<b>Introduction</b>: Kinesiology-style manual muscle testing (kMMT) is a non-invasive assessment method used by various types of practitioners to detect a wide range of target conditions. It is distinctly different from the muscle testing performed in orthopaedic/neurological settings and from Applied kinesiology. Despite being estimated to be used by over 1 million people worldwide, the usefulness of kMMT has not yet been established. The aim of this thesis was to assess the validity of kMMT by examining its accuracy and precision. <b>Methods</b>: A series of 5 diagnostic test accuracy studies were undertaken. In the first study, the index test was kMMT, and the target condition was deceit in verbal statements spoken by Test Patients (TPs). The comparator reference standard was a true gold standard: the actual verity of the spoken statement. The outcomes of the muscle tests were interpreted consistently: a weak result indicated a Lie and a strong result indicated a Truth. A secondary index test was included as a comparator: Intuition, where Practitioners used intuition (without using kMMT) to ascertain if a Lie or Truth was spoken. Forty-eight Practitioners were recruited and paired with 48 unique kMMT-naïve TPs. Each Pair performed 60 kMMTs broken up into 6 blocks of 10, which alternated with blocks of 10 Intuitions. For each Pair, an overall percent correct was calculated for both kMMT and Intuition, and their means were compared. Also calculated for both tests were sensitivity, specificity, positive predictive value and negative predictive value. The second study was a replication of the first, using a sample size of 20 Pairs and a less complex procedure. In the third study, grip strength dynamometry replaced kMMT as the primary index test. In the fourth study, the reproducibility and repeatability of kMMT were examined. In the final study, TPs were presented with emotionally-arousing stimuli in addition to the affect-neutral stimuli used in previous studies, to assess if stimuli valence impacted kMMT accuracy. <b>Results</b>: Throughout this series of studies, mean kMMT accuracies (95% Confidence Intervals; CIs) ranged from 0.594 (0.541 – 0.647) to 0.659 (0.623 - 0.695) and mean Intuition accuracies, from 0.481 (0.456 - 0.506) to 0.526 (0.488 - 0.564). In all studies, mean kMMT accuracies were found to be significantly different from mean Intuition accuracies (p ≤ 0.01), and from Chance (p < 0.01). On the other hand, no difference was found between grip strength following False statements compared to grip strength following True statements (p = 0.61). In addition, the Practitioner-TP complex accounted for 57% of the variation in kMMT accuracy, with 43% unaccounted for. Also, there was no difference in the mean kMMT accuracy when using emotionally-arousing stimuli compared to when using affect-neutral stimuli (p = 0.35). Mean sensitivities (95% CI) ranged from 0.503 (0.421 - 0.584) to 0.659 (0.612 - 0.706) while mean specificities (95% CI) ranged from 0.638 (0.430 - 0.486) to 0.685 (0.616 - 0.754). Finally, while a number of participant characteristic seemed to influence kMMT accuracy during one study or another, no one specific characteristic was found to influence kMMT accuracy consistently (i.e. across the series of studies). <b>Discussion</b>: This series of studies has shown that kMMT can be investigated using rigorous evidence-based health care methods. Furthermore, for distinguishing lies from truths, kMMT has repeatedly been found to be significantly more accurate than both Intuition and Chance. Practitioners appear to be an integral part of the kMMT dynamic because when replaced by a mechanical device (i.e. a grip strength dynamometer), distinguishing Lies from Truth was not possible. In addition, since specificities seemed to be greater than sensitivities, Truths may have been easier to detect than Lies. A limitation of this series of studies is that I have a potential conflict of interest, in that I am a practitioner of kMMT who gets paid to perform kMMT. Another limitation is these results are not generalisable to other applications of kMMT, such as its use in other paradigms or using muscles other than the deltoid. Also, these results suggest that kMMT may be about 60&percnt; accurate, which is statistically different from Intuition and Chance; however it has not been established if 60&percnt; correct is "good enough" in a clinical context. As such, further research is needed to assess its clinical utility, such as randomised controlled trials investigating the effectiveness of whole kMMT technique systems. Also, future investigators may want to explore what factors, such as specific Practitioner and TP characteristics, influence kMMT accuracy, and to investigate the validity of using kMMT to detect other target conditions, using other reference standards and muscles other than the deltoid. <b>Summary</b>: This series of diagnostic test accuracy studies has found that kMMT can be investigated using rigorous methods, and that kMMT used to distinguish Lies from Truths is significantly more accurate that both Intuition and Chance. Further research is needed to assess kMMT’s clinical utility.

