Upper Extremity Kinematics and Muscle Activation Patterns in Subjects With Facioscapulohumeral Dystrophy

French National Protocol for diagnosis and care of facioscapulohumeral muscular dystrophy (FSHD)

Facioscapulohumeral muscular dystrophy (FSHD) is one of the most common genetically inherited myopathies in adults. It is characterized by incomplete penetrance and variable expressivity. Typically, FSHD patients display asymmetric weakness of facial, scapular, and humeral muscles that may progress to other muscle groups, particularly the abdominal and lower limb muscles. Early-onset patients display more severe muscle weakness and atrophy, resulting in a higher frequency of associated skeletal abnormalities. In these patients, multisystem involvement, including respiratory, ocular, and auditory, is more frequent and severe and may include the central nervous system. Adult-onset FSHD patients may also display some degree of multisystem involvement which mainly remains subclinical. In 95% of cases, FSHD patients carry a pathogenic contraction of the D4Z4 repeat units (RUs) in the subtelomeric region of chromosome 4 (4q35), which leads to the expression of DUX4 retrogene, toxic for muscles (FSHD1). Five percent of patients display the same clinical phenotype in association with a mutation in the SMCHD1 gene located in chromosome 18, inducing epigenetic modifications of the 4q D4Z4 repeated region and expression of DUX4 retrogene. This review highlights the complexities and challenges of diagnosing and managing FSHD, underscoring the importance of standardized approaches for optimal patient outcomes. It emphasizes the critical role of multidisciplinary care in addressing the diverse manifestations of FSHD across different age groups, from skeletal abnormalities in early-onset cases to the often-subclinical multisystem involvement in adults. With no current cure, the focus on alleviating symptoms and slowing disease progression through coordinated care is paramount.

Exploration of outcome measures for assessing orthotic intervention in upper extremity peripheral nerve injuries: 2 case reports

In upper extremity peripheral nerve injuries, orthotic intervention has been used as a valuable device to restore function. However, there is lacking evidence to support it. The purpose of this study was to explore the application of body function's outcome measures for orthotic intervention evaluation in patients with peripheral nerve injury. Two participants sustaining a peripheral nerve injury who underwent orthotic intervention were assessed: subject 1 was a 25-year-old man with ulnar and median nerve injury presenting with a composite claw; subject 2, a 28-year-old man with radial nerve injury presenting with a dropped wrist. Strength, range of motion, and electromyography were measured in 2 conditions: wearing the orthosis and without it. The Jamar, Pinch Gauge, a 3D motion capture system (Optitrack-NaturalPoint), and surface electromyography (Trigno Wireless System, Delsys) were the chosen instruments. Both subjects presented differences in grip and pinch strength. In both tasks, subject 1 reached higher wrist extension while wearing the orthosis. Subject 2 reached higher wrist extension and radial deviation while wearing the orthosis. There were marked differences in both tasks for subject 2, especially the maintenance of wrist extension when wearing the orthosis. Electromyographic assessment showed higher root-mean-square values for all muscles, in both tasks for subject 1. For subject 2, a higher root-mean-square value was found for flexor carpi ulnaris during the execution of task 1 wearing the orthosis. Outcome measures of body function can quantify the impact of orthotic intervention in patients sustaining peripheral nerve injury, and therefore, they are feasible for evaluating it.

The effects of facioscapulohumeral dystrophy and dynamic arm support on upper extremity muscle coordination in functional tasks

