Upper extremity asymmetry due to nerve injuries or central neurologic conditions: a scoping review.

BACKGROUND: Peripheral nerve injuries and central neurologic conditions can result in extensive disabilities. In cases with unilateral impairment, assessing the asymmetry between the upper extremity has been used to assess outcomes of treatment and severity of injury. A wide variety of validated and novel tests and sensors have been utilized to determine the upper extremity asymmetry. The purpose of this article is to review the literature and define the current state of the art for describing upper extremity asymmetry in patients with peripheral nerve injuries or central neurologic conditions. METHOD: An electronic literature search of PubMed, Scopus, Web of Science, OVID was performed for publications between 2000 to 2022. Eligibility criteria were subjects with neurological conditions/injuries who were analyzed for dissimilarities in use between the upper extremities. Data related to study population, target condition/injury, types of tests performed, sensors used, real-world data collection, outcome measures of interest, and results of the study were extracted. Sackett's Level of Evidence was used to judge the quality of the articles. RESULTS: Of the 7281 unique articles, 112 articles met the inclusion criteria for the review. Eight target conditions/injuries were identified (Brachial Plexus Injury, Cerebral Palsy, Multiple Sclerosis, Parkinson's Disease, Peripheral Nerve Injury, Spinal Cord Injury, Schizophrenia, and stroke). The tests performed were classified into thirteen categories based on the nature of the test and data collected. The general results related to upper extremity asymmetry were listed for all the reviewed articles. Stroke was the most studied condition, followed by cerebral palsy, with kinematics and strength measurement tests being the most frequently used tests. Studies with a level of evidence level II and III increased between 2000 and 2021. The use of real-world evidence-based data, and objective data collection tests also increased in the same period. CONCLUSION: Adequately powered randomized controlled trials should be used to study upper extremity asymmetry. Neurological conditions other than stroke should be studied further. Upper extremity asymmetry should be measured using objective outcome measures like motion tracking and activity monitoring in the patient's daily living environment.

American Society of Biomechanics Journal of Biomechanics Award 2022: Computer models do not accurately predict human muscle passive muscle force and fiber length: Evaluating subject-specific modeling impact on musculoskeletal model predictions.

Musculoskeletal models are valuable for studying and understanding the human body in a variety of clinical applications that include surgical planning, injury prevention, and prosthetic design. Subject-specific models have proven to be more accurate and useful compared to generic models. Nevertheless, it is important to validate all models when possible. To this end, gracilis muscle-tendon parameters were directly measured intraoperatively and used to test model predictions. The aim of this study was to evaluate the benefits and limitations of systematically incorporating subject-specific variables into muscle models used to predict passive force and fiber length. The results showed that incorporating subject-specific values generally reduced errors, although significant errors still existed. Optimization of the modeling parameter "tendon slack length" was explored in two cases: minimizing fiber length error and minimizing passive force error. The results showed that using all subject-specific values yielded the most favorable outcome in both models and optimization cases. However, the trade-off between fiber length error and passive force error will depend on the specific circumstances and research objectives due to significant individual errors. Notably, individual fiber length and passive force errors were as high as 20% and 37% respectively. Finally, the modeling parameter "tendon slack length" did not correlate with any real-world anatomical length.

Optimal Distal Tendon Insertion Point for Elbow Flexion in Free-Functioning Gracilis Muscle Transfer for Panbrachial Plexus Injuries: A Cadaveric Study.

