Relationship between maximum isometric joint moment and functional task performance in patients with brachial plexus injury: A pilot study

Individuals with rotator cuff tears unsuccessfully treated with exercise therapy have less inferiorly oriented net muscle forces during scapular plane abduction

Exercise therapy for individuals with rotator cuff tears fails in approximately 25.0 % of cases. One reason for failure of exercise therapy may be the inability to strengthen and balance the muscle forces crossing the glenohumeral joint that act to center the humeral head on the glenoid. The objective of the current study was to compare the magnitude and orientation of the net muscle force pre- and post-exercise therapy between subjects successfully and unsuccessfully (e.g. eventually underwent surgery) treated with a 12-week individualized exercise therapy program. Twelve computational musculoskeletal models (n = 6 successful, n = 6 unsuccessful) were developed in OpenSim (v4.0) that incorporated subject specific tear characteristics, muscle peak isometric force, in-vivo kinematics and bony morphology. The models were driven with experimental kinematics and the magnitude and orientation of the net muscle force was determined during scapular plane abduction at pre- and post-exercise therapy timepoints. Subjects unsuccessfully treated had less inferiorly oriented net muscle forces pre- and post-exercise therapy compared to subjects successfully treated (p = 0.039 & 0.045, respectively). No differences were observed in the magnitude of the net muscle force (p > 0.05). The current study developed novel computational musculoskeletal models with subject specific inputs capable of distinguishing between subjects successfully and unsuccessfully treated with exercise therapy. A less inferiorly oriented net muscle force in subjects unsuccessfully treated may increase the risk of superior migration leading to impingement. Adjustments to exercise therapy programs may be warranted to avoid surgery in subjects at risk of unsuccessful treatment.

Upper limb joint coordination preserves hand kinematics after a traumatic brachial plexus injury

Background

Traumatic brachial plexus injury (TBPI) causes a sensorimotor deficit in upper limb (UL) movements.

Objective

Our aim was to investigate the arm–forearm coordination of both the injured and uninjured UL of TBPI subjects.

Methods

TBPI participants (n = 13) and controls (n = 10) matched in age, gender, and anthropometric characteristics were recruited. Kinematics from the shoulder, elbow, wrist, and index finger markers were collected, while upstanding participants transported a cup to their mouth and returned the UL to a starting position. The UL coordination was measured through the relative phase (RP) between arm and forearm phase angles and analyzed as a function of the hand kinematics.

Results

For all participants, the hand transport had a shorter time to peak velocity (p < 0.01) compared to the return. Also, for the control and the uninjured TBPI UL, the RP showed a coordination pattern that favored forearm movements in the peak velocity of the transport phase (p < 0.001). TBPI participants' injured UL showed a longer movement duration in comparison to controls (p < 0.05), but no differences in peak velocity, time to peak velocity, and trajectory length, indicating preserved hand kinematics. The RP of the injured UL revealed altered coordination in favor of arm movements compared to controls and the uninjured UL (p < 0.001). Finally, TBPI participants' uninjured UL showed altered control of arm and forearm phase angles during the deceleration of hand movements compared to controls (p < 0.05).

Conclusion

These results suggest that UL coordination is reorganized after a TBPI so as to preserve hand kinematics.

Design and Preliminary Evaluation of a Wearable Passive Cam-Based Shoulder Exoskeleton

Mechanically passive exoskeletons may be a practical and affordable solution to meet a growing clinical need for continuous, home-based movement assistance. We designed, fabricated, and preliminarily evaluated the performance of a wearable, passive, cam-driven shoulder exoskeleton (WPCSE) prototype. The novel feature of the WPCSE is a modular spring-cam-wheel module, which generates an assistive force that can be customized to compensate for any proportion of the shoulder elevation moment due to gravity. We performed a benchtop experiment to validate the mechanical output of the WPCSE against our theoretical model. We also conducted a pilot biomechanics study (eight able-bodied subjects) to quantify the effect of a WPCSE prototype on muscle activity and shoulder kinematics during three shoulder movements. The shoulder elevation moment produced by the spring-cam-wheel module alone closely matched the desired, theoretical moment. However, when measured from the full WPCSE prototype, the moment was lower (up to 30%) during positive shoulder elevation and higher (up to 120%) during negative shoulder elevation compared to the theoretical moment, due primarily to friction. Even so, a WPCSE prototype, compensating for about 25% of the shoulder elevation moment due to gravity, showed a trend of reducing root mean square electromyogram magnitudes of several muscles crossing the shoulder during shoulder elevation and horizontal adduction/abduction movements. Our results also showed that the WPCSE did not constrain or impede shoulder movements during the tested movements. The results provide proof-of-concept evidence that our WPCSE can potentially assist shoulder movements.

Kinematic Changes in the Uninjured Limb After a Traumatic Brachial Plexus Injury

Background: Traumatic brachial plexus injury (TBPI) typically causes sensory, motor and autonomic deficits of the affected upper limb. Recent studies have suggested that a unilateral TBPI can also affect the cortical representations associated to the uninjured limb.

Objective: To investigate the kinematic features of the uninjured upper limb in participants with TBPI.

Methods: Eleven participants with unilateral TBPI and twelve healthy controls matched in gender, age and anthropometric characteristics were recruited. Kinematic parameters collected from the index finger marker were measured while participants performed a free-endpoint whole-body reaching task and a cup-to-mouth task with the uninjured upper limb in a standing position.

Results: For the whole-body reaching task, lower time to peak velocity (p = 0.01), lower peak of velocity (p = 0.003), greater movement duration (p = 0.04) and shorter trajectory length (p = 0.01) were observed in the TBPI group compared to the control group. For the cup-to-mouth task, only a lower time to peak velocity was found for the TBPI group compared to the control group (p = 0.02). Interestingly, no differences between groups were observed for the finger endpoint height parameter in either of the tasks. Taken together, these results suggest that TBPI leads to a higher cost for motor planning when it comes to movements of the uninjured limb as compared to healthy participants. This cost is even higher in a task with a greater postural balance challenge.

