Yes / Assistive and robotic training devices are increasingly used for rehabilitation of the hemiparetic arm after stroke, although applications for the wrist and hand are trailing behind. Furthermore, applying a training device in domestic settings may enable an increased training dose of functional arm and hand training. The objective of this study was to assess the feasibility and potential clinical changes associated with a technology-supported arm and hand training system at home for patients with chronic stroke. Methods: A dynamic wrist and hand orthosis was combined with a remotely monitored user interface with motivational gaming environment for self-administered training at home. Twenty-four chronic stroke patients with impaired arm/hand function were recruited to use the training system at home for six weeks. Evaluation of feasibility involved training duration, usability and motivation. Clinical outcomes on arm/hand function, activity and participation were assessed before and after six weeks of training and at two-month follow-up. Results: Mean System Usability Scale score was 69 % (SD 17 %), mean Intrinsic Motivation Inventory score was 5.2 (SD 0.9) points, and mean training duration per week was 105 (SD 66) minutes. Median Fugl-Meyer score improved from 37 (IQR 30) pre-training to 41 (IQR 32) post-training and was sustained at two-month follow-up (40 (IQR 32)). The Stroke Impact Scale improved from 56.3 (SD 13.2) pre-training to 60.0 (SD 13.9) post-training, with a trend at follow-up (59.8 (SD 15.2)). No significant improvements were found on the Action Research Arm Test and Motor Activity Log. Conclusions: Remotely monitored post-stroke training at home applying gaming exercises while physically supporting the wrist and hand showed to be feasible: participants were able and motivated to use the training system independently at home. Usability shows potential, although several usability issues need further attention. Upper extremity function and quality of life improved after training, although dexterity did not. These findings indicate that home-based arm and hand training with physical support from a dynamic orthosis is a feasible tool to enable self-administered practice at home. Such an approach enables practice without dependence on therapist availability, allowing an increase in training dose with respect to treatment in supervised settings. / The SCRIPT (Supervised Care & Rehabilitation Involving Personal Telerobotics) project was partly funded by the European Commission Seventh Framework Program under grant agreement no. FP7-ICT-288698.

L’utilisation à long terme d’un fauteuil roulant après une lésion de la moelle épinière (LMÉ) est associée à une augmentation de la sédentarité et une diminution du niveau d’activité physique. Malheureusement, ces changements mènent à un cycle de déconditionnement qui contribue à l’augmentation de risques, au développement ou à l’aggravation de problèmes secondaires de santé touchant les membres supérieurs et inférieurs. En ce sens, 60 % de la population avec LMÉ présentent des douleurs et déficiences aux membres supérieurs. Aux membres inférieurs, l’ostéoporose est fréquente et chaque année, 10 % de la population avec LMÉ subit des fractures. Conséquemment, des répercussions sur la fonction et la qualité de vie en résultent. Pour contrer ce cycle vicieux, l’activité physique est recommandée. La marche au sol assistée par un exosquelette robotisé est une intervention prometteuse puisqu’elle nécessite des efforts musculaires aux membres supérieurs et augmente la mise en charge aux membres inférieurs. Toutefois, des cas de fractures aux membres inférieurs ont été rapportés. Ainsi, cette thèse visait à élaborer un algorithme d’entraînement préliminaire pour minimiser les risques de fractures pendant l’intervention, et à explorer les effets sur la force musculaire aux membres supérieurs, la performance et les habilités auto-rapportées en fauteuil roulant, et des marqueurs de force et de remodelage osseux aux membres inférieurs. L’algorithme d’entraînement a été développé par un consensus d’experts en suivant les critères de densité minérale osseuse de l’Organisation mondiale de la Santé. Dix individus (4 femmes, 46±11 ans) avec une LMÉ chronique (≥18 mois), qui utilisent un fauteuil roulant comme principale mode de locomotion, ont été recrutés pour suivre un programme de marche (16 semaines, 1 à 3 séances/sem). Les mesures suivantes ont été effectuées pré et post intervention : la force musculaire fonctionnelle (poussées/tirées sur une roue de fauteuil roulant, force de préhension), la masse musculaire (absorptiométrie), et la force relative (force/masse) aux membres supérieurs ; des tests de performance (vitesse de propulsion naturelle et maximale, slalom) et