Objective: To compare the effectiveness of complex physical therapy and exercise program which have been completed at home (control group) in shoulder impingement syndrome treatment. Discussion: The use of home exercise program in shoulder impingement physical therapy may have a positive impact, but not that much what we can get from complex physical therapy. By comparison all measures showed statistically significant difference. Conclusion: The shoulder impingement syndrome has to be individualized process and the treatment should be multimodal and include several physical therapy methods. The more methods we would use- the better results we could achieve.

Syfte: Syftet var att undersöka vilken effekt styrketräning, rörlighetsträning, stretching och manuell terapi i form av ledmobilisering och mjukdelsmobilisering har på smärta, funktion och rörlighet i skulderleden hos patienter med subakromiellt impingementsyndrom samt att granska graden av evidens för dessa behandlingsmetoder. Metod: Litteratursökning utfördes i databaserna PubMed, SportDiscus och PEDro. Detta resulterade i 156 publikationer, varav 15 granskades enligt PEDro-metoden.Resultat: Styrketräning av rotatorcuffen och scapulastabilisatorer utfördes i dragapparat, med elastiskt band och hantlar. Evidensen för styrketräning var stark för att lindra vilovärk och förbättra skulderfunktionen. Stretching var en behandling som gjordes avseende bakre ledkapseln, främre ledkapseln, rotatorcuffmusklerna, pectoralis minor, sternocleidomastoideus samt övre delen av trapezius. Måttligt stark evidens fanns för styrketräning kombinerad med stretching av bakre ledkapseln för att lindra nattlig värk och förbättra skulderfunktionen. Manuell terapi användes enligt Kaltenborn med glidmobiliseringar för cervikalcolumna, övre thorakalcolumna och skulderleden. Postero-anteroglidning och behandling i kopplat rörelsemönster i cervikalcolumna enligt Ortopedisk Manuell Terapi rapporteras också som behandlingsmetod. Manuell terapi enligt Maitland användes för att öka rörligheten i skulderleden, cervikalcolumna och costotransversalalederna. Måttligt stark evidens förelåg vad gäller att styrketräning i kombination med manuell terapi och stretching kan leda till förbättrad skulderfunktion. Slutsats: Styrketräning såväl utan som i kombination med stretching har goda effekter på smärta, skulderfunktion och rörlighet med stark till måttligt stark evidensstyrka. Otillräcklig till måttligt stark evidensstyrka påvisades gällande att kombinationen träning och manuell terapi i form av ledmobilisering och mjukdelsmobilisering är effektivt för att lindra smärta, öka rörligheten och därmed resultera i förbättrad skulderfunktion. Det finns ingen evidens att manuell terapi, stretching och rörlighetsträning utan styrketräning kan minska smärta, förbättra rörlighet eller skulderfunktion. / Aim: The purpose of the present investigation was to study the effects of strength training, mobility training, stretching and manual therapy on pain, ROM and function of the shoulder joint in patients with subacromial impingement syndrome. Another purpose was to study the level of evidence for these treatments. Method: A literature review was performed in the databases PubMed, Sport Discus and PEDro. The amount of articles that were found was 156, out of which 15 were reviewed according to the PEDro-method. Results: Strength training of the rotatorcuff muscles and scapula stabilizers was carried out in a pulley machine, with elastic bands and dumbbells. Strong evidence in terms of strength training was found in order to relieve pain at rest and to improve shoulder function. Stretching for the posterior capsule, anterior capsule, rotator cuff muscles, pectoralis minor, sternocleidomastoideus and the upper portion of trapezius was used in the studied articles. Moderate strong evidence in terms of strength training combined with stretching of the posterior capsule was found for relieving pain at night and improve shoulder function. Manual therapy was used according to the concept of Kaltenborn with glide mobilizations for the cervical spine, the upper thoracic spine and the shoulder joint. Postero-anterior glide and treatment in coupled movement pattern were used as well. Manual therapy according to Maitland was used in order to improve ROM of the shoulder joint, cervical spine and costotranversal joints. A moderate strong evidence in terms of strength training combined with stretching and manual therapy was found in order to improve ROM of the shoulder joint. Conclusions: A strong to moderate strong evidence was found in terms of strength training with or without stretching for relieving pain, increase ROM of the shoulder joint and improve shoulder function. An insufficient to moderate strong evidence in terms of strength training combined with manual therapy including joint mobilizations and soft tissue mobilizations was

