The work presented in this dissertation was focused on developing an affordable, automated, upper extremity exercise system suitable for individuals with stroke and spinal cord injury (SCI). The three studies presented in this thesis demonstrated the efficacy of functional electrical stimulation-assisted exercise therapy (FES-ET). Furthermore a protocol was developed to implement FES-ET in participants homes via tele-rehabilitation. The protocol included the use of an improved version of the bionic glove, an FES device that enhanced hand grasp and release in SCI individuals in combination with a custom-built workstation that enabled task-oriented rehabilitation in the home setting, supervised over the Internet. In the course of these studies, an objective hand function assessment tool was developed to complement tele-supervised FES-ET and provide the therapist with an unbiased evaluation of the participants impairment. A major section of this dissertation is concerned with the development and testing of a novel exercise workstation named the ReJoyce (Rehabilitation Joystick for Computer Exercise), that can assess hand function electronically. The ReJoyce is an instrumented workstation that provides standardized upper extremity rehabilitation based on ADLs, in the guise of computer games played by manipulating attachments on the device. The three studies presented in this thesis focus on the scientific merits and the logistics of providing tele-supervised FES-ET with this workstation. The first study demonstrated the feasibility of treating and assessing individuals on the workstation who had recently suffered a stroke. The second study explored the relationship between the quantitative assessment of hand function with the workstation and two widely-used clinical tests. The last study involved daily, tele-supervised FES-ET or conventional exercises and therapeutic electrical stimulation (TES), maintained for 6 weeks, with SCI participants spread out over a large geographical area. FES-ET performed with the workstation resulted in statistically significant and clinically important improvements in hand function that were greater than those produced by the more conventional protocol. The results demonstrated the importance of including a range of exercises aimed at improving both strength and dexterity. It is concluded that tele-supervised FES-ET on a standardized workstation is feasible, effective and affordable in the current healthcare settin

Injury to the cervical spinal cord results in complete or partial loss of arm and hand function, severely limiting the performance of daily activities. Deficits in hand function in individuals with cervical spinal cord injury (SCI) are primarily due to a loss of descending motor pathways that are vital for fine control of the hand and fingers. In addition to these deficits, secondary plastic reorganization may create further loss of function. This thesis will explore the following questions: 1. What are the similarities and differences between cortical organization of muscles affected by a cervical SCI to those not affected by the injury?; 2. Do individuals with cervical SCI improve in hand function and cortical organization after an intensive hand training intervention?; 3. Which physical therapy intervention provides the optimal conditions by which to improve hand function following cervical SCI? In chapter 2 we compare cortical motor maps of transcranial magnetic stimulation (TMS) evoked responses of muscles rostral and caudal to the injury to those of ND individuals. The cortical maps of the biceps brachii or the thenar muscles were constructed, and compared between ND individuals and individuals with SCI. The motor threshold (MT) for the thenar muscles in individuals with SCI was significantly higher than ND individuals. The purpose of the study described in chapter 3 was to compare the functional and cortical changes associated with two different interventions: unimanual or bimanual massed practice training, both combined with somatosensory stimulation. There was a significant difference between pre- and post-intervention scores on tests measuring unimanual hand function, bimanual hand function, and sensory function. This difference was associated with a difference between pre- and post-intervention cortical map area. The purpose of the study described in chapter 4 was to compare clinical and cortical changes associated with either a delayed intervention control period or a combined intervention of massed practice training with electrical stimulation. Participants were randomly assigned to one of two groups: delayed intervention control group or immediate intervention group. Participants were also randomly assigned to one of four groups: unimanual training with somatosensory stimulation, bimanual training with somatosensory stimulation, unimanual training with functional electrical stimulation, or bimanual training with functional electrical stimulation. There was a significant difference between the control and immediate intervention group on the test measuring unimanual hand function. Participants in the bimanual group performed significantly better on the test measuring bimanual hand function. There was a significant difference between the control group and immediate intervention group in cortical map area. In chapter 5 we discuss the clinical relevance of the results of the studies described in three prior chapters. Conclusions drawn include the idea that cortical maps of muscles caudal to the level of injury in individuals with SCI have higher motor thresholds than ND participants. Individuals with tetraplegia can improve in hand function and sensation with a physical therapy intervention of massed practice training combined with somatosensory stimulation. Finally, the type of training (unimanual massed practice or bimanual massed practice) influences the type of improvements gained, however the type of electrical stimulation does not influence the clinical outcome.

