Design requirements of upper extremity supports for daily use in Duchenne muscular dystrophy with severe muscle weakness.

Background: People with Duchenne muscular dystrophy (DMD) cope with progressive muscular weakness and consequential upper extremity function loss. They benefit from arm supports, or arm exoskeletons, to assist arm function. Especially for severe muscle weakness (DMD ≥ Brooke Scale 4), the design of such arm support is challenging. This study aims to structurally develop functional and technical design requirements of arm supports for people with DMD Brooke Scale 4. Methods: An overview of clinical characteristics and a classification of clinically meaningful activities were derived from data from the Dutch Dystrophinopathy Database and available literature. Based on these, functional and technical design requirements of arm supports were developed and matched to the achievable needs of the user. Results: First, the clinical characteristics of the target population, such as strength, range of motion, and functional ability, are given. Next, clinically relevant activities of daily living are translated to functional requirements categorised in a 'must,' 'should,' and 'could' category. Last, the technical requirements to realise these functional goals are presented. Conclusions: The recommendations following from the functional user needs, technical requirements, and safety considerations can be used to make the development of assistive arm supports for people with DMD Brooke Scale 4 more user-centred.

Comparison of Lower Arm Weight and Passive Elbow Joint Impedance Compensation Strategies in Non-Disabled Participants.

People with severe muscle weakness in the upper extremity are in need of an arm support to enhance arm function and improve their quality of life. In addition to weight support, compensation of passive joint impedance (pJimp) seems necessary. Existing devices do not compensate for pJimp yet, and the best way to compensate for it is still unknown. The aim of this study is to 1) identify pJimp of the elbow, and 2) compare four different compensation strategies of weight and combined weight and pJimp in an active elbow support system. The passive elbow joint moments, including gravitational and pJimp contributions, were measured in 12 non-disabled participants. The four compensation strategies (scaled-model, measured, hybrid, and fitted-model) were compared using a position-tracking task in the near vertical plane. All four strategies showed a significant reduction (20-47%) in the anti-gravity elbow flexor activity measured by surface electromyography. The pJimp turned out to contribute to a large extent to the passive elbow joint moments (range took up 60%) in non-disabled participants. This underlines the relevance of compensating for pJimp in arm support systems. The parameters of the scaled-model and hybrid strategy seem to overestimate the gravitational component. Therefore, the measured and fitted-model strategies are expected to be most promising to test in people with severe muscle weakness combined with elevated pJimp.

Development of Tests for Arm Coordination Impairment in Paralympic Classification.

Background: In Paralympic sport, classification of impairment with the ability to detect misrepresentation of abilities is mandatory. In wheelchair rugby, there is currently no objective method to classify arm coordination impairment. In previous research, sufficient correlation between the spiral test (ST) and activity in wheelchair rugby was found in athletes with coordination impairment. However, the ST depends on maximum voluntary effort. Purpose: To assess if the ST is an objective test for arm coordination impairment, in which maximum voluntary effort can be distinguished from intentional misrepresentation. The aims of this study were to (1) assess the test-retest reliability of the ST and (2) assess if Fitts's law is applicable to the ST. Methods: Nineteen volunteers without impairments performed two sessions with three STs per arm. The STs were projected and measured on a tablet and had three different indices of difficulty based on differences in spiral width. The time to complete the spiral was measured and a penalty time was added for each time the borderline of the spiral was touched (3 s) or crossed (5 s). Results: Test-retest reliability was assessed using a Bland-Altman analysis and showed limits of agreement that were wider than the margins of 2SD from the group mean. Repeated measurement correlation coefficients between the index of difficulty according to Fitts's law and the movement time were > 0.95 (p-value < 0.001) for both test and retest. A post-hoc optimisation of penalty times revealed an optimum penalty time of 2.0 s for the dominant arm and 2.5 for the non-dominant arm for any contact with the margins of the spiral. Conclusions: The ST has sufficient test-retest reliability and Fitts's law is applicable. Therefore, it is a promising option for classification of arm coordination impairment with the option to distinguish intentional misrepresentation from maximum voluntary effort.

