Can robotic-based top-down rehabilitation therapies improve motor control in children with cerebral palsy? A perspective on the CPWalker project

[EN] Cerebral Palsy (CP) is one of the most severe disabilities in childhood, and it demands important costs in health, education, and social services. CP is caused by damage to or abnormalities inside the developing brain that disrupt the brain's ability to control movement and maintain posture. Furthermore, CP is often associated with sensory deficits, cognition impairments, communication and motor disabilities, behavior issues, seizure disorder, pain, and secondary musculoskeletal problems. According to the literature, motor modules are peripheral measurements related to automatic motor control. There is a lack of evidence of change in motor modules in children with CP when different treatment approaches have been evaluated. Thus, new strategies are needed to improve motor control in this population. Robotic-based therapies are emerging as an effective intervention for gait rehabilitation in motor disorders such as stroke, spinal cord injury, and CP. There is vast clinical evidence that neural plasticity is the central core of motor recovery and development, and on-going studies suggest that robot-mediated intensive therapy could be beneficial for improved functional recovery. However, current robotic strategies are focused on the peripheral neural system (PNS) facilitating the performance of repetitive movements (a bottom-up approach). Since CP affects primarily brain structures, both the PNS and the central nervous system (CNS) should to be integrated in a physical and cognitive rehabilitation therapy (a top-down approach). This paper discusses perspectives of the top-down approach based on a novel robot-assisted rehabilitative system. Accordingly, the CPWalker robotic platform was developed to support novel therapies for CP rehabilitation. This robotic platform (Smart Walker + exoskeleton) is controlled by a multimodal interface enabling the interaction of CP infants with robot-based therapies. The aim of these therapies is to improve the physical skills of infants with CP using a top-down approach, in which motor related brain activity is used to drive robotic physical rehabilitation therapies. Our hypothesis is that the CPWalker concept will promote motor learning and this improvement will lead to significant improvements in automatic motor control.Lerma Lara, S.; Martínez Caballero, I.; Bayón, C.; Del Castillo, M.; Serrano, I.; Raya, R.; Belda Lois, JM.... (2016). Can robotic-based top-down rehabilitation therapies improve motor control in children with cerebral palsy? A perspective on the CPWalker project. Biomedical Research and Clinical Practice. 22-26. doi:10.15761/BRCP.1000106S222

Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications

BACKGROUND Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients. OBJECTIVES To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs. DESIGN This was a prospective international 1-week observational study using the ‘Assess Respiratory Risk in Surgical Patients in Catalonia risk score’ (ARISCAT score) for PPC for risk stratification. PATIENTS AND SETTING Adult patients requiring intraoperative ventilation during general anaesthesia for surgery in 146 hospitals across 29 countries. MAIN OUTCOME MEASURES The primary outcome was the incidence of patients at increased risk of PPCs based on the ARISCAT score. Secondary outcomes included intraoperative ventilatory management and clinical outcomes. RESULTS A total of 9864 patients fulfilled the inclusion criteria. The incidence of patients at increased risk was 28.4%. The most frequently chosen tidal volume (VT) size was 500 ml, or 7 to 9 ml kg1 predicted body weight, slightly lower in patients at increased risk of PPCs. Levels of positive end-expiratory pressure (PEEP) were slightly higher in patients at increased risk of PPCs, with 14.3% receiving more than 5 cmH2O PEEP compared with 7.6% in patients at low risk of PPCs (P < 0.001). Patients with a predicted preoperative increased risk of PPCs developed PPCs more frequently: 19 versus 7%, relative risk (RR) 3.16 (95% confidence interval 2.76 to 3.61), P < 0.001) and had longer hospital stays. The only ventilatory factor associated with the occurrence of PPCs was the peak pressure. CONCLUSION The incidence of patients with a predicted increased risk of PPCs is high. A large proportion of patients receive high VT and low PEEP levels. PPCs occur frequently in patients at increased risk, with worse clinical outcome

Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications: LAS VEGAS - An observational study in 29 countries

