New functional and biomechanical assessments for the improvement of the surgical navigation systems for joint replacement in the human lower limb

In case of severe osteoarthritis at the knee causing pain, deformity, and loss of stability and mobility, the clinicians consider that the substitution of these surfaces by means of joint prostheses. The objectives to be pursued by this surgery are: complete pain elimination, restoration of the normal physiological mobility and joint stability, correction of all deformities and, thus, of limping. The knee surgical navigation systems have bee developed in computer-aided surgery in order to improve the surgical final outcome in total knee arthroplasty. These systems provide the surgeon with quantitative and real-time information about each surgical action, like bone cut executions and prosthesis component alignment, by mean of tracking tools rigidly fixed onto the femur and the tibia. Nevertheless, there is still a margin of error due to the incorrect surgical procedures and to the still limited number of kinematic information provided by the current systems. Particularly, patello-femoral joint kinematics is not considered in knee surgical navigation. It is also unclear and, thus, a source of misunderstanding, what the most appropriate methodology is to study the patellar motion. In addition, also the knee ligamentous apparatus is superficially considered in navigated total knee arthroplasty, without taking into account how their physiological behavior is altered by this surgery. The aim of the present research work was to provide new functional and biomechanical assessments for the improvement of the surgical navigation systems for joint replacement in the human lower limb. This was mainly realized by means of the identification and development of new techniques that allow a thorough comprehension of the functioning of the knee joint, with particular attention to the patello-femoral joint and to the main knee soft tissues. A knee surgical navigation system with active markers was used in all research activities presented in this research work. Particularly, preliminary test were performed in order to assess the system accuracy and the robustness of a number of navigation procedures. Four studies were performed in-vivo on patients requiring total knee arthroplasty and randomly implanted by means of traditional and navigated procedures in order to check for the real efficacy of the latter with respect to the former. In order to cope with assessment of patello-femoral joint kinematics in the intact and replaced knees, twenty in-vitro tests were performed by using a prototypal tracking tool also for the patella. In addition to standard anatomical and articular recommendations, original proposals for defining the patellar anatomical-based reference frame and for studying the patello-femoral joint kinematics were reported and used in these tests. These definitions were applied to two further in-vitro tests in which, for the first time, also the implant of patellar component insert was fully navigated. In addition, an original technique to analyze the main knee soft tissues by means of anatomical-based fiber mappings was also reported and used in the same tests. The preliminary instrumental tests revealed a system accuracy within the millimeter and a good inter- and intra-observer repeatability in defining all anatomical reference frames. In in-vivo studies, the general alignments of femoral and tibial prosthesis components and of the lower limb mechanical axis, as measured on radiographs, was more satisfactory, i.e. within ±3°, in those patient in which total knee arthroplasty was performed by navigated procedures. As for in-vitro tests, consistent patello-femoral joint kinematic patterns were observed over specimens throughout the knee flexion arc. Generally, the physiological intact knee patellar motion was not restored after the implant. This restoration was successfully achieved in the two further tests where all component implants, included the patellar insert, were fully navigated, i.e. by means of intra-operative assessment of also patellar component positioning and general tibio-femoral and patello-femoral joint assessment. The tests for assessing the behavior of the main knee ligaments revealed the complexity of the latter and the different functional roles played by the several sub-bundles compounding each ligament. Also in this case, total knee arthroplasty altered the physiological behavior of these knee soft tissues. These results reveal in-vitro the relevance and the feasibility of the applications of new techniques for accurate knee soft tissues monitoring, patellar tracking assessment and navigated patellar resurfacing intra-operatively in the contest of the most modern operative techniques. This present research work gives a contribution to the much controversial knowledge on the normal and replaced of knee kinematics by testing the reported new methodologies. The consistence of these results provides fundamental information for the comprehension and improvements of knee orthopedic treatments. In the future, the reported new techniques can be safely applied in-vivo and also adopted in other joint replacements.

