Shoulder joint loadings in post total hip replacement surgery patients during assisted walking: The influence of the crutch setup

A crutch is prescribed to permit the patient to walk safely and independently immediately after total hip replacement (THR) surgery. Purpose of this study is to evaluate the influence of the crutch setup on upper limbs biomechanics, including shoulder joint kinematics and kinetics parameters that will be evaluated to detect possible differences related to the crutch length.Thirty patients were randomly assigned to elbow flexed (EF) or elbow extended (EE) forearm crutch setup. Subjects were asked to walk on the laboratory path, instrumented with motion tracking system and force platforms. Spatiotemporal gait parameters, crutch ground reaction force (GRF) and crutch displacement (measured as the relative distance between the crutch position on the floor and the shoulder joint center), were evaluated. A three-dimensional (3D) biomechanical model was implemented to determine shoulder joint kinematics and kinetics during crutch walking.Results showed that the stride length significantly decreased, and base of support width increased for the EF group when compared to the EE group. Crutch forces and distance to the body significantly decreased in the EE group. Furthermore, shoulder joint moments in all planes of motion, vertical and lateral forces were significantly reduced in the EE group.The present study showed that crutch setup influenced performance and upper limb loading during walking, with EE setup allowing a more stable walking and reducing stress on the shoulder joint when compared to the EF setup. Results may help therapists in rationalizing crutch length adjustments for patients after THR surgery.     

Quantitative analysis of upper limbs during gait: a marker set protocol

Purpose: to develop a marker set for simultaneously assessing upper and lower limb biomechanics during gait.Methods: 24 healthy young subjects (mean age: 23.80 years) were assessed quantitatively using an optoelectronic system, two force platform and a video system. Passive markers were positioned according to the proposed marker set which enables acquiring the upper and lower limb movement simultaneously during Gait Analysis. In addition to the traditional parameters obtained from Gait Analysis, the shoulder and elbow angles were computed from markers coordinates of upper limbs; then, some significant parameters were identified and calculated. From shoulder and elbow position, angles, angular velocities, angular acceleration, moments, and powers were calculated for shoulder and elbow joints. Results: Kinematic and kinetic data were obtained in the three planes (sagittal, frontal, and transversal) for the shoulder and in the sagittal plane for the elbow. Normative ranges were obtained for these parameters from data of healthy participants. Conclusions: The proposed experimental set-up enables simultaneous assessment of upper and lower limb movement during gait. Thus, no further trials are required in addition to those acquired during standard gait analysis in order to assess upper limb motion, which also makes the experimental set-up feasible for clinical applications.     

Morphological and biomechanical analysis of a skeleton from Roman imperial necropolis of Casalecchio di Reno (Bologna, Italy, II-III c. A. D.). A possible case of crutch use

A Roman skeleton (T.130) from the roman necropolis of Casalecchio di Reno has been studied in order to understand if the hypothesis of crutch use, suggested by the severe articular degeneration at the hip joint that caused evident reduction of his locomotory possibilities, could be supported by the morphological alterations of other bones and joints. The pathological changes and muscular development of the upper limbs and shoulder girdle bones suggest that these parts were submitted to a great mechanical stress. The observations are consistent with the hypothesis of crutch use that would have involved a new weight-bearing function of the upper limbs in order to help locomotion, even though it is difficult to assess the number and type of the crutches. The comparison with other possible cases of crutch use reported in literature gives an additional support to the interpretation of the findings.     

Covariance in human limb joint articular morphology

Objectives

Limb synovial joints exhibit complex shapes that must accommodate often-antagonistic demands of function, mobility, and stability. These demands presumably dictate coordination among joint articular shapes, but the structure of morphological covariance within and among joints is unknown. This study analyzes the human shoulder, elbow, hip, and knee to determine how articular covariance is structured in relation to joint structure, accessory cartilage, and function.

