Clinical Remote Monitoring of Individuals With Spinal Cord Injury at Risk for Pressure Injury Recurrence Using mHealth: Protocol for a Pilot, Pragmatic, Hybrid Implementation Trial

BACKGROUND

Pressure injuries are one of the most challenging secondary conditions for individuals with spinal cord injuries and related disorders (SCI/D) owing to inherent, lifelong risk factors that include a lack of sensory and motor function below the level of injury and reliance on a wheelchair for daily mobility, resulting in prolonged periods of sitting. Although many factors contribute to the development of pressure injuries, the pressure between the skin and a surface is always a factor and the development of injury is dependent on the magnitude and duration of the pressure. Clinically, broad recommendations for relieving pressure are used because we know very little about the unique day-to-day life patterns of the individual wheelchair user. Typically, it is after the occurrence of a pressure injury that the therapist will check equipment fit and the effectiveness of pressure offloading and ask about other surfaces they sit on in their home and community. This time-lapsed, largely self-reported data are fraught with recall bias and inaccuracies that the therapist incorporates into a plan of care.

OBJECTIVE

This study's objective is to pilot-test the implementation and clinical effectiveness of a telehealth model of care combined with our mobile health (mHealth) Assisted Weight-Shift device for remote monitoring of factors related to maintaining skin health and wheelchair setup. Our overall hypothesis is that this study will result in an effective implementation plan, and the enhanced connected model of care using remote monitoring of pressure management will result in pilot-level, improved clinical outcomes for adults with spinal cord injury at high risk for pressure injury recurrence.

METHODS

For all aims, we will use a mixed methods design using an exploratory, sequential approach to include the strengths of both qualitative and quantitative data. For aims 1 and 2, we will iteratively collect qualitative data from therapists, patients with SCI/D, and other stakeholders. For aim 3, we will perform a hybrid effectiveness-implementation randomized controlled trial to pilot-test the intervention. The projected results include an iteratively developed and tested implementation plan that meets moderate to high levels of acceptability, feasibility, and appropriateness. Additionally, the pilot trial results are expected to show positive trends in relevant clinical outcomes related to reduced pressure injury incidence, recurrence, and improved healing when compared with the standard of care.

RESULTS

Currently, 6 participants have been recruited for our aim-1 qualitative study.

CONCLUSIONS

This study will expand upon our previous study to move the Assisted Weight-Shift system into routine clinical care, which was a strong desire of adults with SCI/D for improved individualized care plans to prevent pressure injuries. The results of this study will guide the next steps in a full, hybrid effectiveness-implementation trial with the goal of improving care to prevent pressure injuries.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51849.

Long-term effects of premenopausal bilateral oophorectomy with or without hysterectomy on physical aging and chronic medical conditions

OBJECTIVE

We examined the long-term effects of premenopausal bilateral oophorectomy (PBO) with or without concurrent or preceding hysterectomy on physical and cognitive function and on odds of chronic conditions.

METHODS

We enrolled 274 women with PBO with or without concurrent or preceding hysterectomy and 240 referents aged 55 years and older who were residents of Olmsted County, MN as of the PBO or index date. Chronic conditions were assessed via medical record abstraction. Cognitive diagnoses were based on neurocognitive testing. A physical function assessment included measures of strength and mobility. Multivariable regression models compared characteristics for women with PBO <46 years, PBO 46-49 years, and referent women with adjustments for age and other confounders.

RESULTS

The clinical visits (median age, 67 years) were a median of 22 years after the PBO or index date. Of 274 women with PBO, 161 (59%) were <46 years at PBO and 113 (41%) were 46-49 years. Compared with referents, women with a history of PBO <46 years had increased odds of arthritis (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.06-2.55), asthma (OR, 1.74; 95% CI, 1.03-2.93), obstructive sleep apnea (OR, 2.00; 95% CI, 1.23-3.26), and bone fractures (OR, 2.86; 95% CI, 1.17-6.98), and walked a shorter mean distance on a 6-minute walk test ( b = -18.43; P = 0.034). Compared with referents, women with a history of PBO at age 46-49 years had increased odds of arthritis (OR, 1.92; 95% CI, 1.16-3.18) and obstructive sleep apnea (OR, 2.21; 95% CI, 1.33-3.66). There were no significant differences in cognitive status in women with PBO compared with referents.

CONCLUSIONS

Women with a history of PBO with or without concurrent or preceding hysterectomy, especially at age <46 years, have more chronic conditions in late mid-life compared with referents.

Visualization of user interactions with a pressure mapping mobile application for wheelchair users at risk for pressure injuries

Pressure injuries for individuals with spinal cord injuries (SCI) are correlated with mortality and are a leading cause for rehospitalizations. The Assisted Weight Shift (AW-Shift©) is a mobile pressure mapping application designed to provide users with a live map view and reminders to perform weight shifts. Novel visualization techniques were used to understand daily distributions of user interaction wit h AW-Shift©. The date and time of system interactions were recorded for six participants with SCI over 7 days (five males/one female, five manual users/one power user, 55.3 ± 17.3 years old, 10.6 ± 6.5 years since injury). Circular frequency plots were created to visualize the time and frequency participants brought the app to the foreground of their phone and received alerts and reminders to complete weight shifts. While some participants used the system regularly throughout the day, others primarily used it before 8am; highlighting the system's importance for regular spot checks and morning wheelchair setup. Participant adherence to weight shift reminders was low suggesting the live pressure map may be more useful. Circular frequency plots can be used by clinicians to more easily review large amounts of patient data. Future work will investigate raw pressure mat data and create a closed-loop weight shift detection algorithm.

Estimation of manual wheelchair-based activities in the free-living environment using a neural network model with inertial body-worn sensors

Shoulder pain is common in manual wheelchair (MWC) users. Overuse is thought to be a major cause, but little is known about exposure to activities of daily living (ADLs). The study goal was to develop a method to estimate three conditions in the field: (1) non-propulsion activity, (2) MWC propulsion, and (3) static time using an inertial measurement unit (IMU). Upper arm IMU data were collected as ten MWC users performed lab-based MWC-related ADLs. A neural network model was developed to classify data as non-propulsion activity, propulsion, or static, and validated for the lab-based data collection by video comparison. Six of the participants' free-living IMU data were collected and the lab-based model was applied to estimate daily non-propulsion activity, propulsion, and static time. The neural network model yielded lab-based validity measures ≥0.87 for differentiating non-propulsion activity, propulsion, and static time. A quasi-validation of one participant's field-based data yielded validity measures ≥0.66 for identifying propulsion. Participants' estimated mean daily non-propulsion activity, propulsion, and static time ranged from 158 to 409, 13 to 25, and 367 to 609 min, respectively. The preliminary results suggest the model may be able to accurately identify MWC users' field-based activities. The inclusion of field-based IMU data in the model could further improve field-based classification.

