Limited knowledge of the neuromechanical response to use of an ankle foot orthosis-footwear combination (AFO-FC) has created a lack of consensus in understanding orthotic motion control as a therapeutic treatment. Lack of consensus may hinder the clinician’s ability to target the motion control needs of persons with movement impairment (e.g., peripheral nerve injury, stroke, etc.). Some evidence suggests a proportional relationship between joint motion and neuromuscular activity based on the notion that use of lower limb orthoses that constrain joint motion may invoke motor slacking and decreasing levels of muscle activity. Use of AFO-FCs likely alters the biomechanical and neuromuscular output as the central control system gradually forms new movement patterns. If there is proportional relationship between muscle activation and joint motion, then it could be examined by quantifying joint motion and subsequent neuromuscular output. Considering principles of neuromechanical adjustment, my general hypothesis examines whether orthotic control of lower limb motion alters neuromuscular output in proportion to the biomechanical output as a representation of the limb’s dynamics are updated by the neural control system. The rationale for this approach is that reference knowledge of the neuromechanical response is needed to inform clinicians about how a person responds to walking with motion controlling devices such as ankle foot orthoses combined with footwear. In the first line of research, I hypothesize that a newly developed AFO which maximizes leverage and stiffness will constrain the talocrural joint and alter joint kinematics and ground reaction force patterns. To answer the hypothesis, I sampled kinematics and kinetics of healthy subjects’ treadmill walking using an AFO-FC in a STOP condition and confirmed that the AFO substantially limited the range of talocrural plantarflexion and dorsiflexion motion to 3.7° and in a FREE condition maintained talocrural motion to 24.2° compared to 27.7° in a CONTROL (no AFO) condition. A follow up controlled static loading study sampled kinematics of matched healthy subjects limbs and cadaveric limbs in the AFO STOP and FREE conditions. Findings revealed healthy and cadaveric limbs in the AFO STOP condition substantially limited their limb segment motion similar to matched healthy subjects walking in the STOP condition and in the AFO FREE condition healthy and cadaveric limbs maintained similar limb segment motion to matched healthy subjects walking in the FREE condition. In a second line of research, I hypothesize that flexibility of a newly developed footwear system will allow normal walking kinetics due to the shape and flexibility of the footwear. To answer the hypothesis, I utilized a curved-flexible footwear system integrated with an AFO in a STOP condition and sampled kinematics and kinetics of healthy subjects during treadmill walking. Results revealed subjects elicited similar cadence, stance and swing duration and effective leg-ankle-foot roll over radius compared to walking in the curved-flexible footwear integrated with the AFO in a FREE condition and a CONTROL (no AFO) condition. To validate rollover dynamics of the curved-flexible footwear system, a follow up study of healthy subjects’ treadmill walking in newly developed flat-rigid footwear system integrated with the AFO in a STOP condition revealed interrupted leg-ankle-foot rollover compared to walking in curved-flexible footwear in STOP, FREE and CONTROL conditions. In a third line of research, I hypothesize that use of an AFO that limits talocrural motion in a STOP condition will proportionally reduce activation of Tibialis Anterior, Soleus, Medial and Lateral Gastrocnemii muscles compared to a FREE and CONTROL condition due to alterations in length dependent representation of the limb’s dynamics undergoing updates to the central control system that modify the pattern of motor output. To answer the question, the same subjects and AFO-footwear presented in the first two lines of research were used in a treadmill walking protocol in STOP, FREE, and CONTROL conditions. Findings revealed the same subjects and ipsilateral AFO-footwear system presented in Aim 1 exhibited an immediate yet moderate 30% decline in EMG activity of ipsilateral Soleus (SOL), Medial Gastrocnemius (MG) and Lateral Gastrocnemius (LG) muscles in the STOP condition compared to the CONTROL condition. The reduction in EMG activity in ipsilateral SOL, MG and LG muscles continued to gradually decline during 15 minutes of treadmill walking. On the contralateral leg, there was an immediate yet small increase of 1% to 14% in EMG activity in SOL, MG, LG muscles above baseline. After 10 minutes of walking, the EMG activity in contralateral SOL, MG and LG declined to a baseline level similar to the EMG activity in the contralateral CONTROL condition. These collective findings provide compelling evidence that the moderate 30% reduction in muscle activation exhibited by subjects as they experience substantial (85%) constraint of total talocrural motion in the AFO STOP condition is not proportionally equivalent. Further, the immediate decrease in muscle activation may be due to a reactive feedback mechanism whereas the continued decline may in part be explained by a feedforward mechanism. The clinical relevance of these findings suggests that short term use of orthotic constraint of talocrural motion in healthy subjects does not substantially reduce muscle activation. These preliminary findings could be used to inform the development of orthoses and footwear as therapeutic motion control treatments in the development of motor rehabilitation protocols.