Surgery to correct cam femoroacetabular impingement (FAI) is increasingly popular. Despite this, no known study has used motion analysis and ground reaction forces to quantify the outcome of surgery for FAI. The goal of this study was to compare the preoperative and postoperative lower-extremity joint kinematic and kinetic measurements of cam FAI patients during activities of daily living with use of a high-speed motion capture system and force platforms. We hypothesized that the lower-extremity joint mechanics of FAI patients during level walking and maximal squatting would resemble more those of healthy control subjects, after surgery. Ten patients with unilateral symptomatic cam FAI, who underwent corrective surgery using an open or combined technique, performed walking and maximal depth squatting trials preoperatively and postoperatively. Thirteen healthy control subjects, matched for age, sex and body mass index, provided normative data. Results showed that postoperatively, FAI patients had reduced hip ROM in the frontal and sagittal planes, produced smaller peak hip abduction and external rotation moments, and generated less peak hip power compared to the control group during level walking. During maximal squatting, postoperative FAI patients squatted to a greater depth, and had larger knee flexion and ankle dorsiflexion angles, as well as the sum of all joint angles of the affected limb at maximal depth compared to the preoperative values. The lower-extremity joint and pelvic mechanics of FAI patients did not fully return to normal after surgery. Although surgery seemed to reduce hip pain and restore a normal femoral head-neck offset, it further impaired muscle function as a result of muscle incisions. More research is needed to determine the effects of muscle incisions, which could help improve surgical techniques and develop better rehabilitation programs for FAI patients.

Surgery to correct cam femoroacetabular impingement (FAI) is increasingly popular. Despite this, no known study has used motion analysis and ground reaction forces to quantify the outcome of surgery for FAI. The goal of this study was to compare the preoperative and postoperative lower-extremity joint kinematic and kinetic measurements of cam FAI patients during activities of daily living with use of a high-speed motion capture system and force platforms. We hypothesized that the lower-extremity joint mechanics of FAI patients during level walking and maximal squatting would resemble more those of healthy control subjects, after surgery. Ten patients with unilateral symptomatic cam FAI, who underwent corrective surgery using an open or combined technique, performed walking and maximal depth squatting trials preoperatively and postoperatively. Thirteen healthy control subjects, matched for age, sex and body mass index, provided normative data. Results showed that postoperatively, FAI patients had reduced hip ROM in the frontal and sagittal planes, produced smaller peak hip abduction and external rotation moments, and generated less peak hip power compared to the control group during level walking. During maximal squatting, postoperative FAI patients squatted to a greater depth, and had larger knee flexion and ankle dorsiflexion angles, as well as the sum of all joint angles of the affected limb at maximal depth compared to the preoperative values. The lower-extremity joint and pelvic mechanics of FAI patients did not fully return to normal after surgery. Although surgery seemed to reduce hip pain and restore a normal femoral head-neck offset, it further impaired muscle function as a result of muscle incisions. More research is needed to determine the effects of muscle incisions, which could help improve surgical techniques and develop better rehabilitation programs for FAI patients.

Femoroacetabular impingement (FAI) is a hip condition which can limit hip motion and cause pain particularly in young and athletic patients. It is considered as a patho-mechanical process leading to progressive and degenerative damage of the joint. Surgical treatment for femoroacetabular impingement focuses on improving the clearance for hip motion, reducing the femoral impact against the acetabular labrum. The procedure involves the surgical resection of the cause of impingement which consists of trimming the acetabular rim and/or the femoral head-neck offset. Currently, there are no comprehensive tools available for pre-operative planning of FAI surgery and so the area and depth of bone resection are identified based on the skill and experience of the surgeon. This means that it is difficult to predict the degree to which the procedure will be successful, in terms of reducing pain and increasing the range of motion (RoM) of the hip, prior to surgery. In addition, resection can lead to increased stress in the remaining bone which in some cases can result in post-operative femoral neck fracture, a recognized risk of FAI surgery which is increased if the bone is osteoporotic. This thesis describes the development of a framework that will enable a tool to be created that can be used for the diagnosis, preoperative planning and selection of treatment for patients with cam-type FAI. The framework consists of a number of complementary 3-dimensional finite element (FE) models. The models are created from computer tomography (CT) data from actual patients with cam-type FAI. The first FE model was developed in order to predict the stress distribution in the head-neck region of the femur following resection surgery for FAI enabling the effect of resection depth to be investigated under loading conditions corresponding to typical daily activities. The model demonstrates that resection depth should be kept to less than one third of the diameter of the neck in order to ensure structural integrity. The second finite element model developed utilises a quasi-brittle damage plasticity material formulation to investigate the mechanism and risk of femoral neck fracture following femoral osteochondroplasty in osteoporotic and non osteoporotic hips. Predictions indicate that fracture can occur in osteoporotic hips during typical daily activities. Also, the likelihood of fracture increases when patients are subjected to high load conditions and activities, even in non-osteoporotic patients. The third FE model was developed to assess the reduction in the internal rotation movement in hips with cam-type FAI and identify and examine the areas where impingement occurs. The model shows that FAI can result in a significant reduction in hip motion and that impingement area and RoM are patient dependant. All three FE models were validated with results from experimental studies. The three models combined provide the framework for a virtual osteochondroplasty tool. The procedure for using the tool involves undertaking a virtual resection of a FAI hip based on the areas of impingement identified by the RoM analysis provided by the third FE model. Finite element models one and two are employed to ensure that the virtual resection remains within safe limits and stress does not elevate in the remaining bone to levels that would significantly increase the risk of femoral neck fracture. The framework was validated by comparing the RoM predicted following a virtual osteochondroplasty undertaken on a model of a hip from an actual patient with FAI with the results from a model of the same hip created from CT scan data taken after an actual osteochondroplasty had been performed on the patient using a resection area and depth identified in the conventional way by a surgeon.