Trends and advancements in shoulder biomechanics research

The 12th International Shoulder Group (ISG) Conference was held at Mayo Clinic in Rochester, Minnesota, USA, from August 12-13, 2018, and was hosted by Dr. Melissa (Missy) Morrow of Mayo Clinic and Dr. Meghan Vidt of Pennsylvania State University. This conference was held as a satellite conference to the annual 2018 American Society of Biomechanics Conference. This Editorial accompanies the Special Issue of the Journal of Electromyography and Kinesiology, and contains a selection of the work presented during the 12th Meeting of the ISG. Fourteen full-length articles describe advancements in shoulder research relevant to both basic science and clinical outlets. The work presented herein spans the research areas of methodology, mechanistic understanding, and clinical management. These areas are synergistic and equally important to propel the field forward and enhance impact. These manuscripts reinforce the dedication of the ISG and its members and showcase the ongoing drive toward translational application of these concepts across the common themes of rotator cuff, muscle, wheelchair & ergonomics, and methods & modeling. Highlights of each of the special issue publications are described within the context of the current trends in shoulder research and areas for further advancement.

Intraoperative posture and workload assessment in vascular surgery

Quantifying the workload and postural demand on vascular surgeons provides valuable information on the physical and cognitive factors that predispose vascular surgeons to musculoskeletal pain and disorders. The aim of this study was to quantify the postural demand, workload, and discomfort experienced by vascular surgeons and to identify procedural factors that influence surgical workload. Both objective (wearable posture sensors) and subjective (surveys) assessment tools were used to evaluate intraoperative workload during 47 vascular surgery procedures. Results demonstrate unfavorable neck and low back postures as well as high pain scores for those body segments. Additionally, workload from subjective surveys increased significantly as a function of operative duration, and mental workload was high across all procedure types. Neck postural risk exposure and physical demand were among the variables that increased with surgical duration, procedure type, and loupes used by the surgeons. Correlations among postural angles and pain scores showed consistency between the objective assessment and the subjective surveys for neck and trunk. The authors believe that the results of this study highlight the need for developing mitigating measures such as ergonomic interventions for vascular surgery.

Duration of Static and Dynamic Periods of the Upper Arm During Daily Life of Manual Wheelchair Users and Matched Able-Bodied Participants: A Preliminary Report

Background: Manual wheelchair (MWC) users with spinal cord injuries (SCI) are at a significantly higher risk of experiencing rotator cuff pathology than able-bodied individuals. A deeper understanding of where the arm is used dynamically within the humeral workspace during daily life may help explain why MWC users have higher shoulder pathology rates than able-bodied individuals. The purpose of this study was to report the daily percentage and consecutive durations MWC users and matched able-bodied individuals (controls) spent static and dynamic across the humeral elevation workspace. Methods: MWC users with SCI and controls wore three inertial measurement units on their bilateral arms and torso for 1 or 2 days. The percentages of time and average consecutive duration individuals were static or dynamic while in five humeral elevation ranges (0-30°, 30-60°, 60-90°, 90-120°, and >120°) were calculated and compared between cohorts. Results: Forty-four MWC users (10 females, age: 42.8 ± 12.0, time since injury: 12.3 ± 11.5) and 44 age- and sex-matched controls were enrolled. The MWC cohort spent significantly more time dynamic in 60-90° (p = 0.039) and 90-120° (p = 0.029) and had longer consecutive dynamic periods in 30-60° (p = 0.001), 60-90° (p = 0.027), and 90-120° (p = 0.043) on the dominant arm. The controls spent significantly more time dynamic in 0-30° of humeral elevation (p < 0.001) on both arms. Although the average consecutive static durations were comparable between cohorts across all humeral elevation ranges, the MWC cohort spent a significantly higher percentage of their day static in 30-60° of humeral elevation than controls (dominant: p = 0.001, non-dominant: p = 0.01). The MWC cohort had a moderate association of increased age with decreased time dynamic in 30-60° for both arms. Discussion: Remote data capture of arm use during daily life can aid in understanding how arm function relates to shoulder pathology that follows SCI and subsequent MWC use. MWC users spent more time dynamic in higher elevations than controls, and with age, dynamic arm use decreased in the 30-60° humeral elevation range. These results may exemplify effects of performing activities from a seated position and of age on mobility.

Application and Reliability of Accelerometer-Based Arm Use Intensities in the Free-Living Environment for Manual Wheelchair Users and Able-Bodied Individuals

Arm use in manual wheelchair (MWC) users is characterized by a combination of overuse and a sedentary lifestyle. This study aimed to describe the percentage of daily time MWC users and able-bodied individuals spend in each arm use intensity level utilizing accelerometers. Arm use intensity levels of the upper arms were defined as stationary, low, mid, and high from the signal magnitude area (SMA) of the segment accelerations based on in-lab MWC activities performed by eight MWC users. Accelerometry data were collected in the free-living environments from forty MWC users and 40 sex- and age-matched able-bodied individuals. The SMA intensity levels were applied to the free-living data and the percentage of time spent in each level was calculated. The SMA intensity levels were defined as, stationary: ≤0.67 g, low: 0.671-3.27 g, mid: 3.27-5.87 g, and high: >5.871 g. The dominant arm of both MWC users and able-bodied individuals was stationary for most of the day and less than one percent of the day was spent in high intensity arm activities. Increased MWC user age correlated with increased stationary arm time (R = 0.368, p = 0.019). Five and eight days of data are needed from MWC users and able-bodied individuals, respectively, to achieve reliable representation of their daily arm use intensities.