Analysis of human body kinematics using a hybrid markerless video acquisition and processing

A main objective of the human movement analysis is the quantitative description of joint kinematics and kinetics. This information may have great possibility to address clinical problems both in orthopaedics and motor rehabilitation. Previous studies have shown that the assessment of kinematics and kinetics from stereophotogrammetric data necessitates a setup phase, special equipment and expertise to operate. Besides, this procedure may cause feeling of uneasiness on the subjects and may hinder with their walking. The general aim of this thesis is the implementation and evaluation of new 2D markerless techniques, in order to contribute to the development of an alternative technique to the traditional stereophotogrammetric techniques. At first, the focus of the study has been the estimation of the ankle-foot complex kinematics during stance phase of the gait. Two particular cases were considered: subjects barefoot and subjects wearing ankle socks. The use of socks was investigated in view of the development of the hybrid method proposed in this work. Different algorithms were analyzed, evaluated and implemented in order to have a 2D markerless solution to estimate the kinematics for both cases. The validation of the proposed technique was done with a traditional stereophotogrammetric system. The implementation of the technique leads towards an easy to configure (and more comfortable for the subject) alternative to the traditional stereophotogrammetric system. Then, the abovementioned technique has been improved so that the measurement of knee flexion/extension could be done with a 2D markerless technique. The main changes on the implementation were on occlusion handling and background segmentation. With the additional constraints, the proposed technique was applied to the estimation of knee flexion/extension and compared with a traditional stereophotogrammetric system. Results showed that the knee flexion/extension estimation from traditional stereophotogrammetric system and the proposed markerless system were highly comparable, making the latter a potential alternative for clinical use. A contribution has also been given in the estimation of lower limb kinematics of the children with cerebral palsy (CP). For this purpose, a hybrid technique, which uses high-cut underwear and ankle socks as “segmental markers” in combination with a markerless methodology, was proposed. The proposed hybrid technique is different than the abovementioned markerless technique in terms of the algorithm chosen. Results showed that the proposed hybrid technique can become a simple and low-cost alternative to the traditional stereophotogrammetric systems.

Piattaforma off-shore : progettazione delle procedure di movement e lifting relative al lower level deck section 1 e section 2

Progettazione delle procedure necessarie alla realizzazione di piattaforme off-shore, grandi e complesse strutture intelaiate di pilastri, diagonali, travi primarie e travi secondarie, progettate per insediarsi in ambiente marino ed idonee ad ospitare impianti per l'estrazione di idrocarburi. Durante la fase di progettazione si procede con l'ideare la struttura della piattaforma fino a definire le caratteristiche di ogni componente: tale fase ha come esito la redazione dei project drawings (disegni di progetto). La fase di realizzazione è quella che interessa propriamente il lavoro svolto: a seguito della progettazione infatti emergono nuove problematiche a livello applicativo e costruttivo che necessitano di essere studiate e risolte preventivamente alla costruzione fisica dell'opera. In particolar modo è necessario definire quali parti della struttura possono essere acquistate e quali invece devono essere realizzate su misura. Definite le modalità costruttive, viene effettuato lo studio riguardante la movimentazione dei vari piani della piattaforma, movement, e successivamente le problematiche relative al sollevamento degli stessi, lifting. Le due procedure necessitano di raffinate valutazioni euristiche ed analitiche per garantire che la struttura non collassi.

Evolutionary tendencies in flowers of Marantaceae with special reference to the style movement mechanism

