Mechanomyographic Parameter Extraction Methods: An Appraisal for Clinical Applications

The research conducted in the last three decades has collectively demonstrated that the skeletal muscle performance can be alternatively assessed by mechanomyographic signal (MMG) parameters. Indices of muscle performance, not limited to force, power, work, endurance and the related physiological processes underlying muscle activities during contraction have been evaluated in the light of the signal features. As a non-stationary signal that reflects several distinctive patterns of muscle actions, the illustrations obtained from the literature support the reliability of MMG in the analysis of muscles under voluntary and stimulus evoked contractions. An appraisal of the standard practice including the measurement theories of the methods used to extract parameters of the signal is vital to the application of the signal during experimental and clinical practices, especially in areas where electromyograms are contraindicated or have limited application. As we highlight the underpinning technical guidelines and domains where each method is well-suited, the limitations of the methods are also presented to position the state of the art in MMG parameters extraction, thus providing the theoretical framework for improvement on the current practices to widen the opportunity for new insights and discoveries. Since the signal modality has not been widely deployed due partly to the limited information extractable from the signals when compared with other classical techniques used to assess muscle performance, this survey is particularly relevant to the projected future of MMG applications in the realm of musculoskeletal assessments and in the real time detection of muscle activity

A Multicentre Analysis Of Employment Post-Spinal Cord Injury In Malaysia

OBJECTIVES: Employment outcome post-spinal cord injury (SCI) varies internationally due to different socioeconomic backgrounds. However, most previous studies were done in developed countries, with limited studies from developing countries like Malaysia. This research aims to study the employment rate, positive determinants of employment, and reasons for unemployment post-SCI in Malaysia. DESIGN: We conducted a cross-sectional multicentre survey study in Malaysia. This study included eight hospitals with inpatient rehabilitation services and one SCI organisation throughout Malaysia. 280 SCI individuals from 18 to 64 years old with more than one year of SCI duration participated in this study. We administered International Spinal Cord Injury (InSCI) Questionnaires to them. We extracted and analysed the relevant components like demographics, injury-related and work-related data. We identified significant positive determinants of employment by using logistic regression analyses with p-value <0.05 between categorical independent variables and employment status. We described reasons for unemployment post-SCI in frequencies of percentages. RESULTS: The employment rate post-SCI in Malaysia was 29%. Significant positive determinants of employment post-SCI in Malaysia identified from logistic regression analyses with higher odds of employment were female gender (OR [Odds Ratio]: 2.2, 95%, CI [Confidence Interval]: 1.1-4.2); being married (OR: 1.9, CI:1.1-3.4); and tertiary education (OR: 3.2, CI: 1.6-6.8. The five main reasons for unemployment post-SCI in Malaysia were health condition or disability (36.5%), inability to find suitable work (15.5%), not knowing how or where to seek work (11.5%), lack of accessibility to potential workplace (7.4%), and insufficient transportation services (6.2%) CONCLUSION: This study reported a low employment rate post-SCI in Malaysia. Tertiary education was a strong positive determinant of employment. Based on this study ’ s findings, suggested interventions focus on access to tertiary education, health condition optimisation, vocational guidance, exploration of telework options, creating a barrier-free environment, and provision of sufficient transportation services can raise the employment rate post-SCI

Muscle size and strength benefits of functional electrical stimulation-evoked cycling dosage in spinal cord injury: a narrative review

Loss of sensory motor function is one of the main causes of physical and activity limitations among individual with spinal cord injury (SCI). SCI may lead to muscle paralysis, weakness and disused muscle atrophy. Evidences have shown electrical stimulation and strengthening exercise might improve lower limb muscle strength and size among individual with SCI. Functional electrical stimulation (FES) evoked cycling is one of the methods that can elicit leg muscle contractions in order to produce a cycling motion and promote the integrity of the involved muscles. Therefore, this review is to synthesize the scientific literature regarding the effects of multiple dosages of FES-evoked lower limb cycling on muscle properties. A systematic literature search from 1946 to 2016 was performed. From over 1,139 articles retrieved from the database, about 31 potentially relevant articles were retained for possible inclusion. However, only 10 articles out of 31 articles fulfilled the inclusion criteria. Although the available evidence is compelling, there is insufficient quantity and quality evidence to draw conclusions regarding the specific parameter of FES-CE that may optimally increase muscle strength, mass, and circumference. However, it can be safely concluded that an effective training session would spend for 45-60 min, 3 times a week for at least 4 weeks to see changes in muscle size and strength

