Strengthening local road safety capacity in Cambodia

Road crashes and injuries have become a growing issue worldwide. In 2011, more than 75,000 people died in road crashes in the ten member countries of the Association of South East Asian Nations (ASEAN) and many times this number sustained long term injuries. In 2014, the Asian Development Bank (ADB), funded by the Japan Fund for Poverty Reduction, commenced a package of actions to improve road safety in ASEAN. In 2015, as part of the technical assistance for this project, a Road Safety Advisor was appointed for Cambodia for four months. The assignment produced several primary outputs, which included the organization of national training on traffic law enforcement and road safety management, the conduct of a training needs survey and cost analysis study, and the development of a proposal for strengthening speed management. It is important to note that unlike other ADB technical assistance projects, this assignment adopted a capacity building approach, which promoted and encouraged the local road safety team in the government to step up and take action. The research capacity building approach adopted in this project highlighted the feasibility of increasing participation from existing stakeholders, especially the government in identifying existing human resources, building the capacity of relevant government officials and supporting them to take the ownership of the project. It is hoped that similar outcomes will occur in the other ASEAN countries.

Reducing falls in hospital through education to change patient and staff behaviour: A stepped wedge cluster randomised controlled effectiveness trial

Background: Falls remain the most frequent adverse event reported in hospitals, particularly geriatric rehabilitation wards. Randomised trials reducing fall injuries in hospitals have been elusive. Our previous randomised trial (n = 1206) demonstrated that multimedia education with physiotherapist falls educator support reduced falls among patients with higher cognition levels, but this benefit was offset by a potential increase in falls rates among patients with poor cognition. In the previous trial, hospital staff were blinded to the allocation of individual patients, and only delivered usual care.

Fatigue fractures in military conscripts : A study on risk factors, diagnostics and long-term consequences

Fatigue fracture is an overuse injury commonly encountered in military and sports medicine, and known to relate to intensive or recently intensified physical activity. Bone responds to increased stress by enhanced remodeling. If physical stress exceeds bone s capability to remodel, accumulation of microfractures can lead to bone fatigue and stress fracture. Clinical diagnosis of stress fractures is complex and based on patient s anamnesis and radiological imaging. Bone stress fractures are mostly low-risk injuries, healing well after non-operative management, yet, occurring in high-risk areas, stress fractures can progress to displacement, often necessitating surgical treatment and resulting in prolonged morbidity. In the current study, the role of vitamin D as a predisposing factor for fatigue fractures was assessed using serum 25OHD level as the index. The average serum 25OHD concentration was significantly lower in conscripts with fatigue fracture than in controls. Evaluating TRACP-5b bone resorption marker as indicator of fatigue fractures, patients with elevated serum TRACP-5b levels had eight times higher probability of sustaining a stress fracture than controls. Among the 154 patients with exercise induced anterior lower leg pain and no previous findings on plain radiography, MRI revealed a total of 143 bone stress injuries in 86 patients. In 99% of the cases, injuries were in the tibia, 57% in the distal third of the tibial shaft. In patients with injury, forty-nine (57%) patients exhibited bilateral stress injuries. In a 20-year follow-up, the incidence of femoral neck fatigue fractures prior to the Finnish Defence Forces new regimen in 1986 addressing prevention of these fractures was 20.8/100,000, but rose to 53.2/100,000 afterwards, a significant 2.6-fold increase. In nineteen subjects with displaced femoral neck fatigue fractures, ten early local complications (in first postoperative year) were evident, and after the first postoperative year, osteonecrosis of the femoral head in six and osteoarthritis of the hip in thirteen patients were found. It seems likely that low vitamin D levels are related to fatigue fractures, and that an increasing trend exists between TRACP-5b bone resorption marker elevation and fatigue fracture incidence. Though seldom detected by plain radiography, fatigue fractures often underlie unclear lower leg stress-related pain occurring in the distal parts of the tibia. Femoral neck fatigue fractures, when displaced, lead to long-term morbidity in a high percentage of patients, whereas, when non-displaced, they do not predispose patients to subsequent adverse complications. Importantly, an educational intervention can diminish the incidence of fracture displacement by enhancing awareness and providing instructions for earlier diagnosis of fatigue fractures.

