Pulse contour analysis: a valid assessment of central arterial stiffness in children?

In adults the contour analysis of peripheral pressure waves in the upper limb reflects central aortic stiffness. Here, we wanted to demonstrate the appropriateness of pulse contour analysis to assess large artery stiffness in children. Digital volume pulse analysis, with the computation of the stiffness index and pulse wave velocity between carotid and femoral artery, were simultaneously determined in 79 healthy children between 8 years and 15 years (mean age 11.4 years, 32 girls). The stiffness index of 42 healthy adults (mean age 45.6 years, 26 women) served as control. Pulse wave velocity between carotid and femoral artery was directly correlated with systolic pressure and mean blood pressure, as well as with pulse pressure. The results from the stiffness index of children revealed the expected values extrapolated from the linear regression of adulthood stiffness index vs. age. Childhood stiffness index positively correlated with pulse wave velocity (r(2) = 0.07, P = 0.02) but not with blood pressure parameters. The exclusion of individuals with an increased vascular tone, as indicated by a reflexion index > 90%, improved the correlation between stiffness index and pulse wave velocity (r(2) = 0.13, P = 0.001). Our data indicate that digital volume pulse-based analysis has limitations if compared with pulse wave velocity to measure arterial stiffness, mostly in patients with a high vascular tone.

Epidemiology and direct medical costs of osteoporotic fractures in men and women in Switzerland

The aim of this study was to estimate the hospitalization incidence and the total number of hospital days related to all fractures and osteoporotic fractures in the year 2000 in Switzerland and to compare these with data from other frequent disorders in men and women. The official administrative and medical statistics database of the Swiss Federal Office of Statistics (SFOS) from the year 2000 was used. It covered 81.2% of all registered patient admissions and was considered to be representative of the entire population. We included the ICD-10 codes of 84 diagnoses that were compatible with an underlying osteoporosis and applied the best matching age-specific osteoporosis attribution rates published for the ICD-9 diagnosis codes to the individual ICD-10 codes. To preserve comparability with previously published data from 1992, we grouped the data related to the ICD-10 fracture codes into seven diagnosis pools (fractures of the axial skeleton, fractures of the proximal upper limbs, fractures of the distal upper limbs, fractures of the proximal lower limbs, fractures of the distal lower limbs, multiple fractures, and osteoporosis) and analyzed them separately for women and men by age group. Incidences of hospitalization due to fractures were calculated, and the direct medical costs related to hospitalization were estimated. In addition, we compared the results with those from chronic pulmonary obstructive disease (COPD), stroke, acute myocardial infarction, heart failure, diabetes and breast carcinoma from the same database. In Switzerland during 2000, 62,535 hospitalizations for fractures (35,586 women and 26,949 men) were registered. Fifty-one percent of all fractures in women and 24% in men were considered as osteoporotic. The overall incidences of hospitalization due to fractures were 969 and 768 per 100,000 in women and men, respectively. The hospitalization incidences for fractures of the proximal lower limbs and the axial skeleton increased exponentially after the age of 65 years. The direct medical cost of hospitalization of patients with osteoporosis and/or related fractures was 357 million CHF. Hip fractures accounted for approximately half of these costs in women and men. Among other common diseases in women and men, osteoporosis ranked number 1 in women and number 2 (behind COPD) in men. When compared with data from 1992, the average length of stay had shortened by 8.4 days for women and 4.7 days for men, leading to a decrease of almost 40% in direct medical costs related to acute hospitalizations. This apparent decrease in cost might result from a shift into the ambulatory cost segment, for which the assessment and management tools need to be developed. We conclude that, in 2000, osteoporosis continued to be a heavy burden on the Swiss healthcare system. Lack of awareness of the disease and its consequences prevents widespread use of drugs with anti-fracture efficacy. This limits their potential to reduce costs.

ARMin III – arm therapy exoskeleton with an ergonomic shoulder actuation

Rehabilitation robots have become important tools in stroke rehabilitation. Compared to manual arm training, robot-supported training can be more intensive, of longer duration and more repetitive. Therefore, robots have the potential to improve the rehabilitation process in stroke patients. Whereas a majority of previous work in upper limb rehabilitation robotics has focused on end-effector-based robots, a shift towards exoskeleton robots is taking place because they offer a better guidance of the human arm, especially for movements with a large range of motion. However, the implementation of an exoskeleton device introduces the challenge of reproducing the motion of the human shoulder, which is one of the most complex joints of the body. Thus, this paper starts with describing a simplified model of the human shoulder. On the basis of that model, a new ergonomic shoulder actuation principle that provides motion of the humerus head is proposed, and its implementation in the ARMin III arm therapy robot is described. The focus lies on the mechanics and actuation principle. The ARMin III robot provides three actuated degrees of freedom for the shoulder and one for the elbow joint. An additional module provides actuated lower arm pro/supination and wrist flexion/extension. Five ARMin III devices have been manufactured and they are currently undergoing clinical evaluation in hospitals in Switzerland and in the United States.

Effects of arm training with the robotic device ARMin I in chronic stroke: three single cases

BACKGROUND: Several clinical studies on chronic stroke conducted with end-effector-based robots showed improvement of the motor function in the affected arm. Compared to end-effector-based robots, exoskeleton robots provide improved guidance of the human limb and are better suited to train task-oriented movements with a large range of motions. OBJECTIVE: To test whether intensive arm training with the arm exoskeleton ARMin I is feasible with chronic-stroke patients and whether it improves motor function in the paretic arm. METHODS: Three single cases with chronic hemiparesis resulting from unilateral stroke (at least 14 months after stroke). A-B design with 2 weeks of multiple baseline measurements (A), 8 weeks of training (B) with repetitive measurements and a follow-up measurement 8 weeks after training. The training included shoulder and elbow movements with the robotic rehabilitation device ARMin I. Two subjects had three 1-hour sessions per week and 1 subject received five 1-hour sessions per week. The main outcome measurement was the upper-limb part of the Fugl-Meyer Assessment (FMA). RESULTS: The ARMin training was well tolerated by the patients, and the FMA showed moderate, but significant improvements for all 3 subjects (p < 0.05). Most improvements were maintained 8 weeks after discharge. CONCLUSIONS: This study indicates that intensive training with an arm exoskeleton is feasible with chronic-stroke patients. Moderate improvements were found in all 3 subjects, thus further clinical investigations are justified.

