Current topics in clinical FES in Japan

This paper reviews recent topics of clinical application of functional electrical stimulation (FES) for the paralyzed extremities in Japan. Transcutaneous and percutaneous FES systems have been clinically used in Japan. Candidates of extremity FES arer mostly stroke and spinal cord injury patients. By using percutaneous FES system, all of the joints of the upper extremity including the shoulder have been controlled for activities of daily living in the hemiplegic patient. Simultaneous FES control of the hand and wrist and the bilateral hands have also been achieved in C5 and C6 quadriplegics, respectively. Hybrid FES systems using percutaneous and surface electrodes, where FES is used in combination with orthoses, have been applied to the paraplegics because they are highly practical for assisting their locomotive activities. Percutaneous FES have been also provided the amyotropic lateral sclerosis patients with standing up motion. A total implant FES system with 16 output channels is currently developing as a next generation FES system.     

自拟温阳利水汤联合地奥司明治疗乳腺癌术后上肢淋巴水肿的疗效观察

摘要 目的：探究自拟温阳利水汤联合地奥司明治疗乳腺癌术后上肢淋巴水肿的疗效。方法：选择2013年1月至2019年6月在我院经病理确诊为乳腺癌术后上肢淋巴水肿的住院患者80例,根据治疗方式不同分为两组,每组各40例,其中,对照组采用地奥司明进行治疗,研究组在对照组基础上联合自拟温阳利水汤进行治疗,两组均连续治疗15 d;对比两组的治疗总有效率,对比两组治疗前后的腕横纹、肘横纹、腕横纹上10 cm、肘横纹上10 cm处臂围;对比两组患者治疗前后的前屈、后伸、外展、内收等活动角度。结果：研究组治疗总有效率95.00 %（38/40）显著高于对照组75.00 %（30/40）,对比有显著差异（P＜0.05）;治疗前,两组的腕横纹、肘横纹、腕横纹上10 cm、肘横纹上10 cm处臂围对比无统计学差异（P＞0.05）;治疗后,两组的腕横纹、肘横纹、腕横纹上10 cm、肘横纹上10 cm处臂围均比治疗前有所减小,且研究组更小（P＜0.05）;治疗前,两组的前屈、后伸、外展、内收等活动角度对比无统计学差异（P＞0.05）;治疗后,两组患者的前屈、后伸、外展、内收等活动角度均比治疗前有所增大,且研究组更大（P＜0.05）。结论：自拟温阳利水汤联合地奥司明治疗乳腺癌术后上肢淋巴水肿的疗效显著,该方法可有效改善患者的肩关节活动度,临床应用价值较高。     

New biomechanical model for clinical evaluation of the upper extremity motion in subjects with neurological disorders: an application case

Cervical spinal cord injury and acquired brain injury commonly imply a reduction in the upper extremity function which complicates, or even constrains, the performance of basic activities of daily living. Neurological rehabilitation in specialised hospitals is a common treatment for patients with neurological disorders. This study presents a practical methodology for the objective and quantitative evaluation of the upper extremity motion during an activity of daily living of those subjects. A new biomechanical model (with 10 rigid segments and 20 degrees of freedom) was defined to carry out kinematic, dynamic and energetic analyses of the upper extremity motion during a reaching task through data acquired by an optoelectronic system. In contrast to previous upper extremity models, the present model includes the analysis of the grasp motion, which is considered as crucial by clinicians. In addition to the model, we describe a processing and analysis methodology designed to present relevant summaries of biomechanical information to rehabilitation specialists. As an application case, the method was tested on a total of four subjects: three healthy subjects and one pathological subject suffering from cervical spinal cord injury. The dedicated kinematic, dynamic and energetic analyses for this particular case are presented. The resulting set of biomechanical measurements provides valuable information for clinicians to achieve a thorough understanding of the upper extremity motion, and allows comparing the motion of healthy and pathological cases.     