Tai Chi Chuan is a safe alternative for those who wish to improve balance and physical wellbeing. It is a popular form of exercise that is supported by a growing body of research aimed towards improving the health of a sedentary elderly population. The purpose of this study was to examine the biomechanical features of the lower extremity during performance of two Tai Chi movements, the “Repulse Monkey (RM)” and “Wave-hands in clouds (WHIC).” The study’s parameters included quantitative measures of the temporospatial, kinematic, and kinetic characteristics of the lower extremities. A group of experienced male Tai Chi practitioners (n = 15) between the ages of 65 to 75, performed “Repulse Monkey (RM)”, “Wave-hand in Cloud (WHIC)”, and forward walking. Three-dimensional (3-D) kinematic and kinetic data was collected using VICON motion analysis system with 10 infrared cameras and 4 force plates. The following variables were examined: stride width, step length, step width, single- and double-support times, centre of mass (COM) displacement, peak joint angles, range of motion, peak joint moments, time to peak moment, and ground reaction force (GRF). The differences in the measurements of the two Tai Chi movements were compared with walking using two-way ANOVA. The study’s results showed that the two Tai Chi movements elicit gentle and fluid changes to position of the upper body mass and the joints in the lower extremity. In terms of joint kinematics, the knee remained flexed throughout RM and WHIC. Unlike walking, RM had larger abduction and adduction angles at the knee joints and large plantar- and dorsiflexion ROM at the ankle. Reduced posterior, mediolateral, and vertical GRF were seen; the loading joints at the ankle and hip were gentle and smaller than walking. Varus/valgus moments were notably larger at the knee joint during RM and eversion moment was larger at the ankle joint during WHIC movement. A large, but slow loading rate at the knee joint has implication towards the viscoelastic properties of the knee. A better understanding of RM and WHIC would facilitate the improvement of balance, physical capacity, and joint flexibility for the elders.

This thesis analyzes the relationship between upper extremity musculoskeletal disorders and longtime computer usage. Firstly / maastricht upper extremity questionnaire is applied to Financial Control and Information Technology Departments of Turk Telekom. Results are analyzed by using spss 16.0 tool by conduction of ordinal logistic regression analysis to determine the significance between work environment and postural information and upper extremity musculoskeletal complaints. Then / development of a new tool, namely PACU (postural analysis of computer users), takes place aiming to determine the factors of disorders, by mainly focusing on work-related neck and upper limb disorders, for long time computer users of Financial Control and Information Technology Departments of Turk Telekom. Results of the PACU are analyzed by using the methods of correlation, chi square goodness of fit test, factor analysis, and ordinal logistic regression.

Have you ever attempted to rub your abdomen with one hand while tapping your head with the other? Separately these movements are easy to perform but doing them together (bilateral task) requires motor adaptation. Motor adaptation is the process through which the Central Nervous System improves upon performance. Transfer of learning is the process through which learning a motor task in one condition improves performance in another condition. The purpose of this study was to determine whether transfer of learning occurs during bilateral goal-directed reaching tasks. It was hypothesized that transfer of learning would occur from the non-dominant to the dominant arm during bilateral tasks and that position and load feedback from the arms would affect the rate of adaptation and transfer of learning. During the experiments, subjects reached with one or both their index finger(s) to eight targets while a velocity dependent force perturbation (force environment) was applied to the arm(s). Three groups of bilateral tasks were examined: (1) unilateral reaching, where one arm learned to reach in a force environment, while the other arm remained stationary and therefore did not provide movement related position or load feedback; (2) bilateral reaching single load, where both arms performed reaching movements but only one arm learned a force environment and therefore the other arm provided movement related position feedback but not load feedback; (3) bilateral reaching two loads, where both arms performed reaching movements and both learned a force environment, while providing movement related position and load feedback. The rate of adaptation of the force environment was quantified as the speed at which the perturbed index finger trajectory became straight over the course of repeated task performance. The rate of adaptation was significantly slower for the dominant arm during the unilateral reaching tasks than during the bilateral reaching single load tasks (p<0.05). This indicates that the movement related position feedback from the non-dominant arm improved significantly the motor adaptation of the dominant arm; therefore transfer of learning occurred from the non-dominant to the dominant arm. The rate of adaptation for the non-dominant arm did not differ significantly (p>0.05) between the unilateral reaching and bilateral reaching single load tasks. Results also indicated that the rate of adaptation was significantly (p<0.05) faster for both the non-dominant and the dominant arms during the bilateral reaching two loads tasks than during the bilateral reaching single load tasks. The latter results indicate that transfer of learning occurred in both directions - from the dominant to the non-dominant arm and from the non-dominant to the dominant arm - when position and load feedback was available from both arms, but only when the force environment acted in the same joint direction. This study demonstrated that transfer of learning does occur during bilateral reaching tasks and that the direction and degree of transfer of learning may be modulated by the position and load feedback that is available to the central nervous system. This information may be used by physical therapists in order to improve rehabilitation strategies for the upper extremity.

