Optimal effort investment for overcoming the weakest point: new insights from a computational model of neuromuscular adaptation

The occurrence of so-called sticking points in a lift is pervasive in weight training practice. Biomechanically complex exercises often exhibit multi modal variation of effective force exerted against the load as a function of the elevation and velocity of the load. This results in a variety of possible loci for the occurrence of sticking points and makes the problem of designing the optimal training strategy to overcome them challenging. In this article a case founded on theoretical grounds is made against a purely empirical method. It is argued that the nature of the problem considered and the wide range of variables involved limit the generality of conclusions which can be drawn from experimental studies alone. Instead an alternative is described, whereby a recently proposed mathematical model of neuromuscular adaptation is employed in a series of computer simulations. These are used to examine quantitatively the effects of differently targeted partial range of motion (ROM) training approaches. Counter-intuitively and in contrast to common training practices, the key novel insight inferred from the obtained results is that in some cases the most effective approach for improving performance in an exercise with a sticking point at a particular point in the ROM is to improve force production capability at a different and possibly remote position in the lift. In the context of the employed model, this result is explained by changes in the neuromuscular and biomechanical environment for force production.

Goniometric measurements of the forelimb and hindlimb joints in sheep

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Judet quadricepsplasty in the treatment of posttraumatic knee rigidity: Long-term outcomes of 45 cases

BACKGROUND: Posttraumatic knee stiffness is a very debilitating condition. Judet's quadricepsplasty technique has been used for more than 50 years. However, few reports of quadricepsplasty results exist in the literature. METHODS: We report the results of 45 cases of posttraumatic arthrofibrosis of the knee treated with Judet's quadricepsplasty. The results of the procedure were analyzed by measuring the degrees of flexion of the operated knees at different time points (before, immediately after, and late postoperatively). RESULTS: The degree of flexion increased from 33.6 degrees (range, 5-80 degrees) preoperatively to 105 degrees (range, 45-160 degrees) immediately after surgery, followed by a slight fall in the range of motion (ROM) in the late postoperative period, which reached an average of 84.8 degrees. There was no significant correlation between knee strength and the patient's gender, but there was a slight trend of lower strength with age. Although Judet's quadricepsplasty technique dates from more than 50 years ago, it still provides good outcomes in the treatment of rigid knees of various etiologies. In general, all cases showed the same pattern of a small decrease in the ROM in the late postoperative period. CONCLUSION: Judet's quadricepsplasty can increase the ROM of rigid knees. The ROM obtained with the surgery persists long term. (J Trauma. 2012; 72: E77-E80. Copyright (C) 2012 by Lippincott Williams & Wilkins)

An examination chair to measure internal rotation of the hip in routine settings: a validation study

OBJECTIVE: To determine the performance of a newly developed examination chair as compared with the clinical standard of assessing internal rotation (IR) of the flexed hip with a goniometer. METHODS: The examination chair allowed measurement of IR in a sitting position simultaneously in both hips, with hips and knees flexed 90 degrees, lower legs hanging unsupported and a standardized load of 5 kg applied to both ankles using a bilateral pulley system. Clinical assessment of IR was performed in supine position with hips and knees flexed 90 degrees using a goniometer. Within the framework of a population-based inception cohort study, we calculated inter-observer agreement in two samples of 84 and 64 consecutive, unselected young asymptomatic males using intra-class correlation coefficients (ICC) and determined the correlation between IR assessed with examination chair and clinical assessment. RESULTS: Inter-observer agreement was excellent for the examination chair (ICC right hip, 0.92, 95% confidence interval [CI] 0.89-0.95; ICC left hip, 0.90, 95% CI 0.86-0.94), and considerably higher than that seen with clinical assessment (ICC right hip, 0.65, 95% CI 0.49-0.77; ICC left hip, 0.69, 95% CI 0.54-0.80, P for difference in ICC between examination chair and clinical assessment range of motion (ROM) obtained with examination chair and clinical assessment were similar (difference 1.1 degrees, 95% CI - 0.7-2.8 degrees, P=0.23), and the correlation was strong (Pearson's coefficient, 0.75, 95% CI 0.62-0.84). CONCLUSIONS: The use of the examination chair resulted in a precise assessment of hip IR in our population-based inception cohort study of young asymptomatic males. It was strongly correlated with standard clinical assessment of IR but was considerably more reliable.