Accelerometry evaluation of shoulder movement and its association with patient-reported and clinical outcomes following reverse total shoulder arthroplasty

BACKGROUND

Accelerometers provide a new method to objectively measure recovery of movement and physical activity in patients following reverse total shoulder arthroplasty (RTSA) and may overcome common limitations associated with patient-reported outcome measures (PROMs). The aim of this study was to assess changes in upper limb movement using accelerometers following RTSA and investigate their association with other clinical outcome measures.

METHODS

Thirty-six patients who underwent RTSA wore accelerometers on both wrists and arms for 3 days at 3, 6, and 12 months postsurgery. PROMs (Constant score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, visual analog scale for pain, Single Assessment Numerical Evaluation, Shoulder Activity Level) and isometric shoulder strength were also assessed. Accelerometer outcomes were calculated to quantify counts of forearm and arm activity and the contribution of both arms to activity (limb symmetry and magnitude ratio). Changes and differences in all clinical measures and objective movement measures were evaluated with within-subjects analysis of variance. Correlations between limb activity and other clinical measures were investigated using Spearman correlation coefficients.

RESULTS

Objective movement of the operated arm increased from 3-6 months postsurgery (P = .004), but not from 6-12 months (P = .240). Limb asymmetries were observed at 3 and 6 months and improved by 12 months postsurgery. No associations were demonstrated between PROMs and objective upper limb movement at 12 months postsurgery.

DISCUSSION

Despite early recovery of function and pain relief assessed by PROMs, objective movement using accelerometers showed delayed recovery of the operated arm postoperatively, before normalizing by 12 months postsurgery. Accelerometers provide a unique insight into functional recovery following RTSA.

Intraoperative musculoskeletal discomfort and risk for surgeons during open and laparoscopic surgery

BACKGROUND

Surgeon workload is significant both mentally and physically and may differ by procedure type. When comparing laparoscopic surgery and open surgery, studies have reported contrasting results on the physical and mental workload assessed.

METHODS

Wearable posture sensors and pre-/post-surgical questionnaires were employed to assess intraoperative workload and to identify risk factors for surgeons using objective and subjective measures.

RESULTS

Data from 49 cases (27 open and 22 laparoscopic surgeries performed by 13 male and 11 female surgeons) were assessed. More than half the surgeons reported a clinically relevant post-surgical fatigue score. The surgeons also self-reported a significant increase in pain for the neck, upper back, and lower back during/after surgery. Procedural time had significant impacts on fatigue, body part pain, and subjective (NASA-TLX) workload. The objectively assessed intraoperative work postures using wearable sensors showed a high musculoskeletal risk for neck and lower back based on their posture overall. Open surgeries had significantly larger neck angles (median [IQR]: 40 [28-47]°) compared with laparoscopic surgeries (median [IQR]: 23 [16-29]°), p < 0.001) and torso (median [IQR]: 17 [14-22]° vs. 13 [10-17]°, p = 0.006).

CONCLUSION

Surgeons reported significantly higher levels of fatigue and pain in the neck and lower back during or after performing a surgical case. Longer procedural time resulted in more self-rated fatigue, pain, and subjective workload. Open surgery had higher postural risk. Overall, surgeons spent a disturbingly high percentage of time during surgery in high-risk musculoskeletal postures, especially the neck. These results show that intraoperative postural risk is very high and that interventions are necessary to protect surgeon musculoskeletal health for optimal surgeon performance and career longevity.

Ergonomic Robotic Console Configuration in Gynecologic Surgery: An Interventional Study

STUDY OBJECTIVE

The objectives of this study were to (1) pilot a robotic console configuration methodology to optimize ergonomic posture, and (2) determine the effect of this intervention on surgeon posture and musculoskeletal discomfort.

DESIGN

This was an institutional review board-approved prospective cohort study conducted from February 2017 to October 2017.

SETTING

A single tertiary care midwestern academic medical center.

PARTICIPANTS

Six fellowship-trained gynecologic surgeons, proficient in robotic hysterectomy, were recruited: 3 men and 3 women.

INTERVENTIONS

Each surgeon performed 3 robotic hysterectomies using their self-selected robotic console settings (preintervention). Then, a robotic console ergonomic intervention protocol was implemented by trained ergonomists to improve posture and decrease time in poor ergonomic positions. Each surgeon then performed 3 robotic hysterectomies using the ergonomic intervention settings (postintervention). All surgeries used the da Vinci Xi surgical system (Intuitive Surgical, Inc., Sunnyvale, CA) and were the first case of the day. The surgeons wore inertial measurement unit (IMU) sensors on their head, chest, and bilateral upper arms during surgery. The IMU sensors are equipped with accelerometers, gyroscopes, and magnetometers to give objective measurements of body posture. IMU data were then analyzed to determine the percentage of time spent in ergonomically risky postures as categorized using a modified rapid upper limb assessment. Before and after each hysterectomy, the surgeons completed identical questionnaires for an assessment of musculoskeletal pain/discomfort. The outcome measurements were compared pre- versus postintervention on the basis of fitting generalized linear mixed models that handled the individual surgeon as a random effect and "setting" as a fixed effect.

MEASUREMENTS AND MAIN RESULTS

With regard to the IMU posture results, there was a significant decrease in time spent in the moderate- to high-risk neck position and a decrease in average neck angle after the ergonomic intervention. The average percentage of time spent in moderate- to high-risk categories was significantly lower for the neck (mean, 54.3% vs 21.0%; p = .008) and right upper arm (mean, 15.5% vs 0.9%; p = .02) when using the intervention settings compared with the surgeons' settings. Pain score results: There were fewer reported increases in neck (4 [22%] vs 1 [6%]) and right shoulder (4 [22%] vs 2 [11%]) pain or discomfort after completion of robotic hysterectomy postintervention versus preintervention; however, these differences did not attain statistical significance (p = .12 and p = .37, respectively).

CONCLUSION

An ergonomic robotic console intervention demonstrated effectiveness and improved objective surgeon posture at the console when compared with the surgeons' self-selected settings.

Differences in Physical Activity and Sedentary Behavior Patterns of Postmenopausal Women With Normal vs. Low Total Hip Bone Mineral Density

Purpose: Recent evidence suggests that sedentary behavior (SB) may be associated with bone health. This study compares free-living physical activity (PA) and SB distribution patterns of postmenopausal women with normal vs. low total hip bone mineral density (BMD).