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Disertacijoje apžvelgtos viršutinės galūnės segmentų replantacijų indikacijų, kontraindikacijų, terminologijos bei profilaktinio medikamentų vartojimo tendencijos, siekiant sumažinti kraujagyslinių komplikacijų skaičių po replantacijų. Darbe atlikta didžiausio Lietuvos replantologijos centro Vilniaus universiteto ligoninės Santariškių klinikų Centro filialo Plastinės ir rekonstrukcinės chirurgijos skyriaus 1983–2007 metų viršutinės galūnės segmentų replantacijų, ir jų veiksnių apžvalga bei išnagrinėtos replantacijų skaičiaus mažėjimo priežastys. Taip pat nustatyta nemedikamentinių ir medikamentinių veiksnių reikšmė replantatų prigijimui. Gautais rezultatais paneigta šiuo metu paplitusi nuomonė dėl didelės profilaktiškai vartojamų medikamentų reikšmės replantatų prigijimui. Pasiūlytos rekomendacijos dėl terminų replantologijoje naudojimo. / We overviewed indications and contraindications and their tendencies for upper extremity replantations in our dissertation. This work reviewed and analyzed 1983-2007 years material of upper extremity replantations in the oldest and largest replantation center in Lithuania – VUH Centro Affiliate Plastic and Reconstructive Surgery Department. We analyzed trends and causes of changing numbers of upper extremity replantations. We assessed clinical and social factors and determined their relationship of replantated upper extremity segments. We determined dependencies between prophylactic use of medications and replants survival ratio during the investigation period. We also analyzed different meanings of replantology terms and offered some guidelines for their proper usage.

We overviewed indications and contraindications and their tendencies for upper extremity replantations in our dissertation. This work reviewed and analyzed 1983-2007 years material of upper extremity replantations in the oldest and largest replantation center in Lithuania – VUH Centro Affiliate Plastic and Reconstructive Surgery Department. We analyzed trends and causes of changing numbers of upper extremity replantations. We assessed clinical and social factors and determined their relationship of replantated upper extremity segments. We determined dependencies between prophylactic use of medications and replants survival ratio during the investigation period. We also analyzed different meanings of replantology terms and offered some guidelines for their proper usage. / Disertacijoje apžvelgtos viršutinės galūnės segmentų replantacijų indikacijų, kontraindikacijų, terminologijos bei profilaktinio medikamentų vartojimo tendencijos, siekiant sumažinti kraujagyslinių komplikacijų skaičių po replantacijų. Darbe atlikta didžiausio Lietuvos replantologijos centro Vilniaus universiteto ligoninės Santariškių klinikų Centro filialo Plastinės ir rekonstrukcinės chirurgijos skyriaus 1983–2007 metų viršutinės galūnės segmentų replantacijų, ir jų veiksnių apžvalga bei išnagrinėtos replantacijų skaičiaus mažėjimo priežastys. Taip pat nustatyta nemedikamentinių ir medikamentinių veiksnių reikšmė replantatų prigijimui. Gautais rezultatais paneigta šiuo metu paplitusi nuomonė dėl didelės profilaktiškai vartojamų medikamentų reikšmės replantatų prigijimui. Pasiūlytos rekomendacijos dėl terminų replantologijoje naudojimo.

The objective of the research is to examine the impact of auditory stimulus on improving reaching performance in children with cerebral palsy. A form of auditory stimulus, called rhythmic auditory stimulation (RAS), is well-established in neurological fields as well as in music-based rehabilitation and therapy. RAS is a method in which the rhythm functions as a sensory cue to induce temporal stability and enhancement of movement patterns by what is believed to be a temporal constraint of the patient’s internal optimized path of motion. In current neurological studies, it is suggested that activity in the premotor cortex may represent the integration of auditory information with temporally organized motor action during rhythmic cuing. Based on this theory, researchers have shown that rhythmic auditory stimulation can produce significant improvement in mean gait velocity, cadence, and stride length in patients with Parkinson’s disease. Evidence validating this observation was also seen in a study on hemiparetic stroke wherein patients displayed improvements in spatio-temporal arm control, reduction in variability of timing and reaching trajectories, and kinematic smoothing of the wrist joint during rhythmic entrainment. Lastly, studies have suggested an accompaniment of sound feedback in addition to visual feedback can result in a positive influence and higher confidence in patients who have had a stroke or spinal cord injury. Although an effect of rhythmic cuing on upper extremity therapy has been explored in areas where brain injury has occurred (such as patients who have incurred stroke, spinal injury, traumatic brain injury, etc.), what has not been explored is the effect of rhythmic cuing on upper extremity therapy for individuals with neurological movement disorders, such as cerebral palsy. Thus, in this research, we set out to explore the effect of RAS in therapeutic interventions for children with cerebral palsy. Through this investigation, we examine its effect on reaching performance as measured through range of motion, peak angular velocity, movement time, path length, spatio-temporal variability, and movement units. For this assessment, we created a virtual system to test the aforementioned principles. We established clinically based angular measurements that include elbow flexion, shoulder flexion, and shoulder abduction using a 3D depth sensor to evaluate relevant metrics in upper extremity rehabilitation. We validated the output of our measurements through a comparison with a Vicon Motion Capture System. We then confirmed the trends of the metrics between groups of adults, children, and children with cerebral palsy. Through testing our system with adults, children, and children with cerebral palsy, we believe we have constructed a system that may induce engagement, which is critical to physical therapy, and may also have a positive impact on the metrics. Although we see trends indicative of an effect through use of the system on children with cerebral palsy, we believe further testing is needed in order to establish or refute the effect and also to definitively establish or refute the effect of rhythmic auditory stimulation. The system, the angular measurements, and the metrics we employ could provide an excellent foundation for future research in this space.