One of the quickest plant movements ever known is made by the ´explosive´ style in Marantaceae in the service of secondary pollen presentation – herewith showing a striking apomorphy to the sister Cannaceae that might be of high evolutionary consequence. Though known already since the beginning of the 19th century the underlying mechanism of the movement has hitherto not been clarified. The present study reports about the biomechanics of the style-staminode complex and the hydraulic principles of the movement. For the first time it is shown by experiment that in Maranta noctiflora through longitudinal growth of the maturing style in the ´straitjacket´ of the hooded staminode both the hold of the style prior to its release and its tensioning for the movement are brought about. The longer the style grows in relation to the enclosing hooded staminode the more does its capacity for curling up for pollen transfer increase. Hereby I distinguish between the ´basic tension´ that a growing style builds up anyway, even when the hooded staminode is removed beforehand, and the ´induced tension´ which comes about only under the pressure of a ´too short´ hooded staminode and which enables the movement. The results of these investigations are discussed in view of previous interpretations ranging from possible biomechanical to electrophysiological mechanisms. To understand furthermore by which means the style gives way to the strong bending movement without suffering outwardly visible damage I examined its anatomical structure in several genera for its mechanical and hydraulic properties and for the determination of the entire curvature after release. The actual bending part contains tubulate cells whose walls are extraordinarily porous and large longitudinal intercellular spaces. SEM indicates the starting points of cell-wall loosening in primary walls and lysis of middle lamellae - probably through an intense pectinase activity in the maturing style. Fluorescence pictures of macerated and living style-tissue confirm cell-wall perforations that do apparently connect neighbouring cells, which leads to an extremely permeable parenchyma. The ´water-body´ can be shifted from central to dorsal cell layers to support the bending. The geometrical form of the curvature is determined by the vascular bundles. I conclude that the style in Marantaceae contains no ´antagonistic´ motile tissues as in Mimosa or Dionaea. Instead, through self-maceration it develops to a ´hydraulic tissue´ which carries out an irreversible movement through a sudden reshaping. To ascertain the evolutionary consequence of this apomorphic pollination mechanism the diversity and systematic value of hooded staminodes are examined. For this hooded staminodes of 24 genera are sorted according to a minimalistic selection of shape characters and eight morphological types are abstracted from the resulting groups. These types are mapped onto an already available maximally parsimonious tree comprising five major clades. An amazing correspondence is found between the morphological types and the clades; several sister-relationships are confirmed and in cases of uncertain position possible evolutionary pathways, such as convergence, dispersal or re-migration, are discussed, as well as the great evolutionary tendencies for the entire family in which – at least as regards the shape of hooded staminodes – there is obviously a tendency from complicated to strongly simplified forms. It suggests itself that such simplifying derivations may very likely have taken place as adaptations to pollinating animals about which at present too little is known. The value of morphological characters in relation to modern phylogenetic analysis is discussed and conditions for the selection of morphological characters valuable for a systematic grouping are proposed. Altogether, in view of the evolutionary success of Marantaceae compared with Cannaceae the movement mechanism of the style-staminode complex can safely be considered a key innovation within the order Zingiberales.

Analysis of the Slow Food movement impact on the farmers and rural areas’ sustainable development

The evaluation of the farmers’ communities’ approach to the Slow Food vision, their perception of the Slow Food role in supporting their activity and their appreciation and expectations from participating in the event of Mother Earth were studied. The Unified Theory of Acceptance and Use of Technology (UTAUT) model was adopted in an agro-food sector context. A survey was conducted, 120 questionnaires from farmers attending the Mother Earth in Turin in 2010 were collected. The descriptive statistical analysis showed that both Slow Food membership and participation to Mother Earth Meeting were much appreciated for the support provided to their business and the contribution to a more sustainable and fair development. A positive social, environmental and psychological impact on farmers also resulted. Results showed also an interesting perspective on the possible universality of the Slow Food and Mother Earth values. Farmers declared that Slow Food is supporting them by preserving the biodiversity and orienting them to the use of local resources and reducing the chemical inputs. Many farmers mentioned the language/culture and administration/bureaucratic issues as an obstacle to be a member in the movement and to participate to the event. Participation to Mother Earth gives an opportunity to exchange information with other farmers’ communities and to participate to seminars and debates, helpful for their business development. The absolute majority of positive answers associated to the farmers’ willingness to relate to Slow Food and participate to the next Mother Earth editions negatively influenced the UTAUT model results. A factor analysis showed that the variables associated to the UTAUT model constructs Performance Expectancy and Effort Expectancy were consistent, able to explain the construct variability, and their measurement reliable. Their inclusion in a simplest Technology Acceptance Model could be considered in future researches.