PURPOSE: Following pan-brachial plexus injuries, restoration of elbow flexion is widely accepted as the reconstructive priority. A gracilis free functioning muscle transfer (FFMT) can be used to restore elbow flexion alone with insertion into the biceps brachii (BIC) or brachioradialis (BRD) tendons or restore combined elbow and finger flexion with a more distal insertion into the flexor digitorum profundus (FDP) tendons. Using cadaveric experiments, we determined the peak instantaneous moment arm for each insertion option. METHODS: Six simulated gracilis transfer surgeries were performed using both arms of three fresh-frozen full body cadaveric specimens (age: 79 + 10 years. 2 female). The gracilis muscles from both legs were harvested and transferred to the contralateral upper extremity. The elbow was manually moved through three flexion-extension cycles while the instantaneous moment arm was calculated from measurements of gracilis excursion and elbow joint angle for the three distal insertion sites. RESULTS: Peak instantaneous moment arm for all three insertions occurred at an elbow angle between 83° to 92° with a magnitude ranging from 33 mm to 54 mm. The more distal (FDP/BRD) insertions produced a significantly greater (∼1.5 times) peak elbow flexion instantaneous moment arm compared to the BIC insertion. CONCLUSIONS: Based on the instantaneous moment arm, the gracilis FFMT distal insertion locations could result in greater reconstructed elbow flexion strength. In addition, direct measurement of the shape and magnitude of the moment arm curve for differing insertion sites allows high resolution surgical planning and model testing. CLINICAL RELEVANCE: This study presents the first direct experimental quantification of the gracilis FFMT instantaneous moment arm. The experimental evidence supports the use of FDP/BRD insertion locations by providing a quantitative explanation for the increased elbow flexion torque observed clinically in patients with a gracilis FFMT and distal FDP insertion.

Are 4D Motion Sensors Valid and Reliable for Studying Baseball Pitching?

BACKGROUND: Baseball pitching injuries are on the rise. Inertial measurement units (IMUs) provide immediate feedback to players and coaches, allowing for collection outside of the traditional laboratory setting with real-world application. The 4D Motion system provides kinematics throughout the pitching motion and may be beneficial for individualized programs in the throwing athlete. A systematic analysis of these sensors has not been completed. PURPOSE: To evaluate the validity of the 4D Motion IMU system for analyzing the baseball pitching motion compared with marker-based motion capture, and evaluate the internal reliability and consistency of the device. STUDY DESIGN: Controlled laboratory study. METHODS: Ten high school pitchers participated in this study (10 male; 9 right-hand dominant; mean age, 16.6 ± 1.3 years; mean body mass index, 24.1 ± 3.9). Participants were simultaneously outfitted with six 4D Motion IMU sensors and retroreflective markers. The pitchers threw fastballs at maximum effort off a mound at the standard height and distance. A comparison was made between the IMUs and corresponding motion capture values for shoulder external rotation, elbow flexion, chest extension, pelvis and chest rotation velocity, and rotation acceleration. RESULTS: Significant differences were found for 5 of 7 metrics analyzed. The IMU overreported most metrics, except for elbow flexion and pelvis rotation angular acceleration, where both positive and negative errors were observed. The root mean square error and percentage errors indicated smaller discrepancies for chest extension (4°± 5°) and pelvis (38 ± 19 deg/s) and chest (96 ± 42 deg/s) rotation velocity, with elbow flexion having the largest variance (21°± 9°). CONCLUSION: The values of the 4D Motion IMU system should not be considered equivalent when compared with marker-based motion capture studies. The system lacked internal consistency and reliability, with angular velocities being the most consistent. Caution should be used when using the metrics provided by an IMU-based system for individualized monitoring. CLINICAL RELEVANCE: If found valid and reliable, IMUs could be used for longitudinal workload monitoring, individualized throwing and rehabilitation programs, and ultimately injury prevention. This study demonstrates that the data obtained from a 4D Motion system using Gen 3 sensors are not equivalent to the data obtained from a marker-based motion capture system.

Characterization of elbow flexion torque after nerve reconstruction of patients with traumatic brachial plexus injury.

