Margaret Finley

Prevalence and identification of shoulder pathology in athletic and nonathletic wheelchair users with shoulder pain: A pilot study

Although many wheelchair users report shoulder pain, the prevalence of specific pathologies remains controversial. Rotator cuff impingement, glenohumeral instability, and biceps tendonitis have been stated as the most commonly found pathology. This study investigated the prevalence and identity of shoulder pathology in athletic and nonathletic manual wheelchair users (MWCUs). Fifty-two MWCUs (26 athletes, 26 nonathletes) completed a survey regarding the nature of their injury, sports involvement, history, and presence of current and/or past shoulder pathology. Subjects currently experiencing shoulder pain underwent a clinical examination of both shoulders. Analysis of variance (p <or=0.05) determined if differences existed between the groups in demographic variables, history of shoulder pain, and clinical evaluation measures in those with shoulder pain. Chi-squared (p <or=0.05) analysis verified the frequency distribution and association by groups and involved limbs for the clinical shoulder test measures. No difference was found in the incidence of shoulder pain, past or present, between athletes and nonathletes. Collectively, 61.5% (32/52) of the subjects reported experiencing shoulder pain, with 29% reporting shoulder pain at the present time. Years since onset of disability (p = 0.01) and duration of wheelchair use (p = 0.01) were found to be greater in individuals who reported a history of shoulder pain. Of the painful shoulders tested, 44% revealed clinical signs and symptoms of rotator cuff impingement, while 50% revealed signs of biceps tendonitis. Instability was found in 28% of the painful shoulders. These findings indicate that involvement in athletics neither increases nor decreases the risk of shoulder pain in the manual wheelchair population. Bicipital tendonitis with impingement syndrome was the most common pathology.

Short-duration robotic therapy in stroke patients with severe upper-limb motor impairment

Chronic motor deficits in the upper limb (UL) are a major contributor to disability following stroke. This study investigated the effect of short-duration robot-assisted therapy on motor impairment, as measured by clinical scales and robot-derived performance measures in patients with chronic, severe UL impairments after stroke. As part of a larger study, 15 individuals with chronic, severe UL paresis (Fugl-Meyer < 15) after stroke (minimum 6 mo postonset) performed 18 sessions of robot-assisted UL rehabilitation that consisted of goal-directed planar reaching tasks over a period of 3 weeks. Outcome measures included the Fugl-Meyer Assessment, the Motor Power Assessment, the Wolf Motor Function Test, the Stroke Impact Scale, and five robot-derived measures that reflect motor control (aiming error, mean speed, peak speed, mean:peak speed ratio, and movement duration). Robot-assisted training produced statistically significant improvements from baseline to posttreatment in the Fugl-Meyer and Motor Power Assessment scores and the quality of motion (quantified by a reduction in aiming error and movement duration with an increase in mean speed and mean:peak speed ratio). Our findings indicate that robot-assisted UL rehabilitation can reduce UL impairment and improve motor control in patients with severe UL paresis from chronic stroke.

The biomechanics of wheelchair propulsion in individuals with and without upper-limb impairment.

We used an instrumented wheelchair ergometer and 3D motion analysis system to collect joint kinematic and temporal data, as well as hand rim and joint kinetics, in 47 manual wheelchair users (MWCUs) (15 with upper-limb impairment and 32 without upper-limb impairment). The group with upper-limb impairment propelled with a higher stroke frequency and reduced hand-rim contact time, and smaller peak joint angles and joint excursion of the wrist, elbow, and shoulder during the contact phase. They also propelled with a reduced power output and reduced hand-rim propulsive and resultant forces, moments, and joint compressive forces. We concluded that these kinematic and kinetic strategies might be a mechanism for allowing MWCUs with upper-limb impairment to remain independent. Additionally, the reduced joint excursion and reduced magnitude of forces may protect them from the development of secondary upper-limb pathologies.

