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Distally planned lateral arm flap.

The lateral arm flap presents some drawbacks: the vascular pedicle is short (2-6 cm), and the flap is rather thick. An anastomotic network between the posterior radial collateral artery and the recurrent radial artery, demonstrated by our previous anatomical dissections, enables one to locate the skin paddle solely over the epicondylar region and the proximal forearm. Furthermore, since no skin is harvested over the lateral aspect of the arm, a random-type vascularisation for the distal skin can be excluded. This modification increases pedicle length up to 100% and limits the amount of subcutaneous fat. A series of 13 consecutive distally based lateral arm flaps was performed, and eight patients were followed up for a minimum of 12 months postoperatively. Flap size ranged from 8 x 5.5 cm to 23 x 7 cm (average, 14 x 6 cm), and pedicle length ranged from 9 to 14 cm (average, 10.5 cm). No venous grafts were needed. The mean flap harvesting time was 60 minutes. All the donor sites were closed primarily. One flap suffered from an arterial thrombosis and only partially survived, and another healed uneventfully after successful re-exploration of a venous thrombosis. Only one flap had to be partially debulked. The donor site scar was enlarged in one patient. Elbow mobility was unaffected by surgery. Patient self-assessment on the appearance of both the reconstruction and the donor site showed a high satisfaction rate. The distally planned lateral arm flap presents decreased bulk and a longer pedicle when compared with the classical lateral arm flap with no added technical difficulties or morbidity.

Adult↗

Fibrinolytic activity of the arms and legs of patients with lower limb venous disease.

Clearance of subcutaneous 125I-labelled fibrin was prolonged from the legs but not from the arms of patients with uncomplicated varicose veins and patients with healed ulcers, compared with controls. The euglobulin clot lysis time (ECLT) of blood from the arms and legs of those with healed ulcers was prolonged; venous congestion significantly shortened the ECLT of blood from all limbs except legs with healed ulcers. The clearance of interstitial fibrin of both legs and arms correlated with the response of the ECLT to venous congestion (P less than 0.05). The clearance of interstitial 125I-labelled albumin in five patients with healed ulcers was faster from the legs than from the arms, whereas the clearance of interstitial 125I-labelled fibrin was faster from the arms in all cases. These results suggest that there is a defect in interstitial fibrinolytic activity as well as vein wall production of plasminogen activator in legs with chronic venous insufficiency.

Arm↗

Dyspnea-limited response in chronic obstructive pulmonary disease: reduced unsupported arm activities.

Dyspnea, the sensation of uncomfortable breathing, is the primary activity-limiting symptom leading to reduced functional ability in chronic obstructive pulmonary disease (COPD). Patients with severe COPD report a marked increase in the sensation of dyspnea with routine tasks that require arm use, especially activities necessitating unsupported arm elevation. Dyspnea is associated with alterations in respiratory muscle function, such as an increase in muscle force requirement, a reduction in respiratory muscle strength and endurance, and an increase in the recruitment of the rib cage and accessory muscles. Unsupported arm exercise (UAE) further compromises respiratory muscle capacity for ventilation because it requires the muscles' concomitant recruitment in the maintenance of chest wall stabilization. This article presents respiratory muscle mechanisms leading to reduced UAE, methods of measuring unsupported arm endurance, and treatment strategies to improve unsupported arm activity endurance in patients with COPD.

Activities of Daily Living↗

Time and magnitude of torque generation is impaired in both arms following stroke.

Muscle strength, usually measured as the peak torque during maximal contraction, is impaired in persons with stroke. Time-dependent properties of muscle contraction may also be altered but have not been quantified. We quantified both magnitude (peak torque) and time-dependent parameters (times to develop and reduce torque) in eight different isometric joint actions. Parameters were compared among the more and less affected arms of 20 persons with chronic stroke and the nondominant arms of 10 similarly aged healthy persons. Torque-generation parameters were independent from one another (i.e., low correlations) and highly reliable between trials and days. All parameters were impaired in the more affected arm, whereas peak torque and time to develop torque were impaired in the less affected arm. Following stroke, torque-generation impairments include both magnitude and time-dependent properties and exist not only in the more affected but also in the less affected arm. Clinicians attempting to improve upper-extremity function should employ therapeutic exercises that challenge patients to improve both their strength and speed of muscle contraction.

Aged↗

The coordination between trunk and arm motion during pointing movements.