Movement Analysis by means of inertial sensors: from bench to bedside

in the everyday clinical practice. Having this in mind, the choice of a simple setup would not be enough because, even if the setup is quick and simple, the instrumental assessment would still be in addition to the daily routine. The will to overcome this limit has led to the idea of instrumenting already existing and widely used functional tests. In this way the sensor based assessment becomes an integral part of the clinical assessment. Reliable and validated signal processing methods have been successfully implemented in Personal Health Systems based on smartphone technology. At the end of this research project there is evidence that such solution can really and easily used in clinical practice in both supervised and unsupervised settings. Smartphone based solution, together or in place of dedicated wearable sensing units, can truly become a pervasive and low-cost means for providing suitable testing solutions for quantitative movement analysis with a clear clinical value, ultimately providing enhanced balance and mobility support to an aging population.

"Influence of lower-limb joint models on subject-specific musculoskeletal model predictions during gait" ( "modelli muscoloscheletrici personalizzati dell'arto inferiore: Analisi dell'effetto della modellazione dei giunti sulla predizione dei carichi agenti sul sistema scheletrico durante il cammino").

The aim of the present thesis was to investigate the influence of lower-limb joint models on musculoskeletal model predictions during gait. We started our analysis by using a baseline model, i.e., the state-of-the-art lower-limb model (spherical joint at the hip and hinge joints at the knee and ankle) created from MRI of a healthy subject in the Medical Technology Laboratory of the Rizzoli Orthopaedic Institute. We varied the models of knee and ankle joints, including: knee- and ankle joints with mean instantaneous axis of rotation, universal joint at the ankle, scaled-generic-derived planar knee, subject-specific planar knee model, subject-specific planar ankle model, spherical knee, spherical ankle. The joint model combinations corresponding to 10 musculoskeletal models were implemented into a typical inverse dynamics problem, including inverse kinematics, inverse dynamics, static optimization and joint reaction analysis algorithms solved using the OpenSim software to calculate joint angles, joint moments, muscle forces and activations, joint reaction forces during 5 walking trials. The predicted muscle activations were qualitatively compared to experimental EMG, to evaluate the accuracy of model predictions. Planar joint at the knee, universal joint at the ankle and spherical joints at the knee and at the ankle produced appreciable variations in model predictions during gait trials. The planar knee joint model reduced the discrepancy between the predicted activation of the Rectus Femoris and the EMG (with respect to the baseline model), and the reduced peak knee reaction force was considered more accurate. The use of the universal joint, with the introduction of the subtalar joint, worsened the muscle activation agreement with the EMG, and increased ankle and knee reaction forces were predicted. The spherical joints, in particular at the knee, worsened the muscle activation agreement with the EMG. A substantial increase of joint reaction forces at all joints was predicted despite of the good agreement in joint kinematics with those of the baseline model. The introduction of the universal joint had a negative effect on the model predictions. The cause of this discrepancy is likely to be found in the definition of the subtalar joint and thus, in the particular subject’s anthropometry, used to create the model and define the joint pose. We concluded that the implementation of complex joint models do not have marked effects on the joint reaction forces during gait. Computed results were similar in magnitude and in pattern to those reported in literature. Nonetheless, the introduction of planar joint model at the knee had positive effect upon the predictions, while the use of spherical joint at the knee and/or at the ankle is absolutely unadvisable, because it predicted unrealistic joint reaction forces.

Tra pacifismo e ambientalismo: il Nuclear Freeze Movement e la risposta dell'amministrazione Reagan