BACKGROUND Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients. OBJECTIVES To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs. DESIGN This was a prospective international 1-week observational study using the ‘Assess Respiratory Risk in Surgical Patients in Catalonia risk score’ (ARISCAT score) for PPC for risk stratification. PATIENTS AND SETTING Adult patients requiring intraoperative ventilation during general anaesthesia for surgery in 146 hospitals across 29 countries. MAIN OUTCOME MEASURES The primary outcome was the incidence of patients at increased risk of PPCs based on the ARISCAT score. Secondary outcomes included intraoperative ventilatory management and clinical outcomes. RESULTS A total of 9864 patients fulfilled the inclusion criteria. The incidence of patients at increased risk was 28.4%. The most frequently chosen tidal volume (V T) size was 500 ml, or 7 to 9 ml kg−1 predicted body weight, slightly lower in patients at increased risk of PPCs. Levels of positive end-expiratory pressure (PEEP) were slightly higher in patients at increased risk of PPCs, with 14.3% receiving more than 5 cmH2O PEEP compared with 7.6% in patients at low risk of PPCs (P ˂ 0.001). Patients with a predicted preoperative increased risk of PPCs developed PPCs more frequently: 19 versus 7%, relative risk (RR) 3.16 (95% confidence interval 2.76 to 3.61), P ˂ 0.001) and had longer hospital stays. The only ventilatory factor associated with the occurrence of PPCs was the peak pressure. CONCLUSION The incidence of patients with a predicted increased risk of PPCs is high. A large proportion of patients receive high V T and low PEEP levels. PPCs occur frequently in patients at increased risk, with worse clinical outcome.</p

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

The management of acute venous thromboembolism in clinical practice. Results from the European PREFER in VTE Registry

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in Europe. Data from real-world registries are necessary, as clinical trials do not represent the full spectrum of VTE patients seen in clinical practice. We aimed to document the epidemiology, management and outcomes of VTE using data from a large, observational database. PREFER in VTE was an international, non-interventional disease registry conducted between January 2013 and July 2015 in primary and secondary care across seven European countries. Consecutive patients with acute VTE were documented and followed up over 12 months. PREFER in VTE included 3,455 patients with a mean age of 60.8 ± 17.0 years. Overall, 53.0 % were male. The majority of patients were assessed in the hospital setting as inpatients or outpatients (78.5 %). The diagnosis was deep-vein thrombosis (DVT) in 59.5 % and pulmonary embolism (PE) in 40.5 %. The most common comorbidities were the various types of cardiovascular disease (excluding hypertension; 45.5 %), hypertension (42.3 %) and dyslipidaemia (21.1 %). Following the index VTE, a large proportion of patients received initial therapy with heparin (73.2 %), almost half received a vitamin K antagonist (48.7 %) and nearly a quarter received a DOAC (24.5 %). Almost a quarter of all presentations were for recurrent VTE, with &gt;80 % of previous episodes having occurred more than 12 months prior to baseline. In conclusion, PREFER in VTE has provided contemporary insights into VTE patients and their real-world management, including their baseline characteristics, risk factors, disease history, symptoms and signs, initial therapy and outcomes

Biobehavioural analysis of the vestibular system and posture control in patients with cervicogenic dizziness. A cross-sectional study