This study's objective is to understand the effect of muscular weakness in persons with facioscapulohumeral dystrophy as well as the effect of a dynamic arm support on muscle coordination and activity performance, during activities of daily living. People with facioscapulohumeral dystrophy (n=12, 56.0±14.5 years) and healthy controls (n=12, 55.5±13.4 years) performed five simulated daily activity tasks, while unsupported and supported by the Gowing dynamic arm support. Surface electromyography, kinematics, and maximum force output were recorded. Outcomes were calculated for muscle coordination (muscle synergies), maximum muscle activity, movement performance indicators, and upper limb muscular weakness (maximum force output). Muscle coordination was altered and less consistent in persons with facioscapulohumeral dystrophy compared with healthy controls. The dynamic arm support alleviated muscle efforts and affected muscle coordination in both populations. While populations became more similar, the internal consistency of persons with facioscapulohumeral dystrophy remained unaffected and lower than that of healthy controls. Furthermore, the support affected movements' performance in both groups. The maximum force outputs were lower in persons with facioscapulohumeral dystrophy than controls. Muscle coordination differences were presumably the result of individual-specific in muscle weakness and compensatory strategies for dealing with gravity compensation and movement constraints.

An international survey mapping practice and barriers for upper-limb assessments in movement analysis

BACKGROUND

Upper-limb movement analysis could improve our understanding of function, pathological mechanisms and inform rehabilitation and surgical decision-making. Despite the potential benefits, the use of clinical upper-limb motion analysis is not well established and it is not clear what the barriers to clinical motion analysis are.

RESEARCH QUESTION

What is current practice for assessment of the upper-limb and what are the barriers currently limiting upper-limb motion analysis being routinely used in clinical practice?

METHODS

A web-based questionnaire was used to collect responses through international professional movement analysis society coordinators over an 18 month-period.

RESULTS

A total of 55 responses were received and 75% of laboratories performed some form of upper-limb assessment. In total 44% of laboratories performed upper-limb assessments for clinical purposes and only 33% did 3D-movement analysis. The most commonly seen patient groups were those with neurological injury e.g. cerebral palsy (adults and children) and normal controls for comparative purposes. Barriers to upper-limb motion analysis were the availability of standard reference tasks, protocols, software, funding and clinical need. Practice was variable with no universally identified approaches to upper-limb movement analysis. Differences in practice were also identified between laboratories accredited by the Clinical Movement Analysis Society of the UK and Ireland and other international professional societies and affiliate laboratories.

SIGNIFICANCE

These findings may be used to inform the development of practice standards and progress the use of clinical motion analysis in the upper-limb. This study provides a summary and describes current practice, potentially providing access to peer support and experience for laboratories with an identified clinical need looking to conduct upper-limb assessment. A national picture (UK and Ireland) for practice regarding upper-limb assessment in this sub-population is presented. We have laid out further work which is needed to establish standards of practice or consensus initiatives for enhancing clinical upper-limb motion analysis.

Recommendations for studies on dynamic arm support devices in people with neuromuscular disorders: a scoping review with expert-based discussion

PURPOSE

Neuromuscular disorders are characterised by muscle weakness that limits upper extremity mobility, but can be alleviated with dynamic arm support devices. Current research highlights the importance and difficulties of evidence-based recommendations for device development. We aim to provide research recommendations primarily concerning upper extremity body functions, and secondarily activity and participation, environmental and personal factors.

METHODS

Evidence was synthesised from literature, ongoing studies, and expert opinions and tabulated within a framework based on a combination of the International Classification of Functioning, Disability and Health (ICF) model and contextual constructs.

RESULTS

Current literature mostly investigated the motor capacity of muscle function, joint mobility, and upper body functionality, and a few studies also addressed the impact on activity and participation. In addition, experts considered knowledge on device utilisation in the daily environment and characterising the beneficiaries better as important. Knowledge gaps showed that ICF model components and contextual constructs should be better integrated and more actively included in future research.

CONCLUSIONS

It is recommended to, first, integrate multiple ICF model components and contextual constructs within one study design. Second, include the influence of environmental and personal factors when developing and deploying a device. Third, include short-term and long-term measurements to monitor adaptations over time. Finally, include user satisfaction as guidance to evaluate the device effectiveness.IMPLICATIONS ON REHABILITATIONSynthesized evidence will support future research and development of dynamic arm supports.Tabulated evidence stresses the importance of integrating ICF model components and contextual constructs to fill the knowledge gaps.Presented knowledge gaps and proposed steps guide the set up of future studies on dynamic arm supports.