Methods: Sixty nine post-menopausal women [mean (min-max) age: 61 (46–79) years] wore ActiGraph GT3X+ activity monitors on the bilateral ankles for 7 days in free-living. Participants were split into two groups: those with normal hip BMD (T-scores ≥-1.0; N = 34) and those with low hip BMD (T-scores <-1.0; N = 35) as defined by the World Health Organization. Daily active time, step counts, sedentary time, sedentary break number, and median sedentary bout length were estimated from ankle acceleration data. The distribution and accumulation patterns of time spent in sedentary bouts, sedentary breaks, and stepping bouts, and sedentary break and stepping bout lengths' variability were also investigated. Group differences were assessed using two-sampled t-tests and Mann-Whitney U-tests with significance levels of 0.5.

Results: Significant between group differences (p < 0.05) were in total daily active time [median (IQR): 257 (209–326) vs. 249 (199–299) min], step count [14,188 (10,938–18,646) vs. 13,204 (10,337–16,630) steps], sedentary time [669 (584–731) vs. 687 (615–753) min], and sedentary break number [93 (68–129) breaks vs. 88 (64–113) breaks], as well as median sedentary bout length [15.1 (11.9–22.1) vs. 15.8 (12.1–24.9) min]. Participants' sedentary bouts were found to be power law distributed with 52% of sedentary time occurring in bouts ≥20 min for the normal BMD group, and 58% for the low BMD group. Significant differences were observed between groups in sedentary bouts' and sedentary breaks' power distribution exponents (p < 0.0001) and patterns of sedentary and stepping time accumulation using the Gini index (p ≤ 0.0014). Variability was significantly lower for sedentary break and stepping bout lengths for the low BMD group (p ≤ 0.0001). Participants with lower hip BMD have longer sedentary bouts with shorter and less complex activity bouts compared to participants with normal hip BMD.

Conclusion: The results suggest healthier hip BMD may be associated with PA distributed more evenly throughout the day with shorter sedentary bouts. PA distribution should be considered in exercise-based bone health management programs.

Incorporating Sex as a Biological Variable into Clinical and Translational Research Training

Incorporating sex as a biological variable (SABV) into basic and medical research requires a deliberate plan that weaves concepts of basic genetics, cellular and molecular physiology, and pharmacology into translational medicine. An R4 approach (Right content to the Right learner at the Right time with the Right modality) allows for content to be available in a variety of formats that reinforces the concepts at staged levels of integration. Weaving SABV throughout the varied formats of the R4 approach within the Clinical and Translational Research Training Programs, into the mentoring and training of scholars in NIH Building Interdisciplinary Careers in Women's Health (BIRCWH), and into the Career Enhancement Core of the Specialized Centers of Research Excellence (SCORE) on sex differences through curriculum, case-based approach and journal clubs, and workshops ensures that learners grasp its fundamental relevancy to their own research and beyond. In addition, the collaborative work among the BIRCWH and SCORE programs brings collective expertise from centers around the United States to individual programs through development of best practices and materials. These collective efforts assure that the next generation of basic, clinical, and translational scientists will bring the dimension of SABV into their research and clinical practice.

Impact of Procedure Type, Case Duration, and Adjunctive Equipment on Surgeon Intraoperative Musculoskeletal Discomfort

BACKGROUND

Surgeons are at high risk of developing musculoskeletal disorders.

STUDY DESIGN

This study was designed to identify risk factors and assess intraoperative physical stressors using subjective and objective measures, including type of procedure and equipment used. Wearable sensors and pre- and postoperation surveys were analyzed.

RESULTS

Data from 116 cases (34 male and 19 female surgeons) were collected across surgical specialties. Surgeons reported increased pain in the neck, upper, and lower back both during and after operations. High-stress intraoperative postures were also revealed by the real-time measurement in the neck and back. Surgical duration also impacted physical pain and fatigue. Open procedures had more stressful physical postures than laparoscopic procedures. Loupe usage negatively impacted neck postures.

CONCLUSIONS

This study highlights the fact that musculoskeletal disorders are common in surgeons and characterizes surgeons' intraoperative posture as well as surgeon pain and fatigue across specialties. Defining intraoperative ergonomic risk factors is of paramount importance to protect the well-being of the surgical workforce.

Current Evidence Lacking to Guide Clinical Practice for Spinal Cord Stimulation in the Treatment of Neuropathic Pain in Spinal Cord Injury: A Review of the Literature and a Proposal for Future Study

BACKGROUND/OBJECTIVE

Chronic pain is commonly reported in individuals with spinal cord injuries (SCIs), with recent prevalence reported as high as 80%. Uncontrolled pain is known to decrease quality of life, attenuate mood, and impact sleep. Spinal cord stimulation (SCS) for the treatment of refractory pain was first used in the SCI population in 1972. To date there have been no randomized controlled trials examining the effect of SCS on neuropathic pain post-SCI. A literature review in 2009 identified 27 studies, the majority prior to 2000, that included at least 1 patient with SCI. Given the significant advancements in the field of SCS, this review examines the updated evidence of SCS for the treatment of neuropathic pain in individuals with SCI and provides guidance on future investigations.

METHODS

MEDLINE and EMBASE databases were searched. All published reports, case series, and clinical trials reviewing SCS for neuropathic pain that included at least 1 individual with SCI were included.

RESULTS

The initial search identified 376 reports, of which 22 met inclusion criteria, for a total of 69 patients. All reports were of very low quality. A majority of the reported patients were male, underwent tonic stimulation, and reportedly experienced improvement in pain and spasticity, with decreased use of pain medication.

CONCLUSIONS

The synthesized findings from primarily case studies support the safety of SCS in SCI with the suggestion of potential pain relief benefit; however, data from low-quality studies are insufficient for informing clinical practice. A well-designed, prospective clinical trial is proposed to further investigate this indication.

Patient-Reported and Objectively Measured Function Before and After Reverse Shoulder Arthroplasty

BACKGROUND AND PURPOSE

Documenting functional outcomes after reverse shoulder arthroplasty (RSA) is critical to advancing patient care. The interplay been self-reported and objectively measured outcome measures has not been widely described. The utilization of wearable devices to document upper extremity limb activity is a new approach for objectively measuring outcomes. Therefore, the purpose of this study was to evaluate changes in pain, and self-reported function and objectively measured limb activity after RSA. We also assessed the influence of pain on self-reported function and objectively measured limb activity to determine the impact of pain on outcomes after RSA.