The Black Box of Technological Outcome Measures: An Example in Duchenne Muscular Dystrophy.

BACKGROUND: Outcome measures for non-ambulant Duchenne muscular dystrophy (DMD) patients are limited, with only the Performance of the Upper Limb (PUL) approved as endpoint for clinical trials. OBJECTIVE: We assessed four outcome measures based on devices developed for the gaming industry, aiming to overcome disadvantages of observer-dependency and motivation. METHODS: Twenty-two non-ambulant DMD patients (range 8.6-24.1 years) and 14 healthy controls (HC; range 9.5-25.4 years) were studied at baseline and 16 patients at 12 months using Leap Motion to quantify wrist/hand active range of motion (aROM) and a Kinect sensor for reached volume with Ability Captured Through Interactive Video Evaluation (ACTIVE), Functional Workspace (FWS) summed distance to seven upper extremity body points, and trunk compensation (KinectTC). PUL 2.0 was performed in patients only. A stepwise approach assessed quality control, construct validity, reliability, concurrent validity, longitudinal change and patient perception. RESULTS: Leap Motion aROM distinguished patients and HCs for supination, radial deviation and wrist flexion (range p = 0.006 to <0.001). Reliability was low and the manufacturer's hand model did not match the sensor's depth images. ACTIVE differed between patients and HCs (p < 0.001), correlated with PUL (rho = 0.76), and decreased over time (p = 0.030) with a standardized response mean (SRM) of -0.61. It was appraised as fun on a 10-point numeric rating scale (median 9/10). PUL decreased over time (p < 0.001) with an SRM of -1.28, and was appraised as fun (median 7/10). FWS summed distance distinguished patients and HCs (p < 0.001), but reliability in patients was insufficient. KinectTC differed between patients and HCs (p < 0.01), but correlated insufficiently with PUL (rho = -0.69). CONCLUSIONS: Only ACTIVE qualified as potential outcome measure in non-ambulant DMD patients, although the SRM was below the commonly used threshold of 0.8. Lack of insight in technological constraints due to intellectual property and software updates made the technology behind these outcome measures a kind of black box that could jeopardize long-term use in clinical development.

Surface Electromyography Thresholds as a Measure for Performance Fatigability During Incremental Cycling in Patients With Neuromuscular Disorders.

In healthy persons, there is an excellent relation between the timing of the (two) surface electromyography (sEMG) thresholds and the (two) ventilatory thresholds during exercise. The primary aim of this study was to determine the relative timing of both sEMG and ventilatory thresholds in patients with neuromuscular disorders compared with healthy subjects during a maximal ergospirometry cycling test. We hypothesized that in patients with neuromuscular disorders, the sEMG thresholds would occur relatively earlier in time than the ventilatory thresholds, compared to healthy subjects, because performance fatigability occurs more rapidly. In total, 24 healthy controls and 32 patients with a neuromuscular disorder performed a cardiopulmonary exercise test on a bicycle using a 10-min ramp protocol, during which we collected ergospirometry data: power at both ventilatory and sEMG thresholds, and sEMG data of lower leg muscles. In line with our hypothesis, normalized values for all thresholds were lower for patients than healthy subjects. These differences were significant for the first ventilatory (p = 0.008) and sEMG threshold (p < 0.001) but not for the second sEMG (p = 0.053) and ventilatory threshold (p = 0.238). Most parameters for test-retest reliability of all thresholds did not show any fixed bias, except for the second ventilatory threshold. The feasibility of the sEMG thresholds was lower than the ventilatory thresholds, particularly of the first sEMG threshold. As expected, the sEMG thresholds, particularly the first threshold, occurred relatively earlier in time than the ventilatory thresholds in patients compared with healthy subjects. A possible explanation could be (a combination of) a difference in fiber type composition, disuse, and limited muscle-specific force in patients with neuromuscular disorders. sEMG measurements during submaximal dynamic exercises are needed to generalize the measurements to daily life activities for future use in prescribing and evaluating rehabilitation interventions.

