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Bakgrund: En amputation innebär ett avlägsnade av en kroppsdel. De flesta amputationer utförs i de nedre extremiteterna. I Sverige sker årligen ungefär 2250 amputationer i de nedre extremiteterna. Orsaken till amputation kan vara kärlsjukdomar, diabetes samt trauma. Sjuksköterskan har i sin profession en betydande roll i mötet med patienten. Syfte: Syftet var att beskriva patienters upplevelser efter amputation av nedre extremitet. Metod: En litteraturöversikt genomfördes utifrån Fribergs metodbeskrivning. Tio kvalitativa originalartiklar inhämtades via databaserna PubMed och Cinahl Complete. Primära sökord som användes var amputation, nedre extremitet och livsförändrade händelser med begränsningar såsom engelska och peer reviewed. Resultat: Fyra teman identifierades: Upplevelsen av psykiska och fysiska förändringar, Att uppleva rollförändring och förlust av självständighet, Förändrad kroppsuppfattning och känslan av sårbarhet samt Vägen tillbaka efter amputation. Resultatet visade att patienterna upplevde en förlust av självständighet vilket gav upphov till en känsla av att vara en börda för sin familj. Den fysiska förmågan försämrades vilket bidrog till att de inte kunde ta sig utanför hemmet. Detta resulterade i att de kände sig ensamma och isolerade. Slutsats: Patienter upplevde känslomässig chock och rädsla inför framtiden. Att inte kunna prestera till fullo, bidrog till en känsla av förlust av identitet och självständighet. Vikten av stöd från familj, vänner och vårdpersonal har en central betydelse för återhämtning efter amputation. Amputation innebär att patienten genomgår en övergång till en ny fas i livet, en transition. / Background: An amputation implies a removal of a body part. Most amputations transact at the lower extremities. In Sweden approximately 2250 lower extremity amputations are made a year. The causes of amputation may be vascular diseases, diabetes or trauma. The profession of a nurse has a major role in the relation to the patient. Aim: The aim was to investigate patients’ experiences after an amputation of lower extremity. Method: To approach the aim a literature review was performed by the method of Friberg. Ten qualitative original articles were collected by the databases PubMed and Cinahl Complete. Primary keywords were amputation, lower extremity and life change events. Limitations were English and peer reviewed. Results: Four themes were identified: Experience of psychological and physical changes, To experience changes of identity and loss of independents, Changes of self-perceptions and the feeling of being vulnerable and How to recover after an amputation. The result showed that the patients’ experienced a loss of independence which resulted in a feeling of being a burden. The physical ability was impaired and contributed to a feeling of being isolated and lonely. Conclusion: The patients’ experienced emotional shock and a fear for the future. Not being able to perform to the fullest produced a loss of identity and independence. Support from family, friends and healthcare professionals has a central value for the recovery. To be amputated results in a transitioning and a new phase in life.

<p>The purpose of this thesis was to evaluate musculoskeletal contributions to joint stiffness in the distal upper extremity. An <em>in-vitro</em> and <em>in-vivo</em> approach was used to examine muscle and ligament contributions to mechanical joint stiffness at the elbow and wrist. In Chapters 2 and 3 an <em>in-vitro</em> approach was used to evaluate ligament contributions to carpal tunnel mechanics. Chapter 2 documented transverse carpal ligament (TCL) mechanical properties and provided a calculation of TCL length when stretched, which confirmed the ligaments importance in carpal tunnel mechanics and carpal bone stability. Chapter 3 quantified mechanical properties of the TCL at six different locations using a biaxial tensile testing method. It was found that the complex TCL fibre arrangement makes the tissue properties location dependent. The TCL contributes to carpal tunnel mechanics and carpal stability and the ligament contributions are different depending on the tissue location tested. Chapters 4 and 5 focused on the effects of hand loads and arm postures on the muscular response to sudden arm perturbations. The elbow flexors demonstrated stiffness contributions immediately prior to a perturbation and were influenced by posture and hand loading. The forearm muscles provided a small contribution to elbow joint stiffness. Chapter 6 also found muscular contributions that increased wrist joint stiffness immediately prior to a sudden perturbation. Additionally, for a small grip-demanding task, forearm muscle co-contraction resulted in large increases in wrist joint stiffness.</p> <p>This thesis has provided a detailed analysis of the TCL which improves our understanding of the carpal tunnel and specific mechanisms of injury. It is the first to document individual muscle contributions to elbow and wrist joint stiffness. The comprehensive analysis of ligament and muscular contributions to joint stiffness has provided insight into joint stability in the distal upper extremity. This can improve our understanding of injury caused by sudden joint loading.</p> / Doctor of Philosophy (PhD)