Influence of Partial Lateral Corpectomy with and without Hemilaminectomy on Canine Thoracolumbar Stability: A Biomechanical Study

OBJECTIVE: To analyze the biomechanical changes induced by partial lateral corpectomy (PLC) and a combination of PLC and hemilaminectomy in a T13-L3 spinal segment in nonchondrodystrophic dogs. STUDY DESIGN: In vitro biomechanical cadaveric study. SAMPLE POPULATION: T13-L3 spinal segments (n = 10) of nonchondrodystrophic dogs (weighing, 25-38 kg). METHODS: A computed tomography (CT) scan of each T13-L3 spinal segment was performed. A loading simulator for flexibility analysis was used to determine the range of motion (ROM) and neutral zone (NZ) during flexion/extension, lateral bending, and axial rotation. A servohydraulic testing machine was used to determine the changes in stiffness during compression, dorsoventral, and lateral shear. All spines were tested intact, after PLC in the left intervertebral space of L1-L2, and after a combination of PLC and hemilaminectomy. RESULTS: Statistically significant increases in ROM and NZ (P < .05) were detected during flexion/extension and lateral bending when PLC was performed. A significant increase in ROM (P < .001) was noted during axial rotation and flexion after PLC and hemilaminectomy. Stiffness decreased significantly during compression and dorsoventral shear after each procedure. Decreased stiffness during lateral shear was only significant after a combination of both procedures. CONCLUSION: PLC might lead to some spinal instability; these changes are enhanced when a hemilaminectomy is added.

Noninvasive three-dimensional assessment of femoroacetabular impingement

A CT-based method ("HipMotion") for the noninvasive three-dimensional assessment of femoroacetabular impingement (FAI) was developed, validated, and applied in a clinical pilot study. The method allows for the anatomically based calculation of hip range of motion (ROM), the exact location of the impingement zone, and the simulation of quantified surgical maneuvers for FAI. The accuracy of HipMotion was 0.7 +/- 3.1 degrees in a plastic bone setup and -5.0 +/- 5.6 degrees in a cadaver setup. Reliability and reproducibility were excellent [intraclass correlation coefficient (ICC) > 0.87] for all measures except external rotation (ICC = 0.48). The normal ROM was determined from a cohort of 150 patients and was compared to 31 consecutive hips with FAI. Patients with FAI had a significantly decreased flexion, internal rotation, and abduction in comparison to normal hips (p < 0.001). Normal hip flexion and internal rotation are generally overestimated in a number of orthopedic textbooks. HipMotion is a useful tool for further assessment of impinging hips and for appropriate planning of the necessary amount of surgical intervention, which represents the basis for future computer-assisted treatment of FAI with less invasive surgical approaches, such as hip arthroscopy.

ANKLE IMPEDANCE AND ANKLE ANGLES DURING STEP TURN AND STRAIGHT WALK: IMPLICATIONS FOR THE DESIGN OF A STEERABLE ANKLE-FOOT PROSTHETIC ROBOT

During locomotion, turning is a common and recurring event which is largely neglected in the current state-of-the-art ankle-foot prostheses, forcing amputees to use different steering mechanisms for turning, compared to non-amputees. A better understanding of the complexities surrounding lower limb prostheses will lead to increased health and well-being of amputees. The aim of this research is to develop a steerable ankle-foot prosthesis that mimics the human ankle mechanical properties. Experiments were developed to estimate the mechanical impedance of the ankle and the ankles angles during straight walk and step turn. Next, this information was used in the design of a prototype, powered steerable ankle-foot prosthesis with two controllable degrees of freedom. One of the possible approaches in design of the prosthetic robots is to use the human joints’ parameters, especially their impedance. A series of experiments were conducted to estimate the stochastic mechanical impedance of the human ankle when muscles were fully relaxed and co-contracting antagonistically. A rehabilitation robot for the ankle, Anklebot, was employed to provide torque perturbations to the ankle. The experiments were performed in two different configurations, one with relaxed muscles, and one with 10% of maximum voluntary contraction (MVC). Surface electromyography (sEMG) was used to monitor muscle activation levels and these sEMG signals were displayed to subjects who attempted to maintain them constant. Time histories of ankle torques and angles in the lateral/medial (LM) directions, inversion-eversion (IE), and dorsiflexionplantarflexion (DP) were recorded. Linear time-invariant transfer functions between the measured torques and angles were estimated providing an estimate of ankle mechanical impedance. High coherence was observed over a frequency range up to 30 Hz. The main effect of muscle activation was to increase the magnitude of ankle mechanical impedance in all degrees of freedom of the ankle. Another experiment compared the three-dimensional angles of the ankle during step turn and straight walking. These angles were measured to be used for developing the control strategy of the ankle-foot prosthesis. An infrared camera system was used to track the trajectories and angles of the foot and leg. The combined phases of heel strike and loading response, mid stance, and terminal stance and pre-swing were determined and used to measure the average angles at each combined phase. The Range of motion (ROM) in IE increased during turning while ML rotation decreased and DP changed the least. During the turning step, ankle displacement in DP started with similar angles to straight walk and progressively showed less plantarflexion. In IE, the ankle showed increased inversion leaning the body toward the inside of the turn. ML rotation initiated with an increased medial rotation during the step turn relative to the straight walk transitioning to increased lateral rotation at the toe off. A prototype ankle-foot prosthesis capable of controlling both DP and IE using a cable driven mechanism was developed and assessed as part of a feasibility study. The design is capable of reproducing the angles required for straight walk and step turn; generates 712N of lifting force in plantarflexion, and shows passive stiffness comparable to a nonload bearing ankle impedance. To evaluate the performance of the ankle-foot prosthesis, a circular treadmill was developed to mimic human gait during steering. Preliminary results show that the device can appropriately simulate human gait with loading and unloading the ankle joint during the gait in circular paths.