MATERIALS

This study implemented a prospective, repeated-measures design. Fourteen patients undergoing RSA underwent testing before surgery, and 2 and 12 months after surgery. Patient-reported instruments included pain, Disabilities of Arm, Shoulder and hands (DASH), and physical component summary (PCS) of the 36-Item Short Form Health Survey. Objective limb activity (mean activity value, m/s/min epoch; inactive time, %; low activity, %; and high activity, %) was captured with triaxial accelerometers worn on the upper and lower arm. A repeated-measures ANOVA tested for differences across time. The Spearman rank-order correlation was calculated to evaluate the influence of pain on DASH, PCS scores, and mean limb activity.

RESULTS

Patient-reported measures improved after surgery (pain, P < .01; DASH, P < .01; PCS, P = .01). No change in limb activity was found at 1 year compared with preoperative values for mean (forearm, P = 1.00; arm, P = .36), inactivity (forearm, P = .33; arm, P = .22), low (forearm, P = .77; arm, P = .11) or high (forearm, P = 1.00; arm, P = .20) activity. There was a relationship between pain and DASH scores 1 year after surgery (P = .04) but not before surgery (P = .16), or 2 months after surgery (P = .30). There was no relationship between pain and PCS scores at any time point (preoperative, P = .97; 2 months, P = .21; 1 year, P = .08) nor pain and limb activity (forearm: preoperative, P = .36; 2 months, P = .67; 1 year, P = .16; arm: preoperative, P = .97; 2 months, P = .59; 1 year, P = .51).

CONCLUSIONS

RSA reduced pain and enhanced patient-perceived function. Objectively measured upper extremity limb activity is not different 1 year after surgery compared with preoperative levels.

LEVEL OF EVIDENCE

III.

Kinematic and ergonomic assessment of laparoendoscopic single-site surgical instruments during simulator training tasks

While laparoendoscopic single-site surgery (LESS) appears to be feasible and safe, instrument triangulation, tissue handling, and other bimanual tasks are difficult even for experienced surgeons. Novel technologies emerged to overcome LESS' procedural and ergonomic difficulties of "tunnel vision" and "instrument clashing." Surgeon kinematics, self-reported workload and upper body discomfort were used to compare straight, bent and two articulating instruments while performing two basic surgical tasks in a LESS simulator. All instruments resulted in bilateral elevation and rotation of the shoulders, excessive forearm motion and flexion and ulnar deviation of wrists. Surgeons' adopted non-neutral upper extremity postures and performed excessive joint excursions to compensate for reduced freedom of movement at the single insertion site and to operate the instrument mechanisms. LESS' cosmetic benefits continue to impact laparoscopic surgery and by enabling performance through improved instruments, ergonomic improvement for LESS can reduce negative impact on surgeon well-being and patient safety.

Technical Note: Development of a combined molecular breast imaging/ultrasound system for diagnostic evaluation of MBI-detected lesions

PURPOSE

The purpose of this study was to perform a pilot evaluation of an integrated molecular breast imaging/ultrasound (MBI/US) system designed to enable, in real-time, the registration of US to MBI and diagnostic evaluation of breast lesions detected on MBI.

METHODS

The MBI/US system was constructed by modifying an existing dual-head cadmium zinc telluride (CZT)-based MBI gamma camera. The upper MBI detector head was replaced with a mesh panel, which allowed an ultrasound probe to access the breast. An optical tracking system was used to monitor the location of the ultrasound transducer, referenced to the MBI detector. The lesion depth at which ultrasound was targeted was estimated from analysis of previously acquired dual-head MBI datasets. A software tool was developed to project the US field of view onto the current MBI image. Correlation of lesion location between both modalities with real-time MBI/US scanning was confirmed in a breast phantom model and assessed in 12 patients with a breast lesion detected on MBI.

RESULTS

Combined MBI/US scanning allowed for registration of lesions detected on US and MBI as validated in phantom experiments. In patient studies, successful registration was achieved in 8 of 12 (67%) patients, with complete registration achieved in seven and partial registration achieved in one patient. In 4 of 12 (37%) patients, lesion registration was not achieved, partially attributed to uncertainty in lesion depth estimates from MBI.

CONCLUSION

The MBI/US system enabled successful registration of US to MBI in over half of patients studied in this pilot evaluation. Future studies are needed to determine if real-time, registered US imaging of MBI-detected lesions may obviate the need to proceed to more expensive procedures such as contrast-enhanced breast MRI for diagnostic workup or biopsy of MBI findings.

Effect of chair types on work-related musculoskeletal discomfort during vaginal surgery

BACKGROUND

Evidence supports that surgeons are at high risk for work-related musculoskeletal disorders.

OBJECTIVE

The objective of the study was to compare the effect of different chairs on work-related musculoskeletal discomfort for surgeons during vaginal operations.

STUDY DESIGN

This crossover study randomly assigned 4 surgeons to 4 chair types using a 4 × 4 Latin square model: a conventional round stool, a round stool with a backrest, a saddle chair with a backrest, and a Capisco chair. Subjective assessments of surgeon discomfort were performed with a validated body discomfort survey, and workload was assessed with the surgical task load index. The objective postural load was quantified with inertial measurement units of the modified rapid upper limb assessment limits. Subjective and objective assessments of chair comfort were performed with an 11 point scale and seat interface pressure-mapped distributions, respectively. The primary outcome was the difference in body discomfort scores between pre- and postsurgery measurements. Secondary outcomes were the differences in chair comfort scores, postural load, and seating interface pressure-mapped distribution. For each outcome, comparisons among the chair types were based on fitting a linear mixed model that handled the surgeon as a random effect and the chair type as a fixed effect.

