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Section 1: General Topics

Chapter 7: Clinical Considerations of Observational Gait Analysis

Section 1: General Topics

References

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3. Pinzur MS, Cox W, Kaiser J, Morris T, Patwardhan A, Vrbos L: e eect of prosthetic alignment on relative limb loading in persons with trans-tibial amputation: A preliminary report. J Rehabil Res Dev 1995;32(4):373-377. Medline

4. Schmalz T, Blumentritt S, Jarasch R: Energy expenditure and biomechanical characteristics of lower limb amputee gait: e inuence of prosthetic alignment and dierent prosthetic components. Gait Posture 2002;16(3):255-263. Medline DOI

5. Jia X, Suo S, Meng F, Wang R: Eects of alignment on interface pressure for transtibial amputee during walking.

Disabil Rehabil Assist Technol 2008;3(6):339-343. Medline DOI

6. Gailey R, Allen K, Castles J, Kucharik J, Roeder M: Review of secondary physical conditions associated with lower-limb amputation and longterm prosthesis use. J Rehabil Res Dev 2008 ;45(1):15-29. Medline DOI

7. Lloyd CH, Stanhope SJ, Davis IS, Royer TD: Strength asymmetry and osteoarthritis risk factors in unilateral trans-tibial, amputee gait. Gait Posture 2010;32(3):296-300.

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8. Toro B, Nester C, Farren P: A review of observational gait assessment in clinical practice. Physiother eory Pract 20 03;19(3):137-149. DOI

9. Rathinam C, Bateman A, Peirson J, Skinner J: Observational gait assessment tools in paediatrics: A systematic review. Gait Posture 2014;40(2):279-285. Medline DOI

10. Saleh M, Murdoch G: In defence of gait analysis: Observation and measurement in gait assessment. J Bone Joint Surg Br 1985;67(2):237-241.

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11. Ford N, Poole B, Bach T: Interobserver reliability of observational gait analysis in transtibial prosthesis alignment. Prosthet Orthot Australia 1996;11:27-31.

12. Hobson D, Eng M: A powered aid for aligning the lower-limb modular prosthesis. Bull Prosthet Res 1972;10(18):159-163.

13. Boone DA, Kobayashi T, Chou TG, et al: Perception of socket alignment perturbations in amputees with transtibial prostheses. J Reha- bil Res Dev 2012;49(6):843-853.

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14. Geil MD: Variability among practitioners in dynamic observational alignment of a transfemoral prosthesis. J Prosthet Orthot 2002;14(4):159-

164. DOI

15. Zahedi MS, Spence WD, Solomonidis SE, Paul JP: Alignment of lower-limb prostheses. J Rehabil Res Dev 1986;23(2):2-19. Medline

16. Sin SW, Chow DH, Cheng JC: Signicance of non-level walking on transtibial prosthesis tting with particular reference to the eects of

Chapter 7: Clinical Considerations of Observational Gait Analysis

anterior-posterior alignment. J Rehabil Res Dev 2001;38(1):1-6. Medline

17. Chow DH, Holmes AD, Lee CK, Sin SW: e eect of prosthesis alignment on the symmetry of gait in subjects with unilateral transtibial amputation. Prosthet Orthot Int 2006;30(2):114-128. Medline DOI

18. Kark L, Simmons A: Patient satisfaction following lower-limb amputation: e role of gait deviation. Prosthet Orthot Int 2011;35(2):225-

233. Medline DOI

19. Kobayashi T, Orendur MS, Zhang M, Boone DA: Eect of alignment changes on sagittal and coronal socket reaction moment interactions in transtibial prostheses. J Biomech 2013;46(7):1343-1350. Medline DOI

20. Boone DA, Kobayashi T, Chou TG, et al: Inuence of malalignment on socket reaction moments during gait in amputees with transtibial prostheses. Gait Posture 2013;37(4):620-626.

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21. Yang L, Solomonidis SE, Spence WD, Paul JP: e inuence of limb alignment on the gait of above-knee

amputees. J Biomech 19 91;24(11):981-

997. Medline DOI

22. Neumann ES: State-of-the-science review of transtibial prosthesis alignment perturbation. J Prosthet Orthot 20 09;21(4):175-193. DOI

23. Kobayashi T, Orendur MS, Zhang M, Boone DA: Eect of transtibial prosthesis alignment changes on out-of-plane socket reaction moments during walking in amputees. J Biomech 2012;45(15):2603-2609.