Materials and Methods

Surface models were created from the CT scans of 200 modern skeletons from the University of Tennessee Donated Skeletal Collection. Three-dimensional landmarks were collected on the shoulder, elbow, hip, and knee joints. Two-block partial least squares were conducted to determine associations between surfaces of conarticular shapes, functionally analogous articulations, and articulations belonging to the same bone.

Results

Except for the components of the shoulder, all conarticular pairs exhibit covariance, though the strength of these relationships appears unrelated to the amount of accessory cartilage in the joint. Only the analogous articulations of the humerus and femur exhibit significant covariance, but it is unlikely that this pattern is due to function alone. Stronger covariance within the lower limb than the upper limb is consistent broader primate patterns of within-limb integration.

Discussion

With the exception of the elbow, complementary joint function does not appear to promote strong covariance between articulations. Analogous humeral and femoral surfaces are also serially homologous, which may result in the articular associations observed between these bones. Broadly, these patterns highlight the indirect relationship between joint congruence and covariance.

     

Shoulder muscle function depends on elbow joint position: an illustration of dynamic coupling in the upper limb

Shoulder muscle function has been documented based on muscle moment arms, lines of action and muscle contributions to contact force at the glenohumeral joint. At present, however, the contributions of individual muscles to shoulder joint motion have not been investigated, and the effects of shoulder and elbow joint position on shoulder muscle function are not well understood. The aims of this study were to compute the contributions of individual muscles to motion of the glenohumeral joint during abduction, and to examine the effect of elbow flexion on shoulder muscle function. A three-dimensional musculoskeletal model of the upper limb was used to determine the contributions of 18 major muscles and muscle sub-regions of the shoulder to glenohumeral joint motion during abduction. Muscle function was found to depend strongly on both shoulder and elbow joint positions. When the elbow was extended, the middle and anterior deltoid and supraspinatus were the greatest contributors to angular acceleration of the shoulder in abduction. In contrast, when the elbow was flexed at 90°, the anterior deltoid and subscapularis were the greatest contributors to joint angular acceleration in abduction. This dependence of shoulder muscle function on elbow joint position is explained by the existence of dynamic coupling in multi-joint musculoskeletal systems. The extent to which dynamic coupling affects shoulder muscle function, and therefore movement control, is determined by the structure of the inverse mass matrix, which depends on the configuration of the joints. The data provided may assist in the diagnosis of abnormal shoulder function, for example, due to muscle paralysis or in the case of full-thickness rotator cuff tears.     

Peculiarities of Activation of Muscles of the Shoulder Belt in Voluntary Two-Joint Movements of the Upper Limb

We studied coordination of central motor commands (СMCs) coming to muscles of the shoulder and shoulder belt in the course of single-joint and two-joint movements including flexion and extension of the elbow and shoulder joints. Characteristics of rectified and averaged EMGs recorded from a few muscles of the upper limb were considered correlates of the CMC parameters. Special attention was paid to coordination of CMCs coming to two-joint muscles that are able to function as common flexors (m. biceps brachii, caput breve, BBcb) and common extensors (m. triceps brachii, caput longum, TBcl) of the elbow and shoulder joints. Upper limb movements used in the tests included planar shifts of the arm from one spatial point to another resulting from either simultaneous changes in the angles of the shoulder and elbow joints or isolated sequential (two-stage) changes in these joint angles. As was found, shoulder muscles providing movements of the elbow with changes in the angle of the elbow joint, i.e., BBcb and TBcl, were also intensely involved in the performance of single-joint movements in the shoulder joint. The CMCs coming to two-joint muscles in the course of two-joint movements appeared, in the first approximation, as sums of the commands received by these muscles in the course of corresponding single-joint movements in the elbow and shoulder joints. Therefore, if we interpret the isolated forearm movement performed due to a change in the angle of the elbow joint as the main motor event, while the shoulder movement is considered the accessory one, we can conclude that realization of a two-joint movement of the upper-limb distal part is based on superposition of CMCs related to basic movements (main and accessory). Neirofiziologiya/Neurophysiology, Vol. 41, No. 1, pp. 48–56, January–February, 2009.     

