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[Evolution of tetrapod locomotion].

Fish-like ancestors of tetrapods did not need strong limb musculature because they inhabited waters and were practically imponderable. In the primitive tetrapods, principal function of the limbs was initially restricted to passive anchoring in the course of animal movements on the substrate by means of lateral bending of the body (undulation). However, progressive development of carrying function of tetrapod limbs lead to clearing the body off the substrate which reduced friction costs and made the tetrapods less dependent on the substrate properties. Along with this, the limbs became more important as the active locomotory organs. But at the beginning, this diminished locomotory speed as the momentum caused by undulation could no longer provide additional forward sliding. Locomotory function of the tetrapod limb could be carried out due to both retraction and pronation at the shoulder joint. Relatively short humerus of the primitive tetrapods made it indifferent which of these two particular actions lead to elongation of the steps. In most of the recent tetrapods with sprawling limbs (Urodela, Lacertilia Sphenodontia, Crocodilia), step elongation was carried out mainly by retraction at the shoulder joint. Contrary to this, in Tachyglossidae (Mammalia: Monotremata) retraction is absent while pronation at the shoulder joint becomes the most important component of step elongation. This made it possible to recognize two principal types, pronatory and retractory, of locomotion on the basis of the main movement in the phase of support. A mathematical model describing changes in step length during the phase of support in both of these types is elaborated. It takes into account relative sizes of stylopodium and zeugopodium, the angles of pronation and retraction at the shoulder joint, the angle of adduction at the elbow joint, and the angle of body undulation arc. It is shown on the basis of this model, varying of which of the above parameters is advantageous and which is disadvantageous in each of the locomotory types. In the pronatory locomotory type, adduction (lateral mobility) at the elbow joint is employed. It leads to special changes in morphology of the elbow joint due to which humeral condyle becomes spherical and promotes both adduction and rotation of the entire antebrachium. In the retractory locomotory type, amplification of pronation is to be limited in order to provide step elongation, so certain morphological adaptations occur in the elbow joint which prevent adduction at this joint. For step elongation, retraction at the shoulder joint is usually more advantageous than pronation, therefore historical emergence of the pronatory type could be considered as inadaptive. However, transversal horizontal axis of rotation at the shoulder joint appeared to be a prerequisite of the subsequent appearance of the most perfect locomotion in the therian mammals with their parasagittal limbs. Transition to the parasagittal limb construction was associated with adaptation to jumping asymmetric locomotion. It caused elongation of the shoulder bone downward which lead to widening of rotation cone of the humerus and, at the same time, to reduction of the coracoid portion of the glenoid fossa, the latter became horizontal rather than lateral. As a part of this process, the longitudinal axis of the scapula was displacing caudally with destruction of the suture-like articulation of the acromion process with the clavicle. The latter became articulated with the sternum directly or via much reduced interclavicle (or via procoracoid rudiment). This increases amortisatory function of the shoulder girdle during landing at the final stage of jump.

Amphibians↗

Motor planning of arm movements is direction-dependent in the gravity field.

In the present study we analyzed kinematic and dynamic features of arm movements in order to better elucidate how the motor system integrates environmental constraints (gravity) into motor planning and control processes. To reach this aim, we experimentally manipulated the mechanical effects of gravity on the arm while maintaining arm inertia constant (i.e. the distribution of the mass around the shoulder joint). Six subjects performed single-joint arm movements (rotation around the shoulder joint) in both sagittal (upward, U, versus downward, D) and horizontal (left, L, versus right, R) planes, at different amplitudes and from different initial positions. Under these conditions, shoulder gravitational torques (SGTs) significantly varied when arm movements were performed in the sagittal but not in the horizontal plane. Contrary to SGTs, arm inertia remained constant and similar for both horizontal and sagittal planes since subjects performed arm movements with only one degree of freedom. All subjects, whatever the movement direction, appropriately scaled shoulder joint kinematic parameters according to movement amplitude. Furthermore, peak velocity and movement duration were equivalent for both horizontal and sagittal planes. Interestingly, some kinematic parameters significantly differed according to U/D but not L/R directions. Specifically, acceleration duration was greater for D than U movements, while the opposite was true for peak acceleration. Consequently, although vertical and horizontal arm movements shared a general common strategy (i.e. scaling law), the kinematic asymmetries between U and D arm movements, especially those that reflect central planning process (i.e. peak acceleration), indicated different motor intentions regarding the direction of the upcoming movement. These findings indicate that the interaction of the arm with the dynamics of the environment is internally represented during the generation of arm trajectories.

