A new in vivo technique for three-dimensional shoulder kinematics analysis

Objective. The field of shoulder kinematics research has long relied upon the use of cadaveric models or invasive techniques in human volunteers. In this paper, a novel method is presented that utilizes magnetic resonance imaging (MRI) and a software system called 3DVEWNIX. This method permits non-invasive, repetitive evaluation of living patients for glenohumeral kinematics analysis. The objectives of this study were twofold: to validate the quantitative accuracy of this technique; and to demonstrate glenohumeral relationships in asymptomatic volunteers during internal and external rotation of the arm. Design. The translational accuracy was first assessed by comparing known cadaveric glenohumeral translations with calculations from MR images of the cadaver. Nine asymptomatic volunteers were subsequently placed in an external shoulder positioning device in the scanner and imaged in 10° increments of actively achieved internal and external rotation. Three-dimensional reconstructions of the glenoid and humerus were used to evaluate the glenohumeral relationships in the tested positions of rotation. Results. The quantitative analysis revealed an error of 0.61 mm (SEM 0.11 mm). Examination of the volunteers demonstrated normal relationships about the glenohumeral joint in internal and external rotation. In addition, this method provided detailed images of the bony surface architecture from any perspective. These images can be transformed into a cinematic three-dimensional depiction of active shoulder rotation. Conclusion. This new technique offers an accurate, non-invasive method for assessing the normal glenohumeral relationships in shoulder kinematics. We now possess the capability to investigate the kinematics of normal and abnormal shoulder conditions non-invasively in a large patient population.     

Differences in lower-extremity kinematics between the male military personnel with and without plantar fasciitis

ObjectiveTo evaluate the factors that influence gait by comparing lower extremity kinematics during the stance phase of the gait cycle between individuals with and without plantar fasciitis.DesignA cross-sectional study.SettingMotion analysis research laboratory.ParticipantsThirty subjects with plantar fasciitis and 30 aged-matched controls.Main outcome measure(s)Range of motion of the lower extremity and multi-segment foot during gait using a three-dimensional motion analysis system.ResultsThe plantar fasciitis group showed significant differences in motion in the multi-segment foot, ankle, knee, and hip from the control group during various subphases of the stance phase. Specifically, relative to the control group, the plantar fasciitis group had more rearfoot adduction, forefoot eversion, ankle abduction, and hip abduction. They also had less midfoot dorsiflexion, forefoot dorsiflexion, knee extension, knee external rotation, and hip extension (all Ps < 0.05).ConclusionsIndividuals with plantar fasciitis exhibited more flexibility in the ankle-foot complex and poorer quality of lower-extremity movement than the group that did not have plantar fasciitis. Thus, differences in structures in both the ankle-foot complex as well as those in the hip and knee joints appear to be associated with the presence of plantar fasciitis.     

The influence of tracking marker locations on three-dimensional wrist kinematics

ObjectivesTo determine the influence of tracking marker locations on wrist kinematics during free movements and the golf swing, with the intention of recommending a solution that generates meaningful three-dimensional wrist kinematics.DesignRepeated measures.MethodsSix participants performed free movements of flexion/extension, radial/ulnar deviation and forearm supination/pronation, with a further sixteen participants performing golf drives. A passive motion capture system tracked four different marker sets located on participants’ hand and forearm segments. Variables of peak angle and range of motion were used to compare marker sets during free movements and angles at the top of the backswing and impact were compared during the golf swing.ResultsWrist marker set had a large (η² ≥ 0.557) and often significant (p ≤ 0.051) effect on the variables measured during free movements, and a mixed (η² ≥ 0.108, p ≤ 0.198) effect on wrist angles during the golf swing. Wrist axial rotation range of motion during free forearm supination/pronation revealed the greatest difference between marker sets (∼42°). The large values generated by two of the marker sets for this rotation appeared to influence the values of flexion/extension and radial/ulnar deviation during the golf swing.ConclusionsThe location of markers used to measure wrist kinematics can have a large effect on the angles generated. A solution of two markers located at the distal end of the forearm and one at the proximal, appears to minimise values of wrist axial rotation during free forearm supination/pronation and, consequently, produce more meaningful three-dimensional wrist kinematics.     

