Análisis de la reproducibilidad en sujetos sanos de un nuevo sistema de medida tridimensional de la cinemática escapulotorácica

Cada vez existe mayor evidencia de que la escápula y su comportamiento dinámico juegan un papel clave en casi cualquier patología del hombro. No obstante, la identificación y manejo de la discinesia escapular, tiene como principal obstáculo la falta de herramientas para evaluarla de manera estandarizada y objetiva en la práctica clínica habitual. El objetivo del presente trabajo es evaluar un nuevo sistema de análisis tridimensional de la cinemática escapular: el sistema SHoW Motion 3D. Éste es un sistema portátil y no invasivo, que podría usarse en un entorno de consulta convencional. Para ello, se evaluó la reproducibilidad intra e interobservador de dicho sistema en 25 sujetos sanos. Además de analizar y obtener patrones de cinemática escapular normal de una población sana (27 sujetos) y comparar la cinemática escapular de ambos hombros en todos ellos. El análisis de reproducibilidad se realizó analizando la concordancia intra e interobservador mediante los coeficientes de correlación múltiple (CMC) y el error cuadrático medio (RMSE). El sistema mostró muy buena (CMC>0,90) reproducibilidad intra e interobservador para la inclinación escapular y las rotaciones ascendente-descendentes. Y obtuvo resultados más variables para la rotación escapular interna-externa. Los cálculos de RMSE mostraron consistentemente una buena reproducibilidad, con RSM

Definition of anatomical zero positions for assessing shoulder pose with 3D motion capture during bilateral abduction of the arms

Background: Surgical interventions at the shoulder may alter function of the shoulder complex. Clinically, the outcome can be assessed by universal goniometry. Marker-based motion capture may not resemble these results due to differing angle definitions. Methods: The clinical inspection of bilateral arm abduction for assessing shoulder dysfunction is performed with a marker based 3D optical measurement method. An anatomical zero position of shoulder pose is proposed to determine absolute angles according to the Neutral-0-Method as used in orthopedic context. Static shoulder positions are documented simultaneously by 3D marker tracking and universal goniometry in 8 young and healthy volunteers. Repetitive bilateral arm abduction movements of at least 150° range of motion are monitored. Similarly a subject with gleno-humeral osteoarthritis is monitored for demonstrating the feasibility of the method and to illustrate possible shoulder dysfunction effects. Results: With mean differences of less than 2°, the proposed anatomical zero position results in good agreement between shoulder elevation/depression angles determined by 3D marker tracking and by universal goniometry in static positions. Lesser agreement is found for shoulder pro-/retraction with systematic deviations of up to 6°. In the bilateral arm abduction movements the volunteers perform a common and specific pattern in clavicula-thoracic and gleno-humeral motion with maximum shoulder angles of 32° elevation, 5° depression and 45° protraction, respectively, whereas retraction is hardly reached. Further, they all show relevant out of (frontal) plane motion with anteversion angles of 30° in overhead position (maximum abduction). With increasing arm anteversion the shoulder is increasingly retroverted, with a maximum of 20° retroversion. The subject with gleno-humeral osteoarthritis shows overall less shoulder abduction range of motion but with increased out-of-plane movement during abduction. Conclusions: The proposed anatomical zero definition for shoulder pose fills the missing link for determining absolute joint angles for shoulder elevation/depression and pro-/retraction. For elevation-/depression the accuracy suits clinical expectations very well with mean differences less than 2° and limits of agreement of 8.6° whereas for pro-/retraction the accuracy in individual cases may be inferior with limits of agreement of up to 24.6°. This has critically to be kept in mind when applying this concept to shoulder intervention studies

Métodos clínicos de avaliação dinâmica e quantitativa do complexo ombro e escápula: uma revisão de escopo