New Technologies and Concepts for Rehabilitation in the Acute Phase of Stroke: A Collaborative Matrix

The process of developing a successful stroke rehabilitation methodology requires four key components: a good understanding of the pathophysiological mechanisms underlying this brain disease, clear neuroscientific hypotheses to guide therapy, adequate clinical assessments of its efficacy on multiple timescales, and a systematic approach to the application of modern technologies to assist in the everyday work of therapists. Achieving this goal requires collaboration between neuroscientists, technologists and clinicians to develop well-founded systems and clinical protocols that are able to provide quantitatively validated improvements in patient rehabilitation outcomes. In this article we present three new applications of complementary technologies developed in an interdisciplinary matrix for acute-phase upper limb stroke rehabilitation – functional electrical stimulation, arm robot-assisted therapy and virtual reality-based cognitive therapy. We also outline the neuroscientific basis of our approach, present our detailed clinical assessment protocol and provide preliminary results from patient testing of each of the three systems showing their viability for patient use.

Disorganization and timing of motor behavior : insight from gesture impairments and movement patterns in schizophrenia

Background: Motor symptoms are frequent phenomena across the entire course of schizophrenia1. Some have argued that disorganized behavior was associated with aberrant motor behavior. We have studied the association of motor disturbances and disorganization in two projects focusing on the timing of movements. Method: In two studies, we assessed motor behavior and psychopathology. The first study applied a validated test of upper limb apraxia in 30 schizophrenia patients2,3. We used standardized video assessments of hand gestures by a blinded rater. The second study tested the stability of movement patterns using time series analysis in actigraphy data of 100 schizophrenia patients4. Both stability of movement patterns and the overall amount of movement were calculated from data of two hours with high degrees of social interaction comparable across the 100 subjects. Results: In total, 67% of the patients had gesture performance deficits3. Most frequently, they made spatial, temporal and body-part-as-object errors. Gesture performance relied on frontal lobe function2. Poor gesture performance was associated with increased disorganization scores. In the second study, we found disorganization to be predicted only by more irregular movement patterns irrespective of the overall amount of movement4. Conclusion : Both studies provide evidence for a link between aberrant timing of motor behavior and disorganization. Disturbed movement control seems critical for disorganized behavior in schizophrenia.

Different visual exploration of tool-related gestures in left hemisphere brain damaged patients is associated with poor gestural imitation.

According to the direct matching hypothesis, perceived movements automatically activate existing motor components through matching of the perceived gesture and its execution. The aim of the present study was to test the direct matching hypothesis by assessing whether visual exploration behavior correlate with deficits in gestural imitation in left hemisphere damaged (LHD) patients. Eighteen LHD patients and twenty healthy control subjects took part in the study. Gesture imitation performance was measured by the test for upper limb apraxia (TULIA). Visual exploration behavior was measured by an infrared eye-tracking system. Short videos including forty gestures (20 meaningless and 20 communicative gestures) were presented. Cumulative fixation duration was measured in different regions of interest (ROIs), namely the face, the gesturing hand, the body, and the surrounding environment. Compared to healthy subjects, patients fixated significantly less the ROIs comprising the face and the gesturing hand during the exploration of emblematic and tool-related gestures. Moreover, visual exploration of tool-related gestures significantly correlated with tool-related imitation as measured by TULIA in LHD patients. Patients and controls did not differ in the visual exploration of meaningless gestures, and no significant relationships were found between visual exploration behavior and the imitation of emblematic and meaningless gestures in TULIA. The present study thus suggests that altered visual exploration may lead to disturbed imitation of tool related gestures, however not of emblematic and meaningless gestures. Consequently, our findings partially support the direct matching hypothesis.

Determining appropriate measurement methods for etiological research of computing-related musculoskeletal symptoms and disorders

Two studies among college students were conducted to evaluate appropriate measurement methods for etiological research on computing-related upper extremity musculoskeletal disorders (UEMSDs). ^ A cross-sectional study among 100 graduate students evaluated the utility of symptoms surveys (a VAS scale and 5-point Likert scale) compared with two UEMSD clinical classification systems (Gerr and Moore protocols). The two symptom measures were highly concordant (Lin's rho = 0.54; Spearman's r = 0.72); the two clinical protocols were moderately concordant (Cohen's kappa = 0.50). Sensitivity and specificity, endorsed by Youden's J statistic, did not reveal much agreement between the symptoms surveys and clinical examinations. It cannot be concluded self-report symptoms surveys can be used as surrogate for clinical examinations. ^ A pilot repeated measures study conducted among 30 undergraduate students evaluated computing exposure measurement methods. Key findings are: temporal variations in symptoms, the odds of experiencing symptoms increased with every hour of computer use (adjOR = 1.1, p < .10) and every stretch break taken (adjOR = 1.3, p < .10). When measuring posture using the Computer Use Checklist, a positive association with symptoms was observed (adjOR = 1.3, p < 0.10), while measuring posture using a modified Rapid Upper Limb Assessment produced unexpected and inconsistent associations. The findings were inconclusive in identifying an appropriate posture assessment or superior conceptualization of computer use exposure. ^ A cross-sectional study of 166 graduate students evaluated the comparability of graduate students to College Computing & Health surveys administered to undergraduate students. Fifty-five percent reported computing-related pain and functional limitations. Years of computer use in graduate school and number of years in school where weekly computer use was ≥ 10 hours were associated with pain within an hour of computing in logistic regression analyses. The findings are consistent with current literature on both undergraduate and graduate students. ^

