Caratterizzazione dei sintomi neurovegetativi e neuropsicologici nella malattia di Parkinson associata a mutazioni del gene glucocerebrosidasi

Pochi studi hanno indagato il profilo dei sintomi non-motori nella malattia di Parkinson associata al gene glucocerebrosidasi (GBA). Questo studio è mirato alla caratterizzazione dei sintomi non-motori, con particolare attenzione alla valutazione delle funzioni neurovegetativa, cognitiva e comportamentale, nel parkinsonismo associato a mutazione del gene GBA con la finalità di verificare se tali sintomi non-motori siano parte dello spettro clinico di questi pazienti. E’ stato condotto su una coorte di pazienti affetti da malattia di Parkinson che erano stati tutti sottoposti ad una analisi genetica per la ricerca di mutazioni in uno dei geni finora associati alla malattia di Parkinson. All’interno di questa coorte omogenea sono stati identificati due gruppi diversi in relazione al genotipo (pazienti portatori della mutazione GBA e pazienti non portatori di nessuna mutazione) e le caratteristiche non-motorie sono state confrontate nei due gruppi. Sono state pertanto indagati il sistema nervoso autonomo, mediante studio dei riflessi cardiovascolari e analisi dei sintomi disautonomici, e le funzioni cognitivo-comportamentali in pazienti affetti da malattia di Parkinson associata a mutazione del gene GBA. I risultati sono stati messi a confronto con il gruppo di controllo. Lo studio ha mostrato che i pazienti affetti da malattia di Parkinson associata a mutazione del gene GBA presentavano maggiore frequenza di disfunzioni ortosimpatiche, depressione, ansia, apatia, impulsività, oltre che di disturbi del controllo degli impulsi rispetto ai pazienti non portatori. In conclusione, i pazienti GBA positivi possono esprimere una sintomatologia non-motoria multidominio con sintomi autonomici, cognitivi e comportamentali in primo piano. Pertanto l’impostazione terapeutica in questi pazienti dovrebbe includere una accurata valutazione dei sintomi non-motori e un loro monitoraggio nel follow up clinico, allo scopo di ottimizzare i risultati e ridurre i rischi di complicazioni.

Inflammation as a psychophysiological biomarker in chronic psychosocial stress

The measurement of inflammation by biomarkers not only documents clinically relevant infections but also offers an important tool to pin point potentially harmful effects of chronic psychosocial stressors. This article focuses firstly on basic biology of inflammation and lists main biomarkers currently used in psycho-physiologic research. In the second part, the effects of the hypothalamic-pituitary-adrenal (HPA) axis and the autonomic nervous system as pathways modulating stress-related inflammation are discussed. Furthermore, current evidence of how chronic psychosocial stressors are related to alterations in inflammatory activity is presented. In summary, job stress, low socioeconomic status, childhood adversities as well as life events, caregiver stress, and loneliness were all shown to exert effects on immunologic activity.

An anatomical investigation of the cervicothoracic ganglion

Anatomical variability within the autonomic nervous system has long been accepted. This study evaluated the anatomical variability of the cervicothoracic ganglion (CTG) according to its form and, in addition, provided precise measurements between the CTG and the anterior tubercle of the transverse process of the sixth cervical vertebra (C6TP), the first costovertebral articulation, and the vertebral artery. Forty-two adult cadavers were dissected, 22 male and 20 females. Five main forms of CTG were documented; spindle (31.9%), dumbbell (23.2%), truncated (21.7%), perforated (14.5%), and inverted-L (8.7%). The means for length, width, and thickness of the CTG were 18.5 mm, 8.2 mm, and 4.5 mm, respectively. The dimensions were found to be slightly larger in the males than females and on the left sides as compared to the right. The mean shortest distance between the CTGs and the vertebral artery was found to be 2.8 mm, whilst the mean shortest distances to C6TP was 25.7 mm and to the first costovertebral articulation was 1.7 mm. There is great variability in the morphology of the CTG with five common forms consistently seen. The relation to the vertebral artery may influence the form of the ganglion. Two previously undocumented forms are recorded; the truncated which describes the important juxtaposition of the CTG and the vertebral artery and the perforated which describes the piercing of the ganglion itself by the artery. The findings are considered to be of clinical importance to anesthetists, surgeons, neurosurgeons, and anatomists.