Bakgrund: En underbensamputation innebär en stor livsförändring för patienten. En förlorad kroppsdel är inte bara en förlust av de funktionella förmågorna, de psykologiska förändringar som en amputation innebär ger upphov till en förlust av ett sätt att leva och en förlorad kontroll. Sjuksköterskans roll inom omvårdnaden efter en amputation är en central del för att främja rehabiliteringen, där kunskap för det psykiska måendet och lyhördhet inför den nya livssituationen är av stor vikt. Syftet: Syftet med litteraturstudien är att belysa forskning om patienters upplevelse av det dagliga livet efter en underbensamputation. Metod: Litteraturstudie baserad på tolv studier med kvalitativ studiedesign. Lämpliga studier valdes ut och kvalitetsgranskning genomfördes enligt SBU:s kvalitetsgranskningsmall (SBU 2014). Därefter genomfördes analys utifrån Popenoe m.fl. (2021) där resultatet kategoriserades. Resultat: Tre huvudkategorier identifierades i resultatet, upplevelse av förändring i det dagliga livet, en förändrad kroppsuppfattning och att främja välbefinnandet. Under respektive huvudkategori urskildes subkategorier, dessa innefattade upplevda hinder i vardagen, upplevelse av smärta och fantomsmärta, förändring i relationer, förlust av självständighet, känsla av maktlöshet, upplevelsen av den nya spegelbilden, det sociala nätverket som stöd, vägen till självständighet och anpassningen till den nya livssituationen. Konklusion: Förlusten av en kroppsdel är permanent och innebär en stor förändring hos patienterna i det dagliga livet. Oavsett bakomliggande orsak till amputationen gav detta upphov till olika hinder i vardagen, en förlust av självständighet och en förändrad spegelbild. För att främja återhämtning och rehabilitering var förberedelse, tydlig information och delaktighet av stor vikt samtidigt som en personcentrerad vård såg till hela patientens behov. / Background: Lower limb amputation represents a major life change for the patient. The loss of a limb is a loss of functional abilities where psychological changes lead to a loss of way of life and control. The nurses can help promote rehabilitation, where knowledge of the patient’s well-being and sensitivity to the new life situation are important. Purpose: The purpose of this literature review is to highlight research on patients’ experience of daily life after a lower limb amputation. Method: Qualitative literature review based on twelve studies with a qualitative study design. Suitable studies were selected, a quality review was conducted according to SBU's quality review template (SBU 2014). Analysis was then carried out according to Popenoe et al. (2021), where the results were categorized. Results: Three main categories were identified, experience of change in daily life, changed body image and promoting well- being. Under each main category, subcategories were distinguished, perceived barriers in daily life, experience of pain and phantom pain, change in relationships, loss of independence, feeling powerless, experiencing a new mirror image, the social network as support, the path to independence and adaptation to the new life situation. Conclusion: The loss of a limb is permanent and represents a major change in patients’ lives. Regardless of the case of the amputation, it resulted in various barriers to daily life, loss of independence and an altered reflection. To promote recovery and rehabilitation, preparation, clear information, and participation were essential while person-centred care addressed the needs of the whole patient.

The outputs that form the basis of this PhD submission include a web site that summarises a unique collection of over 200 Court Judgments in personal injury claims for work-related upper limb disorders heard in the UK, together with a number of more conventional publications. Individually, these outputs all address upper limb disorders associated with work although they each had slightly different objectives and the audiences for which they were produced significantly influenced the type of publication in which they appeared. Together, they help illustrate when, how and, to some extent, why upper limb disorders associated with keyboard use became the issue it did in the UK in the late 1980s and 1990s. While many might now regard keyboard or computer use as an innocuous task, in the late 1980s and 1990s upper limb disorders associated with keyboard use, particularly computer use, became the subject of litigation, legislation, industrial disputes and widespread publicity. The outputs on which this submission is based, together, suggest that following the importation of the concept of repetitive strain injuries (RSI) from Australia in the later 1980s, the activities of trades unions and journalists in the UK promoted work-relevant upper limb symptoms and disorders associated with keyboard use as work-induced injuries. Subsequently, a small number of successful, union-backed, personal injury claims, which involved contentious medical evidence and perhaps an element of iatrogenesis, were widely promoted as proof that computer use causes injury. Around the same time, the government chose to implement flawed Regulations relating to the design and use of computer workstations, which failed to distinguish between that which might give rise to discomfort, fatigue and frustration and that which might give rise to injury. The existence of these Regulations, which among other things require regular, individual risk assessments of computer users, unlike any other type of work, could be interpreted as further 'proof' that computer use causes injury. The approach to the prevention and management of musculoskeletal disorders advocated in current HSE guidance, including the risk assessment strategy, remain capable of generating distorted perceptions of the risks arising from keyboard and computer use.