Neural Network-Based Muscle Torque Estimation Using Mechanomyography During Electrically-Evoked Knee Extension and Standing in Spinal Cord Injury

This study sought to design and deploy a torque monitoring system using an artificial neural network (ANN) with mechanomyography (MMG) for situations where muscle torque cannot be independently quantified. The MMG signals from the quadriceps were used to derive knee torque during prolonged functional electrical stimulation (FES)-assisted isometric knee extensions and during standing in spinal cord injured (SCI) individuals. Three individuals with motor-complete SCI performed FES-evoked isometric quadriceps contractions on a Biodex dynamometer at 30° knee angle and at a fixed stimulation current, until the torque had declined to a minimum required for ANN model development. Two ANN models were developed based on different inputs; Root mean square (RMS) MMG and RMS-Zero crossing (ZC) which were derived from MMG. The performance of the ANN was evaluated by comparing model predicted torque against the actual torque derived from the dynamometer. MMG data from 5 other individuals with SCI who performed FES-evoked standing to fatigue-failure were used to validate the RMS and RMS-ZC ANN models. RMS and RMS-ZC of the MMG obtained from the FES standing experiments were then provided as inputs to the developed ANN models to calculate the predicted torque during the FES-evoked standing. The average correlation between the knee extension-predicted torque and the actual torque outputs were 0.87 ± 0.11 for RMS and 0.84 ± 0.13 for RMS-ZC. The average accuracy was 79 ± 14% for RMS and 86 ± 11% for RMS-ZC. The two models revealed significant trends in torque decrease, both suggesting a critical point around 50% torque drop where there were significant changes observed in RMS and RMS-ZC patterns. Based on these findings, both RMS and RMS-ZC ANN models performed similarly well in predicting FES-evoked knee extension torques in this population. However, interference was observed in the RMS-ZC values at a time around knee buckling. The developed ANN models could be used to estimate muscle torque in real-time, thereby providing safer automated FES control of standing in persons with motor-complete SCI

A three-step formative assessment model for rehabilitation medicine postgraduate programme clinical skills training

The stepwise formative assessment scheme was introduced into the Rehabilitation Medicine Postgraduate programme beginning from theory assessment to application of clinical skills on simulated and real patients to enable students or trainees to understand and competently apply theoretical knowledge to clinical practice. Formative assessment is intended to foster learning and assist students to develop under conditions that are nonthreatening. A key feature of formative assessment is to provide feedback and proper guidance to trainees on how to enhance performance. In this study, year 1 postgraduate students or trainees of Rehabilitation Medicine (n=9) were evaluated. The study was divided into three intervention phases. In Phase II, trainees were given educational materials on different specific clinical skills such as the Montreal Cognitive Assessment (MOCA), neurological examination of spinal cord injury based on ISNCSCl-motor examination, and GAIT assessment. Phase II was divided Into three steps, namely: 1) an applied pre-and post-theoretical quiz on which trainees must achieve 80% and above as a passing mark; 2) trainees conduct a clinical examination on a simulated patient after receiving the educational material; and 3) assessment of trainees using real patients after a month's assessment with the simulated patients. Phases I and II were conducted for approximately within three months of the intervention. All the assessments were conducted for 15 minutes, Including the debriefing session. In Phase 111, further evaluation will be conducted based on a focus group Interview (FGI). To date, Phases I and II of the clinical assessment have been completed. Results have shown that trainees had improvement In terms of the passing rate for both the theory and clinical assessment parts. The post- theoretical quiz assessment showed that 66.7% passed compared to 11.1 % in the pre-theory t est. Meanwhile, for the clinical assessments of ISNCSCI, MOCA and GAIT assessments, results show significant statistical differences of passes between the simulated and real patient (p<0.05). Overall, the result showed significant improvement in clinical competency for the trainees within three months of Phase land Phase II intervention. In addition, the results allow us to identify weak trainees for greater guidance during Year 1 to improve their clinical competency before their professional exams and able continue to Phase II postgraduate clinical training. The study also showed a feasible duration of formative assessment intervention to achieve satisfactory clinical competency which is perceived to be a practical approach towards structured clinical teaching and learning

Physical activity in individuals with spinal cord injury: Exercise and technologies for health promotion / Nazirah Hasnan