un questionnaire d’habilités en fauteuil roulant (Wheelchair Skills Test Questionnaire) ; l’ostéodensitométrie et la géométrie osseuse (CT-scan) aux membres inférieurs, ainsi que des marqueurs sanguins de remodelage osseux (ostéocalcine, télopeptide-C). La taille d’échantillon étant limitée (tests non paramétriques), un changement était significatif si : p<0,1 ; taille d’effet ≥0,5 ; et variation relative >5 %. D’une part, l’algorithme préliminaire a permis de moduler le volume d’entraînement en fonction du profil osseux (ostéoporose, ostéopénie et préservé) et aucun cas de fracture n’a été rapporté pendant le programme d’entrainement. D’autre part, suivant l’intervention, la force et la masse musculaire aux membres supérieurs sont demeurées stables. Néanmoins, la vitesse de propulsion naturelle a augmenté. Par ailleurs, une réponse osseuse prometteuse a été observée aux membres inférieurs (fémur : augmentation du contenu minéral osseux, et des indexes de résistance à la compression et à la flexion, mais réduction de l’épaisseur de l’os cortical ; tibia : augmentation de la section transversale corticale, et de l’index de résistance à la torsion). Ainsi, à la lumière des résultats, des interventions multimodales (ex. : combinées à des exercices plus ciblés aux membres supérieurs ou la pharmacothérapie pour l’ostéoporose aux membres inférieures) pourraient s’avérer nécessaires pour optimiser les effets potentiellement bénéfiques d’un tel programme, tant aux niveaux des membres supérieurs et inférieurs que sur la fonction quotidienne. / Long-term wheelchair use following a spinal cord injury (SCI) is associated with increased sedentary behaviour and decreased levels of physical activity. Unfortunately, these changes lead to a cycle of deconditioning that increases the risk, development, and/or aggravation of one or more secondary health conditions affecting the upper and lower limbs. In the upper limbs, pain and impairments are present in up to 60% of the SCI population. In the lower limbs, osteoporosis is commonly experienced. Further, each year up to 10% of this population experience fractures. Consequently, negative repercussions on function and quality of life are experienced. To counter this vicious cycle, physical activity is recommended. Overground exoskeleton-assisted walking is a promising intervention to help counter the cycle, since it requires muscular efforts in the upper limbs and increases weight bearing on the lower limbs. However, such an intervention is not without risk: cases of fractures in the lower limbs have been reported. Thus, this thesis aimed to develop a preliminary training algorithm to minimize the risk of fractures during the intervention, and to explore the effects of exoskeleton-assisted walking on upper limb muscle strength, performance and self-reported wheelchair skills, and strength and bone remodeling markers in the lower limbs. First, the training algorithm was developed by expert consensus following bone mineral density criteria from the World Health Organization. Thereafter, 10 individuals (4 women, 46±11 years) with chronic SCI (≥18 months), who use a wheelchair as their primary mode of locomotion, were recruited into the walking program (16 weeks, 1 to 3 sessions/week). The following measurements were taken pre and post intervention: functional muscle strength (pushing/pulling on a wheelchair wheel, grip strength), muscle mass (absorptiometry), and relative strength (strength/mass) of the upper limbs; wheelchair performance tests (natural and maximal propulsion speed, slalom) and skills (Wheelchair Skills Test Questionnaire); bone densitometry and bone geometry (CT-scan) in the lower limbs, as well as blood markers of bone remodeling (osteocalcin, telopeptide-C). Since the sample size was limited (non-parametric tests), a significant change was observed if three criteria were met: p<0.1; effect size ≥0.5; and relative change >5%. The preliminary algorithm modulated the training volume according to bone profile (osteoporosis, osteopenia and preserved) and no cases of fracture occurred. Following the intervention, strength and muscle mass in the upper limbs remained stable whereas only natural propulsion speed increased. Overall, a promising bone response was measured in the lower limbs (femur: increased bone mineral content, bone strength index, and stress-strain index, but decreased cortical bone thickness; tibia: increased cortical cross-sectional area, and polar moment of inertia). Ultimately, multimodal interventions (e.g., combining with specific upper limb exercises or pharmacotherapy for osteoporosis in the lower limbs) may be necessary to optimize the potential beneficial effects of such a program, both on the upper and lower limbs, and on function.

