The influence of simulated rotator cuff tears on the risk for impingement in handbike and handrim wheelchair propulsion

Differences in Glenohumeral Joint Contact Forces Between Recovery Hand Patterns During Wheelchair Propulsion With and Without Shoulder Muscle Weakness: A Simulation Study

The majority of manual wheelchair users (MWCU) develop shoulder pain or injuries, which is often caused by impingement. Because propulsion mechanics are influenced by the recovery hand pattern used, the pattern may affect shoulder loading and susceptibility to injury. Shoulder muscle weakness is also correlated with shoulder pain, but how shoulder loading changes with specific muscle group weakness is unknown. Musculoskeletal modeling and simulation were used to compare glenohumeral joint contact forces (GJCFs) across hand patterns and determine how GJCFs vary when primary shoulder muscle groups are weakened. Experimental data were analyzed to classify individuals into four hand pattern groups. A representative musculoskeletal model was then developed for each group and simulations generated to portray baseline strength and six muscle weakness conditions. Three-dimensional GJCF peaks and impulses were compared across hand patterns and muscle weakness conditions. The semicircular pattern consistently had lower shear (anterior-posterior and superior-inferior) GJCFs compared to other patterns. The double-loop pattern had the highest superior GJCFs, while the single-loop pattern had the highest anterior and posterior GJCFs. These results suggest that using the semicircular pattern may be less susceptible to shoulder injuries such as subacromial impingement. Weakening the internal rotators and external rotators resulted in the greatest increases in shear GJCFs and decreases in compressive GJCF, likely due to decreased force from rotator cuff muscles. These findings suggest that strengthening specific muscle groups, especially the rotator cuff, is critical for decreasing the risk of shoulder overuse injuries.

Changes in neuromuscular activation, heart rate and rate of perceived exertion over the course of a wheelchair propulsion fatigue protocol

Shoulder pain is common in persons with spinal cord injury and has been associated with wheelchair use. Fatigue related compensation strategies have been identified as possibly impacting the development of shoulder injury and pain. The purpose of this study was to investigate the progression of performance fatigability (i.e., decline in objective measure of performance including neuromuscular activation and increase in heart rate) and perceived fatigability (i.e., increased perceived exertion) during a 15-min fatigue protocol including maximum voluntary overground wheelchair propulsion. Fifty participants with paraplegic spinal cord injury completed three 4-min rounds of wheelchair propulsion, separated by 90 s of rest, on a figure-8 course consisting of two turns and full stops per lap in their manual wheelchairs (ClinicalTrials.gov: NCT03153033). Electromyography (EMG) signal of five muscles acting on the shoulder joint, heart rate (HR), and rate of perceived exertion (RPE) were measured at the beginning and end of every 4 min of propulsion. Root Mean Square (RMS) and Mean Power Frequency were calculated from EMG data. There was a significant increase in %RMS of the pectoralis major pars sternalis and trapezius pars descendens, HR, and RPE with greatest changes during the first 4 min of the protocol. The observed changes in neuromuscular activation in only two of the shoulder muscles may impact muscular imbalances and the development of shoulder injuries and should be further studied. The current study gives clearer insight into the mechanisms of performance fatigability and perceived fatigability throughout a wheelchair propulsion fatigue protocol.

Movement compensation is driven by the deltoid and teres minor muscles following severe rotator cuff tear

BACKGROUND

Rotator cuff tears are common in older adults, negatively affecting function. Previous simulation-based studies reported more posterior and superior oriented glenohumeral loading with increased cuff tear severity and task performance, although corresponding muscle compensation strategies are unclear. Our objective is to determine how shoulder muscle forces change with increased rotator cuff tear severity during functional task performance.

METHODS

Eight musculoskeletal models of increasing tear severity were developed to represent no rotator cuff tear to massive three-tendon tears. Simulations were performed using each combination of model and kinematics for five functional tasks. Individual muscle forces were averaged for each task and tear severity, then normalized by the sum of the muscle forces across the shoulder. Forces were compared across tear severity and muscle.

FINDINGS

For muscle force contribution, interactions between tear severity and muscle and a main effect of muscle were seen for all tasks (P < 0.0001). Middle deltoid increased force contribution by >10% in the greatest tear severity model compared to no cuff tear model for all tasks (all P < 0.0001). Teres minor contribution increased by 7.7%, 5.6%, and 11% in the greatest tear severity model compared to the no cuff tear model for forward reach, axilla wash, and upward reach 105° tasks, respectively (all P < 0.0001).

INTERPRETATION

Functional tasks elicit compensatory responses from uninjured muscles following severe cuff tears, notably in middle deltoid and teres minor, leading to posterior-superior glenohumeral loading. The muscles are potential targets for strengthening to avoid injury from sustained increased muscle force.