An upper extremity inverse dynamics model for pediatric Lofstrand crutch-assisted gait

The objective of this study was to develop an instrumented Lofstrand crutch system, which quantifies three-dimensional (3-D) upper extremity (UE) kinematics and kinetics using an inverse dynamics model. The model describes the dynamics of the shoulders, elbows, wrists, and crutches and is compliant with the International Society of Biomechanics (ISB) recommended standards. A custom designed Lofstrand crutch system with four, six-degree-of-freedom force transducers was implemented with the inverse dynamics model to obtain triaxial UE joint reaction forces and moments. The crutch system was validated statically and dynamically for accuracy of computing joint reaction forces and moments during gait. The root mean square (RMS) error of the system ranged from 0.84 to 5.20%. The system was demonstrated in children with diplegic cerebral palsy (CP), incomplete spinal cord injury (SCI), and type I osteogenesis imperfecta (OI). The greatest joint reaction forces were observed in the posterior direction of the wrist, while shoulder flexion moments were the greatest joint reaction moments. The subject with CP showed the highest forces and the subject with SCI demonstrated the highest moments. Dynamic quantification may help to elucidate UE joint demands in regard to pain and pathology in long-term assistive device users.     

An upper extremity kinematic model for evaluation of hemiparetic stroke

Quantification of rehabilitation progress is necessary for accurately assessing clinical treatments. A three-dimension (3D) upper extremity (UE) kinematic model was developed to obtain joint angles of the trunk, shoulder and elbow using a Vicon motion analysis system. Strict evaluation confirmed the system's accuracy and precision. As an example of application, the model was used to evaluate the upper extremity movement of eight hemiparetic stroke patients with spasticity, while completing a set of reaching tasks. Main outcome measures include kinematic variables of movement time, range of motion, peak angular velocity, and percentage of reach where peak velocity occurs. The model computed motion patterns in the affected and unaffected arms. The unaffected arm showed a larger range of motion and higher angular velocity than the affected arm. Frequency analysis (power spectrum) demonstrated lower frequency content for elbow angle and angular velocity in the affected limb when compared to the unaffected limb. The model can accurately quantify UE arm motion, which may aid in the assessment and planning of stroke rehabilitation, and help to shorten recovery time.     

Kinematic Analysis of the Neck and Upper Extremities During Walking in Healthy Young Adults

The objective of this paper is to quantify the local stabilities of the neck and upper extremities (right/left shoulders and right/left elbows), and investigate differences between linear and nonlinear measurements of the associated joint motions and differences in the local stability between the upper and lower extremities. This attempt involves the calculation of a nonlinear parameter, Lyapunov Exponent (LE), and a linear parameter, Range of Motion (ROM), during treadmill walking in conjunction with a large population of healthy subjects. Joint motions of subjects were captured using a three-dimensional motion-capture system. Then mathematical chaos theory and the Rosenstein algorithm were employed to calculate LE of joints as the extent of logarithmic divergence between the neighboring state-space trajectories of flexion-extension angles. LEs computed over twenty males and twenty females were 0.037±0.023 for the neck, 0.043±0.021 for the right shoulder, 0.045±0.030 for the left shoulder, 0.032±0.021 for the right elbow, and 0.034±0.026 for the left elbow. Although statistically significant difference in the ROM was observed between all pairs of the neck and upper extremity joints, differences in the LE between all pairs of the joints as well as between males and females were not statistically significant. Between the upper and lower extremities, LEs of the neck, shoulder, and elbow were significantly smaller than those of the hip (∼0.064) and the knee (∼0.062). These results indicate that a statistical difference in the local stability between the upper extremity joints is not significant. However, the different result between the ROM and LE gives a strong rationale for applying both linear and nonlinear tools together to the evaluation of joint movement. The LEs of the joints calculated from a large population of healthy subjects could provide normative values for the associated joints and can be used to evaluate the recovery progress of patients with joint related diseases.     