BACKGROUND: The modified British Medical Research Council muscle grading system remains the primary method for assessing outcomes following surgical intervention despite its subjectivity and numerous inherent flaws. A new objective outcome measure of elbow function in patients with a brachial plexus injury is proposed. METHODS: 11 patients with a reconstructed brachial plexus (nerve reconstruction) and 10 unimpaired control subjects were evaluated. A custom apparatus measuring elbow flexion torque was developed. The subjects were asked to match their elbow flexion torque to a predefined torque. Time taken to achieve this predefined elbow flexion torque (latency) and duration of steady torque output were used as outcome measures. RESULTS: Healthy individuals were better at maintaining and regulating elbow torque. The patients with a brachial plexus injury showed similar latency while increasing their elbow torque (normalized to maximum elbow torque) but lacked the ability to modulate the latency with demand as the healthy subjects. INTERPRETATION: This novel measure provides objective information regarding the patient's ability to control elbow torque after nerve reconstruction.

Objective assessment of patients with idiopathic normal pressure hydrocephalus following ventriculoperitoneal shunt placement using activity-monitoring data: pilot study.

OBJECTIVE: Idiopathic normal pressure hydrocephalus (iNPH) results in significant morbidity in the elderly with symptoms of dementia, gait instability, and urinary incontinence. In well-selected patients, ventriculoperitoneal shunt (VPS) placement often results in clinical improvement. Most postshunt assessments of patients rely on subjective scales. The goal of this study was to assess the utility of remote activity monitoring to provide objective evidence of gait improvement following VPS placement for iNPH. METHODS: Patients with iNPH were prospectively enrolled and fitted with 5 activity monitors (on the hip and bilateral thighs and ankles) that they wore for 4 days preoperatively within 30 days of surgery and for 4 days within 30 days postoperatively. Monitors collected continuous data for number of steps, cadence, body position (upright, prone, supine, and lateral decubitus), gait entropy, and the proportion of each day spent active or static. Data were retrieved from the devices and a comparison of pre- and postoperative movement assessment was performed. The gait data were also correlated with formal clinical gait assessments before and after lumbar puncture and with motion analysis laboratory testing at baseline and 1 month and 1 year after VPS placement. RESULTS: Twenty patients fulfilled the inclusion and exclusion criteria (median age 76 years). The baseline median number of daily steps was 1929, the median percentage of the day spent inactive was 70%, the median percentage of the day with a static posture was 95%, the median gait velocity was 0.49 m/sec, and the median number of steps required to turn was 8. There was objective improvement in median entropy from pre- to postoperatively, increasing from 0.6 to 0.8 (p = 0.002). There were no statistically significant differences for any of the remaining variables measured by the activity monitors when comparing the preoperative to the 1-month postoperative time point. All variables from motion analysis testing showed statistically significant differences or a trend toward significance at 1 year after VPS placement. Among the significantly correlated variables at baseline, cadence was inversely correlated with percentage of gait cycle spent in the support phase (contact with ground vs swing phase). CONCLUSIONS: This pilot study suggests that activity monitoring provides an early objective measure of improvement in gait entropy after VPS placement among patients with iNPH, although a more significant improvement was noted on the detailed clinical gait assessments. Further long-term studies are needed to determine the utility of remote monitoring for assessing gait improvement following VPS placement.

Direct intraoperative measurement of isometric contractile properties in living human muscle.

Skeletal muscle's isometric contractile properties are one of the classic structure-function relationships in all of biology allowing for extrapolation of single fibre mechanical properties to whole muscle properties based on the muscle's optimal fibre length and physiological cross-sectional area (PCSA). However, this relationship has only been validated in small animals and then extrapolated to human muscles, which are much larger in terms of length and PCSA. The present study aimed to measure directly the in situ properties and function of the human gracilis muscle to validate this relationship. We leveraged a unique surgical technique in which a human gracilis muscle is transferred from the thigh to the arm, restoring elbow flexion after brachial plexus injury. During this surgery, we directly measured subject specific gracilis muscle force-length relationship in situ and properties ex vivo. Each subject's optimal fibre length was calculated from their muscle's length-tension properties. Each subject's PCSA was calculated from their muscle volume and optimal fibre length. From these experimental data, we established a human muscle fibre-specific tension of 171 kPa. We also determined that average gracilis optimal fibre length is 12.9 cm. Using this subject-specific fibre length, we observed an excellent fit between experimental and theorical active length-tension curves. However, these fibre lengths were about half of the previously reported optimal fascicle lengths of 23 cm. Thus, the long gracilis muscle appears to be composed of relatively short fibres acting in parallel that may not have been appreciated based on traditional anatomical methods. KEY POINTS: Skeletal muscle's isometric contractile properties represent one of the classic structure-function relationships in all of biology and allow scaling single fibre mechanical properties to whole muscle properties based on the muscle's architecture. This physiological relationship has only been validated in small animals but is often extrapolated to human muscles, which are orders of magnitude larger. We leverage a unique surgical technique in which a human gracilis muscle is transplanted from the thigh to the arm to restore elbow flexion after brachial plexus injury, aiming to directly measure muscles properties in situ and test directly the architectural scaling predictions. Using these direct measurements, we establish human muscle fibre-specific tension of ∼170 kPa. Furthermore, we show that the gracilis muscle actually functions as a muscle with relatively short fibres acting in parallel vs. long fibres as previously assumed based on traditional anatomical models.