Effect of Gravity on Robot-Assisted Motor Training After Chronic Stroke: A Randomized Trial

OBJECTIVES To determine the efficacy of 2 distinct 6-week robot-assisted reaching programs compared with an intensive conventional arm exercise program (ICAE) for chronic, stroke-related upper-extremity (UE) impairment. To examine whether the addition of robot-assisted training out of the horizontal plane leads to improved outcomes. DESIGN Randomized controlled trial, single-blinded, with 12-week follow-up. SETTING Research setting in a large medical center. PARTICIPANTS Adults (N=62) with chronic, stroke-related arm weakness stratified by impairment severity using baseline UE motor assessments. INTERVENTIONS Sixty minutes, 3 times a week for 6 weeks of robot-assisted planar reaching (gravity compensated), combined planar with vertical robot-assisted reaching, or intensive conventional arm exercise program. MAIN OUTCOME MEASURE UE Fugl-Meyer Assessment (FMA) mean change from baseline to final training. RESULTS All groups showed modest gains in the FMA from baseline to final with no significant between group differences. Most change occurred in the planar robot group (mean change ± SD, 2.94 ± 0.77; 95% confidence interval [CI], 1.40-4.47). Participants with greater motor impairment (n=41) demonstrated a larger difference in response (mean change ± SD, 2.29 ± 0.72; 95% CI, 0.85-3.72) for planar robot-assisted exercise compared with the intensive conventional arm exercise program (mean change ± SD, 0.43 ± 0.72; 95% CI, -1.00 to 1.86). CONCLUSIONS Chronic UE deficits because of stroke are responsive to intensive motor task training. However, training outside the horizontal plane in a gravity present environment using a combination of vertical with planar robots was not superior to training with the planar robot alone.

Upper-limb fatigue-related joint power shifts in experienced wheelchair users and nonwheelchair users

This paper evaluates power transfer or shifting across upper-limb segments, resulting from fatigue-inducing wheelchair propulsion. Nineteen manual wheelchair users (WCUs) and ten nonwheelchair users (NUs) participated in this study. Subjects propelled an instrumented wheelchair ergometer at a workload corresponding to 75% of the peak oxygen uptake attained during a maximal-graded exercise tolerance test. Subjects were required to propel the wheelchair for as long as they could at a constant velocity of 3 km/h (32 rpm). The test was terminated when subjects could no longer maintain the target velocity. Peak Performance video-capture system was used to determine upper-limb kinematics. Handrim forces and joint kinematics were used to calculate joint moments and power with the use of an inverse dynamics approach. Results showed that with fatigue, joint power shifts from the shoulder joint to the elbow and wrist joints. Implications for joint injury and propulsion efficiency are discussed.

Improved upper-body endurance following a 12-week home exercise program for manual wheelchair users.

This study determined if a 12-week monitored home exercise program would improve cardiorespiratory endurance in a heterogeneous group of manual wheelchair users, which incorporated subsets of individuals with and without upper-limb impairment. Twenty-seven subjects made up two groups of manual wheelchair users: 20 without upper-limb impairment and 7 with upper-limb impairment. Subjects completed wheelchair ergometer tests using a 1 min JUMP protocol that resulted in volitional exhaustion in 6 to 12 min. Following a recovery period (time > 30 min), subjects completed subsequent constant work rate endurance tests to exhaustion at a power output corresponding to 60% of the maximum attained on the JUMP test. Subjects then underwent 12 weeks of simulated wheelchair rolling exercise using elastic straps positioned to mimic the motion of propulsion. JUMP and constant work rate tests were performed before training and after 6 and 12 weeks of exercise. Oxygen consumption (VO2) increased from rest to peak exercise in both groups and was significantly (p < 0.016) higher at peak for subjects without upper-limb impairment than for those with upper-limb impairment. Heart rate (HR) responses between the groups were similar. No significant differences in peak VO2, anaerobic threshold, or peak HR were observed at 6 or 12 weeks of the training program. Substantial improvement (p < 0.001) in maximum constant work rate tests time (10.37 +/- 2.79 min) was noted at 6 and 12 weeks, with no significant difference between 6 and 12 weeks and no significant intergroup difference. Results of this study indicated that simulated propulsion exercise endurance was improved as a result of the home exercise program.

Effects of a repetitive gaming intervention on upper extremity impairments and function in persons with chronic stroke: a preliminary study.