RESULTS

Data were collected for 48 vaginal procedures performed for pelvic organ prolapse. Mean (SD) duration of surgery was 122.3 (25.1) minutes. Surgeons reported body discomfort during 31 procedures (67.4%). Subjective increase in discomfort from the preoperative state was noted most commonly in the lower back (n = 14, 30.4%), followed by right shoulder (n = 12, 26.1%), upper back (n = 8, 17.4%), hips and buttocks (n = 7, 15.2%), left shoulder (n = 6, 13.0%), right or left thigh (n = 6, 13.0%), and neck (n = 6, 13.0%). Pre- and postsurgery body discomfort scores did not differ with respect to chair type. Chair discomfort scores for the round stool and the saddle chair were significantly higher than the round stool with backrest and the Capisco chair (P < .001). Although the average modified rapid upper limb assessment postural scores showed moderate to high musculoskeletal risk of neck and shoulder discomfort across the 4 surgeons; chair type did not affect postural scores. The saddle chair had significantly reduced dispersion of seated pressure vs the round stool with backrest (P ≤ .001), depicted by the number of cells with pressure values >5 mm Hg. An increased dispersion of pressure across the chair surface was associated with increased comfort (Spearman correlation, 0.40, P = .006).

CONCLUSION

Musculoskeletal strain and associated discomfort for surgeons are very high during vaginal operations. Chair type can affect comfort, and chairs with more uniform distribution and fewer pressure points are more comfortable. However, the chair type used in surgery did not influence the musculoskeletal postural load findings.

Scapulothoracic and Glenohumeral Kinematics During Daily Tasks in Users of Manual Wheelchairs

BACKGROUND

Rates of shoulder pain in individuals who use manual wheelchairs (MWCs) as their primary means of mobility have been reported to be as high as 70% during activities of daily living. Current prevailing thought is that mechanical impingement of the soft tissues that reside within the subacromial space between the humeral head and coracoacromial arch is a major contributor to the shoulder pain in users of MWCs. The subacromial space size is directly related to the kinematics at the shoulder joint. Yet to be answered are questions about which common daily tasks are characterized by the most potentially detrimental kinematics.

OBJECTIVE

The purpose of this analysis was to quantify and compare potentially detrimental kinematics in three common tasks performed by individuals with spinal cord injury and shoulder pain. These data will add to the body of knowledge and test common assumptions about relative risk of tasks.

DESIGN

A cross-sectional study of 15 MWC users with shoulder pain.

METHODS

Electromagnetic surface sensor measures of mean and peak scapulothoracic (ST) internal and downward rotation, anterior tilt, and glenohumeral (GH) internal rotation were compared across propulsion, weight relief, and scapular plane abduction tasks using one-way repeated-measure ANOVA.

RESULTS

Statistical differences were observed between the tasks for all rotations. Mean ST anterior tilt was greater in weight relief and propulsion than during scapular plane abduction (24°, 23°, and 13° of anterior tilt, respectively). Mean GH axial rotation during weight relief was more internally rotated than during propulsion and scapular plane abduction (9°, 26°, and 51° of external rotation, respectively).

LIMITATIONS

Surface-based measures of kinematics are subject to skin motion artifact, especially in translation which was not addressed in this study.

CONCLUSION

Each task presented with specific variables that might contribute to risk of developing shoulder "impingement" and pain. These data may assist therapists in their assessment of movement contributions to shoulder pain in this population, as well as in subsequent treatment planning.

Novel approaches to objectively assess shoulder function

BACKGROUND

The purpose of this study was to evaluate the effectiveness of existing technologies implemented in a novel manner to objectively capture upper extremity function.

MATERIALS AND METHODS

Patients scheduled to undergo reverse shoulder arthroplasty were recruited for the study. Functional limb use was measured with triaxial accelerometers worn in the subjects' natural living environment. Functional reach area was captured by 3-dimensional motion analysis testing as subjects were asked to circumduct their limb, reaching as far as possible in a circular manner. Statistical testing (α ≤ .05) was performed by paired t tests to identify differences between limbs.

RESULTS

There was no difference in functional limb activity between sides for the lower (P = .497) or upper arm (P = .918) for inactivity time. Mean activity was greater for the uninvolved limb compared with the involved limb (lower arm, P = .045; upper arm, P = .005). Low-intensity activity was greater for the involved arm compared with the uninvolved arm (lower arm, P = .007; upper arm, P = .015), whereas high-intensity activity was greater for the uninvolved arm (lower arm, P = .013; upper arm, P = .005). Radius of the functional reach area was greater for the uninvolved limb compared with the involved limb (P = .006).

CONCLUSIONS

Novel methods of capturing function were effective in discerning differences in side-to-side abilities among patients scheduled to undergo reverse shoulder arthroplasty. These testing procedures may be used to capture function across a spectrum of shoulder diseases. These objective data are invaluable in assessing the impact of disease and recovery after intervention and obtaining reimbursement from third-party payers.

A comparison of static and dynamic optimization muscle force predictions during wheelchair propulsion

The primary purpose of this study was to compare static and dynamic optimization muscle force and work predictions during the push phase of wheelchair propulsion. A secondary purpose was to compare the differences in predicted shoulder and elbow kinetics and kinematics and handrim forces. The forward dynamics simulation minimized differences between simulated and experimental data (obtained from 10 manual wheelchair users) and muscle co-contraction. For direct comparison between models, the shoulder and elbow muscle moment arms and net joint moments from the dynamic optimization were used as inputs into the static optimization routine. RMS errors between model predictions were calculated to quantify model agreement. There was a wide range of individual muscle force agreement that spanned from poor (26.4% Fmax error in the middle deltoid) to good (6.4% Fmax error in the anterior deltoid) in the prime movers of the shoulder. The predicted muscle forces from the static optimization were sufficient to create the appropriate motion and joint moments at the shoulder for the push phase of wheelchair propulsion, but showed deviations in the elbow moment, pronation-supination motion and hand rim forces. These results suggest the static approach does not produce results similar enough to be a replacement for forward dynamics simulations, and care should be taken in choosing the appropriate method for a specific task and set of constraints. Dynamic optimization modeling approaches may be required for motions that are greatly influenced by muscle activation dynamics or that require significant co-contraction.

Effectiveness of home exercise on pain, function, and strength of manual wheelchair users with spinal cord injury: a high-dose shoulder program with telerehabilitation

OBJECTIVE

To test the effectiveness of a high-dose home exercise/telerehabilitation program for manual wheelchair users who have a spinal cord injury (SCI) by determining whether the intervention would reduce pain and increase function, as we hypothesized.