Negli anni Ottanta si assiste tanto nel vecchio quanto nel nuovo continente alla rinascita del movimento antinucleare. Mentre in Europa l’origine di questa ondata di proteste antinucleari è collegata alla “doppia decisione” NATO del 1979, negli Stati Uniti la genesi si colloca nel contesto dalla mobilitazione dei gruppi ambientalisti in seguito all’incidente alla centrale nucleare di Three Mile Island. Dopo l’elezione di Ronald Reagan, alle proteste contro le applicazioni pacifiche dell’atomo si affiancarono quelle contro la politica nucleare del Paese. La retorica di Reagan, il massiccio piano di riarmo, unitamente al rinnovato deteriorarsi delle relazioni tra USA e URSS contribuirono a diffondere nell’opinione pubblica la sensazione che l’amministrazione Reagan, almeno da un punto di vista teorico, non avesse escluso dalle sue opzioni il ricorso alle armi nucleari nel caso di un confronto con l’URSS. I timori legati a questa percezione produssero una nuova ondata di proteste che assunsero dimensioni di massa grazie alla mobilitazione provocata dalla Nuclear Weapons Freeze Campaign (NWFC). Il target della NWFC era l’ampio programma di riarmo nucleare sostenuto da Reagan, che secondo gli attivisti nucleari, in un quadro di crescenti tensioni internazionali, avrebbe fatto aumentare le possibilità di uno scontro atomico. Per evitare lo scenario dell’olocausto nucleare, la NWFC proponeva «un congelamento bilaterale e verificabile del collaudo, dell’installazione e della produzione di armi nucleari». L’idea del nuclear freeze, che era concepito come un passo per fermare la spirale del riarmo e tentare successivamente di negoziare riduzioni negli arsenali delle due superpotenze, riscosse un tale consenso nell’opinione pubblica americana da indurre l’amministrazione Reagan a formulare una risposta specifica. Durante la primavera del 1982 fu, infatti, creato un gruppo interdipartimentale ad hoc, l’Arms Control Information Policy Group, con il compito di arginare l’influenza della NWFC sull’opinione pubblica americana e formulare una risposta coerente alle critiche del movimento antinucleare.

The reconstruction of skeletal movement: the soft tissue artefact issue

In 3D human movement analysis performed using stereophotogrammetric systems and skin markers, bone pose can only be estimated in an indirect fashion. During a movement, soft tissue deformations make the markers move with respect to the underlying bone generating soft tissue artefact (STA). STA has devastating effects on bone pose estimation and its compensation remains an open question. The aim of this PhD thesis was to contribute to the solution of this crucial issue. Modelling STA using measurable trial-specific variables is a fundamental prerequisite for its removal from marker trajectories. Two STA model architectures are proposed. Initially, a thigh marker-level artefact model is presented. STA was modelled as a linear combination of joint angles involved in the movement. This model was calibrated using ex-vivo and in-vivo STA invasive measures. The considerable number of model parameters led to defining STA approximations. Three definitions were proposed to represent STA as a series of modes: individual marker displacements, marker-cluster geometrical transformations (MCGT), and skin envelope shape variations. Modes were selected using two criteria: one based on modal energy and another on the selection of modes chosen a priori. The MCGT allows to select either rigid or non-rigid STA components. It was also empirically demonstrated that only the rigid component affects joint kinematics, regardless of the non-rigid amplitude. Therefore, a model of thigh and shank STA rigid component at cluster-level was then defined. An acceptable trade-off between STA compensation effectiveness and number of parameters can be obtained, improving joint kinematics accuracy. The obtained results lead to two main potential applications: the proposed models can generate realistic STAs for simulation purposes to compare different skeletal kinematics estimators; and, more importantly, focusing only on the STA rigid component, the model attains a satisfactory STA reconstruction with less parameters, facilitating its incorporation in an pose estimator.

Stratospheric aerosol extinction retrieved from SCIAMACHY measurements in limb geometry