Effects of upper body strength,hand placement and foot placement on ladder fall severity

BackgroundA plurality of fatal falls to lower levels involve ladders. After a slip/misstep on a ladder, climbers use their upper and lower limbs to reestablish contact with the ladder.Research questionThis study investigates the impact of upper body strength, hand placement and foot placement on fall severity after a ladder climbing perturbation.MethodsParticipants performed upper body strength tests (breakaway and grip strength) and climbed a vertical, fixed ladder while a misstep perturbation was applied under the foot. After the perturbation, three hand placement and two foot placement responses were generally observed. Common hand placement responses included the hand moving two rungs, one rung, or did not move to a different rung. Foot placement responses included at least one foot or no feet reestablished contact with the ladder rung(s). Fall severity was quantified by the peak harness force observed after the perturbation.ResultsIncreased strength, reestablishing at least one foot on the ladder, and ascending (compared with descending) the ladder was associated with a reduction in fall severity. An interaction effect indicated that the impact of hand placement was altered by climbing direction. Moving the hand one rung during ascent and moving the hand two rungs during descent was associated with an increased fall severity. Cases where the hand decoupled from the ladder was associated with higher fall severity. Upper body strength assessed using a portable grip dynamometer was sufficient to predict fall severity.DiscussionThis study confirms the multifactor role of upper body strength, hand placement and foot placement in preventing falls from ladders. Furthermore, a portable dynamometer shows potential to screen for high-risk individuals. Results of this investigation may guide targeted interventions to prevent falls from ladders.     

Hallux rigidus affects lower limb kinematics assessed with the Gait Profile Score

BackgroundPrevious research showed that hallux rigidus (HR) affects foot and ankle kinematics during gait. It is unclear if HR affects lower limb kinematics as well.Research questionDoes HR affect lower limb kinematics, and if so, is gait deviation correlated with patient-reported outcome?MethodsThis was a retrospective case-control study, including 15 HR patients and 15 healthy controls who underwent three-dimensional gait analysis by using the Plug-in Gait lower body model. The Gait Profile Score (GPS), a gait index score describing gait deviation and composed out of nine Gait Variable Scores (GVS), and intersegmental range of motion of lower limb joints were assessed. Patient-reported outcome was assessed with the Foot Function Index (FFI) and Manchester-Oxford Foot Questionnaire (MOXFQ). Data were analysed with Student t-tests and Spearman rank correlations.ResultsHR significantly affects gait, reflected by a higher GPS in HR subjects as compared to healthy controls. Gait deviation was seen in ankle flexion (GVS_{ankle flexion}) and to a lesser extent in pelvic rotation (GVS_{pelvic rotation}). Interestingly, these differences were not detected when lower limb kinematics were evaluated by comparing the intersegmental ranges of motion of these joints. Positive correlations were present between patient-reported outcomes and GPS, especially functional subdomains, were positively correlated with GPS and GVS_{ankle flexion}.SignificanceThis study demonstrated that HR, next to foot kinematics, additionally affects lower limb kinematics evaluated with an objective gait index score, i.e. GPS. The positive correlation between the GPS and patient-reported outcome can be seen as the first step in defining whether objectively measured gait indices can be used in considering surgery since most of the benefit of surgery will be expected in the patients with most gait deviation.     

Ultrasonographic evaluation of the iatrogenic peripheral nerve injuries in upper extremity

The aim of our study is to assess the efficiency of the ultrasonography (US) in the diagnosis of peripheral nerve injury. This study includes nine patients (six radial, one median and two posterior interosseous (PIO) nerves) with peripheral nerve injury diagnosed by clinical and electrophysiological methods in the last 3 years. Preoperatively, an ultrasonographic examination was performed and correlated with physical exam and surgical findings. Five patients, who were diagnosed as peripheral nerve transection by US, underwent surgery. The ultrasonographic findings were concordant with the intraoperative findings. Axonal swelling alone was found in the remaining three patients, who were treated conservatively because of preserved nerve continuity without display of nerve compression. In one patient, we were unable to visualize the nerve due to obesity and soft tissue edema. High-resolution US provide morphological information about the exact location, intensity and extent of the nerve injuries, facilitating the preoperative diagnosis. Thus, US may be a useful method for planning optimal treatment strategy in especially iatrogenic nerve injuries.     