Comparison of the biomechanical properties of a ventral cervical intervertebral anchored fusion device with locking plate fixation applied to cadaveric canine cervical spines

OBJECTIVE: To evaluate fixation properties of a new intervertebral anchored fusion device and compare these with ventral locking plate fixation. STUDY DESIGN: In vitro biomechanical evaluation. ANIMALS: Cadaveric canine C4-C7 cervical spines (n = 9). METHODS: Cervical spines were nondestructively loaded with pure moments in a nonconstraining testing apparatus to induce flexion/extension while angular motion was measured. Range of motion (ROM) and neutral zone (NZ) were calculated for (1) intact specimens, (2) specimens after discectomy and fixation with a purpose-built intervertebral fusion cage with integrated ventral fixation, and (3) after removal of the device and fixation with a ventral locking plate. RESULTS: Both fixation techniques resulted in a decrease in ROM and NZ (P < .001) compared with the intact segments. There were no significant differences between the anchored spacer and locking plate fixation. CONCLUSION: An anchored spacer appears to provide similar biomechanical stability to that of locking plate fixation.

Biomechanical evaluation of the stabilizing function of the atlantoaxial ligaments under shear loading: A canine cadaveric study

OBJECTIVES To evaluate the stabilizing function of atlanto-axial ligaments in dogs. STUDY DESIGN Cadaveric biomechanical study. ANIMALS Beagle dog cadavers (n = 10). METHODS The craniocervical region was collected from 10 Beagle cadavers, and the occipito-atlanto-axial region was prepared and freed from the surrounding muscles. Care was taken to preserve integrity of the atlantoaxial ligaments and atlantoaxial joint capsule. The atlanto-occipital joints were blocked with 2 diverging transarticular 1.8 mm positive threaded K-wires. Specimen extremities were embedded in polymethylmethacrylate (PMMA) and mounted on a simulator testing shear load at the atlantoaxial joint. Range of motion (ROM) and neutral zone (NZ) were determined with all ligaments intact, after cutting the apical ligament, both alar ligaments, the transverse ligaments and finally after cutting the dorsal atlantoaxial ligament. RESULTS ROM increased similarly and stepwise during testing. The most significant increase was observed after transection of the alar ligaments. CONCLUSION The alar ligaments seem to be the most important ligamentous structures for stabilization of the atlantoaxial joint under shear load.

The lesser trochanter as a cause of hip impingement: pathophysiology and treatment options

Impingement of the lesser trochanter on the ischium or the posterior acetabular rim is not a frequent pathology, but has recently received increased recognition. We have seen 14 cases over a period of 14 years, but concentrate on eight hips showing complex deformities revealing similar characteristics. All eight hips had a residual Perthes or a Perthes-like disease with an elliptically deformed femoral head, but a congurent joint a short or absent femoral neck, a high riding greater trochanter, and a reduced vertical distance between the head and the lesser trochanter. Impingement took place between the lesser trochanter and the ischium or the posteroinferior acetabular border, but was hardly recognisable due to the predominant intraarticular impingement of the nonspherical femoral head and the extraarticular impingement of the greater trochanter. In three cases the impingement showed reproducible subluxation of the hip. While in our hips, excision was the preferred treatment for impingement due to an oversized lesser trochanter, distal advancement was used in the hips with the Perthes morphology; the surgical time was not longer. The overall clinical results in this group however were dominated by a substantial increase in the range of motion (ROM), dependent mainly on the achieved contour of the femoral head and the relative lengthening of the neck. Strength of active hip flexion was normal. Recurrent subluxation disappeared and no complications were recorded.