Drug suicide: a sex-equal cause of death in 16 European countries

Background There is a lack of international research on suicide by drug overdose as a preventable suicide method. Sex- and age-specific rates of suicide by drug self-poisoning (ICD-10, X60-64) and the distribution of drug types used in 16 European countries were studied, and compared with other self-poisoning methods (X65-69) and intentional self-injury (X70-84). Methods Data for 2000-04/05 were collected from national statistical offices. Age-adjusted suicide rates, and age and sex distributions, were calculated. Results No pronounced sex differences in drug self-poisoning rates were found, either in the aggregate data (males 1.6 and females 1.5 per 100,000) or within individual countries. Among the 16 countries, the range (from some 0.3 in Portugal to 5.0 in Finland) was wide. 'Other and unspecified drugs' (X64) were recorded most frequently, with a range of 0.2-1.9, and accounted for more than 70% of deaths by drug overdose in France, Luxembourg, Portugal and Spain. Psychotropic drugs (X61) ranked second. The X63 category ('other drugs acting on the autonomic nervous system') was least frequently used. Finland showed low X64 and high X61 figures, Scotland had high levels of X62 ('narcotics and hallucinogens, not elsewhere classified') for both sexes, while England exceeded other countries in category X60. Risk was highest among the middle-aged everywhere except in Switzerland, where the elderly were most at risk. Conclusions Suicide by drug overdose is preventable. Intentional self-poisoning with drugs kills as many males as females. The considerable differences in patterns of self-poisoning found in the various European countries are relevant to national efforts to improve diagnostics of suicide and appropriate specific prevention. The fact that vast majority of drug-overdose suicides came under the category X64 refers to the need of more detailed ICD coding system for overdose suicides is needed to permit better design of suicide-prevention strategies at national level.

Music, perceived arousal, and intensity: psychophysiological reactions to Chopin's "Tristesse"

The present study investigates the relation of perceived arousal (continuous self-rating), autonomic nervous system activity (heart rate, heart rate variability) and musical characteristics (sound intensity, musical rhythm) upon listening to a complex musical piece. Twenty amateur musicians listened to two performances of Chopin's "Tristesse" with different rhythmic shapes. Besides conventional statistical methods for analyzing psychophysiological reactions (heart rate, respiration rate) and musical variables, semblance analysis was used. Perceived arousal correlated strongly with sound intensity; heart rate showed only a partial response to changes in sound intensity. Larger changes in heart rate were caused by the version with more rhythmic tension. The low-/high-frequency ratio of heart rate variability increased-whereas the high frequency component decreased-during music listening. We conclude that autonomic nervous system activity can be modulated not only by sound intensity but also by the interpreter's use of rhythmic tension. Semblance analysis enables us to track the subtle correlations between musical and physiological variables.

Day-to-night time differences in the relationship between cardiorespiratory coordination and heart rate variability

Heart rate variability (HRV) and cardiorespiratory coordination, i.e. the temporal interplay between oscillations of heartbeat and respiration, reflect information related to the cardiovascular and autonomic nervous system. The purpose of this study was to investigate the relationship between spectral measures of HRV and measures of cardiorespiratory coordination. In 127 subjects from a normal population a 24 h Holter ECG was recorded. Average heart rate (HR) and the following HRV parameters were calculated: very low (VLF), low (LF) and high frequency (HF) oscillations and LF/HF. Cardiorespiratory coordination was quantified using average respiratory rate (RespR), the ratio of heart rate and respiratory rate (HRR), the phase coordination ratio (PCR) and the extent of cardiorespiratory coordination (PP). Pearson's correlation coefficient r was used to quantify the relationship between each pair of the variables across all subjects. HR and HRR correlated strongest during daytime (r = 0.89). LF/HF and PP showed a negative correlation to a reasonable degree (r = -0.69). During nighttime sleep these correlations decreased whereas the correlation between HRR and RespR (r = -0.47) as well as between HRR and PCR (r = 0.73) increased substantially. In conclusion, HRR and PCR deliver considerably different information compared to HRV measures whereas PP is partially linked reciprocally to LF/HF.

[What are the physical complaints without pathological clinical signs in patients with diabetes mellitus?]