A 53 year-old male presented with a one-day history of a swollen arm and dull, aching pain in the right upper extremity. The patient reported commencing exercising daily over the prior week with a modified, oscillating dumbbell; commonly referred to as a Shake Weight. Imaging revealed an occlusive thrombus in the right axillary, proximal brachial and basilic veins. The patient was treated with a 24-hour tPA infusion followed by mechanical thrombectomy, balloon angioplasty, and stent placement for a residual thrombus and stenosis. The patient was discharged the following day on warfarin and aspirin. This is the first report of effort-induced thrombosis of the upper extremity following the use of a modified, oscillating dumbbell. Due to the growing popularity of modified dumbbells and the possible risk for axillary vein thrombosis, consideration should be made to caution consumers of this potential complication.

Upper extremity splinting is a popular treatment method for a range of conditions, such as rheumatoid arthritis. The intent of this treatment approach is multifaceted, but fundamentally, the provision of tools to enable and encourage patients to carry out everyday activities and to improve their quality of life is paramount. However, the aesthetic and functional limitations of wrist immobilisation splints demonstrate various weaknesses in terms of wear duration and frequency. Patient compliance is often compromised due to a number of factors, including the perceived stigma associated with assistive devices. Additive Manufacturing (AM) has proved its worth in a number of applications relating to the design of assistive devices; builds of complex, bespoke fitting geometries make AM an ideal fabrication method for upper extremity splints. However, recent advances in system technology to enable multi-material builds have been limited in this field, and a distinct need for a specialised three-dimensional (3D) Computer Aided Design (CAD) software approach is required to allow therapists to design splints for AM. Furthermore, the intent to keep practising therapists at the forefront of splint prescription is of utmost importance. This research proposes a digitised splinting approach, specifically through development of a 3D CAD software strategy to allow therapists to capture their design intent without compromising creativity. Furthermore, the approach proposes the exploration of AM build capabilities by allowing the integration of more creative features, such as aesthetically pleasing lattice structures for increased skin ventilation. The approach also proposes the integration of multiple materials to replicate and improve upon current splint design and fabrication practises. The approach therefore explores an exciting new paradigm for upper extremity splinting, the driving characteristics of which have not been proposed before as a collective medium. This research describes the feasibility of capturing therapists design intent in a 3D CAD virtual environment, whilst capturing therapists opinions of the approach with suggestions for future research and development. Results concluded that therapists were excited by the proposed transition in AM splinting, but that significant development is required elsewhere to establish a supporting infrastructure in order to make the approach a viable option in future upper extremity splinting.

Many women who have experienced breast cancer (BC) report continued impairments in upper extremity (UE) function beyond the time required for normal healing after surgical treatment. Most research supporting this has not made comparisons between survivors of breast cancer (BCS) to a sample of healthy women. This lack of comparison to a healthy cohort prevents an understanding of whether continued deficits in UE function are due to normal aging or the BC treatment. The purpose of this research was to compare quality of life (QOL) and UE function among long term breast cancer survivors and similar aged women without cancer. Both self-report and objective measurements of UE function were used to create an understanding of UE functional abilities in both populations. Data on self-reported QOL and UE function, ROM, strength, and muscular endurance were collected on 79 healthy women ages 30-69, stratified by decade. Comparisons between decades and between dominant and non-dominant limbs were made. Findings supported no effect of aging on measures, and that dominance does affect some objective measures of motion, strength, and muscular endurance. A group of 42 survivors of breast cancer (BCS) were compared to the data from healthy controls on the same measures. BCS reported lower levels of QOL and UE function, and demonstrated less motion and strength than the healthy cohort, particularly when cancer occurred on the non-dominant limb. The values of the measures, however, are not clinically relevant, and reveal that BCS 6 years after treatment recover UE function to levels similar to healthy controls. In view of a lack of clinically feasible measures of UE muscular endurance, a new test to assess this was designed and implemented: the modified Upper Body Strength and Endurance test (mUBSE). It was believed this new test would be less variable than the Functional Impairment Test – Hand and Neck, Shoulder, Arm – FIT-HaNSA. Seventeen BCS and 17 matched controls were compared on the mUBSE and FIT-HaNSA. Findings were similar for both tests. Furthermore, BCS who are 6 years post BC treatment appear to recover muscular endurance levels to normal ranges.