Background and Purpose: Tai Chi (TC) has been reported as beneficial for improving balance post stroke, yet its use for upper limb (UL) rehabilitation remains unknown. The purpose of this study was to evaluate the feasibility and efficacy of TC on UL rehabilitation post stroke. Methods: Twelve chronic stroke survivors with a persistent paresis underwent 60-minute adapted TC sessions twice a week for eight weeks and a 4-week follow-up evaluation. A 10-minute TC home program was recommended for the days without sessions. TC level of performance, adapted movements used, attendance to the sessions and duration of self-practice at home were recorded. Shoulder pain (Visual Analogue Scale (VAS)), motor function of the paretic arm ((Fugl-Meyer Assessment upper-limb section (FMA-UL), Wolf Motor Function Test (WMFT)) and paretic arm use in daily life (Motor Activity Log (MAL)) were measured at baseline, post-treatment and follow-up. A feedback questionnaire was used to evaluate participants’ perception of the use of TC at follow-up. Results: Eleven participants completed the 8-week study. A clinical reasoning algorithm underlying the adaptation of TC was developed based on different functional levels of the participants. Participants with varying profiles including severely impaired UL, poor balance, shoulder pain, and severe spasticity were not only capable of practicing the adapted TC but attended all 16 sessions and practiced TC at home more than recommended (a total of 16.51±9.21 hours). The self-practice amount for subgroups with lower UL function, shoulder pain or moderate-to-severe spasticity, was similar to subgroups with higher functional UL, no shoulder pain, and minimal-to-no spasticity. Participants demonstrated significant improvement over time in the FMA-UL (p=.009), WMFT functional scale (p=.003), WMFT performance time (p=.048) and MAL Amount of Use scale (p=.02). Shoulder pain of four participants decreased following TC (VAS 5.5±3, 3±2.8, 2.5±2.5 for the pre, post and follow-up period respectively). Moreover, participants confirmed the usefulness and ease of practicing the adapted TC. Conclusion: Adapted TC is feasible, acceptable and effective for UL rehabilitation post stroke. Low UL function, insufficient balance, spasticity, and shoulder pain do not seem to hinder practicing TC. Further large-scale randomized trials evaluating TC for UL rehabilitation are warranted. / Contexte et objectifs: Le Tai Chi (TC) a été rapporté comme bénéfique pour améliorer l'équilibre suite à un accident vasculaire cérébral (AVC), mais son utilisation pour la réadaptation du membre supérieur reste inconnue. Le but de cette étude était d’évaluer la faisabilité et l'efficacité du TC pour la réadaptation du membre supérieur post-AVC. Méthode: Douze personnes ayant un AVC en phase chronique avec une parésie persistante ont participé à des sessions de 60 minutes de TC adaptées deux fois par semaine pendant 8 semaines et au suivi à 12 semaines. Un programme à domicile de 10 minutes de TC a été recommandé pour les jours sans session. Le niveau de performance du TC, les mouvements adaptés utilisés, la participation aux sessions et la durée de pratique à domicile ont été documentés. La douleur à l’épaule (Visual Analogue Scale (VAS)), la fonction motrice du bras parétique ((Fugl-Meyer Assessment upper-limb section (FMA-UL), Wolf Motor Function Test (WMFT)) et l'utilisation du bras parétique dans la vie quotidienne (Motor Activity Log (MAL)) ont été mesurées au départ, après le traitement et au suivi (4 semaines post-traitement). Un questionnaire de rétroaction a été utilisé pour évaluer la perception des participants sur l'utilisation du TC lors du suivi. Résultats: Onze participants ont terminé l'étude de 8 semaines. Un algorithme de raisonnement clinique qui sous-tend l’adaptation du TC a été développé sur la base des niveaux fonctionnels des participants. Les participants ayant des profils différents, y compris le membre supérieur sévèrement atteint, l'équilibre atteint, de la douleur à l'épaule et de la spasticité sévère étaient non seulement capables de pratiquer le TC adapté, mais ont participé à l'ensemble des 16 sessions et pratiquaient le TC à la maison plus que recommandé (un total de 16.51 ± 9.21 heures). La quantité de pratique à domicile des sous-groupes avec la fonction inférieure du