Bone Stress Injuries of the Foot and Ankle

Bone stress injuries of the foot have been known for more than 150 years. For a century, their primary diagnostic imaging tool has been radiography. However, currently the golden standard for establishing the diagnosis of stress injuries is magnetic resonance imaging (MRI). Although the injury type has been fairly well documented in the earlier literature, little information is available on the healing of stress injuries located in e.g. the talus and calcaneus. The current study retrospectively evaluated the stress injuries of the foot and ankle treated at the Central Military Hospital over a period of eight years in patients who underwent MRI for stress injury of the foot. The imaging studies of the patients were reevaluated to determine the exact nature of the stress injury. Moreover, the hospital records of the patients were reviewed to determine the healing of stress injuries of the talus and calcaneus. Patients with a stress fracture in the talus were recalled for a follow-up examination and MRI scan one to six years after the initial injury to determine if the fracture had completely healed, clinically and radiologically. The bone stress injuries of the foot were found to affect more than one bone in a majority of the cases. The talus and the calcaneus were the bones most commonly affected. In the talus, the most common site for the injuries was the head of the bone, and in the calcaneus, the posterior part of the bone. The injuries in these bones were associated with injuries in the surrounding bones. Stress injuries in the calcaneus seemed to heal well. No complications were seen in the primary healing process. The patients were, however, sometimes compelled to refrain from physical training for up to months. In the talus, minor degenerative findings of the articular surface were seen in half of the patients who participated in a follow-up MRI scan and radiographs taken one to six years after the initial injury. Half of the patients also reported minor exercise related symptoms in the follow-up. The symptoms were, however, not noticeable in everyday life.

The skin safety model: Reconceptualizing skin vulnerability in older patients

Purpose: To develop a unique skin safety model (SSM) that offers a new and unified perspective on the diverse yet interconnected antecedents that contribute to a spectrum of potential iatrogenic skin injuries in older hospitalized adults. Organizing Construct: Discussion paper. Methods: A literature search of electronic databases was conducted for published articles written in English addressing skin integrity and iatrogenic skin injury in elderly hospital patients between 1960 and 2014. Findings: There is a multiplicity of literature outlining the etiology, prevention, and management of specific iatrogenic skin injuries. Complex and interrelated factors contribute to iatrogenic skin injury in the older adult, including multiple comorbidities, factors influencing healthcare delivery, and acute situational stressors. A range of injuries can result when these factors are com- plicated by skin irritants, pressure, shear, or friction; however, despite skin injuries sharing multiple ntecedents, no unified overarching skin safety conceptual model has been published. Conclusions: The SSM presented in this article offers a new, unified framework that encompasses the spectrum of antecedents to skin vulnerability as well as the spectrum of iatrogenic skin injuries that may be sustained by older acute care patients. Current skin integrity frameworks address prevention and management of specific skin injuries. In contrast, the SSM recognizes the complex interplay of patient and system factors that may result in a range of iatrogenic skin injuries. Skin safety is reconceptualized into a single model that has the potential for application at the individual patient level, as well as health-care systems and governance levels. Clinical Relevance: Skin safety is concerned with keeping skin safe from any iatrogenic skin injury, and remains an ongoing challenge for healthcare providers. A conceptual framework that encompasses all of the factors that may contribute to a range of iatrogenic skin injuries is essential, and guides the clinician in maintaining skin integrity in the vulnerable older patient.

