ED visits by older adults for ambulatory care-sensitive and supply-sensitive conditions

OBJECTIVES

The aim of this study was to examine the effect of advanced age on ED outcomes, including hospitalization for any reason, ambulatory care-sensitive hospitalizations (ACSHs), and supply-sensitive hospitalizations.

METHODS

A secondary data analysis of the National Hospital Ambulatory Care Survey was conducted. National estimates of patient visits were obtained using available sampling weights from National Hospital Ambulatory Care Survey, and population estimates were calculated using estimates published by the US Census Bureau.

RESULTS

Older adults made 48 million patient visits to ED between 2000 and 2002. Overall, 20.3% was for an ambulatory care-sensitive condition, yielding 5 million ACSH, whereas 62% was for a supply-sensitive condition, yielding 9.5 million supply-sensitive hospitalizations. Residents from nursing homes and patients aged 85 years or older were more likely to be hospitalized for any reason, for ACSH, and for supply-sensitive conditions.

CONCLUSIONS

Further research is needed to understand how comorbidity contributes to increasing ED and hospital use among older adults.

Gait analysis in rehabilitation medicine: a brief report

Gait analysis can be a powerful tool for rehabilitation research and clinical practice. However, there has been little coordinated effort to set goals for the application of gait analysis in rehabilitation. Therefore, a priority setting process was engaged to obtain the opinions of a diverse pool of experts related to human motion analysis. The primary goal of this process was to develop priorities for future research, development, and standardization in gait analysis. A multistep approach was used that included expert testimony, group discussions, individually developed priorities, and a ranking process. Several important priorities emerged from this activity. The highest priority was assigned to research on the efficacy, outcomes, and cost-effectiveness of gait analysis.

The anthroform biorobotic arm: a system for the study of spinal circuits

This paper reports the design, construction, and testing of a replica of the human arm, which aims to be dynamically as well as kinematically accurate. The arm model is actuated with McKibben pneumatic artificial muscles, and controlled by a special purpose digital signal processing system designed to simulate spinal neural networks in real time. An artificial muscle spindle has also been designed and tested. Design and test data are reviewed, and the paper describes how we hope to use the system to improve our understanding of the reflexive control of human movement and posture.

An improved muscle-reflex actuator for use in large-scale neuro-musculoskeletal models

This paper extends the systematic approach described in Winters and Stark (62) for developing muscle models. The underlying motivation is our finding that for larger scale shoulder and head-neck postural systems to be mechanically stable, open-loop muscle properties are often not sufficient. There are three primary contributions. First, the previous muscle mechanical model structure and parameter estimation process of (62) is updated to reflect recent experimental findings. Second, an intrafusal (IF) muscle model is developed that includes a gamma static motoneuron (MN) drive, a Hill muscle model, and a muscle spindle sensor across the IF series element; this provides a more appropriate muscle spindle output signal, especially for studies of posture. Third, the conceptual cut between the neuro-control input and the actuator is raised from just below the MN summing junction to a higher location, allowing a "muscle-reflex actuator" to be defined that satisfies the formal theoretical requirement for possessing passive spring-like behavior when the neurocontrol input is constant, alpha-gamma MN coactivation is assumed, and three types of intrinsic autogenic reflex responses (spindle, Golgi tendon organ, Rhenshaw cell) are developed. Default feedback gains are set based on the criteria that inherent feedback should not sculpt the feedforward excitation drive by more than +/- 10% of maximum. This new actuator model only mildly affects voluntary goal-directed dynamic performance, but enhances spring-like performance around the postural equilibrium state, in line with available animal and human studies and with several theories on postural regulation.