Fall Prevention Training for Service Members With an Amputation or Limb Salvage Following Lower Extremity Trauma.

INTRODUCTION: Recent military conflicts have resulted in a significant number of lower extremity injuries to U.S. service members that result in amputation or limb preservation (LP) procedures. Service members receiving these procedures report a high prevalence and deleterious consequences of falls. Very little research exists to improve balance and reduce falls, especially among young active populations such as service members with LP or limb loss. To address this research gap, we evaluated the success of a fall prevention training program for service members with lower extremity trauma by (1) measuring fall rates, (2) quantifying improvements in trunk control, and (3) determining skill retention at 3 and 6 months after training. MATERIALS AND METHODS: Forty-five participants (40 males, mean [±SD] age, 34 ± 8 years) with lower extremity trauma (20 with unilateral transtibial amputation, 6 with unilateral transfemoral amputation, 5 with bilateral transtibial amputation, and 14 with unilateral LP procedures) were enrolled. A microprocessor-controlled treadmill was used to produce task-specific postural perturbations which simulated a trip. The training was conducted over a 2-week period and consisted of six 30-minute sessions. The task difficulty was increased as the participant's ability progressed. The effectiveness of the training program was assessed by collecting data before training (baseline; repeated twice), immediately after training (0 month), and at 3 and 6 months post-training. Training effectiveness was quantified by participant-reported falls in the free-living environment before and after training. Perturbation-induced recovery step trunk flexion angle and velocity was also collected. RESULTS: Participants reported reduced falls and improved balance confidence in the free-living environment following the training. Repeated testing before training revealed that there were no pre-training differences in trunk control. The training program improved trunk control following training, and these skills were retained at 3 and 6 months after training. CONCLUSION: This study showed that task-specific fall prevention training reduced falls across a cohort of service members with diverse types of amputations and LP procedures following lower extremity trauma. Importantly, the clinical outcome of this effort (i.e., reduced falls and improved balance confidence) can lead to increased participation in occupational, recreational, and social activities and thus improved quality of life.

Muscle activation for targeted elbow force production following surgical reconstruction in adults with brachial plexus injury.

Nerve transfer or grafting surgery to restore elbow flexion in peripheral nerve injuries has been an effective technique, but alters neuromuscular control compared with healthy individuals. This study compared neuromuscular control in the elbow flexors of 11 unimpaired control subjects and 11 adult patients with traumatic brachial plexus injury who underwent a nerve transfer or grafting procedure to the biceps motor branch to restore elbow flexion. The subjects performed a series of trials to generate a specific percentage of their maximum elbow torque. Each trial had an increasing and decreasing stairstep torque pattern that the subjects were asked to match. The amount of time that the subject's elbow torque was maintained within 5% of the target torque was calculated. The hypothesis was that there was a significant difference in the neuromuscular control between the two groups during elbow isometric torque generation. A secondary hypothesis was that a relationship existed between the neuromuscular control and the torque level for each group. The results demonstrated that neuromuscular control was different between the groups and there were significant differences in how torque levels are generated. The control group more easily modulated their myoelectric activation and achieved greater neuromuscular control variability with varying torque demand. The nerve transfer or grafting group could not modulate their myoelectric activation with changing torque demands. Further studies focusing on the improvement of neuromuscular control are needed to optimize functional outcomes in nerve injury patients.