Imaging of knee injuries with special focus on tibial plateau fractures

Acute knee injury is a common event throughout life, and it is usually the result of a traffic accident, simple fall, or twisting injury. Over 90% of patients with acute knee injury undergo radiography. An overlooked fracture or delayed diagnosis can lead to poor patient outcome. The major aim of this thesis was retrospectively to study imaging of knee injury with a special focus on tibial plateau fractures in patients referred to a level-one trauma center. Multi-detector computed tomography (MDCT) findings of acute knee trauma were studied and compared to radiography, as well as whether non-contrast MDCT can detect cruciate ligaments with reasonable accuracy. The prevalence, type, and location of meniscal injuries in magnetic resonance imaging (MRI) were evaluated, particularly in order to assess the prevalence of unstable meniscal tears in acute knee trauma with tibial plateau fractures. The possibility to analyze with conventional MRI the signal appearance of menisci repaired with bioabsorbable arrows was also studied. The postoperative use of MDCT was studied in surgically treated tibial plateau fractures: to establish the frequency and indications of MDCT and to assess the common findings and their clinical impact in a level-one trauma hospital. This thesis focused on MDCT and MRI of knee injuries, and radiographs were analyzed when applica-ble. Radiography constitutes the basis for imaging acute knee injury, but MDCT can yield information beyond the capabilities of radiography. Especially in severely injured patients , sufficient radiographs are often difficult to obtain, and in those patients, radiography is unreliable to rule out fractures. MDCT detected intact cruciate ligaments with good specificity, accuracy, and negative predictive value, but the assessment of torn ligaments was unreliable. A total of 36% (14/39) patients with tibial plateau fracture had an unstable meniscal tear in MRI. When a meniscal tear is properly detected preoperatively, treatment can be combined with primary fracture fixation, thus avoiding another operation. The number of meniscal contusions was high. Awareness of the imaging features of this meniscal abnormality can help radiologists increase specificity by avoiding false-positive findings in meniscal tears. Postoperative menisci treated with bioabsorbable arrows showed no difference, among different signal intensities in MRI, among menisci between patients with operated or intact ACL. The highest incidence of menisci with an increased signal intensity extending to the meniscal surface was in patients whose surgery was within the previous 18 months. The results may indicate that a rather long time is necessary for menisci to heal completely after arrow repair. Whether the menisci with an increased signal intensity extending to the meniscal surface represent improper healing or re-tear, or whether this is just the earlier healing feature in the natural process remains unclear, and further prospective studies are needed to clarify this. Postoperative use of MDCT in tibial plateau fractures was rather infrequent even in this large trauma center, but when performed, it revealed clinically significant information, thus benefitting patients in regard to treatment.

Estimation of discard mortality of sablefish (Anoplopoma fimbria) in Alaska longline fisheries

Sablefish (Anoplopoma fimbria) are often caught incidentally in longline fisheries and discarded, but the extent of mortality after release is unknown, which creates uncertainty for estimates of total mortality. We analyzed data from 10,427 fish that were tagged in research surveys and recovered in surveys and commercial fisheries up to 19 years later and found a decrease in recapture rates for fish originally captured at shallower depths (210–319 m) during the study, sustaining severe hooking injuries, and sustaining amphipod predation injuries. The overall estimated discard mortality rate was 11.71%. This estimate is based on an assumed survival rate of 96.5% for fish with minor hooking injuries and the observed recapture rates for sablefish at each level of severity of hook injury. This estimate may be lower than what actually occurs in commercial fisheries because fish are likely not handled as carefully as those in our study. Comparing our results with data on the relative occurrence of the severity of hooking injuries in longline fisheries may lead to more accurate accounting of total mortality attributable to fishing and to improved management of this species.

Prevalência das injúrias orofaciais e uso de protetores bucais em uma população de atletas que praticam futebol e jiu-jitsu

Este estudo epidemiológico teve por objetivo investigar a prevalência de injúria orofacial em dois grupos de atletas. O primeiro grupo foi de atletas integrantes do Fluminense Futebol Clube, em Xerém, e o segundo de atletas praticantes do jiu-jitsu em diferentes academias ou que participaram do Campeonato Brasileiro em 2011, no Rio de Janeiro. Um examinador calibrado, auxiliado por um assistente, preencheu os questionários com todos os atletas, seguido do exame clínico de todos. Grupo I: 260 atletas do Fluminense Futebol Clube com idade média de 14,08 (DP 2,71) anos de idade, todos do gênero masculino. Grupo II: 315 atletas de diversas academias de jiu-jitsu com idade média de 26,86 (DP 8,99), dentre esses indivíduos, apenas 10 eram do gênero feminino. A prevalência de injúrias orofaciais encontrada para o Grupo I foi de 47% (n=122; IC 95% 40,94% a 52,99%) e no Grupo II de 74,6% (n=235; IC 95% 69,52% a 79,09%). Considerando-se a prevalência de trauma apenas no elemento dentário, a prevalência diminuiu de 147 injúrias para 57 traumas dentais no futebol e de 289 injúrias para 93 traumas dentais no jiu-jitsu. Foi observada uma menor prevalência de injúria orofacial nos goleiros quando comparados aos outros jogadores de futebol. A maior parte das injúrias ocorreu durante o período do treino (n=42; IC 95% 26,59% a 43,22%) e apenas 4 desses atletas usavam protetor bucal. Por outro lado, no jiu-jitsu, a prevalência de injúria variou de acordo com a cor da faixa do uniforme do atleta. Os atletas da faixa preta exibiram mais injúrias (n=83). Atletas que treinavam de 7 a 15 horas por semana, sofreram mais injúria (n=109). A maioria das injúrias ocorreu durante o treino. Somente 28,57% dos atletas (IC 95% 23,86% a 33,79%) usavam protetor bucal. Nos dois esportes, a maioria dos atletas sofreu apenas uma injúria, sendo o tipo mais frequente em tecido mole. O dente mais atingido foi o incisivo central superior. Estes dados ressaltam a importância de incentivar o uso de protetores bucais em esportes de contato como o futebol e o jiu-jitsu, onde o seu uso não é obrigatório, apesar da prevalência de injúria orofacial ser alta.