Palmar shelf arthroplasty, the next generation: distraction/interposition for rheumatoid arthritis of the wrist

Rheumatoid arthritis affects approximately 1 percent of the adult population. Bilateral symmetric involvement of the wrist occurs in 85 percent of these patients, with recurrent flares and relentless progression. Anatomic changes consist of radiocarpal, intercarpal, and radioulnar subluxation and joint destruction. For advanced disease, both wrist arthrodesis and arthroplasty have been recommended. Arthrodesis has been successful for pain relief at the expense of motion. Implant arthroplasty has been unreliable, with failure rates of 25 to 50 percent at 2 to 9 years. Palmar shelf arthroplasty was introduced in 1970 as a resectional fibrous arthroplasty. The results were good but the series was small. Subsequent reports of this procedure have been inconsistent. In 1990, I initiated and have since followed a series of patients treated with the palmar shelf arthroplasty. To the basic procedure, I added joint distraction by external fixator, collagen/bone wax interposition, scapholunate stabilization, and increased immobilization time. Fourteen consecutive patients were enrolled in this study. Each carried a diagnosis of rheumatoid or psoriatic arthritis of the wrist. There were 11 women and 3 men. Age ranged from 28 to 56 years. Follow-up ranged from 2 to 7 years (average 4.2). The patients were interviewed, examined, and x-rayed. A questionnaire using an analog scale as well as the Hospital for Special Surgery scoring system was completed to assess the clinical outcome of the wrist postoperatively compared with its preoperative status and with the contralateral wrist. No patient has requested or required a revision procedure. All patients experienced improvement with both pain and function; no wrist spontaneously fused. Patient satisfaction was high. Patients with ipsilateral arthroplasty and contralateral arthrodesis preferred the arthroplasty. Hospital for Special Surgery score increased from 53 to 91 out of 100 points (p < 0.001). Range of motion averaged 50 degrees flexion, 30 degrees extension. Palmar shelf arthroplasty remains a viable option for severe rheumatoid disease of the wrist. Ideally, the procedure is performed on the dominant wrist of a patient with bilateral wrist involvement in the setting of inflammatory arthritis.     

Distal, dorsal superior extremity plasty

Multiple deep wrinkles and redundant skin over the dorsal hand, wrist, and forearm develop and become of cosmetic importance to some patients as they age. Distal, dorsal superior extremity plasty was performed in selected patients by excising redundant skin and wrinkles from the dorsal hands, wrists, and forearms. The area of skin to be excised is elliptical, with the long axis of the ellipse centered over the wrinkles on the dorsal wrist. The amount of skin to be excised (i.e., the short axis of the ellipse) is determined by grasping the dorsal wrist skin, hence advancing the dorsal forearm and hand skin, while the patient flexes the wrist. This maneuver is performed to avoid excessive excision of dorsal wrist skin, which would cause decreased wrist flexion. The surgical procedure is performed with use of magnification to avoid sensory nerve injury. A relatively large volume of lidocaine is injected subcutaneously to increase the distance between the skin and nerves and therefore decrease the risk of nerve injury. The skin edges are undermined for 1 to 1(1/2) cm, and the wound is closed in two layers. The wrist is splinted in 30 to 45 degrees of extension to decrease wound tension. The procedure produces long-lasting, good to excellent cosmetic improvement and patient satisfaction. The dorsal wrist, hand, and forearm appear smoother and more youthful, and scars are relatively inconspicuous. Potential significant complications include injury to the superficial branch of the radial nerve and dorsal branch of the ulnar nerve, wound dehiscence, and decreased range of motion of the wrist. Use of magnification, a bloodless field, injection of a relatively large volume of local anesthetic (10 to 12 cc), knowledge of regional anatomy, and careful surgical technique decrease the risk of nerve injury. Avoidance of injury to the superficial sensory branches of the radial and ulnar nerves is absolutely necessary for patient satisfaction. Avoidance of injury to the wound edges with good surgical technique, postoperative immobilization with the wrist in an extended position, and subsequent advancement of the wrist to a neutral position for several weeks decrease the risk of wound dehiscence. Avoidance of excessive skin excision and prolonged wrist immobilization lowers the risk of decreasing range of motion. There have been no complications in patients who underwent this procedure.     

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.     

The radial forearm skin graft-fascial flap

The radial forearm flap has become a versatile flap for upper extremity reconstruction. The use of the forearm flap for hand reconstruction in the patient with previously burned forearms has not been widely appreciated. In those patients whose forearms have been previously split-thickness skin-grafted on fascia, we have employed the reverse radial forearm flap as a skin graft-fascial flap for hand reconstruction and have obtained excellent functional results. Three patients at various intervals postburn are presented to demonstrate use of this flap for wrist contracture release, coverage of arthroplasties, first web space contracture release, and acute salvage of phalanges and tendons. Assessment of the hand's vascular anatomy and careful treatment of the donor area have contributed to no added morbidity and an excellent aesthetic result at the donor site.     