La articulación del hombro tiene la mayor amplitud demovimiento y es más susceptible a disfunciones. Las evaluacionesdinámicas y cuantitativas de esta región proporcionan mejoresinformaciones para la clínica, pero la elección del método a utilizardepende de sus propiedades de medición. El objetivo de esteestudio fue identificar los métodos existentes de evaluacióndinámica cuantitativa del complejo del hombro y escápula enun contexto clínico para la población general, identificandolas propiedades de medición y los resultados evaluados paracada método. La revisión de alcance incluyó estudios in vivo,con muestras sin una condición clínica específica y con métodosaplicables en un contexto clínico. Se identificaron el resultadoevaluado, el método de medición y sus propiedades de medición.Se seleccionaron 29 estudios que investigaron 12 métodos demedición, y se evaluó su validez y confiabilidad para 17 resultadosdiferentes. La posición del hombro y de la escápula, y losresultados derivados fueron abordados por el mayor númerode estudios (n=21), y sus principales métodos de evaluaciónfueron las unidades de medición inercial (n=5) y las unidades demedición magnética inercial (n=6). Los resultados que presentaronmétodos válidos y confiables fueron: amplitud articular del hombro;amplitud de movimiento de la escápula y del hombro; actividadmuscular; centro articular del hombro; longitud del húmero; curvatorque-tiempo; desempeño funcional; discinesia escapular; fuerzade los rotadores externos del hombro; funcionalidad y amplitudarticular; movimiento escapular inicial; posición de la escápula ydel hombro; y velocidad angular del hombro.Shoulder joint has the greatest range of motion and is the most exposed to dysfunctions. Dynamic and quantitative evaluations of this region provide better information, but the choice of the method to be used relies on its measurement properties. The aim of this study was to identify the existing methods of quantitative dynamic evaluation of the shoulder and scapula complex, in a clinical context for the general population, identifying the measurement properties and the outcomes that were evaluated for each method. This scope review includes in vivo studies, with samples without a specific clinical condition and involving methods applicable in a clinical context. It was identified the evaluated outcome, the measurement method and measurement properties analyzed. 29 studies were selected that investigated 12 measurement methods, and their validity and reliability were evaluated for 17 different outcomes. The shoulder and scapula position and derived outcomes have been addressed by the largest number of studies (n=21) and their main assessment methods were inertial measurement units (n=5) and magnetic inertial measurement units (n=6). The outcomes that presented valid and reliable methods were: shoulder range of joint; shoulder and scapular range of motion; muscular activity; shoulder joint center; humerus length; torque-time curve; functional performance; scapular dyskinesis; shoulder external rotators strength; functional capabilities and range of joint; initial scapular movement; shoulder and scapula position; shoulder angular velocity.A articulação do ombro possui a maior amplitude de movimento e está mais exposta a disfunções. Avaliações dinâmicas e quantitativas dessa região fornecem melhores informações para a clínica, mas a escolha do método a ser utilizado depende de suas propriedades de medição. O objetivo desse estudo foi identificar os métodos existentes de avaliação dinâmica quantitativa do complexo ombro e escápula, em um contexto clínico para a população em geral, identificando as propriedades de medição e os desfechos que foram avaliados para cada método. A revisão de escopo incluiu estudos in vivo, com amostras sem uma condição clínica específica e envolvendo métodos aplicáveis em um contexto clínico. Foram identificados: desfecho avaliado, método de medição e suas propriedades de medição. Foram selecionados 29 estudos que investigaram 12 métodos de medição, sendo avaliadas sua validade e confiabilidade para 17 desfechos diferentes. A posição do ombro e da escápula e desfechos derivados foram abordados pelo maior número de estudos (n=21), sendo seus principais métodos de avaliação as unidades de medição inercial (n=5) e unidades de medição magnética inercial (n=6). Os desfechos que apresentaram métodos válidos e confiáveis foram: amplitude articular de ombro; amplitude de movimento da escápula e do ombro; atividade muscular; centro articular do ombro; comprimento do úmero; curva torque-tempo; desempenho funcional; discinese escapular; força de rotadores externos do ombro; funcionalidade e amplitude articular; movimento escapular inicial; posição da escápula e do ombro e velocidade angular do ombr