Plantar Loading During Cutting While Wearing a Rigid Carbon Fiber Insert.

Context : Stress fractures are one of the most common injuries in sports, accounting for approximately 10% of all overuse injuries. Treatment of fifth metatarsal stress fractures involves both surgical and nonsurgical interventions. Fifth metatarsal stress fractures are difficult to treat because of the risks of delayed union, nonunion, and recurrent injuries. Most of these injuries occur during agility tasks, such as those performed in soccer, basketball, and lacrosse. Objective : To examine the effect of a rigid carbon graphite footplate on plantar loading during 2 agility tasks. Design :  Crossover study. Setting : Laboratory. Patients or Other Participants : A total of 19 recreational male athletes with no history of lower extremity injury in the past 6 months and no previous metatarsal stress fractures were tested. Main Outcome Measure(s) :  Seven 45° side-cut and crossover-cut tasks were completed in a shoe with or without a full-length rigid carbon plate. Testing order between the shoe conditions and the 2 cutting tasks was randomized. Plantar-loading data were recorded using instrumented insoles. Peak pressure, maximum force, force-time integral, and contact area beneath the total foot, the medial and lateral midfoot, and the medial, middle, and lateral forefoot were analyzed. A series of paired t tests was used to examine differences between the footwear conditions (carbon graphite footplate, shod) for both cutting tasks independently (α = .05). Results : During the side-cut task, the footplate increased total foot and lateral midfoot peak pressures while decreasing contact area and lateral midfoot force-time integral. During the crossover-cut task, the footplate increased total foot and lateral midfoot peak pressure and lateral forefoot force-time integral while decreasing total and lateral forefoot contact area. Conclusions : Although a rigid carbon graphite footplate altered some aspects of the plantar- pressure profile during cutting in uninjured participants, it was ineffective in reducing plantar loading beneath the fifth metatarsal.

Focal irradiation of perforating eye injuries

Plaques constructed with 125I were used to irradiate the sites of perforating ocular injuries in rabbits. An approximate dose of 16Gy given over a period of 6 days was shown to significantly reduce intraocular cellular proliferation when irradiation was commenced within 24 hours after injury. If irradiation was delayed until day 5, this reduction in cellular proliferation and intraocular membrane formation did not occur. Smaller radiation doses of approximately 6Gy given within 24 hours post-injury and administered over 6 days also reduced the extent of cellular proliferation but was not as effective as the 16Gy dose.

DNA damage in two bivalve species: Mytilus galloprovincialis and Ruditapes decussatus from the South coast of Portugal

Dissertação de mest., Estudos Marinhos e Costeiros, Faculdade de Ciências e Tecnologia, Universidade do Algarve, 2009

Influência do tipo de chuteira em variáveis preditoras do risco de entorse lateral do tornozelo