In previous research it was found that patients with diabetes mellitus suffer from multiple physical symptoms even early in their disease course. Such complaints may relate to blood glucose levels or can be understood as a sign of distress in respect to the diagnosis of a chronic disease. PURPOSE: This study was performed to evaluate in a cross-sectional analysis all the symptoms that patients may complain of and to relate these symptoms to a possible dysfunction of the autonomic nervous system. METHOD: We assessed the complaints of 66 patients with diabetes mellitus and compared these variables with those of patients with psychological disturbances (n = 794) or somatic disease (n = 162). The symptoms were recorded by means of several questionnaires such as the "Giessener Beschwerdebogen" (GBB), "the Freiburger Persönlichkeitsinventar" (FPI), the German version of the State Trait Anxiety Inventory (STAI) and the German version of the State Trait Anger Expression Inventory (STAXI). The autonomic nervous system was assessed using resting and mental stress conditions in a subset of patients with diabetes mellitus (n = 29) and psychological disturbances (n = 44). RESULTS: Patients suffering from diabetes mellitus and psychological disturbances showed a tendency to higher scores in GBB, STAI and STAXI. As far as psychological disturbances are concerned, the complaints experienced by patients with diabetes mellitus were found to be similar to those with somatic diseases. Both groups, however, rate clearly below those with psychological disturbances. The results of autonomic testing showed a significant disturbance in patients with diabetes mellitus with reduced sensitivity of the baroreceptor indicating autonomic neuropathy. CONCLUSION: Some of the physical complaints of patients with diabetes mellitus can be understood in connection with autonomic dysfunction. Moreover, an explicitly psychological view of these complaints may not be correct.

Genome-wide association study on dimethylarginines reveals novel AGXT2 variants associated with heart rate variability but not with overall mortality.

AIMS The purpose of this study was to identify novel genetic variants influencing circulating asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA) levels and to evaluate whether they have a prognostic value on cardiovascular mortality. METHODS AND RESULTS We conducted a genome-wide association study on the methylarginine traits and investigated the predictive value of the new discovered variants on mortality. Our meta-analyses replicated the previously known locus for ADMA levels in DDAH1 (rs997251; P = 1.4 × 10(-40)), identified two non-synomyous polymorphisms for SDMA levels in AGXT2 (rs37369; P = 1.4 × 10(-40) and rs16899974; P = 1.5 × 10(-38)) and one in SLC25A45 (rs34400381; P = 2.5 × 10(-10)). We also fine-mapped the AGXT2 locus for further independent association signals. The two non-synonymous AGXT2 variants independently associated with SDMA levels were also significantly related with short-term heart rate variability (HRV) indices in young adults. The major allele (C) of the novel non-synonymous rs16899974 (V498L) variant associated with decreased SDMA levels and an increase in the ratio between the low- and high-frequency spectral components of HRV (P = 0.00047). Furthermore, the SDMA decreasing allele (G) of the non-synomyous SLC25A45 (R285C) variant was associated with a lower resting mean heart rate during the HRV measurements (P = 0.0046), but not with the HRV indices. None of the studied genome-wide significant variants had any major effect on cardiovascular or total mortality in patients referred for coronary angiography. CONCLUSIONS AGXT2 has an important role in SDMA metabolism in humans. AGXT2 may additionally have an unanticipated role in the autonomic nervous system regulation of cardiac function.

Pathophysiologie des Schmerzes und Neuraltherapie

Die Neuraltherapie nach Huneke ist eine Injektionsbehandlung, welche Lokalanästhetika zur Diagnostik und Therapie einsetzt. Je nach Situation erfolgt der Reiz (und/oder die Unterbrechung einer pathologischen Belastung) im Bereiche der Segmentreflektorik oder über das sogenannte Störfeld. Dieses kann ausserhalb jeder segmentalen Ordnung eine Erkrankung oder ein Schmerzbild auslösen und unterhalten. Mit der Neuraltherapie werden gezielt autoregulatorische Mechanismen des Vegetativums (insbesondere des Sympathikus) angesprochen. Theoretische Grundlagen hierzu sind Erkenntnisse aus der Neurophysiologie und der Modernen Physik.

Psychometric and biohormonal indices of dental anxiety in children. A prospective cohort study.