Martial Arts Training for Boys With Duchenne Muscular Dystrophy.

PURPOSE: The primary aim of this pilot study was to investigate the safety and feasibility of a 3-month martial arts-based training (MAT) program for patients with Duchenne muscular dystrophy (DMD). The secondary aim was to examine changes in physical and psychosocial abilities after participating in the MAT program. METHODS: Twelve patients with DMD (10 ambulant and 2 nonambulant) were included. The MAT program was evaluated on feasibility and safety. Changes in physical abilities were measured using the Motor Function Measure, Performance of Upper Limb scale, and the North Star Ambulatory Assessment. Changes in psychosocial abilities were measured using the Strength and Difficulties Questionnaire, Personal Adjustment and Role Skills for DMD, and the Self-Perception Profile for Children/Adolescents. RESULTS: Two participants did not complete the MAT program. Attendance rate for the 10 remaining participants was 91%. Eleven falls were reported during the training, but these falls did not result in injuries. Therefore, the MAT program was found feasible and safe. After completing the MAT program, most participants showed an improvement of their psychosocial abilities, and their physical abilities did not show deterioration. CONCLUSION: The MAT program is feasible and safe for boys with DMD.

Feasibility and effectiveness of a novel dynamic arm support in persons with spinal muscular atrophy and duchenne muscular dystrophy.

BACKGROUND: Neuromuscular disorders (NMD) commonly affect the upper extremity. Due to muscle weakness, performance of daily activities becomes increasingly difficult, which leads to reduced independence and quality of life. In order to support the performance of upper extremity tasks, dynamic arm supports may be used. The Yumen Arm is a novel dynamic arm support specially developed for people with NMD. The aim of this study is to evaluate the feasibility and effectiveness of the Yumen Arm in persons with Duchenne Muscular Dystrophy (DMD) and persons with Spinal Muscular Atrophy (SMA). METHODS: Three persons with DMD and three persons with SMA participated in this study. All participants conducted a set of measures with and without the Yumen Arm. Outcome measures were: active range of motion of the arm and trunk (i.e. Reachable Workspace, Functional Workspace, and trunk movement), fatigue (OMNI-RPE), Performance of Upper Limb (PUL) scale and some additional activities of daily living. User experiences were collected using a questionnaire. RESULTS: The Yumen Arm could be used by all participants. Results showed a median increase in active range of motion (4% relative surface area), and a median increase of function ability (> 11% PUL score) when using the Yumen Arm. In addition, three out of four (data from 2 participants was missing) participants indicated that activity performance was less fatiguing when using the Yumen Arm. Four out of five (data from 1 participant was missing) participants indicated that they would like to use the Yumen Arm in their daily lives. CONCLUSION: This study is one of the first studies describing a range of objective measures to examine the effectiveness of a dynamic arm support. Based on these measurements we can conclude that the Yumen Arm effectively improves arm function in NMD patients, however the effectiveness varies a lot between individual subjects. We provided detailed recommendations for the improvement of the Yumen Arm, and possible also for the development of other dynamic arm supports. This study showed a lot of variability between individual subjects, which emphasizes the importance of tuning dynamic arm supports based on individual user characteristics, such as scoliosis, functional capacity and muscle strength.

Quantitative description of upper extremity function and activity of people with spinal muscular atrophy.