Adult↗

[Analysis of the collective term "periarthritis humeroscapularis"].

The functional and anatomical consideration of the shoulder joint in relation to the clinical aspects can differentiate the general term of "scapulohumeral periarthritis". The most frequently pathological findings are seen in the rotary cuff and the long head of the biceps muscle. Significant causes are further arthrosis of the acromioclavicular joint, the instability of the shoulder joint and the frozen shoulder. The exact diagnosis of the disease makes on operative therapy possible.

Acromioclavicular Joint↗

A new shoulder range of motion screening measurement: its reliability and application in the assessment of the prevalence of shoulder contractures in patients with impaired consciousness caused by severe brain damage.

OBJECTIVES: To determine the reliability of a new shoulder joint range of motion (ROM) measurement for unconscious patients and to assess the prevalence of shoulder joint contractures in such patients. DESIGN: Prospective cohort survey. SETTING: An early rehabilitation center for adult persons with neurologic disorders. PARTICIPANTS: Fifty patients with impaired consciousness caused by severe cerebral damage of various etiologies. In addition, reference values were measured in 60 healthy adults. INTERVENTION: Shoulder ROM was assessed by measuring the distance between the olecranon and underlay while the patient lay supine on a solid surface and the patient's hands were passively positioned behind the neck. Distances between the olecranon and underlay were measured, first, manually by the rater and, second, for control, digitally by a blinded person from a digital photo taken while a constant force was applied to the elbow. MAIN OUTCOME MEASURES: Prevalence of contractures defined as increased distance between the olecranon and underlay or impossibility of positioning the hands passively behind the neck, and intra- and interrater-reliability of the 2 shoulder ROM measurements with the interclass correlation coefficient (ICC). RESULTS: Measurement of shoulder ROM showed high intra-(ICC range, .78-.91) and interrater reliability (ICC range, .77-.90) for manual measurement, high intra- (ICC range, .91-.95) and interrater reliability (ICC range, .90-.94) for the digital analysis, and a high ICC for both methods (ICC=.87). The prevalence of shoulder contractures was 56% in the patients and 50% of all shoulder joints. CONCLUSIONS: The described method provided a reliable measurement for reduced shoulder ROM and appears to be a useful screening method to show the prevalence of shoulder joint contracture in these patients.

Adult↗

Evaluation of a new rehabilitation program for postoperative patients with breast cancer.

The purpose of the present study was to evaluate the efficacy of a newly designed rehabilitation program for postoperative patients with breast cancer. This was achieved through examinations to clarify the range of motion (ROM) of the shoulder joint, postoperative pain and recovery of activities of daily living (ADL). The ROM of the shoulder joint was evaluated with respect to five items and determinations were carried out five times. Patients were orally questioned four times regarding their pain after surgery, movement-associated chest pain, pain at night and operative wound pain. Evaluation of the ADL after discharge was conducted using a three-level rating method at postoperative week 4 and week 12. A total of 72 patients were studied, comprising 39 who underwent pectoral muscle-conserving mastectomy and 33 who underwent breast-conserving surgery. The arm movement of forward raising showed the greatest decline, followed by lateral raising of the arm. Postoperative time-course changes in internal/external arm rotation, as well as backward arm raising were slight. Comparison of the operative procedures revealed differences only for lateral arm raising at postoperative week 4, while there were no differences in any of the shoulder joint movements. Lowering of the ROM of the shoulder joint was more marked at an earlier time (week 1 to week 2) after surgery, but it was not statistically significant. Pain at night and operative wound pain were prolonged over the period, and reported in postoperative week 1 to week 12 by 3-15% of patients. All ADL items became almost normal in approximately 90% of patients at postoperative week 4. The efficacy of the present rehabilitation program early after surgery was demonstrated in terms of recovery of ADL as well as the ROM of the arm on the affected side.

