Hallux rigidus: Arthroplasty or arthrodesis. What technique produces better results?

Hallux rígidus (HR) affects the first metatarsophalangeal joint (MTPJ) between 35% and 60% of the population over 65 years and there are multiple ways of treatment. Depending on the radiological stage where you find the deformity determines the procedure to be performed; in the early stages cheilectomy techniques and corrective osteotomy is performed while the more advanced ratings, the surgeon chooses destructive techniques considered as arthrodesis and arthroplasty. This final of degree project aims to focus on 1 MTPJ destructive techniques to clarify which of the procedures generates better results by a number of parameters; outcomes of the American Orthopaedic Foot scale and Ankle Society Hallux metatarsophalangeal Interphalangeal-scale (AOFAS), range of motion (ROM) of the 1ºAMTF, radiological classification. As for the implant arthroplasty technique, this article offers information on material and design that generates better relating to patient characteristics such as age, inflammatory joint diseases, viability and durability of the implant results. The conclusion from this review is that the values obtained in the arthrodesis according AOFAS decrease due to loss of mobility, but both techniques have similar values of effectiveness and concludes with the decision that the technique used is determined taking into account various factors and patient characteristics. Keywords: Hallux rígidus; (Hallux Rígidus) and surgery treatment; Hallux Rígidus arthrodesis; Hallux Rígidus arthroplasty; Hallux Rígidus (arthroplasty and arthrodesis).

Athletic groin pain (part 2): a prospective cohort study on the biomechanical evaluation of change of direction identifies three clusters of movement patterns

Background: Athletic groin pain (AGP) is prevalent in sports involving repeated accelerations, decelerations, kicking and change-of-direction movements. Clinical and radiological examinations lack the ability to assess pathomechanics of AGP, but three-dimensional biomechanical movement analysis may be an important innovation. Aim: The primary aim was to describe and analyse movements used by patients with AGP during a maximum effort change-of-direction task. The secondary aim was to determine if specific anatomical diagnoses were related to a distinct movement strategy. Methods: 322 athletes with a current symptom of chronic AGP participated. Structured and standardised clinical assessments and radiological examinations were performed on all participants. Additionally, each participant performed multiple repetitions of a planned maximum effort change-of-direction task during which whole body kinematics were recorded. Kinematic and kinetic data were examined using continuous waveform analysis techniques in combination with a subgroup design that used gap statistic and hierarchical clustering. Results: Three subgroups (clusters) were identified. Kinematic and kinetic measures of the clusters differed strongly in patterns observed in thorax, pelvis, hip, knee and ankle. Cluster 1 (40%) was characterised by increased ankle eversion, external rotation and knee internal rotation and greater knee work. Cluster 2 (15%) was characterised by increased hip flexion, pelvis contralateral drop, thorax tilt and increased hip work. Cluster 3 (45%) was characterised by high ankle dorsiflexion, thorax contralateral drop, ankle work and prolonged ground contact time. No correlation was observed between movement clusters and clinically palpated location of the participant's pain. Conclusions: We identified three distinct movement strategies among athletes with long-standing groin pain during a maximum effort change-of-direction task. These movement strategies were not related to clinical assessment findings but highlighted targets for rehabilitation in response to possible propagative mechanisms. Trial registration number NCT02437942, pre results.

Development of an active orthosis prototype for lower limbs

ARAUJO, Márcio V. ; ALSINA, Pablo J. ; MEDEIROS, Adelardo A. D. ; PEREIRA, Jonathan P.P. ; DOMINGOS, Elber C. ; ARAÚJO, Fábio M.U. ; SILVA, Jáder S. . Development of an Active Orthosis Prototype for Lower Limbs. In: INTERNATIONAL CONGRESS OF MECHANICAL ENGINEERING, 20., 2009, Gramado, RS. Proceedings… Gramado, RS: [s. n.], 2009

Modelling the relationship between biomechanics and performance of young sprinting swimmers

The aim of this study was to compute a swimming performance confirmatory model based on biomechanical parameters. The sample included 100 young swimmers (overall: 12.3 ± 0.74 years; 49 boys: 12.5 ± 0.76 years; 51 girls: 12.2 ± 0.71 years; both genders in Tanner stages 1-2 by self-report) participating on a regular basis in regional and national-level events. The 100 m freestyle event was chosen as the performance indicator. Anthropometric (arm span), strength (throwing velocity), power output (power to overcome drag), kinematic (swimming velocity) and efficiency (propelling efficiency) parameters were measured and included in the model. The path-flow analysis procedure was used to design and compute the model. The anthropometric parameter (arm span) was excluded in the final model, increasing its goodness-of-fit. The final model included the throw velocity, power output, swimming velocity and propelling efficiency. All links were significant between the parameters included, but the throw velocity-power output. The final model was explained by 69% presenting a reasonable adjustment (model's goodness-of-fit; x(2)/df = 3.89). This model shows that strength and power output parameters do play a mediator and meaningful role in the young swimmers' performance.