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24. Morgenroth DC, Segal AD, Zelik KE, et al: e eect of prosthetic foot push-o on mechanical loading associated with knee osteoarthritis in lower extremity amputees. Gait Posture 2011;34(4):502-507.

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25. Hafner BJ, Sanders JE, Czerniecki J, Fergason J: Energy storage and return prostheses: Does patient perception correlate with biomechanical analysis? Clin Biomech (Bristol, Avon) 2002;17(5):325-344. Medline DOI

26. Chen CW, Andrysek J, Heim W, et al: Evaluation of an instrument-assisted dynamic prosthetic alignment

technique for individuals with transtibial amputation. Prosthet Orthot Int

2015. Medline DOI

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28. Borel S, Schneider P, Newman CJ: Video analysis soware increases the interrater reliability of video gait assessments in children with cerebral pa lsy. Gait Posture 2011;33(4):727-729.

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29. Peterson M, Ewins D, Shaheen A, Formento PC: Evaluation of methods based on conventional videography for detection of gait events, in Braidot A, Hadad A, eds: IFMBE Proceed-

ings: VI Latin American Congress on Biomedical Engineering CLAIB 2014, Paraná, Argentina 29, 30 & 31 Oc tober 2 014. Cham, Switzerland,

Springer, 2015. pp 234-237.

30. Hillman SJ, Donald SC, Herman J, et al: Repeatability of a new observational gait score for unilateral lower limb amputees. Gait Posture 2010;32(1):39-45. Medline DOI

Chapter 8

Kinesiology of the Upper Limb

Michael S. Pinzur, MD

Abstract

From an evolutionary perspective, the ability of humans to stand on their hind limbs freed the upper limbs from the task of weight bearing. is allows the upper limbs to function as both organs of prehension and as sensory probes for interacting with the environment. Many activities that are perceived as simple hand functions are only possible through the integration of the entire body with the upper limb and hand. e analysis of body motion in terms of mechanical forces is the domain of kinesiology, which considers motion as it occurs under living conditions. Motion is studied as activities are performed against extrinsic forces, such as gravity, or against the resistance of objects that are grasped, pushed, or thrown by the upper limb. It is helpful to understand the major patterns of upper limb activity and the details of the mechanical and nonmechanical factors fundamental to functional task performance, including the roles of sensory function, muscle strength, and skeletal integrity.

Keywords: function; hand; kinesiology; prehension

Introduction

The functional capacity of the upper limb is determined by the shoulder complex, elbow, wrist, and hand developing multiple integrated spheres of action. In normally proportioned limb segments, this capacity is limited in relation to the surrounding space. For example, in the standing position, the upper limb ﬁeld of motion reaches the midthigh region. Any more distal point on the lower limb

A maximum arcuate ﬁeld or envelope of action termed E1 (Figure 2) is traced by the most distal point of the upper limb through the motion of the shoulder complex, with all other joints being held in extension. Within this envelope, the elbow, wrist, and ﬁngers have their own ﬁelds of motion, E2, E3, and E4, respectively. These contained capabilities enrich the functional performance of the upper limb.

or on the ground is reached through mobility provided by the hip, knee, ankle, and trunk (Figure 1). More distant points in space come within the reach of the upper limb action when functionally integrated with gait.

Stability of the Spine and Trunk

Stability of spine and trunk is essential before the hand can be placed within the envelope of action/function. Paralyzed patients without spinal and trunk

Dr. Pinzur is a member of a speakers’ bureau or has made paid presentations on behalf of Biomimetic, KCI, SBI, Smith & Nephew, and Wright Medical Technology; serves as a paid consultant to or is an employee of Biomimetic, KCI, and SBI; has received research or institutional support from Biomimetic; and serves as a board member, owner, ocer, or committee member of the American Academy of Orthopaedic Surgeons and the American Orthopaedic Foot and Ankle Society. is chapter is adapted from Hartigan BJ, Sarraan SK: Kinesiology and functional characteristics of the upper limb, in Smith DG, Michael JW, Bowker JH, eds: Atlas of Amputations and Limb Deciencies: Surgical, Prosthetic, and Rehabilitation Principles, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 101-130.