Purpose: The purpose of this study was to examine the feasibility and effects of an upper extremity gaming system on impairments, activity and participation restrictions in persons with chronic stroke. Method: Nine participants with chronic (5.4 SD 3 years after stroke) upper extremity impairment due to stroke completed 18 sessions over 6 weeks with the Hand Dance Pro™ gaming system that included trunk restraint. Measures collected at pretest and posttest included three-dimensional motion analysis of paretic upper extremity reaching, Wolf Motor Function Test (WMFT) and Stroke Impact Scale (SIS). Data were analyzed across time, with effect sizes (Cohen’s d), and by categorizing participants with Fugl-Meyer Upper Extremity Motor Assessment scores (mild >50/66, moderate 26–50/66 and severe <26/66). Results: Statistically, significant improvements and medium-to-large effect sizes from pretest to posttest were found with ipsilateral reaching kinematic outcomes of movement duration, mean velocity and elbow excursion (p < 0.05). Participants with mild impairment demonstrated the greatest change in elbow excursion. No significant differences and small effect sizes were found for the WMFT and SIS. Conclusion: The gaming intervention with high repetitions of reaching to targets and trunk restraint was feasible and led to improvements in upper extremity movement kinematics in this group of participants with chronic stroke. Implications for Rehabilitation Persons with chronic stroke can tolerate a high number of repetitions (between 800 and 2000) of reaching for targets during 30 minutes of playing a video game. Gaming systems that incorporate multiple repetitions of reaching for targets with trunk restraint can improve movement patterns in the paretic upper extremity of persons with chronic stroke.

Three-dimensional shoulder complex kinematics in individuals with upper extremity impairment from chronic stroke

Purpose: To evaluate shoulder complex kinematics in persons with chronic upper extremity (UE) impairments due to stroke and determine if kinematics predicts motor function based on the Fugl-Meyer Motor Assessment (FMA). Methods: Sixteen stroke survivors with chronic UE impairments (age range = 46–80 years, male = 8, female = 8, mean (SD) 66 (40) months post-stroke) performed the UE portion of the FMA with the shoulder/elbow subscale (FM_se) documented. Three-dimensional kinematics of the shoulder complex was collected with the Motion Monitor™ (Innsport, Chicago, IL, USA). Participants performed three repetitions of arm elevation in the frontal, sagittal and self-selected planes. The third repetition was analyzed. Scapular and humeral kinematics were calculated in the self-selected plane. Scapulohumeral rhythm was analyzed at peak elevation. Backward stepwise regression analysis predicted kinematic contributions to the FM_se. Results: Mean (SD) FM_se score was 25.3 1(10.9). Peak humeral elevation ranged from 45.6° to 129.2° (median 106.7°). Scapulohumeral rhythm was 4.1:1 when humeral elevation ranged from 45° to 50°, 1.5:1 from 80° to 95° and 2.1:1 from 105° to 130°. Humeral elevation, scapular upward rotation and scapular internal rotation predicted 65.4% of FM_se score variability. Conclusions: Persons with chronic UE impairments from stroke demonstrated reduced peak elevation and altered scapulohumeral rhythm. Three predictors of the FM_se were humeral elevation, scapular upward rotation and scapular internal rotation. Implications for Rehabilitation Three-dimensional analyses of shoulder elevation in stroke survivors with chronic upper extremity impairments reveal altered scapulohumeral rhythm in their paretic limb. Those with greater elevation limitations demonstrate larger scapular contribution. Humeral elevation, scapular upward rotation and scapular internal rotation predict motor function as measured by the Fugl-Meyer Motor Assessment. Clinicians should include examination of and intervention to all the components of the shoulder complex to address functional deficits.

Upper extremity joint stresses during walkerassisted ambulation in post-surgical patients

BACKGROUND A walker is a common device prescribed for ambulatory assistance for individuals with balance difficulties or to reduce lower extremity demands following injury or surgery. The long-term use of a walker imposes significant demands on the patients upper extremities that may lead to increased risk for development of secondary conditions such as wrist, elbow or shoulder pain. OBJECTIVE To describe the joint kinematics, forces and moments of the wrist, elbow and shoulder in a sample of twenty patients that were using a walker as a result of total joint surgery of the hips and knees. METHODS Three-dimensional upper extremity kinematics were recorded using a motion capture system synchronized with forces and torques transmitted through a walker instrumented with force transducers in the handles. RESULTS Compressive forces were found to be nearly 20% of the body weight at each of the upper extremity joints, both surgical and non-surgical sides, being the greatest force at the wrist and decreasing proximally. Compression forces were greater in the non-surgical side limb at the wrist and at the elbow. CONCLUSION Our findings indicated that loads on upper extremity joints associated with the use of a walker for assisted ambulation are high and further studies are needed to address the cause-effect relationship between the actual joint loading and the development of secondary musculoskeletal upper extremity complaints in more frail patients.

Reliability and validity of active and passive pectoralis minor muscle length measures

Highlights • This manuscript presents the measurement properties of a novel technique for lengthening the pectoralis minor muscle.• Active and passive lengthening procedures resulted in greater changes in pectoralis minor muscle length when compared to previously reported pectoralis minor muscle stretches.• This investigation provides the first evidence to support measurement of the extensibility of the pectoralis minor muscle.