Sensitivity of Neuromechanical Predictions to Choice of Glenohumeral Stability Modeling Approach

Most upper-extremity musculoskeletal models represent the glenohumeral joint with an inherently stable ball-and-socket, but the physiological joint requires active muscle coordination for stability. The authors evaluated sensitivity of common predicted outcomes (instability, net glenohumeral reaction force, and rotator cuff activations) to different implementations of active stabilizing mechanisms (constraining net joint reaction direction and incorporating normalized surface electromyography [EMG]). Both EMG and reaction force constraints successfully reduced joint instability. For flexion, incorporating any normalized surface EMG data reduced predicted instability by 54.8%, whereas incorporating any force constraint reduced predicted instability by 43.1%. Other outcomes were sensitive to EMG constraints, but not to force constraints. For flexion, incorporating normalized surface EMG data increased predicted magnitudes of joint reaction force and rotator cuff activations by 28.7% and 88.4%, respectively. Force constraints had no influence on these predicted outcomes for all tasks evaluated. More restrictive EMG constraints also tended to overconstrain the model, making it challenging to accurately track input kinematics. Therefore, force constraints may be a more robust choice when representing stability.

Spatial Dependency of Glenohumeral Joint Stability during Dynamic Unimanual and Bimanual Pushing and Pulling

Degenerative wear to the glenoid from repetitive loading can reduce effective concavity depth and lead to future instability. Workspace design should consider glenohumeral stability to prevent initial wear. While stability has been previously explored for activities of daily living including push-pull tasks, whether stability is spatially dependent is unexplored. We simulated bimanual and unimanual push-pull tasks to 4 horizontal targets (planes of elevation: 0º, 45º, 90º, and 135º) at 90º thoracohumeral elevation and 3 elevation targets (thoracohumeral elevations: 20º, 90º, 170º) at 90º plane of elevation. The 45º horizontal target was most stable regardless of exertion type and would be the ideal target placement when considering stability. This target is likely more stable because the applied load acts perpendicular to the glenoid, limiting shear force production. The 135º horizontal target was particularly unstable for unimanual pushing (143% less stable than the 45º target), and the applied force acts parallel to the glenoid, likely creating shear forces. Pushing was less stable than pulling (all targets except sagittal 170º for both task types and horizontal 45º for bimanual) (p<0.01), which is consistent with prior reports. For example, unimanual pushing at the 90º horizontal target was 197% less stable than unimanual pulling. There were limited stability benefits to task placement for pushing, and larger stability benefits may be seen from converting pushing to pulling rather than optimizing task layout. There was no difference in stability between bimanual and unimanual tasks, suggesting no stability benefit to bimanual operation.

Modeling a rotator cuff tear: Individualized shoulder muscle forces influence glenohumeral joint contact force predictions

BACKGROUND

Rotator cuff tears in older individuals may result in decreased muscle forces and changes to force distribution across the glenohumeral joint. Reduced muscle forces may impact functional task performance, altering glenohumeral joint contact forces, potentially contributing to instability or joint damage risk. Our objective was to evaluate the influence of rotator cuff muscle force distribution on glenohumeral joint contact force during functional pull and axilla wash tasks using individualized computational models.

METHODS

Fourteen older individuals (age 63.4 yrs. (SD 1.8)) were studied; 7 with rotator cuff tear, 7 matched controls. Muscle volume measurements were used to scale a nominal upper limb model's muscle forces to develop individualized models and perform dynamic simulations of movement tracking participant-derived kinematics. Peak resultant glenohumeral joint contact force, and direction and magnitude of force components were compared between groups using ANCOVA.

FINDINGS

Results show individualized muscle force distributions for rotator cuff tear participants had reduced peak resultant joint contact force for pull and axilla wash (P ≤ 0.0456), with smaller compressive components of peak resultant force for pull (P = 0.0248). Peak forces for pull were within the glenoid. For axilla wash, peak joint contact was directed near/outside the glenoid rim for three participants; predictions required individualized muscle forces since nominal muscle forces did not affect joint force location.

INTERPRETATION

Older adults with rotator cuff tear had smaller peak resultant and compressive forces, possibly indicating increased instability or secondary joint damage risk. Outcomes suggest predicted joint contact force following rotator cuff tear is sensitive to including individualized muscle forces.

Changes in propulsion technique and shoulder complex loading following low-intensity wheelchair practice in novices

Background

Up to 80% of wheelchair users are affected by shoulder pain. The Clinical Practice Guidelines for preservation of upper limb function following spinal cord injury suggest that using a proper wheelchair propulsion technique could minimize the shoulder injury risk. Yet, the exact relationship between the wheelchair propulsion technique and shoulder load is not well understood.

Objective

This study aimed to examine the changes in shoulder loading accompanying the typical changes in propulsion technique following 80 min of low-intensity wheelchair practice distributed over 3 weeks.

Methods

Seven able-bodied participants performed the pre- and the post-test and 56 min of visual feedback-based low-intensity wheelchair propulsion practice. Kinematics and kinetics of propulsion technique were recorded during the pre- and the post-test. A musculoskeletal model was used to calculate muscle force and glenohumeral reaction force.