The prediction of the flows and temperatures in the moderator system of CANDU reactors is important in the safety evaluation during some potential transients. An experimental program to collect data for CFD validation, including integrated moderator circulation tests has been funded by the CANDU Owners Group. This thesis constitutes a separate effect test within this larger moderator flow study, investigating the behaviour of a jet impinging onto a single heated cylinder. A number of experiments were conducted to investigate the behaviour of the jet flow under a variety of scenarios. The inlet Reynolds number and the heater power level were the primary variables considered to assess the impact of the buoyant forces generated by the heated cylinder on the flow. Alongside the experiments, simulations were performed using the experimental geometry to evaluate the performance of some of the most commonly-used turbulence modelling approaches – namely the standard k-ε, realizable k-ε, and standard k-ω RANS models. The agreement between the turbulence models and experimental results was determined to be reasonable in the free jet regions, however nearer the cylinder, the simulated results exhibited a wider core region and steeper gradient in the shear layer than the experimental data. At lower Reynolds numbers, over-prediction of velocities both in the axial and lateral direction was also seen. The impact of heating proved minimal in the jet core, however differences were observed in the shear layer at lower Reynolds numbers, and the heated case exhibiting decreased lateral velocities as compared to the isothermal case. / Thesis / Master of Applied Science (MASc)

A three-dimensional flow field produced by supersonic twin-jet impingement is studied using a large eddy simulation (LES). The numerical model consists of two parallel axisymmetric jets of diameter 𝐷*, 3𝐷* apart, issuing from a plane which is at a distance H*=4𝐷* above the ground. The jet diameter 𝐷*, mean velocity 𝑊ₒ*, mean density 𝜌ₒ* and mean temperature 𝑇ₒ* at the jet center in the exit plane are used as reference values. The Mach number and Reynolds number of the jets are M=1.5 and Re=550,000, respectively. This model is closely related to the experimental setup of Elavarasan <i>et al.</i>(Elavarasan <i>et al.</i>, 2000). The three-dimensional time-dependent compressible Navier-Stokes equations are solved using the method of lines. The convective terms are discretized using a fifth-order WENO scheme, whereas the viscous terms are discretized using a fourth-order central-differencing scheme. A low-storage five-stage fourth-order Runge-Kutta scheme is used to advance the solution in time. Code verification is achieved by comparison with flat-plate boundary-layer linear stability analysis, and computational data by Bendiks <i>et al.</i> (Bendiks <i>et al.</i>, 1999). for a compressible turbulent round jet. Instantaneous flow, mean flow and Reynolds stresses for the twin-jet impingement are presented and discussed. The results reveal the existence of flapping behavior in the fountain. The flapping fountain is the vortical structure formed by the alternating merging of a primary vortex tube with a secondary vortex tube induced by the neighboring primary vortex tube. The nondimensional period of flapping is found to be 7𝐷*/𝑊ₒ*. High unsteadiness and strong interaction between the fountain and the jets are also observed. Due to the high diffusion and spreading rate of the fountain, the interaction between the fountain and the jets is only significant up to a height which is less than 3𝐷*. It is found that the mean peak velocity in the fountain is 0.40406 𝑊ₒ* and it occurs at 0.536607𝐷* from the ground. The suitability of the fifth-order WENO scheme to simulate turbulent flow field with embedded shocks is also demonstrated by its capability to capture unsteady shock waves in the impingement regions. / Ph. D.