多节变形固定板在上肢创伤外固定治疗的应用研究

目的探讨自行研制的多节变形固定板,应用于上肢创伤外固定治疗的效果。方法216例上肢创伤患者,其中男138例,女78例;年龄7～81岁,平均61岁。随机分成多节变形固定板治疗组110例,高分子树脂固定治疗组106例,疗效按HospitalforSpecialistSurgeon(HSS)肘关节计分法对两种不同固定方法进行比较,并分析患者并发症发生率和满意率。结果多节变形固定板治疗组骨折愈合期并发症发生率低(4.5%,5/110),患者满意率高(95.5%,105/110);而高分子树脂固定治疗组并发症发生率高(35.8%,38/106),患者满意率低(64.2%,68/106)。两组并发症发生率、患者满意率比较,差异有统计学意义(P<0.05)。HSS肘关节计分,多节变形固定板治疗组平均97.4,高分子树脂固定治疗组平均74.9(P<0.05)。结论多节变形固定板适应于上肢创伤的外固定治疗,与高分子树脂固定相比,除对患部具有相同的外固定作用外,还具有随时调节变形的功能,而且操作简便、重量轻、透气好,患者骨折愈合期并发症发生率低、满意率高,是临床骨科创伤中较理想的外固定物。     

Deep vein thrombosis of the upper extremity: intra- and interobserver study of digital subtraction venography

Our objective was to assess the inter-observer and intra-observer agreement in the interpretation of digital subtraction venography (DSV) in patients with suspected deep vein thrombosis of the upper extremity (DVTUE). Prospectively, 62 consecutive DSV studies in 54 patients with clinically suspected DVTUE were included. Hard copies were presented without demographic data or original report. All venograms were read twice, at 3-month intervals, by an interventional vascular radiologist (observer 1) and an experienced general radiologist (observer 2). Consensus reading took place in the presence of a third experienced interventional radiologist. Inter-observer and intra-observer agreement were assessed using kappa statistics. Initial reading in 62 venograms showed an inter-observer agreement of 71% (kappa 0.48). The inter-observer agreement of the second reading was 83% (kappa 0.71). The agreement with the consensus report ranged from 76 to 94%. The intra-observer agreement for the first and second observer was 94% (kappa 0.89) and 76% (kappa 0.56), respectively (p<0.01). Digital subtraction venography has moderate to excellent intra- and inter-observer agreement, suggesting that digital subtraction venography is reliable for the diagnosis of DVTUE. Electronic Publication     

An extended index to quantify normality of gait in children

Clinical gait analysis aims to quantify and assess the mechanics of walking and identify deviations from ‘normal’ movement patterns. To facilitate the use of clinical equipment, protocols are required to process data and produce a few meaningful summary measurements which can, in turn, be used to flag gait abnormalities. Earlier work produced a one-dimensional index of gait, calculated from sagittal hip, knee and ankle rotation angle patterns. The objective of this study was to extend the original index, incorporating kinematic and kinetic data from multiple planes, while allowing for correlations between component measures. A one-dimensional index of normal gait was developed, based on normative gait data (N = 45 children, aged 3–13 years). The new one-dimensional index was calculated using correlation patterns between seven component indices, each of which has diagnostic interpretation. The effectiveness of the new index was tested using immature normative data (N = 14) and hypotonic data (N = 10). Approximately 85% of immature normative children and 100% of hypotonic children were classified as either unusual or extreme by the one-dimensional index. These data reduction protocols improve objective gait analyses in the clinical setting.     

Local thrombolytic infusion in arterial ischemia of the upper limb: Mid-term results