Effects of the Racket Polar Moment of Inertia on Dominant Upper Limb Joint Moments during Tennis Serve

This study examined the effect of the polar moment of inertia of a tennis racket on upper limb loading in the serve. Eight amateur competition tennis players performed two sets of 10 serves using two rackets identical in mass, position of center of mass and moments of inertia other than the polar moment of inertia (0.00152 vs 0.00197 kg.m²). An eight-camera motion analysis system collected the 3D trajectories of 16 markers, located on the thorax, upper limbs and racket, from which shoulder, elbow and wrist net joint moments and powers were computed using inverse dynamics. During the cocking phase, increased racket polar moment of inertia was associated with significant increases in the peak shoulder extension and abduction moments, as well the peak elbow extension, valgus and supination moments. During the forward swing phase, peak wrist extension and radial deviation moments significantly increased with polar moment of inertia. During the follow-through phase, the peak shoulder adduction, elbow pronation and wrist external rotation moments displayed a significant inverse relationship with polar moment of inertia. During the forward swing, the magnitudes of negative joint power at the elbow and wrist were significantly larger when players served using the racket with a higher polar moment of inertia. Although a larger polar of inertia allows players to better tolerate off-center impacts, it also appears to place additional loads on the upper extremity when serving and may therefore increase injury risk in tennis players.     

Mental practice-based rehabilitation training to improve arm function and daily activity performance in stroke patients: a randomized clinical trial

Background  

Over 50% of patients with upper limb paresis resulting from stroke face long-term impaired arm function and ensuing disability in daily life. Unfortunately, the number of effective treatments aimed at improving arm function due to stroke is still low. This study aims to evaluate a new therapy for improving arm function in sub-acute stroke patients based on mental practice theories and functional task-oriented training, and to study the predictors for a positive treatment result. It is hypothesized that a six-week, mental practice-based training program (additional to regular therapy) targeting the specific upper extremity skills important to the individual patient will significantly improve both arm function and daily activity performance, as well as being cost effective.     

A musculoskeletal model to estimate the relative changes in wrist strength due to interacting wrist and forearm postures

Wrist rotations about one wrist axis (e.g. flexion/extension) can affect the strength about another wrist axis (e.g. radial/ulnar deviation). This study used a musculoskeletal model of the distal upper extremity, and an optimization approach, to quantify the interaction effects of wrist flexion/extension (FE), radial/ulnar deviation (RUD) and forearm pronation/supination (PS) on wrist strength. Regression equations were developed to predict the relative changes in strength from the neutral posture, so that the changes in strength, due to complex and interacting wrist and forearm rotation postures, can be incorporated within future ergonomics assessments of wrist strength.     

Upper limb kinematics and the role of the wrist during stone tool production

Past studies have hypothesized that aspects of hominin upper limb morphology are linked to the ability to produce stone tools. However, we lack the data on upper limb motions needed to evaluate the biomechanical context of stone tool production. This study seeks to better understand the biomechanics of stone tool‐making by investigating upper limb joint kinematics, focusing on the role of the wrist joint, during simple flake production. We test the hypotheses, based on studies of other upper limb activities (e.g., throwing), that upper limb movements will occur in a proximal‐to‐distal sequence, culminating in rapid wrist flexion just prior to strike. Data were captured from four amateur knappers during simple flake production using a VICON motion analysis system (50 Hz). Results show that subjects utilized a proximal‐to‐distal joint sequence and disassociated the shoulder joint from the elbow and wrist joints, suggesting a shared strategy employed in other contexts (e.g., throwing) to increase target accuracy. The knapping strategy included moving the wrist into peak extension (subject peak grand mean = 47.3°) at the beginning of the downswing phase, which facilitated rapid wrist flexion and accelerated the hammerstone toward the nodule. This sequence resulted in the production of significantly more mechanical work, and therefore greater strike forces, than would otherwise be produced. Together these results represent a strategy for increasing knapping efficiency in Homo sapiens and point to aspects of skeletal anatomy that might be examined to assess potential knapping ability and efficiency in fossil hominin taxa. Am J Phys Anthropol 143:134‐145, 2010. © 2010 Wiley‐Liss, Inc.     