Le complexe articulaire de l'épaule est extrêmement sollicité au cours de la pratique du tennis. Le service, notamment, impose des contraintes mécaniques importantes et requiert des positions articulaires extrêmes plaçant l'épaule dans des situations à risque de blessures. La pratique intensive du tennis conduit à des adaptations musculo-squelettiques et fonctionnelles qui seraient bénéfiques à la performance. Cependant, il est difficile de savoir quand elles deviennent excessives ou déséquilibrées ce qui augmenterait les risques de blessures. Alors que la détection des futurs talents commence dès 5-6 ans, peu d'informations sur les caractéristiques de leur épaule, des facteurs de risque de blessures et de la pathomécanique spécifique sont actuellement disponibles. De telles connaissances seraient utiles pour optimiser leur prise en charge par les entraîneurs. L'objectif de ce travail de thèse était de caractériser l'épaule du jeune joueur de tennis, d'identifier des facteurs de risque de blessures et décrire la pathomécanique de l'épaule en lien avec le service du tennis. Afin de caractériser l'épaule du jeune joueur de tennis, 67 joueurs de tennis asymptomatiques âgés de 7 à 13 ans ont été répartis en trois groupes en fonction de leur âge biologique. En comparant les amplitudes articulaires et les forces des muscles de l'épaule, il a été observé que ces caractéristiques musculo-squelettiques s'adaptaient dès le plus jeune. Par la suite, afin d'identifier des facteurs de risque de blessures à l'épaule, ces mêmes caractéristiques ont été comparées entre 31 joueurs avec antécédent de douleur et 60 joueurs asymptomatiques. Les joueurs avec antécédent de douleur présentaient une plus grande amplitude de rotation de l'articulation glénohumérale ainsi qu'une faiblesse des muscles rotateurs externes de l'articulation glénohumérale et des muscles fixateurs de la scapula. Cependant, il restait difficile de savoir si ces maladaptations étaient la cause ou la conséquence de la blessure à l'épaule. Un suivi longitudinal par les analyses de transitions des profils latents a été réalisé pour apporter un éclairage. Par ailleurs, afin de mieux décrire la pathomécanique de l'épaule en lien avec le service, la cinématique des articulations glénohumérale et scapulothoracique enregistrée lors du service a été comparée entre 13 joueurs sans antécédent de douleur et 15 avec antécédent de douleur. Ces joueurs avec antécédent de douleur modifiaient leur cinématique glénohumérale et scapulothoracique à la fin de la phase d'armer du service afin probablement d'éviter la douleur et de poursuivre leur pratique du tennis. Enfin, l'étude précédente a été complétée par une analyse biomécanique du service avant et après affaiblissement du trapèze inférieur par fatigue avec électrostimulation. La faiblesse des fixateurs de la scapula, décrite chez des joueurs avec antécédent de douleur, conduisait à une cinématique scapulaire inappropriée et une diminution d'activation des muscles antérieurs de l'épaule pouvant mettre en péril les structures anatomiques du complexe articulaire de l'épaule. Ces résultats apportent des informations essentielles pour améliorer la qualité des entraînements et la prévention des blessures à l'épaule chez les jeunes joueurs de tennis. Ils soulignent notamment l'importance d'un travail de renforcement des muscles stabilisateurs de l'épaule (muscles rotateurs de l'articulation glénohumérale et stabilisateurs de la scapula) / The shoulder joint complex is largely involved in the tennis strokes. Particularly, the tennis serve applies high mechanical constraints and requires extreme joint positions making the shoulder vulnerable to injuries. Intensive tennis practice leads to musculoskeletal and functional adaptations that are thought to be beneficial to performance. However, it remains unclear when they become unbalanced or excessive that increases the risk of injury. The prospects are scouted from 5 years old, but little is known on their