Activities of Daily Living↗

Degenerative joint disease: multiple joint involvement in young and mature dogs.

Radiologic, pathologic, and ancillary methods were used to determine the occurrence of degenerative joint disease involving multiple joints of immature and adult dogs. Animals were selected for the development of hip joint dysplasia and chronic degenerative joint disease. Of disease-prone dogs, 82% (45 of 55 dogs) had radiologic changes, indicative of hip dysplasia, by 1 year of age. At necropsy, more abnormal joints were identified than by radiographic examination. Among 92 dogs between 3 to 11 months of age that had joint abnormalities, 71% had hip joint involvement; 38%, shoulder joint involvement; 22%, stifle joint involvement; and 40% had multiple joint involvement. Polyarthritis was asymptomatic and unexpected. Radiographic examination of older dogs also revealed evidence of degenerative joint disease in many joints. Multiple joint involvement was substantiated at necropsy of young and mature dogs. A similar pattern of polyarticular osteoarthritis was revealed in a survey (computer search) of necropsy reports from medical case records of 100 adult and elderly dogs. Usually, the joint disease was an incidental observation, unrelated to the clinical disease or to the cause of death. The frequent occurrence of degenerative changes in several joints of dogs aged 6 months to 17 years indicated that osteoarthritis may be progressive in these joints and raises the possibility that systemic factors are involved in the disease process.

Age Factors↗

[Results of posterior inferior capsular shift in posterior shoulder instability].

PURPOSE: The purpose of this study was the evaluation of our results after posteroinferior capsular shift in patients with a posterior shoulder instability. MATERIALS AND METHODS: In a prospective study we evaluated 12 patients (14 shoulder joints) with recurrent posterior shoulder dislocations who were stabilized by a posteroinferior capsular shift procedure. For the clinical documentation the Rowe-Score, the ASES-Score and the SF-36 were used. Furthermore the patients were submitted to standardized EMG-, isokinetic and proprioceptive tests. RESULTS: After an average follow-up of 22.2 months there were two recurrences which occurred during the first postoperative year. The Rowe-Score improved from 46.25 to 76.34 points. The ASES-Score showed an average of 42.43 points pre-operatively and at the time of follow-up an average of 78.86 points. Most parameters of the ASES-Score as well as the score in total had a constant positive tendency. Only the subjective rating of stability showed a slight decrease after the first six months due to the two redislocations. But even the stable shoulder joints demonstrated limitations when throwing a ball. The SF-36 showed a definite gain in the overall quality of living as well. The EMG-tests at follow-up showed a deficit for the patients compared with a control group; even more for the female than for the male patients. Similar tendencies were found with the isokinetic strength. The proprioception did not show any differences between the patients and the control group. CONCLUSION: With adequate patient selection and after failure of all possible conservative treatments the posteroinferior capsular shift is a therapeutical option in recurrent posterior shoulder instability.

Adolescent↗

[Subchondral osteonecroses of large joints in rheumatoid arthritis].

The frequency and preferred localisation of overt subchondral osteonecrosis in large joints have been studied in a roentgenological and clinical study. Among 619 patients (454 female, 165 male) a severe subchondral osteonecrosis was found 44 times on one or more (maximum 3) large joints of 30 patients. The hip and shoulder joints were most frequently attacked, while patients with an advanced stage or longer duration of the disease and those in the middle age groups showed this most often. Osteonecrosis did not necessarily correlate with the activity of the disease process and with the presence of a positive rheumatoid factor. Radiologically, osteolytic appearances are seen most often in the elbow and osteochondritis dissecans in the knee joint. In the hip and shoulder joint the appearances are those of reparative states with a distinct demarcation, more rarely a severe osteolysis also involving the adjacent skeletal parts, occasionally a diffuse irregular lytic osteoporosis and necrosis. The pathogenesis is discussed in detail.

Adult↗

Supraspinatus tendinosis associated with biceps brachii tendon displacement in a dog.