Background: Cervicogenic dizziness is a musculoskeletal disorder mainly characterised by dizziness and disequilibrium associated with neck pain. The pathophysiology is unclear and the neurophysiological basis remains to be ascertained. The aim of this study is to compare the vestibulo-ocular reflex and postural control between patients with cervicogenic dizziness and asymptomatic subjects, and to assess the association between debilitating dizziness and other psychosocial variables. Materials and methods: A total of 20 patients and 22 asymptomatic subjects were selected. Vestibulo-ocular reflex was assessed by performing the head impulse test. Computerised dynamic posturography was used to evaluate the postural control by means of the sensory organisation test. In addition, subjects self-reported their degree of disability due to dizziness, cervical disability, kinesiophobia, and state of anxiety and depression. Results: There were no differences in the vestibulo-ocular reflex (P > .05). However, we found differences with a medium-to-large effect size (d > 0.60) in variables related to proprioception and visual information integration; the former variable set was related to disability due to dizziness. Disability due to dizziness presents strong-to-moderate associations with cervical disability, kinesiophobia, and anxiety. Conclusion: Our data rule out changes in the vestibular system in cervicogenic dizziness, but they do point to proprioceptive impairment. According to our results, the association between dizziness-related disability and other psychosocial factors in cervicogenic dizziness is very relevant for clinical medicine and for future research projects. Resumen: Introducción: El mareo cervicogénico es una afección que se caracteriza por mareos y desequilibrio que se asocia a dolor de cuello. La fisiopatología no está clara, y es necesario conocer la base neurofisiológica del trastorno. El objetivo de estudio es comparar la actividad del reflejo vestíbulo-ocular y el control postural entre pacientes que presentan mareo cervicogénico y sujetos asintomáticos; además, se pretende evaluar la asociación entre la discapacidad por mareo con otras variables psicosociales. Material y métodos: Se seleccionaron un total de 20 pacientes y 22 sujetos asintomáticos, a los que se realizó una valoración del reflejo vestíbulo-ocular con el test del impulso cefálico y una valoración del control postural mediante posturografía dinámica y el test de organización sensorial, además se evaluaron mediante autoinforme la discapacidad por mareo, la discapacidad cervical, el miedo al movimiento y el estado de ansiedad y depresión. Resultados: No se encontraron diferencias en la actividad del reflejo vestíbulo-ocular (p > 0,05); a nivel del control postural se encontraron diferencias con un tamaño del efecto mediano-grande (d > 0,60) en variables relacionadas con la propiocepción e integración de la información visual, asociándose esta variable a la discapacidad por mareo. La discapacidad por mareo presentó asociaciones moderadas-fuertes con la discapacidad cervical, el miedo al movimiento y la ansiedad. Conclusión: Los resultados obtenidos descartan una alteración del sistema vestibular en el mareo cervicogénico, aunque sí se comprueba la existencia de una alteración propioceptiva. La asociación de la discapacidad por mareo con otras variables psicosociales a la vista de nuestros resultados debe tomarse en cuenta en la clínica y en futuras investigaciones. Keywords: Neck pain, Dizziness, Vestibular system, Posture control, Vestibulo-ocular reflex, Disability, Palabras clave: Dolor de cuello, Mareo, Sistema vestibular, Control postural, Reflejo vestíbulo-ocular, Discapacida

A robot-based gait training therapy for pediatric population with Cerebral Palsy: goal setting, proposal and preliminary clinical implementation

BACKGROUND: The use of robotic trainers has increased with the aim of improving gait function in patients with limitations. Nevertheless, there is an absence of studies that deeply describe detailed guidelines of how to correctly implement robot-based treatments for gait rehabilitation. This contribution proposes an accurate robot-based training program for gait rehabilitation of pediatric population with Cerebral Palsy (CP). METHODS: The program is focused on the achievement of some specifications defined by the International Classification of Functioning, Disability and Health framework, Children and Youth version (ICF-CY). It is framed on 16 non-consecutive sessions where motor control, strength and power exercises of lower limbs are performed in parallel with a postural control strategy. A clinical evaluation with four pediatric patients with CP using the CPWalker robotic platform is presented. RESULTS: The preliminary evaluation with patients with CP shows improvements in several aspects as strength (74.03±40.20%), mean velocity (21.46±33.79%), step length (17.95±20.45%) or gait performance (e.g. 18.88±14.31% in Gross Motor Function Measure-88 items, E and D dimensions). CONCLUSIONS: The improvements achieved in the short term show the importance of working strength and power functions meanwhile over-ground training with postural control. This research could serve as preliminary support for future clinical implementations in any robotic device. TRIAL REGISTRATION: The study was carried out with the number R-0032/12 from Local Ethical Committee of the Hospital Infantil Niño Jesús. Public trial registration: ISRCTN18254257. Registered 23 March 2017, retrospectively registered.Authors would like to thank Biomechanical Institute of Valencia and other colleges from Spanish National Research Council and Niño Jesús Hospital for their collaboration in other aspects and achievements carried out with CPWalker robotic platform. Authors appreciate Dr. Gaebler's advice for the development of the robotic program proposal. We would like to thank Made for Movement company for supporting us with NF- Walker device. We also acknowledge the effort and contribution from all testing children and their families. We acknowledge support of the publication fee by the CSIC Open Access Publication Support Initiative through its Unit of Information Resources for Research (URICI). The work presented in this paper has been carried out with the financial support from the Ministerio de Economía y Competitividad of Spain, under Contract DPI2012-39133-C03-01.Peer reviewe