The stress of dental treatment often elicits negative emotions in children, expressed as dental fear or anxiety. Highly anxious children obstruct treatment and avoid therapy, further amplifying oral health problems. The aim of this study was to examine the neuroendocrine and autonomic nervous system responses to dental treatment and their possible interactions and associations with psychometric indices of anxiety, caries, previous dental experience, anesthesia, age and gender in school children. Upon informed consent, saliva was obtained from 97 children (59% males, mean age ±  SD: 89.73 ± 15 months) in the Clinic of pediatric dentistry before treatment, immediately post-treatment and at the recall visit to determine cortisol and salivary alpha-amylase (sAA) levels. Dental and general anxiety was assessed through specific questionnaires completed by the children. Compared to pre-treatment, cortisol levels were increased following treatment, while sAA levels were higher at the recall. Pre- and post-treatment cortisol and sAA responses were positively correlated. Dental and general anxiety questionnaire scores were also significantly correlated with each other. The integrated autonomic and neuroendocrine responses prior to treatment were correlated with state anxiety and those following treatment with dental anxiety. However, univariable and multivariable linear regression analysis associated post-treatment cortisol, but not sAA, levels with dental anxiety. No associations of cortisol or sAA responses with caries, age, gender, previous dental experience or anesthesia were detected. These data provide some evidence that both sAA and cortisol levels are altered in children in anticipation or during dental treatment, but only cortisol levels are associated to dental anxiety.

Influence of transrectal and transabdominal ultrasound examination on salivary cortisol, heart rate, and heart rate variability in mares

Pregnancy diagnostics in equine reproduction are routinely performed using transrectal ultrasonography, although it is also possible to visualize the fetus by transabdominal ultrasound examinations from the 90th day of gestation onward. We hypothesized that ultrasound examinations may stress the mare and that the gestational stage status and lactation may influence the mare's stress reaction. To investigate the stress reaction, 25 thoroughbred mares of different age, pregnancy and lactational status underwent a transrectal examination. In pregnant mares, an additional transabdominal examination was performed. Salivary cortisol concentration, mean heart rate, and heart rate variability of mares were assessed to evaluate the reactions of hypothalamic–pituitary–adrenal (HPA) axis and of the autonomic nervous system. Significant differences were observed between lactating and nonlactating mares; with a lower responsiveness to stress in lactating mares. The transrectal ultrasound examination in nonlactating mares induced a significant increase in salivary cortisol (P < 0.05), and in the heart rate variability parameter, ratio of low to high frequencies (P < 0.05). This reflects an activation of the HPA axis and a shift to more sympathetic dominance. In contrast, a transabdominally performed pregnancy check did not induce an activation of the HPA axis over basal level but increased the mean heart rate and low to high frequency ratio. The results of this study indicate that checks of advanced pregnancies can be easily performed by transabdominal ultrasonography. With regard to animal welfare, this technique should be preferred during midgestation in nonlactating mares.

Das Elektrokardiogramm des Sporttreibenden und der Sport-assoziierte plötzliche Herztod.

Regelmässiges körperliches Training induziert strukturelle, elektrische und funktionelle Anpassungen des Herzens. Die grösste Herausforderung für den Arzt liegt darin, Veränderungen hinweisend für eine strukturelle Herzerkrankung von physiologischen, trainingsassoziierten Anpassungen im Sinne eines 'Athlete's heart' zu unterscheiden. Bei zugrundliegender Kardiopathie ist sportliche Aktivität nicht die Ursache, sondern kann ein Trigger für belastungsabhängige Tachyarrhythmien bzw. für den belastungsabhängigen plötzlichen Herztod (SCD) sein. Um Athleten mit einer kardialen Grunderkrankung und erhöhtem Risiko für einen SCD frühzeitig zu identifizieren wird in Europa ein Preparticipation Screening empfohlen, welches von der Schweizerischen Gesellschaft für Sportmedizin (SGSM) übernommen wurde. Dieses Screening umfasst neben der spezifischen Anamnese und der Herzauskultation auch ein Ruhe-Elektrokardiogramm (Ruhe-EKG). Aufgrund der hohen Anzahl falsch-positiver EKG-Befunde wurden in den letzten Jahren die Beurteilungskriterien des Athleten-EKGs wiederholt angepasst, die Sensitivität und insbesondere auch die Spezifität konnte mit den „verfeinerten Seattle Kriterien“ 2014 deutlich verbessert werden. Der frühen Repolarisation galt in den letzten Jahren ein Hauptaugenmerk: neben dem (Ausdauer-) Training besteht eine klare Assoziation zum männlichen Geschlecht, zur Ethnie, zu den Veränderungen des vegetativen Nervensystems und zu erhöhten QRS-Voltage-Kriterien.