BACKGROUND: Therapeutic management of the upper extremity (UE) function of people with spinal muscular atrophy (SMA) requires sensitive and objective assessment. Therefore, we aimed to measure physiologic UE function of SMA patients with different functional abilities and evaluate the relation between these physiologic measures and functional UE scales. METHODS: 12 male and 5 female SMA patients (mean age 42 years; range 6-62 years) participated in this explorative study. Concerning the physiologic level, the maximal muscle torque, the maximal and normalized surface electromyography (sEMG) amplitudes, and the maximal passive and active joint angles were measured. Concerning the activity level, the Performance of the Upper Limb (PUL) scale was used, and hand function was examined using the Nine-Hole Peg Test and the Timed Test of In-Hand Manipulation (TIHM). RESULTS: Outcome measures that significantly related to the functional ability were: the PUL score (all dimensions); the finger to palm task of the Timed TIHM; biceps, triceps, and forearm extensor strength; and the active range of motion of shoulder abduction, shoulder flexion, and wrist extension. In addition, the following physiologic variables were related to the activity level (PUL score): hand function (the Nine-Hole Peg Test; Rs = - 0.61), the Timed TIHM (Rs = - 0.53), the maximal muscle torque (Rs = 0.74), the maximal sEMG amplitude (Rs = 0.79), and the maximal active joint angle (Rs = 0.88). CONCLUSIONS: Muscle functions in SMA patients are already affected before activity limitations are noticeable. Consequently, monitoring the maximal muscle strength and the normalized muscle activity during task performance could play a role in the early detection of UE limitations. The mechanism behind the loss of arm activities due to SMA is primarily caused by decreasing muscle capacity, which influences the ability to move an arm actively. In clinical practices, these dimensions should be considered separately when monitoring disease progression in order to better evaluate the need for interventions.

Patients With Spinal Muscular Atrophy Use High Percentages of Trunk Muscle Capacity to Perform Seated Tasks.

OBJECTIVE: The aim of the study was to investigate trunk function during seated upper limb tasks in patients with spinal muscular atrophy types 2 and 3. DESIGN: Seventeen persons with spinal muscular atrophy and 15 healthy controls performed several tasks when sitting unsupported, such as reaching (and placing) forward and sideward. Joint torque and muscle activity were measured during maximum voluntary isometric contractions. Three-dimensional kinematics and normalized muscle activity were analyzed when performing tasks. RESULTS: Trunk joint torques were significantly decreased, approximately 45%, in patients with spinal muscular atrophy compared with healthy controls. Active range of trunk motion was also significantly decreased in all directions. When performing tasks, the average back muscle activity was 27% and 56% of maximum voluntary isometric contractions for healthy controls and spinal muscular atrophy and for abdominal muscles 10% and 44% of maximum voluntary isometric contractions, respectively. Trunk range of motion did not differ when performing daily tasks. CONCLUSIONS: The trunk of patients with spinal muscular atrophy is weaker compared with healthy controls, reflected by reduced trunk torques and decreased active range of motion. In addition, patients with spinal muscular atrophy use high percentages of their trunk muscle capacity to perform tasks. Clinicians should take this into account for intervention development, because using high percentages of the maximum muscle capacity results in fatigue and muscle overloading.

Unraveling upper extremity performance in Duchenne muscular dystrophy: A biophysical model.

This study aimed to identify critical physiological outcome variables underlying reduced upper extremity task performance in Duchenne muscular dystrophy (DMD). These critical variables were used to propose an explanatory biophysical model of the upper extremity working mechanisms in DMD. Twenty-three DMD patients (8-21 years) participated in this study. Correlations with Brooke scale and Performance of Upper Limb (PUL) score were very high for maximal active joint angle, high for maximal muscle torque and maximal surface electromyography amplitude, and moderate for mean echogenicity and maximal passive joint angle. Multivariable regression analysis showed that maximal active joint angle and maximal muscle torque were significantly associated with Brooke score (R2 = 0.91). Maximal active joint angle, maximal passive joint angle, and maximal muscle torque were significantly associated with PUL score (R2 = 0.94). Based on the most critical physiological outcome variables, we constructed an exploratory biophysical model of the working mechanisms leading to limitations in upper extremity task performance. Better insights in these working mechanisms could support clinical management of upper extremity limitations and facilitate the development of interventions. In addition, the model could form the basis for new multi-layered outcome measures for clinical trials.