Stable isotope record and lithic fragments distribution in sediments of MIS9-14 of the North Atlantic

Stable isotope and ice-rafted debris records from three core sites in the mid-latitude North Atlantic (IODP Site U1313, MD01-2446, MD03-2699) are combined with records of ODP Sites 1056/1058 and 980 to reconstruct hydrographic conditions during the middle Pleistocene spanning Marine Isotope Stages (MIS) 9-14 (300-540 ka). Core MD03-2699 is the first high-resolution mid-Brunhes record from the North Atlantic's eastern boundary upwelling system covering the complete MIS 11c interval and MIS 13. The array of sites reflect western and eastern basin boundary current as well as north to south transect sampling of subpolar and transitional water masses and allow the reconstruction of transport pathways in the upper limb of the North Atlantic's circulation. Hydrographic conditions in the surface and deep ocean during peak interglacial MIS 9 and 11 were similar among all the sites with relative stable conditions and confirm prolonged warmth during MIS 11c also for the mid-latitudes. Sea surface temperature (SST) reconstructions further reveal that in the mid-latitude North Atlantic MIS 11c is associated with two plateaus, the younger one of which is slightly warmer. Enhanced subsurface northward heat transport in the eastern boundary current system, especially during early MIS 11c, is denoted by the presence of tropical planktic foraminifer species and raises the question how strongly it impacted the Portuguese upwelling system. Deep water ventilation at the onset of MIS 11c significantly preceded surface water ventilation. Although MIS 13 was generally colder and more variable than the younger interglacials the surface water circulation scheme was the same. The greatest differences between the sites existed during the glacial inceptions and glacials. Then a north - south trending hydrographic front separated the nearshore and offshore waters off Portugal. While offshore waters originated from the North Atlantic Current as indicated by the similarities between the records of IODP Site U1313, ODP Site 980 and MD01-2446, nearshore waters as recorded in core MD03-2699 derived from the Azores Current and thus the subtropical gyre. Except for MIS 12, Azores Current influence seems to be related to eastern boundary system dynamics and not to changes in the Atlantic overturning circulation.

Stable isotope record of benthic foraminifera from DSDP Site 68-502

Benthic foraminiferal delta13C data from site 502 in the Caribbean Sea (sill depth ?1800 m) indicate that throughout the past 2.6 m.y., glacial delta13C values in the middepth Atlantic were higher during glaciations than interglaciations. This is interpreted as indicating a greater proportion of Upper North Atlantic Deep Water (UNADW) relative to southern source waters during glaciations. The contribution of UNADW during interglaciations to the middepth Atlantic remained approximately constant, and the contribution during glaciations may have been as much as 10 % higher in the late Pleistocene than in the late Pliocene. This small increase is in striking contrast to the much larger decrease in glacial Lower North Atlantic Deep Water (LNADW) contribution relative to southern sources, from about 80% to about 20%, that occurred over the past 2.6 m.y. Glacial intensification over the past 2.6 m.y. was probably coupled with a decrease in northward heat transport by the upper limb of the North Atlantic circulation cell, as was previously suggested on the basis of a LNADW record alone. Late Pleistocene (1 Ma-present) delta13C values in the Caribbean Sea were approximately 0.2? higher than they were from 2.6 to 2.0 Ma. The delta13C rise is not due to an increase in the mean ocean delta13C value, nor can it be entirely attributed to an increase in the proportion of high-delta13C source waters. An increase in the delta13C value of the surface source waters must have contributed to the delta13C rise.

Metodologías de modelado, monitorización y asistencia robótica en neurorrehabilitación funcional de extremidad superior