Sex differences in heart rate variability: a longitudinal study in international elite cross-country skiers

PURPOSE: Exercise-related sudden cardiac deaths (SCD) occur with a striking male predominance. A higher sympathetic tone in men has been suggested as risk factor for SCD. Elite athletes have the highest risk for exercise-related SCD. We aimed to analyze the autonomic nervous system of elite cross-country skiers from Norway, Russia and Switzerland in supine position and after orthostatic challenge in various training periods (TP). METHOD: Measurements of heart rate variability (HRV) were performed on a weekly basis over 1 year using an orthostatic challenge test with controlled breathing. Main outcome parameters were the high-frequency power in supine position (HFsupine) as marker of cardiac parasympathetic activity and the low-frequency/high-frequency power ratio after orthostatic challenge (LF/HFstand) as marker of cardiac sympathetic activation. Training intensity and duration were recorded daily and expressed as training strain. The training year was divided into three TPs. An average of weekly HRV measurements was calculated for each TP. RESULT: Female (n = 19, VO2max 62.0 +/- 4.6 ml kg(-1) min(-1), age 25.8 +/- 4.3 years) and male (n = 16, VO2max 74.3 +/- 6.3 ml kg(-1) min(-1), age 24.4 +/- 4.2 years) athletes were included. Training strain was comparable between sexes (all p > 0.05) and changed between TPs (all p < 0.05) while no HRV parameters changed over time. There were no sex differences in HFsupine while the LF/HFstand was significantly higher in male athletes in all TPs. CONCLUSION: For a comparable amount of training, male athletes showed constantly higher markers of sympathetic activity after a provocation maneuver. This may explain part of the male predominance in sports-related SCD.

Influencia del ejercicio físico desarrollado durante el embarazo en la respuesta cardiaca fetal = Influence of a physical activity program performed during pregnancy on fetal heart response

