Carel G.M. Meskers

3D shoulder position measurements using a six-degree-of-freedom electromagnetic tracking device

OBJECTIVE: To describe a recording and processing methodology for obtaining kinematic data of the shoulder which meets three more criteria besides usual requirements regarding precision and accuracy: sufficient speed, obtaining complete 3D kinematics including joint rotations, and usage of coordinate systems based on reference points. DESIGN: Static recordings of shoulder bone orientations during standardized humerus elevations based on the palpation technique using a six-degree-of-freedom electromagnetic tracking device. BACKGROUND: An easy, fast, well standardized measurement methodology for obtaining complete 3D shoulder kinematic data is urgently needed for fundamental musculoskeletal and clinical research. METHODS: A measurement methodology was designed and developed. Shoulder kinematics were obtained from repeated measurements on 15 healthy subjects performed by two observers. Inter-trial, inter-day, inter-observer and inter-subject variability were established. Results were compared to literature. RESULTS: Complete kinematic descriptions were obtained. A measurement speed of about one position per second could be reached. The measured kinematics and accuracy of the measurements were found to be in concordance with the literature. CONCLUSION: All previously formulated criteria for a clinical useful method for obtaining shoulder kinematics have been met.

Estimation of instantaneous moment arms of lower-leg muscles

Muscle moment arms at the human knee and ankle were estimated from muscle length changes measured as a function of joint flexion angle in cadaver specimens. Nearly all lower-leg muscles were studied: extensor digitorum longus, extensor hallucis longus, flexor digitorum longus, flexor hallucis longus, gastrocnemius lateralis, gastrocnemius medialis, peroneus brevis, peroneus longus, peroneus tertius, plantaris, soleus, tibialis anterior, and tibialis posterior. Noise in measured muscle length was filtered by means of quintic splines. Moment arms of the mm. gastrocnemii appear to be much more dependent on joint flexion angles than was generally assumed by other investigators. Some consequences for earlier analyses are mentioned.

In vivo estimation of the glenohumeral joint rotation center from scapular bony landmarks by linear regression

In this paper, a method is described for in vivo prediction of the glenohumeral joint rotation center (GH-r), necessary for the construction of a humerus local coordinate system in shoulder kinematic studies. The three-dimensional positions of five scapula bony landmarks as well as a large number of data points on the surface of the glenoid and humeral head were collected at 36 sets of cadaver scapulae and adjacent humeri. The position of GH-r in each scapula was estimated by mathematically fitting spheres to the glenoid and humeral head. GH-r prediction from scapula geometry parameters by linear regression resulted in a RMSE between measured and predicted GH-r of 2.32 mm for the x-coordinate, 2.69 mm for the y-coordinate and 3.04 mm for the z-coordinate. Application in vivo revealed a random humerus orientation error due to measurement inaccuracies of 1.35, 0.29 and 1.26 degrees standard deviation per rotation angle. The estimated total humerus orientation error including the offset error due to the regression model inaccuracy was 2.86, 0.84 and 2.69 degrees standard deviation. As these errors were about 15 and 20% of, respectively, the intra- and inter-subject variability of the humerus orientations measured, it is concluded that the method described in this paper allows for an adequate construction of a humerus local coordinate system.

Patterns of muscle strength loss with age in the general population and patients with a chronic inflammatory state

Abstract Background There is growing recognition of the serious consequences of sarcopenia on the functionality and autonomy in old age. Recently, the age-related changes in several inflammatory mediators have been implicated in the pathogenesis of sarcopenia. The purposes of this systematic review were two-fold: (1) to describe the patterns of muscle strength loss with age in the general population, and (2) to quantify the loss of muscle strength in rheumatoid arthritis as representative for an underlying inflammatory state. Handgrip strength was used as a proxy for overall muscle strength. Results Results from 114 studies (involving 90,520 subjects) and 71 studies (involving 10,529 subjects) were combined in a meta-analysis for the general and rheumatoid arthritis population respectively and standardized at an equal sex distribution. For the general population we showed that between the ages of 25 years and 95 years mean handgrip strength declined from 45.5kg to 23.2kg for males and from 27.1kg to 12.8kg for females. We noted a steeper handgrip strength decline after 50 years of age (rate of 0.37kg/year). In the rheumatoid arthritis population handgrip strength was not associated with chronological age between the ages of 35 years and 65 years and was as low as 20.2kg in male and 15.1 in female. Rheumatoid arthritis disease duration was inversely associated with handgrip strength. Conclusions This meta-analysis shows distinct patterns of age-related decrease of handgrip strength in the general population. Handgrip strength is strongly associated with the presence and duration of an inflammatory state as rheumatoid arthritis. The putative link between age-related inflammation and sarcopenia mandates further study as it represents a potential target for intervention to maintain functional independence in old age.

Determination of the optimal elbow axis for evaluation of placement of prostheses.