The coordination between the trunk and arm of six subjects was examined during unrestrained pointing movements to five target locations. Two targets were within arm's length, three were beyond. The trunk participated in reaching primarily when the target could not be attained by arm and scapular motion. When the trunk did contribute to hand transport, its motion started simultaneously with arm movement and continued until target contact. Redundancy in the degrees of freedom used to execute the movement had no effect on the configuration of joints and segments used to attain a specified target; no difference in variability was noted regardless of whether redundancy existed. However, different configurations were used to achieve the same wrist coordinates along a common endpoint path, depending on the final position of the hand. The addition of trunk flexion, rotation and scapular motion did not alter the coupling between the elbow and shoulder joints and had no effect on the path of the hand or the smoothness of its velocity profile. Thus, trunk motion was integrated smoothly into the transport phase of the hand. As the trunk's contribution to hand transport increased, it played a progressively greater role in positioning the hand close to the target during the terminal stage of the reach. Of the movement components measured, trunk flexion was the last component to complete its motion when target reaches were made beyond arm's length. Hence, the trunk not only acts as a postural stabilizer during reaching, but becomes an integral component in positioning the hand close to the target.

Adult↗

Shift of preferred directions of premotor cortical cells with arm movements performed across the workspace.

The activity of 156 neurons was recorded in the premotor cortex (Weinrich and Wise 1982) and in an adjoining rostral region of area 6 (area 6 DR; Barbas and Pandya 1987) while monkeys made visually-guided arm movements of similar direction within different parts of space. The activity of individual neurons varied most for a given preferred direction of movement within each part of space. These neurons (152/156, 97.4%) were labeled as directional. The spatial orientation of their preferred directions shifted in space to "follow" the rotation of the shoulder joint necessary to bring the arm into the different parts of the work-space. These results suggest that the cortical areas studied represent arm movement direction within a coordinate system rotating with the arm and where signals about the movement direction relate to the motor plan through a simple invariant relationship, that between cell preferred direction and arm orientation in space.

Animals↗

Coordination of fast eye and arm movements in a tracking task.

Eye and arm movements to single and double-step target displacements were studied to investigate whether or not the motor systems of the eye and arm share common command signals from the internal representation, which specify a) when a movement is initiated and b) the end position of a movement. The correlation between the time of onset of eye and arm movements was significant for single-step and double-step target displacements into the same direction. However, it was small and not significant for double-step target displacements into opposite directions if the time interval between first and second target displacement was 75 or 100 ms. This indicates that the command signal which specifies when a movement is started is different for both systems. However, the reconstructed signal in the internal representation, which specifies the end position of movements, is rather similar for eye and arm movements which seems to point to a common command signal. This result was corroborated by experiments in which eye and arm were found to jump always to the same target in the condition that two different targets were presented simultaneously.

Adult↗

Arm movement performance during reversible basal ganglia lesions in the monkey.

Arm motor performance of eight Cebus monkeys was examined during reversible cooling in the ventral lateral region of the putamen and globus pallidus (primarily the external segment), where neurons discharging during arm movements have been found (DeLong 1972). When attempting to hold a handle stationary during basal ganglia cooling, all monkeys developed flexion at the wrist and some developed a slow flexion drift of the arm at the elbow. The prominence of wrist flexion emphasizes that the basal ganglia may normally influence distal musculature. During basal ganglia cooling an increase in segmental stretch reflexes (15-30 ms) was sometimes observed following arm perturbations, but no consistent increase occurred in the later EMG responses (30-95 ms) in contrast to results obtained in Parkinsonian patients (Tatton and Lee 1975). No major changes were observed in the time of onset of the earliest EMG activity in the agonist muscle in a simple reaction time elbow movement task during basal ganglia cooling. Basal ganglia lesions produced major disorders in both flexion and extension movements including slowing of movements and rebound of the arm towards its initial position after onset of movement. These disorders were accompanied by an increase in tonic activity of both flexors and extensors while holding and by increased levels of cocontraction of agonists and antagonists during attempted movements. It is suggested that this basal ganglia disorder is due to a failure to achieve the correct balance of activity between agonists and antagonists that is appropriate for a particular motor act.

Animals↗

Control of human arm movements in two dimensions: paths and joint control in avoiding simple linear obstacles.