INTRODUCCIÓN: El riesgo de padecer enfermedades cardiovasculares y los índices de obesidad infantil han ido en aumento durante los últimos años empobreciendo la salud de la población. La Teoría de Barker relaciona el estado de salud de la madre con el desarrollo fetal, asociando a un deficiente estado físico y hábitos de vida negativos de la mujer embarazada con el aumento del riesgo de padecer cardiopatías en la infancia y adolescencia, así como predisponer al recién nacido a padecer sobrepeso y/u obesidad en su vida posterior. Por otro lado los estudios efectuados sobre ejercicio físico durante el embarazo reportan beneficios para salud materna y fetal. Uno de los parámetros más utilizados para comprobar la salud fetal es su frecuencia cardiaca, mediante la que se comprueba el buen desarrollo del sistema nervioso autónomo. Si se observa este parámetro en presencia de ejercicio materno podría encontrarse una respuesta crónica del corazón fetal al ejercicio materno como consecuencia de una adaptación y mejora en el funcionamiento del sistema nervioso autónomo del feto. De esta forma podría mejorar su salud cardiovascular intrauterina, lo que podría mantenerse en su vida posterior descendiendo el riesgo de padecer enfermedades cardiovasculares en la edad adulta. OBJETIVOS: Conocer la influencia de un programa de ejercicio físico supervisado en la frecuencia cardiaca fetal (FCF) en reposo y después del ejercicio materno en relación con gestantes sedentarias mediante la realización de un protocolo específico. Conocer la influencia de un programa de ejercicio físico en el desarrollo del sistema nervioso autónomo fetal, relacionado con el tiempo de recuperación de la FCF. MATERIAL Y MÉTODO: Se diseñó un ensayo clínico aleatorizado multicéntrico en el que participaron 81 gestantes (GC=38, GE=43). El estudio fue aprobado por el comité ético de los hospitales que participaron en el estudio. Todas las gestantes fueron informadas y firmaron un consentimiento para su participación en el estudio. Las participantes del GE recibieron una intervención basada en un programa de ejercicio físico desarrollado durante la gestación (12-36 semanas de gestación) con una frecuencia de tres veces por semana. Todas las gestantes realizaron un protocolo de medida de la FCF entre las semanas 34-36 de gestación. Dicho protocolo consistía en dos test llevados a cabo caminando a diferentes intensidades (40% y 60% de la frecuencia cardiaca de reserva). De este protocolo se obtuvieron las principales variables de estudio: FCF en reposo, FCF posejercicio al 40 y al 60% de intensidad, tiempo de recuperación de la frecuencia cardiaca fetal en ambos esfuerzos. El material utilizado para la realización del protocolo fue un monitor de frecuencia cardiaca para controlar la frecuencia cardiaca de la gestante y un monitor fetal inalámbrico (telemetría fetal) para registrar el latido fetal durante todo el protocolo. RESULTADOS: No se encontraron diferencias estadísticamente significativas en la FCF en reposo entre grupos (GE=140,88 lat/min vs GC= 141,95 lat/min; p>,05). Se encontraron diferencias estadísticamente significativas en el tiempo de recuperación de la FCF entre los fetos de ambos grupos (GE=135,65 s vs GC=426,11 s esfuerzo al 40%; p<,001); (GE=180,26 s vs GC=565,61 s esfuerzo al 60%; p<,001). Se encontraron diferencias estadísticamente significativas en la FCF posejercicio al 40% (GE=139,93 lat/min vs GC=147,87 lat/min; p<,01). No se encontraron diferencias estadísticamente significativas en la FCF posejercicio al 60% (GE=143,74 lat/min vs GC=148,08 lat/min; p>,05). CONLUSIÓN: El programa de ejercicio físico desarrollado durante la gestación influyó sobre el corazón fetal de los fetos de las gestantes del GE en relación con el tiempo de recuperación de la FCF. Los resultados muestran un posible mejor funcionamiento del sistema nervioso autónomo en fetos de gestantes activas durante el embarazo. ABSTRACT INTRODUCTION: The risk to suffer cardiovascular diseases and childhood obesity index has grown in the last years worsening the health around the population. Barker´s Theory related maternal health with fetal development establishing an association between a poorly physical state and an unhealthy lifestyle in the pregnant woman with the risk to suffer heart disease during childhood and adolescence, childhood overweight and/or obese is related to maternal lifestyle. By the other way researches carried out about physical exercise and pregnancy show benefits in maternal and fetal health. One of the most studied parameters to check fetal health is its heart rate, correct fetal autonomic nervous system development and work is also corroborated by fetal heart rate. Looking at this parameter during maternal exercise a chronic response of fetal heart could be found due to an adaptation and improvement in the working of the autonomic nervous system. Therefore its cardiovascular health could be enhanced during its intrauterine life and maybe it could be maintained in its posterior life descending the risk to suffer cardiovascular diseases in adult life. OBJECTIVES: To know the influence of a supervised physical activity program in the fetal heart rate (FHR) at rest, FHR after maternal exercise related to sedentary pregnant women by a FHR assessment protocol. To know the influence of a physical activity program in the development of the autonomic nervous system related to FHR recovery time. MATERIAL AND METHOD: A multicentric randomized clinical trial was design in which 81 pregnant women participated (CG=38, EG=43). The study was approved by the ethics committee of all of the hospitals participating in the study. All of the participants signed an informed consent for their participation in the study. EG participants received an intervention based on a physical activity program carried out during gestation (12-36 gestation weeks) with a three days a week frequency. All of the participants were tested between 34-36 weeks of gestation by a specific FHR assessment protocol. The mentioned protocol consisted in two test performed walking and at a two different intensities (40% and 60% of the reserve heart rate). From this protocol we obtained the main research variables: FHR at rest, FHR post-exercise at 40% and 60% intensity, and FHR recovery time at both walking test. The material used to perform the protocol were a FH monitor to check maternal HR and a wireless fetal monitor (Telemetry) to register fetal beats during the whole protocol. RESULTS: There were no statistical differences in FHR at rest between groups (EG=140,88 beats/min vs CG= 141,95 beats/min; p>,05). There were statistical differences in FHR recovery time in both walking tests between groups (EG=135,65 s vs CG=426,11 s test at 40% intensity; p<,001); (EG=180,26 s vs CG=565,61 s test at 60% intensity; p<,001). Statistical differences were found in FHR post-exercise at 40% intensity between groups (EG=139,93 beats/min vs CG=147,87 beats/min; p<,01). No statistical differences were found in FHR at rest post-exercise at 60% intensity between groups (EG=143,74 beats/min vs CG=148,08 beats/min; p>,05). CONCLUSIONS: The physical activity program performed during gestation had an influence in fetal heart of the fetus from mother in the EG related to FHR recovery time. These results show a possible enhancement on autonomic nervous system working in fetus from active mothers during gestation.