Results

Participants decreased push frequency (51→36 pushes/min, p = 0.04) and increased contact angle (68→94°, p = 0.02) between the pre- and the post-test. The excursion of the upper arm increased, approaching significance (297→342 mm, p = 0.06). Range of motion of the hand, trunk and shoulder remained unchanged. The mean glenohumeral reaction force per cycle decreased by 13%, approaching significance (268→232 N, p = 0.06).

Conclusions

Despite homogenous changes in propulsion technique, the kinematic solution to the task varied among the participants. Participants exhibited two glenohumeral reaction force distribution patterns: 1) Two individuals developed high force at the onset of the push, leading to increased peak and mean glenohumeral forces 2) Five individuals distributed the force more evenly over the cycle, lowering both peak and mean glenohumeral forces.

Fibrosis, low vascularity, and fewer slow fibers after rotator-cuff injury

INTRODUCTION

Rotator-cuff injury (RCI) represents 50% of shoulder injuries, and prevalence increases with age. Even with successful tendon repair, muscle and joint function may not return.

METHODS

To explore the dysfunction, supraspinatus and ipsilateral deltoid (control) muscles were biopsied during arthroscopic RCI repair for pair-wise histological and protein-expression studies.

RESULTS

Supraspinatus showed fiber atrophy (P <  0.0001), fibrosis (by Sirius Red, P = 0.05), reduced vascular density (P <  0.001), and a lower proportion of slow fibers (P <  0.0001) compared with the ipsilateral control muscle. There were also higher levels of atrogin-1 (P = 0.05), vascular endothelial growth factor (VEGF, P <  0.01), and dystrophin (P <  0.008, relative to fiber diameter) versus control.

CONCLUSIONS

Adaptive changes in vascular endothelial growth factor and dystrophin were likely associated with reduced vascular supply, fatigue resistance, and fibrosis, accompanied by disuse atrophy from mechanical unloading of supraspinatus after tendon tear. Treatment to promote growth and vascularity in atrophic supraspinatus muscle may help improve functional outcome after surgical repair. Muscle Nerve 55: 715-726, 2017.

The influence of wheelchair propulsion hand pattern on upper extremity muscle power and stress

The hand pattern (i.e., full-cycle hand path) used during manual wheelchair propulsion is frequently classified as one of four distinct hand pattern types: arc, single loop, double loop or semicircular. Current clinical guidelines recommend the use of the semicircular pattern, which is based on advantageous levels of broad biomechanical metrics implicitly related to the demand placed on the upper extremity (e.g., lower cadence). However, an understanding of the influence of hand pattern on specific measures of upper extremity muscle demand (e.g., muscle power and stress) is needed to help make such recommendations, but these quantities are difficult and impractical to measure experimentally. The purpose of this study was to use musculoskeletal modeling and forward dynamics simulations to investigate the influence of the hand pattern used on specific measures of upper extremity muscle demand. The simulation results suggest that the double loop and semicircular patterns produce the most favorable levels of overall muscle stress and total muscle power. The double loop pattern had the lowest full-cycle and recovery-phase upper extremity demand but required high levels of muscle power during the relatively short contact phase. The semicircular pattern had the second-lowest full-cycle levels of overall muscle stress and total muscle power, and demand was more evenly distributed between the contact and recovery phases. These results suggest that in order to decrease upper extremity demand, manual wheelchair users should consider using either the double loop or semicircular pattern when propelling their wheelchairs at a self-selected speed on level ground.

Compensatory strategies during manual wheelchair propulsion in response to weakness in individual muscle groups: A simulation study

BACKGROUND

The considerable physical demand placed on the upper extremity during manual wheelchair propulsion is distributed among individual muscles. The strategy used to distribute the workload is likely influenced by the relative force-generating capacities of individual muscles, and some strategies may be associated with a higher injury risk than others. The objective of this study was to use forward dynamics simulations of manual wheelchair propulsion to identify compensatory strategies that can be used to overcome weakness in individual muscle groups and identify specific strategies that may increase injury risk. Identifying these strategies can provide rationale for the design of targeted rehabilitation programs aimed at preventing the development of pain and injury in manual wheelchair users.

METHODS

Muscle-actuated forward dynamics simulations of manual wheelchair propulsion were analyzed to identify compensatory strategies in response to individual muscle group weakness using individual muscle mechanical power and stress as measures of upper extremity demand.

FINDINGS

The simulation analyses found the upper extremity to be robust to weakness in any single muscle group as the remaining groups were able to compensate and restore normal propulsion mechanics. The rotator cuff muscles experienced relatively high muscle stress levels and exhibited compensatory relationships with the deltoid muscles.

INTERPRETATION

These results underline the importance of strengthening the rotator cuff muscles and supporting muscles whose contributions do not increase the potential for impingement (i.e., the thoracohumeral depressors) and minimize the risk of upper extremity injury in manual wheelchair users.