A pilot study of a single intermittent arm cycling exercise programme on people affected by Facioscapulohumeral dystrophy (FSHD)

For patients affected by Facioscapulohumeral dystrophy (FSHD), alternate methods for increasing physical activity engagement that may benefit shoulder function and wider health are needed. Arm cycling has been proposed as a potential method for achieving this although dosage parameters and evidence is limited. The aim of this study was to conduct a pilot study evaluating the effect of a single intermittent arm cycling exercise programme on people affected by FSHD. People with confirmed genetic diagnosis of FSHD between the ages 18-60 years were recruited to attend a single session for the exercise intervention (5 exercise efforts lasting 2 minutes each with 30 seconds of rest between each effort). Prior to exercise, measures of shoulder function (Oxford shoulder score), strength and range of movement were recorded. During the exercise participants were video recorded to quantify range of movement and extract movement profile features. Participants comments were recorded and followed up four days later to check for adverse events. Fifteen participants, (6F:9M) were recruited with median (IQR) Oxford Shoulder Scores of 25 (18 to 39). All participants successfully completed the exercise intervention with only transient symptoms consistent with exercise being reported and achieving a median (IQR) rate of perceived exertion scores of 13 (12 to 13). Movement profile data was available for 12 out of 15 participants and suggests that exercise intensity did not compromise movement. An association between strength and shoulder function (R2 = 0.5147), Rate of perceived exertion (RPE) of the final effort against shoulder function and strength (R2 = 0.2344 and 0.1743 respectively) was identified. Participant comments were positive regarding the exercise intervention. Our study demonstrates that an intermittent arm cycling programme is feasible for people affected by FSHD. Further work is needed to evaluate physiological responses to exercise across variations in programme variables and equipment set up in a larger sample of people affected by FSHD.

Upper Limb Rehabilitation in Facioscapulohumeral Muscular Dystrophy: A Patients' Perspective

OBJECTIVE

To identify (1) what exercise modalities people living with facioscapulohumeral muscular dystrophy (FSHD) are undertaking in the community as a part of their ongoing rehabilitation and (2) what future research projects would gain the support of people with FSHD.

DESIGN

An online questionnaire composed of open and closed questions. Conventional content analysis was used for open questions, and quantitative analysis was used for closed questions.

SETTING

Online questionnaire distributed to a United Kingdom FSHD registry.

PARTICIPANTS

A total of 232 patients on the United Kingdom FSHD registry (N=232).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

None.

RESULTS

A response rate of 43.6% was achieved with 232 of 532 patients completing the survey. Despite 85.8% (n=199) of patients experiencing shoulder instability that affects daily living, only 44.4% (n=103) engaged with exercises targeting the upper body. The themes from the data were understanding of disease mechanism shaping exercise choice, lack of understanding about the condition and the benefit of exercise, support from professionals, barriers to exercise, and thoughts about future research. Participants (92.2%, n=214) agreed additional research into upper limb exercises is needed and felt a 3-month arm cycling intervention with monthly clinical visits and magnetic resonance imaging would be appropriate.

CONCLUSIONS

Exercise selection was variable among patients with FSHD, and lack of information, pain, fatigue, availability and access to facilities, cost, and time were identified as barriers to exercise. This may account for the limited engagement with upper limb rehabilitation despite the high percentage of shoulder instability in patients with FSHD. Further research is needed to develop evidence-based exercise interventions, and guidance for upper limb exercise prescription in FSHD, and patients are supportive of this.