Análisis de la marcha: evaluación de un exoesqueleto aplicado a la marcha asistida

La marcha humana es el mecanismo de locomoción por el cual el cuerpo humano se traslada en línea recta gracias a una serie de movimientos coordinados de la pelvis y de las articulaciones del miembro inferior. Frecuentemente se encuentra influenciada por factores biomecánicos, anatómicos o patologías del sistema neuromusculoesquelético que modifican la forma de caminar de cada individuo. La lesión de médula espinal es una de las patologías que afectan el desarrollo normal de los patrones de la marcha por alteración de la movilidad, de la sensibilidad o del sistema nervioso autónomo. Aunque la lesión medular afecta otras funciones, además de la pérdida de función motora y sensorial, la recuperación de la capacidad de caminar es la mayor prioridad identificada por los pacientes durante la rehabilitación. Por ello, el desarrollo de dispositivos que faciliten la rehabilitación o compensación de la marcha es uno de los principales objetivos de diferentes grupos de investigación y empresas. En el contexto del proyecto Hybrid Technological Platform for Rehabilitation, Functional Compensation and Training of Gait in Spinal Cord Injury Patients se ha desarrollado un dispositivo que combina una órtesis activa (exoesqueleto) y un andador motorizado. Este sistema, como otros dispositivos, tiene el movimiento humano como estándar de referencia, no obstante no se evalúa de manera habitual, cómo es el patrón de la marcha reproducido y su similitud o diferencias con la marcha humana, o las modificaciones o adaptaciones en la interacción con el cuerpo del paciente. El presente estudio trata de examinar las características de la marcha normal en diversos grupos de población, y las diferencias con el patrón de marcha lenta. Finalmente, se pretende evaluar qué modificaciones y adaptaciones sufre el patrón de marcha lenta teórico al ser reproducido por el exoesqueleto. La presente investigación consiste en un estudio cuantitativo transversal desarrollado en dos etapas: estudio 1 y estudio 2. En el estudio 1 se analizó el patrón de la marcha a velocidad libremente seleccionada (normal) y el patrón de la marcha a velocidad lenta (0.25m/s) en 62 sujetos distribuidos en grupos considerando el sexo y los percentiles 25, 50 y 75 de estatura de la población española. Durante el estudio 2 se analizó el patrón de la marcha lenta reproducido por el dispositivo Hybrid a diferentes porcentajes de peso corporal (30%, 50% y 70%) en diez sujetos seleccionados aleatoriamente de la muestra del estudio 1. En ambos estudios se obtuvieron variables espacio-temporales y cinemáticas mediante un sistema de captura de movimiento con 6 cámaras distribuidas a lo largo de un pasillo de marcha. Se calcularon las medias, las desviaciones estándar y el 95% de intervalo de confianza, y el nivel alfa de significación se estableció en α=0.05 para todas las pruebas estadísticas. Las principales diferencias en el patrón normal de la marcha se encontraron en los parámetros cinemáticos de hombres y mujeres, aunque también se presentaron diferencias entre los grupos en función de la estatura. Las mujeres mostraron mayor flexión de cadera y rodilla, y mayor extensión de tobillo que los hombres durante el ciclo normal, aunque la basculación lateral de la pelvis, mayor en las mujeres, y el desplazamiento lateral del centro de gravedad, mayor en los hombres, fueron los parámetros identificados como principales discriminantes entre sexos. La disminución de la velocidad de la marcha mostró similares adaptaciones y modificaciones en hombres y en mujeres, presentándose un aumento de la fase de apoyo y una disminución de la fase de oscilación, un retraso de los máximos y mínimos de flexoextensión de cadera, rodilla y tobillo, y una disminución del rango articular en las tres articulaciones. Asimismo, la basculación lateral de la pelvis y el movimiento vertical del centro de gravedad disminuyeron, mientras que el movimiento lateral del centro de gravedad y el ancho de paso aumentaron. Durante la evaluación del patrón de la marcha reproducido por el exoesqueleto se observó que las tres articulaciones del miembro inferior disminuían el rango de movimiento por la falta de fuerza de los motores para contrarrestar el peso corporal, incluso con un 70% de descarga de peso. Además, la transferencia de peso se encontró limitada por la falta de movimiento de la pelvis en el plano frontal y se sustituyó por un aumento de la inclinación del tronco y, por tanto, del movimiento lateral del centro de gravedad. Este hecho, junto al aumento del desplazamiento vertical del centro de gravedad, hizo del patrón de la marcha reproducido por el exoesqueleto un movimiento poco eficiente. En conclusión, se establecen patrones de marcha normal diferenciados por sexos, siendo la basculación lateral de la pelvis y el movimiento lateral del centro de gravedad los parámetros discriminantes más característicos entre sexos. Comparando la marcha a velocidad libremente seleccionada y la velocidad lenta, se concluye que ambos sexos utilizan estrategias similares para adaptar el patrón de la marcha a una velocidad lenta y se mantienen las características diferenciadoras entre hombres y mujeres. En relación a la evaluación del dispositivo Hybrid, se deduce que