A new approach to reaching control for tetraplegic subjects

A simple upper limb control strategy to guide reaching in preparation to grasp for tetraplegic subjects is proposed. The control is based on new studies of self-paced human arm movements involving rotations about the shoulder and elbow joints. An experimental study of reaching, while grasping, by able-bodied humans, allowed us to reduce the dimensionality of the control vector from two to a single variable. This was accomplished by detailed analysis of the synergy between shoulder and elbow joint angles. This study examined only movements in teh horizontal plane. In the experiments we varied: (a) the shape of targets; (b) their position relative to the initial position of the hand; and (c) the speed of reaching. A synergy between shoulder and elbow joint angles was found in most analysed movements, and it was characterized by a scaling parameter between elbow and shoulder angular velocities. The scaling parameter was determined from the target position presented in the visual perceptive field and initial shoulder and elbow angles. The same experimental setup in studies with tetraplegics with retained shoulder movements showed that this natural synergism is preserved even though the motor and sensory components of the upper limb are reduced or absent. Tetraplegics originally showed a very different reaching pattern, but after short training sessions they developed a reaching behaviour which was similar to able-bodied subjects. The results presented can be used in the following way: a tetraplegic subject lacking elbow extension and flexion may be fitted with an assistive system which will be volitionally controlled only from ipsilateral shoulder movements. The assistive system can comprise either a motorized brace, or a functional electrical stimulation system applied to elbow flexors and extensors. With this system volitional movements at the shoulder would bring the hand into the correct position to accomplish an assisted grasping motion.     

Peculiarities of Activation of the Upper Limb Muscles in Realization of Two-Joint Movements in Humans

In tests on humans, we recorded EMG activity from the muscles flexing and extending the forearm and shoulder in the course of realization of sequential single-joint and simultaneous two-joint movements of the upper limb. As was shown, the shoulder muscles m. biceps brachii and m. triceps brachii are involved in flexion/extension of both elbow and shoulder joints. Central commands sent to the above muscles in the course of a two-joint movement could be considered a superposition of the central commands coming to the same muscles in realization of the corresponding sequential single-joint movements with the same changes in the angles of the elbow and shoulder joints. External loadings applied in the direction of extension of the elbow and shoulder joints induced, in general, similar changes in coordination of the activity of muscles moving the forearm and shoulder under conditions of both single-joint and two-joint movements. These facts allow us to suppose that coordination of the muscle activity in two-joint movements depends to a greater extent on the forces influencing limb links than on the mode of realization of the movements (two sequential single-joint movements vs a two-joint movement corresponding to the above motor events).     

Effect of walking speed and severity of hip osteoarthritis on gait variability

Gait analysis in orthopaedic and neurological examinations is important; however, few studies assess gait variability at different walking speeds in patients with varying degrees of hip osteoarthritis. We aimed to clarify (1) how different controlled speeds and (2) various severities of hip osteoarthritis influence gait variability. Gait variability was described by the standard deviation (SD) of the spatial–temporal and mean standard deviation (MeanSD) of angular parameters. The spatial positions of the anatomical points for calculating gait parameters were determined in 20 healthy elderly controls and 20 patients with moderate and 20 patients with severe hip osteoarthritis with a zebris CMS-HS ultrasound-based motion analysis system at three walking speeds. The SD of the spatial–temporal and MeanSD of angular parameters of gait, which together describe gait variability, significantly depended on speed and osteoarthritis severity. The lowest variability in the gait was found near the self-selected walking speeds. Hip joint degeneration significantly worsened variability on the affected side, with non-affected joints and the pelvis compensating by increasing flexibility and adapting to step-by-step motions. Particular attention must be paid to improving gait stability and the reliability of limb movements in the presence of and increasing severity of osteoarthritis.     