Short-term Functional and Patient Outcome of the Bi-cruciate Stabilized Total Knee Replacement: Prospective Consecutive Case-series

Background: Total knee replacement is the gold standard treatment for patients suffering from advanced symptomatic knee osteoarthritis. The main goals of knee prosthetics are pain reduction and restoration of knee motion. The new prostheses on the market such as the bi-cruciate stabilized Journey knee implant, promise a reconstruction of total physiological function of the knee with physiological range of motion and therefore high patient satisfaction. Purpose: The aim of this study was to analyze the patient-based Knee Injury and Osteoarthritis Outcome Score (KOOS) outcome after total knee replacement with new physiological bi-cruciate stabilized Journey knee prosthesis. Study Design: Prospective, consecutive case-series. Patients: Ninety nine patients, who received bi-cruciate stabilized Journey total knee prosthesis between January 1st 2006 and May 31st 2012, were included in the study. A single surgeon operated all patients. There were 61.1% females and the overall average age was 68 years (range 41-83 years). Left knee was replaced in 55.6%. Methods: The patients filled in KOO’s questionnaire pre- and 1 year postoperative. Range of motion (ROM) was studied preoperatively and at 1-year follow-ups. The pre- and postoperative KOOS subscores and ROM were compared using the Wilcoxon signed rank test. Results: There are significant improvements of all KOOS subscores. Ninety percent of patients have reached the minimum clinically relevant 10 points in symptoms, 94.5% in pain, 94.5% in activities of daily living, 84.9% in sport and recreation, and 90% in knee related quality of life. Postoperative, the average passive ROM was 131° (range 110-145°) and the average active ROM 122° (range 105-135°). The highest correlation coefficients ROM and the KOOS were observed for the activity and pain subscores. Very low or no correlation was seen for the sport subscore. Conclusions: Bi-cruciate stabilized knee prosthetic offers a solid outcome 1 year postoperative based on the results measured with the KOOS evaluation questionnaire. The Patients showed a generalized improvement in all domains measured in the KOOS of minimally 35, and up to over 52 points, what can be described as statistically significant. Patients described the level of functionality close to double compared to the preoperative status.

Short-term functional versus patient-reported outcome of the bicruciate stabilized total knee arthroplasty: prospective consecutive case series

BACKGROUND The main goals of the standard treatment for advanced symptomatic knee osteoarthritis, total knee arthroplasty (TKA), are pain reduction and restoration of knee motion.The aim of this study was to analyse the outcome of the patient-based Knee Injury and Osteoarthritis Outcome Score (KOOS), and the surgeon-based Knee Society Score (KSS) and its Knee Score (KS) and Knee Functional Score (KFS) components after (TKA) using the Journey knee prosthesis, and to assess the correlation of these scores with range of motion (ROM). METHODS In a prospective case series study between August 1st 2008 and May 31st 2011, 99 patients, all operated by a single surgeon, received Journey bicruciate stabilized total knee prostheses. The female/male ratio was 53/34, the mean patient age at surgery was 68 years (range 41-83 years), and the left/right knee ratio was 55/44. The KOOS, range of motion, and KS and KFS were obtained preoperatively and at 1-year follow-up. The pre- and postoperative levels of the outcome measures were compared using the Wilcoxon signed-rank test. Correlation between ROM and patient outcomes was analysed with the Spearman coefficient. RESULTS All KOOS subscores improved significantly. Ninety percent of patients improved by at least the minimum clinically relevant difference of 10 points in stiffness and other symptoms, 94.5% in pain, 94.5% in activities of daily living, 84.9% in sports and recreation, and 90% in knee-related quality of life. The mean passive and active ROM improved from 122.4° (range 90-145°) and 120.4° (range 80-145°) preoperatively to 129.4° (range 90-145°) and 127.1° (range 100-145°) postoperatively. The highest correlation coefficients for ROM and KOOS were observed for the activity and pain subscores. Very low or no correlation was seen for the sport subscore.There was a significant and clinically relevant improvement of KSS (preop/postop 112.2/174.5 points), and its KS (preop/postop 45.6/86.8 points) and KFS (preop/postop 66.6/87.8 points) components. CONCLUSIONS The Journey bicruciate stabilized knee prosthesis showed good 1-year postoperative results in terms of both functional and patient-based outcome. However, higher knee ROM correlates only moderately with patient-based outcome, implying that functionality afforded by the Journey bicruciate TKA is not equivalent to patient satisfaction.