A 4-year-old spayed female Australian Cattle Dog (Blue Heeler) was evaluated because of right forelimb lameness of 5 months' duration. Orthopedic evaluation revealed signs of pain localized to the cranial aspects of both shoulder joints. Via magnetic resonance imaging, the mass of the supraspinatus tendon insertion in both shoulder joints was increased, compared with findings in cadavers of clinically normal dogs; additional imaging procedures revealed that, compared with clinically normal tendons, the tendon had increased signal intensity that was consistent with increased fluid content. The increased supraspinatus tendon mass in each shoulder joint was associated with medial displacement of the biceps brachii tendon, which was more severe in the right limb. Arthroscopic evaluations of both shoulder joints revealed no abnormalities. The dog underwent surgery, and the abnormal parts of the tendons were resected. The most prominent finding on histologic examination of excised tissues was severe myxomatous degeneration. The lameness resolved, and at 22 months after surgery, the dog was reported to have had no recurrence of lameness. The clinical signs and histologic appearance of the tendons in this dog strongly resemble findings associated with tendinosis in humans. Decompression of the biceps brachii tendon may have contributed to the successful outcome after surgery in this dog. Supraspinatus tendinosis should be considered among the differential diagnoses in dogs with uni- or bilateral forelimb lameness.

Animals↗

Cineradiographic study of forelimb movements during quadrupedal walking in the brown lemur (Eulemur fulvus, Primates: Lemuridae).

Movements of forelimb joints and segments during walking in the brown lemur (Eulemur fulvus) were analyzed using cineradiography (150 frames/sec). Metric gait parameters, forelimb kinematics, and intralimb coordination are described. Calculation of contribution of segment displacements to stance propulsion shows that scapular retroversion in a fulcrum near the vertebral border causes more than 60% of propulsion. The contribution by the shoulder joint is 30%, elbow joint 5%, and wrist joint 1%. Correlation analysis was applied to reveal the interdependency between metric and kinematic parameters. Only the effective angular movement of the elbow joint during stance is speed-dependent. Movements of all other forelimb joints and segments are independent of speed and influence, mainly, linear gait parameters (stride length, stance length). Perhaps the most important result is the hitherto unknown and unexpected degree of scapular mobility. Scapular movements consist of ante-/retroversion, adduction/abduction, and scapular rotation about the longitudinal axis. Inside rotation of the scapula (60 degrees -70 degrees ), together with flexion in the shoulder joint, mediates abduction of the humerus, which is not achieved in the shoulder joint, and is therefore strikingly different from humeral abduction in man. Movements of the shoulder joint are restricted to flexion and extension. At touch down, the shoulder joint of the brown lemur is more extended compared to that of other small mammals. The relatively long humerus and forearm, characteristic for primates, are thus effectively converted into stride length. Observed asymmetries in metric and kinematic behavior of the left and right forelimb are caused by an unequal lateral bending of the spinal column.

Animals↗

Shoulder destruction in rheumatoid arthritis. Classification and prognostic signs in 83 patients followed 5-23 years.

We studied the natural course and the possibility of making prognoses about shoulder joint destructions in 83 patients with rheumatoid arthritis (RA) (166 shoulder joints). For this purpose, we used radiographic patterns and 2 indices (upward migration and medial displacement). The patterns of joint destruction were classified into 5 groups: 1) non-progressive type (n 74) with normal radiographs, only osteopenia or small erosions even after 15-20 years of RA; 2) erosive type (n 22) showing marginal erosions but no collapse; 3) collapse type (n 34) showing subchondral cysts, followed by collapse; 4) arthrosis-like type (n 12) showing arthrotic features; 5) mutilating type (n 14) showing mutilating bone destructions. From the radiographic findings and the 2 indices determined at 5-10 years, we could predict the prognosis of shoulder joint destruction after 15-20 years of RA. Our findings may be of value for selecting treatment, including surgery, for the rheumatoid shoulder.

Adult↗

Evaluation of arthritis in Reiter's disease by bone scintigraphy and radiography.