Purpose Evaluation of local thrombolytic infusion in arterial ischemia of the upper limbs.Methods Thirteen patients, 4 male and 9 female, aged 31 to 83 (mean 63.6) were treated. The occlusion was determined to be thrombosis in 6 and cardiogenic embolism in 7 patients. Duration of symptoms varied from 2 hours to 3 weeks. Streptokinase (SK) was used in 4 patients at a rate of 5,000 units per hour, Urokinase (UK) in 8 patients at a rate of 75,000 units per hour and r-tPA in 1 patient at a rate of 4 mg per hour for 5 hours. Mean duration of infusion was 16 hours (3–39 hr) for SK and 35 hours (10–93 hr) for UK. Heparin was administered concommitantly at a rate of 300 to 1000 units per hour without a loading dose.Results Clinical limb salvage was obtained in all patients. Angiography showed complete clot dissolution and full clinical recovery in 8 patients. Five patients had partial clot clearing, 3 with full recovery and 2 with modest residual symptoms. One patient incurred a catheter-related transient cerebral ischemia, 1 patient a large arm hematoma from catheter-related trauma and 6 patients a moderate puncture site hematoma. Three patients died during the first month due to stroke, ventricular fibrillation, or cardiac failure, and 1 patient after 22 months from cardiac failure. No limb ischemia recurred during a follow-up of 1 to 5 years.Conclusion Local thrombolytic infusion is a safe and effective treatment for acute and subacute upper extremity arterial thromboembolism.     

Accuracy of upper abdominal ultrasound examinations by sonographers in Norway

BackgroundNorway educated their first sonographers in 2008. The Norwegian Society of Radiology made a public statement discouraging Norwegian hospital departments of radiology to employ sonographers. Few sonographers work in Norway.PurposeTo investigate the accuracy of sonographers educated in Norway and to assess the quality of their work.Material and method244 patients were included in a prospective controlled study involving five sonographers and four advanced radiologists working in three separately located radiological departments belonging to the same hospital trust. All patients underwent ultrasound examinations by a sonographer and subsequently by an advanced radiologist who assessed the work of the sonographer.ResultsThe sonographers demonstrated a sensitivity of 0.97 and a specificity of 0.93, and there was an agreement of 0.9 (Cohens Kappa test) between the sonographers and the advanced radiologists. 95.1% of the sonographers' main findings were consistent with those of the radiologists. 99.2% of their examinations were found to be “best” or “medium” in the overall evaluation by the advanced radiologists. The advanced radiologists reported to have been mistaken in 3.3% of the cases where they considered the sonographers' results to be correct. If examined by the sonographers alone, pathology would have been undetected in 1.64% of the cases.ConclusionNorwegian sonographers are able to differentiate negative from positive findings in the upper abdomen, and demonstrate accuracies similar to experienced radiologists.     

The Arm Profile Score: A new summary index to assess upper limb movement pathology

Although three-dimensional movement analysis is being increasingly used to evaluate upper limb (UL) movements, information on how to interpret the complex data is still missing. This paper introduces a new summary index, the “Arm Profile Score” (APS), to evaluate the severity of UL movement pathology based on kinematic data, similar to the “Gait Profile Score”. The APS is calculated from the root mean square (RMS) difference between kinematic data of the individual child with UL movement deficits and average data from typically developing children. The APS can be decomposed into 13 Arm Variable Scores (AVS), representing the different joint angles. The APS, together with the AVSs form the “Arm Movement Analysis Profile” (A-MAP).Face and construct validity were established for eight UL tasks in a group of 20 children with hemiplegic cerebral palsy (HCP). Intra-session variability was low for the different tasks, with median inter-quartile ranges below 2°. Correlation analysis showed few significant correlations between the individual AVSs and between the AVS and APS, implying that the A-MAP provides considerably more information compared to the APS only. The APS also showed good correlations with the House classification, and with measures of muscle tone, manual muscle strength and grip strength.This study provides a sound base to use the APS to evaluate UL movement pathology in children with HCP. Further study will need to confirm its value as an outcome measurement.     

Characterization of normative angular joint kinematics during two functional upper limb tasks

BackgroundOptical motion capture is a powerful tool for assessing upper body kinematics, including compensatory movements, in different populations. However, the lack of a standardized protocol with clear functional relevance hinders its clinical acceptance.Research questionThe objective of this study was to use motion capture to: (1) characterize angular joint kinematics in a normative population performing two complex, yet standardized upper limb tasks with clear functional relevance; and (2) assess the protocol’s intra-rater reliability.MethodsTwenty non-disabled adults performed the previously developed Pasta Box Task and Cup Transfer Task. The kinematics of the upper body were captured using an optoelectronic motion capture system and rigid plates with reflective markers. Angular joint trajectories, peak angle, range of motion (RoM), and peak angular velocity were extracted for the trunk, shoulder, elbow, forearm, and wrist. Intra-class correlation was used to assess the intra-rater reliability of the kinematic measures.ResultsBoth tasks required minimal trunk motion. Cross-body movements required greater RoM at the trunk, shoulder, and elbow joints compared to movements in front of the body. Reaches to objects further away from the body required greater trunk and elbow joint RoM compared to reaches to objects closer to the body. Transporting the box of pasta required the wrist to maintain an extended position. The two different grasp patterns in the Cup Transfer Task forced the wrist into a flexed and ulnar-deviated position for the near cup, and an extended and radial-deviated position for the far cup. For both tasks, the majority of measures displayed intra-class correlation values above 0.75, indicating good reliability.SignificanceOur protocol and functional tasks elicit a degree of movement sensitivity that is not available in current clinical assessments. Our study also provides a comprehensive dataset that can serve as a normative benchmark for quantifying movement compensations following impairment.     