specific shoulder characteristics, risk factors for injury and pathomechanics. Such knowledge would be useful to optimize their monitoring by coaches. This thesis aimed to characterize the young tennis player's shoulder, identify risk factors for injury and describe the shoulder pathomechanisms related to the tennis serve. To characterize the young tennis player’s shoulder, 67 asymptomatic tennis players aged 7 to 13 years old were divided into three groups according to their biological age. The comparison between our three groups highlighted that the glenohumeral ranges of motion and the shoulder muscle strength adaptions occurred from an early age. Then to bring risk factor for shoulder injuries to light, these parameters were also compared between 31 players with a history of shoulder pain and 60 asymptomatic players. Players with a history of shoulder pain presented a larger glenohumeral joint total rotation range of motion as well as a weakness of the glenohumeral external rotator muscles and the scapular stabilizer muscles. A longitudinal study, using a latent profile transition analysis, was conducted to determine whether the factors previously identified were the cause or consequence of the shoulder injury. Furthermore, in the aim to describe the shoulder pathomechanisms related to the tennis serve motion, the glenohumeral and scapulothoracic kinematics of the tennis serve were compared between 13 players without and 15 with a history of shoulder pain. Players with a history ofshoulder pain adapted their glenohumeral and scapulothoracic kinematics at the end of the cocking phase to probably preserve the sub-acromial space and the rotator cuff tendons during the tennis serve. Finally, the previous study was completed by a study analyzing the shoulder biomechanics of a tennis serve before and after the fatigue of the lower trapezius. The weakness of the scapular stabilizer muscles impaired the scapular kinematics and decreased the activation of the anterior shoulder muscles that may jeopardize the shoulder joint anatomical structures. These findings bring new knowledge to improve the young players monitoring and the injury prevention. Particularly, it highlights the importance to strengthen the stabilizer muscles (glenohumeral external rotator muscles and scapular stabilizer muscles)

[Truncated abstract] Anterior cruciate ligament injuries are a major problem in sport. The purpose of this thesis was to investigate the causative factors of ACL injuries and to study the effect of various types of lower-limb training on underlying neuromuscular mechanisms involved in stabilisation and risk of ACL injury. Investigation of the mechanisms was conducted on controlled balance and strength tests as well as in sporting manoeuvres. It was aimed to assess if the neuromuscular changes map over into the performance of sporting manoeuvres and if potential for loading on the ACL and risk of injury was reduced or exacerbated . . . ACL strain can be decreased through reduction in the applied loads and greater knee flexion. Further to this, muscle activation has the ability to reduce loading on the ACL through co-contraction and selective activation patterns. This thesis demonstrated differing neuromuscular adaptations from various training types that map over into the performance of sporting manoeuvres. The research indicated that the Balance-Training was the most favourable in reducing potential for injury risk on the ACL. Alternatively strength training elicited neuromuscular changes that were likely to increase the risk of force on the ACL. The Machine+Balance training resulted in some negative and positive outcomes with the balance training tending to counteract the negative affects of machine weights training resulting in small improvements in muscular support and load reduction. This study provides us with better understanding of the underlying mechanisms from various training types and their potential affect on risk of ACL injury.