Assessment of motor function of the hand in aged rhesus monkeys

In the elderly, intact motor functions of the upper extremity are critical for the completion of activities of daily living. Many studies have provided insight into age-related changes in motor function. However, the precise nature and extent of motor impairments of the upper extremity remains unclear. In the current study we have modified two tasks to assess hand/digit function in both young and aged rhesus monkeys. We tested monkeys from 9 to 26 years of age on these tasks to determine the level of fine motor performance across the adult age range. Compared to young monkeys (9–12 years of age), aged monkeys (15–26 years of age) were mildly impaired on fine motor control of the digits. These findings are consistent with previous studies that have found age-related impairment in fine motor function. However, the magnitude and extent of impairment in the current study does differ from previous findings and is likely due to methodological differences in the degree of task complexity.     

A method for assessing recovery of fine motor function of the hand in a rhesus monkey model of cortical injury: an adaptation of the Fugl–Meyer Scale and Eshkol–Wachman Movement Notation

Motor dysfunction of the upper extremity can result from stroke, cortical injury and neurological diseases and causes significant disruption of activities of daily living. While some spontaneous recovery in terms of compensatory movements does occur after injury to cortical motor areas, full recovery is rare. The distinction between complete recovery and compensatory recovery is important as the development of compensatory movements in the upper extremity may not translate into full functional use in human patients. However, current animal models of stroke do not distinguish full recovery from compensatory recovery. We have developed a Non-Human Primate Grasp Assessment Scale (GRAS) to quantify the precise recovery of composite movement, individual digit action, and finger-thumb pinch in our rhesus monkey model of cortical injury. To date, we have applied this GRAS scale to assess the recovery of fine motor function of the hand in young control and cell-therapy treated monkeys with cortical injury confined to the hand representation in the dominant primary motor cortex. We have demonstrated that with this scale we can detect and quantify significant impairments in fine motor function of the hand, the development of compensatory function during recovery and finally a return to full fine motor function of the hand in monkeys treated with a cell therapy.     

Three-dimensional motion of the upper extremity joints during various activities of daily living

Highly reliable information on the range of motion (ROM) required to perform activities of daily living (ADL) is important to allow rehabilitation professionals to make appropriate clinical judgments of patients with limited ROM of the upper extremity joints. There are, however, no data available that take full account of corrections for gimbal-lock and soft tissue artifacts, which affect estimation errors for joint angles. We used an electromagnetic three-dimensional tracking system (FASTRAK) to measure the three-dimensional ROM of the upper extremity joints of healthy adults (N=20, age range 18–34) during 16 ADL movement tasks. The ROM required for the performance of each movement was shown in terms of the joint angle at the completion of the task, using a new definition of joint angle and regression analysis to compensate for estimation errors. The results of this study may be useful in setting goals for the treatment of upper extremity joint function.     

Recognition of tennis serve performed by a digital player: comparison among polygon, shadow, and stick-figure models

The objective of this study was to assess the cognitive effect of human character models on the observer's ability to extract relevant information from computer graphics animation of tennis serve motions. Three digital human models (polygon, shadow, and stick-figure) were used to display the computationally simulated serve motions, which were perturbed at the racket-arm by modulating the speed (slower or faster) of one of the joint rotations (wrist, elbow, or shoulder). Twenty-one experienced tennis players and 21 novices made discrimination responses about the modulated joint and also specified the perceived swing speeds on a visual analogue scale. The result showed that the discrimination accuracies of the experienced players were both above and below chance level depending on the modulated joint whereas those of the novices mostly remained at chance or guessing levels. As far as the experienced players were concerned, the polygon model decreased the discrimination accuracy as compared with the stick-figure model. This suggests that the complicated pictorial information may have a distracting effect on the recognition of the observed action. On the other hand, the perceived swing speed of the perturbed motion relative to the control was lower for the stick-figure model than for the polygon model regardless of the skill level. This result suggests that the simplified visual information can bias the perception of the motion speed toward slower. It was also shown that the increasing the joint rotation speed increased the perceived swing speed, although the resulting racket velocity had little correlation with this speed sensation. Collectively, observer's recognition of the motion pattern and perception of the motion speed can be affected by the pictorial information of the human model as well as by the perturbation processing applied to the observed motion.     

