Le but de ce travail est d’améliorer les techniques de mesure cinématique tridimensionnelle (3D) afin d’étudier les schémas cinématiques du complexe de l’épaule et du rachis cervical chez des sujets sains et pathologiques. La première partie de ce travail propose un rappel d’anatomie fonctionnelle, une revue de la littérature de la cinématique du complexe scapulo-huméral et une mise au point sur les techniques de mesure de ces deux complexes articulaires. La deuxième partie de ce travail a pour objectif d’évaluer à partir d’études cliniques originales : - la reproductibilité des techniques de mesure des rotations des complexes scapulo-huméral et cervical et d’en proposer une amélioration par une analyse simultanée des translations du barycentre de la scapula ainsi que par la mesure couplée des deux complexes articulaire. - les schémas cinématiques de la scapula dans différents modèles de pathologies ostéo-articulaires au cours de gestes analytiques et fonctionnels. En conclusion, ce travail de thèse met en évidence : une variabilité intra-individuelle dans la capacité à reproduire un mouvement à l’identique avec le membre supérieur et à conserver la même précision dans le repositionnement de la tête. - des mouvements de translation 3D de la scapula, dont certains de grande amplitude, associés aux rotations des mouvements de faible amplitude du rachis cervical associés aux mouvements du membre supérieur en faveur de son rôle proprioceptif. - des schémas cinématiques scapulaires spécifiques : - de la lésion neurologique en cas de scapula alata dynamique. - de la nature fonctionnelle de la tâche en cas de pathologies ostéo-articulaires communes / The aim of this work was to improve the methods of kinematic assessment of the shoulder complex and of the cervical spine in order to improve understanding of scapular and cervical spine kinematics in asymptomatic and symptomatic subjects. The first part of this work provides a reminder of functional anatomy, a literature review of the 3D kinematics of the shoulder complex and issues relating to measurement techniques of both articular complexes. The second part is based on original clinical studies assessing: - the reliability of the measurement techniques of the rotations of both articular complexes and their enhancement by addition of scapular translations and the coupled mobility of the cervical spine and shoulder complexes. - the patterns of scapular kinematic in different ostéo-articular pathologies In conclusion, this work highlights: - intra-individual variability in the ability to reproduce a movement with the upper arm and in the accuracy of repositioning the head . -3D scapular translations (some with large ranges) associated with scapular rotations. - small movements of the cervical spine associated with upper limb movements relating to the proprioceptive role of the cervical. - spine specific scapular kinematic patterns depending on: - neurological lesions in the case of dynamic scapula alata, - the type of movement in common osteo articular pathologies

Title: PNF technique after arthroscopic stabilization of the shoulder joint Objectives: The objective of this work is to consider the possibility of use of the proprioceptive neuromuscular facilitation technique (PNF) in early stages of rehabilitation after arthroscopic stabilization of the shoulder joint. The idea is to use the phenomen of irradiation with which this concept works. Methods: The pilot experimental group consisted of 7 healthy participants with simulated arthroscopic stabilization of the left shoulder joint. The electromyography was used to record the electric activity of musculus trapezius pars descendens, pars transversa et pars ascendens, musculus deltoideus pars acromialis, musculus infraspinatus and musculus pectoralis major pars sternocostalis on the immobilized left arm; while using the PNF technique on the peripheral parts of the immobilised arm; and on the contra lateral arm. A 5s sequence of stabilised isometric contraction was analysed and all data further normalised to Maximal Voluntary Contraction (MVC). Considering the literature the 20% increase above the MVC was defined as substantial to assure sufficient functional capacity of the muscle fibres and therefore sufficient to stop muscle atrophy during immobilisation of the arm. Results: Results of this study support...