OBJECTIVE To present a method to determine the position and orientation of the mean optimal flexion axis of the elbow in vivo to be used in clinical research. DESIGN Registering the movements of the forearm with respect to the upper arm during five cycles of flexion and extension of the elbow using a 6 degrees-of-freedom electromagnetic tracking device. BACKGROUND Loosening of elbow endoprostheses could be caused by not placing the prostheses in a biomechanically optimal way. To evaluate the placement of endoprostheses with regard to loosening, a method to determine the elbow axis is needed. METHODS The movements of the right forearm with respect to the upper arm during flexion and extension were registered with a 6 degrees-of-freedom electromagnetic tracking device. A mean optimal instantaneous helical axis of 10 elbows was calculated in a coordinate system related to the humerus. RESULTS The average position of the flexion/extension axis was 0.81 cm (SD 0.66 cm) cranially and 1.86 cm (SD 0.72 cm) ventrally of the epicondylus lateralis. The average angle with the frontal plane was 15.3 degrees (SD 2 degrees). CONCLUSIONS A useful estimation of the position and orientation of a mean optimal flexion axis can be obtained in vivo.

Guideline for diagnosis and treatment of subacromial pain syndrome: A multidisciplinary review by the Dutch Orthopaedic Association

Treatment of “subacromial impingement syndrome” of the shoulder has changed drastically in the past decade. The anatomical explanation as “impingement” of the rotator cuff is not sufficient to cover the pathology. “Subacromial pain syndrome”, SAPS, describes the condition better. A working group formed from a number of Dutch specialist societies, joined by the Dutch Orthopedic Association, has produced a guideline based on the available scientific evidence. This resulted in a new outlook for the treatment of subacromial pain syndrome. The important conclusions and advice from this work are as follows: (1) The diagnosis SAPS can only be made using a combination of clinical tests. (2) SAPS should preferably be treated non-operatively. (3) Acute pain should be treated with analgetics if necessary. (4) Subacromial injection with corticosteroids is indicated for persistent or recurrent symptoms. (5) Diagnostic imaging is useful after 6 weeks of symptoms. Ultrasound examination is the recommended imaging, to exclude a rotator cuff rupture. (6) Occupational interventions are useful when complaints persist for longer than 6 weeks. (7) Exercise therapy should be specific and should be of low intensity and high frequency, combining eccentric training, attention to relaxation and posture, and treatment of myofascial trigger points (including stretching of the muscles) may be considered. (8) Strict immobilization and mobilization techniques are not recommended. (9) Tendinosis calcarea can be treated by shockwave (ESWT) or needling under ultrasound guidance (barbotage). (10) Rehabilitation in a specialized unit can be considered in chronic, treatment resistant SAPS, with pain perpetuating behavior. (11) There is no convincing evidence that surgical treatment for SAPS is more effective than conservature management. (12) There is no indication for the surgical treatment of asymptomatic rotator cuff tears.

Impact of early applied upper limb stimulation: The EXPLICIT-stroke programme design

BackgroundMain claims of the literature are that functional recovery of the paretic upper limb is mainly defined within the first month post stroke and that rehabilitation services should preferably be applied intensively and in a task-oriented way within this particular time window. EXplaining PLastICITy after stroke (acronym EXPLICIT-stroke) aims to explore the underlying mechanisms of post stroke upper limb recovery. Two randomized single blinded trials form the core of the programme, investigating the effects of early modified Constraint-Induced Movement Therapy (modified CIMT) and EMG-triggered Neuro-Muscular Stimulation (EMG-NMS) in patients with respectively a favourable or poor probability for recovery of dexterity.Methods/design180 participants suffering from an acute, first-ever ischemic stroke will be recruited. Functional prognosis at the end of the first week post stroke is used to stratify patient into a poor prognosis group for upper limb recovery (N = 120, A2 project) and a group with a favourable prognosis (N = 60, A1 project). Both groups will be randomized to an experimental arm receiving respectively modified CIMT (favourable prognosis) or EMG-NMS (poor prognosis) for 3 weeks or to a control arm receiving usual care. Primary outcome variable will be the Action Research Arm Test (ARAT), assessed at 1,2,3,4,5, 8, 12 and 26 weeks post stroke. To study the impact of modified CIMT or EMG-NMS on stroke recovery mechanisms i.e. neuroplasticity, compensatory movements and upper limb neuromechanics, 60 patients randomly selected from projects A1 and A2 will undergo TMS, kinematical and haptic robotic measurements within a repeated measurement design. Additionally, 30 patients from the A1 project will undergo fMRI at baseline, 5 and 26 weeks post stroke.ConclusionEXPLICIT stroke is a 5 year translational research programme which main aim is to investigate the effects of early applied intensive intervention for regaining dexterity and to explore the underlying mechanisms that are involved in regaining upper limb function after stroke. EXPLICIT-stroke will provide an answer to the key question whether therapy induced improvements are due to either a reduction of basic motor impairment by neural repair i.e. restitution of function and/or the use of behavioural compensation strategies i.e. substitution of function.EXPLICIT is registered at the Netherlands Trial Register (NTR, http://www.trialregister.nl., TC 1424)

Spring-like Ankle Foot Orthoses reduce the energy cost of walking by taking over ankle work