Biomechanical Evaluation of the Stabilizing Function of Three Atlantoaxial Implants Under Shear Loading: A Canine Cadaveric Study

OBJECTIVE: To compare the biomechanical properties of a ventral transarticular lag screw fixation technique, a new dorsal atlantoaxial instability (AAI) clamp, and a new ventral AAI hook plate under sagittal shear loading after transection of the ligaments of the atlantoaxial joint. STUDY DESIGN: Cadaveric biomechanical study. ANIMALS: Canine cadavers (n = 10). MATERIALS AND METHODS: The occipitoatlantoaxial region of Beagles euthanatized for reasons unrelated to the study was prepared leaving only ligamentous structures and the joint capsules between the first 2 cervical vertebrae (C1 and C2). The atlanto-occipital joints were stabilized with 2 transarticular diverging positive threaded K-wires. The occipital bone and the caudal end of C2 were embedded in polymethylmethacrylate and loaded in shear to a force of 50 Newtons. The range of motion (ROM) and neutral zone (NZ) of the atlantoaxial joint were determined after 3 loading cycles with atlantoaxial ligaments intact, after ligament transection, and after fixation with each implant. The testing order of implants was randomly assigned. The implants tested last were subjected to failure testing. RESULTS: All stabilization procedures decreased the ROM and NZ of the atlantoaxial joint compared to transected ligament specimens. Only stabilization with transarticular lag screws and ventral plates produced a significant reduction of ROM compare to intact specimens. CONCLUSION: Fixation with transarticular lag screws and a ventral hook plate was biomechanically similar and provided more rigidity compared to dorsal clamp fixation. Further load cycling to failure tests and clinical studies are required before making clinical recommendations.

The comparison of maximal and endurance strength of quadriceps femori in trained and untrained elderly

The purpose of this study was to examine the differences in knee extensor maximal and endurance strength in elderly. Sixteen healthy elderly served as subjects, eight of them trained , age 61.0±8.9 yrs; height, 170.6±6.8 cm; weight, 71.8±11.7 kg [mean ± standard deviation] and eight untrained 61.4±8.1 yrs, height 174.6±7.4 cm; weight 83.9 ±14.2 kg. Maximal strength in single leg extension exercise was measured unilaterally with the dominant leg until the subjects reached their 1 Repetition Maximum (RM) covering the full Range of Motion (ROM). Muscular endurance was obtained with a load of 75% of 1-RM for 3 consecutive sets, with 2 min rest periods till failure. Load at 1 RM was lower in absolute terms in untrained, but not significant, while the relative 1-RM test was significantly lower in untrained subjects (0.20 vs. 0.25 kg load/kg body weight) (p<0.05). The number of repetitions and amount of weight lifted performed of all 3 sets was higher in trained subjects, but not significant. In the trained group both repetitions and the load managed in the third set was significant lower compared with the first two sets. The result that maximal force output is more affected compared to muscular endurance in these subjects might be due to the habitual use of quadriceps femoris muscles during activity of daily living in both trained and untrained elderly.

Effects of early intensive postoperative physiotherapy on limb function after tibial plateau leveling osteotomy in dogs with deficiency of the cranial cruciate ligament

Objective-To determine effects of early intensive postoperative physiotherapy on limb function in dogs after tibial plateau leveling osteotomy (TPLO) for deficiency of the cranial cruciate ligament (CCL). Animals-8 adult dogs with CCL deficiency. Procedure-After TPLO, dogs underwent a physiotherapy program 3 times/wk (physiotherapy group; n = 4) or a walking program (home-exercise group; 4). All dogs were evaluated before surgery, 1 and 10 days after surgery, and 3 and 6 weeks after surgery. Thigh circumference (TC), stifle joint flexion and extension range of motion (ROM), lameness, and weight-bearing scores were recorded. Results-Before surgery, CCL-deficient limbs had significantly reduced TC and reduced flexion and extension ROMs, compared with values for the contralateral control limb. Six weeks after TPLO, the physiotherapy group had significantly larger TC than the home-exercise group, with the difference no longer evident between the affected and nonaffected limbs. Extension and flexion ROMs were significantly greater in the physiotherapy group, compared with values for the home-exercise group, 3 and 6 weeks after surgery. Six weeks after surgery, the difference in flexion and extension ROMs was no longer evident between the affected and nonaffected limbs in the physiotherapy group. Both groups had improvements for lameness and weight-bearing scores over time, but no difference was found between the 2 groups. Conclusions and Clinical Relevance-After TPLO in CCL-deficient dogs, early physiotherapy intervention should be considered as part of the postoperative management to prevent muscle atrophy, build muscle mass and strength, and increase stifle joint flexion and extension ROMs.