Figure 1

that the eld of motion of the upper limb is a circle, with the length of the limb the radius. Any point more distant in space or distal to the midthigh is reached through associated hip, knee, ankle, and trunk motion.

Schematic drawing showing

stability must hook one upper limb about the back or the side of their chair if they lean forward to hold an object. The need to use an arm to maintain stability not only decreases the size of the envelope of action but prevents the individual from using both upper limbs for performing functional tasks.

Shoulder Complex

Motion in the Coronal (Frontal) Plane

When the arm and forearm are held in the neutral position, the upper limb sweeps a circular surface in the coronal plane. The very distal point of the limb traces an envelope of action E (Figure 3). The shoulder is in neutral rotation in position 1, and the limb can be elevated in the outer half of the circle

Section 1: General Topics

Figure 2

elevation of an externally rotated upper limb in the coronal plane. Complete exploration of the outer half of a circle is possible through the envelope of action E1. The elbow allows sweeping of space E2. The wrist develops motion eld E3. The spiral envelope of motion E4 is determined by nger motion.

Figure 5

motion in the coro nal plane with the uppe r limb in complete internal rotation. The eld of motion E1 is limited, but elbow motion is possible

continuously functional.

Schematic drawing showing the

Schematic drawing showing

. The wrist and digits are

Figure 3

motion in the coronal plane, starting with the neutral position of the upper limb, position 1. It is possible to explore space from position 1 to 2 without associated external rotation. No elbow action is possible then. The limb is elevated from position 3 to 4 through association of external rotation. Descent from position 4 to 5 involves internal rotation. From position 5 to 6 and 1, the limb derotates to reach a neutral position.

Schematic drawing showing

to positions 2 and 3. The elbow does not contribute to functional exploration in this segment of the arc of motion. If the wrist is initially held in neutral rotation, the hand sweeps the space E3, and the ﬁngers explore the interior of this space through E4. Beyond position 3, the shoulder rotates externally and complete elevation is achieved at position 4. In this second arc of motion, the elbow explores the segment of the space through its action envelope E2. The sweeping of the inner half of the coronal circle is possible from position 4 to 5 through internal rotation of the shoulder, and the elbow action dissipates. The shoulder rotates externally from position 5 to 6, and elbow function reappears, whereas with further external rotation from position 6 to 1, the elbow action dissipates again.

When the upper limb is maintained

in neutral rotation at the shoulder,

Figure 4

motion in the coro nal plane with the uppe r limb in neutral rotation. No elbow action is present in this plane.

Schematic drawing showing

motion is quite restricted (Figure 4), and no elbow action is possible in this plane. Maintaining the limb in complete external rotation permits easy exploration of the outer half of the coronal circle, whereas any functional motion in the inner half is very restricted. The elbow envelope of action is clearly visible now in all positions (Figure 2).

Placement of the limb in complete internal rotation substantially restricts the ﬁeld of motion (Figure 5), but elbow action is possible from position 1 to 2. The coronal plane is also explored posteriorly in the inner half space (Fig- ure 6). With a position of internal rotation at the shoulder, the limb traces a small arc of displacement that allows the elbow, wrist, and hand to sweep the surface corresponding to the gluteal area and up to the opposite scapular region. From position 3, the elbow envelope of action scans the posterior aspect of the back and shoulder.

During elevation of the upper limb in the coronal plane, motion is determined by the glenohumeral joint and scapulothoracic upward rotation (Figure 7). Scapular rotation not only contributes

Chapter 8: Kinesiology of the Upper Limb

Figure 6

motion in the coronal plane posterior to the body. The gluteal area and mid and lower portions of the back are within reach of the internally rotated upper limb, position 1, combined with the elbow eld of motion, position 2. The posterior aspect of the neck and shoulders is reached by external rotation, position 3, combined with the elbow eld of motion E2.