Caractérisation tridimensionnelle de l’amplitude articulaire de l’épaule

L’épaule est l’articulation la plus mobile et la plus instable du corps humain dû à la faible quantité de contraintes osseuses et au rôle des tissus mous qui lui confèrent au moins une dizaine de degrés de liberté. La mobilité de l’épaule est un facteur de performance dans plusieurs sports. Mais son instabilité engendre des troubles musculo-squelettiques, dont les déchirures de la coiffe des rotateurs sont fréquentes et les plus handicapantes. L’évaluation de l’amplitude articulaire est un indice commun de la fonction de l’épaule, toutefois elle est souvent limitée à quelques mesures planaires pour lesquelles les degrés de liberté varient indépendamment les uns des autres. Ces valeurs utilisées dans les modèles de simulation musculo-squelettiques peuvent amener à des solutions non physiologiques. L’objectif de cette thèse était de développer des outils pour la caractérisation de la mobilité articulaire tri-dimensionnelle de l’épaule, en passant par i) fournir une méthode et son approche expérimentale pour évaluer l’amplitude articulaire tridimensionnelle de l’épaule incluant des interactions entre les degrés de liberté ; ii) proposer une représentation permettant d’interpréter les données tri-dimensionnelles obtenues; iii) présenter des amplitudes articulaires normalisées, iv) implémenter une amplitude articulaire tridimensionnelle au sein d’un modèle de simulation numérique afin de générer des mouvements sportifs optimaux plus réalistes; v) prédire des amplitudes articulaires sécuritaires et vi) des exercices de rééducation sécuritaires pour des patients ayant subi une réparation de la coiffe des rotateurs. i) Seize sujets ont été réalisé séries de mouvements d’amplitudes maximales actifs avec des combinaisons entre les différents degrés de liberté de l’épaule. Un système d’analyse du mouvement couplé à un modèle cinématique du membre supérieur a été utilisé pour estimer les cinématiques articulaires tridimensionnelles. ii) L’ensemble des orientations définies par une séquence de trois angles a été inclus dans un polyèdre non convexe représentant l’espace de mobilité articulaire prenant en compte les interactions entre les degrés de liberté. La combinaison des séries d’élévation et de rotation est recommandée pour évaluer l’amplitude articulaire complète de l’épaule. iii) Un espace de mobilité normalisé a également été défini en englobant les positions atteintes par au moins 50% des sujets et de volume moyen. iv) Cet espace moyen, définissant la mobilité physiologiques, a été utilisé au sein d’un modèle de simulation cinématique utilisé pour optimiser la technique d’un élément acrobatique de lâcher de barres réalisée par des gymnastes. Avec l’utilisation régulière de limites articulaires planaires pour contraindre la mobilité de l’épaule, seulement 17% des solutions optimales sont physiologiques. En plus, d’assurer le réalisme des solutions, notre contrainte articulaire tridimensionnelle n’a pas affecté le coût de calculs de l’optimisation. v) et vi) Les seize participants ont également réalisé des séries d’amplitudes articulaires passives et des exercices de rééducation passifs. La contrainte dans l’ensemble des muscles de la coiffe des rotateurs au cours de ces mouvements a été estimée à l’aide d’un modèle musculo-squelettique reproduisant différents types et tailles de déchirures. Des seuils de contrainte sécuritaires ont été utilisés pour distinguer les amplitudes de mouvements risquées ou non pour l’intégrité de la réparation chirurgicale. Une taille de déchirure plus grande ainsi que les déchirures affectant plusieurs muscles ont contribué à réduire l’espace de mobilité articulaire sécuritaire. Principalement les élévations gléno-humérales inférieures à 38° et supérieures à 65°, ou réalisées avec le bras maintenu en rotation interne engendrent des contraintes excessives pour la plupart des types et des tailles de blessure lors de mouvements d’abduction, de scaption ou de flexion. Cette thèse a développé une représentation innovante de la mobilité de l’épaule, qui tient compte des interactions entre les degrés de liberté. Grâce à cette représentation, l’évaluation clinique pourra être plus exhaustive et donc élargir les possibilités de diagnostiquer les troubles de l’épaule. La simulation de mouvement peut maintenant être plus réaliste. Finalement, nous avons montré l’importance de personnaliser la rééducation des patients en termes d’amplitude articulaire, puisque des exercices passifs de rééducation précoces peuvent contribuer à une re-déchirure à cause d’une contrainte trop importante qu’ils imposent aux tendons.The shoulder is the most mobile but instable joint of the human body due to bony constraint scarcity and soft tissue function unlocking several degrees of freedom (DoF). Shoulder mobility is a factor of performance in some sports. But its instability leads to musculoskeletal impairments, the rotator cuff tear being the most debilitating disorder. Evaluation of the shoulder range of motion (RoM) is a common indicator of shoulder function but it is often limited to a few monoplanar measurements where each DoF varies independently. These values used in computer simulation models lead to non-physiological movements. The aim of this thesis was to develop tools for caracterizing tridimensional shoulder mobility. In this purpose it was mandatory to i) provide a method and its experimental approach to assess shoulder 3D (three-dimensional) RoM with DoF interactions; ii) propose a representation allowing 3D kinematical data interprestation; iii) present normalized shoulder amplitudes; iv) implement 3D RoM into computer simulation models to generate more realistic optimal sports technique; and v) predict safe 3D RoM and vi) safe rehabilitation exercises for patients after rotator cuff repair. i) Sixteen participants performed series of active arm movements with maximal amplitude with interactions between all the shoulder degrees-of-freedom. A motion analysis system combined with an upper limb kinematic model was used to estimate the 3D joint kinematics. ii) All 3D angular poses were included into a nonconvex hull representing the RoM space accounting for DOF interactions. The combination of elevation and rotation series is recommended to fully evaluate shoulder RoM. iii) A normalized 3D RoM space was defined by including 3D poses common to 50% of the participants into a hull of average volume. iv) This average hull, defining physiologic mobility, was used in a computer simulation model to optimize the technique of a release move in gymnastics. With commonly used monoplanar constraints of shoulder mobility, only 17% of the simulations led to a physiological shoulder kinematics, while our 3D RoM constraints systematically ensures realistic shoulder kinematics without extra computational cost. v) and vi) The 16 participants performed 3D shoulder range-of-motion and passive rehabilitation exercises. Stress in all rotator cuff tendons was predicted during each movement by means of a musculoskeletal model using simulations with different type and size of tears. Safety stress thresholds were used to discriminate safe from unsafe ranges-of-motion. Increased tear size and multiple tendons tear decreased safe range-of-motion. Mostly, glenohumeral elevations below 38°, above 65°, or performed with the arm held in internal rotation cause excessive stresses in most types and sizes of injury during abduction, scaption or flexion. This thesis established an innovative representation of the shoulder mobility, which accounts for DoF interactions. Clinical evaluation will be more accurate with a large potential to better diagnose shoulder disorders. Computer simulations are now more realistic. Finally, we showed the importance of personalized rehabilitation in terms of 3D RoM, since passive early rehabilitation exercises could contribute to re-tear due to excessive stress