La Organización Mundial de la Salud (OMS) prevé que para el año 2020, el Daño Cerebral Adquirido (DCA) estará entre las 10 causas más comunes de discapacidad. Estas lesiones, dadas sus consecuencias físicas, sensoriales, cognitivas, emocionales y socioeconómicas, cambian dramáticamente la vida de los pacientes y sus familias. Las nuevas técnicas de intervención precoz y el desarrollo de la medicina intensiva en la atención al DCA han mejorado notablemente la probabilidad de supervivencia. Sin embargo, hoy por hoy, las lesiones cerebrales no tienen ningún tratamiento quirúrgico que tenga por objetivo restablecer la funcionalidad perdida, sino que las terapias rehabilitadoras se dirigen hacia la compensación de los déficits producidos. Uno de los objetivos principales de la neurorrehabilitación es, por tanto, dotar al paciente de la capacidad necesaria para ejecutar las Actividades de Vida Diaria (AVDs) necesarias para desarrollar una vida independiente, siendo fundamentales aquellas en las que la Extremidad Superior (ES) está directamente implicada, dada su gran importancia a la hora de la manipulación de objetos. Con la incorporación de nuevas soluciones tecnológicas al proceso de neurorrehabilitación se pretende alcanzar un nuevo paradigma centrado en ofrecer una práctica personalizada, monitorizada y ubicua con una valoración continua de la eficacia y de la eficiencia de los procedimientos y con capacidad de generar conocimientos que impulsen la ruptura del paradigma de actual. Los nuevos objetivos consistirán en minimizar el impacto de las enfermedades que afectan a la capacidad funcional de las personas, disminuir el tiempo de incapacidad y permitir una gestión más eficiente de los recursos. Estos objetivos clínicos, de gran impacto socio-económico, sólo pueden alcanzarse desde una apuesta decidida en nuevas tecnologías, metodologías y algoritmos capaces de ocasionar la ruptura tecnológica necesaria que permita superar las barreras que hasta el momento han impedido la penetración tecnológica en el campo de la rehabilitación de manera universal. De esta forma, los trabajos y resultados alcanzados en la Tesis son los siguientes: 1. Modelado de AVDs: como paso previo a la incorporación de ayudas tecnológicas al proceso rehabilitador, se hace necesaria una primera fase de modelado y formalización del conocimiento asociado a la ejecución de las actividades que se realizan como parte de la terapia. En particular, las tareas más complejas y a su vez con mayor repercusión terapéutica son las AVDs, cuya formalización permitirá disponer de modelos de movimiento sanos que actuarán de referencia para futuros desarrollos tecnológicos dirigidos a personas con DCA. Siguiendo una metodología basada en diagramas de estados UML se han modelado las AVDs 'servir agua de una jarra' y 'coger un botella' 2. Monitorización ubícua del movimiento de la ES: se ha diseñado, desarrollado y validado un sistema de adquisición de movimiento basado en tecnología inercial que mejora las limitaciones de los dispositivos comerciales actuales (coste muy elevado e incapacidad para trabajar en entornos no controlados); los altos coeficientes de correlación y los bajos niveles de error obtenidos en los corregistros llevados a cabo con el sistema comercial BTS SMART-D demuestran la alta precisión del sistema. También se ha realizado un trabajo de investigación exploratorio de un sistema de captura de movimiento de coste muy reducido basado en visión estereoscópica, habiéndose detectado los puntos clave donde se hace necesario incidir desde un punto de vista tecnológico para su incorporación en un entorno real 3. Resolución del Problema Cinemático Inverso (PCI): se ha diseñado, desarrollado y validado una solución al PCI cuando el manipulador se corresponde con una ES humana estudiándose 2 posibles alternativas, una basada en la utilización de un Perceptrón Multicapa (PMC) y otra basada en sistemas Artificial Neuro-Fuzzy Inference Systems (ANFIS). La validación, llevada a cabo utilizando información relativa a los modelos disponibles de AVDs, indica que una solución basada en un PMC con 3 neuronas en la capa de entrada, una capa oculta también de 3 neuronas y una capa de salida con tantas neuronas como Grados de Libertad (GdLs) tenga el modelo de la ES, proporciona resultados, tanto de precisión como de tiempo de cálculo, que la hacen idónea para trabajar en sistemas con requisitos de tiempo real 4. Control inteligente assisted-as-needed: se ha diseñado, desarrollado y validado un algoritmo de control assisted-as-needed para una ortesis robótica con capacidades de actuación anticipatoria de la que existe un prototipo implementado en la actualidad. Los resultados obtenidos demuestran cómo el sistema es capaz de adaptarse al perfil disfuncional del paciente activando la ayuda en instantes anteriores a la ocurrencia de movimientos incorrectos. Esta estrategia implica un aumento en la participación del paciente y, por tanto, en su actividad muscular, fomentándose los procesos la plasticidad cerebral responsables del reaprendizaje o readaptación motora 5. Simuladores robóticos para planificación: se propone la utilización de un simulador robótico assisted-as-needed como herramienta de planificación de sesiones de rehabilitación personalizadas y con un objetivo clínico marcado en las que interviene una ortesis robotizada. Los resultados obtenidos evidencian como, tras la ejecución de ciertos algoritmos sencillos, es posible seleccionar automáticamente una configuración para el algoritmo de control assisted-as-needed que consigue que la ortesis se adapte a los criterios establecidos desde un punto de vista clínico en función del paciente estudiado. Estos resultados invitan a profundizar en el desarrollo de algoritmos más avanzados de selección de parámetros a partir de baterías de simulaciones Estos trabajos han servido para corroborar las hipótesis de investigación planteadas al inicio de la misma, permitiendo, asimismo, la apertura de nuevas líneas de investigación. Summary The World Health Organization (WHO) predicts that by the year 2020, Acquired Brain Injury (ABI) will be among the ten most common ailments. These injuries dramatically change the life of the patients and their families due to their physical, sensory, cognitive, emotional and socio-economic consequences. New techniques of early intervention and the development of intensive ABI care have noticeably improved the survival rate. However, in spite of these advances, brain injuries still have no surgical or pharmacological treatment to re-establish the lost functions. Neurorehabilitation therapies address this problem by restoring, minimizing or compensating the functional alterations in a person disabled because of a nervous system injury. One of the main objectives of Neurorehabilitation is to provide patients with the capacity to perform specific Activities of the Daily Life (ADL) required for an independent life, especially those in which the Upper Limb (UL) is directly involved due to its great importance in manipulating objects within the patients' environment. The incorporation of new technological aids to the neurorehabilitation process tries to reach a new paradigm focused on offering a personalized, monitored and ubiquitous practise with continuous assessment of both the efficacy and the efficiency of the procedures and with the capacity of generating new knowledge. New targets will be to minimize the impact of the sicknesses affecting the functional capabilitiies of the subjects, to decrease the time of the physical handicap and to allow a more efficient resources handling. These targets, of a great socio-economic impact, can only be achieved by means of new technologies and algorithms able to provoke the technological break needed to beat the barriers that are stopping the universal penetration of the technology in the field of rehabilitation. In this way, this PhD Thesis has achieved the following results: 1. ADL Modeling: as a previous step to the incorporation of technological aids to the neurorehabilitation process, it is necessary a first modelling and formalization phase of the knowledge associated to the execution of the activities that are performed as a part of the therapy. In particular, the most complex and therapeutically relevant tasks are the ADLs, whose formalization will produce healthy motion models to be used as a reference for future technological developments. Following a methodology based on UML state-chart diagrams, the ADLs 'serving water from a jar' and 'picking up a bottle' have been modelled 2. Ubiquitous monitoring of the UL movement: it has been designed, developed and validated a motion acquisition system based on inertial technology that improves the limitations of the current devices (high monetary cost and inability of working within uncontrolled environments); the high correlation coefficients and the low error levels obtained throughout several co-registration sessions with the commercial sys- tem BTS SMART-D show the high precision of the system. Besides an exploration of a very low cost stereoscopic vision-based motion capture system has been carried out and the key points where it is necessary to insist from a technological point of view have been detected 3. Inverse Kinematics (IK) problem solving: a solution to the IK problem has been proposed for a manipulator that corresponds to a human UL. This solution has been faced by means of two different alternatives, one based on a Mulilayer Perceptron (MLP) and another based on Artificial Neuro-Fuzzy Inference Systems (ANFIS). The validation of these solutions, carried out using the information regarding the previously generated motion models, indicate that a MLP-based solution, with an architecture consisting in 3 neurons in the input layer, one hidden layer of 3 neurons and an output layer with as many neurons as the number of Degrees of Freedom (DoFs) that the UL model has, is the one that provides the best results both in terms of precission and in terms of processing time, making in idoneous to be integrated within a system with real time restrictions 4. Assisted-as-needed intelligent control: an assisted-as-needed control algorithm with anticipatory actuation capabilities has been designed, developed and validated for a robotic orthosis of which there is an already implemented prototype. Obtained results demonstrate that the control system is able to adapt to the dysfunctional profile of the patient by triggering the assistance right before an incorrect movement is going to take place. This strategy implies an increase in the participation of the patients and in his or her muscle activity, encouraging the neural plasticity processes in charge of the motor learning 5. Planification with a robotic simulator: in this work a robotic simulator is proposed as a planification tool for personalized rehabilitation sessions under a certain clinical criterium. Obtained results indicate that, after the execution of simple parameter selection algorithms, it is possible to automatically choose a specific configuration that makes the assisted-as-needed control algorithm to adapt both to the clinical criteria and to the patient. These results invite researchers to work in the development of more complex parameter selection algorithms departing from simulation batteries Obtained results have been useful to corroborate the hypotheses set out at the beginning of this PhD Thesis. Besides, they have allowed the creation of new research lines in all the studied application fields.