Changes in Elbow Stress and Ball Velocity During Reduced Effort Pitching: A Marker-Based Motion Capture Analysis.

BACKGROUND: Baseball pitchers often participate in throwing programs that involve throwing at reduced effort levels to gradually increase the amount of stress experienced across the elbow. It is currently unknown how reduced effort pitching compares with maximum effort with respect to elbow stress and ball velocity. PURPOSE/HYPOTHESIS: The purpose was to determine the correlation between elbow stress and ball velocity with reduced effort pitching. We hypothesized that decreased perceived effort would disproportionately correlate with elbow stress and ball velocity. STUDY DESIGN: Descriptive laboratory study. METHODS: Ten healthy male high school baseball pitchers threw 5 pitches from a regulation pitching mound at 3 effort levels: maximum effort, 75% effort, and 50% effort. Elbow stress, specifically elbow varus torque, was calculated for all pitches using a validated marker-based 3-dimensional motion capture system. Ball velocity was measured using a Doppler radar gun. Intrathrower variability was calculated for each effort level. RESULTS: Elbow stress and ball velocity decreased with reduced effort throws (P < .001 and P = .003, respectively). However, the reductions in elbow stress and ball velocity were not proportional. At 75% effort throws, elbow stress measured 81% (intraclass correlation coefficient [ICC], 0.95), and ball velocity measured 90% (ICC, 0.80) of maximum, respectively. At 50% effort throws, elbow stress measured 75% (ICC, 0.93), and ball velocity measured 85% (ICC, 0.87) of maximum. Intrathrower reliability was excellent for elbow stress and ball velocity, with all ICCs ≥0.80. CONCLUSION: Pitching at a reduced effort level resulted in decreased elbow stress and ball velocity. However, for every 25% reduction in perceived effort, elbow stress decreased by a mean 13%, and ball velocity decreased 7.5%. When baseball pitchers attempt to throw at a reduced effort of maximum, throwing metrics do not decrease proportionately. CLINICAL RELEVANCE: While pitching at a reduced effort of maximum decreases elbow stress and ball velocity, the decrease is not proportional, subjecting the elbow to more stress than intended. This has significant clinical importance to pitchers, coaches, and medical professionals in the setting of injury prevention and return to sports.

Outcome of bracing vs. surgical treatment in adolescents with idiopathic scoliosis based on device measured daily physical activity: a prospective pilot study.

Adolescent idiopathic scoliosis (AIS) can be treated with bracing or surgery, which may affect patient's physical activity (PA). However, there are limited objective assessments of PA in patients with AIS. This study aims to compare the outcome of spinal bracing vs. surgery in patients with AIS based on a device that measured daily PA. In total 24 patients with AIS participated, including 12 patients treated with bracing and 12 with spinal surgery. Daily PA was measured throughout 4 consecutive days using four tri-axial accelerometers and patient-reported functional status was reported using the SRS-22 questionnaire. The participants were assessed both before the treatment and after treatment at a 12-month follow-up. Patients with AIS had no significant change in their PA levels at the 12-month follow-up after surgical correction. On the contrary, patients with AIS following a year-long bracing treatment had significantly reduced time spent active ( P = 0.04) with an average reduction in walking steps by 2137 steps/day ( P = 0.005). There was no significant difference in function, pain, self-image and mental health domains following both treatments, as reported by the SRS-22. There was a significant improvement in satisfaction for both treatment groups ( P ≤ 0.02). Significantly reduced PA and increased sedentary time are reported in patients with AIS following bracing treatment. An objective PA assessment is recommended to track the effect of scoliosis treatment on PA. Patients with AIS should be actively encouraged to achieve and maintain their recommended daily PA levels irrespective of the type of treatment. Level of evidence: Level II.