Spinal cord injury (SCI) adversely affects the physiological functions of most organ systems resulting in restrictions in performance of daily activities and social participation. Depending on the level of injury, SCI individuals can be amongst the most physically deconditioned of individuals with a disability. SCI renders profound effects on fitness, exercise capacities and health. There is increased risk of developing secondary health conditions such as cardiovascular disease and diabetes in chronic SCI survivors. There is good evidence that exercise is effective for improving physical fitness and general health in the SCI population. Leg exercise is usually restricted because of paralysis after SCI and upper body exercise is not as beneficial as lower body exercise due to the relatively small muscle mass in the arms. Technological advancements have allowed functional electrical stimulation (FES) muscle contractions to enable exercise for the paralysed lower limbs of persons with SCI. Other technologies including virtual reality (VR) approaches have also begun to be deployed as exercise and rehabilitation strategies in recent years. This thesis comprised of three studies, which examined exercise outcomes involving the use of assistive technologies (FES and VR) for exercise testing and training in persons with SCI. The acute physiological response of FES-assisted cycling exercise was first assessed comparing the different exercise modalities that were available for people with SCI. These vii were arm crank ergometry (ACE), FES–leg cycle ergometry (FES-LCE), ACE+FES-LCE and an integrated arm and FES-leg tricycle. It was found that combined arm and leg (hybrid) FES cycling exercise could develop higher oxygen uptake and cardiovascular demand compared to ACE or FES-LCE alone. Hybrid FES cycling evoked up to 148% higher oxygen uptake, 49% greater cardiac output and 47% higher heart rate than FES-LCE during steady-state exercise thereby concluding that FES-LCE by itself was insufficient to promote aerobic fitness and training benefit in people with SCI. Based on the findings of the first experiment, the acute physiological and psychological responses to hybrid FES cycling were then further assessed in different exercise environment i.e. natural outdoor and simulated VR-enhanced indoor environment. With only 5% and 1% difference in the cardiorespiratory and perceptual-psychological responses respectively between the two modes, it was concluded that indoor and outdoor modes have similar exercise “dose-potency” and self-perceived effort. Following these experiments on acute responses, a final study which examined the fitness, carbohydrate and lipid metabolisms and psychological outcomes following a 6-week high intensity interval training employing hybrid FES cycling training was carried out. The study demonstrated greater aerobic fitness by 16% and increased muscle mass by 6%. The 6-week training resulted in 60-80% improvement in negative mood states and up to 76% increase in post-exercise positive feeling states. However there was a lack of change in their lipid profile and glucose metabolism. viii The importance of incorporating regular physical activity and exercise into the lifestyle of people with SCI is evident. The studies conducted herein identified the best exercise modality; propose strategies for enhancement of exercise participation and highlight the benefits of exercise in this population

Characteristics of persons with spinal cord injury who drive in Malaysia and its barriers: a cross sectional study

Study design: Cross sectional study. Objectives: To determine the prevalence, characteristics of and barriers to driving among persons with a spinal cord injury (SCI). Setting: SCI Rehabilitation Clinic, University Malaya Medical Centre (UMMC). Methods: This is a questionnaire-based study on persons with SCI who attended the UMMC SCI Rehabilitation Clinic between June 2015 and November 2016. The questionnaire comprised demographic data, clinical characteristics, driving variables, Spinal Cord Independence Measure III, WHOQOL-BREF, and Craig Handicap Assessment and Reporting Technique Short Form. Malaysians aged greater than 18 years old with any etiology and levels of SCI, had no other physical disabilities and not suffering from progressive illness were recruited. A single investigator administered the questionnaire via face-to-face interviews. Results: A total of 160 participants were included in this study. Overall, 37% of persons with SCI drove and owned a modified vehicle. Almost half of persons with paraplegia (47%) drove, but only 12% of tetraplegia did. A majority (93%) of those who drove aged below 60 years, and had higher level of independence in activity of daily living. More drivers (81%) compared to non-drivers (24%) were employed; drivers also reported better community reintegration and quality of life. Three commonest barriers to driving included medical reasons (38%), fear and lack of confidence (17%), and inability to afford vehicle modifications (13%). Conclusions: The percentage of persons with SCI driving post injury is low. Based on the findings of this study, more efforts are needed to motivate and facilitate persons with SCI to drive

Nutritional status of post-acute stroke patients during rehabilitation phase in hospital