Schematic drawing showing

to overall elevation but also is important for maintaining constant ﬁber length of the deltoid, allowing deltoid motion over a variety of arm positions. The acromioclavicular and sternoclavicular joints also participate in a synchronized manner, producing clavicular rotation and elevation. Humeral external rotation accompanies the elevation for the performance of a smooth motion (Figure 8). Beyond 90° of elevation, this external rotation is necessary to free the greater tuberosity from the coracoacromial arch. In addition, external rotation of the humerus relaxes the inferior glenohumeral ligaments, releasing the inferior checkrein effect.

From 0° to 30° of elevation (Figure 7), a variably greater amount of motion occurs at the glenohumeral joint compared with the scapulothoracic joint. The precise ratio has been debated and is subject to individual variation. During the last 60° of elevation,

Figure 7

motion in the upper limb. A, Elevation of the upper limb from 0° to 180°. From 0° to 30°, the motion is mostly glenohumeral (GH), with scapulothoracic (ST) motion occurring to a variable degree. Overall, the ratio between glenohumeral and scapulothoracic motion (GH:ST) is 2:1. B, Sternoclavicular (SC) motion occurs during the initial 130° of arm elevation. Acromioclavicular (AC) motion occurs from 0° to 30° and then from 135° to 180°, with a range of motion of 20°.

Schematic drawing showing

the glenohumeral and scapulothoracic joints contribute equally. Through the entire arc of elevation, the overall ratio of glenohumeral joint motion to scapulothoracic joint motion is 2:1.

During upper limb elevation, the clavicle does not remain still. It elevates 30° to 40° at the sternoclavicular joint, with the maximum at approximately 130° of elevation2 (Figure 9). The clavicle also rotates on its long axis beyond 90° of arm elevation. Approximately 40° of clavicular rotation occurs with respect to the sternum. However, less rotation occurs with respect to the acromion because of the concomitant synchronous rotation of the scapula during elevation of the arm. A combined acromioclavicular motion of 20° occurs during the initial and terminal phases of elevation (Figure 7).

The motor units responsible for glenohumeral elevation are the middle segment of the deltoid muscle and the muscles of the rotator cuff: the

Figure 8

that natural elevation of the upper limb in the coronal plane involves 90° of external rotation. Elevation in the lower and inner segment of a circle involves internal rotation.

Schematic drawing showing

supraspinatus, infraspinatus, teres minor, and subscapularis muscles (Figure

10). Electromyography (EMG) and selective nerve blocks, used to study the contributions of these muscles, have shown that the deltoid and all four rotator cuff muscles are active throughout the full range of motion in both ﬂexion and abduction.

2,3

The deltoid and supraspinatus act synergistically to produce glenohumeral elevation, whereas the infraspinatus, teres minor, and subscapularis muscles stabilize the humeral head to prevent cephalic migration. Although the exact contributions of the deltoid and supraspinatus have been debated, it appears that the deltoid becomes progressively more effective with increasing elevation, most likely the result of the improved moment arm.

EMG studies (Fig ure 11) show that the deltoid action potential increases steadily with elevation, reaches a maximum at 110°, and maintains a plateau level of activity with a ﬁnal peak at full elevation. The supraspinatus reaches a peak at 100°, and beyond this point its activity diminishes and traces a sine

Section 1: General Topics

Figure 9

A, Sternoclavicular motion in the form of clavicular elevation of 40° occurs, primarily during the initial 130°. B, Beyond 90°, clavicular rotation occurs on the long axis. (Reproduced with permission from Inman VT, Saunders M, Abbott LC: Observations on the function of the shoulder joint. J Bone Joint Surg Am 1944;26:1-30.)

wave. The subscapularis reaches a peak at 90°, maintains a plateau level up to 130°, and diminishes rapidly in action. The teres minor reaches the maximum at 120° and maintains a high level of activity, whereas the infraspinatus increases steadily in activity from the initial position to that of full elevation. The action of the teres minor and infraspinatus is necessary to continue the external rotation of the humerus during the last stage of elevation. The posterior segment of the deltoid also participates as an external rotator (Figure 12).