In patients with central neurological disorders, gait is often limited by a reduced ability to push off with the ankle. To overcome this reduced ankle push-off, energy-storing, spring-like carbon-composite Ankle Foot Orthoses (AFO) can be prescribed. It is expected that the energy returned by the AFO in late stance will support ankle push-off, and reduce the energy cost of walking. In 10 patients with multiple sclerosis and stroke the energy cost of walking, 3D kinematics, joint power, and joint work were measured during gait, with and without the AFO. The mechanical characteristics of the AFO were measured separately, and used to calculate the contribution of the AFO to the ankle kinetics. We found a significant decrease of 9.8% in energy cost of walking when walking with the AFO. With the AFO, the range of motion of the ankle was reduced by 12.3°, and the net work around the ankle was reduced by 29%. The total net work in the affected leg remained unchanged. The AFO accounted for 60% of the positive ankle work, which reduced the total amount of work performed by the leg by 11.1% when walking with the AFO. The decrease in energy cost when walking with a spring-like energy-storing AFO in central neurological patients is not induced by an augmented net ankle push-off, but by the AFO partially taking over ankle work.

Kinematic alterations in the ipsilateral shoulder of patients with hemiplegia due to stroke

Meskers CGM, Koppe PA, Konijnenbelt H, Veeger HEJ, Janssen TWJ: Kinematic alterations in the ipsilateral shoulder of patients with hemiplegia due to stroke. Am J Phys Med Rehabil 2005;84:97–105. Objective:To evaluate the assumption that shoulder kinematic patterns of the ipsilateral, nonparetic shoulder in hemiplegia are similar to kinematics recorded in a healthy population. Design:Case control study of a convenience sample of ten patients with hemiplegia due to stroke in the subacute phase compared with a control group of similar age. Three-dimensional positions of the scapula and humerus were measured and expressed in Euler angles as a function of active arm elevation in the frontal and sagittal plane and during passive humeral internal/external rotation at an elevation angle of 90 degrees in the frontal and sagittal plane. Results:Compared with controls, in the ipsilateral shoulder of patients, we found both a statistically significant diminished scapular protraction during elevation in the sagittal plane (35 ± 5 vs. 51 ± 8 degrees at 110 degrees of humeral elevation) and humeral external rotation during arm elevation in the frontal plane (51 ± 7 vs. 69 ± 14 degrees at 110 degrees of humeral elevation). Maximal passive humeral external rotation was found to be impaired in the frontal (64 ± 13 vs. 98 ± 14 degrees) and sagittal planes (65 ± 11 vs. 94 ± 12 degrees). In addition, there was significantly diminished anterior spinal tilt during humeral internal rotation (−5 ± 10 vs. −20 ± 9 degrees) and diminished posterior spinal tilt during external rotation in the frontal plane (−14 ± 8 vs. −3 ± 6 degrees). Maximal thoracohumeral elevation in patients was significantly impaired (126 ± 12 vs. 138 ± 8 degrees). Conclusion:Clear kinematic changes in the ipsilateral shoulder in patients with hemiplegia were found, indicating underlying alterations in muscle contraction patterns. The cause remains speculative. These results suggest that the ipsilateral shoulder should not be considered to function normally beforehand.

Effects of Robot-Assisted Therapy for the Upper Limb After Stroke

Background. Robot technology for poststroke rehabilitation is developing rapidly. A number of new randomized controlled trials (RCTs) have investigated the effects of robot-assisted therapy for the paretic upper limb (RT-UL). Objective. To systematically review the effects of poststroke RT-UL on measures of motor control of the paretic arm, muscle strength and tone, upper limb capacity, and basic activities of daily living (ADL) in comparison with nonrobotic treatment. Methods. Relevant RCTs were identified in electronic searches. Meta-analyses were performed for measures of motor control (eg, Fugl-Meyer Assessment of the arm; FMA arm), muscle strength and tone, upper limb capacity, and basic ADL. Subgroup analyses were applied for the number of joints involved, robot type, timing poststroke, and treatment contrast. Results. Forty-four RCTs (N = 1362) were included. No serious adverse events were reported. Meta-analyses of 38 trials (N = 1206) showed significant but small improvements in motor control (~2 points FMA arm) and muscle strength of the paretic arm and a negative effect on muscle tone. No effects were found for upper limb capacity and basic ADL. Shoulder/elbow robotics showed small but significant effects on motor control and muscle strength, while elbow/wrist robotics had small but significant effects on motor control. Conclusions. RT-UL allows patients to increase the number of repetitions and hence intensity of practice poststroke, and appears to be a safe therapy. Effects on motor control are small and specific to the joints targeted by RT-UL, whereas no generalization is found to improvements in upper limb capacity. The impact of RT-UL started in the first weeks poststroke remains unclear. These limited findings could mainly be related to poor understanding of robot-induced motor learning as well as inadequate designing of RT-UL trials, by not applying an appropriate selection of stroke patients with a potential to recovery at baseline as well as the lack of fixed timing of baseline assessments and using an insufficient treatment contrast early poststroke.