Effects of Altered Somatosensory Input on Lower Limb Mechanics via Different Shoes and Barefoot Walking in Individuals with Chronic Post-Stroke Hemiparesis

[Purpose/Hypothesis] Stroke is a leading cause of disability that results in various neurological deficits. Stroke can cause impaired somatosensory input, which results in decreased balance and gait speed, ultimately increasing fall risks. Therapies to increase somatosensory input have shown promise for people with stroke as well as other neurological populations. However, few studies have systematically investigated varying somatosensory input via different footwear to improve walking in people post-stroke. The purpose of this study was to investigate the effects of altering somatosensory input via different types of footwear (i.e., barefoot, self-selected shoes, and memory foam shoes) on gait kinetics and ankle kinematics during gait in individuals with chronic post-stroke hemiparesis. We hypothesized that increased somatosensory input via barefoot walking would improve paretic propulsive force, reduce paretic braking force, and improve paretic ankle kinematics. [Number of Subjects] 9 individuals post-stroke (62.9±11.2 years old; 5.9±4.4 years post-stroke) and 5 non-neurologically impaired (53.4±17.0 years old) individuals. [Methods/Materials] Reflective markers were placed over lower extremities landmarks, and surface electromyography sensors over ankle muscles. Participants then walked over a dual belt instrumented treadmill for 5 minutes, under self-selected walking speed, wearing self-selected shoes. Subsequently, trials were conducted barefoot and with memory foam shoes, in randomly assigned order. Peak propulsive force, peak braking force, peak plantarflexion angle at push-off, and peak dorsiflexion angle during swing phase were assessed using a 3 (Limbs: paretic, non-paretic, and non-impaired) X 3 (Shoes: self-selected footwear, memory foam shoes, and barefoot) mixed factorial ANOVA. A priori significance was set at p \u3c 0.05. [Results] A statistically significant interaction was observed for Shoes x Limb for peak propulsive force (p=0.04). Additionally, simple main effects revealed that in non-impaired legs, greater propulsive forces were generated when wearing self-selected shoes compared to memory foam or barefoot. A statistically significant main effect of Shoes was observed for ankle angle at toe off (p \u3c 0.01), suggesting that regardless of limb, wearing self-selected shoes increases plantarflexion at toe off, whereas wearing memory foam shoes increases dorsiflexion at toe off. A statistically significant main effect of Shoes was observed for peak dorsiflexion during swing (p \u3c 0.01), indicating that regardless of limb, wearing memory foam shoes causes more dorsiflexion during swing than self-selected shoes. [Conclusion] We found that memory foam shoes can encourage paretic ankle dorsiflexion during swing phase of gait, which could be used to address foot-drop in post-stroke gait training. If the goal of gait training was to target propulsive force to increase walking speed, then memory foam shoes or barefoot is not recommended. [Clinical Relevance] Findings can help inform clinicians on appropriate footwear recommendations to ensure safety for community ambulation and may be incorporated into gait training paradigms in rehabilitation

The Customary International Law Game

Structural realists in political science and some rationalist legal scholars argue that customary international law cannot affect state behavior: that it is “epiphenomenal.” This article develops a game theoretic model of a multilateral prisoner’s dilemma in the customary international law context that shows that it is plausible that states would comply with customary international law under certain circumstances. Our model shows that these circumstances relate to: (i) the relative value of cooperation versus defection, (ii) the number of states effectively involved, (iii) the extent to which increasing the number of states involved increases the value of cooperation or the detriments of defection, including whether the particular issue has characteristics of a commons problem, a public good, or a network good, (iv) the information available to the states involved regarding compliance and defection, (v) the relative patience of states in valuing the benefits of long-term cooperation compared to short-term defection, (vi) the expected duration of interaction, (vii) the frequency of interaction, and (viii) whether there are also bilateral relationships or other multilateral relationships between the involved states. This model shows that customary international law is plausible in the sense that it may well affect state behavior where certain conditions are met. It shows what types of contexts, including malleable institutional features, may affect the ability of states to produce and comply with customary international law. This article identifies a number of empirical strategies that may be used to test the model

Racial segregation and disparities in breast cancer care and mortality

Objectives: To examine whether residential segregation is a mediator of racial/ ethnic disparities in breast cancer care and breast cancer mortality, or has a differential effect by race/ ethnicity. Methods: Data from the Surveillance, Epidemiology and End Results-Medicare database on white, black, and Hispanic women age 66 to 85 years with breast cancer were examined to look at the receipt of adequate breast cancer care. Results: Blacks were less likely than whites to receive adequate breast cancer care (odds ratio {OR} 0.78; 95% confidence interval {CI} 0.71 - 0.86). Individuals, both black and white, who lived in areas with greater black segregation were less likely to receive adequate breast cancer care (0.73; 0.64 – 0.82). Black segregation was a mediator of the black/ white disparity in breast cancer care, explaining 8.9% of the difference. After adjustment, adequate care for Hispanics did not significantly differ from whites, but individuals, both Hispanic and white, who lived in areas with greater Hispanic segregation were less likely to receive adequate breast cancer care (0.73; 0.61 – 0.89). While Blacks experienced greater breast cancer mortality than whites, black segregation did not substantially mediate the black-white disparity in survival, and was not significantly associated with mortality (hazard ratio 1.03; CI 0.87– 1.21). Breast cancer mortality did not differ between Hispanics and whites. Conclusions: Among seniors, segregation mediates some of the black-white disparity in breast cancer care, but not mortality. Individuals who live in more segregated areas are less likely to receive adequate breast cancer care

Legalized Dispute Resolution: Interstate and Transnational

International courts and tribunals are flourishing. Depending on howthese bodies are defined, they now number between seventeen and forty.1In recent years we have witnessed the proliferation of new bodies and astrengthening of those that already exist. When future internationallegal scholars look back at . . . the end of the twentiethcentury ,one analyst has written, they probably will refer to the enormousexpansion of the international judiciary as the single most importantdevelopment of the post Cold War age.