Upper extremity biomechanics in computer tasks differ by gender

ObjectivesThis laboratory study examined gender differences in upper extremity postures, applied forces, and muscle activity when a computer workstation was adjusted to individual anthropometry according to current guidelines.MethodsFifteen men and 15 women completed five standardized computer tasks: touch-typing, completing a form, editing text, sorting and resizing graphical objects and navigating intranet pages. Subjects worked at a height-adjustable workstation with the keyboard on top of the work surface and the mouse to the right. Subjects repeated the text editing task with the mouse in two other locations: a “high” mouse position, which simulated using a keyboard drawer with the mouse on the primary work surface, and “center” mouse position with the mouse between the keyboard and the body, centered with the body’s center line. Surface electromyography measured muscle activity; electrogoniometric and magnetic motion analysis system measured wrist, forearm and upper arm postures; load-cells measured typing forces; and a force-sensing mouse measured applied forces.ResultsRelative forces applied to the keyboard, normalized muscle activity of two forearm muscles, range of motion for the wrist and shoulder joints and external rotation of the shoulder were higher for women (p < 0.05). When subjects were dichotomized instead by anthropometry (either large/small shoulder width or arm length), the differences in forces, muscle activity of the shoulder and wrist posture and shoulder posture became more pronounced with smaller subjects having higher values. Postural differences between the genders increased in the high mouse position and decreased in the center mouse location.ConclusionsWhen a workstation is adjusted per current guidelines differences in upper extremity force, muscle activity and postural factors still exist between genders. However, these were often stronger when subjects were grouped by anthropometry suggesting that perhaps the computer input devices themselves should be scaled to be more in proportion with the anthropometry and strength of the user.     

Motion Analytics of Trapezius Muscle Activity in an 18-Year-Old Female with Extended Upper Brachial Plexus Birth Palsy

Background  The trapezius muscle is often utilized as a muscle or nerve donor for repairing shoulder function in those with brachial plexus birth palsy (BPBP). To evaluate the native role of the trapezius in the affected limb, we demonstrate use of the Motion Browser, a novel visual analytics system to assess an adolescent with BPBP. Method  An 18-year-old female with extended upper trunk (C5–6–7) BPBP underwent bilateral upper extremity three-dimensional motion analysis with Motion Browser. Surface electromyography (EMG) from eight muscles in each limb which was recorded during six upper extremity movements, distinguishing between upper trapezius (UT) and lower trapezius (LT). The Motion Browser calculated active range of motion (AROM), compiled the EMG data into measures of muscle activity, and displayed the results in charts. Results  All movements, excluding shoulder abduction, had similar AROM in affected and unaffected limbs. In the unaffected limb, LT was more active in proximal movements of shoulder abduction, and shoulder external and internal rotations. In the affected limb, LT was more active in distal movements of forearm pronation and supination; UT was more active in shoulder abduction. Conclusion  In this female with BPBP, Motion Browser demonstrated that the native LT in the affected limb contributed to distal movements. Her results suggest that sacrificing her trapezius as a muscle or nerve donor may affect her distal functionality. Clinicians should exercise caution when considering nerve transfers in children with BPBP and consider individualized assessment of functionality before pursuing surgery.     

Vascularized fibular graft after excision of giant-cell tumor of the distal radius: wrist arthroplasty versus partial wrist arthrodesis

Several reconstructive procedures have been described for the complete defect of the distal radius that is created after a wide excision of a giant-cell tumor of bone, including hemiarthroplasty using the vascularized fibular head and partial wrist arthrodesis between a vascularized fibula and the scapholunate portion of the proximal carpal row. The objectives of this study are to compare clinical and radiographic results between the partial wrist arthrodesis and the wrist arthroplasty, and to discuss which procedure is superior. Four patients with giant-cell tumors involving the distal end of the radius were treated with en bloc resection and reconstruction with a free vascularized fibular graft. The wrists in two patients were reconstructed with an articular fibular head graft and the remaining two patients underwent partial wrist arthrodesis using a fibular shaft transfer. There was radiographic evidence of bone union at the host-graft junctions in all cases. In the newly reconstructed wrist joint, there was palmar subluxation of the carpal bones and degenerative changes in both patients. Local recurrence was seen in one patient. According to the functional results described by Enneking et al., the mean functional score was 67 percent. The functional scores including wrist/forearm range of motion in the cases with partial wrist arthrodesis were superior to those with wrist arthroplasty. A partial wrist arthrodesis using a vascularized fibular shaft graft appears a more useful and reliable procedure for reconstruction of the wrist after excision of the giant-cell tumor of the distal end of the radius than a wrist arthroplasty using the vascularized fibular head, although our study includes only a small number of patients.