The wrist is one of the most complex joints in the human body. As such, the wrist joint is difficult to model due to the number of bones involved and its intricate soft tissue interactions. Many studies have attempted modeling the wrist previously; however, the majority of these studies simplify the joint into two-dimensions or idealized mechanical joints to reduce the complexity of the simulation. While these approaches still yield valuable information, the omission of a third-dimension or geometry defined movements limits the models’ usefulness in predicting joint function under non-idealized conditions. Therefore, the goal of this study was to develop a computational model of the wrist joint complex using commercially available software, whereby joint motion and behavior is dictated by highly accurate three-dimensional articular contact, ligamentous constraints, muscle loads, and external perturbations only. As such, a computational model of the human wrist was created using computed tomography (CT) images of a cadaver right upper extremity. Commercially available medical imaging software and three-dimensional computer aided design (CAD) software were used to reconstruct the osteoarticular surfaces and accurately add soft tissue constraints, as well as calculate kinematic motion simulations. The model was able to reproduce physiologic motion including flexion/extension and radial/ulnar deviation. Validation of the model was achieved by comparing predicted results from the model to the results of a published cadaveric experiment that analyzed wrist function under effects of various surgical procedures. The model was used to replicate the exact testing conditions prescribed for the experiment, and the model was able to accurately reproduce the trends and, in many instances, the magnitudes of the range of motion measurements in the study. Furthermore, the model can now be used to predict the magnitudes for the joint contact forces within the wrist as well as the tension developed in ligaments in hopes locating potential areas of concern after these surgical procedures have been conducted, including further development of arthritis in the wrist and ligament breakdown.

The goal of this study was to evaluate biomechanical differences between healthy subjects and those with ankle instability during the gradual onset of lower extremity fatigue from a landing activity. An understanding of these differences is needed in order to prevent future injury to or further debilitation in individuals with ankle instability. A functional fatiguing activity was designed to focus fatigue on the quadriceps muscles, as those are the muscles most frequently fatigued during sport. Measures were taken throughout the progression of fatigue with a force plate and a motion tracking system and included vertical ground reaction force and lower extremity kinetics, kinematics, and energetics. The time required to reach self-reported fatigue and a balance assessment, the Star Excursion Balance Test, before and after the onset of fatigue was also recorded. Significant differences were observed between groups in peak ground reaction force, ground reaction force impulse, and frontal plane ankle joint impulse. Results indicated that subjects with ankle instability not only exhibited a different baseline for most measurements than normal subjects, but also managed the progression of fatigue differently. With this information and information from further studies, recommendations and/ or training schemes could be made and implemented to help those with ankle instability avoid recurrent injuries.

Author: Bc. Michaela Richtrová Tittle: Golf swing in subjects with amputation of lower extremity Objectives: The study aims at evaluation of the technique of golf swing used by patients with a different type and level of lower extremity amputation as compared to able-bodied golfers. Another objective is determination of the relation between individual phases of the golf swing and weight transfer, using different golf clubs, as compared to able-bodied golfers. Method: By its topic the work is a pilot study. The research has been divided into three descriptive case studies. The experimental group included two amateur golfers and one professional golfer. The control group was represented by an able-bodied golfer. Evaluation of kinematic parameters (trajectory of shoulders, hips, knee joints) was based on the Qualysis Motion Capture System. Evaluation of dynamic parameters (weight transfer) in the course of golf swing was made using two dynamometric Kistler platforms. Results: The measuring has demonstrated that in terms of both kinematics and dynamics, the mode of movement of a patient with a trans-tibial amputation during a golf swing corresponds to that of an able-bodied golfer. The same results were achieved by the patient also with the use of another type of golf club. A change, both in terms of...