DESIGN

A pre-post trial with outcomes measured at 3 time points: baseline, postintervention (12wk), and follow-up (>24 wk).

SETTING

Subjects performed an exercise program at their homes using telerehabilitation for therapist monitoring of technique and exercise advancement. Baseline and postintervention data were collected at a motion analysis laboratory in a tertiary medical center.

PARTICIPANTS

A convenience sample of manual wheelchair users (N=16, 3 women; average age, 41y; average time in a wheelchair, 16y) with shoulder pain (average pain duration, 9y) and mechanical impingement signs on physical examination.

INTERVENTIONS

A 12-week home exercise program of rotator cuff and scapular stabilization exercises was given to each participant. The program included a high dose of 3 sets of 30 repetitions, 3 times weekly, and regular physical therapist supervision via videoconferencing.

MAIN OUTCOME MEASURES

Primary outcomes of pain and function were measured with the Wheelchair User's Shoulder Pain Index (WUSPI), Disabilities of Arm, Shoulder, and Hand (DASH) Index, and Shoulder Rating Questionnaire (SRQ). Secondary outcomes of strength were measured with isometric strength tests of scapulothoracic and glenohumeral muscles, and a static fatigue test of the lower trapezius.

RESULTS

Pain was reduced and function improved after the intervention. There was a significant main effect for pain and function between the 3 time points based on the Friedman signed-ranked test, WUSPI (χ(2)2=5.10, P=.014), DASH Index (χ(2)2=5.41, P=.012), and SRQ (χ(2)2=23.71, P≤.001). Wilcoxon signed-rank tests demonstrated that isometric strength measurements of the serratus anterior and scapular retractors increased after the exercise intervention ([t=2.42, P=.04] and [t=4.67, P=.003], respectively). Muscle impulse produced by the lower trapezius during a fatigue task also improved (t=2.2, P=.02). No differences were measured in isometric strength for the lower trapezius, glenohumeral rotators, and abductors between the baseline and 12-week time points.

CONCLUSIONS

A high-dose scapular stabilizer and rotator cuff strengthening program using telerehabilitation for supervision holds promise for shoulder pain treatment in manual wheelchair users with SCI. Additional work is needed to determine the effectiveness compared with other interventions, as well as the potential for earlier intervention to prevent development of shoulder pain.

Elevated postoperative blood glucose and preoperative hemoglobin A1C are associated with increased wound complications following total joint arthroplasty

BACKGROUND

Diabetes is an established risk factor for complications following total joint arthroplasty. However, the correlation between postoperative blood glucose and preoperative hemoglobin A1C levels with complications following total joint arthroplasty is not well described.

METHODS

All patients undergoing elective primary total joint arthroplasty at our institution from 2004 through 2011 with both postoperative blood glucose and preoperative hemoglobin A1C levels were identified in a retrospective review. From among 1702 patients, those with wound complications within thirty days after the index arthroplasty were identified. A control group matched for exact age, sex, procedure, tourniquet use, surgical approach, and use of antibiotic cement was also created. Thirty patients met the study group inclusion criteria. The mean patient age was seventy-two years (range, fifty-three to eighty-nine years); the majority (53%) of patients were female.

RESULTS

The odds ratio for developing a wound complication was 3.75 (95% confidence interval, 1.25 to 11.22; p = 0.02) in patients with a mean postoperative glucose of >200 mg/dL, 3.0 (95% confidence interval, 0.97 to 9.30; p = 0.08) in patients with a maximum postoperative blood glucose of >260 mg/dL, and 9.0 (95% confidence interval, 1.14 to 71.20; p = 0.03) in patients with a preoperative hemoglobin A1C value of >6.7%.

CONCLUSIONS

Patients with a mean postoperative blood glucose of >200 mg/dL or a preoperative hemoglobin A1C level of >6.7% are at increased risk for wound complications following elective primary total joint arthroplasty. These results show that poor preoperative and postoperative glucose control is independently associated with wound complications.

Biomechanic evaluation of upper-extremity symmetry during manual wheelchair propulsion over varied terrain

OBJECTIVE

To evaluate upper-extremity symmetry during wheelchair propulsion across multiple terrain surfaces.

DESIGN

Case series.

SETTING

A biomechanics laboratory and the general community.

PARTICIPANTS

Manual wheelchair users (N=12).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Symmetry indexes for the propulsion moment, total force, tangential force, fractional effective force, time-to-peak propulsion moment, work, length of push cycle, and power during wheelchair propulsion over outdoor and indoor community conditions, and in laboratory conditions.

RESULTS

Upper-extremity asymmetry was present within each condition. There were no differences in the magnitude of asymmetry when comparing laboratory with indoor community conditions. Outdoor community wheelchair propulsion asymmetry was significantly greater than asymmetry measured during laboratory conditions.

CONCLUSIONS

Investigators should be aware that manual wheelchair propulsion is an asymmetrical act, which may influence interpretation when data is collected from a single limb or averaged for both limbs. The greater asymmetry identified during outdoor versus laboratory conditions emphasizes the need to evaluate wheelchair biomechanics in the user's natural environment.

Direct comparison of the task-dependent discharge of M1 in hand space and muscle space

Since its introduction in the early 1980s, the concept of a "preferred direction" for neuronal discharge has proven to be a powerful means of studying motor areas of the brain. In the current paper, we introduce the concept of a "muscle-space"-preferred direction (PD(M)) that is analogous to the familiar hand-space-preferred direction (PD(H)). PD(M) reflects the similarity between the discharge of a given neuron and the activity of each muscle in much the way that PD(H) reflects the similarity of discharge with motion along each of the three Cartesian coordinate axes. We used PD(M) to analyze the data recorded from neurons in the primary motor cortex (M1) of three different monkeys. The monkeys performed center-out movements within two different cubical workspaces centered either to the left or right of the monkey's shoulder while we simultaneously recorded neuronal discharge, muscle activity, and limb orientation. We calculated preferred directions in both hand space and muscle space, and computed the angles between these vectors under a variety of conditions. PDs for different neurons were broadly distributed throughout both hand space and muscle space, but the muscle-space vectors appeared to form clusters of functionally similar neurons. In general, repeated estimates of PD(M) were more stable over time than were similar estimates of PD(H). Likewise, there was less change in PD(M) than in PD(H) for data recorded from the two different workspaces. However, although a majority of neurons had this muscle-like property, a significant minority was more stable in Cartesian hand space, reflecting a heterogeneity of function within M1.