In order to examine path planning and the control of redundant degrees of freedom in the human arm, the movements of the shoulder, elbow and wrist were recorded as subjects moved a pointer to a target and avoided a simple obstacle. With respect to joint control, the results show that the extra degree of freedom provided by the wrist is incorporated into target movements in a systematic manner for both large and small obstacles; it is not used only when there is no geometrical alternative. For the wrist, two strategies are apparent, depending upon the length of the obstacle. Wrist extension predominates for shorter obstacles, while flexion or extension and flexion predominate for longer obstacles. These wrist movements shorten the effective length of the distal segments (lower arm plus hand and pointer) and thus reduce the excursion required at the proximal joints. In part, they correspond to assuming the most comfortable arm configuration at each point in the new path necessitated by the obstacle and can be described by static cost functions. However, wrist extension is also used to move the hand and pointer away from the obstacle as shoulder and elbow movements carry the wrist itself towards the obstacle. Wrist flexion is also used to move the pointer tip rapidly past the obstacle. These components, which cannot be explained by static cost functions alone, confirm for the human arm the hypothesized use of redundant degrees of freedom in obstacle avoidance. With respect to path planning, the results show that the minimum distance between pointer and obstacle remains fairly constant over a large range of obstacle lengths; this relative invariance is interpreted to support the hypothesis that workspace coordinates are important for movement planning. However, minimum distance and several other path parameters do depend significantly on the orientation and location of the movement in the workspace. This inhomogeneity implies that movement planning does not occur exclusively in workspace coordinates; it suggests an influence of joint space criteria. In frontal movements, for example, the systematic decline in the minimum distance with increasing obstacle length is interpreted as a compromise reducing the amount of extra joint movement and the discomfort of arm configurations.

Adult↗

The control of hand equilibrium trajectories in multi-joint arm movements.

According to the equilibrium trajectory hypothesis, multi-joint arm movements are achieved by gradually shifting the hand equilibrium positions defined by the neuromuscular activity. The magnitude of the force exerted on the arm, at any time, depends on the difference between the actual and equilibrium hand positions and the stiffness and viscosity about the equilibrium position. The purpose of this paper is to test the validity and implications of this hypothesis in the context of reaching movements. A mathematical description of the behavior of an arm tracking the equilibrium trajectory was developed and implemented in computer simulations. The joint stiffness parameters used in these simulations were derived from experimentally measured static stiffness values. The kinematic features of hand equilibrium trajectories which were derived from measured planar horizontal movements gave rise to the suggestion that the generation of reaching movements involves explicit planning of spatially and temporally invariant hand equilibrium trajectories. This hypothesis was tested by simulating actual arm movements based on hypothetical equilibrium trajectories. The success of the predicted behavior in capturing both the qualitative features and the quantitative kinematic details of the measured movements supports the equilibrium trajectory hypothesis. The control strategy suggested here may allow the motor system to avoid some of the complicated computational problems associated with multi-joint arm movements.

Arm↗

Measurements of the impedance of the hand and arm.

The mechanical impedance of the hand and arm was studied on ten healthy subjects during exposure to sinusoidal vibration within the frequency range of 2 to 1000 Hz. A special handle for the measurements was constructed. The influence of vibration direction, handle grip, grip force, vibration level, hand-arm posture and sex as well as anthropometric data were studied. The results show that the impedance of the hand-arm mainly depends on the frequency and direction of the vibration stimuli. Higher vibration levels, as well as more firm hand-grips, resulted in higher impedance. Furthermore, the outcome shows that experiments conducted with different hand-arm postures had an active influence on the mechanical impedance. Moreover, the subjects' sex and constitution of the hand and arm affected the impedance to a large extent.

Adult↗

Phantom phenomena (phantom arm) following cervical root avulsion. Effect of dorsal root entry zone thermocoagulation.

We report on nine male patients with cervical root avulsions and brachial plexus injuries following traffic accidents. These non-amputees (mean age 33.7 years) had a phantom arm beside the paralysed arm. Cervical root avulsions were demonstrated either by myelography or surgically. Mostly the roots C5-Th1 were affected. Eight of the nine patients had Horner's syndrome on the side of the root avulsion. The phantom arm appeared immediately after the accident, except in one patient who was symptom-free for 2 weeks. In two cases the phantom arm disappeared spontaneously. Four patients underwent a DREZ lesion. After surgery the phantom arm disappeared, and three of the patients became painfree, while one patient experienced pain relief of 20% to 50%. Reviewing the literature it is assumed that phantom limb following injury to the brachial plexus indicates cervical root avulsion. In such cases Horner's syndrome is a good indication for lower cervical root avulsion (C8-Th2).