Advanced cooling techniques are required to increase the Brayton cycle temperature ratio necessary for the increase of the overall cycle's efficiency. Current turbine components are cooled with an array of internal cooling channels in the midchord section of the blade, pin fin arrays at the trailing edge and impingement channels in the leading edge. Impingement channels provide the designer with high convective coefficients on the target surface. Increasing the heat transfer coefficient of these channels has been a subject of research for the past 20 years. In the current study, a triple row impingement channel is studied with a jet to target spacing of 6, 8 and 10. The effects of sidewalls are also analyzed. Temperature sensitive paint alongside thin foil heaters are used to obtain heat transfer distributions throughout the target and side walls of the three different channels. Thermal performances were also calculated for the two largest channels. It was found that the side walls provide a significant amount of cooling especially when the channels are mounted side by side so that their sidewalls behave as fins. Similar to literature it was found that an increase in Z/D decreases heat transfer coefficient and provides a more uniform profile. It was also found that the Z/D = 6 and 8 target wall heat transfer profiles are very similar, hinting to the fact that successful potential core impingement may have occurred at height of eight diameters. A Computational Fluid Dynamics, or CFD, study was also performed to provide better insight into the flow field that creates such characteristic heat transfer profiles. The Realizable k-µ solution with enhanced wall functions gave surface heat transfer coefficients 30% off from the experimental data.

Die Resektion der lateralen Klavikula ist eine häufig durchgeführte Operation bei symptomatischer AC-Gelenkarthrose. Es lagen bislang allerdings keine Daten vor, in welchem Abstand zum AC- Gelenk die Ligg. coracoclavicularia an der Klavikula inserieren. In vorliegender Studie wurden 36 Schulterpräparate, 18 von Männern und 18 von Frauen untersucht. Es wurde der Abstand der AC- Gelenkkapsel, des Lig. trapezoideum und des Lig conoideum zum AC-Gelenk gemessen. Zusätzlich wurde der Abstand des N. suprascapularis aufgrund seiner Nähe zum AC-Gelenk an der Incisura scapula und am Lig. spinoglenoidale zum AC- Gelenk gemessen. Der Abstand der an der Klavikula inserierenden Kapselfasern zum AC-Gelenk betrug im Durchschnitt bei Frauen 0,7 cm und bei Männern 0,8 cm. Die Fasern des Lig. trapezoideum an der Klavikula waren durchschnittlich 0,9 – 2,4 cm bei Frauen und 1,0 – 2,8 cm bei Männern vom distalen Klavikulaende entfernt. Die an der Klavikula inserierenden Fasern des Lig. conoideum lagen durchschnittlich bei Frauen 2,3 – 4,4 cm und bei Männern 2,9 – 5,0 cm vom lateralen Klavikulaende entfernt. Der N. suprascapularis verlief an der Incisura scapula durchschnittlich im Abstand von 3,8 cm und am Lig. spinoglenoidale durchschnittlich im Abstand von 3,3 cm zum AC-Gelenk. Es besteht also ein ausreichender Sicherheitsabstand zum Nerv bei der empfohlenen Resektionsweite von maximal 1 cm. Bei einer Resektion der lateralen Klavikula von 1 cm würden im Durchschnitt 8 % des Lig. trapezoideum durchtrennt werden. Bei einer Resektionsweite von 2 cm wären bereits 63 % des Lig. trapezoideum und bei einer Resektionsweite von 1 inch (2,54 cm) 90 % durchtrennt. Daher ist eine Resektionsweite der lateralen Klavikula von maximal 0,8 cm bei Frauen und maximal 1,0 cm bei Männern zu empfehlen. Falls sich bei Bewegungen wie Hyperabduktion und Hyperadduktion immer noch Knochenkontakt zwischen Akromion und Klavikula zeigt, sollten auch wenige Millimeter vom medialen Akromion reseziert werden. Bei einer größeren Resektionsweite an der lateralen Klavikula wäre eine Instabilität und damit verbundene Beschwerden möglich. / Resection of the lateral end of the clavicle is a common procedure for arthrosis of the acromioclavicular joint (AC-joint). However, no anatomical data on the distance between the insertions of the coracoclavicular ligaments and the AC-joint have been reported. In 36 cadaver shoulders (18 male), we studied the relation between the AC-joint and the insertions of the joint capsule, trapezoid and conoid ligaments. The distance from the AC-joint to the medial end of its capsule was, on average, 0.7 cm in women and 0.8 cm in men. In women, the trapezoid ligament began, on average, at 0.9 cm and ended at 2.4 cm and in men, it began at 1.0 cm and ended at 2.8 cm medial to the AC joint. The corresponding figures for the conoid ligament were 2,3-4,4 cm and 2,9-5,0 cm. A resection of 1 cm of the lateral clavicle detaches 8%, a resection of 2 cm 63% and a resection of 2.5 cm 90% of the trapezoid ligament. We recommend a maximum resection of 0,8 in women and 1,0 cm in men of the lateral clavicle because a resection of 2 cm or more maycause postoperative AC-joint instability and related pain.