Effect of arm swinging on lumbar spine and hip joint forces

During level walking, arm swing plays a key role in improving dynamic stability. In vivo investigations with a telemeterized vertebral body replacement showed that spinal loads can be affected by differences in arm positions during sitting and standing. However, little is known about how arm swing could influence the lumbar spine and hip joint forces and motions during walking. The present study aims to provide better understanding of the contribution of the upper limbs to human gait, investigating ranges of motion and joint reaction forces.A three-dimensional motion analysis was carried out via a motion capturing system on six healthy males and five patients with hip instrumented implant. Each subject performed walking with different arm swing amplitudes (small, normal, and large) and arm positions (bound to the body, and folded across the chest). The motion data were imported in a commercial musculoskeletal analysis software for kinematic and inverse dynamic investigation.The range of motion of the thorax with respect to the pelvis and of the pelvis with respect to the ground in the transversal plane were significantly associated with arm position and swing amplitude during gait. The hip external-internal rotation range of motion statistically varied only for non-dominant limb. Unlike hip joint reaction forces, predicted peak spinal loads at T12-L1 and L5-S1 showed significant differences at approximately the time of contralateral toe off and contralateral heel strike.Therefore, arm position and swing amplitude have a relevant effect on kinematic variables and spinal loads, but not on hip loads during walking.     

Upper extremity kinematic and kinetic adaptations during a fatiguing repetitive task

Repetitive low-force contractions are common in the workplace and yet can lead to muscle fatigue and work-related musculoskeletal disorders. The current study aimed to investigate potential motion adaptations during a simulated repetitive light assembly work task designed to fatigue the shoulder region, focusing on changes over time and age-related group differences. Ten younger and ten older participants performed four 20-min task sessions separated by short breaks. Mean and variability of joint angles and scapular elevation, joint net moments for the shoulder, elbow, and wrist were calculated from upper extremity kinematics recorded by a motion tracking system. Results showed that joint angle and joint torque decreased across sessions and across multiple joints and segments. Increased kinematic variability over time was observed in the shoulder joint; however, decreased kinematic variability over time was seen in the more distal part of the upper limb. The changes of motion adaptations were sensitive to the task-break schedule. The results suggested that kinematic and kinetic adaptations occurred to reduce the biomechanical loading on the fatigued shoulder region. In addition, the kinematic and kinetic responses at the elbow and wrist joints also changed, possibly to compensate for the increased variability caused by the shoulder joint while still maintaining task requirements. These motion strategies in responses to muscle fatigue were similar between two age groups although the older group showed more effort in adaptation than the younger in terms of magnitude and affected body parts.     

Joint reaction forces at the first MTP joint in a normal elderly population

The calculation of net ankle, knee, and hip joint reaction forces is an often applied procedure in the analysis of gait. Except for very few studies, joint reaction forces have not been measured in other joints such as the fingers, wrist, elbow, shoulder and toes. In this study the joint reaction forces between the metatarsal head and the proximal phalanx and the metatarsal head and the sesamoids are calculated for the push off phase during gait. The results of ten normal elderly subjects show that the maximum resultant loads of the two articulations lie close to the longitudinal axis of the metatarsal. The knowledge of the magnitude and direction of the joint reaction forces of a normal elderly population will be essential for the design of an optimal fixation of an artificial anatomical first MTP joint.     