Cross-validation of marker configurations to measure pelvic kinematics in gait

External tracking of three-dimensional lumbar spine and pelvic oscillations is a method recently used in clinical gait analysis. This investigation validated the use of plate mounted marker configurations overlying the median sacral crest (S1) against single marker sets placed over the anterior and posterior superior iliac spine for the assessment of angular kinematic profiles of the pelvis during treadmill ambulation. Rotational pelvic movements of 12 asymptomatic male subjects were recorded by a 3D-ultrasonic measurement device using four single markers placed over the anterior and posterior superior iliac spine. Additionally, three external ultrasound markers were mounted on a rigid plate placed over S1. No significant differences (P>0.05) for movement variability or range of motion between marker configurations could be obtained. It could be concluded that trucking of plate-mounted markers overlying S1 seems to be adequate for monitoring rotational pelvic motions in normal gait.     

Clinical effect of radiation synovectomy of the upper extremity joints: a randomised,double-blind,placebo-controlled study

Purpose To compare the clinical efficacy of radiosynoviorthesis (RSO) with intra-articular radionuclide plus glucocorticoid (GC) injection (group A) with that of placebo plus GC injection (group B) for the treatment of persistent synovitis in joints of the upper extremity. Methods At baseline and at 6 and 12 months after intra-articular injection, six clinical parameters were scored. Changes in clinical values over time were summed to provide a change composite index (CCI), ranging from 0 (no effect) to 12 (maximal effect). A CCI ≥6 was considered to indicate successful treatment. Differences in response rate and CCI between groups A and B were examined. Regression analyses were performed to explore whether baseline variables could predict therapeutic effect. Results Sixty-eight joints in 44 patients were treated. Six months after intra-articular injection, response rates (CCI ≥6) were 69% (25/36) in group A and 29% (9/31) in group B (p=0.001). The mean CCIs ± standard deviation at 6 months were 6.7±3.2 for group A and 3.3±3.8 for group B (p=0.001). At 12 months the response rates were 69% (25/36) in group A and 32% (8/25) in group B (p=0.004). The mean CCIs at 12 months were 6.8±3.3 for group A and 4.2±4.7 for group B (p= 0.046). None of the baseline variables predicted the therapeutic effect. Conclusion RSO (radionuclide plus GC) of upper extremity joints with immobilisation for 72 h shows a significantly better response rate than placebo plus GC in patients with persistent synovitis after at least one failed outpatient intra-articular GC injection.     

Reliability and validity of a return to sports testing battery for the shoulder

ObjectiveTo determine the validity, intra- and inter-rater, and absolute reliability of a return to sport testing battery for the shoulder in a healthy cohort.DesignCross-sectional design. All participants completed a battery of strength (isokinetic, isometric, and repetition to failure) and functional assessments on two occasions. Concurrent validity to isokinetic testing was assessed, and intra-rater, inter-rater, and absolute reliability were established for all assessments.SettingControlled clinical environment.ParticipantsThirty healthy adults active in recreational sports participated, mean age 24.0 ± 1.6 years;Main outcome measuresCorrelations (Pearson’s r), reliability (Intraclass Correlation Coefficient), Standard error of the measurement, Minimal detectable change.ResultsCorrelations to isokinetic assessments at 60° & 180°/second were moderate to strong for isometric (r: 0.68–0.80) and functional testing (r: 0.55–0.83) and weak for repetition to failure testing (r: 0.37–0.74). All isokinetic (ICC: 0.88–0.94), isometric (ICC: 0.83–0.94), and functional assessments (ICC: 0.80–0.92) had good to excellent intra-rater reliability, while repetition to failure testing had poor to moderate reliability (ICC: 0.48–0.57). The inter-rater reliability of the isometric assessments was moderate to excellent (ICC: 0.71–0.92) across movements. Expressed as a percentage of the mean, the standard error of the measurement ranged from 7% to 25% and the minimal detectable change ranged from 20% to 69% across all assessment methods.ConclusionThe isokinetic, isometric, and functional assessments used in this return to sports testing battery demonstrates acceptable validity and reliability. Further refinement to the methods used to assess muscular endurance is needed to improve reliability. This study offers clinicians information that can be utilized in clinical decision-making as it relates the testing battery’s psychometric properties.     