Natural variability of daily physical activity measured by accelerometry in children with a mitochondrial disease.

In this exploratory study we aimed to select the most valid and feasible accelerometer to measure daily physical activity at home in 10 children with mitochondrial disease. Using the experimentally-selected GENEActiv, good to excellent short- and long-term test-retest reliability of daily physical activity was found. Especially in children with more severe limitations daily physical activity seemed more stable and less susceptible to weather conditions. Moreover, small standard errors of measurement were found, indicating high precision of this measuring method. We conclude that measuring daily physical activity using accelerometry is a promising outcome measure for future studies in this unique population.

A Novel Setup and Protocol to Measure the Range of Motion of the Wrist and the Hand.

The human hand is important for the performance of activities of daily living which are directly related to quality of life. Various conditions, such as Duchenne muscular dystrophy (DMD) can affect the function of the human hand and wrist. The ability to assess the impairment in the hand and the wrist by measuring the range of motion (ROM), is essential for the development of effective rehabilitation protocols. Currently the clinical standard is the goniometer. In this study we explore the feasibility and reliability of an optical sensor (Leap motion sensor) in measuring active hand/wrist ROM. We measured the hand/wrist ROM of 20 healthy adults with the goniometer and the Leap motion sensor, in order to check the agreement between the two methods and additionally, we performed a test-retest of the Leap motion sensor with 12 of them, to assess its reliability. The results suggest low agreement between the goniometer and the leap motion sensor, yet showing a large decrease in measurement time and high reliability when using the later. Despite the low agreement between the two methods, we believe that the Leap motion sensor shows potential to contribute to the development of hand rehabilitation protocols and be used with patients in a clinical setting.

Towards a short questionnaire for stepwise assessment of upper limb function, pain and stiffness in Duchenne muscular dystrophy.

PURPOSE: Duchenne muscular dystrophy can lead to upper extremity limitations, pain and stiffness. In a previous study, these domains have been investigated using extensive questionnaires, which are too time-consuming for clinical practice. This study aimed at gaining insight into the underlying dimensions of these questionnaires, and to construct a short questionnaire that can be used for clinical assessment. METHODS: Exploratory factor analysis was performed on the responses of 213 participants to a web-based survey to find the underlying dimensions in the Capabilities of Upper Extremity questionnaire, the ABILHAND questionnaire, and questionnaires regarding pain and stiffness. Based on these underlying dimensions, a stepwise approach was formulated. In addition, construct validity of the factors was investigated. RESULTS: In total, 14 factors were identified. All had high internal consistency (Cronbach's alpha >0.89) and explained 80-88% of the variance of the original questionnaires. Construct validity was supported, because participants in the early ambulatory stage performed significantly better (p< 0.001) than participants in the late non-ambulatory stage. CONCLUSION: The factors identified from the set of questionnaires provide a valid representation of upper extremity function, pain and stiffness in Duchenne muscular dystrophy. Based on the factor commonalities, the Upper Limb Short Questionnaire was formulated. Implications for Rehabilitation New insights into the underlying dimensions of upper extremity function, pain and stiffness in Duchenne muscular dystrophy are gained. Fourteen factors, with good internal consistency and construct validity, are identified regarding upper extremity function, pain and stiffness in Duchenne muscular dystrophy. Based on these factors, the Upper Limb Short Questionnaire is presented. The Upper Limb Short Questionnaire can be used as an identifier of arm-hand limitations and the start of more thorough clinical investigation.

Different profiles of upper limb function in four types of neuromuscular disorders.