Les tendinopathies sont la première cause de maladie professionnelle en France. Elles sont devenues une préoccupation majeure de santé publique. Cependant, leurs mécanismes physiopathologiques restent encore mal définis. Au cours de cette thèse, nous nous sommes intéressés aux phases précoces de la tendinopathie engendrées par une sur-utilisation du tendon supra-épineux (tSE) de la coiffe de rotateurs de l’épaule chez le rat. Nous avons tenté de comprendre les mécanismes à l’origine de cette pathologie afin de pouvoir agir et la traiter en amont de l’apparition des symptômes.Nous montrons que le profil d’évolution moléculaire des collagènes, des protéoglycanes et des glycosaminoglycanes (GAGs) associé aux phases précoces de la sur-utilisation, témoigne d’un profond remaniement matriciel et d’une différenciation chondroïde des fibroblastes tendineux. Nous avons identifié les métalloprotéinases (MMPs) majeures et leurs inhibiteurs (TIMPs) susceptibles d’être impliqués dans ce remaniement. Nos résultats suggèrent que le mécanisme lésionnel initial et les changements matriciels observés sont dus à un processus induit par des médiateurs locaux libérés par les ténocytes et non à une réaction inflammatoire. Enfin, nous avons cherché à établir une corrélation entre les changements moléculaires observés et le degré de sévérité d’une tendinopathie diagnostiquée chez l’Homme. Nous avons montré, sur des échantillons de tendon patellaire humain une relation entre la quantité des GAGs et le score (VISA score) reflétant le degré pathologique du tendon.Cette étude nous a donc permis d’améliorer nos connaissances des phases précoces du processus d’altération du tSE. Cependant, d’importants efforts restent néanmoins à accomplir dans la caractérisation de la pathogenèse précoce notamment pour préciser le contexte biomécanique qui la génère. / Tendinopathies are the first cause of professional diseases in France. They are a major public health concern. However, their physiopathological mechanisms remain poorly understood. This project aimed at investigating the early stages of supraspinatus tendinopathy caused by overuse. Using a rat animal model, we attempted to understand the mechanisms behind this disease in order to act and treat the symptoms upstream of their onset.We have shown that the molecular changes of collagens, proteoglycans and glycosaminoglycans (GAGs) associated with the early events of overuse attest a major matrix remodeling and chondrogenic differentiation of tendon cells. We identified the main metalloproteinases (MMPs) and their inhibitors (TIMPs) that may be involved in this remodeling. Our results further suggest that the initial mechanisms linked to the observed matrix changes are due to local mediators release by tenocytes rather than an inflammatory process. Finally, we attempted to correlate molecular changes observed during overuse with the severity of the tendinopathy diagnosed in humans. We have shown a relationship between the amount of GAGs and the pathological score (VISA score) on human patellar tendons.This study improved our knowledge of the early pathological events of the supraspinatus tendon. However, more remains to be done for characterizing the early stages of tendinopathy especially to clarify the biomechanical context up-stream.

The aim of this thesis was to evaluate the influence of Vojta's reflex locomotion on the activity of the shoulder girdle's muscles with surface electromyography. We also observed the activity of some of the trunk's muscles. We tested phasic and support function of the upper extremity in several movements on 15 healthy people. It didn't bring many significant values. It could be caused by different sensitivities of the participants for the stimulation, the short time of the stimulation, individual motoric stereotypes or not so strongly expressed muscle dysbalantion within healthy individuals.

Title: Effect of core training on anterior shoulder instability on semiprofessional rugby players. The concept of the problem: With Rugby Union football being a contact-collision sport there is a high risk of injury incidence, especially for the upper extremities. The anterior shoulder dislocation carries the highest incidence and severity and may frequently lead to an anterior shoulder instability and is therefore a risk factor for decreasing sporting performance. Working with anterior shoulder instability on a complex basis, there are many possibilities to influence this problem and on of them is incorporating a "core-training" program into functional training patterns. In sports, the core provides a foundation upon which muscles of the extremties and their coordination rely. Objectives: To evaluate the incidence of anterior shoulder instability on semiprofessional rugby players and, subsequently, to attest the effectivity of the "core-training" exercise program on anterior shoulder instability of these athletes, on explosive power of the upper extremities and the performance of "medvěd"- an examination of the "Integrated Stabilizing System of the Spine" (HSSP) from Kolář. Methods: The theoretical part follows up the given issue as a research and theoretical overview of the current findings based...

Title: The effect of scapular specific kinesio tape on the movement quality of the upper limb. Objectives: The aim of this study is to evaluate the effectiveness of specific kinesio tape of shoulder blade on the quality of the movement of the upper limb. Currently, kinesio taping is very popular method in the treatment of myoskeletal diseases. Kinesio taping is mostly used by athletes, however the method becomes one of the common methods in physiotherapist practice. In this diploma thesis, specific method of kinesio taping was used. The method is focused on the facilitation of the lower blade fixators and is frequently used. Positive effect of the method on the position of the shoulder joint is obvious. The movement quality of the upper limb is represented by visual motor skills coordination, which was objectified with selected testing method. The prerequisite is a close relation between the position of the shoulder girdle with the function of the hand. Centred position of the shoulder blade ensured with the fixation of the lower blade fixators allows precise movement of the entire upper limb. The diploma thesis was focused on the population of people working on a computer. This way of working is now the most common cause of pain for patients who visit a physiotherapist. Measurement was attended by...