SAMMANFATTNING Bakgrund: Incidensen av löprelaterade skador varierar mellan 19.4-79.3% varje år. Knäsmärta är den vanligaste skadeorsaken. Ökad stegfrekvens har visat sig minska fotisättningsbelastning mot underlaget, minska vertikal förflyttning av tyngdpunkten och belastning mot leder i nedre extremitet. Syfte: Syftet med denna studie var att undersöka om 10-15% stegfrekvensökning vid föredragen hastighet minskar knäsmärta hos vuxna löpare på motionsnivå. Design: Pilotstudie Metod: Stegfrekvens hos 15 vuxna försökspersoner med knäsmärta under eller efter långdistanslöpning undersöktes vid en föredragen hastighet. Stegfrekvensen ökades med 10-15% vid samma hastighet och de fick därefter springa med den nya frekvensen i två veckor. En metronom styrde frekvensen. Knee Osteoarthritis Outcome Score (KOOS) samt upplevd knäsmärta mättes med Numeric Rating Scale, (NRS). Mätningar gjordes före och efter träningsperioden. Resultat: En signifikant reducering av knäsmärta uppmättes på NRS (p=0.001). Signifikant förbättring av KOOS (p=0.004), KOOS funktion, fritid och idrott (p=0.007) och KOOS livskvalité (p=0.023) vid ökad stegfrekvens på 10-15% efter två veckors träning. Slutsats: Resultatet av denna pilotstudie visar att det förefaller vara viktigt att analysera stegfrekvens som första rehabiliteringsinsats hos motionslöpare med knäsmärtor. / ABSTRACT Background: The incidence of running related injuries every year ranges from 19.4-79.3%. Knee pain is the most common injury. It has been shown that increased step-rate reduces peak ground forces, vertical displacement of the centre of mass and joint loads in the lower extremity. The purpose of this study was to investigate if 10-15% increased step-rate at self selected speed could decrease knee pain in adult recreational runners. Design: Pilot study Methods: 15 adult recreational runners with knee pain during or after training sessions were recruited. Step rate/min were measured at self selected speed. Step-rate was increased by 10-15% at the same speed. The participants used a metronome to remember the frequency in a 2 week training session and then we did a follow up. Knee Osteoarthritis Outcome score (KOOS) and numeric rating scale (NRS) were measured before and after the training session.   Results: There was a significant reduction in knee pain on the NRS (p=0.001). Significant improvement in KOOS (p=0.004), KOOS sport/recreation (p=0.007) and KOOS knee related quality of life (p=0.023) after two week training session with increased step rate 10-15% at a self selected speed. Conclusion: The results from this pilot study implies that it is important to analyze step-rate as a first intervention in physical therapy when we rehabilitate long distance runners with knee pain.

