of this study was, therefore, to assess the effects of rocker shoes on running economy in comparison with standard and minimalist running shoes. DESIGN Cross-over design. METHODS Eighteen endurance female runners (age=23.6 ± 3 years), who were inexperienced in running with rocker shoes and with minimalist/barefoot running, participated in this study. Oxygen consumption, carbon dioxide production, heart rate and rate of perceived exertion were measured while participants completed a 6-min sub-maximal treadmill running test for each footwear condition. The data of the last 2 min of each shoe condition were averaged for analysis. A linear mixed model was used to compare differences among three footwear conditions. RESULTS Oxygen consumption during running with rocker shoes was on average 4.5% higher than with the standard shoes (p<0.001) and 5.6% higher than with the minimalist shoe (p<0.001). No significant differences were found in heart rate and rate of perceived exertion across three shoe conditions. CONCLUSIONS Female runners, who are not experienced in running with the rocker shoes and minimalist shoes, show more energy expenditure during running with the rocker shoes compared with the standard and minimalist shoes. As the studied shoes were of different masses, part of the effect of increased energy expenditure with the rocker shoe is likely to be due to its larger mass as compared with standard running shoes and minimalist shoes.