The aim of this research was to study impairments, activity limitations and participation restrictions due to upper limb involvement in people with four different types of neuromuscular disorders (NMD) - FacioScapuloHumeral Dystrophy (FSHD), Limb-Girdle Muscular Dystrophy (LGMD), Spinal Muscular Atrophy (SMA) and Duchenne Muscular Dystrophy (DMD) - and to investigate whether common or different profiles could be identified. Total of 267 respondents with NMD from the Netherlands answered a set of questionnaires covering upper limb impairments (pain and stiffness), activity limitations and participation restrictions. Pain was most often reported by persons with FSHD. Problems in the FSHD group were mainly characterized by relatively high scores for pain and stiffness and low scores for activity limitations. People with LGMD reported also low scores for activity limitations. Conversely, people with SMA and DMD experienced in general relatively low scores for pain and stiffness and high scores for activity limitations. Although people with FSHD and LGMD had relatively few activity limitations, all NMD groups experienced restrictions when participating in social activities. Our results indicate specific profiles of upper limb function in different types of NMD. While the profile observed in persons with FSHD seems to reflect overuse, the profile seen in persons with DMD and SMA is suspicious of disuse, each requiring a specific rehabilitation strategy.

Surface EMG signals in very late-stage of Duchenne muscular dystrophy: a case study.

BACKGROUND: Robotic arm supports aim at improving the quality of life for adults with Duchenne muscular dystrophy (DMD) by augmenting their residual functional abilities. A critical component of robotic arm supports is the control interface, as is it responsible for the human-machine interaction. Our previous studies showed the feasibility of using surface electromyography (sEMG) as a control interface to operate robotic arm supports in adults with DMD (22-24 years-old). However, in the biomedical engineering community there is an often raised skepticism on whether adults with DMD at the last stage of their disease have sEMG signals that can be measured and used for control. FINDINGS: In this study sEMG signals from Biceps and Triceps Brachii muscles were measured for the first time in a 37 year-old man with DMD (Brooke 6) that lost his arm function 15 years ago. The sEMG signals were measured during maximal and sub-maximal voluntary isometric contractions and evaluated in terms of signal-to-noise ratio and co-activation ratio. Beyond the profound deterioration of the muscles, we found that sEMG signals from both Biceps and Triceps muscles were measurable in this individual, although with a maximum signal amplitude 100 times lower compared to sEMG from healthy subjects. The participant was able to voluntarily modulate the required level of muscle activation during the sub-maximal voluntary isometric contractions. Despite the low sEMG amplitude and a considerable level of muscle co-activation, simulations of an elbow orthosis using the measured sEMG as driving signal indicated that the sEMG signals of the participant had the potential to provide control of elbow movements. CONCLUSIONS: To the best of our knowledge this is the first time that sEMG signals from a man with DMD at the last-stage of the disease were measured, analyzed and reported. These findings offer promising perspectives to the use of sEMG as an intuitive and natural control interface for robotic arm supports in adults with DMD until the last stage of the disease.

Comparison between sEMG and force as control interfaces to support planar arm movements in adults with Duchenne: a feasibility study.