A síndrome da dor patelofemural é uma das disfunções mais comuns que acometem o joelho, principalmente mulheres jovens fisicamente ativas. No entanto, o tratamento permanece desafiador por carecer de bases científicas que direcionem sua reabilitação. Distúrbios no alinhamento estático e dinâmico dos membros inferiores, como a pronação excessiva do retropé, têm sido associados na clínica e embasados teoricamente como fatores de risco para a disfunção. No entanto, estudos experimentais que embasem esta relação ainda são controversos. O objetivo geral deste estudo foi verificar a influência da síndrome da dor patelofemural no alinhamento postural do retropé e joelho, assim como na distribuição da pressão plantar durante a fase apoio do descer escadas e em três subfases do apoio da marcha. Foram estudados 77 adultos jovens de ambos os sexos, divididos em grupo controle (GC=47) e grupo síndrome da dor patelofemural (GSPF=30). Para responder a questões científicas específicas, foram realizados três experimentos. O experimento 1 teve o objetivo específico de verificar a associação entre a síndrome da dor patelofemural e o alinhamento postural dos membros inferiores (n=77; GC=47,GSPF=30). Para tanto, foram avaliadas três medidas clínicas: o ângulo do retropé, o ângulo Q (fotogrametria digital) e a orientação médiolateral da patela (método adaptado de Mc Connell). O experimento 2 teve como objetivo específico investigar a distribuição da pressão plantar de indivíduos com e sem diagnóstico de síndrome da dor patelofemural durante o descer escadas, e avaliar a dor dos sujeitos com essa disfunção antes e após a tarefa proposta (n=74; GC=44,GSPF=30). Para tanto, avaliouse a distribuição da pressão plantar por meio de palmilhas capacitivas (Pedar X System) na fase de apoio do descer escadas e a dor referida pelos sujeitos pela escala analógica visual de dor antes e depois da tarefa motora. O experimento 3 (n=57; GC=35,GSPF=22) buscou especificamente avaliar a influência da síndrome da dor patelofemural na distribuição da pressão plantar durante o contato inicial, médio-apoio e propulsão da fase de apoio da marcha. Os principais resultados demonstraram que não houve influência da disfunção no alinhamento postural do retropé e joelho. No entanto, durante o descer escadas, a síndrome da dor patelofemural esteve associada à um contato medialmente direcionado no retropé e médio-pé, assim como menores sobrecargas plantares, provavelmente associadas ao aumento significativo da dor relatada pelos sujeitos após a tarefa. Na marcha, os sujeitos com a disfunção realizaram novamente um contato inicial medialmente direcionado no retropé e uma propulsão mais lateralizada no antepé. Os resultados deste estudo mostram que a síndrome da dor patelofemural não esteve relacionada ao alinhamento postural do retropé e joelho, mas influenciou o padrão dinâmico da distribuição da pressão plantar tanto na marcha como no descer escadas. Estes achados confirmam a importância da avaliação dinâmica durante a reabilitação dos indivíduos com esta disfunção. / Patellofemoral pain syndrome is one of the most common dysfunctions of the knee, particularly among young physically active females. Its treatment remains challenger due to the lack of scientific rationales bases to guide its rehabilitation. Static and dynamic misalignment of the lower extremity, like excessive rearfoot pronation has been clinically and theoretically associated as risk factors for this dysfunction. However, scientific studies to confirm this association are still controversial. The general purpose of this study was to verify the influence of patellofemoral pain syndrome on rearfoot and knee postural alignment as well as on plantar pressure distribution during the stance phase of stair descent and three sub phases of stance gait. 77 young adults of both sexes divided in to control group (GC=47) and patellofemoral pain goup(PFPG=30) were studied. Three experiments were realized in order to respond the specific scientific questions. The experiment 1 had the specific purpose of verify the association between patellofemoral pain syndrome and postural alignment of rearfoot and knee (n=77; CG=47, PFPG=30). Therefore, three clinical measurements were evaluated: rearfoot angle, Q angle (digital photogrammetry) and the medio-lateral orientation of the patella (adapted from McConnell). The experiment 2 aimed specifically to investigate plantar pressure distribution in subjects with and without patellofemoral pain syndrome, during the stair descent, and evaluate the pain referred by the subjects before and after the motor task (n=74;CG=44,PFPG=30), plantar pressure distribution was evaluated with capacitive insoles(Pedar X System) during the stance phase of stair descent as well as the pain referred by the subjects by Visual Analogue Scale before and after the task. The experiment 3 intended specifically to verify the influence of patellofemoral pain syndrome on plantar pressure distribution during initial contact, midstance and propulsion of the gait stance (n=57; GC=35, GSPF=22). The principal results of this study showed that there was no influence of the dysfunction on postural alignment of rearfoot and knee. However, patellofemoral pain syndrome during the stair descent was related to a medially directed contact at the rearfoot and midfoot and lower plantar loads probably due to the increase in pain observed after the task. During gait, the subjects with the dysfunction showed again an initial contact medially directed at the rearfoot and laterally directed propulsion on forefoot. The results of this study show that patellofemoral pain syndrome was not associated to postural alignment but influenced the plantar pressure distribution during gait as well as stair descending task. These findings confirm the importance of the dynamic evaluation of subjects with this dysfunction during their rehabilitation.