Diagnosing shoulder pain conditions is a challenging area of musculoskeletal practice. Subacromial impingement syndrome (SIS) is a clinical syndrome that indicates pain and pathology involving the subacromial bursa and rotator cuff tendons within the subacromial space. The three stages of SIS are subacromial bursitis, partial thickness and full thickness rotator cuff tears. The cause of SIS is believed to be multi-factorial with both extrinsic and intrinsic factors involved in its pathogenesis. Clinicians have traditionally diagnosed SIS using a clinical examination including a subjective history followed by confirmatory clinical tests. A review of the evidence for diagnostic accuracy of clinical tests highlights that individual tests have poor diagnostic accuracy. A combination of clinical tests or a clinical examination per se may be useful at ruling out rotator cuff tears, but is less accurate at detecting rotator cuff tears when it is present. There is consensus in the literature that particular combinations of signs and clinical features may be useful in diagnosing rotator cuff tears but not for diagnosing SIS. The vast majority of research to date examining the clinical diagnosis of SIS has been focused on individual clinical tests carried out by medical practitioners in specialist and tertiary care settings. This review has established that the majority of diagnostic accuracy studies for SIS and rotator cuff tears have had poor methodological design. This exploratory study was conducted with subjects undergoing a standardized clinical examination (index test) by a physiotherapist. The decision as to which specific tests were chosen for this research was based on supporting research within the literature and the test’s actual use within the New Zealand clinical setting. This included subjective history questions, active and passive shoulder movement tests and eleven SIS tests. Subjects were referred for a diagnostic ultrasound scan immediately following the clinical examination and results from the scan stood as the criterion reference standard. Thirty eight individuals (males n=23, females n=15) with new onset shoulder pain, who met the inclusion criteria, were assessed by a participating physiotherapist. Sensitivity, specificity, positive likelihood ratios, negative likelihood ratios and respective 95% confidence intervals were calculated for all variables of the examination. Individual variables from the clinical examination were tested for their association with the diagnostic ultrasound scan reference criterion using Pearson Chi-Squared Exact test. Potential predictor variables were retained as potential predictors for use in the logistic regression analysis to determine the most accurate set of clinical examination variables for diagnosing SIS and the individual pathological stages of SIS. The results indicate that no historical, subjective or objective features from the clinical examination are accurate in diagnosing SIS or rotator cuff tears. The presence of night pain demonstrated a significant correlation (P<0.02) with the criterion reference standard for the presence of subacromial bursa fluid/bunching. Night pain and pain with overhead activity has a high sensitivity for subacromial bursa fluid/bunching being present. The absence of night pain and the absence of pain with overhead activity are two subjective phenomena from a clinical examination that are useful in ruling out subacromial bursa fluid/bunching being present. Night pain was also found to be the best predictor of subacromial bursa fluid/bunching being present (P<0.012). Male gender (P<0.034) was the best predictor of partial thickness rotator cuff tears while being 60 years of age or older (P<0.01) significantly correlated with full thickness rotator cuff tears. The Drop Arm Sign (P<0.01) and External Rotation Lag Sign (P<0.01) were significantly correlated with SIS and full thickness rotator cuff tears. Clinical tests for all three pathological stages of SIS and subacromial bursa fluid/bunching being present, had equivalent or if not greater diagnostic accuracy than previous report studies in the literature. The Hawkins-Kennedy Test and Neer Sign can be used in the primary care setting to rule out the presence of subacromial bursa fluid/bunching or SIS if the tests are negative. For mid to end stage SIS (rotator cuff tears) the Empty Can Test and Drop Arm Sign with their high sensitivity can be used to rule out rotator cuff tears especially to the supraspinatus tendon when the tests are negative. Despite the small sample size and other limitations of this study, the findings are an important addition to the current literature surrounding the diagnostic accuracy of clinical tests for SIS and rotator cuff tears. This is the first study to use physiotherapists as examiners and to be set in a primary care setting. The study is also the first to examine the diagnostic accuracy of a range of historical and subjective features from the clinical examination. The results found in the current study could be used by future studies as a starting point in the development of a clinical decision or prediction rule to assist clinicians in the diagnosis of SIS and rotator cuff tears.