membre supérieur, de la douleur à l'épaule ou de la spasticité modérée-à-sévère, était similaire aux sous-groupes avec une fonction supérieure du membre supérieur, sans douleur à l'épaule et une spasticité minimale ou non-présente. Les participants ont montré une amélioration significative au fil du temps selon le FMA -UL (p=.009), l’échelle fonctionnelle du WMFT (p=.003), le temps de performance du WMFT (p=.048) et l’échelle du montant de l’utilisation du MAL (p=.02). La douleur à l'épaule des quatre participants a diminué suite au TC (VAS 5.5±3, 3±2.8, 2.5±2.5 pour la période de pré-traitement, post-traitement et suivi). En outre, les participants ont confirmé l'utilité et la facilité de la pratique du TC adapté. Conclusion: Le TC adapté est faisable, acceptable et efficace pour la réadaptation du membre supérieur après un AVC. Une fonction diminuée au membre supérieur, l’équilibre insuffisant, la spasticité et la douleur à l'épaule ne semblent pas empêcher la pratique du TC. Plus d’essais randomisés à grande échelle sont nécessaire pour évaluer l’effet du TC sur la réadaptation du membre supérieur.

Bakgrund I Sverige drabbas årligen 50 000 personer av förvärvad hjärnskada. Vanliga komplikationer är funktionsnedsättning i övre extremitet, skuldersmärta, spasticitet och sänkt livskvalitet. En fysioterapeutisk rehabiliteringsmetod som försöker minska dessa komplikationer, men som ännu inte utvärderats vetenskapligt är Vasa-konceptet. Syfte Att undersöka vilken effekt en fem veckor lång intervention enligt Vasa-konceptet hade på nämnda komplikationer hos tre personer med förvärvad hjärnskada. Metod   Studien har en Singel Subject Experimentell Design med AB-design för att kunna följa förändringsprocessen över tid hos tre individer. Utfallsmått var Reaching Performance Scale, Patient-Specifik Funktionell Skala, Numerisk Skala, Modifierad Ashworth Skala och Modifierad Short version of Stroke Specific Quality of Life Scale. Studien pågick under sex veckor. Data bearbetades med visuell analys av trender, lutning och stabilitet. Resultat Arm/handfunktionen ökade hos två av tre deltagare. Den självskattade arm/handfunktionen ökade hos samtliga deltagare. Skuldersmärtan slutade öka hos en deltagare och övriga hade ingen smärta under interventionen, förutom vid några enstaka tillfällen. Spasticiteten i armbågsflexorer ökade hos en deltagare och förblev oförändrad hos övriga. I handledsflexorer minskade spasticiteten hos två av deltagarna och var oförändrad hos en. Livskvaliteten ökade hos samtliga deltagare. Konklusion Interventionen i studien hade positiva effekter på arm/handfunktion, skuldersmärta och livskvalitet. Ytterligare studier krävs dock för att kunna bekräfta dessa effekter av Vasa-konceptet. / Background Each year 50 000 persons are affected by acquired brain injury in Sweden. Common complications include disability in the upper extremity, shoulder pain, spasticity and reduced quality of life. A physiotherapeutic rehabilitation method which tries to reduce these complications, but has not yet been evaluated scientifically is the Vasa-concept. Purpose To examine the impact of a five-week intervention with the Vasa-concept on the mentioned complications in three persons with acquired brain injury. Method The study has a Single Subject Experimental Design with an AB-design, focusing on changes over time in three individuals. Outcome measures were Reaching Performance Scale, Patient-Specific Functional Scale, Numeric scale, Modified Ashworth Scale and Modified Short version of Stroke Specific Quality of Life Scale. The entire study lasted for six weeks. Data were processed by visual analysis of trends, tilt and stability. Results Upper extremity function increased in two of three participants. Self-rated upper extremity function increased in all participants. Shoulder pain stopped to increase in one participant and did not occur in the remainders, except for a few occasions. Spasticity in elbow flexors increased in one participant and was unchanged in the remainders. In wrist flexors the spasticity decreased in two participants and was unchanged in one. Quality of life increased in all participants. Conclusion The intervention had positive effects on arm/hand function, shoulder pain and quality of life. Further studies are needed to confirm these effects of the Vasa concept.