Slot Film Cooling: A Comprehensive Experimental Characterization

When components of a propulsion system are exposed to elevated flow temperatures there is a risk for catastrophic failure if the components are not properly protected from the thermal loads. Among several strategies, slot film cooling is one of the most commonly used, yet poorly understood active cooling techniques. Tangential injection of a relatively cool fluid layer protects the surface(s) in question, but the turbulent mixing between the hot mainstream and cooler film along with the presence of the wall presents an inherently complex problem where kinematics, thermal transport and multimodal heat transfer are coupled. Furthermore, new propulsion designs rely heavily on CFD analysis to verify their viability. These CFD models require validation of their results, and the current literature does not provide a comprehensive data set for film cooling that meets all the demands for proper validation, namely a comprehensive (kinematic, thermal and boundary condition data) data set obtained over a wide range of conditions. This body of work aims at solving the fundamental issue of validation by providing high quality comprehensive film cooling data (kinematics, thermal mixing, heat transfer). 3 distinct velocity ratios (VR=uc/u∞) are examined corresponding to wall-wake (VR~0.5), min-shear (VR ~ 1.0), and wall-jet (VR~2.0) type flows at injection, while the temperature ratio TR= T∞/Tc is approximately 1.5 for all cases. Turbulence intensities at injection are 2-4% for the mainstream (urms/u∞, vrms/u∞,), and on the order of 8-10% for the coolant (urms/uc, vrms/uc,). A special emphasis is placed on inlet characterization, since inlet data in the literature is often incomplete or is of relatively low quality for CFD development. The data reveals that min-shear injection provides the best performance, followed by the wall-jet. The wall-wake case is comparably poor in performance. The comprehensive data suggests that this relative performance is due to the mixing strength of each case, as well as the location of regions of strong mixing with respect to the wall. Kinematic and thermal data show that strong mixing occurs in the wall-jet away from the wall (y/s>1), while strong mixing in the wall-wake occurs much closer to the wall (y/s<1). Min-shear cases exhibit noticeably weaker mixing confined to about y/s=1. Additionally to these general observations, the experimental data obtained in this work is analyzed to reveal scaling laws for the inlets, near-wall scaling, detecting and characterizing coherent structures in the flow as well as to provide data reduction strategies for comparison to CFD models (RANS and LES).

Cognitive and structural aspects of addiction: Relation between iris patterns, time perception, eyeblink rate, impulsivity and cigarette addiction

Objectif : Le but de ce travail est d'étudier les corrélations existantes entre les patterns de l'iris, la perception du temps et la fréquence de clignement des paupières (eye blink rate) et ceci en relation avec l'addiction à la cigarette. Méthodologie: Revue de la littérature existante. Expériences sur une cohorte d'au moins trente sujets fumeurs/non-fumeurs. Analyses statistiques. Résultats: Nos résultats confirment qu'il existe des relations entre l'impulsivité, les patterns d'iris, l'eye blink rate spontané et la perception du temps. Nous observons également que l'addiction à la cigarette et son niveau de dépendance ont une influence sur ces différentes mesures. En effet, les sujets fumeurs tendent à avoir une personnalité plus impulsive par rapport aux sujets contrôles. On remarque également une nette diminution de l'eye blink rate dans le groupe des fumeurs et une tendance à la sur-estimation du temps qui passe. Conclusion : Ce travail nous permet de mieux comprendre les différentes corrélations qui existent entre les différentes variables que nous avons mesurées (patterns d'iris, score d'impulsivité et eye blink rate) ainsi que leur relation à l'addiction à la cigarette. Dès lors qu'il est avéré que les fumeurs peuvent avoir une perception du temps altérée par rapport au groupe contrôle, il serait intéressant d'en étudier l'évolution sur le long terme (aggravation avec la durée du tabagisme actif) ainsi que les conséquences qui en découlent écologiquement au moyen d'études longitudinales et de terrain.