BACKGROUND: Adults with Duchenne muscular dystrophy (DMD) can benefit from devices that actively support their arm function. A critical component of such devices is the control interface as it is responsible for the human-machine interaction. Our previous work indicated that surface electromyography (sEMG) and force-based control with active gravity and joint-stiffness compensation were feasible solutions for the support of elbow movements (one degree of freedom). In this paper, we extend the evaluation of sEMG- and force-based control interfaces to simultaneous and proportional control of planar arm movements (two degrees of freedom). METHODS: Three men with DMD (18-23 years-old) with different levels of arm function (i.e. Brooke scores of 4, 5 and 6) performed a series of line-tracing tasks over a tabletop surface using an experimental active arm support. The arm movements were controlled using three control methods: sEMG-based control, force-based control with stiffness compensation (FSC), and force-based control with no compensation (FNC). The movement performance was evaluated in terms of percentage of task completion, tracing error, smoothness and speed. RESULTS: For subject S1 (Brooke 4) FNC was the preferred method and performed better than FSC and sEMG. FNC was not usable for subject S2 (Brooke 5) and S3 (Brooke 6). Subject S2 presented significantly lower movement speed with sEMG than with FSC, yet he preferred sEMG since FSC was perceived to be too fatiguing. Subject S3 could not successfully use neither of the two force-based control methods, while with sEMG he could reach almost his entire workspace. CONCLUSIONS: Movement performance and subjective preference of the three control methods differed with the level of arm function of the participants. Our results indicate that all three control methods have to be considered in real applications, as they present complementary advantages and disadvantages. The fact that the two weaker subjects (S2 and S3) experienced the force-based control interfaces as fatiguing suggests that sEMG-based control interfaces could be a better solution for adults with DMD. Yet force-based control interfaces can be a better alternative for those cases in which voluntary forces are higher than the stiffness forces of the arms.

Dynamic arm study: quantitative description of upper extremity function and activity of boys and men with duchenne muscular dystrophy.

BACKGROUND: Therapeutic management of upper extremity (UE) function of boys and men with Duchenne Muscular Dystrophy (DMD) requires sensitive and objective assessment. Therefore, we aimed to measure physiologic UE function of healthy subjects and DMD patients in different disease stages, and to evaluate the relation between these physiologic measures and functional UE scales. METHODS: Twenty-three DMD patients and twenty healthy controls (7-23 years) participated in this explorative case-control study. Maximal muscle torque, maximal and normalized surface electromyography (sEMG) amplitudes, muscle thickness, echogenicity and maximal passive and active joint angles were measured. At activity level, Brooke upper extremity rating scale and the Performance of Upper Limb (PUL) scale were used. RESULTS: Outcome measures related to proximal UE function could discriminate between disease stages. Increased normalized sEMG amplitudes were found in patients, even in early disease stages. Maximal active joint angles showed the strongest relation to Brooke scale (R 2 = 0.88) and PUL scale (R 2 = 0.85). CONCLUSIONS: The decline of muscle functions precedes the decline in performance of UE activities, and therefore may play a role in early detection of UE limitations. Increased sEMG levels demonstrate that DMD patients use more of their muscle capacity compared to healthy subjects, to perform daily activities. This might result in increased fatigability. Active maximal joint angles are highly related to functional scales, so preserving the ability to use the full range of motion is important for the performance of daily activities. Close monitoring of active joint angles could therefore help in starting interventions that minimize functional UE decline in DMD patients timely.

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.

Variables associated with upper extremity function in patients with Duchenne muscular dystrophy.

Preserving upper extremity (UE) function in patients with Duchenne muscular dystrophy (DMD) is extremely important as it is related to independence and quality of life. For clinical decision making, knowledge of variables associated with UE function is necessary. This knowledge is, however, limited. Therefore, this study aims to gain more insight into the variables associated with UE function in DMD. Data from an international web-based questionnaire on UE function, obtained from 213 DMD patients, were used. Six dependent variables regarding UE function were used in multivariable linear regression analyses. In addition, 26 independent variables regarding patient characteristics, medication, therapy, supportive aids, pain, stiffness and participation were used. Twelve independent variables showed a significant relation to UE function. Variables with a negative relation to UE function were: later disease stage, occurrence of scoliosis, higher age, use of UE splints, more frequent stiffness complaints, more limitations due to stiffness, more frequent elbow pain, and having physical therapy. A positive relation with UE function was seen for going to school or work, use of corticosteroids, higher BMI, and higher age at diagnosis. These variables explained 56-81 % of the variation of the different measures of UE function. Knowledge of variables associated with UE function is very important in the clinical management of DMD patients. The results of this study suggest that corticosteroid use and participation in school and work related activities are positively related to UE function in DMD patients, as well as reducing pain and stiffness and preventing scoliosis.