The 6DOF knee kinematics of healthy subjects during sloped walking compared to level walking

BackgroundLevel Walking is a frequent functional movement during daily life. However, sloped walking is also common. Exploring 6DOF knee kinematics during sloped walking is important. It provides a reference for the rehabilitation, safety, and knee health of patients with knee diseases walking on sloped surfaces.Research questionThe study aimed to explore 6DOF knee kinematics characteristics during sloped walking compared to level walking. We hypothesized that tibial anteroposterior translation and flexion angle (the sagittal plane) were significantly different from those of level walking.MethodsOne hundred young, healthy adults (50 males and 50 females) were recruited for this study. A three-dimensional gait analysis system was used to collect 6DOF knee kinematics during level and sloped walking. The slope was set to ± 15% when the sloped walking was performed.ResultsSloped walking mainly increased knee flexion angle (upslope, 2.5–26.2°, 1–100% gait cycle (GC), p < 0.05; downslope, 1.7–11.9°, 15–95% GC, p < 0.05) and anterior tibial translation (upslope, 0.7–4.1 mm, 3–54% GC & 0.6–2.1 mm, 80–94% GC; downslope, 1.0–2.2 mm, 21–69% GC) in the participants’ knees. However, participants' other 4DOF knee kinematics during sloped walking were significantly different from those during level walking (p < 0.05). Participants had ‘drastically changeable’ knee kinematic alterations in the transverse and coronal plane (the other 4DOF knee kinematics) during sloped walking compared to level walking.SignificanceOur results confirmed the hypothesis. Sloped walking significantly increased anterior tibial translation (in most GC) and flexion angle. These kinematic changes in healthy subjects should be evaluated and further explored for patients with knee diseases, such as anterior cruciate ligament deficiency. Our findings are meaningful for their rehabilitation or safety or knee health while walking on sloped surfaces. Our study may provide a pilot reference for the 6DOF knee kinematic exploration of sloped walking.     

Effects of medially wedged insoles on the biomechanics of the lower limbs of runners with excessive foot pronation and foot varus alignment

BackgroundExcessive foot pronation during running in individuals with foot varus alignment may be reduced by medially wedged insoles.Research questionThis study investigated the effects of a medially wedged insole at the forefoot and at the rearfoot on the lower limbs angles and internal moments of runners with excessive foot pronation and foot varus alignment.MethodsKinematic and kinetic data of 19 runners (11 females and 8 males) were collected while they ran wearing flat (control condition) and medially wedged insoles (insole condition). Both insoles had arch support. We used principal component analysis for data reduction and dependent t-test to compare differences between conditions.ResultsThe insole condition reduced ankle eversion (p = 0.003; effect size = 0.63); reduced knee range of motion in the transverse plane (p = 0.012; effect size = 0.55); increased knee range of motion in the frontal plane in early stance and had earlier knee adduction peak (p = 0.018; effect size = 0.52); reduced hip range of motion in the transverse plane (p = 0.031; effect size = 0.48); reduced hip adduction (p = 0.024; effect size = 0.50); reduced ankle inversion moment (p = 0.012; effect size = 0.55); and increased the difference between the knee internal rotation moment in early stance and midstance (p = 0.012; effect size = 0.55).SignificanceInsoles with 7˚ medial wedges at the forefoot and rearfoot are able to modify motion and moments patterns that are related to lower limb injuries in runners with increased foot pronation and foot varus alignment with some non-desired effects on the knee motion in the frontal plane.