Gait analysis of the hind limb in Labrador Retrievers with and without cranial cruciate ligament disease

Cranial cruciate ligament (CCL) deficiency is the leading cause of lameness affecting the stifle joints of large breed dogs, especially Labrador Retrievers. Although CCL disease has been studied extensively, its exact pathogenesis and the primary cause leading to CCL rupture remain controversial. However, weakening secondary to repetitive microtrauma is currently believed to cause the majority of CCL instabilities diagnosed in dogs. Techniques of gait analysis have become the most productive tools to investigate normal and pathological gait in human and veterinary subjects. The inverse dynamics analysis approach models the limb as a series of connected linkages and integrates morphometric data to yield information about the net joint moment, patterns of muscle power and joint reaction forces. The results of these studies have greatly advanced our understanding of the pathogenesis of joint diseases in humans. A muscular imbalance between the hamstring and quadriceps muscles has been suggested as a cause for anterior cruciate ligament rupture in female athletes. Based on these findings, neuromuscular training programs leading to a relative risk reduction of up to 80% has been designed. In spite of the cost and morbidity associated with CCL disease and its management, very few studies have focused on the inverse dynamics gait analysis of this condition in dogs. The general goals of this research were (1) to further define gait mechanism in Labrador Retrievers with and without CCL-deficiency, (2) to identify individual dogs that are susceptible to CCL disease, and (3) to characterize their gait. The mass, location of the center of mass (COM), and mass moment of inertia of hind limb segments were calculated using a noninvasive method based on computerized tomography of normal and CCL-deficient Labrador Retrievers. Regression models were developed to determine predictive equations to estimate body segment parameters on the basis of simple morphometric measurements, providing a basis for nonterminal studies of inverse dynamics of the hind limbs in Labrador Retrievers. Kinematic, ground reaction forces (GRF) and morphometric data were combined in an inverse dynamics approach to compute hock, stifle and hip net moments, powers and joint reaction forces (JRF) while trotting in normal, CCL-deficient or sound contralateral limbs. Reductions in joint moment, power, and loads observed in CCL-deficient limbs were interpreted as modifications adopted to reduce or avoid painful mobilization of the injured stifle joint. Lameness resulting from CCL disease affected predominantly reaction forces during the braking phase and the extension during push-off. Kinetics also identified a greater joint moment and power of the contralateral limbs compared with normal, particularly of the stifle extensor muscles group, which may correlate with the lameness observed, but also with the predisposition of contralateral limbs to CCL deficiency in dogs. For the first time, surface EMG patterns of major hind limb muscles during trotting gait of healthy Labrador Retrievers were characterized and compared with kinetic and kinematic data of the stifle joint. The use of surface EMG highlighted the co-contraction patterns of the muscles around the stifle joint, which were documented during transition periods between flexion and extension of the joint, but also during the flexion observed in the weight bearing phase. Identification of possible differences in EMG activation characteristics between healthy patients and dogs with or predisposed to orthopedic and neurological disease may help understanding the neuromuscular abnormality and gait mechanics of such disorders in the future. Conformation parameters, obtained from femoral and tibial radiographs, hind limb CT images, and dual-energy X-ray absorptiometry, of hind limbs predisposed to CCL deficiency were compared with the conformation parameters from hind limbs at low risk. A combination of tibial plateau angle and femoral anteversion angle measured on radiographs was determined optimal for discriminating predisposed and non-predisposed limbs for CCL disease in Labrador Retrievers using a receiver operating characteristic curve analysis method. In the future, the tibial plateau angle (TPA) and femoral anteversion angle (FAA) may be used to screen dogs suspected of being susceptible to CCL disease. Last, kinematics and kinetics across the hock, stifle and hip joints in Labrador Retrievers presumed to be at low risk based on their radiographic TPA and FAA were compared to gait data from dogs presumed to be predisposed to CCL disease for overground and treadmill trotting gait. For overground trials, extensor moment at the hock and energy generated around the hock and stifle joints were increased in predisposed limbs compared to non predisposed limbs. For treadmill trials, dogs qualified as predisposed to CCL disease held their stifle at a greater degree of flexion, extended their hock less, and generated more energy around the stifle joints while trotting on a treadmill compared with dogs at low risk. This characterization of the gait mechanics of Labrador Retrievers at low risk or predisposed to CCL disease may help developing and monitoring preventive exercise programs to decrease gastrocnemius dominance and strengthened the hamstring muscle group.