Definición e implementación de métricas objetivas para la evaluación funcional del miembro superior: aplicación a población con lesión medular cervical

En personas que padecen una Lesión Medular cervical, la función de los miembros superiores se ve afectada en mayor o menor medida, dependiendo fundamentalmente del nivel de la lesión y de la severidad de la misma. El déficit en la función del miembro superior hace que la autonomía e independencia de las personas se vea reducida en la ejecución de Actividades de la Vida Diaria. En el entorno clínico, la valoración de la función del miembro superior se realiza principalmente con escalas clínicas. Algunas de ellas valoran el nivel de dependencia o independencia en la ejecución de Actividades de la Vida Diaria, como, por ejemplo, el índice de Barthel y la escala FIM (Medida de la Independencia Funcional). Otras escalas, como Jebsen-Taylor Hand Function, miden la función del miembro superior valorando la destreza y la habilidad en la ejecución de determinadas tareas funcionales. Estas escalas son generales, es decir, se pueden aplicar a distintas poblaciones de sujetos y a la presencia de distintas patologías. Sin embargo, existen otras escalas desarrolladas específicamente para valorar una patología concreta, con el objetivo de hacer las evaluaciones funcionales más sensibles a cambios. Un ejemplo es la escala Spinal Cord Independence Measure (SCIM), desarrollada para valorar Lesión Medular. Las escalas clínicas son instrumentos de medida estandarizados, válidos para su uso en el entorno clínico porque se han validado en muestras grandes de pacientes. No obstante, suelen poseer una elevada componente de subjetividad que depende principalmente de la persona que puntúa el test. Otro aspecto a tener en cuenta, es que la sensibilidad de las escalas es alta, fundamentalmente, a cambios groseros en el estado de salud o en la función del miembro superior, de forma que cambios sutiles en el sujeto pueden no ser detectados. Además, en ocasiones, poseen saturaciones en el sistema de puntuación, de forma que mejorías que se puedan producir por encima de un determinado umbral no son detectadas. En definitiva, estas limitaciones hacen que las escalas clínicas no sean suficientes, por sí mismas, para evaluar estrategias motoras del miembro superior durante la ejecución de movimientos funcionales, siendo necesaria la búsqueda de instrumentos de medida que aporten objetividad, complementen las valoraciones y, al mismo tiempo, intenten solventar las limitaciones que poseen las escalas. Los estudios biomecánicos son ejemplos de métodos objetivos, en los que diversas tecnologías se pueden utilizar para recoger información de los sujetos. Una concreción de estos estudios son los estudios cinemáticos. Mediante tecnología optoelectrónica, inercial o electromagnética, estos estudios proporcionan información objetiva acerca del movimiento realizado por los sujetos, durante la ejecución de tareas concretas. Estos sistemas de medida proporcionan grandes cantidades de datos que carecen de una interpretación inmediata. Estos datos necesariamente deben ser tratados y reducidos a un conjunto de variables que, a priori, posean una interpretación más sencilla para ser utilizados en la práctica clínica. Estas han sido las principales motivaciones de esta investigación. El objetivo principal fue proponer un conjunto de índices cinemáticos que, de forma objetiva, valoren la función del miembro superior; y validar los índices propuestos en poblaciones con Lesión Medular, para su uso como instrumentos de valoración en el entorno clínico. Esta tesis se enmarca dentro de un proyecto de investigación: HYPER (Hybrid Neuroprosthetic and Neurorobotic Devices for Functional Compensation and Rehabilitation of Motor Disorders, referencia CSD2009-00067 CONSOLIDER INGENIO 2010). Dentro de este proyecto se lleva a cabo investigación en el desarrollo de modelos, para determinar los requisitos biomecánicos y los patrones de movimiento de los miembros superiores en sujetos sanos y personas con lesión medular. Además, se realiza investigación en la propuesta de nuevos instrumentos de evaluación funcional en el campo de la rehabilitación de los miembros superiores. ABSTRACT In people who have suffered a cervical Spinal Cord Injury, upper limbs function is affected to a greater or lesser extent, depending primarily on the level of the injury and the severity of it. The deficit in the upper limb function reduces the autonomy and independence of persons in the execution of Activities of Daily Living. In the clinical setting, assessment of upper limb function is mainly performed based on clinical scales. Some value the level of dependence or independence in performing activities of daily living, such as the Barthel Index and the FIM scale (Functional Independence Measure). Other scales, such as the Jebsen-Taylor Hand Function, measure upper limb function in terms of the skill and ability to perform specific functional tasks. These scales are general, so can be applied to different populations of subjects and the presence of different pathologies. However, there are other scales developed for a specific injury, in order to make the functional assessments more sensitive to changes. An example is the Spinal Cord Independence Measure (SCIM), developed for people with Spinal Cord Injury. The clinical scales are standardized instruments measure, valid for use in the clinical setting because they have been validated in large patient samples. However, they usually have a high level of subjectivity which mainly depends on the person who scores the test. Another aspect to take into account is the high sensitivity of the scales mainly to gross changes in the health status or upper limb function, so that subtle changes in the subject may not be detected. Moreover, sometimes, have saturations in the scoring system, so that improvements which may occur above a certain threshold are not detected. For these reasons, clinical scales are not enough, by themselves, to assess motor strategies used during movements. So, it’s necessary to find measure instruments that provide objectivity, supplement the assessments and, at the same time, solving the limitations that scales have. Biomechanical studies are examples of objective methods, in which several technologies can be used to collect information from the subjects. One kind of these studies is the kinematic movement analysis. By means of optoelectronics, inertial and electromagnetic technology, these studies provide objective information about the movement performed by the subjects during the execution of specific tasks. These systems provide large quantities of data without easy and intuitive interpretation. These data must necessarily be treated and reduced to a set of variables that, a priori, having a simpler interpretation for their use in the clinical practice. These were the main motivations of this research. The main objective was to propose a set of kinematic indices, or metrics that, objectively, assess the upper limb function and validate the proposed rates in populations with Spinal Cord Injury, for use as assessment tools in the clinical setting. This dissertation is framed within a research project: HYPER (Neurorobotic Devices for Functional Compensation and Rehabilitation of Motor Disorders, grant CSD2009- 00067 CONSOLIDER INGENIO 2010). Within this research project, research is conducted in relation to the biomechanical models development for determining the biomechanical requirements and movement patterns of the upper limb in healthy and people with Spinal Cord Injury. Moreover, research is conducted with respect to the proposed of new functional assessment instruments in the field of upper limb rehabilitation.