Tc-99m MDP bone scans were used to evaluate the articular inflammation in 38 patients with Reiter's disease and compared with clinical examination and radiologic findings. Our data showed that Reiter's disease predominantly involves the lower limbs, especially the heels, which may be a characteristic feature of Reiter's disease. Bone scans revealed a high diagnostic sensitivity in the detection of clinical arthritis in all peripheral joints, especially in the small joints of the four limbs. The diagnostic sensitivity of radiography was generally lower than bone scintigraphy. In the presence of positive radionuclide findings, clinical arthritis was found in most joints. The scintigram, however, detects a greater number of abnormalities than does clinical assessment in the sternoclavicular joints, shoulders, metacarpophalangeal joints, and tarsals. Because of its high sensitivity, bone scintigraphy is capable of detecting subclinical arthritis, and might provide more objective evidence of early inflammatory joint disease and additional information regarding the pattern of joint involvement. In view of the advantages of low patient radiation exposure, high sensitivity, and the ability to survey the whole body, we consider bone scintigraphy as useful and better than radiography in the detection of early articular inflammation and in establishing the extent and pattern of arthritis in Reiter's disease.

Adolescent↗

[Arthroscopic surgery].

Although arthroscopy of the knee joint had already been reported during the 1930's, the general dissemination of this method first began in the 1970's. The main reason for the rapid dissemination of this method was especially the fact that in addition to diagnostics, therapeutic possibilities were recognized and immediately implemented. This meant that arthroscopy had great potential and was made well known since the surgery was minimally invasive. Today we can assume that the technological side of the arthroscopic method is very widely developed and new innovations only arise slowly. Innovations are mostly connected with new innovative operating techniques. Surgery of the knee joint was the dominant application of arthroscopy in the beginning. The method was quickly applied to other joints. Today there is practically no joint which is inaccessible to arthroscopy. From surgical and therapeutic perspectives, arthroscopy is most frequently used today for the knee joint, followed by the shoulder joint, ankle joint, elbow joint, hip joint as well as wrist joint. Arthroscopic surgery within the field of joint surgery is regarded as indispensable. This specific surgery needs corresponding ability and skill, which must be individually acquired. Arthroscopic surgery evidently depends on technology and accordingly requires a corresponding fully operational medical infrastructure and knowledge. The big advantage of arthroscopic surgery lies in the minimally invasive technique, which has reduced the primary postoperative mortality significantly. Therefore, with good indicators the patient has decisive advantages as well as good cost to benefit ratios.

Ankle Joint↗

Relation between bilharzial arthropathy and histocompatibility leucocytic antigen B27.

Fifty cases of active schistosomiasis divided into group I test group consists of twenty-five patients with arthropathy and group II control group consists of twenty-five patients without arthropathy, were subjected to clinical examination, indirected haemagglutination test (IHAT) for bilharziasis and plain X-ray on lumbosacral, sacroiliac and knee joints. HLA-B27 antigen typing was also done as a trial to find association between this antigen and the Egyptian cases of bilharzial arthropathy. Clinical examination of patients with arthropathy showed that the frequency of joint affection was knee joint 76%, shoulder joint 12% and hip, elbow and sacroiliac joints were equally 4% affected. Although the affected joints were tender and with limited movement, there were no hotness, deformities and morning stiffness. There was no effusion nor swelling except in one case of knee joint arthropathy. The results of the IHAT showed hundred percent positivity in all the patients without significant statistical difference between the test and the control groups (P greater than 0.05). X-ray on the sacroiliac, lumbosacral and knee joints showed no abnormalities in all the cases. The results of the HLA-B27 antigen typing showed that the frequency of this antigen in the test group was 16% and in the control group was 4%. The relation risk was 4.57 and the aetiological fraction was very small 0.12. However there was insignificant statistical difference between the test and the control groups (P greater than 0.05).

HLA-B27 Antigen↗

Systematic review of outpatient services for chronic pain control.