Rehabilitation engineering training for the future: influence of trends in academics, technology, and health reform

A perspective is offered on rehabilitation engineering educational strategies, with a focus on the bachelor's and master's levels. Ongoing changes in engineering education are summarized, especially as related to the integration of design and computers throughout the curriculum; most positively affect rehabilitation engineering training. The challenge of identifying long-term "niches" for rehabilitation engineers within a changing rehabilitation service delivery process is addressed. Five key training components are identified and developed: core science and engineering knowledge, synthesized open-ended problem-solving skill development, hands-on design experience, rehabilitation breadth exposure, and a clinical internship. Two unique abilities are identified that help demarcate the engineer from other providers: open-ended problem-solving skills that include quantitative analysis when appropriate, and objective quantitative evaluation of human performance. Educational strategies for developing these abilities are addressed. Finally, a case is made for training "hybrid" engineers/therapists, in particular bachelor-level engineers who go directly to graduate school to become certified orthotists/prosthetists or physical/occupational therapists, pass the RESNA-sponsored assistive technology service provision exam along the way, then later in life obtain a professional engineer's license and an engineering master's degree.

Three-dimensional head axis of rotation during tracking movements. A tool for assessing neck neuromechanical function

The purpose of this article is to report normal variation in the screw (helical) axis of rotation of the head during various types of natural tracking movements. Nine normal subjects and eighteen subjects with neck injury faced a grid of targets separated by 10-degree intervals, and were instructed to use a head pointer (laser) to track whatever target was lit. Various horizontal, vertical, and oblique target sequences were employed. The normal subjects exhibited several consistent trends in finite screw axis parameter variation: vertical movements have a laterally-directed axis whose midsagittal plane crossing position is a function of the head orientation (typical range C3-T1); oblique movements have a diagonally-directed axis and an even greater orientation-specific range (C1-T1); and horizontal movements have a vertical axis that is modified near horizontal orientation extremes and is asymmetrically influenced by upward and downward bias orientations. Subjects with neck injury were seen to exhibit a variety of abnormal screw axis patterns.

Assessment of 3-D joint contact load predictions during postural/stretching exercises in aged females

Our goal was to estimate knee and hip joint contact forces during a variety of unconstrained "stretching" exercises that are often recommended for people with arthritis. The population of interest was aged females with and without significant osteoarthritis (OA). Three-dimensional (3-D) kinematic, force platform, and selected electromyographic (EMG) data were measured. A relatively standard and reasonably efficient technique was used for all subjects and tasks: inverse dynamics to estimate joint reaction forces and net moments, followed by heuristic reductionist techniques for predicting muscle load-sharing. Muscle force predictions were compatible with measured EMG activity for some tasks but less so for others, especially those with significant axial and medio-lateral movement components or high co-contraction. Such results suggest several improvements, which come at computational cost: 3-D joint models which better document muscle and passive tissue loading-sharing in abduction and axial torsion, and dynamic or novel static optimization approaches that can inherently predict muscle co-contraction. Nonetheless, the predicted joint contact loadings provide estimates that are essentially lower bounds on the likely joint contact loads. Based on our results we suggest that the side-kick and back-kick tasks be modified because the loading levels on the support leg are potentially excessive for the aged arthritic population.

Effect of initial upper-limb alignment on muscle contributions to isometric strength curves

Male and female isometric strength curves for elbow fixation, shoulder flexion, and wrist supination-pronation are obtained during systematic variation in arm configuration. The shape of a given moment-angle curve is found to be a function of the orientations of joints kinematically coupled to the primary joint. It is also found that female elbow strength curves are shifted toward flexion with respect to male elbow-strength curves, suggesting that the in situ rest length of upper-limb muscles relative to joint angle may be longer for males than for females. Experimental results were contrasted with simulation results obtained using a three-dimensional musculoskeletal model which estimates the relationships between initial joint orientations, muscle tension-length behavior, and joint moments. In most of the cases, simulation results complimented experimental data and provided insights into likely in situ muscle rest lengths and moments arms, especially for the multiarticular biceps brachii muscle. Where inconsistencies exist between simulated and experimental data, subtle biomechanical complexities within the forearm and the shoulder girdle complex are identified that require future investigation.

Three-dimensional head kinematics and clinical outcome of patients with neck injury treated with spinal manipulative therapy: a pilot study

OBJECTIVE

Finite helical axis parameters (FHAP) of the cervical spine and clinical measures were obtained to evaluate neck function and the clinical effects of spinal manipulative therapy in patients with "whiplash" (WL) type neck injury.