Guía de tratamiento del deterioro de la marcha con fampridina de liberación prolongada (Fampyra®) en pacientes con esclerosis múltiple

Resumen: Introducción: La alteración de la marcha es frecuente en la esclerosis múltiple (EM) y tiene un gran impacto negativo en los pacientes pues conlleva a la pérdida progresiva de autonomía personal y social, y de productividad laboral. Esta guía pretende establecer recomendaciones para la evaluación del deterioro de la marcha y el uso de fampridina de liberación prolongada (fampridina-LP) como tratamiento de pacientes con EM y deterioro de la marcha en España. Desarrollo: Fampridina-LP a dosis de 10 mg cada 12 h es actualmente el único fármaco autorizado para mejorar el trastorno de la marcha en adultos con EM. En la práctica clínica, el fármaco ha demostrado además que mejora de forma significativa la calidad de vida de los pacientes que responden al tratamiento. La respuesta se puede evaluar mediante la prueba cronometrada de la marcha de 25 pies (T25FW) o el cuestionario MSWS-12 que deben realizarse antes y después del inicio del tratamiento. El tiempo mínimo recomendado para evaluar la respuesta inicial es de 2 semanas. Para considerar a un paciente como respondedor y continuar el tratamiento debe presentar, según indica la ficha técnica, una disminución en el tiempo T25FW o mejoría en el MSWS-12. Se recomienda realizar las revaluaciones al menos cada 6 meses. En los casos en que se considere la valoración de la calidad de vida, se recomienda la utilización del cuestionario de salud Short Form-36 (SF-36) o la escala MS Impact Scale-29 (MSIS-29). Es un fármaco en general bien tolerado y con buen perfil de seguridad. Se recomienda su administración en ayunas y control periódico de la función renal. Conclusiones: Estas recomendaciones permiten garantizar una prescripción eficiente y más segura, y ayudan al manejo de fampridina-LP como tratamiento del deterioro de la marcha en pacientes adultos con EM en España. Abstract: Introduction: Gait impairment, a frequent sign in multiple sclerosis (MS), places a major burden on patients since it results in progressive loss of personal and social autonomy, along with work productivity. This guide aims to provide recommendations on how to evaluate gait impairment and use prolonged-release fampridine (PR-fampridine) as treatment for MS patients with gait impairment in Spain. Development: PR-fampridine dosed at 10 mg every 12 hours is currently the only drug approved to treat gait impairment in adults with MS. Additionally, PR-fampridine has been shown in clinical practice to significantly improve quality of life (QoL) in patients who respond to treatment. Treatment response can be assessed with the Timed 25-Foot Walk (T25FW) or the 12-item MS Walking Scale (MSWS-12); tests should be completed before and after starting treatment. The minimum time recommended for evaluating treatment response is 2 weeks after treatment onset. Patients are considered responders and permitted to continue the treatment when they demonstrate a decrease in their T25FW time or an increase in MSWS-12 scores. A re-evaluation is recommended at least every 6 months. The SF-36 (Short Form-36) and the MSIS-29 (MS Impact Scale-29) tests are recommended for clinicians interested in performing a detailed QoL assessment. This drug is generally well-tolerated and has a good safety profile. It should be taken on an empty stomach and renal function must be monitored regularly. Conclusions: These recommendations will help ensure safer and more efficient prescription practices and easier management of PR-fampridine as treatment for gait impairment in Spanish adults with MS. Palabras clave: Fampridina, Marcha, Calidad de vida, Esclerosis múltiple, Timed 25-Foot Walk Test, The 12-item multiple sclerosis walking scale, Keywords: Fampridine, Gait impairment, Quality of life, Multiple sclerosis, T25FW, MSWS-1