Introdução: No futebol, a entorse lateral do tornozelo (ELT) destaca-se como sendo a lesão mais prevalente. Potenciada pela variedade de chuteiras disponíveis no mercado e pela crescente utilização de relvados sintéticos, a interação entre o terreno e o calçado tem assumido elevada relevância como fator de risco para a ELT. A maior incidência de lesões na 2ª parte do jogo traduz a necessidade do estudo dessa interação durante tarefas que envolvam fadiga. Objetivo: Estudar a influência das chuteiras em variáveis preditoras do risco de ELT em relvado sintético sob duas condições: sem e com fadiga dos músculos eversores do tornozelo Métodos: Foi utilizada uma amostra de atletas saudáveis. Todos os indivíduos realizaram 3 séries de 5 saltos médio-laterais uni-podálicos, cada uma com 1 de 3 modelos de chuteiras (Turf, Hard e Firm ground) em duas condições: sem e com fadiga induzida pelo dinamómetro isocinético. Durante a tarefa, a atividade eletromiográfica do longo e curto peroniais, o valor das forças de reação do solo e o movimento do retro-pé (plano frontal), foram recolhidos e usados para calcular variáveis cinemáticas (eversão/inversão do tornozelo, o deslocamento e velocidade do centro de pressão), cinéticas (taxa de crescimento das forças de reação do solo) e neuromusculares (tempo de ativação muscular dos peroniais). Resultados: À exceção do tempo de ativação do curto peronial com o modelo Hard ground (sem fadiga vs com fadiga (p=0,050), não foram identificadas diferenças estatisticamente significativas nas variáveis preditoras de lesão, entre chuteiras, nem entre as duas condições avaliadas. Conclusão: Para o teste funcional escolhido e executado por atletas saudáveis em sintético de 3ª geração, nenhuma das chuteiras apresenta maior risco de lesão (com e sem fadiga), tendo em conta as variáveis em estudo.

A Eficácia do Programa Fifa 11+ na Prevenção de Lesões em Atletas de Futebol Sub18

Introdução: No futebol, as lesões são da mais fulcral importância pelo que a sua prevenção se revela de extrema pertinência. A FIFA criou o FIFA 11+, um programa de prevenção de lesões, que revelou resultados positivos em equipas jovens tanto femininas como masculinas. No entanto, em Portugal, os resultados da sua implementação são escassos, principalmente em camadas jovens. Objetivo: Estudar a eficácia do programa FIFA 11+ na prevenção de lesões em atletas de futebol – sub 18. Métodos: O presente estudo quasi experimental teve como amostra uma equipa de 24 atletas, divididos voluntariamente em 2 grupos: o grupo experimental (GE) (n=12), e o grupo controlo (GC) (n= 12). Ambos os grupos realizaram os treinos normais sendo o grupo experimental sujeito adicionalmente ao programa FIFA 11+ duas vezes por semana, durante 12 semanas. Foi utilizado ainda o Orchard Sports Injury Classification System (OSICS-10) como sistema de classificação de lesões, sendo estas divididas em graves, moderadas, leves e mínimas. O teste Mann-Whitney foi utilizado para a comparação entre grupos, e o teste de Wilcoxon para a comparação intra grupo. Resultados: Quando comparados o GE com o GC em M0 não se observaram diferenças estatisticamente significativas (p=0.065), no número de lesões entre os grupos. O mesmo se verificou após a implementação do programa FIFA 11+ (p=1,000). Na comparação intra-grupo de M0 e M1 o grupo controlo não apresentou diferenças estatisticamente significativas (p=0,317) enquanto que no grupo experimental se observou que existiam significativamente menos lesões após a implementação do programa. (p=0,025). Conclusão: O programa FIFA 11+ parece ser indicado para a prevenção e diminuição de lesões desportivas em jogadores amadores de equipas sub-18, quando aplicado duas vezes por semana. Apesar disso, para eleger o programa como uma ferramenta de eleição na promoção da saúde, mais estudos são sugeridos utilizando uma amostra maior e se possível num período superior.