Tectonic expression of an active slab tear from high-resolution seismic and bathymetric data offshore Sicily (Ionian Sea)

Subduction of a narrow slab of oceanic lithosphere beneath a tightly curved orogenic arc requires the presence of at least one lithospheric scale tear fault. While the Calabrian subduction beneath southern Italy is considered to be the type example of this geodynamic setting, the geometry, kinematics and surface expression of the associated lateral, slab tear fault offshore eastern Sicily remain controversial. Results from a new marine geophysical survey conducted in the Ionian Sea, using high-resolution bathymetry and seismic profiling reveal active faulting at the seafloor within a 140 km long, two-branched fault system near Alfeo Seamount. The previously unidentified 60 km long NW trending North Alfeo Fault system shows primarily strike-slip kinematics as indicated by the morphology and steep-dipping transpressional and transtensional faults. Available earthquake focal mechanisms indicate dextral strike-slip motion along this fault segment. The 80 km long SSE trending South Alfeo fault system is expressed by one or two steeply dipping normal faults, bounding the western side of a 500+ m thick, 5 km wide, elongate, syntectonic Plio-Quaternary sedimentary basin. Both branches of the fault system are mechanically capable of generating magnitude 6-7 earthquakes like those that struck eastern Sicily in 1169, 1542, and 1693.

Optical Enhancement of Exoskeleton-Based Estimation of Glenohumeral Angles

In Robot-Assisted Rehabilitation (RAR) the accurate estimation of the patient limb joint angles is critical for assessing therapy efficacy. In RAR, the use of classic motion capture systems (MOCAPs) (e.g., optical and electromagnetic) to estimate the Glenohumeral (GH) joint angles is hindered by the exoskeleton body, which causes occlusions and magnetic disturbances. Moreover, the exoskeleton posture does not accurately reflect limb posture, as their kinematic models differ. To address the said limitations in posture estimation, we propose installing the cameras of an optical marker-based MOCAP in the rehabilitation exoskeleton. Then, the GH joint angles are estimated by combining the estimated marker poses and exoskeleton Forward Kinematics. Such hybrid system prevents problems related to marker occlusions, reduced camera detection volume, and imprecise joint angle estimation due to the kinematic mismatch of the patient and exoskeleton models. This paper presents the formulation, simulation, and accuracy quantification of the proposed method with simulated human movements. In addition, a sensitivity analysis of the method accuracy to marker position estimation errors, due to system calibration errors and marker drifts, has been carried out. The results show that, even with significant errors in the marker position estimation, method accuracy is adequate for RAR.

Graph-based structural analysis of planar mechanisms.

Kinematic structure of planar mechanisms addresses the study of attributes determined exclusively by the joining pattern among the links forming a mechanism. The system group classification is central to the kinematic structure and consists of determining a sequence of kinematically and statically independent-simple chains which represent a modular basis for the kinematics and force analysis of the mechanism. This article presents a novel graph-based algorithm for structural analysis of planar mechanisms with closed-loop kinematic structure which determines a sequence of modules (Assur groups) representing the topology of the mechanism. The computational complexity analysis and proof of correctness of the implemented algorithm are provided. A case study is presented to illustrate the results of the devised method.

Increased Levels of Diadenosine Polyphosphates in Dry Eye

Purpose. To analyze the levels of the diadenosine polyphosphates Ap4A and Ap5A in tears, in a set of control subjects and in groups of symptomatic and nonsymptomatic persons with dry eye. Methods. Ninety-seven subjects participated in the study. The subjects were divided into five experimental groups: control subjects; symptomatic patients with normal tear secretion; symptomatic patients with low tear secretion; forced blink; and corneal mechanical stimulation provided by a gas esthesiometer. The Schirmer I test was used to measure and collect tear secretions from each subject. All samples were processed by high pressure liquid chromatography (HPLC) and their Ap4A and Ap5A levels determined. Results. The levels of Ap4A and Ap5A in tears were greater in all symptomatic patients than in control subjects, especially in symptomatic subjects with low tear secretion. Within the symptomatic subjects with normal tear secretion, significant differences in concentrations of Ap4A and Ap5A were found between men and women. In the forced blink experiments, concentrations of the Ap4A and Ap5A rose with increasing blink frequency. When the cornea was mechanically stimulated, the levels of Ap4A and Ap5A rose significantly during both moderate and high-flow rate tests. Conclusions. The increased levels of Ap4A and Ap5A in tears of patients with dry eye allow these dinucleotides to be used as objective biomarkers in dry eye conditions.