la falta de movimiento lateral de la pelvis condiciona la transferencia de peso y el aumento del rango de movimiento del centro de gravedad y, en consecuencia, tiene como resultado un patrón de la marcha poco eficiente. Este patrón no resultaría indicado para los procesos de rehabilitación o recuperación de la marcha, aunque podría considerarse adecuado para la compensación funcional de la bipedestación y la locomoción. ABSTRACT The human walking is a means of moving body forward using a repetitious and coordinated sequence of pelvis and lower limb motions. It is frequently influenced by biomechanical and anatomical factors or by musculoskeletal pathologies which modify the way of walking. The spinal injury is one of those pathologies which affect the normal pattern of walking, due to the alteration of the mobility, the sensory or the autonomic nervous system. Although the spinal injury affects many other body functions, apart from the motor and sensory ones, the main priority for patients is to recover the ability of walking. Consequently, the main objective of many research groups and private companies is the development of rehabilitation and compensation devices for walking. In this context, the Hybrid Technological Platform for Rehabilitation, Functional Compensation and Training of Gait in Spinal Cord Injury Patients project has developed a device which integrates an exoskeleton and a motorized smart walker. This system, as other similar devices, has the human movement as standard reference. Nevertheless, these devices are not usually evaluated on the way they reproduce the normal human pattern or on the modifications and in the interactions with the patient’s body. The aim of the present study is to examine the normal walking characteristics, to analyze the differences between self-selected and low speed walking patterns, and to evaluate the modifications and adaptations of walking pattern when it is reproduced by the exoskeleton. The present research is a quantitative cross-sectional study carried out in two phases: study 1 and study 2. During the study 1, the self-selected and the low speed (0.25m/s) walking patterns were analyzed in sixty-two people distributed in groups, according to sex and 25th, 50th and 75th percentiles of height for Spanish population. The study 2 analyzed the low speed walking pattern reproduced by the Hybrid system in three conditions: 30%, 50% and 70% of body weight support. To do this, ten subjects were randomly selected and analyzed from the people of study 1. An optoelectronic system with six cameras was used to obtain spatial, temporal and kinematic parameters in both studies. Means, standard deviations and 95% confidence intervals of the study were calculated. The alpha level of significance was set at α=0.05 for all statistical tests. The main differences in normal gait pattern were found in kinematic parameters between men and women. The hip and the knee were more flexed and the ankle plantar flexion was higher in women than in men during normal gait cycle. Although the greater pelvic obliquity of women and the higher lateral movement of center of gravity of men were the most relevant discriminators between male and female gait patterns. Comparing self-selected and low speed walking patterns, both sexes showed similar adaptations and modifications. At low speed walking, men and women increased the stance phase ratio and decreased the swing phase ratio. The maximum and minimum peak flexion of hip, knee and ankle appeared after and the range of motion of them decreased during low speed walking. Furthermore, the pelvic obliquity and the vertical movement of the center of gravity decreased, whereas the lateral movement of center of gravity and step width increased. Evaluating the gait pattern reproduced by the exoskeleton, a decrease of lower limb range of motion was observed. This was probably due to the lack of strength of the engines, which were not able to control the body weight, even with the 70% supported. Moreover, the weight transfer from one limb to the contralateral side was restricted due to the lack of pelvis obliquity. This movement deficiency was replaced by the lateral torso sway and, consequently, the increase of lateral movement of the center of gravity. This fact, as well as the increase of the vertical displacement of the center of gravity, made inefficient the gait pattern reproduced by the exoskeleton. In conclusion, different gait patterns of both sexes have been determined, being pelvis obliquity and lateral movement of center of gravity the most relevant discriminators between male and female gait patterns. Comparing self-selected and low speed walking patterns, it was concluded that both sexes use similar strategies for adapting the gait pattern to a low speed, and therefore, the differentiating characteristics of normal gait are maintained. Regarding the Hybrid system evaluation, it was determined that the gait pattern reproduced by the exoskeleton is inefficient. This was due to the lack of pelvis obliquity and the increase of the center of gravity displacement. Consequently, whereas the walking pattern reproduced by the exoskeleton would not be appropriated for the rehabilitation process, it could be considered suitable for functional compensation of walking and standing.