Superficial Shoulder Muscle Synergy Analysis in Facioscapulohumeral Dystrophy During Humeral Elevation Tasks

Facioscapulohumeral dystrophy (FSHD) is a progressive muscle-wasting disease which leads to a decline in upper extremity functionality. Although the scapulohumeral joint's stability and functionality are affected, evidence on the synergetic control of the shoulder muscles in FSHD individuals is still lacking. The aim of this paper is to understand the neuromuscular changes in shoulder muscle control in people with FSHD. Upper arm kinematics and electromyograms (EMG) of eight upper extremity muscles were recorded during shoulder abduction-adduction and flexion-extension tasks in eleven participants with FSHD and 11 healthy participants. Normalized muscle activities were extracted from EMG signals. Non-negative matrix factorization was used to compute muscle synergies. Maximum muscle activities were compared using non-parametric analysis of variance. Similarities between synergies were also calculated using correlation. The Biceps Brachii was significantly more active in the FSHD group (25±2%) while Trapezius Ascendens and Serratus Anterior were less active (32±7% and 39±4%, respectively). Muscle synergy weights were altered in FSHD individuals and showed greater diversity while controls mostly used one synergy for both tasks. The decreased activity by selected scapula rotator muscles and muscle synergy weight alterations show that neuromuscular control of the scapulohumeral joint is less consistent in people with FSHD compared to healthy participants. Assessments of muscle coordination strategies can be used to evaluate motor output variability and assist in management of the disease.

Kinematic analysis of scapular movements in patients with facioscapulohumeral muscular dystrophy

The purpose of this study is to evaluate scapular movements by the three-dimensional electromagnetic system during shoulder elevation in FSHMD patients, and to compare the results with healthy individuals. 10 patients with FSHMD and 10 healthy individuals were included in the study. Scapular anterior-posterior tilt, upward-downward rotation and internal-external rotation at 30°, 60° and 90° were evaluated using the three-dimensional electromagnetic system during the elevation of the upper limbs in the scapular plane. Humerothoracic elevation levels on the dominant and non-dominant sides were found to be lower in the patients than healthy individuals (p < .001). Both scapula were rotated downwards at 30° (dominant/non-dominant p < .001) and 60° (dominant p = .009, non-dominant p = .04) of humerothoracic elevation, the scapula was rotated internally at 30° of humerothoracic elevation on the non-dominant side (p = .03), and the scapula was tilted posteriorly at 90° of humerothoracic elevation on the non-dominant side (p = .009) in patients. These existing abnormal patterns of the scapula in the patients increase the risk of impairment, pain, impingement and instability especially in the activities that require arm elevation. It is thought that physiotherapy approaches should first be emphasized to improve scapular stabilization and strengthening exercises should then be performed for the shoulder girdle muscles.

Dynamic thoracohumeral kinematics are dependent upon the etiology of the shoulder injury

Obtaining kinematic patterns that depend on the shoulder injury may be important when planning rehabilitation. The main goal of this study is to explore whether the kinematic patterns of continuous and repetitive shoulder elevation motions are different according to the type of shoulder injury in question, specifically tendinopathy or rotator cuff tear, and to analyze the influence of the load handled during its assessment. For this purpose, 19 individuals with tendinopathy and 9 with rotator cuff tear performed a repetitive scaption movement that was assessed with stereophotogrammetry. Furthermore, static range of motion (ROM) and isometric strength were evaluated with a goniometer and a dynamometer, respectively. Dynamic measurements of maximum elevation (Emax), variablility of the maximum angle (VMA), maximum angular velocity (Velmax), and time to maximum velocity (tmaxvel) were found to be significantly different between the tendinopathy group (TG) and the rotator cuff tear group (RTCG). No differences were found in the ROM assessed with goniometry and the isometric strength. The effect of increasing the load placed in the hand during the scaption movement led to significant differences in Emax, VMA, tmaxvel and repeatability. Therefore, only the dynamic variables showed sufficient capability of detecting differences in functional performance associated with structural shoulder injury. The differences observed in the kinematic variables between patients with tendinopathy and rotator cuff tear seem to be related to alterations in thoracohumeral rhythm and neuromuscular control. Kinematic analysis may contribute to a better understanding of the functional impact of shoulder injuries, which would help in the assessment and treatment of shoulder pain.

Modifying Kinect placement to improve upper limb joint angle measurement accuracy

STUDY DESIGN

Repeated measures.

INTRODUCTION

The Kinect (Microsoft, Redmond, WA) is widely used for telerehabilitation applications including rehabilitation games and assessment.