Development of a 3D workspace Shoulder Assessment Tool Incorporating Electromyography and an Inertial Measurement Unit - A preliminary study

Traditional shoulder Range of Movement (ROM) measurement tools suffer from inaccuracy or from long experimental set-up times. Recently, it has been demonstrated that relatively low-cost wearable inertial measurement unit (IMU) sensors can overcome many of the limitations of traditional motion tracking systems. The aim of this study is to develop and evaluate a single IMU combined with an Electromyography (EMG) sensor to monitor the 3D reachable workspace with simultaneous measurement of deltoid muscle activity across the shoulder ROM. Six volunteer subjects with healthy shoulders and one participant with a ‘frozen’ shoulder were recruited to the study. Arm movement in 3D space was plotted in spherical coordinates while the relative EMG intensity of any arm position is presented graphically. The results showed that there was an average ROM surface area of 27291±538 deg2 among all six healthy individuals and a ROM surface area of 13571±308 deg2 for the subject with frozen shoulder. All three sections of the deltoid show greater EMG activity at higher elevation angles. Using such tools enables individuals, surgeons and physiotherapists to measure the maximum envelope of motion in conjunction with muscle activity in order to provide an objective assessment of shoulder performance in the voluntary 3D workspace

Estudio de la cinemática del miembro superior e inferior mediante sensores inerciales.

