NND: Progress and demonstrations€¦ · NND: Progress and demonstrations MD-Paedigree Final Review...

NND: Progress and demonstrations

MD-Paedigree Final Review

Marjolein van der Krogt & Frans Steenbrink

Brussels, 6/7 July 2017

AcknowledgementsJaap Harlaar, Laura Oudenhoven, Eline Flux, Marjolein Piening (VUmc)

Kaat Desloovere, Marije Goudriaan (KUL)

Maurizio Petrarca, Gessica Vasco, Allessandra Pisano, Enrico Castelli, Enrico Bettine (OPBG)

Maria Costa (SHC)

Jose Pozo Soler (USFD)

Thomas Geijtenbeek, Marcin Burdzy, Hulda Jonasdottir, Frans van der Helm (TUD)

Ben van Basten, Johannes Gijsbers, Lars Aarts, Ali Benyahia (Motek)

Brussels, 6-7 July, 2017

What treatment is best for this patient?

Final review Brussels

SpasticityContracture

BalanceLimited neural

control Bone deformities

Weakness

Pat

ien

t m

eas

ure

me

nts

OVERVIEW

MD-Paedigree EU database

Probabilistic modelling

Biophysical modelling

WP6: Harmonized clinical practice



Aim

• To reach consensus and develop a standardizedmeasurement protocol for gait analysis

• To enable standardized data collection throughout gait labs in Europe

• To define a set of clinical relevant outcome parameters (crops) extracted from the data and reach consensus on folder structure and file format


Consensus gait analysis protocol

1. General history

2. Gait-specific information

3. 3D clinical gait analysis

4. Standardized physical exam

5. Energy expenditure (CP)

6. 6-min walk test (DMD+CMT)

7. Lower body MRI

http://www.md-paedigree.eu/clinical-scenario-nnd/gait-analysis-protocol/


Data collected

N=863Patient Reference Complete Acquired GOAL

TOTAL OVERALL PATIENT DATA 863 830

Total CP prospective extended 28 30

Total CP prospective clinical 136 120

Total CP retrospective 626 600

Total DMD T0 26 20

Total DMD T1 16 20

Total CMT T0 18 20

Total CMT T1 13 20


Outcome parameters and file format

• Clinical exam: digitized in standard .xls format


Outcome parameters and file format

• Gait analysis: crops and curves

Scientific studies WP6

• Interlaboratory reproducibilityPaper under review

Final review Brussels, 6-7 July 2017



• Complexity of motor control in CP versus DMDPaper submitted





• Automatic classification of gait patternsJoint project with Athena& Siemens





• Automatic classification of gait patternsJoint project with Athena

• Studies on effect of functional power training, orthopedic surgery, …


Achievements WP6

• Consensus gait analysis protocol

• 863 data sets for CP, DMD and CMT

• Standardized outcome measures and formats

• All data stored in repository


Limitations of current practice

1. Data collection & processing is time consuming

– More than 4 hours for collection and analysis

2. Little information at muscle level

– No muscle lengths and forces

– No information on deeper muscles

3. Only examine comfortable gait

– Compensations mask underlying impairments

What do we need?


Faster software?


Personalized musculoskeletal modeling?


Gait perturbations?

WP11: Demo of Modelling Applications


What do we need?


Faster software?




Gait perturbations?

Brussels – 6-7 May 2014

Musculoskeletal modelling for clinical applications

• MD-PAEDIGREE consensus protocol

• Less pose dependent

• Up-to-date with current scientific knowledge

• Segment definitions match ISB recommendations (Wu et al. 2005)

• Updated hip joint center regression (Harrington 2007)

• Functional hip and knee calibration procedures (Halvorsen2003)

• Clinical workflow/protocol– Feedback to user

Functional calibration

The comparison of three models: PiG, CAST & HBM

Models (42 markers total)

- Plug-in-Gait (PiG)

- CAST (ISB)

- Human Body Model (HBM)

Subjects

- 18 children with CP- 6 OPBG (overground)

- 6 KUL (overground)

- 6 VUmc (GRAIL)

- Average over 3 strides per subject

Statistics

- Statistical Parametric Mapping (SPM)with ANOVA & t-tests

- RMSE

PiG CAST HBM

Sagittal plane angles


*HBM vs PIG *CAST *PIG/CAST/HBM *PIG/CAST/HBM

SPM

{F}

ext

(⁰)

fle

x

Gait Off-line Analysis Tool

Achievements WP11

• Clinically applicable gait analysis software

Added value for clinical practice

• Much more efficient 3D gait analysis– Currently being implemented in clinical practice

• HBM 2.0 release mail June 26

• 51 users, part of total solution for gaitanalysis & training

• Real-time gait analysis– Dutch charity grant (k€185)

obtained for clinical implementation

– 2 ITN project funded by EC

– 2 EU proposals under review

Brussels – 6-7 May 2014

What do we need?


Faster software?




Gait perturbations?