Regulación del movimiento y anticipación en el resto del primer servicio en tenis

Aunque se han logrado importantes avances en estudios de laboratorio con diseños experimentales poco representativos (e.g., Farrow y Reid, 2012; Nieminen, Piirainen, Salmi, y Linnamo, 2013), a día de hoy, todavía se desconoce a cabalidad cómo los jugadores de tenis de diferente nivel de pericia calibran o ajustan sus movimientos a las demandas espacio-temporales presentes en la tarea de resto de un primer servicio. ! Escasos trabajos se han llevado a cabo in situ y a la mayoría se les puede cuestionar algún aspecto de la metodología empleada. Así pues, en varios estudios la frecuencia de grabación ha sido limitada (e.g., a 50 Hz en Jackson y Gudgeon, 2004; Triolet, Benguigui, Le Runigo y Williams, 2013), o la velocidad del saque ha sido visiblemente inferior a la habitual (cf. Carboch, Süss y Kocib, 2014; Williams, Singer y Weigelt, 1998). También, en algunos estudios los participantes experimentados no han sido jugadores de nivel internacional (e.g., Avilés, Ruiz, Sanz y Navia, 2014), y el tamaño muestral ha sido muy pequeño (e.g., Gillet, Leroy, Thouvarecq, Mégrot y Stein, 2010). ! Además, en los diferentes trabajos se han utilizado una diversidad de métodos e instrumentos de medida y los criterios de codificación del inicio de los movimientos y de las respuestas han diferido; como consecuencia el lapso visomotor de respuesta (LVMr) ha sido muy dispar variando considerablemente de 198 a 410 ms. Considerando los inconvenientes señalados anteriormente, el presente estudio tuvo como objetivo determinar un modelo técnico de regulación temporal de los movimientos y de la respuesta del restador, tomando en cuenta el flujo continuo de información proporcionado por el sacador. Para ello, se realizó un análisis cronométrico de los restos de doce jugadores de diferente nivel deportivo (seis internacionales y seis nacionales) que respondieron de forma natural enviando sus devoluciones hacia las dianas. Se grabaron las acciones de los restadores y sacadores con una cámara Casio Exilim Pro Ex-F1 de alta velocidad (300 Hz) y luego se realizó un análisis imagen por imagen cada 3.33 ms. Una vez obtenidos los datos de los vídeos se realizaron análisis con las pruebas de ANOVA de un factor, ANCOVA con la velocidad del saque como covariable, U de Mann-Whitney y Chi-cuadrado de Pearson. En cuanto a la regulación del movimiento hasta el momento del despegue, los jugadores internacionales iniciaron sus acciones antes que los jugadores nacionales lo que podría indicar una mejor preparación al ejecutar los movimientos como reflejo del nivel de pericia. Los jugadores internacionales iniciaron la elevación del pie posterior a -293 ms y los jugadores nacionales a -202 ms. Todas estas acciones se fueron enlazando unas con otras y fue en el momento del impacto del sacador donde los restadores demostraron una remarcable coordinación perceptivo-motriz. Por consiguiente, los jugadores internacionales despegaron e iniciaron el vuelo a tan solo -6.5 ms del impacto y los jugadores nacionales lo hicieron más tarde a +19.5 ms. A lo largo de la secuencia temporal, todo parece indicar que las informaciones que utilizan los restadores interactúan entre sí; información más temprana y menos fiable para anticipar o moverse antes e información más tardía y más fiable para regular la temporalización de las acciones. Los restadores de nivel internacional y nacional anticiparon a nivel espacial en un bajo porcentaje (7.7% vs. 13.6%) y en tiempos similares (-127 vs. -118 ms) sugiriendo que la utilización de variables ópticas tempranas y menos fiables solo se produce en contadas ocasiones. Por otra parte, estos datos se relacionan con una gran precisión en la respuesta ya que tanto los jugadores internacionales como los nacionales demostraron un alto porcentaje de acierto al responder (95.4% vs. 96.7%). Se había señalado que los jugadores internacionales y nacionales se diferenciarían en el tiempo de caída (i.e., aterrizaje) del primer pie del salto preparatorio, sin embargo ese efecto no fue encontrado (128 vs. 135 ms). Tampoco se hallaron diferencias en el porcentaje de caída con el pie contrario a la dirección de la pelota (58% vs. 62%). Donde sí ambos grupos se diferenciaron fue en el tiempo de caída del segundo pie (147 vs. 168 ms). Esta diferencia de 21 ms fue crucial y fue una prueba de la mayor rapidez de los jugadores internacionales; sugiriendo que ésta acción se podría relacionar con el momento del inicio de la respuesta. Aunque los jugadores internacionales hayan demostrado ser más rápidos en relación con sus capacidades funcionales, ambos grupos no se diferenciaron en todas las variables relacionadas con el LVMr. Ellos no utilizaron esos valiosos milisegundos ganados en el instante de la caída del segundo pie para responder más pronto, ya que el LVMr del miembro superior fue el mismo para ambos grupos (179 vs. 174 ms). Es como si hubiesen tenido todo el tiempo del mundo para seguir ajustando sus acciones hasta el propio golpeo. Además, estos tiempos largos sugieren que en la gran mayoría de los restos la información clave que determinó la respuesta fue detectada (extraída) en momentos cercanos al golpeo del sacador y en la primera parte del vuelo de la pelota. Asimismo, se constató que en general el LVMr se ve influenciado por el tipo de información utilizada. De esta manera, cuando se tomaron en cuenta los ensayos en los que hubo anticipación espacial reflejados en el LVMr del cuerpo entero los tiempos disminuyeron (152 vs. 136 ms). Por otra parte, existieron ocasiones (13%) en los que tanto los jugadores internacionales como los nacionales respondieron tarde recibiendo saques directos (208 vs. 195 ms). Es muy posible que en estos casos los jugadores hayan tenido problemas para detectar la información respondiendo fuera de los márgenes temporales de acción lo que mermó su rendimiento. Lo mismo pudo haber ocurrido cuando ambos grupos de jugadores corrigieron el movimiento del miembro superior tras el impacto (17% vs. 10%) lo que aumentó el tiempo en responder al redirigir la respuesta hacia el lado correcto (208 vs. 205 ms). Además, los