Advancements in computational capabilities have allowed researchers to turn towards modeling as an efficient tool to replicate and predict outcomes of complex systems. Computational models of the musculoskeletal system have gone through various iterations with early versions employing dramatic simplifications. In this work, a three-dimensional computational model of the wrist joint was developed. It accurately recreated the skeletal structures of the hand and wrist and represented the constraints imposed by soft tissue structures like ligaments, tendons, and other surrounding tissues. It was developed to function as a tool to investigate the biomechanical contributions of structures and the kinematic response of the wrist joint. The model was created with the use of a commercially available computer-aided design software employing the rigid body modeling methodology. It was validated against three different cadaveric experimental studies which investigated changes in biomechanical response following radioscapholunate fusion and proximal row carpectomy procedures. The kinematic simulations performed by the model demonstrated quantitatively accurate responses for the range of motions for both surgical procedures. It also provided some understanding to the trends in carpal bone contact force changes observed in surgically altered specimens. The model provided additional insight into the importance of structures like the triangular fibrocartilage and the capsular retinacular structures, both of which are currently not very well understood. As better understanding of components of the wrist joint is achieved, this model could function as an important tool in preoperative planning and generating individualized treatment regiments.

Musculoskeletal computational modeling is a versatile and effective tool which may be used to study joint mechanics, examine muscle and ligament function, and simulate surgical reconstructive procedures. While injury to the elbow joint can be significantly debilitating, questions still remain regarding its normal, pathologic, and repaired behavior. Biomechanical models of the elbow have been developed, but all have assumed fixed joint axes of rotation and ignored the effects of ligaments. Therefore, the objective of this thesis was to develop and validate a computational model of the elbow joint whereby joint kinematics are dictated by three-dimensional bony geometry contact, ligamentous constraints, and muscle loading.Accurate three-dimensional bone geometry was generated by acquiring CT scans, segmenting the images to isolate skeletal features, and fitting surfaces to the segmented data. Ligaments were modeled as tension-only linear springs, and muscle were represented as force vectors with discrete attachment points. Bone contact was modeled by a routine which applied a normal force at points of penetration, with a force magnitude being a function of penetration depth. A rigid body dynamics simulator was used to predict the model's behavior under particular external loading conditions.The computational model was validated by simulating past experimental investigations and comparing results. Passive flexion-extension range of motion predicted by the model correlated exceptionally well with reported values. Bony and ligamentous structures responsible for enforcing motion limits also agreed with past observations. The model's varus stability as a function of elbow flexion and coronoid process resection was also investigated. The trends predicted by the model matched those of the associated cadaver study.This thesis successfully developed an accurate musculoskeletal computational model of the elbow joint complex. While the model may now be used in a predictive manner, further refinements may expand its applicability. These include accounting for the interference between soft tissue and bone, and representing the dynamic behavior of muscles.

Name: Alice Oktábcová Supervisor: Mgr. et Mgr. Jaromíra Uhlířová Oponent: ……………. Diploma thesis: The Application of Robot-Assisted Therapy of Hand after Stroke: Follow-Up Trial of Application of AMADEO Instrument Key words: stroke, robot-assisted therapy, Amadeo Instrument, follow-up study, upper extremity In recent years, western countries noted a gradual increase in stroke survivors. Stroke can cause motor activity impairment and also senzoric and cognitive disorders which lead into restriction of participation of activities of daily living and also reduction of social and community activities. Functional improvment of upper and lower extremity after stroke is a very complex proces which has to be solved in multidiscplinary and multifactorial approach in result of every stroke survivor to live in the most independent way as possible. Robot-assisted therapy for motor recovery could be a successful way to improve motor activity of stroke survivors. Amadeo Instrument is one of robot-assisted therapy for hand rehabilitation of stroke survivors. This instrument can be described as final effector without exoskeleton which allows functional motor therapy for fingers and also a motivational feedback. Amadeo therapy can be passive, assisted, active and also interactive. The aim of this thesis is to...