Stratosphärische Partikel sind typischerweise mit dem bloßen Auge nicht wahrnehmbar. Dennoch haben sie einen signifikanten Einfluss auf die Strahlungsbilanz der Erde und die heteorogene Chemie in der Stratosphäre. Kontinuierliche, vertikal aufgelöste, globale Datensätze sind daher essenziell für das Verständnis physikalischer und chemischer Prozesse in diesem Teil der Atmosphäre. Beginnend mit den Messungen des zweiten Stratospheric Aerosol Measurement (SAM II) Instruments im Jahre 1978 existiert eine kontinuierliche Zeitreihe für stratosphärische Aerosol-Extinktionsprofile, welche von Messinstrumenten wie dem zweiten Stratospheric Aerosol and Gas Experiment (SAGE II), dem SCIAMACHY, dem OSIRIS und dem OMPS bis heute fortgeführt wird. rnrnIn dieser Arbeit wird ein neu entwickelter Algorithmus vorgestellt, der das sogenannte ,,Zwiebel-Schäl Prinzip'' verwendet, um Extinktionsprofile zwischen 12 und 33 km zu berechnen. Dafür wird der Algorithmus auf Radianzprofile einzelner Wellenlängen angewandt, die von SCIAMACHY in der Limb-Geometrie gemessen wurden. SCIAMACHY's einzigartige Methode abwechselnder Limb- und Nadir-Messungen bietet den Vorteil, hochaufgelöste vertikale und horizontale Messungen mit zeitlicher und räumlicher Koinzidenz durchführen zu können. Die dadurch erlangten Zusatzinformationen können verwendet werden, um die Effekte von horizontalen Gradienten entlang der Sichtlinie des Messinstruments zu korrigieren, welche vor allem kurz nach Vulkanausbrüchen und für polare Stratosphärenwolken beobachtet werden. Wenn diese Gradienten für die Berechnung von Extinktionsprofilen nicht beachtet werden, so kann dies dazu führen, dass sowohl die optischen Dicke als auch die Höhe von Vulkanfahnen oder polarer Stratosphärenwolken unterschätzt werden. In dieser Arbeit wird ein Verfahren vorgestellt, welches mit Hilfe von dreidimensionalen Strahlungstransportsimulationen und horizontal aufgelösten Datensätzen die berechneten Extinktionsprofile korrigiert.rnrnVergleichsstudien mit den Ergebnissen von Satelliten- (SAGE II) und Ballonmessungen zeigen, dass Extinktionsprofile von stratosphärischen Partikeln mit Hilfe des neu entwickelten Algorithmus berechnet werden können und gut mit bestehenden Datensätzen übereinstimmen. Untersuchungen des Nabro Vulkanausbruchs 2011 und des Auftretens von polaren Stratosphärenwolken in der südlichen Hemisphäre zeigen, dass das Korrekturverfahren für horizontale Gradienten die berechneten Extinktionsprofile deutlich verbessert.

Impact of long-term corticosteroid therapy on the distribution pattern of lower limb atherosclerosis

OBJECTIVE: Ectopic calcification and mediacalcinosis can be promoted by corticosteroid use. Aim of the present investigation is to describe macrovascular disease features in patients with long-term corticosteroid therapy and symptomatic lower limb peripheral arterial occlusive disease (PAD). METHODS: A consecutive series of 2783 patients undergoing clinical and angiographic work-up of PAD were screened for long-term (>5 years) corticosteroid use (group A). Comparison was performed to a randomly selected age-, sex- and risk factor-matched PAD control cohort from the same series without corticosteroid use (group B). Patients with diabetes mellitus or severe renal failure were excluded. Arterial calcification was evaluated by qualitative assessment on radiographic images. Severity of atherosclerotic lesions was analysed from angiographic images using a semi-quantitative score (Bollinger score). RESULTS: In general, 12 patients (5 males, mean age 78.5 +/- 9.0 years) with 15 ischaemic limbs qualified to be enrolled in group A and were compared to 23 matching control patients (6 2 males, mean age 79.5 +/- 6 years) with 32 ischaemic limbs. Incompressibility of ankle arteries determined by measurement of the ankle-brachial index was seen in 12 limbs (80%) in group A compared to 3 limbs (9%) in group B (p = 0.0009). No significant difference was found comparing group A and B for segmental calcification, whereas comparison of the atherosclerotic burden using the angiographic severity score showed a significantly higher score at the infragenicular arterial level in group A (p = 0.001). CONCLUSION: Findings suggest that the long-term corticosteroid therapy is associated with a distally accentuated, calcifying peripheral atherosclerosis inducing arterial incompressibility. This occlusion pattern is comparable to patients with renal failure or diabetes. Further research is required to support our observations.