AIM OF REPORT. This report reviews the evidence about the effectiveness of treatments for chronic pain. While treatment of chronic pain is usually seen as an integrated service, this report concentrates on the individual interventions that constitute the service. HOW THE RESEARCH WAS CONDUCTED. Searches of databases and journals identified over 15,000 randomised studies with pain as an outcome, and many more which were not randomised. Over 150 systematic reviews relevant to chronic pain treatment were identified and their quality assessed using a simple scoring system. Systematic reviews conducted for this report were based mainly on randomised trials. The number needed to treat (NNT) was chosen as the output for the report. NNTs of 2-4 indicate effective treatments. Because NNT is treatment-specific it overcomes problems associated with highly variable placebo or control event rates in pain trials. Such variability is predominantly due to the limited numbers of patients in the clinical trials. Dichotomous outcome measures are important in synthesising information from many studies, and in deriving NNTs. Methods have been developed which allow mean information on pain relief and intensity to be converted reliably into the simple dichotomous outcome of at least 50% pain relief. RESEARCH FINDINGS. PHYSICAL INTERVENTIONS. Transcutaneous electrical nerve stimulation (TENS) has been shown not to be effective in postoperative and labour pain. In chronic pain, there is evidence that TENS effectiveness increases slowly, and that large doses need to be used. There is lack of evidence for the effectiveness of TENS in chronic pain. There is a lack of evidence for the effectiveness of relaxation. Intravenous systemic regional blockade with guanethidine has been shown to be without effect. Epidural corticosteroids are effective in the short term for back pain and sciatica. Injections of corticosteroids in or around shoulder joints for shoulder pain have been shown not to be effective. There is a lack of evidence supporting spinal cord stimulators. Case series are of poor quality and do not provide evidence of effectiveness, although at least 50% pain relief at 5 years is reported in over 50% of patients. PHARMACOLOGICAL INTERVENTIONS. Minor analgesics are important in chronic pain. NNTs were calculated for analgesics given orally for moderate or severe acute postoperative pain. The NNTs found ranged from 17 (poor) for codeine, 60 mg, to 2.5 (good) for ibuprofen, 400 mg. Anticonvulsant and antidepressant drugs are prescribed for neuropathic pains like diabetic neuropathy. NNTs are of the order of 2.5, showing them to be effective treatments. However, there are too few studies with too few patients to determine which is the best drug. Minor adverse events are common, and major adverse events occur in about 1 in 20 patients. There are no studies comparing antidepressants and anticonvulsants directly. Systemic local anaesthetic-type drugs have been shown to be effective in nerve injury pain but there is little or no evidence to support their use in migraine or cancer-related pain. Topical NSAIDs (for example, gels, creams) are effective in rheumatological conditions with an overall NNT of 3. There are too few studies to determine which is the best agent. Topical NSAIDs have few adverse events; most importantly they are without the major gastrointestinal adverse events found with oral NSAIDs, which might make them an important choice for some patients with peripheral arthritis. (ABSTRACT TRUNCATED)

Ambulatory Care↗

[A comparison between the pain relief effect of electroacupuncture, regional never block and electroacupuncture plus regional never block in frozen shoulder].

BACKGROUND: Frozen shoulder is a kind of spontaneous, progressive peri-arthritis over the shoulder joint. The etiology is not yet clear. Traditional treatments for frozen shoulder included conservative medical therapy, physical therapy, nerve block and acupuncture and so on. The purpose of our study is to determine the pain relief effect of electroacupuncture (EAP), regional nerve block (RNB) and the combination of EAP + RNB for frozen shoulder. MATERIALS & METHODS: One hundred and fifty patients with fresh frozen shoulder were, randomly divided into 3 groups. Group I patients (n = 50) had RNB with stellate ganglion block and suprascapular nerve block by 1% xylocaine 10 ml. Group II patients (n = 50) had EAP with local acupoint--Chien-Yu, Chien-Ching, Chien-Nei-Ling, Ah-Shih Hsueh treatment and Group III (n = 50) patients had RNB+EAP performed with acupuncture first, then followed by the regional nerve block. Six vectors of movements were checked in all methods. Four graded Bromage score was used for pain assessment, Grade 1 means complete painless; Grade 2 means slight pain (i.e. pain on motion); Grade 3 means moderate pain (i.e. pain on silence); Grade 4 means severe pain (i.e. need analgesics). The range of shoulder joint was also recorded. Patients were requested for second treatment if pain recurred. The onset (time from injection to maximal pain relief), duration (time from injection to grade 3) Bromage score and side effects were recorded. RESULTS: The results showed that the combined EAP and RNB method had significant high pain control quality, longer duration, and better range of movement of the shoulder joint than that of EAP or RNB performed alone.

Analgesia↗