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<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)

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...

Os movimentos do membro superior na distrofia muscular de Duchenne devem ser avaliados para acompanhar a evolução clínica e estabelecer abordagens terapêuticas. Testes que cronometram o desempenho em tarefas funcionais representam uma forma precisa de avaliar a independência funcional e monitorar a progressão da doença. O tempo necessário para a realização de uma tarefa pode refletir a evolução e predizer a habilidade funcional. Contudo, o desempenho pode ser influenciado por movimentos compensatórios, que são comumente adotados para a manutenção da independência funcional. Esta Tese é composta por quatro artigos científicos, que objetivaram: (1) investigar a relação entre as características cinesiológicas, avaliadas pelo teste Performance of Upper Limb e tempo no Teste de Jebsen-Taylor; (2) investigar possíveis diferenças e relações entre o desempenho do membro superior dominante e do membro superior não-dominante de pacientes com distrofia muscular de Duchenne e comparar o desempenho dos pacientes com o de controles saudáveis; (3) descrever a confiabilidade teste-reteste e a consistência interna dos tempos de pacientes com distrofia muscular de Duchenne no Teste de Jebsen-Taylor e (4) comparar os movimentos compensatórios de pacientes e controles saudáveis na tarefa de levar uma colher à boca. Os quatro estudos foram realizados de forma prospectiva observacional. Os resultados mostraram que (1) o Teste de Jebsen-Taylor está correlacionado com o Teste padrão-ouro (Performance of Upper Limb) e o tempo reflete a função motora de membros superiores de pacientes com distrofia muscular de Duchenne; (2) não há diferença na assimetria entre os membros superiores de pacientes quando comparados a indivíduos saudáveis; o desempenho do membro superior dominante é fortemente correlacionado com o do membro superior não-dominante; (3) o Teste de Jebsen-Taylor possui boas propriedades psicométricas e (4) ao levar uma colher à boca, pacientes realizam movimentos compensatórios, como aumento da flexão de cabeça e de cotovelo. Como conclusão, o Teste de Jebsen-Taylor contribui para a avaliação da função motora do membro superior em pacientes com distrofia muscular de Duchenne, por meio da medida do tempo e dos movimentos compensatórios. Os dados normativos apresentados nesta Tese podem ser usados como parâmetros para acompanhamento clínico e terapêutico de pacientes com distrofia muscular de Duchenne / The upper limb movements in Duchenne muscular dystrophy must be evaluated to monitor clinical evolution and establish therapeutic approaches. Tests that measure timed performance on functional tasks represent an accurate way of assessing functional independence and monitoring disease progression. Timed performance can accurately reflect evolution and predict functional skills. However, performance can be influenced by compensatory movements that are commonly adopted to maintain functional independence. This Thesis comprises four articles that aimed to: (1) investigate the relationship between the kinesiological characteristics evaluated by Performance of Upper Limb test and timed performance of the Jebsen-Taylor Test; (2) to investigate possible differences and relationships between the performance of the dominant and the non-dominant upper limbs of patients with Duchenne muscular dystrophy and to compare the performance of patients with healthy controls; (3) describe the timed performance of patients with muscular dystrophy and to investigate the test-retest reliability and internal consistency of the Jebsen-Taylor Test and (4) compare the compensatory movements of patients and healthy controls in bringing a spoon to the mouth. The four studies were observational and prospective. The results showed that (1) Jebsen-Taylor Test is strongly correlated to the gold standard test (Performance of Upper Limb) and timed performance reflects upper limb motor function in patients with Duchenne muscular dystrophy; (2) upper limbs asymmetry in patients with Duchenne muscular dystrophy is not higher than in healthy individuals, and the dominant upper limb performance is strongly correlated to the non-dominant upper limb performance; (3) Jebsen-Taylor test has good psychometric properties and (4) patients perform compensatory movements while bringing a spoon to the mouth, as increased head flexion and increased elbow flexion. In conclusion, Jebsen-Taylor test contributes to upper limb motor function assessment in patients with Duchenne muscular dystrophy, as it measures time and compensatory movements. This thesis provides normative data that can be parameters for clinical and therapeutic follow up of patients with muscular dystrophy