Upward rotation of the scapula is

achieved by the upper trapezius, levator

Line graphs and schematic drawings demonstrate clavicular elevation and rotation.

scapulae, and upper portion of the serratus anterior contracting concomitantly with the lower trapezius and lower serratus anterior to act on the scapula as a force couple (Figure 13). When the upper limb moves in the lower and inner quadrant of the envelope of action E1, it is adducted and internally rotated. The internal rotation is brought about by the subscapularis, pectoralis major, and anterior segments of the deltoid (Figure 12). Adduction is determined by the latter two muscles, supplemented by the action of the coracobrachialis (Fig ure 14). During the anterior adduction-internal rotation, the scapula

Figure 10

elevators at the scapulohumeral joint in the coronal plane. 1 = middle deltoid, 2 = supraspinatus, 3 = infraspinatus, 4 = teres minor. The subscapularis, which lies anteriorly and cannot be seen on this view, is also an elevator.

Schematic drawing showing

is abducted or protracted. This motion is controlled by the serratus anterior and the pectoralis minor (Figure 15). When the upper limb moves in a similar lower and inner quadrant but posterior to the body, the limb is once more adducted and internally rotated. Posterior adduction is brought about by the latissimus dorsi, teres major, long head of the triceps, and posterior segment of the deltoid (Fig u r e 14). The latissimus dorsi and teres major also determine the associated internal rotation (Figure 12). During this same motion, the scapula is adducted or retracted by the middle segment of the trapezius and the combined action of the rhomboidei and latissimus dorsi (Fig u re 16).

When the upper limb is in a maximum position of elevation and is brought down in the coronal plane in the outer half circle, the scapula makes a downward rotation. This is determined by the combined action of the latissimus dorsi, the lower segment of the pectoralis major (the pectoralis minor acting as the lower component for a force couple), and the levator scapulae, with the rhomboidei acting as the upper component of the

100

Chapter 8: Kinesiology of the Upper Limb

Figure 11

humeral joint in the coronal plane. All ve muscles are active from 0° to 90°. Beyond 110°, the deltoid holds a maximum level of activity. The supraspinatus decreases in activity beyond 100°. The infraspinatus and teres minor maintain high levels of activity during the second half of elevation to ensure necessary external rotation of the shoulder. (Reproduced with permission from Inman VT, Saunders M, Abbott LC: Observations on the function of the shoulder joint. J Bone Joint Surg Am 1944;26:1-30.)

rotational couple (Fig u r e 17 ). Downward stabilization of the limb in the coronal plane is functionally important in activities such as crutch walking or parallel bar exercising. Depressors of the shoulder complex responsible for this function include the latissimus dorsi, the lower segment of the trapezius, the lower segment of the pectoralis major, the pectoralis minor, and the subclavius (Figure 18).

Upward stabilization in the coronal plane is also necessary for functional purposes, as in carrying heavy loads on the shoulders. This is controlled by the elevators of the scapula: the levator scapulae, upper segment of the trapezius, and rhomboidei (Fig ure 19).

Line graph showing electromyographic activity of the elevators at the scapulo-

and sweeps the surface from position 1 to 3 (Figure 20). The elbow, wrist, and hand are capable of functioning in this plane through their envelopes of action E2, E3, and E4, respectively.

In position 3, the elbow action extends farther posteriorly, with the hand reaching the posterior aspect of the shoulder. Further movement in the posterior half of the ﬁeld is possible through the internal rotation of the shoulder, followed by gradual external rotation to bring the limb to its neutral initial position (Figure 21). Elevation of the upper limb, or ﬂexion from position 1 to 3, is determined by the anterior segment of the deltoid, biceps, coracobrachialis, and clavicular head of the pectoralis major (Figure 22). The

Motion in the Sagittal and Transverse (Horizontal) Planes

From a neutral rotational position, the upper limb moves in the sagittal plane

rotator cuff is also active in stabilizing the humeral head. The scapulothoracic mechanism participates in the motion through upward scapular rotation at

Figure 12

rotators at the scapulohumeral joint. Internal rotators: 1 = subscapularis, 2 = latissimus dorsi and teres major, 3 = pectoralis major, 4 = anterior deltoid. External rotators: 5 = infraspinatus and teres minor, 6 = posterior deltoid.

Figure 13

the muscles that contribute to upward rotation of the scapula. 1 = upper trapezius, 2 = lower trapezius, 3 = serratus anterior.

Schematic drawing showing

a glenohumeral/scapulothoracic ratio of 2:1.2 From the elevated position 3,

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