A través del conjunto de artículos recogidos en la presente Tesis se describe y analiza las variables relacionadas con el movimiento humano en distintas regiones corporales. Para el estudio del complejo articular del hombro, se eligió estudiar la abducción y flexión del hombro a través de los distintos segmentos corporales que lo conforman. Los dispositivos empleados para la medición de las variables cinemáticas fueron los sensores inerciales y el Smartphone. Por un lado, en el artículo I, se pudieron describir valores de referencia de movilidad en segmentos corporales y articulaciones en sujetos jóvenes sanos. En el artículo II, se pudieron observar diferencias entre sujetos sanos de distinto rango etario. Posteriormente el artículo III, con los sensores inerciales se pudo establecer diferencias cinemáticas entre sujetos asintomáticos y aquellos que presentan patología del hombro. En línea con el Smartphone, en el Artículo IV se obtuvieron valores descriptivos de la cinemática del húmero con el sensor embebido en un Smartphone. En el Artículo V, se validó una aplicación basada en imagen para medir el ángulo de abducción del brazo en sujetos sanos y patológicos, mostrando ser válida y fiable. La funcionalidad del complejo lumbo-pélvico-femoral se estudió a través de la prueba o Test “Sit-to-Stand” (STS), que representa el movimiento de levantarse de una silla. En el artículo VI, se profundizó en la actividad muscular y la fatiga durante la prueba STS a través de distintas variantes del test. Los resultados de este estudio permitieron establecer valores de referencia en sujetos sanos y analizar cómo varían las variables electromiográficas cuando se modifican las características de STS. Se demostró que la velocidad modifica la actividad muscular, y que se produce más fatiga a mayor número de repeticiones y velocidad. Por tanto, posteriormente los estudios se centraron en la variante más exigente de este test: 30-STS, levantarse tan rápido como sea posible el mayor número de veces durante 30 segundos. En el artículo VII, se buscó correlacionar la fatiga medida con electromiografía con la fatiga a través de la cinemática medida en el tronco con un Smartphone, no habiendo una correlación evidente. Posteriormente, en el artículo VIII, se decidió analizar la fatiga durante la prueba 30-STS a través de la aceleración como única variable proporcionada por un Smartphone situado en el esternón. Para ello, se analizaron esta vez los datos de aceleración, encontrándose un aumento del porcentaje de energía en el segundo 19 del test. Por tanto, de los resultados obtenidos en los estudios sobre el complejo articular del hombro y el complejo lumbopélvico-femoral en la presente Tesis se puede resumir que la cinemática del movimiento humano a través de variables inerciales ofrece al fisioterapeuta una potente herramienta aplicable al ámbito de evaluativo, diagnóstico y de tratamiento transferibles a la clínica a través de dispositivos de bajo coste como el Smartphone y, que, en conjunto con otras herramientas tales como cuestionarios auto-informados y electromiografía, permite abarcar más dimensiones dentro de la complejidad del movimiento humano

Shoulder Complex Motion and Coordination Impairments, and the Associated Clinical Factors in Women with a History of Breast Cancer Treatment