jugadores internacionales obtuvieron tiempos de movimiento menores que el de los jugadores nacionales (509 vs. 531 ms) lo que se reflejó en un tiempo total de actuación menor (683 vs. 703 ms). Por último, en cuanto al rendimiento del resto, los jugadores internacionales obtuvieron valores superiores a los jugadores nacionales (1.3 vs. 0.9). ABSTRACT Although there have been significant advances in laboratory studies with unrepresentative experimental designs (e.g., Farrow y Reid, 2012; Nieminen, Piirainen, Salmi, y Linnamo, 2013), today it is still unknown to full extent how tennis players of different levels of expertise calibrate or adjust their movements to the spatial-temporal demands present in the return of a first serve. Few studies have been carried out in situ and some aspects of the methodology most of them used can be questioned. Thus, in several studies the recording frequency has been limited (e.g., a 50 Hz en Jackson y Gudgeon, 2004; Triolet, Benguigui, Le Runigo y Williams, 2013), or serve speed was visibly lower than the usual one (cf. Carboch, Süss y Kocib, 2014; Williams, Singer y Weigelt, 1998). Also, in some studies, experienced participants have not played at international level (e.g., Avilés, Ruiz, Sanz y Navia, 2014), and the sample size has been very small (e.g., Gillet, Leroy, Thouvarecq, Mégrot y Stein, 2010). Furthermore, different works have used a variety of methods and measurement instruments and coding criteria of the onset of movements and responses have differed; due to this, visuomotor response delay (LVMr) has been very uneven, varying considerably from 198-410 ms. Considering the drawbacks mentioned above, this study aimed to determine a technical model of temporal regulation of movements and returner’s response, taking into account the continuous flow of information provided by the server. For this, a chronometric analysis of the returns of twelve players (six international and six national) of different sports level, that naturally responded by hitting their returns towards the targets, was performed. Actions of servers and returners were recorded with a Casio Exilim Pro Ex-F1 high speed camera (300 Hz) and then every 3.33 ms analysis was made frame by frame. Once the data of the videos were obtained, analyses were performed using one factor ANOVA test, ANCOVA with the speed of the serve as a covariate, U of Mann- Whitney and Pearson’s Chi-square test. As for the regulation of movement until the moment of serve, international players began their actions before national players, which could indicate that they were better prepared to execute movements reflecting the level of their expertise. International players began raising the rear foot at -293 ms and national players at -202 ms. All these actions were being linked to each other and it was at the moment of impact of the server when the receivers demonstrated a remarkable perceptual-motor coordination. Therefore, international players took off and started their flight just -6.5 ms before the serve and national players did the same somewhat later: +19.5 ms after the serve. Along the timeline, everything seems to indicate that the information used by returners interact with each other; early information which is less reliable to anticipate or move before, and later information more reliable appears to regulate the timing of actions. Returners of international and national levels anticipated at spatial level in a low percentage (7.7% vs. 13.6%) and in similar times (-127 vs. -118 ms) suggesting that the use of early and less reliable optical variables is only produced on rare occasions. Moreover, these data relate to a precise response as both international and national players showed a high percentage of success in responding (95.4% vs. 96.7%). It had been noted that international and national players would differ in the time the fall (i.e., landing) of the first foot of the split-step, however, this effect was not found (128 vs. 135 ms). No differences in the percentage of fall with the opposite foot to the direction of the ball (58% vs. 62%) were found. Where the two groups differed was in the time of the fall of the second foot (147 vs. 168 ms). This difference of 21 ms was crucial and it was a proof of mayor speed of international players; suggesting that this action could be related to the onset time of response. Although international players have proven to be faster in relation to their functional capabilities, both groups did not differ in all variables related to LVMr. They did not use those precious milliseconds earned at the time of the fall of the second foot to respond as soon, since the LVMr of the upper limb was the same for both groups (179 vs. 174 ms). It is as if they had all the time in the world to continue to adjust their actions until the return itself. Furthermore, these long times suggest that in the vast majority of the returns, key information that determined the response was detected (pick-up) in moments close to the hit of the server and in the first part of the ball flight. It was also found that in general the LVMr is influenced by the type of information used. Thus, when taking into account the trials during which there was spatial anticipation, reflected in LVMr of the whole body, the times decreased (152 vs. 136 ms). On the other hand, there were occasions (13%) where both international and national players responded late, thus receiving aces (208 vs. 195 ms). It is quite possible that in these cases the players have had trouble to pick-up information, responding out of temporary margins of action, which affected their performance. The same could have occurred when both groups of players corrected upper limb movement after impact (17% vs. 10%), which increased the time to respond and to redirect the return towards the right side (208 vs. 205 ms). Moreover, international players scored lower movement times than the national players (509 vs. 531 ms), which was reflected in a shorter total response time (683 vs. 703 ms). Finally, as far as the performance of return is concerned, international players scored above the national players values (1.3 vs. 0.9).