Factors that Increase Elbow Stress in the Throwing Athlete: a Systematic Review of Biomechanical and Motion Analysis Studies of Baseball Pitching and Throwing.

PURPOSE OF REVIEW: Elbow pain poses a unique challenge in the throwing athlete. Due to the high levels of elbow stress during the throwing motion, elbow injuries are common in throwers of all ages. There are several postulated factors believed to contribute increased stress to the throwing elbow. A detailed review of the published biomechanical studies evaluating the stresses experienced by the throwing elbow is needed. Here, we review these biomechanical studies to extrapolate the contributing factors that increase stress, the modifications that may reduce such stress, and the post-injury rehabilitation that optimizes outcomes and reduces recurrence. RECENT FINDINGS: The biomechanical forces on the elbow have been further investigated delineated in recent work. Rotational malalignment of the shoulder, including both GIRD and decreased adduction, increases torque experienced by the elbow during pitching motions. Exact interactions between lower extremity, lumbopelvic or trunk rotation, and elbow forces during throwing remain uncertain with mixed results in recent literature. Pitch types may influence elbow stresses although delivery mechanism and distance thrown do not. Several biomechanical factors influence the stresses imparted on the throwing elbow. Throwing volume, proper throwing mechanics, and appropriate rehabilitation are likely to be to be the most influential on mitigating unnecessary stresses imparted to the elbow in the throwing athlete. A proper understanding of these factors may reduce the occurrence of these injuries in this population. Moreover, an understanding of proper rehabilitation following injury may ensure optimized results and reduce recurrence.

A single-subject comparison of functional outcomes between lower limb salvage vs. transtibial amputation through sequential participation in a fall-prevention program.

PURPOSE: Prior research has noted similar functional and subjective outcomes between individuals with delayed amputation vs. limb salvage; however, these reports are generally retrospective in nature. Here, we prospectively compare functional and subjective outcomes from an individual with limb salvage to a delayed transtibial amputation using a single-subject design with sequential participation in a fall-prevention program. MATERIALS AND METHODS: The subject participated in a fall-prevention rehabilitation training program, once before undergoing a delayed transtibial amputation and again after. As part of the fall-prevention program, the participant completed pretraining and post-training assessments which quantified trunk control by 1) trunk flexion and flexion velocity after trip-inducing perturbations on a treadmill and 2) trunk sway parameters during unstable sitting. In addition, the four square step test was administered, and patient-reported outcomes, including pain, prosthetic/orthotic comfort, and walking/running endurance, were collected. RESULTS: In general, the participant demonstrated improved trunk control after amputation, as evidenced by decreases in trunk flexion and flexion velocity after perturbation and sway parameters during unstable sitting. In addition, four square step test times were shorter with amputation vs. limb salvage; the participant also reported reduced pain and greater comfort with amputation (vs. limb salvage). CONCLUSIONS: Although just a single participant, within-subject comparisons provide quantitative evidence that, for some individuals, delayed/late (transtibial) amputation after prolonged limb salvage may be beneficial in reducing pain and restoring function.

Military training alters the fractal behavior of step width.

Non-linear analyses have been successfully applied to gait with evidence that fractal behavior of gait-related variables provide insights into function. Specifically, shifts in the fractal behavior of step width from pink toward white noise reflects a loss of complexity and diminished adaptive capacity and functionality. We previously reported an apparent difference in the fractal behavior of step width during treadmill walking between Service members with transtibial amputations and able-bodied civilian. We now combine recently collected data and data from two previous studies to further explore the relationship between lower limb injury, military service, and step width fractal behavior. Service member, regardless of the presence or type of injury, demonstrate step width fractal behavior walked in a way that the fractal behavior of their gait was significantly closer to white noise (-0.5 dB/Hz2) than uninjured civilians (-0.82 dB/Hz2). This data suggests that military training/service leads to a change in step width fractal behavior. Further studies are needed to explore what may cause this difference and any implications this may have on stability or performance.