Introdução: alguns pacientes com zumbido podem apresentar pontosgatilho miofasciais, principalmente na musculatura mastigatória e cervical. No entanto, este tema é pouco abordado na literatura. Os objetivos deste estudo foram investigar a associação entre (1) zumbido e pontos-gatilho, (2) a orelha com pior zumbido e o lado do corpo com maior número de pontosgatilho, além de (3) verificar a capacidade de o ponto-gatilho modular o zumbido. Métodos: neste estudo caso-controle foram avaliados 94 pacientes com zumbido e 94 assintomáticos, pareados por sexo e idade, sem queixa de dor generalizada ou mioclonia. Todos foram submetidos, pelo mesmo investigador, a um protocolo de avaliação e à pressão digital para pesquisa de pontos-gatilho em 9 músculos bilateralmente: infra-espinal, levantador da escápula, trapézio, esplênio da cabeça, escaleno, esternocleidomastóideo, digástrico, masseter e temporal. A intensidade do zumbido foi avaliada por uma escala numérica de 0 a 10, considerando-se como modulação o aumento ou diminuição imediata de pelo menos um ponto na escala e/ou mudança no tipo de som. Os exames foram executados em local silencioso para facilitar a percepção da modulação do zumbido. Resultados: os pontos-gatilho estavam presentes em 72,3% dos pacientes com zumbido (OR= 4,87; p< 0,001) e 55,9% deles relataram modulação do sintoma durante a pressão digital nos pontos-gatilho ativos e latentes, em pelo menos um músculo, principalmente no masseter, esplênio da cabeça, esternocleidomastóideo e temporal. A modulação do zumbido pelo ponto-gatilho examinado foi predominantemente ipsilateral em 6 dos 9 músculos avaliados. Houve correlação de lateralidade entre a orelha com pior zumbido e o lado do corpo com maior número de pontos-gatilho em 56,5% dos casos (Kappa= 0,29; p< 0,001). Houve diferença significante quanto à presença de queixa prévia de dor na comparação dos pacientes com zumbido que modularam com aqueles que não modularam (p< 0,008). Conclusões: a presença significante dos pontos-gatilho em pacientes com zumbido associada à freqüente modulação do sintoma durante sua palpação, além da sua presença em maior número no lado da orelha com pior zumbido, sugere que os pontos-gatilho sejam um fator etiológico ou coadjuvante do zumbido. / Introduction: some patients suffering from tinnitus may present myofascial trigger points, mainly in head and neck muscles. However, this issue is poorly explored in the literature. The objectives of this study were to investigate an association between (1) tinnitus and trigger points, (2) the ear with the worst tinnitus and the side of the body with more trigger points, (3) presence of trigger points and their capacity of modulating tinnitus. Methods: in this case control study 94 subjects with tinnitus, and 94 without such symptom were analyzed, matched by age and gender, excluding those with widespread musculoskeletal pain or myoclonus. All of them underwent an evaluation protocol and digital pressure in order to search for trigger points in 9 bilateral muscles: infraspinatus, levator scapulae, trapezius, splenius capitis, scalenus, sternocleidomastoid, digastric, masseter and temporalis. The intensity of tinnitus was evaluated with a scale ranging from 0 to 10, and modulation was considered present in cases of immediate increase or decrease of at least one point in the scale and/or changes in the type of sound. The exams took place in a silent environment, so as to make it easier for tinnitus\' modulation to be perceived. Results: the presence of trigger points was observed in 72.3% of tinnitus patients (OR= 4.87; p< 0,001). Among them, 55.9% reported tinnitus modulation during digital pressure in both active and latent trigger points, in at least one muscle, mainly in masseter, splenius capitis, sternocleidomastoid and temporalis muscles. The rate of tinnitus modulation was significantly higher at the same side of the trigger point subject to examination in 6 out of 9 muscles. There was an association of laterality between the ear with worst tinnitus and the side of the body with more trigger points in 56.5% of the cases (Kappa value = 0.29; p< 0.001). There was a significant difference related to the presence of previous pain complaint when patients with tinnitus that modulated were compared to patients with tinnitus that did not modulate (p< 0.008). Conclusions: significant presence of trigger points in tinnitus patients, associated to frequent modulation of this symptom during palpation, besides the presence of more trigger points in the side of the ear with the worst tinnitus, suggests that trigger points are an etiologic factor or adjuvant in tinnitus onset.