Renal insufficiency is independently associated with a distal distribution pattern of symptomatic lower-limb atherosclerosis

Objectives The purpose of this study was to assess the impact of renal insufficiency (RI) on the distribution pattern of peripheral arterial disease (PAD). We hypothesised that RI is associated with a distally accentuated involvement of the peripheral arterial tree. Design This is a retrospective analysis. Materials and Methods Analysis was based on a consecutive series of 2709 patients with chronic PAD of atherosclerotic origin undergoing primary endovascular treatment of lower-extremity arteries. Atherosclerotic pattern was grouped into femoropopliteal (n = 2085) and infragenicular (n = 892) disease according to target lesions treated while using iliac disease (n = 1133) as reference. Univariable and multivariable multinomial regression analyses were performed to assess relation with RI. Results are shown as relative risk ratio (RRRs) with 95% confidence intervals (95% CIs). A p < 0.05 was considered statistically significant. RI was defined as glomerular filtration rate (GFR) < 60 ml min−1 1.73 m−2. Results Presence of RI was an independent risk factor for a centrifugal lesion pattern (RRR 1.48, 95% CI: 1.17–1.86, p = 0.001). Moreover, a decrease in GFR by 10 ml min−1 1.73 m−2 was associated with an RRR of 1.08 for below-the-knee arterial disease (95% CI: 1.03–1.13, p = 0.003). Conclusion Presence and severity of RI are independent predictors of a distal obstructive pattern in patients with symptomatic PAD.

Kinematic improvement following Botulinum Toxin-A injection in upper-limb spasticity due to stroke

Background Focal spasticity is a significant motor disorder following stroke, and Botulinum Toxin Type-A (BoNT-A) is a useful treatment for this. The authors evaluated kinematic modifications induced by spasticity, and whether or not there is any improvement following injection of BoNT-A. Methods Eight patients with stroke with upper-limb spasticity, showing a flexor pattern, were evaluated using kinematics before and after focal treatment with BoNT-A. A group of sex- and age-matched normal volunteers acted as a control group. Results Repeated-measures ANOVA showed that patients with stroke performed more slowly than the control group. Following treatment with BoNT-A, there was a significant improvement in kinematics in patients with stroke, while in the control group, performance remained unchanged. Conclusions Focal treatment of spasticity with BoNT-A leads to an adaptive change in the upper limb of patients with spastic stroke.

Eye movement and diffusion tensor imaging analysis of treatment effects in a Niemann-Pick Type C patient

New treatment options for Niemann-Pick Type C (NPC) have recently become available. To assess the efficiency and efficacy of these new treatment markers for disease status and progression are needed. Both the diagnosis and the monitoring of disease progression are challenging and mostly rely on clinical impression and functional testing of horizontal eye movements. Diffusion tensor imaging (DTI) provides information about the microintegrity especially of white matter. We show here in a case report how DTI and measures derived from this imaging method can serve as adjunct quantitative markers for disease management in Niemann-Pick Type C. Two approaches are taken--first, we compare the fractional anisotropy (FA) in the white matter globally between a 29-year-old NPC patient and 18 healthy age-matched controls and show the remarkable difference in FA relatively early in the course of the disease. Second, a voxelwise comparison of FA values reveals where white matter integrity is compromised locally and demonstrate an individualized analysis of FA changes before and after 1year of treatment with Miglustat. This method might be useful in future treatment trials for NPC to assess treatment effects.

Comprehensive assessment of gesture production: a new test of upper limb apraxia (TULIA)

BACKGROUND: Only few standardized apraxia scales are available and they do not cover all domains and semantic features of gesture production. Therefore, the objective of the present study was to evaluate the reliability and validity of a newly developed test of upper limb apraxia (TULIA), which is comprehensive and still short to administer. METHODS: The TULIA consists of 48 items including imitation and pantomime domain of non-symbolic (meaningless), intransitive (communicative) and transitive (tool related) gestures corresponding to 6 subtests. A 6-point scoring method (0-5) was used (score range 0-240). Performance was assessed by blinded raters based on videos in 133 stroke patients, 84 with left hemisphere damage (LHD) and 49 with right hemisphere damage (RHD), as well as 50 healthy subjects (HS). RESULTS: The clinimetric findings demonstrated mostly good to excellent internal consistency, inter- and intra-rater (test-retest) reliability, both at the level of the six subtests and at individual item level. Criterion validity was evaluated by confirming hypotheses based on the literature. Construct validity was demonstrated by a high correlation (r = 0.82) with the De Renzi-test. CONCLUSION: These results show that the TULIA is both a reliable and valid test to systematically assess gesture production. The test can be easily applied and is therefore useful for both research purposes and clinical practice.