Accidents, Traffic↗

Effect of arm-shoulder fatigue on carpenters at work.

The purpose of the study was to analyse the effect of arm-shoulder fatigue on manual performance. Ten experienced carpenters performed three standardized tasks (nailing, sawing and screwing). Electromyographic activity was recorded from six arm-shoulder muscles and the performances were video-filmed. After 45 min of standardized arm-cranking (arm-shoulder-fatiguing exercise of approximately 70%-80% maximal oxygen consumption), the tasks were repeated. The number of work movements and the time taken for each task were recorded and the quality of the work performed was compared. After the fatiguing exercise, only nailing was perceived as being harder and more mistakes were made during nailing and sawing. Movement performance was not influenced during nailing but was slightly slower during sawing and faster during screwing. However, there were increased mean EMG amplitudes in the upper trapezius and biceps muscles during nailing, in the upper trapezius, anterior deltoid and infraspinatus muscles during sawing and in the anterior deltoid muscle during screwing. Of the muscles studied the upper trapezius and anterior deltoid muscles increased their activity most after the arm-shoulder-fatiguing exercise.

Adult↗

Strength-velocity relationship and fatiguability of unilateral versus bilateral arm extension.

Strength-velocity relations and fatigue resistance in an arm bench press manoeuvre were compared between conditions of bilateral (BL, both arms acting together) and unilateral muscle contraction in 9 young men. BL and UL (sum of the 2 arms acting singly) strength was similar for isometric and slow isokinetic maximal voluntary contractions (MVC); at high velocities BL MVC declined more than UL. In both types of contractions a curvilinear relation was observed between strength and velocity, with significantly higher peak torques (PT) being produced under isometric conditions than for slow velocity efforts (p less than 0.01). Mean declines in PT during 100 repetitive MVCs of approximately 70s were to 25% of initial values for the BL fatigue test and to 37% for UL (p less than 0.01). In contrast to results of a similar investigation of leg extension in the same subjects, the arms showed no BL deficit of strength in the initial part of the strength-velocity curve and approximately twice as much fatigue in repetitive contractions. These physiological differences may stem from the varying habitual activity patterns of the arms and legs.

Adult↗

[Evidence-based arm rehabilitation--a systematic review of the literature].

Based on a systematic MEDLINE search and informal sources, 40 references were identified that evaluate training therapy or neuromuscular electric stimulation for arm paresis after stroke and describe either a systematic review, meta-analysis, randomised controlled trial, or controlled cohort study. The evidence was grouped into three areas of interest: comparison of physiotherapy schools, effects of intensity of training, and efficacy of specific arm rehabilitation techniques. The only physiotherapy school with evidence of superior efficacy was the task-oriented 'motor relearning programme'. Higher intensities of motor rehabilitation can accelerate motor recovery. Various training techniques with demonstrated efficacy are available for specific patient subgroups: arm ability training for mildly affected patients with reduced efficiency of motor control, constrained-induced movement therapy for patients with partial functional deficits and learned nonuse of the affected arm, and repetitive sensorimotor training techniques, EMG-biofeedback, functional electrical stimulation, and robot-assisted training for patients with severe arm paresis.

Arm↗

Restricting arm use enhances compensatory reactions of leg muscles during walking.

A number of recent studies have indicated that whole-body coordinated reactions are employed to regain balance following disturbances during walking. However, it is not always the case that all body segments are available to contribute to balance corrective strategies. We hypothesize that balance corrective strategies will adapt to task and environment constraints such that greater responses are generated in the available body segments when other body segments are unable to participate. In this study, we tested the hypothesis that voluntarily restricting the arms during walking would result in an increase in the amplitude of the electromyographic responses evoked in leg muscles when subjects are perturbed at the torso during walking. To do so, subjects were asked to walk on a motorized treadmill while either crossing their arms across their front or back, or with their arms swinging normally. Periodic perturbations, forwards and backwards, were applied at the pelvis randomly throughout the step cycle. This resulted in short latency responses in leg muscles. The amplitude of these responses was increased when subjects walked with their arms crossed, as compared with normal, unrestricted walking. Facilitation of these evoked responses was restricted to the early part of the stance phase, particularly at heel-strike. The pattern of muscle activation and the latency of the responses were not affected by restricting the arms. We suggest that this finding indicates that whole-body balance corrective strategies employed during walking are selected based upon the demands of the general features of the task, but that components of the strategy are scaled according to the specific context-dependent needs of the task.