Clinic Siemens USFD TU Delft Motek ClinicNext stepsBrussels, 6-7 july, 2017 WP11 - NND

WP11 – modelling pipeline

Siemens USFD MotekTU Delft

MRI Segmented3D Models

OpenSim Model Motek HumanBody Model

Complete Anatomical Model


Segmentation and parameter extractionMORPHING COMPLETE

ANATOMICAL TEMPLATE (TLEM) EXTRACTING GEOMETRIC PARAMETERSSEGMENTATION

Clinic Siemens USFD TU Delft Motek ClinicNext stepsBrussels, 6-7 July, 2017 WP11 - NND

Final Result for CP 4


Pipeline summary

• MD-Paedigree

– 43 patient cases processed with personalized muscle models

– Repository: probabilistic modelling/case matching

• All gait parameters

• Muscle activation/lengths

• Visualization tool


Inverse dynamics validation

Rome, 12 – 13 May 2017


Inverse dynamics validation

• Conclusions– Reasonable agreement between EMG and simulation– Relatively small inter-model variance

• Challenges– No ground truth– No pathological control

• Future work– Cost-benefit of MRI-based models for clinical practice

Rome, 12 – 13 May 2017


Personalized models for clinical practice


Summary WP11


• 43 personalized models and simulations


Added value for clinical practice: Muscle-tendon lengths

Muscle-tendon lengthTibialis posterior right

Muscle-tendon lengthTibialis posterior left

green = genericpurple = MRI-based

Important for clinical decision making


Added value for clinical practice: Muscle activations of deeper muscles

Muscle activationTibialis posterior right

Muscle activationTibialis posterior left

green = genericpurple = MRI-based

Important for clinical decision making!


What do we need?


Faster software?




Gait perturbations?

D11.4: Disease-specific muscle model

• Task 11.3: Disease specific muscle model– Muscle model based on clinical asessment

– Musce model based on joint perturbations

• Task 11.4: Gait perturbations– Mechanical

– Visual

Disease specific muscle model (1)

Brussels – 6-7 July 2017

• Optimizing hamstrings contracture andspasticity parameters

• Using instrumented clinical assessment

Van der Krogt et al. 2016

Disease specific muscle model (2)

Brussels – 6-7 July 2017

• Separating neural and tissue parameters

• Using mechanical joint perturbations

Sloot et al. 2015

Clinic Siemens USFD TU Delft Motek ClinicNext stepsRome, 22-23 May, 2017 WP11 - NND

Advanced Clinical Gait Analysis

• Steady state gait

– Might not be sensitive enough

• Patient compensation

• Not very functional

• Dynamics of gait perturbations

– Mechanical gait perturbations

• Inertial compensation

– Visual gait perturbations


Mechanical perturbations


Inertial compensation

* Patent pending


Mechanical gait perturbations

Sloot, L.H., van den Noort, J.C., van der Krogt, M.M., Bruijn, S.M., Harlaar, J. (2015) Can treadmill perturbations evoke stretch reflexes in the calf muscles? PLoS ONE 10(12): e0144815.


Visual gait perturbations

Van Gelder et al. 2016Booth et al. 2017


Visual gait perturbations


Achievements WP11


• 43 personalized models and simulations

• Dynamics of gait perturbations



• Mechanical perturbations for diagnostics

– Nominated best paper ESMAC 2015&2017

• Visual gait perturbations for gait training

– Nominated for best poster award RehabWeek 2017

– Implemented in rehabilitation practice

– Grant application pending for training evaluation

WP 12 – NNDValidating Musculoskeletal Models

Brussels, 6-7 July 2017

Inverse vs Forward Simulation


Neuro-logical signals

Muscle Activation

Muscle Force

Joint Moments

External Forces

Motion

Musculoskeletal model



Inverse simulation

Advantages Disadvantages

Established method Limited validation options

Efficient processing No prediction (“what-if?”)


Muscle Activation

Muscle Force

Joint Moments

External Forces

Motion

Musculoskeletal modelControl model

Contactmodel



Advantages Disadvantages

Strong model validation potential Open research

Predict interventions (“what-if?”) Longer processing time

Forward simulation


Muscle Activation

Muscle Force

Joint Moments

External Forces

Motion

Forward dynamics validation


Generation 1 Generation ~5 Generation ~20 Generation ~1000

Healthy model


Shortened hamstrings


Shortened hamstrings + surgery


Weak quadriceps


Spastic gastrocnemius


Spastic gastrocnemius + BOTOX


Predictive simulations: Face validity

• 10 clinical experts asked to score validity of simulation outcome:


Simulation Validity score

Healthy gait 4.1 (/5) > quite realistic

Shortened Hamstrings 4.2 (/5) > quite realistic

Weakened Vastii 3,0 (/5) > fair

General muscle weakness 3,2 (/5) > fair

Spastic Gastrocnemius 4,4 (/5) > very realistic

Major achievements

• Consensus protocol for clinical gait analysis• Consistent data-set (n=863) in the repository• Standardized outcome measures and formats• Personalized modelling pipe-line• Clinically commercial available state-of-the-art

musculoskeletal model and off-line analysis tool– Medical certification

• 2 protocols for advance perturbation-based CGA• Forward dynamic model for predictive modelling• 1 international patent• 20 international (conference) publications


AcknowledgementsJaap Harlaar, Laura Oudenhoven, Eline Flux, Marjolein Piening (VUmc)

Kaat Desloovere, Marije Goudriaan (KUL)

Maurizio Petrarca, Gessica Vasco, Allessandra Pisano, Enrico Castelli, Enrico Bettine (OPBG)

Maria Costa (SHC)

Jose Pozo Soler (USFD)

Thomas Geijtenbeek, Marcin Burdzy, Hulda Jonasdottir, Frans van der Helm (TUD)

Ben van Basten, Johannes Gijsbers, Lars Aarts, Ali Benyahia (Motek)


NND: Progress and demonstrations€¦ · NND: Progress and demonstrations MD-Paedigree Final Review...

Documents

Transcript of NND: Progress and demonstrations€¦ · NND: Progress and demonstrations MD-Paedigree Final Review...