Common medical management for breast cancer (BC) most often includes lumpectomy and radiation (LR) or mastectomy and reconstruction (MR). Due to these procedures involving the shoulder, it is not surprising that some women experience shoulder complex motion and coordination problems. However, the long-term effect that BC treatments have on shoulder complex motion and coordination during functional tasks is not well understood. The rationale for impaired shoulder complex motion and coordination among women with BC is that these women frequently experience impairments that are believed to contribute to these problems including soft tissue pain, decreased shoulder complex muscle strength, decreased tissue flexibility, altered resting scapular alignment (RSA), and lymphedema. However, limited research exists to support this notion. Therefore, the aims of this dissertation were 1) determine the effect that breast cancer treatments (LR and MR) have on shoulder complex motion and coordination, 2) identify clinical factors associated with impaired shoulder complex coordination in women with a history of breast cancer treatment. Scapular and humeral kinematic data and clinical measures of pain, RSA, tissue flexibility, strength and lymphedema were collected on 30 women with BC (mean age ± SD = 53.8 ± 10.9 yrs.) and 30 women without BC (mean age ± SD = 52.7 ± 10.8 yrs.). Separate one-way multivariate analysis of variance (MANOVA) were conducted to determine whether differences in shoulder complex motion existed between groups (p < .05). Angle-angle and relative motion graphs were created for 3 scapular and 2 clavicular rotations. Mean curves with 95% minimal detectable change bands (MDCB) were calculated using data from women without BC. Each woman with BC’s curve was individually compared to the mean curve and MDCB. Women with BC were classified as having normal (curve fell within MDCB) or impaired shoulder complex coordination (curve fell outside MDCB). Discriminant analyses were used to identify clinical variables that could classify women as having normal or impaired shoulder complex coordination (p < .05). There were no significant differences in shoulder complex motion between women with and without BC or between those with different medical management (LR, MR). Over 93% of women with BC demonstrated impaired shoulder complex coordination for at least 1 scapular or clavicular rotation. Discriminant analysis revealed that clinical measures of pain, RSA, tissue flexibility, strength, and lymphedema were associated with impaired shoulder complex coordination. Cross-validated classification showed that 43.4% to 73.3% of women were grouped correctly. Failure to find group differences in motion may be due to the fact that women in our study were relatively high functioning and recovered from their medical management. Additionally, the majority of women in our study were previously educated on a home exercise program (73.3%) and attended physical therapy (56.7%). A lack of significant differences in shoulder complex motion between women with and without a BC suggests that the women in our study had sufficient range of motion to accomplish the functional tasks. Although we did not find differences in motion between women with and without BC across functional tasks, the majority women with BC demonstrated impaired shoulder complex coordination. Clinical measures of tissue flexibility (ROM and pectoralis minor length) were associated with impaired shoulder complex coordination across multiple scapular and clavicular rotations.Ph.D., Rehabilitation Sciences -- Drexel University, 201

Proceedings SIAMOC 2019

Il congresso annuale della Società Italiana di Analisi del Movimento in Clinica, giunto quest'anno alla sua ventesima edizione, ritorna a Bologna, che già ospitò il terzo congresso nazionale nel 2002. Il legame tra Bologna e l'analisi del movimento è forte e radicato, e trova ampia linfa sia nel contesto accademico che nel ricco panorama di centri clinici d'eccellenza. Il congresso SIAMOC, come ogni anno, è l’occasione per tutti i professionisti dell’ambito clinico, metodologico ed industriale di incontrarsi, presentare le proprie ricerche e rimanere aggiornati sulle più recenti innovazioni nell’ambito dell’applicazione clinica dei metodi di analisi del movimento. Questo ha contribuito, in questi venti anni, a fare avanzare sensibilmente la ricerca italiana nel settore, conferendole un respiro ed un impatto internazionale, e a diffonderne l'applicazione clinica per migliorare la valutazione dei disordini motori, aumentare l'efficacia dei trattamenti attraverso l'analisi quantitativa dei dati e una più focalizzata pianificazione dei trattamenti, ed inoltre per quantificare i risultati delle terapie correnti

Proceedings SIAMOC 2019

Il congresso annuale della Società Italiana di Analisi del Movimento in Clinica, giunto quest'anno alla sua ventesima edizione, ritorna a Bologna, che già ospitò il terzo congresso nazionale nel 2002. Il legame tra Bologna e l'analisi del movimento è forte e radicato, e trova ampia linfa sia nel contesto accademico che nel ricco panorama di centri clinici d'eccellenza. Il congresso SIAMOC, come ogni anno, è l’occasione per tutti i professionisti dell’ambito clinico, metodologico ed industriale di incontrarsi, presentare le proprie ricerche e rimanere aggiornati sulle più recenti innovazioni nell’ambito dell’applicazione clinica dei metodi di analisi del movimento. Questo ha contribuito, in questi venti anni, a fare avanzare sensibilmente la ricerca italiana nel settore, conferendole un respiro ed un impatto internazionale, e a diffonderne l'applicazione clinica per migliorare la valutazione dei disordini motori, aumentare l'efficacia dei trattamenti attraverso l'analisi quantitativa dei dati e una più focalizzata pianificazione dei trattamenti, ed inoltre per quantificare i risultati delle terapie correnti