Growing up as fairly successful female-athlete, I have always felt somewhat undermined and frustrated when I take a look at the double-standards and social injustice compared to those male counterparts. When it comes to intercollegiate athletics, so much integrity has been lost because of this injustice, as well as the "win at all costs" mentality. Through my upbringing and the many positive experiences that came into play, however, I have been raised to uphold a strong level of integrity and live my life with honesty. By living and leading with authenticity, feelings of vulnerability and shame often come up. As a female leader, these vulnerable feelings are often shielded and masked in order to better suit the patriarchal athletic society. Through my personal experiences in the sport world, I have found that accepting one's vulnerability is a method to grow as a leader. By tackling feelings of shame directly, female leaders take on a new meaning of resiliency. Through the process of evaluating my own personal experiences of resiliency during the stages of childhood, collegiate athlete, collegiate coach, and female leader, I have come up with universal applications that look at the role of vulnerability in leadership.

Introdução. Pacientes portadores de diabetes mellitus tipo 2 (DM2) podem apresentar fraqueza da musculatura inspiratória. O efeito do treinamento muscular inspiratório (TMI) nesses pacientes ainda é desconhecido. Objetivos. Avaliar os efeitos do TMI sobre a força muscular inspiratória, a função pulmonar, a capacidade funcional e a modulação autonômica em pacientes com DM2 com fraqueza da musculatura inspiratória. Métodos. A pressão inspiratória máxima (PImáx) foi avaliada em uma amostra de 148 pacientes com DM2 da qual 25 pacientes com PImáx < 70% do previsto foram randomizados para um programa de 8 semanas de TMI diário (n=12) ou TMI-placebo (n=13). A PImáx, a função pulmonar, o consumo máximo de oxigênio e a variabilidade da freqüência cardíaca foram avaliados antes e após o TMI. Resultados. Do total de pacientes avaliados, 29,05% (43 pacientes) apresentaram fraqueza muscular inspiratória. O TMI aumentou significativamente a PImáx (118%) e a resistência muscular inspiratória (320%), sem alterar a função pulmonar, a capacidade funcional e a modulação autonômica. Conclusões. O TMI, em pacientes com DM2 e fraqueza dos músculos inspiratórios, aumentou significativamente a PImáx sem modificar a função pulmonar, a capacidade funcional e a modulação autonômica. / Introduction. Subject with type 2 diabetes mellitus (DM2) can present weakness of the inspiratory muscle. The effect of the inspiratory muscle training (IMT) in these patients still is unknown. Objectives. To evaluate the effect of the IMT on the inspiratory muscle force, the pulmonary function, the functional capacity and the autonômica modulation in patients DM2 with weakness of the inspiratory muscle. Methods. The maximum inspiratory pressure (PImáx) was evaluated in a sample of 148 patients with DM2 of which 25 patients with PImáx < 70% of the foreseen one had been randomizeds for a program of 8 weeks of daily IMT (n=12) or IMT-placebo (n=13). The PImáx, the function pulmonary, the VO2 and the variability of the cardiac frequency had been evaluated before and after the IMT. Results. Of the total of evaluated patients, 29.05% (43 patients) had presented inspiratory muscle weakness. The IMT significantly increased the PImáx (118%) and the inspiratory muscle resistance (320%), without modifying the function pulmonary, the exercise capacity and the modulation autonomic. Conclusions. The IMT in patients with DM2 and weakness of the inspiratory muscles increased the PImáx without modifying the function pulmonary, the exercise capacity and the modulation autonomic significantly.

El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado. / OBJECTIVE: To assess the relationship between physical performance (PP) and muscle strength (MS) in elderly subjects with and without diabetes in a public hospital of Lima, Peru. SUBJECTS AND METHOD: A cross-sectional analysis of subjects aged 60 years or older with and without diabetes. MS was measured with a handheld dynamometer, and PP with the «timed get-up-and-go» test. Nutritional status was determined using body mass index, body fat percentage measured with a handheld fat loss monitor and protein intake based on the 24-hour recall. Age, sex, and history of hospitalization and supplementation were also recorded. The association was assessed using adjusted prevalence ratios. RESULTS: Overall, 139 patients with diabetes (26.6% with low PP and 13.7% with decreased MS) and 382 subjects without diabetes (36.6% with low PP and 23.0% with decreased MS) were evaluated. No association was found between T2DM and MS (aPR: 0.99; 95% CI: 0.67-1.57) or PP (aPR: 1.13; 95% CI: 0.84-1.52). Protein and supplement consumption was also unrelated (P>.05); however, history of hospitalization, age, sex, nutritional status, and body fat percentage were related (P>.05). CONCLUSIONS: No association was found between T2DM, MS, and PP. However, low PP was associated to female sex and overweight/obesity, and decreased MS was associated to high body fat percentage and underweight. Moreover, MS and PP were related to older age and history of hospitalization. / Revisión por pares