A comparison of injuries among children and adult football (soccer) players

Football is a universal and an affordable game but we need to minimize the incidence of accidents among the increasing number of young football players. Our 11 year retrospective epidemiological study (1990-2000) of football injuries in children (N= 1000) was compared with those of adult players in the 2006 European Championship. This comparative study confirmed that the anatomical, biomechanical and biological conditions differ between adults and children and that they warrant particular attention to protect the latter vulnerable group against bone avulsions, overuse pathologies and fatigue-fractures. Injuries were shown to increase significantly with age up to 16 years (P=0.005). Children suffer mainly from contusions, fractures and sprain injuries. Head injuries were more common in boys (P=0.070), while girls were more prone to sprains. The types of injuries differ between adults and children (sprain versus fractures), the anatomical location of injuries is different (lower limbs in adults, lower and upper limbs in children), the circumstances of the injuries are different (contact in adults versus non-contact in children), and teenage girls have different types of injuries than teenage boys. An increased incidence of injuries is due to changes in the position of the center of gravity and in the morphotype during rapid growth. For these reasons it is mandatory to adapt the training to the age and sex of the players. It is unsafe to train children the same way as adults. The height, the weight and the speed of growth must be taken into account by the multidisciplinary team when organising the training programmes. -- Le football fait partie des sports les plus pratiqués au monde en raison de sa popularité et de son accessibilité économ ique. L'incidence des blessures liées à cette pratique doit être diminuée surtout chez les jeunes joueurs en raison de la croissance exponentielle du nombre de joueurs féminins et masculins. Une étude épidémiologique rétrospective sur 11 ans (1990-2000) a été réalisée chez les enfants victimes de blessures liées au football (N==1000), puis a été comparée aux données recueillies de l'UEFA lors d'un Championnat Européen en 2006 sur les lésions des joueurs adultes. Cette étude comparative confirme que les structures anatomiques, biologiques et les tensions biomécaniques chez l'enfant diffèrent de celles de l'adulte. Les enfants ont un risque plus élevé de souffrir d'avulsion osseuse et de fractures de fatigue que les adultes. Les blessures augmentent significativement avec l'âge jusqu'à 16 ans (P==0,005). Les traumatismes crâniens sont plus fréquents chez les garçons tandis que les entorses sont plus à risque chez les filles. Les adultes font plus souvent des entorses tandis que les enfants font plus de fractures. La localisation anatomique diffère également entre ces deux groupes (les membres inférieurs chez l'adulte et les membres inférieurs et supérieurs chez l'enfant). La circonstance des blessures diffère également (choc avec un autre joueur chez l'adulte et des blessures sans contact chez l'enfant). Chez les adolescents, les blessures des filles diffèrent de celles des garçons. L'augmentation chez les enfants de cette incidence est liée au déplacement lors de la croissance du centre de gravité, avec une maladresse accrue lors des phases de croissance. Pour toutes ces raisons, il est justifié d'adapter les entraînements de football en fonction de l'âge, du sexe et du morphotype. L'entrainement des enfants doit être différent de celui des adultes. Le poids, la taille et la vitesse de croissance doit être prise en compte dans des structures multidisciplinaires afin de permettre une meilleure longévité sportive des jeunes joueurs de football.

3D movement and muscle activity patterns in a violin bowing task

Objective: Overuse injuries in violinists are a problem that has been primarily analyzed through the use of questionnaires. Simultaneous 3D motion analysis and EMG to measure muscle activity has been suggested as a quantitative technique to explore this problem by identifying movement patterns and muscular demands which may predispose violinists to overuse injuries. This multi-disciplinary analysis technique has, so far, had limited use in the music world. The purpose of this study was to use it to characterize the demands of a violin bowing task. Subjects: Twelve injury-free violinists volunteered for the study. The subjects were assigned to a novice or expert group based on playing experience, as determined by questionnaire. Design and Settings: Muscle activity and movement patterns were assessed while violinists played five bowing cycles (one bowing cycle = one down-bow + one up-bow) on each string (G, D, A, E), at a pulse of 4 beats per bow and 100 beats per minute. Measurements: An upper extremity model created using coordinate data from markers placed on the right acromion process, lateral epicondyle of the humerus and ulnar styloid was used to determine minimum and maximum joint angles, ranges of motion (ROM) and angular velocities at the shoulder and elbow of the bowing arm. Muscle activity in right anterior deltoid, biceps brachii and triceps brachii was assessed during maximal voluntary contractions (MVC) and during the playing task. Data were analysed for significant differences across the strings and between experience groups. Results: Elbow flexion/extension ROM was similar across strings for both groups. Shoulder flexion/extension ROM increaslarger for the experts. Angular velocity changes mirrored changes in ROM. Deltoid was the most active of the muscles assessed (20% MVC) and displayed a pattern of constant activation to maintain shoulder abduction. Biceps and triceps were less active (4 - 12% MVC) and showed a more periodic 'on and off pattern. Novices' muscle activity was higher in all cases. Experts' muscle activity showed a consistent pattern across strings, whereas the novices were more irregular. The agonist-antagonist roles of biceps and triceps during the bowing motion were clearly defined in the expert group, but not as apparent in the novice group. Conclusions: Bowing movement appears to be controlled by the shoulder rather than the elbow as shoulder ROM changed across strings while elbow ROM remained the same. Shoulder injuries are probably due to repetition as the muscle activity required for the movement is small. Experts require a smaller amount of muscle activity to perform the movement, possibly due to more efficient muscle activation patterns as a result of practice. This quantitative multidisciplinary approach to analysing violinists' movements can contribute to fuller understanding of both playing demands and injury mechanisms .