Biomechanical and morphological adaptations in women during pregnancy and the postpartum period in walking

A gravidez é uma fase especial da vida, com diversas alterações nos sistemas hormonais, anatómicos, e na composição corporal da mulher. No entanto, não é claro que alterações biomecânicas tridimensionais ocorrerem. Através do acompanhamento da mulher na gravidez e pós-parto, os objetivos da presente tese foram: 1) determinar os parâmetros temporais e espaciais do ciclo da marcha; 2) descrever a cinemática angular do membro inferior; 3) calcular os momentos e potências articulares do tornozelo, joelho e coxofemoral, utilizando o cálculo por dinâmica inversa; 4) descrever as magnitudes dos picos dos momentos e potências articulares dos membros inferiores; 5) identificar possíveis diferenças entre as fases de recolha relativamente aos parâmetros biomecânicos; 6) descrever longitudinalmente a composição corporal as alterações morfológicas; 7) analisar a influência das alterações antropométricas na cinética articular. Os resultados mostram que as mulheres mantêm os parâmetros temporais e espaciais da marcha. A cinemática angular do membro inferior tem o mesmo padrão, no entanto, a magnitude de alguns picos, especialmente na bacia e coxofemoral durante a fase terminal do apoio, pré-balanço e de balanço, apresentam alterações significativas. A coxofemoral é a articulação com mais alterações na cinética articular, com um aumento da carga interna associada aos momentos articulares da coxofemoral no plano transversal. No entanto, diversos momentos e potências articulares revelam uma diminuição significativa para o final da gravidez e/ou um aumento entre alguns trimestres da gravidez e o pós-parto. Como esperado, a maioria das variáveis associadas à composição corporal e às dimensões corporais tem um aumento significativo durante a gravidez e uma diminuição no pós-parto. Os modelos desenvolvidos para prever a carga interna aplicada ao membro inferior da grávida através de variáveis antropométricas, incluem quatro modelos com variáveis associadas à quantidade de gordura, quatro modelos com variáveis associadas à massa corporal global, três modelos que incluem a massa livre de gordura, e um modelo que inclui a forma do tronco. Os altos valores do R2 ajustado, mostram que as alterações na composição corporal e morfologia, determinam em grande parte a cinética articular da mulher nesta fase particular da vida.

Faint Galaxies in the Megaparsec-Scale Environments of Hyperluminous QSOs at Redshifts 2 < z < 3

This thesis presents detailed observational studies of the extended distributions of gas, galaxies, and dark matter around hyperluminous quasars (HLQSOs) at high redshift. Taken together, these works aim to coherently describe the relationships between these massive, accreting black holes and their environments: the nature of the regions that give rise to such massive black holes, the effect of HLQSO radiation on their surrounding galaxies and gas, and the ability of both galaxies and black holes to shed new light on the formation and evolution of the other.

Chapter 2 focuses on the continuum-color-selected galaxies drawn from the Keck Baryonic Structure Survey (KBSS). The KBSS is a uniquely deep spectroscopic survey of star-forming galaxies in the same volumes of space as 15 HLQSOs at 2.5 < z < 2.9. The three-dimensional distribution of these galaxies among themselves and the nearby HLQSOs is used to infer the extent to which these black holes are associated with overdense peaks in the dark matter and galaxy distribution as quantified by clustering statistics. In conjunction with recent dark-matter simulations, these data provide the first estimates of the host dark-matter halo masses for HLQSOs, providing new insight into the formation and evolution of the most massive black holes at high redshift.

Chapter 3 describes the first results from a new survey (KBSS-Lyα) conducted for this thesis. The KBSS-Lyα survey uses narrowband imaging to identify Lyα-emitters (LAEs) in the ~Mpc regions around eight of the KBSS HLQSOs. Many of these LAEs show the effect of reprocessed HLQSO radiation in their emission through the process known as Lyα fluorescence. In this chapter, these fluorescent LAEs are used to generate a coarse map of the average HLQSO ionizing emission on Mpc scales, thereby setting the first direct constraints of the lifetime and angular distribution of activity for a population of these uniquely luminous black holes.