Following a review of the paradigmatic context of broch towers in 2012, a revised standard model (the RSM) was defined. The then prevailing paradigm supports a view of broch remains as single monuments of highly variable form that continued in use over perhaps a millennium or more, without significant modification of their original tectonics i.e. their people/constructed-space relationships. This thesis challenges the pre-2012 paradigm by testing the hypothesis that brochs were built to the standard canonical form of the RSM and that their apparent diversity results from anthropic and, or natural modification, not design variability. The fieldwork tests could but did not find refutation of these hypotheses in the observable evidence and offered more profound interpretations of several surviving feature-types. The loading on the stone lintels of the entrance passage through the massively built outer wall and the structurally overladen inner wall created a major structural challenge, evoking a complex engineering solution. Its elements were individually noted pre-2012 but the significance of the engineering response to compression management had not been identified. This structural response was necessary for a tall structure with massive loads, and meaningless without one and its elements are therefore, jointly and severally, clear diagnostics of a broch tower. The entrance engineering was probably the inspiration of one individual or of a small group of master mason-types, not vernacular responses, contra the 2012 paradigm. Isolated stacked voids high in the inner wall are relict features indicative of significant modification of the inner wall. Other anomalous features are shown to be relict stacked void fragments. The East/West differences in brochs across Scotland have long been identified and these are generally attributed to their lithologies. Accepting that, this thesis argues that the principal differences are attributable to the social processes that gave rise to centralisation of settlement around, in and over brochs in the east and north, possibly during the first century BC, and the absence of centralisation in the west; perhaps also explaining the differences in the scale and composition of the artefact assemblages between the two zones. The canonical form facilitates calculation of the relative social costs of broch building for hard-rock and sedimentary stone types. This indicates that the costs of building, increase between 16-, and 32- fold over the buildable range of brochs. Constraints of design down-scalability, design weakness in ground loading, and design cost were major constraints on the mind of the broch builders. Canonicity and the limitations of drystone building technologies predicated specific forms of decomposition on the canonical broch, further complicating their autobiographies and their conservation: the main challenge now being that of finding ways to conserve the evidence for a sequence of processes while conserving the products of those processes.

Sepsis is a severe life-threatening critical illness that damages multiple physiological systems. After hospital discharge, more than 70% of severe sepsis survivors report profound weakness which significantly impacts quality of life. Such weakness gives rise to new limitations of daily living, which ultimately leads to loss of independence in many patients. Despite wide recognition of this serious issue by clinicians and researchers alike, the mechanisms contributing to chronic skeletal muscle dysfunction after sepsis are not well understood. Lack of progress in this field is largely due to the absence of an appropriate animal model; current models are either too mild to induce muscle weakness or too severe and cause death within a few days. As such, this dissertation work first focused on establishing a clinically-relevant animal model of sepsis which yields surviving mice with chronic skeletal muscle weakness (Aim 1). This aim involved refining the cecal slurry injection model of polymicrobial sepsis in young adult animals, as well as optimizing the timing, duration, and dose of multiple therapeutic agents. The resulting resuscitation protocol was adapted for use in late-middle-aged animals, and muscle strength was evaluated using an ex vivo system which confirmed significant muscle weakness in sepsis survivors, long after sepsis was resolved. Next, using this novel model, we sought to characterize sepsis-induced long-term muscle dysfunction at the molecular level (Aim 2). The first set of experiments under this aim was designed to identify the primary global mechanism(s) (i.e. atrophy, polyneuropathy, and/or myopathy) responsible for muscle weakness in sepsis survivors. Analysis of the force-frequency curves and specific force measurements led to the conclusion that myopathy is the primary cause. Electron micrograph observation, functional assays, and protein analysis then showed that sepsis survivors’ skeletal muscles are characterized by profound mitochondrial abnormalities and oxidative damage. Collectively, these studies demonstrate that long-term muscle weakness is apparent in sepsis-surviving animals, and the functional decline is associated with unresolved mitochondrial damage and dysfunction. This work suggests that medical treatments beyond targeting muscle wasting alone could allow sepsis survivors to regain function and return to productive lives.