Le but de cette thèse a été de redéfinir le diagnostic d’hyperlaxité de l’épaule. Ce travail s’appui sur plusieurs études cliniques, chirurgicales et d’analyse du mouvement. Pour mener ce travail, nous avons tout d’abord défini l’hyperlaxité telle qu’elle est actuellement décrite dans la littérature, ainsi que ses liens avec l’instabilité de l’épaule et son traitement. Ce premier chapitre décrit également les moyens techniques d’analyse du mouvement qui seront utilisés dans cette thèse. Ensuite, plusieurs études ont été proposées. L’étude 2 est une étude chirurgicale, qui a cherché à corréler la laxité capsulaire étudiée en per opératoire et l’hyperlaxité clinique. L’étude 3 a ensuite rechercher les moyens de rendre plus reproductible la mesure de la rotation externe dans le cadre de l’hyperlaxité. Les études 4 et 5 sont des études utilisant l’analyse du mouvement. La première a cherché à fiabiliser la mesure clinique des amplitudes articulaires de l’épaule en tentant d’analyser les facteurs d’erreur de mesure. La deuxième étude a ensuite eut pour but de définir le volume articulaire global du complexe articulaire de l’épaule et de préciser la relation de ce volume avec les différents degrés de liberté de l’épaule. Une dernière étude (Etude 6) a enfin permis de corréler le volume articulaire de l’épaule et les signes cliniques d’hyperlaxité. Enfin, le chapitre « conclusions générales et perspectives » rassemble les éléments de conclusion de ces différents travaux et a pour ambition de redéfinir le diagnostic d’hyperlaxité de l’épaule. Ce chapitre ouvre plusieurs perspectives. La première est de proposer des modifications de l’examen clinique de l’épaule et notamment pour le diagnostic d’hyperlaxité. La seconde est d’utiliser la description volumétrique de l’épaule dans d’autres situations physiologiques ou pathologiques. Enfin, nous rapportons les résultats préliminaires d’une étude anatomique visant à identifier la place respective de chaque articulation dans cette définition volumétrique des amplitudes articulaires de l’épaule. / The aim of this study was to give a new definition to shoulder hyperlaxity. This work was conduced with clinical, surgical andmotion capture experimentations. We first gave a definition of hyperlaxity, as described actually in the literature, and its link with shoulder instability and treatment. Chapter 1 described also motion capture technics used along this work. Then, several studies were proposed. Study n°2 was a surgical one, and tempted to correlate peroperative capsular laxity and hyperlaxity. Therafter, study n°3 looked for an optimized way to examine external rotation of the shoulder. Studies N° 4 and 5 used motion capture analysis to assess clinical shoulder examination patterns and global reachable shoulder space volume. This volume was finally correlated to shoulder sign of hyperlaxity in study n°6. The last chapter, « general conclusions and perspectives » gather together conclusions of each study and redefine hyperlaxity. Finally, we report our prospect, giving first results of an anatomical study exploring the volumetric definition of shoulder range of motion described previously