PURPOSE OF THE STUDY

To determine effects of the Kinect location relative to a person on measurement accuracy of upper limb joint angles.

METHODS

Kinect error was computed as difference in the upper limb joint range of motion (ROM) during target reaching motion, from the Kinect vs 3D Investigator Motion Capture System (NDI, Waterloo, Ontario, Canada), and compared across 9 Kinect locations.

RESULTS

The ROM error was the least when the Kinect was elevated 45° in front of the subject, tilted toward the subject. This error was 54% less than the conventional location in front of a person without elevation and tilting. The ROM error was the largest when the Kinect was located 60° contralateral to the moving arm, at the shoulder height, facing the subject. The ROM error was the least for the shoulder elevation and largest for the wrist angle.

DISCUSSION

Accuracy of the Kinect sensor for detecting upper limb joint ROM depends on its location relative to a person.

CONCLUSION

This information facilitates implementation of Kinect-based upper limb rehabilitation applications with adequate accuracy.

LEVEL OF EVIDENCE

3b.

Upper limb function and activity in people with facioscapulohumeral muscular dystrophy: a web-based survey

Purpose To investigate the upper extremity (UE) at the level of impairments and related activity limitations and participation restrictions in people with facioscapulohumeral muscular dystrophy (FSHD). Methods The study was conducted using web-based questionnaires that were distributed amongst people with FSHD in the Netherlands. Eighty-eight respondents started the survey, and 71 completed it. The questionnaires covered the following dimensions: Function, Activity and Participation of the International Classification of Functioning Disability and Health. Results More than 40% of the respondents experienced pain in one arm or both the arms. Increased pain and stiffness scores and longer disease duration were associated with increased limitation scores. For basic activities, lifting the arm above shoulder-level was most frequently reported as most limited, coherent with the clinical picture of FSHD. Among the respondents, 50% indicated restrictions at school, 78% indicated restrictions at work and more than 80% indicated restrictions whilst participating in sports, hobbies, household activities and romantic relationships. Conclusions This study has shown that alongside the well-known problem of lifting the arms above shoulder-level, UE activities below shoulder height during vocational and occupational activities are also problematic in patients with FSHD. Alongside disease duration, pain and stiffness are associated with UE activity limitations. Implications for Rehabilitation Attention is needed for pain and experienced stiffness in the upper extremity as it is frequently present in patients with FSHD. Rehabilitation professionals need to be aware that patients with FSHD not only experience problems with activities above shoulder height, but also with activities below shoulder height. At least 50% of the patients with FSHD experience restrictions in participation as a result of limitations in their UE.

Upper extremity coordination strategies depending on task demand during a basic daily activity

Injury conditions affecting the upper extremity may lead to severe functional impairment and an accurate evaluation is needed in order to select the most effective treatment in a rehabilitation program. This study focused on simultaneous electromyographic and kinematic analysis to assess movement patterns of upper extremity during a basic daily activity, considering different demands existing within the task. Twenty-five healthy subjects, average age 19.8 ys SD 1.7 ys, with no upper extremity impairment, were assessed by means of electromyography (EMG) and a 3D motion capture system while performing a task that required reach, transport and release. Integrated EMG (iEMG), timing of muscle onset and active range of motion (AROM) were calculated for each subject. Data were compared within each phase and between the three phases and a repeated measure ANOVA was used for statistical analysis. We found early activation of upper trapezius associated with high activity of serratus anterior for proximal stability while anterior deltoid and triceps brachii performed shoulder flexion and elbow extension, in Reach phase. In Transport phase there was early and higher activation of upper trapezius, higher muscle activity of almost all muscles and increased AROM of all joints. No change in flexion/extension wrist posture with increased forearm muscles activity were identified as the main control strategy to keep optimal grasping. Triceps brachii was found to act as an important synergist in shoulder abduction and extension in free load conditions. Such information can lead clinicians to more specific assessment and subsequent better intervention in upper extremity rehabilitation.