Background: Joint stability has been experimentally and clinically linked to mechanisms of knee injury and joint degeneration. The only dynamic, and perhaps most important, regulators of knee joint stability are contributions from muscular contractions. In participants with unstable knees, such as anterior cruciate ligament (ACL) injured, a range of neuromuscular adaptations has been observed including quadriceps weakness and increased co-activation of adjacent musculature. This co-activation is seen as a compensation strategy to increase joint stability. In fact, despite increased co-activation, instability persists and it remains unknown whether observed adaptations are the result of injury induced quadriceps weakness or the mechanical instability itself. Furthermore, there exists conflicting evidence on how and which of the neuromuscular adaptations actually improve and/or reduce knee joint stability. Purpose: The overall aim of this thesis is therefore to elucidate the role of injury and muscle weakness on muscular contributions to knee joint stability by addressing two main objectives: (1) to further our understanding of individual muscle contribution to internal knee joint moments; and (2) to investigate neuromuscular adaptations, and their effects on knee joint moments, caused by either ACL injury and experimental voluntary quadriceps inhibition (induced by pain). Methods: The relationship between individual muscle activation and internal net joint moments was quantified using partial least squares regression models. To limit the biomechanical contributions to force production, surface electromyography (EMG) and kinetic data was elicited during a weight-bearing isometric force matching task. A cross-sectional study design determined differences in individual EMG-moment relationships between ACL deficient and healthy controls (CON) groups. A crossover placebo controlled study design determined these differences in healthy participants with and without induced quadriceps muscle pain. Injections of hypertonic saline (5.8%) to the vastus medialis induced muscle pain. Isotonic saline (0.9%) acted as control. Effect of muscle pain on muscle synergies recruited for the force matching task, lunging and squatting tasks was also evaluated. Synergies were extracted using a concatenated non-negative matrix factorization framework. Results/Discussion: In CON, significant relationships of the rectus femoris and tensor fascia latae to knee extension and hip flexion; hamstrings to hip extension and knee flexion; and gastrocnemius and hamstrings to knee rotation were identified. Vastii activation was independent of moment generation, suggesting mono-articular vastii activate to produce compressive forces, essentially bracing the knee, so that bi-articular muscles crossing the hip can generate moments for the purpose of sagittal plane movement. Hip ab/adductor muscles modulate frontal plane moments, while hamstrings and gastrocnemius support the knee against externally applied rotational moments. Compared to CON, ACL had 1) stronger relationships between rectus femoris and knee extension, semitendinosus and knee flexion, and gastrocnemius and knee flexion moments; and 2) weaker relationships between biceps femoris and knee flexion, gastrocnemius and external knee rotation, and gluteus medius and hip abduction moments. Since the knee injury mechanism, is associated with shallow knee flexion angles, valgus alignment and rotation, adaptations after ACL injury are suggested to improve sagittal plane stability, but reduce frontal and rotational plane stability. During muscle pain, EMG-moment relationships of 1) semitendinosus and knee flexor moments were stronger compared to no pain, while 2) rectus femoris and tensor fascia latae to knee extension moments and 3) semitendinosus and lateral gastrocnemius to knee internal rotation moments were reduced. Results support the theory that adaptations to quadriceps pain reduces knee extensor demand to protect the joint and prevent further pain; however, changes in non-painful muscles reduce rotational plane stability. Individual muscle synergies were identified for each moment type: flexion and extension moments were respectively accompanied by dominant hamstring and quadriceps muscle synergies while co-activation was observed in muscle synergies associated with abduction and rotational moments. Effect of muscle pain was not evident on muscle synergies recruited for the force matching task. This may be due to low loading demands and/or a subject-specific redistribution of muscle activation. Similarly, muscle pain did not affect synergy composition in lunging and squatting tasks. Rather, activation of the extensor dominant muscle synergy and knee joint dynamics were reduced, supporting the notion that adaptive response to pain is to reduce the load and risk of further pain and/or injury. Conclusion: This thesis evaluated the interrelationship between muscle activation and internal joint moments and the effect of ACL injury and muscle pain on this relationship. Findings indicate muscle activation is not always dependent on its anatomical orientation as previous works suggest, but rather on its role in maintaining knee joint stability especially in the frontal and transverse loading planes. In tasks that are dominated by sagittal plane loads, hamstring and quadriceps will differentially activate. However, when the knee is required to resist externally applied rotational and abduction loads, strategies of global co-activation were identified. Contributions from muscles crossing the knee for supporting against knee adduction loads were not apparent. Alternatively hip abductors were deemed more important regulators of knee abduction loads. Both muscle pain and ACL groups demonstrated changes in muscle activation that reduced rotational stability. Since frontal plane EMG-moment changes were not present during muscle pain, reduced relationships between hip muscles and abduction moments may be chronic adaptions by ACL that facilitate instability. Findings provide valuable insight into the roles muscles play in maintaining knee joint stability. Rehabilitative/ preventative exercise interventions should focus on neuromuscular training during tasks that elicit rotational and frontal loads (i.e. side cuts, pivoting maneuvers) as well as maintaining hamstring balance, hip abductor and plantarflexor muscle strength in populations with knee pathologies and quadriceps muscle weakness.