Conclusion: This study expands the current knowledge on bilateral sensorimotor alterations after unilateral TBPI and should guide rehabilitation after a peripheral injury.

A novel instrumented shoulder functional test using wearable sensors in patients with brachial plexus injury

BACKGROUND

Because nerve injury of muscles around the shoulder can be easily disguised by "trick movements" of the trunk, shoulder dysfunction following brachial plexus injury is difficult to quantify with conventional clinical tools. Thus, to evaluate brachial plexus injury and quantify its biomechanical consequences, we used inertial measurement units, which offer the sensitivity required to measure the trunk's subtle movements.

METHODS

We calculated 6 kinematic scores using inertial measurement units placed on the upper arms and the trunk during 9 functional tasks. We used both statistical and machine learning techniques to compare the bilateral asymmetry of the kinematic scores of 15 affected and 15 able-bodied individuals (controls).

RESULTS

Asymmetry indexes from several kinematic scores of the upper arm and trunk showed a significant difference (P < .05) between the affected and control groups. A bagged ensemble of decision trees trained with trunk and upper arm kinematic scores correctly classified all controls. All but 2 patients were also correctly classified. Upper arm scores showed correlation coefficients ranging from 0.55-0.76 with conventional clinical scores.

CONCLUSIONS

The proposed wearable technology is a sensitive and reliable tool for objective outcome evaluation of brachial plexus injury and its biomechanical consequences. It may be useful in clinical research and practice, especially in large cohorts with multiple follow-ups.

Wearable Shoulder Exoskeleton with Spring-Cam Mechanism for Customizable, Nonlinear Gravity Compensation

Wearable, mechanically passive (i.e. spring-powered) exoskeletons may be more practical and affordable than active, motorized exoskeletons for providing continuous, home-based, antigravity movement assistance for people with shoulder disability. However, the biomechanical moment due to gravity is a nonlinear function of shoulder elevation angle and, thus, challenging to counteract proportionally across the shoulder elevation range of motion with a spring alone. We designed, fabricated, and tested an integrated spring-cam-wheel system that can generate a nonlinear moment to proportionally compensate for the expected antigravity moment at the shoulder. We then incorporated the proposed system in a benchtop model and a novel wearable passive cable-driven exoskeleton that was intended to counteract half of the gravitational moment during shoulder elevation movements. The rotational moment measured from the benchtop model closely matched the theoretical moment during simulated positive shoulder elevation. However, a larger moment (up to 12.5% larger) was required during simulated negative shoulder elevation to stretch the spring to its initial length due to spring hysteresis and friction losses. The wearable exoskeleton prototype was qualitatively tested for assisting shoulder elevation movements; we identified several aspects of the prototype design that need to be improved before further testing on human participants. In future studies, we will quantitatively evaluate human kinematics and neuromuscular coordination with the exoskeleton to determine its suitability for assisting patients with shoulder disability.

Effect of Mechanically Passive, Wearable Shoulder Exoskeletons on Muscle Output During Dynamic Upper Extremity Movements: A Computational Simulation Study

Wearable passive (ie, spring powered) shoulder exoskeletons could reduce muscle output during motor tasks to help prevent or treat shoulder musculoskeletal disorders. However, most wearable passive shoulder exoskeletons have been designed and evaluated for static tasks, so it is unclear how they affect muscle output during dynamic tasks. The authors used a musculoskeletal model and Computed Muscle Control optimization to estimate muscle output with and without a wearable passive shoulder exoskeleton during 2 simulated dynamic tasks: abduction and upward reach. To an existing upper extremity musculoskeletal model, the authors added an exoskeleton model with 3-dimensional representations of the exoskeleton components, including a spring, cam wheel, force-transmitting shoulder cable, and wrapping surfaces that permitted the shoulder cable to wrap over the shoulder. The exoskeleton reduced net muscle-generated moments in positive shoulder elevation by 28% and 62% during the abduction and upward reach, respectively. However, muscle outputs (joint moments and muscle effort) were higher with the exoskeleton than without at some points of the movement. Muscle output was higher with the exoskeleton because the exoskeleton moment opposed the muscle-generated moment in some postures. The results of this study highlight the importance of evaluating muscle output for passive exoskeletons designed to support dynamic movements to ensure that the exoskeletons assist, rather than impede, movement.

Shoulder Strength Requirements for Upper Limb Functional Tasks: Do Age and Rotator Cuff Tear Status Matter?

Understanding upper limb strength requirements for daily tasks is imperative for early detection of strength loss that may progress to disability due to age or rotator cuff tear. We quantified shoulder strength requirements for 5 upper limb tasks performed by 3 groups: uninjured young adults and older adults, and older adults with a degenerative supraspinatus tear prior to repair. Musculoskeletal models were developed for each group representing age, sex, and tear-related strength losses. Percentage of available strength used was quantified for the subset of tasks requiring the largest amount of shoulder strength. Significant differences in strength requirements existed across tasks: upward reach 105° required the largest average strength; axilla wash required the largest peak strength. However, there were limited differences across participant groups. Older adults with and without a tear used a larger percentage of their shoulder elevation (p < .001, p < .001) and external rotation (p < .001, p = .017) strength than the young adults, respectively. Presence of a tear significantly increased percentage of internal rotation strength compared to young (p < .001) and uninjured older adults (p = .008). Marked differences in strength demand across tasks indicate the need for evaluating a diversity of functional tasks to effectively detect early strength loss, which may lead to disability.