Adult↗

Differential exploitation of the inertia tensor in multi-joint arm reaching.

The identification of the kinaesthetic information used for directing 3D multi-joint arm movements toward a target remains an open question. Several psychophysical studies have suggested that the ability to perceive and control the spatial orientation of our limbs depends on the exploitation of the eigenvectors (e (3)) of the inertia tensor (I ( ij )), which correspond to the arm rotational inertial axes. The present experiment aimed at investigating whether e (3) was used as a collective variable to direct the masses toward the target and hence to control the spatial accuracy of the final hand position. Natural, unconstrained, three-dimensional multi-joint reaching movements were submitted to alterations of forearm mass distribution. Given the existence of several "sensorimotor strategies" for the control of arm movements, the participants were a priori contrasted and ranged in groups according to their reliance on either visual or kinaesthetic information. The results indicated (1) the dependency of the arm's directional control on I ( ij ) parameters, (2) a non-linear relationship between the performance predicted by the inertia tensor and the observed performance, depending on the deviation amplitude and (3) the presence of a large inter-individual variability suggesting the existence of different strategies, including proprioceptive compensation mechanisms. This study validates in unconstrained multi-joint arm movements the exploitation of the inertia tensor by the central nervous system, thus simplifying the coordination of the segments' masses during reaching. The results also provide evidence for the existence of motor alternatives in exploiting proprioceptive information that may depend on spatial referencing modes.

Adult↗

Threshold control of arm posture and movement adaptation to load.

We addressed the fundamental questions of which variables underlie the control of arm movement and how they are stored in motor memory, reproduced and modified in the process of adaptation to changing load conditions. Such variables are defined differently in two major theories of motor control (internal models and threshold control). To resolve the controversy, these theories were tested (experiment 1) based on their ability to explain why active movement away from a stable posture is not opposed by stabilizing mechanisms (the posture-movement problem). The internal model theory suggests that the system counteracts the opposing forces by increasing the muscle activity in proportion to the distance from the initial posture (position-dependent EMG control). In contrast, threshold control fully excludes these opposing forces by shifting muscle activation thresholds and thus resetting the stabilizing mechanisms to a new posture. Subjects were sitting, holding the vertical handle of a double-joint manipulandum with their right hand and were facing a computer screen on which the handle and target to be reached were displayed. In response to an auditory signal, subjects quickly moved the handle from an initial position to one of two (frontal and sagittal) targets. No load was applied during the movement but in separate trials, a brief perturbation was applied to the handle by torque motors controlling the manipulandum. Perturbations were applied prior to or 3 s after movement offset, in the latter case in one of eight directions. The EMG activity of the majority of the seven recorded muscles was at zero level before movement onset and returned to zero level after movement offset. Those muscles that remained active before or after the movement could be made silent whereas previously silent muscles could be activated after a small passive displacement (several millimeters) elicited by perturbations in appropriate directions. Results showed that the activation thresholds of motoneurons of arm muscles were reset from the initial to a final position and that EMG activity was not position-dependent. These results were inconsistent with the internal model theory but confirmed the threshold control theory. Then the ability of threshold control theory to explain rapid movement adaptation to a position-dependent load was investigated (experiment 2 and 3). Subjects produced fast movement to the frontal target with and without a position-dependent load applied to the handle. Trials were organized in blocks alternating between the load and no-load condition (20 blocks in total, with randomly chosen number of five to ten trials in each). Subjects were instructed "do not correct" in experiment 2 and "correct" movement errors during the trial in experiment 3. Five threshold arm configurations underlying the movement production and adaptation were identified. When instructed "do not correct", movement precision was fully restored on average after two trials. No significant improvement was observed as the experiment progressed despite the fact that the same load condition was repeated after one block of trials. Thus, in each block, the adaptation was made anew, implying that subjects relied on short-term memory and could not recall the threshold arm configurations they specified to accurately reach the same target in the same load condition in previous blocks. When instructed to "correct" within each trial, precision was restored faster, on average after one trial. Major aspects of the production and adaptation of arm movement (including the kinematics, movement errors, instruction-dependent behavior, and absence of position-related EMG activity) are explained in terms of threshold control.

Adaptation, Physiological↗