Purpose: The literature indicates that normal healthy women can increase the strength of the pelvic floor muscles (PFMs) by simultaneously contracting the transverse abdominus (TrA) muscle. This study investigated the relationship of the PFMs and the TrA in women with stress urinary incontinence (SUI). Subjects: 15 women with SUI, verified by scores on the Questionnaire of Urinary Incontinence Diagnosis (QUID), were randomly assigned, blocked by age, into 2 exercise groups. The 6 women in the PFM only group had a mean age of 63 years and the 9 women in the PFM+TrA group had a mean age of 49 years. Method: For 2 weeks, all women were trained by rehabilitative ultrasound imaging (RUSI) to correctly contract the TrA or relax the TrA during a PFM contraction depending upon the group assignment. Each woman was examined using the PERFECT scheme and prescribed a patient-specific PFM exercise program. The exercise protocols required 6 weeks of supervised patient specific exercises. Data collection occurred at 3 time periods (before intervention, after intervention, and follow-up) and included: measurement of TrA thickness changes and PFM lift by RUSI, PFM strength and endurance with pressure perineometry, number of incontinence episodes and pad use from bladder diaries, and quality of life (QOL) measurements using the Incontinence Impact Questionnaire (IIQ) and the Patient Specific Functional Scale (PSFS). Results: MANOVA identified no significant difference after interventions between groups. All women significantly improved in PFM strength (PConclusion: PFM exercises done in isolation or with recruitment of the TrA increased PFM strength, endurance, lift and decreased incontinence in women with SUI. Recommendations: Women with SUI can benefit from physical therapists prescribing PFM exercises in isolation or in combination with TrA contractions.

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Every year, 250,000 people worldwide suffer a spinal cord injury (SCI) that leaves them with chronic paraplegia - permanent loss of ability to move their legs. SCI interrupts axons passing along the spinal cord, thereby isolating motor neurons from brain inputs. To date, there are no effective treatments that can reconnect these interrupted axons. In a recent breakthrough, .NeuroRestore developed the STIMO neuroprosthesis that can restore walking after paralyzing SCI using Epidural Electrical Stimulation (EES) of the lumbar spinal cord. Yet, the calibration of EES requires highly trained personnel and a vast amount of time, and the mechanism by which EES restores movement is not fully understood. In this master thesis, we propose to address this issue using modeling combined with Artificial Neural Networks (ANNs). To do so, we introduce the CyberSpine model to predict EES-induced motor response. The implementation of the model relies on the construction of a multipolar basis of solution of the Poisson equation which is then coupled to an ANN trained against actual data of an implanted STIMO user. Furthermore, we show that our CyberSpine model is particularly well adapted to extract biologically relevant information regarding the efficient connectivity of the patient’s spine. Finally, a user-friendly interactive visualization software is built. / Varje år drabbas 250 000 människor i hela världen av en ryggmärgsskada som ger dem kronisk paraplegi - permanent förlust av förmågan att röra benen. Vid en ryggmärgsskada bryts axonerna som passerar längs ryggmärgen, vilket isolerar de motoriska neuronpoolerna från hjärnans ingångar. Hittills finns det inga effektiva behandlingar som kan återansluta dessa avbrutna axoner. NeuroRestore utvecklade nyligen neuroprotesen STIMO som kan återställa gångförmågan efter förlamande ryggmärgsskada med hjälp av epidural elektrisk stimulering (EES) av ländryggmärgen. Kalibreringen av EES-stimuleringar kräver dock högutbildad personal och mycket tid, och den mekanism genom vilken EES återställer rörelse är inte helt klarlagd. I denna masteruppsats föreslår vi att vi tar itu med denna fråga med hjälp av modellering i kombination med artificiell intelligens. För att göra detta introducerar vi CyberSpine-modellen, en modell som kan förutsäga EES-inducerad motorisk respons. Implementeringen av modellen bygger på konstruktionen av en multipolär bas för lösning av Poisson-ekvationen som sedan kopplas till ett artificiellt neuralt nätverk som tränas mot faktiska data från en implanterad STIMO-deltagare. Dessutom visar vi att vår CyberSpine-modell är särskilt väl anpassad för att extrahera biologiskt relevant information om den effektiva anslutningen av patientens ryggrad. Slutligen bygger vi en användarvänlig interaktiv visualiseringsprogramvara.