Traditionally, results from caloric testing and optokinetic nystagmus (OKN) testing are analyzed separately because caloric testing is a measure of peripheral function and OKN testing is considered to be a measure of central function. However, there is a connection between the visual system and the vestibular system in the vestibular nucleus of the brainstem. The purpose of this paper was to determine whether a relationship exists between optokinetic nystagmus results and unilateral caloric weakness results. This was determined by conducting a retrospective study of forty patients who exhibited a unilateral caloric weakness greater than or equal to twenty percent and symptoms consistent with an uncompensated vestibulopathy. Patients were later divided into two groups based on involved side. A control group consisting of ten subjects with no reported hearing or vestibular problems was also recruited. When the data of all subjects with a unilateral caloric weakness was considered together, no correlation was found between caloric response (right and left ear) and optokinetic results (gain and slow phase velocity). However, a potential trend emerged at the slow stimulus velocity (15 degrees) when comparing the patients with a right caloric weakness to those with a left caloric weakness. Subjects with a right caloric weakness showed decreased OKN gain for the right eye with a right-moving stimulus compared to the subjects with a left caloric weakness. Alternatively, subjects with a left caloric weakness showed decreased OKN gain for the left eye with a left-moving stimulus compared to the subjects with a right caloric weakness. We conclude that interpretation of OKN along with caloric results may offer potential for identification and tracking of compensation after a unilateral loss of vestibular function, but further research is needed.

The incidence data provided by previous investigations of peripheral vestibulopathy in patients with benign paroxysmal positional vertigo (BPPV) are quite variable. This variability may be explained, in part, by the otologic history of the patients included in these studies. Specifically, patients with a prior history of other otologic disease and BPPV should be more likely to present with peripheral vestibulopathy than patients without no prior history of otologic disease and BPPV. The purpose of this study was to determine the incidence of peripheral vestibulopathy in these two groups of BPPV patients. Caloric responses were analyzed for two groups of patients with posterior canal BPPV, those with a positive history of otologic disease and those with a negative history of otologic disease. Data were analyzed retrospectively for 157 BPPV patients. Patients with a positive history of otologic disease exhibited a greater incidence of peripheral vestibulopathy than the negative history group. The positive history group, on average, also exhibited a larger unilateral weakness than those patients in the negative history group. We conclude that patients with BPPV and a prior history of otologic disease are more likely to present with peripheral vestibulopathy than patients with BPPV and no history of otologic disease.

<p>After the acute spell of poliomyelitis, patients commonly suffers from sequelae of weakness. Some of these patients experience new weakness after a time period of stable symptoms.</p><p>The aim of this thesis was to evaluate the possible mechanisms for persistent weakness and development of new weakness in prior polio patients.</p><p>The usefulness of neurophysiologic methods to study prior polio was evaluated. Also two follow up investigations were performed in the attempt to investigate a possible relationship between development of weakness over time and possible failure in neuromuscular function and relation to muscular activity. In another investigation an evaluation of the exceptional finding of a history of paralytic poliomyelitis without neurophysiologic signs of anterior horn cell death was made. The last investigation dealt with reflex pattern in prior polio and it’s relation to weakness and anterior horn cell loss.</p><p>The weakness in prior polio is mainly due to loss of motor neurons with incomplete compensatory mechanisms of reinnervation. The new weakness is mainly due to exaggerated physiological age dependent loss of whole motor neurons, but also fragmentation of the motor unit is likely when these have reached an upper size. Defective neuromuscular transmission and failure in the central drive contribute to a lesser degree to weakness. </p><p>Neurophysiologic method of choice for the assessment of motor unit size and the micro-physiology of the motor unit is Macro EMG.</p><p>Muscular overuse may accelerate motor unit loss over time in prior polio. Extremely large motor units measured with Macro EMG predict new weakness and Macro EMG can be used for prognostication of development of new weakness in prior polio.</p>

After the acute spell of poliomyelitis, patients commonly suffers from sequelae of weakness. Some of these patients experience new weakness after a time period of stable symptoms. The aim of this thesis was to evaluate the possible mechanisms for persistent weakness and development of new weakness in prior polio patients. The usefulness of neurophysiologic methods to study prior polio was evaluated. Also two follow up investigations were performed in the attempt to investigate a possible relationship between development of weakness over time and possible failure in neuromuscular function and relation to muscular activity. In another investigation an evaluation of the exceptional finding of a history of paralytic poliomyelitis without neurophysiologic signs of anterior horn cell death was made. The last investigation dealt with reflex pattern in prior polio and it’s relation to weakness and anterior horn cell loss. The weakness in prior polio is mainly due to loss of motor neurons with incomplete compensatory mechanisms of reinnervation. The new weakness is mainly due to exaggerated physiological age dependent loss of whole motor neurons, but also fragmentation of the motor unit is likely when these have reached an upper size. Defective neuromuscular transmission and failure in the central drive contribute to a lesser degree to weakness. Neurophysiologic method of choice for the assessment of motor unit size and the micro-physiology of the motor unit is Macro EMG. Muscular overuse may accelerate motor unit loss over time in prior polio. Extremely large motor units measured with Macro EMG predict new weakness and Macro EMG can be used for prognostication of development of new weakness in prior polio.