INTRODUÇÃO: Na patogênese da rotura do manguito rotador, diminuição da síntese e aumento da degradação das fibras colágenas são encontradas, associadas ao aumento da atividade das metaloproteinases da matriz 1 e 3 (MMP-1 e MMP-3). Há evidências que fatores genéticos estão envolvidos na produção das metaloproteinases e na etiologia da rotura do manguito rotador. O objetivo deste estudo foi avaliar a associação entre o polimorfismo genético das MMP-1 e MMP-3 com a rotura de espessura completa do manguito rotador. Como objetivos secundários, tivemos avaliar a correlação dos haplótipos da MMP-1 e MMP-3 com a rotura de espessura completa do manguito rotador e comparar se indíviduos com rotura transfixante do manguito rotador têm maior proporção de familiares com a mesma doença, em relação aos indíviduos controles. MÉTODOS: Avaliamos 64 pacientes com rotura transfixante do manguito rotador e 64 controles assintomáticos. Foram incluídos apenas pacientes com idade inferior a 65 anos e rotura de espessura completa não traumática. A rotura ou integridade do manguito rotador foi avaliada por ressonância magnética ou ultrassonografia em todos indivíduos. Os pacientes e os controles foram pareados por idade. O ácido desoxirribonucleico (DNA) dos voluntários foi obtido a partir de células epiteliais da mucosa bucal. Os genótipos das MMP-1 e MMP-3 foram determinados utilizando as técnicas de Reação em Cadeia de Polimerase (PCR) e Polimorfismo no Comprimento de Fragmentos de Restrição (RFLP). RESULTADOS: Observamos uma presença de 77% do alelo 1G e 64% do genótipo 1G/1G no grupo controle. Os pacientes com rotura transfixante do manguito rotador apresentaram uma taxa de 48% do alelo 2G e 73% de genótipos 1G/2G ou 2G/2G (p < 0,001). Indivíduos com genótipo 1G/2G e 2G/2G tiveram maior chance de ter uma rotura do manguito rotador: razão de chances (RC) igual a 4,8 (Intervalo de confiança de 95% [IC 95%] 2,1 a 11,0) e 5,2 (IC 95% 1,8 a 14,9), respectivamente. Também observamos uma distribuição significativamente diferente nos alelos e genótipos da MMP-3 (p = 0,045, p = 0,021, respectivamente) entre os casos e controles. Indivíduos com genótipo 5A/5A tiveram maior chance de apresentarem uma rotura do manguito rotador (RC 5,5; IC 95% 1,4 a 20,9). Indíviduos com haplótipo 2G/5A tiveram maior possibilidade de ter uma rotura do manguito rotador, este haplótipo foi encontrado em 42 de 64 pacientes (66%) e em 17 de 64 controles (27%), com razão de chances de 5,3 (IC 95% 2,5 a 11,3). Pacientes com rotura do manguito rotador relataram, em maior número (19 de 64 pacientes, 30%), a existência de familiares que realizaram tratamento para rotura do manguito rotador em relação aos pacientes controles (quatro de 64 pacientes, 6%; p = 0,001). CONCLUSÃO: O polimorfismo genético das MMP-1 e MMP-3 foi associado à rotura do manguito rotador / INTRODUCTION: In the pathogenesis of rotator cuff tear, decreased synthesis and increased degradation of collagen fibers are found, associated with an increase in activity of matrix metalloproteinases 1 and 3 (MMP-1 and MMP-3). There is evidence that genetic factors may be involved in metalloproteinase production and the etiology of rotator cuff tear. The aim of this study was to evaluate the association between the genetic polymorphism of MMP-1 and MMP-3 and full-thickness rotator cuff tear. As secondary aims, we measured the correlation of MMP-1 and MMP-3 haplotypes with full-thickness rotator cuff tears and compared if individuals with full-thickness rotator cuff tears have a higher proportion of relatives with the same disease than the control subjects. METHODS: We evaluated 64 patients with full-thickness rotator cuff tear and 64 asymptomatic controls. Patients aged below 65 years, with non-traumatic full thickness tears, were included. The rotator cuff tear or integrity was evaluated by magnetic resonance or ultrasound in all individuals. The patients and controls were paired by age. The deoxyribonucleic acid (DNA) of the volunteers was obtained from oral mucosa epithelial cells. MMP-1 and MMP-3 genotypes were determined using the Polimerase Chain Reaction (PCR) and Restriction Fragment Length Polymorphism (RFLP) assays. RESULTS: We observed a 77% presence of allele 1G and 64% of genotypes 1G/1G in the control group. The patients with full-thickness rotator cuff tear presented 48% of allele 2G and 73% of genotypes 1G/2G or 2G/2G (p < 0.001). Individuals with genotypes 1G/2G and 2G/2G were more likely to have a rotator cuff tear: odds ratio equal to 4.8 (95% confidence interval [95% CI] 2.1 to 11.0) and 5.2 (95% CI 1.8 to 14.9), respectively. We also observed a significantly different distribution in the alleles and genotypes of MMP-3 (p = 0.045, p = 0.021, respectively) among the cases and controls. Individuals with the 5A/5A genotype were more likely to have a rotator cuff tear (OR 5.5; 95% CI 1.4 to 20.9). Individuals with the haplotype 2G/5A were more likely to have rotator cuff tears develop, this haplotype was found in 42 of 64 patients (66%) and in 17 of 64 controls (27%) with odds ratio 5.3 (95% CI 2.5 to 11.3). Patients with rotator cuff tears reported, in higher number (19 of 64 patients, 30%), the existence of relatives who previously had treatment for rotator cuff tears compared to control patients (four of 64 patients, 6%; p = 0,001). CONCLUSION: The genetic polymorphism of MMP-1 and MMP-3 was associated with rotator cuff tear