Prevalence, nature, severity and correlates of postpartum depressive symptoms in Vietnam

OBJECTIVE

To examine depressive symptomatology in women after childbirth in Ho Chi Minh City, Vietnam.

DESIGN

A cross sectional survey.

SETTING

Hung Vuong Obstetrics and Gynaecology Hospital and the Maternal, Child Health and Family Planning Center of Ho Chi Minh City, Vietnam.

POPULATION

Mothers of infants aged +/- six weeks attending well-baby clinics.

METHOD

Participants were recruited consecutively in the postnatal wards and invited to take part in the study at the first clinic visit. Individual structured interviews about health and social circumstances, including the Edinburgh Postnatal Depression Scale (EPDS) were administered during clinic visits. The interview schedule was translated into Vietnamese, back translated for verification and piloted. Interviewers were specifically trained members of staff of the two centres.

MAIN OUTCOME MEASURES

EPDS scores and responses to structured questions about specific and non-specific symptoms.

RESULTS

Of 506 women who participated, 166 (33%) had EPDS scores in the clinical range of > 12 and 99 (19%) acknowledged suicidal ideation. In a forward stepwise logistic regression analysis, 77% of cases with EPDS scores > 12 were correctly classified in a model which included unwelcome pregnancy, lack of a permanent job, < 30 days complete rest after childbirth, an unsettled baby, not being given special foods, avoiding proscribed foods and being unable to confide in their husbands.

CONCLUSION

Depressive symptomatology is more prevalent among parturient women in Ho Chi Minh City, Vietnam than reported rates in developed countries and is at present unrecognised.

Prediction of muscle activity by populations of sequentially recorded primary motor cortex neurons

We have adopted an analysis that produces a post hoc prediction of the time course of electromyogram (EMG) activity from the discharge of ensembles of neurons recorded sequentially from the primary motor cortex (M1) of a monkey. Over several recording sessions, we collected data from 50 M1 neurons and several distal forelimb muscles during a stereotyped precision grip task. Ensemble averages were constructed from 5 to 10 trials for each neuron and EMG signal. We used multiple linear regression on randomly chosen subsets of these neurons to find the best fit between the neuronal and EMG data. The fixed delay between neuronal and EMG signals that yielded the largest coefficient of determination (R(2)) between predicted and actual EMG was 50 ms. R(2) averaged 0.83 for ensembles composed of 15 neurons. If, instead, each neuronal signal was delayed by the time of its peak cross-correlation with the EMG signal, R(2) increased to 0.88. Using all 50 neurons, R(2) under these conditions averaged nearly 0.97. A similar analysis was conducted with signals recorded during both a power grip and a precision grip task. Quality of the fit dropped dramatically when parameters from the precision grip for a given set of neurons were used to fit data recorded during the power grip. However, when a single set of regression parameters was used to fit a combination of the two tasks, the quality of the fits decreased by <10% from that of a single task.

Health technologies for the developing world. Promoting self-reliance through improving local procurement and manufacturing capabilities

To reduce their dependency on donors or the international currency costs of essential health care products, developing countries are building or improving capability for local manufacturing or competitive international procurement. Through long-term strategic planning, public/private partnerships, collaboration with firms in industrialized nations, and farsighted donor policies, the capacity for alternative supply can be increased in stages from importation through local processing and packaging to full production and multiproduct enterprises.

Medicare Physician Payment Reform: implications for nurse practitioners

In January 1992, the federal government implemented a package of physician payment reforms for use in the Medicare program. Among these reforms is a resource-based fee schedule that replaces the customary, prevailing, and reasonable (CPR) method of payment that has been used since Medicare's inception. This article describes the recommendations of the Physician Payment Review Commission, a Congressional advisory group, concerning the implications of the resource-based fee schedule on nurse practitioners and other non-physician practitioners. Absent changes in current law, services provided by nurse practitioners will be paid based on the same formulas that were used under CPR. This author advises that these payment formulas be revised to reflect the differences in resource costs borne by physicians and nonphysicians. Furthermore, revisions to the payment formulas should be made in the near future before the Medicare fee schedule and the rules governing its use are adopted by other public (e.g., Medicaid) and private payers.

Relationship between condom strength and failure during use

The relationship between condom strength and failure during use was examined in six volunteers using artificially deteriorated condoms. Samples of each condom set exposed to ultraviolet light for three to eleven hours were tested for strength by air burst procedures. The remaining condoms were used by volunteers protected from pregnancy by other means. Burst pressure fell to 35% and burst volume to 17% of untreated levels after six hours of ultraviolet exposure. A maximum mean breakage rate during use of 30% was obtained at this time, although individuals experienced breakage rates up to 70% at this stage of deterioration. No failures occurred during use until condoms had deteriorated by more than 25%. Conclusions were: 1) that burst test parameters can effectively and sensitively measure changes in condom strength, 2) that condoms produced to western industrial standards carry a wide margin of strength over and above the minimum required for effective use, 3) that stored condoms should not necessarily be thrown out if they are uniform in strength but fall below original acceptance standards.

Advances in sterilization equipment

From the array of sterilization procedures that are safe, simple and effective, the service provider must select procedures that fit his or her logistical criteria, which include the cost and maintenance of equipment, availability of supplies, and training of the requisite personnel. In this paper, these criteria are discussed for each of the various sterilization procedures. Information about female sterilization equipment for conventional postpartum laparotomy, minilaparotomy, colpotomy, laparoscopy, and culdoscopy is presented, together with facts about the related tubal occlusion techniques. The standard ligation techniques for male sterilization are compared with the newer electrocoagulation and thermocoagulation methods. A variety of methods for both female and male sterilization that are in the research stage are also mentioned. It is concluded that, from a programmatic point of view, vasectomy and postpartum ligation via laparotomy are the optimal sterilization procedures. For women who have not recently been pregnant, minilaparotomy with a standard tubal ligation technique is recommended, except in large teaching hospitals where laparoscopy can be performed efficiently.