Common fall-risk indicators are not associated with fall prevalence in a high-functioning military population with lower limb trauma.

BACKGROUND: Persons with lower limb trauma are at high risk for falls. Although there is a wide range of measures used to assess stability and fall-risk that include performance measures, temporal-spatial gait parameters, and nonlinear dynamic stability calculations, these measures are typically derived from fall-prone populations, such as older adults. Thus, it is unclear if these commonly used fall-risk indicators are effective at evaluating fall-risk in a younger, higher-functioning population of Service members with lower limb trauma. METHODS: Twenty-one Service members with lower limb trauma completed a battery of fall-risk assessments that included performance measures (e.g., four-square-step-test), and gait parameters (e.g., step width, step length, step time) and dynamic stability measures (e.g., local divergence exponents) during 10 min of treadmill walking. Participants also reported the number of stumbles and falls over the previous 4 weeks. Negative Binomial and Quasibinomial Regressions were used to evaluate the strength of associations between fall-risk indicators and self-reported falls. FINDING: Participants reported on average stumbling 6(4) times and falling 2(3) times in the previous 4 weeks. At least one fall was reported by 62% of the participants. None of the fall-risk indicators were significantly associated with fall prevalence in this population of Service members with lower limb trauma (p > 0.1). INTERPRETATION: Despite the high number of reported falls in this young active population, none of the fall-risk indicators investigated effectively captured and quantified the fall-risk. Further research is needed to identify appropriate fall-risk assessments for young, high-functioning individuals with lower limb trauma.

Human Exposure to Hand-Arm Vibration from a Surgical Drill During Simulated Spine Surgery.

OBJECTIVE: During spine surgery, surgeons are exposed to vibrations from surgical drills. Increased exposure to vibration can result in neurologic, vascular, and musculoskeletal impairments. To reduce these risks, occupational health standards have been implemented to limit exposure levels. The purpose of this study was to quantify human exposure to hand-arm vibration from a surgical drill during a simulation of a common spine procedure. METHODS: Vibration measurements were collected during three 30-second surgical trials on a fresh frozen cadaver torso specimen using a standard surgical drill. The daily vibration exposure A(8) was evaluated on the basis of International Organization for Standardization 5349-1, and the occupational health standards, exposure action value, and exposure limit value were calculated. RESULTS: On the basis of vibration exposure, surgeons in this study reached their exposure limits in 8 minutes to monitor tool usage and 32 minutes to terminate equipment usage. CONCLUSIONS: The results demonstrate that a common surgical drill transmits hand-arm vibration levels approaching the exposure action value and exposure limit value over short periods of use. Further investigation is needed to determine the total vibration exposure over an entire workday, specifically in surgeons who perform multiple surgeries within a single day.

Ulnar Wrist Pain in a Tennis Player: Case Review and Discussion: A Team-Based Approach.

¼: Ulnar-sided wrist pain is a common cause of debilitating wrist pain in stick-handling athletes. Due to the complexity of surrounding anatomy, the evaluation and diagnosis can be challenging. ¼: Injury of the triangular fibrocartilage complex (TFCC) is the most common cause of ulnar-sided wrist pain. Repetitive, unrestricted pronosupination, wrist deviation, and axial-loading activity, such as in tennis, place substantial stress on the TFCC. ¼: The ulnotriquetral (UT) ligament is a palmar thickening of the ulnar capsule arising from the palmar radioulnar (PRU) ligament of the TFCC. When injured, the UT ligament can be a source of acute or chronic ulnar-sided wrist pain. The ligament can avulse off bone, can rupture completely, or can split longitudinally. ¼: Arthroscopic-assisted repair is a safe, reliable, and effective treatment for UT ligament split tears and peripheral TFCC tears. ¼: Although the benefit of a team-based approach may be realized by most patients, high-performing, stick-handling athletes are part of a unique population who execute repetitive, extraordinary wrist movements. The high demand and functional requirement expected of the wrists require a uniquely tailored approach to return them to the same level of competitive play.