O objetivo do estudo foi investigar o efeito da adição de exercícios de controle motor da escápula a um programa de exercícios de fortalecimento convencional em desfechos clínicos, força muscular e amplitude de movimento em pacientes com síndrome do impacto subacromial. Métodos: Sessenta pacientes com SIS foram alocados aleatoriamente em dois grupos distintos: fortalecimento ou exercícios focalizados na escápula de controle motor. As intervenções foram realizadas três vezes por semana durante oito semanas. Função, dor, cinesiofobia, efeito percebido global, satisfação com o tratamento, força muscular, amplitude de movimento e posição da escápula foram medidos antes da intervenção (baseline), 4 semanas após o início, no final da intervenção (8 semanas após o início) e 16 semanas após a linha de base. A dor e a função do ombro foram avaliadas pela versão brasileira do Índice de Dor e Incapacidade no Ombro (SPADI-Br). Um avaliador cego para a atribuição de grupo mediu todos os resultados. Não houve diferenças entre os grupos nos desfechos primário e secundário. Em conclusão, a adição de exercícios de controle motor ao fortalecimento muscular forneceu pouco valor agregado para melhora da função e da dor em pacientes com SIS / The objective of the study was investigate the effect of adding scapula motor control exercises to a program of conventional strengthening exercises in clinical outcomes, muscle strength and range of motion in patients with subacromial impingement syndrome. Methods: Sixty patients with SIS were randomly allocated in two different groups: strengthening or motor control scapula-focused exercises. The interventions were performed three times a week for eight weeks. Function, pain, kinesiophobia, global perceived effect, satisfaction with treatment, muscle strength, range of motion and scapula position were measured before intervention (baseline), 4 weeks after baseline, at the end of intervention (8 weeks after baseline) and 16 weeks after baseline. Shoulder pain and function were assessed by the Brazilian version of Shoulder Pain and Disability Index (SPADI-Br). An assessor blinded to group assignment measured all outcomes. There were no between-group differences in primary and secondary outcomes. In conclusion, the addition of motor control exercises to strengthening treatment provides little-added value regarding improving function or pain in patients with SIS.

Os músculos do manguito rotador são os responsáveis pelo movimento de rotação do ombro e representam sítio freqüente de processos patológicos.O desequilíbrio de forças do manguito rotador pode desencadear patologias distintas do ombro ou ser resultado destas. A quantificação da força muscular do manguito rotador com dados precisos, somente é possível com aparelhos de alto custo, longe do alcance da maioria dos profissionais envolvidos com o problema em nosso país. No presente estudo, um aparelho relativamente simples e de baixo custo, capaz de mensurar com precisão a força muscular isométrica de rotação interna e rotação externa do ombro, foi projetado e construído com materiais de fácil obtenção e preço acessível. Ele consiste basicamente de uma plataforma de medição do torque de rotação do ombro acoplada a uma cadeira e adaptável para avaliação bilateral. O aparelho foi projetado para que o indivíduo permaneça sentado durante o teste, com cotovelo fletido a 90 graus e o antebraço apoiado sobre uma superfície plana. Um torquímetro, devidamente calibrado, foi fixado na porção inferior da plataforma, no ponto correspondente ao centro de rotação do ombro. A mudança no comprimento do braço de alavanca foi permitida pela variação na posição de um manípulo para apoio da mão durante os esforços de rotação interna e de rotação externa do ombro. Variações no comprimento do braço de alavanca e na altura da plataforma foram projetadas para adaptarem-se aos braços e antebraços dos indivíduos. O aparelho foi testado em 20 indivíduos saudáveis e demonstrou ser completamente versátil para uso em diversas condições e confiável na produção de informações sobre o torque dos músculos rotadores do ombro. / The rotator cuff muscles are responsible for the rotation movements of the shoulder and frequent site of pathological processes. Rotator cuff muscle power imbalance may unchain or result from distinct shoulder diseases. To date precise quantification of rotator cuff muscle power is only possible with the use of expensive machines, far from the reach of most of the professionals involved with the problem in our country. In the present investigation, a relatively simple and low cost device, able to precisely measuring isometric internal and external rotator muscle power, was developed and built with easily obtainable and low cost materials. It consists basically of a platform for measuring the rotational torque of the shoulder adaptable to both sides of a chair for bilateral evaluation. It was designed for the individual to remain seated while in test, the elbow flexed at 90o and the forearm rested on a flat surface. A properly calibrated torquimeter was adapted to the bottom side of the platform in a point corresponding to the shoulder’s center of rotation. The moving lever was provided with a handle to be grasped by the individual while doing internal or external efforts with the shoulder. Both platform height and moving lever were made adaptable to individual arm and forearm lengths. The device was tested with 20 healthy individuals and demonstrated to be quite versatile for use in many different conditions and reliable in providing information on the torque of the rotator muscle of the shoulder.