DESIGN

Descriptive case series, 1 yr follow-up.

SETTING

Three private chiropractic practices.

SUBJECTS

Ten consecutive new patients with a history of neck injury, nine asymptomatic, volunteer controls.

INTERVENTIONS

A 6-wk regimen of short lever manually assisted adjustments with an Activator Instrument, while acute, four patients received interferential electrotherapy.

MAIN OUTCOME MEASURES

Cervical FHAP during normal movements, neck pain (visual analogue scale), active cervical range of motion and follow-up questionnaire.

RESULTS

Based on six patients, the FHAPs appeared to mirror the clinical condition, being markedly deviant from the patterns observed in the control group for at least one or more of the tracking tasks for all but one of the patients. Mean pain scores decreased from 44.1 to 10.5 (t = 4.93; p < .0001) and mean total range of motion increased from 234 to 297 degrees (t = 5.68; p < .0001). At 1 yr, seven respondents noted stability of their symptoms at or near the level reported immediately after the 6-wk treatment period.

CONCLUSIONS

Based on these preliminary data: a) FHAPs may aid in diagnosing and monitoring treatment of neck dysfunction, b) spinal manipulative therapy may be beneficial to some patients with neck injury and future study is warranted as a means to promote recovery of patients with neck injuries.

Estimated mechanical properties of synergistic muscles involved in movements of a variety of human joints

One of the most challenging aspects of biomechanical modelling is parameter estimation. Parameter values that define the nonlinear relations within the classic Hill-based muscle model structure have been estimated for a large number of muscles involved in movements of a number of joints. The technique used to estimate these parameters is based on combining information on muscle as a material with geometrical data on muscle-joint anatomy. The resulting relations are compatible with available human experimental data and with past modelling estimates. An estimation of the relative importance of the various synergistic muscle properties during dynamic movement tasks is also provided, aided by examples of muscle load-sharing as a function of optimization criteria including measures of position error, muscle stress and neural effort.

Response of an advanced head-neck model to transient loading

A second-generation mechanical head-neck model was constructed, instrumented and subjected to pendulum impact tests against both the head and torso and directed from the front, rear and side. The response history of the system was measured by thirty channels of instrumentation including disk pressure transducers and muscle displacement gages in the neck, and a central accelerometer, intracranial pressure transducers and skull strain gages for the cranium and its contents. The kinematics of the unit was observed by an intermediate speed framing camera and the input was determined by a calibrated force transducer located at the contact point. It was found that peak head linear acceleration and velocity occur either during or immediately after the impact, with corresponding peak rotational values manifested somewhat later, but well before maximum head displacement. Head accelerations were similar, albeit slightly lower than in corresponding cases for an earlier model and displacement values were also similar until large extensions were reached. For rear head or frontal base impact, the head experienced a significant period of translation without rotation immediately after loading, and the system appears to respond more violently to side than to corresponding front or rear impact. The muscle beahvior, which support the findings from the head kinematics, is analyzed in detail and shows its strong influence on limiting head excursions, with strain values up to 40 percent. Disk pressure histories were similar to those found in tests on an earlier model with the highest values between T2 and C4, while the intercranial pressure exhibited more realistic values, about an order of larger magnitude.

Comparison of Methods for Determination of Sulfur in Fertilizer: Collaborative Study

Methods with applications for total sulfur (sulfate, elemental sulfur) in dry fertilizers, for total sulfur (sulfate, sulfite, thiosulfate, sulfide) in liquid fertilizers, for total sulfur (elemental sulfur) in sulfur-coated urea and elemental sulfur formulations, and for thiosulfate sulfur in ammonium thiosulfate liquid fertilizer (12-0-0, 26 S), and 7 samples with background and directions were submitted to 12 collaborating laboratories for comparison to official methods 2.160–2.161 and 2.162. The methods studied are simple and rapid, and recover the total sulfur in fertilizers containing high levels of elemental sulfur and thiosulfate sulfur. Method 2.160–2.161 does not recover total sulfur in these products. The first 3 methods have been adopted as official first action, and the present official methods for sulfur, 2.160–2.161 and 2.162, have been repealed, official first action.