Limits of recovery against slip-induced falls while walking

Slip-induced falls in gait often have devastating consequences. The purposes of this study were 1) to select the determinants that can best discriminate the outcomes (recoveries or falls) of an unannounced slip induced in gait (and to find their corresponding threshold, i.e., the limits of recovery, which can clearly separate these two outcomes), and 2) to verify these results in a subset of repeated-slip trials. Based on the data collected from 69 young subjects during a slip induced in gait, nine different ways of combining the center of mass (COM) stability, the hip height, and its vertical velocity were investigated with the aid of logistic regression. The results revealed that the COM stability (s) and limb support (represented by the quotient of hip vertical velocity to hip height, S(hip)) recorded at the instant immediately prior to the recovery step touchdown were sufficiently sensitive to account for all (100%) variance in falls, and specific enough to account for nearly all (98.3%) variability in recoveries. This boundary (S(hip)=-0.22s-0.25), which quantifies the risk of falls in the stability-limb support quotient (s-S(hip)) domain, was fully verified using second-slip and third-slip trials (n=76) with classification of falls at 100% and recoveries at 98.6%. The severity of an actual fall is likely to be greater further below the boundary, while the likelihood of a fall diminishes above it. Finally, the slope of the boundary also indicates the tradeoff between the stability and limb support, whereby high stability can compensate for the insufficiency in limb support, or vice versa.     

空气压力波联合等速肌力训练对乳腺癌改良根治术后康复效果的影响研究

摘要 目的：观察空气压力波联合等速肌力训练对乳腺癌改良根治术后康复效果。方法：选取湖南中医药大学第一附属医院于2021年1月-2022年12月期间收治的160例行乳腺癌改良根治术的患者,采用双色球法分为对照组（等速肌力训练联合常规干预）和研究组（空气压力波联合等速肌力训练和常规干预）,每组例数为80例。比较两组淋巴水肿发生率、视觉模拟评分法（VAS）、Constant-Murley肩关节评分、关节活动度（ROM）和三角肌下缘、肘上、肘下、腕上的周径,同时观察两组生活质量变化情况。结果：研究组的淋巴水肿发生率低于对照组（P<0.05）。干预1个月后,研究组VAS低于对照组,Constant-Murley肩关节评分和ROM高于对照组（P<0.05）。干预1个月后,研究组三角肌下缘、肘上、肘下、腕上的周径小于对照组（P<0.05）。干预1个月后,研究组生理职能（RP）、情感职能（RE）、社会功能（SF）、生理功能（PF）、总体健康（GH）、活力（VT）、躯体疼痛（BP）及精神健康（MH）评分均高于对照组（P<0.05）。结论：乳腺癌改良根治术后康复采用等速肌力训练联合空气压力波干预,可减轻患者术后疼痛,缩小上肢周径,降低淋巴水肿的发生率,促进患者肩关节功能和生活质量改善。     

Modulation of shoulder muscle and joint function using a powered upper-limb exoskeleton

Robotic-assistive exoskeletons can enable frequent repetitive movements without the presence of a full-time therapist; however, human-machine interaction and the capacity of powered exoskeletons to attenuate shoulder muscle and joint loading is poorly understood. This study aimed to quantify shoulder muscle and joint force during assisted activities of daily living using a powered robotic upper limb exoskeleton (ArmeoPower, Hocoma). Six healthy male subjects performed abduction, flexion, horizontal flexion, reaching and nose touching activities. These tasks were repeated under two conditions: (i) the exoskeleton compensating only for its own weight, and (ii) the exoskeleton providing full upper limb gravity compensation (i.e., weightlessness). Muscle EMG, joint kinematics and joint torques were simultaneously recorded, and shoulder muscle and joint forces calculated using personalized musculoskeletal models of each subject’s upper limb. The exoskeleton reduced peak joint torques, muscle forces and joint loading by up to 74.8% (0.113 Nm/kg), 88.8% (5.8%BW) and 68.4% (75.6%BW), respectively, with the degree of load attenuation strongly task dependent. The peak compressive, anterior and superior glenohumeral joint force during assisted nose touching was 36.4% (24.6%BW), 72.4% (13.1%BW) and 85.0% (17.2%BW) lower than that during unassisted nose touching, respectively. The present study showed that upper limb weight compensation using an assistive exoskeleton may increase glenohumeral joint stability, since deltoid muscle force, which is the primary contributor to superior glenohumeral joint shear, is attenuated; however, prominent exoskeleton interaction moments are required to position and control the upper limb in space, even under full gravity compensation conditions. The modeling framework and results may be useful in planning targeted upper limb robotic rehabilitation tasks.