Behavioral inferences from the Skhul/Qafzeh early modern human hand remains

Two groups of humans are found in the Near East ≈100,000 years ago, the late archaic Neanderthals and the early modern Skhul/Qafzeh humans. Observations that Neanderthals were more heavily muscled, had stronger upper-limb bones, and possessed unusual shapes and orientations of some upper-limb joint complexes relative to the Skhul/Qafzeh hominids, have led some researchers to conclude that significant between-group upper-limb-related behavioral differences must have been present, despite the association of the two groups with similar Middle Paleolithic archeological complexes. A three-dimensional morphometric analysis of the hand remains of the Skhul/Qafzeh hominids, Neanderthals, early and late Upper Paleolithic humans, and Holocene humans supports the dichotomy. The Skhul/Qafzeh carpometacarpal remains do not have any unique morphologies relative to the other fossil samples remains examined. However, in the functionally significant metacarpal 1 and 3 bases they resemble Upper Paleolithic humans, not Neanderthals. Furthermore, the Skhul/Qafzeh sample differs significantly from the Neanderthals in many other aspects of hand functional anatomy. Given the correlations between changes in tool technologies and functional adaptations seen in the hands of Upper Paleolithic humans, it is concluded that the Skhul/Qafzeh hand remains were adapted to Upper Paleolithic-like manipulative repertoires. These results support the inference of significant behavioral differences between Neanderthals and the Skhul/Qafzeh hominids and indicate that a significant shift in human manipulative behaviors was associated with the earliest stages of the emergence of modern humans.

Análise de grandezas cinemáticas e dinâmicas inerentes à hemiparesia através da descoberta de conhecimento em bases de dados

Em virtude de uma elevada expectativa de vida mundial, faz-se crescente a probabilidade de ocorrer acidentes naturais e traumas físicos no cotidiano, o que ocasiona um aumento na demanda por reabilitação. A terapia física, sob o paradigma da reabilitação robótica com serious games, oferece maior motivação e engajamento do paciente ao tratamento, cujo emprego foi recomendado pela American Heart Association (AHA), apontando a mais alta avaliação (Level A) para pacientes internados e ambulatoriais. No entanto, o potencial de análise dos dados coletados pelos dispositivos robóticos envolvidos é pouco explorado, deixando de extrair informações que podem ser de grande valia para os tratamentos. O foco deste trabalho consiste na aplicação de técnicas para descoberta de conhecimento, classificando o desempenho de pacientes diagnosticados com hemiparesia crônica. Os pacientes foram inseridos em um ambiente de reabilitação robótica, fazendo uso do InMotion ARM, um dispositivo robótico para reabilitação de membros superiores e coleta dos dados de desempenho. Foi aplicado sobre os dados um roteiro para descoberta de conhecimento em bases de dados, desempenhando pré-processamento, transformação (extração de características) e então a mineração de dados a partir de algoritmos de aprendizado de máquina. A estratégia do presente trabalho culminou em uma classificação de padrões com a capacidade de distinguir lados hemiparéticos sob uma precisão de 94%, havendo oito atributos alimentando a entrada do mecanismo obtido. Interpretando esta coleção de atributos, foi observado que dados de força são mais significativos, os quais abrangem metade da composição de uma amostra.