Malnutrition is highly prevalent among stroke patients during post-acute rehabilitation phase and may give a negative effect on rehabilitation and impair recovery. However, to date, there is no reported study in Malaysia investigating the nutritional status of stroke patients during rehabilitation phase. Thus, this paper aims to report the preliminary results of nutritional assessment for a randomized controlled trial at baseline. All participating patients were assessed for anthropometric measurements, nutritional status using validated Mini Nutrition Assessment (MNA), 24 h diet recall, and handgrip strength. Demographic data, biochemical profiles and functional outcomes (Modified Barthel Index Score, Motor Assessment Scale) were obtained from patients’ medical record. From a total of 45 post-acute stroke patients at baseline, 24.4% of them were malnourished during admission to rehabilitation ward and 66.7% of the patients were at risk of malnutrition. Mean dietary intake and protein intake of the patients were 1489 ± 297 kcal/day and 66.1 ± 17.2 g/day, respectively. Mean handgrip strength for the patients was 17.9 ± 8.1 kg. Weight, body mass index, serum albumin, handgrip strength, Modified Barthel Index and Motor Assessment Scale score were positively correlated with MNA score (p<0.05), but no correlation was found for the dietary intake (r=0.163, p=0.285) and protein intake (r=0.288, p=0.055). This preliminary result showed that stroke patients are particularly at risk of malnutrition or malnourished during the rehabilitation period. Therefore, early identification of malnutrition for stroke patients is important for a successful rehabilitation program

Muscle Size and Strength Benefits of Functional Electrical Stimulation-Evoked Cycling Dosage in Spinal Cord Injury: A Narrative Review

Loss of sensory motor function is one of the main causes of physical and activity limitations among individual with spinal cord injury (SCI). SCI may lead to muscle paralysis, weakness and disused muscle atrophy. Evidences have shown electrical stimulation and strengthening exercise might improve lower limb muscle strength and size among individual with SCI. Functional electrical stimulation (FES) evoked cycling is one of the methods that can elicit leg muscle contractions in order to produce a cycling motion and promote the integrity of the involved muscles. Therefore, this review is to synthesize the scientific literature regarding the effects of multiple dosages of FES-evoked lower limb cycling on muscle properties. A systematic literature search from 1946 to 2016 was performed. From over 1,139 articles retrieved from the database, about 31 potentially relevant articles were retained for possible inclusion. However, only 10 articles out of 31 articles fulfilled the inclusion criteria. Although the available evidence is compelling, there is insufficient quantity and quality evidence to draw conclusions regarding the specific parameter of FES-CE that may optimally increase muscle strength, mass, and circumference. However, it can be safely concluded that an effective training session would spend for 45-60 min, 3 times a week for at least 4 weeks to see changes in muscle size and strength. © 2019 Penerbit Universiti Kebangsaan Malaysia. All rights reserved

Contributions of the Cybathlon championship to the literature on functional electrical stimulation cycling among individuals with spinal cord injury: A bibliometric review

Background: Due to its clinically proven safety and health benefits, functional electrical stimulation (FES) cycling has become a popular exercise modality for individuals with spinal cord injury (SCI). Since its inception in 2013, the Cybathlon championship has been a platform for publicizing the potential of FES cycling in rehabilitation and exercise for individuals with SCI. This study aimed to evaluate the contribution of the Cybathlon championship to the literature on FES cycling for individuals with SCI 3 years pre and post the staging of the Cybathlon championship in 2016. Methods: Web of Science, Scopus, ScienceDirect, IEEE Xplore, and Google Scholar databases were searched for relevant studies published between January 2013 and July 2019. The quality of the included studies was objectively evaluated using the Downs and Black checklist. Results: A total of 129 articles on FES cycling were retained for analysis. A total of 51 articles related to Cybathlon were reviewed, and 14 articles were ultimately evaluated for the quality. In 2017, the year following the Cybathlon championship, Web of Science cited 23 published studies on the championship, which was almost 5-fold more than that in 2016 (n = 5). Training was most often reported as a topic of interest in these studies, which mostly (76.7%) highlighted the training parameters of interest to participating teams in their effort to maximize their FES cycling performance during the Cybathlon championship. Conclusion: The present study indicates that the Cybathlon championship in 2016 contributed to the number of literature published in 2017 on FES cycling for individuals with SCI. This finding may contribute to the lessons that can be learned from participation in the Cybathlon and potentially provide additional insights into research in the field of race-based FES cycling