Procedures for obtaining muscle physiology parameters during a gracilis free-functioning muscle transfer in adult patients with brachial plexus injury.

A complete understanding of muscle mechanics allows for the creation of models that closely mimic human muscle function so they can be used to study human locomotion and evaluate surgical intervention. This includes knowledge of muscle-tendon parameters required for accurate prediction of muscle forces. However, few studies report experimental data obtained directly from whole human muscle due to the invasive nature of these experiments. This article presents an intraoperative, in vivo measurement protocol for whole muscle-tendon parameters that include muscle-tendon unit length, sarcomere length, passive tension, and active tension in response to external stimulation. The advantage of this protocol is the ability to obtain these rare experimental data in situ in addition to muscle volume and weight since the gracilis is also completely removed from the leg. The entire protocol including the surgical steps for gracilis harvest takes ~ 3 h. Actual testing of the gracilis where experimental data is measured takes place within a 30-min window during surgery.

Scoping review to evaluate existing measurement parameters and clinical outcomes of transtibial prosthetic alignment and socket fit.

INTRODUCTION: Fit and alignment are observable objectives of the prosthesis rendering process for individuals with lower limb amputation. Nevertheless, there is a dearth of validated measures to directly assess the quality of this clinical procedure. OBJECTIVES: The objectives of this scoping review are to evaluate existing measurement parameters and clinical outcomes used in investigations of transtibial socket fit or prosthetic alignment and to identify gaps in the literature regarding tools for evaluation of prosthetic fitting. STUDY DESIGN: Scoping literature review. METHODS: A comprehensive search was conducted in the following databases: MEDLINE (through PubMed), Embase (through Elsevier), Scopus (through Elsevier), and Engineering Village (through Elsevier), resulting in 6107 studies to be screened. RESULTS: Sixty-three studies were included in the review. When measuring fit, studies most frequently reported on patient-reported comfort (n = 22) and socket size compared with the residual limb volume (n = 9). Alignment was most frequently measured by the prosthetists' judgment and/or use of an alignment jig (n = 34). The measurement parameters used to determine alignment or fit varied greatly among the included studies. CONCLUSION: This review demonstrated that most measures of socket fit rely on a patient's self-report and may vary with biopsychosocial factors unrelated to the socket fitting process. Meanwhile, alignment is determined mostly by the prosthetist's judgment, paired with objective measurements, such as alignment jigs and gait analysis. Efforts to standardize and validate measures of these parameters of prosthetic fitting are vital to improving clinical practice and reporting outcomes.

Upper extremity function in the free living environment of adults with traumatic brachial plexus injuries.

Transition of data acquisition out of the laboratory, into the real world offers a previously inaccessible perspective of physical function. This proves to be beneficial when assessing surgical intervention, especially after a traumatic brachial plexus injury (BPI) causing loss of motor function in an upper extremity (UE). Moving towards the use of real world data in clinical practice as an outcome measure, this study developed a method to report bilateral UE activity in patients with BPI. Three groups of ten subjects each participated in this study-healthy controls, subjects with traumatic BPI prior to surgical treatment (pre-), and subjects who had surgical reconstruction to treat BPI (post-). Subjects wore four activity monitors on bilateral forearms and upper arms for four days. Tri-axial acceleration data were used to calculate asymmetry indices for forearm and upper arm usage. Analysis revealed a bimodal distribution in the post- group, prompting division of this group into two subgroups based on injury type: pan-plexus and upper trunk. While median asymmetry indices at the forearm and upper arm were decreased in the post- group when compared to the pre- group, these differences were not significant. Compared to controls, the pre-surgery group (p < 0.0001, p < 0.0001) and post-surgery group with pan-plexus injuries (p = 0.0074, p = 0.0242) both exhibited statistically significant differences in forearm and upper arm asymmetry, respectively. Further investigation to establish clinically significant differences in asymmetry index is warranted. Importantly, analyzing the activity of UEs following treatment of a BPI provides objective real world evidence of function.