Chapter 4 contains a more detailed description of the KBSS-Lyα survey itself and the detailed properties of the star-forming and fluorescent objects selected therein. Using imaging and spectroscopic data covering rest-frame UV and optical wavelengths, including spectra from the new near-infrared spectrometer MOSFIRE, we characterize this population of nascent galaxies in terms of their kinematics, enrichment, gas properties, and luminosity distribution while comparing and contrasting them with previously-studied populations of continuum-selected galaxies and LAEs far from the effects of HLQSO emission.

At the conclusion of this thesis, I briefly present future directions for the continuation of this research. In Appendix A, I provide background information on the instrumentation used in this thesis, including my own contributions to MOSFIRE.

Biomechanics of the trunk and lower limbs during gait in individuals with and without chronic low back pain

Combining information on kinetics and kinematics of the trunk during gait is important for both clinical and research purposes, since it can help in better understanding the mechanisms behind changes in movement patterns in chronic low back pain patients. Although three-dimensional gait analysis has been used to evaluate chronic low back pain and healthy individuals, the reliability and measurement error of this procedure have not been fully established. The main purpose of this thesis is to gain a better understanding about the differences in the biomechanics of the trunk and lower limbs during gait, in patients and healthy individuals. To achieve these aims, three studies were developed. The first two, adopted a prospective design and focused on the reliability and measurement error of gait analysis. In these test-retest studies, chronic low back pain and healthy individuals were submitted to a gait assessment protocol, with two distinct evaluation moments, separated by one week. Gait data was collected using a 13-camera opto-electronic system and three force platforms. Data analysis included the computation of time-distance parameters, as well as the peak values for lower limb and trunk joint angles/moments. The third study followed a cross sectional design, where gait in chronic low back pain individuals was compared with matched controls. Step-to-step variability of the thoracic, lumbar and hips was calculated, and step-to-step deviations of these segments from their average pattern (residual rotations) were correlated to each other. The reliability studies in this thesis show that three-dimensional gait analysis is a reliable and consistent procedure for both chronic low back pain and healthy individuals. The results suggest varied reliability indices for multi-segment trunk joint angles, joint moments and time-distance parameters during gait, together with an acceptable level of error (particularly regarding sagittal plane). Our findings also show altered stride-to-stride variability of lumbar and thoracic segments and lower trunk joint moments in patients. These kinematic and kinetic results lend support to the notion that chronic low back pain individuals exhibit a protective movement strategy.

Proton Form Factor Puzzle and the CEBAF Large Acceptance Spectrometer(CLAS) Two-Photon Exchange Experiment

The electromagnetic form factors are the most fundamental observables that encode information about the internal structure of the nucleon. The electric ($G_{E}$) and the magnetic ($G_{M}$) form factors contain information about the spatial distribution of the charge and magnetization inside the nucleon. A significant discrepancy exists between the Rosenbluth and the polarization transfer measurements of the electromagnetic form factors of the proton. One possible explanation for the discrepancy is the contributions of two-photon exchange (TPE) effects. Theoretical calculations estimating the magnitude of the TPE effect are highly model dependent, and limited experimental evidence for such effects exists. Experimentally, the TPE effect can be measured by comparing the ratio of positron-proton elastic scattering cross section to that of the electron-proton $\large(R = \frac{\sigma (e^{+}p)}{\sigma (e^{-}p)}\large)$. The ratio $R$ was measured over a wide range of kinematics, utilizing a 5.6 GeV primary electron beam produced by the Continuous Electron Beam Accelerator Facility (CEBAF) at Jefferson Lab. This dissertation explored dependence of $R$ on kinematic variables such as squared four-momentum transfer ($Q^{2}$) and the virtual photon polarization parameter ($\varepsilon$). A mixed electron-positron beam was produced from the primary electron beam in experimental Hall B. The mixed beam was scattered from a liquid hydrogen (LH$_{2}$) target. Both the scattered lepton and the recoil proton were detected by the CEBAF Large Acceptance Spectrometer (CLAS). The elastic events were then identified by using elastic scattering kinematics. This work extracted the $Q^{2}$ dependence of $R$ at high $\varepsilon$ ($\varepsilon > $ 0.8) and the $\varepsilon$ dependence of $R$ at $\langle Q^{2} \rangle \approx 0.85$ GeV$^{2}$. In these kinematics, our data confirm the validity of the hadronic calculations of the TPE effect by Blunden, Melnitchouk, and Tjon. This hadronic TPE effect, with additional corrections contributed by higher excitations of the intermediate state nucleon, largely reconciles the Rosenbluth and the polarization transfer measurements of the electromagnetic form factors.