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тов из Европы также связана с умением разбираться в людях (ASOl), социальном зрелостью (ПГТ), ответственностью (GT) и уверенностью в себе (PT).
Исследование показало, что при планировании социальных мероприятий по оптимизации адаптации иностранной молодежи к условиям обучения в России необходимо учитывать этническое своеобразие, которое задает специфичные эталоны коммуникации, которые могут улучшать или осложнять процесс интеграции индивида в иную культуру.
K. J. van Zwieten1, D. Lambrichts 2, K. Nackaerts 2, S. Hauglustaine 2, K. P. Schmidt1, G. J. Bex1, A. Mewis 3, W. Duyvendak 4, F. H. M. Narain 5, K. S. Lamur5, P. L. Lippens 1, A. V. Zinkovsky 6, V. A. Sholukha 6, A. A. Ivanov 6, V. V. Potekhin 6, O. E. Piskun 6,
S. A. Varzin 6, I. A. Zoubova 6 LOWER ARM AND HAND MUSCLES IN FOCAL DYSTONIAS-SOME ANATOMICAL
AND THERAPEUTIC ASPECTS
1. Department of Anatomy, BioMed, University of Hasselt, transnational University Limburg, Diepenbeek, Belgium.
2. Department Gezondheidszorg, Opleiding Kinesitherapie, Provinciale Hogeschool Limburg, Hasselt, Belgium.
3. Clinical Microbiology Laboratory, Virga Jesse Hospital, Hasselt, Belgium.
4. Department of Neurosurgery Virga Jesse Hospital, Hasselt, Belgium.
5. Department of Anatomy, University of Suriname, Paramaribo, Suriname.
6. Department of Biomechanics, Saint-Petersburg State Polytechnical University, Saint-Petersburg, Russia.
INTRODUCTION AND SUMMARY
Computer simulation of normal goal-oriented motion of human lower arm and hand may be also successfully applied in studying movement disorders, known as focal dystonias 1 - 3). Upper limb focal dystonia includes disturbed muscle tension balances, leading to painful, impaired and often aberrant motions. In their attemps to trace the backgrounds of this disorder, several authors have stressed the importance of the brain primary somatosensory cortex, and its role in brain-mapping 14). This turns out to be especially relevant during learning processes of new motor skills like practising by musicians 15, 22). The present overview however will mainly analyse musculoskeletal mechanisms of arm and hand movements, with regard to their kinematics in repetitive motions. We will concentrate on pronation and supination movements of the lower arm during re-
peated shifting of the hand, as in handling a computer mouse, and focus on the maintaining of stable finger position during PC mouse scrolling 23, 24). Physical therapy (PT) already proved itself useful in treating these focal dystonias, also known as repetitive strain injury (RSI) 24). As an adjuvant to PT, we wish to propose local vibration therapies 29). Positive results of such a treatment, emanating from a recent pilot-study, are presented in conclusion 31).
LOWER ARM - COMPARATIVE ANATOMICAL BACKGROUNDS
Locomotion in small arboreal quadrupeds that are generally regarded as precursors of lower primates includes rotational movements in shoulder, upper and lower arm, wrist and hand. A basic functional demand in those species is: keeping each hand alternatingly in contact with the substratum, while the body moves forward in the parasagittal plane. By this motion, the relative conservative feature of lateral rotation by the upper arm at the onset of each stance (to end up in a medial rotation at late stance) coincides with a decrease of crossing by the radius over the ulna, as long as the propulsion stroke proceeds 4 - 6). In the opossum lower arm, this uncrossing or supination of radius respective to ulna is accentuated by widening of the spatium interosseum antebrachii, as well as by early take-offs of the flexed 4th and 5th digits (Figure 1).
Figure 1 Figure 2 Figure 3
Fig. 1 Walking opossum, top to base: propulsion includes lower arm supination Fig. 2 Man, start propulsion stroke: medial rotation (arrow) of humerus (yellow) Fig. 3 In propulsion: lateral rotation humerus, radius (red) crosses (*) ulna (blue)
In many primates including man, mainly as a consequence of the different positions of their shoulder blades, such rotational phenomena as the ones described above present themselves differ-
ently. Propulsion stroke by the arm, as long as the hand stays palm downwards in contact with the substratum, may show increasing lateral rotation of the upper arm, while the radius gradually crosses the ulna 7 - 8). This is: pronation of the lower arm. Hereby the spatium interosseum ante-brachii becomes narrower, as the radius gradually overlaps the ulna (Figures 2 and 3).
LOWER ARM - THE SITUATION IN MODERN MAN
Quite comparable phenomena do occur when a seated person shifts his hand, palm downwards, to and from his body, e.g. by moving the computer mouse over a mouse-pad. By repeating these movements numerous times daily, the muscles of trunk, shoulder, upper and lower arm may start to display focal dystonia. In order to study one of the muscles that are possibly involved in developing such a dystonia, the pronator teres muscle was selected, based on its obvious capacity (just by muscle contraction) to move the radius over the ulna and to narrow the spatium interosseum an-tebrachii as a hallmark of pronation 13). Remarkably a recent 2008 study on lower arm muscle activities while handling various types of PC mouse left m. pronator teres activities out of consideration, although the positions of lower arm pronation were taken into account 9).
LOWER ARM - THEORETICAL KINEMATIC ANALYSIS
Anatomical and kinematic features of m. pronator teres were investigated theoretically, in human anatomical specimens by dissection, with use of magnifying loupes, and by roentgenphoto-grammetry. In a small number (5) of anatomical specimens of the lower arm of otherwise normal subjects, as currently used during the practical courses of anatomy organized by our department, the pronator teres muscle was brought into view, and its various fibre bundles were carefully dissected 11). Humeral and ulnar heads of m. pronator teres fuse, their common tendon inserting on the tuberositas pronatoria of the radius (Figure 4). The precise position of pronator teres muscle was identified in anteroposterior radiographs, by means of lead markings attached to the various muscle fibre bundles prior to radiography (Figure 5). Pronator teres muscle was represented by straight lines between its markers, indicated on tracings of these radiographs (Figure 6). In each tracing, the average position of such lines representing the vector of m. pronator teres was introduced, to be used for a mathematical vector analysis of forces.
During pronation the radius approximately follows a conical path. The apex of this virtual cone is located at the head of the radius, while the centre of the circular base of this cone is the ulnar
styloid process. The axis of this cone may be regarded as identical to the axis of forearm pronation and supination 10). In the radiographs, the centre of the articular facet of the head of the radius, and the tip of the ulnar styloid process, served as the bony landmarks concerned. In the tracings the axes of pronation and supination were also introduced, by drawing a straight line connecting these two points.
A two-dimensional representation of this cone, which is an isosceles triangle, was then used to introduce the average pronator teres vector at one slant side of this triangle, starting from the point representing tuberositaspronatoria of the radius in pronation. The direction of this vector was then used to estimate the muscle's contribution to lower arm pronation (Figure 7). Mathematical vector analysis of forces revealed that, at least theoretically, the effective contribution of m. prona-tor teres to forearm pronation constitutes only about 25 % of its contribution to forearm flexion at the elbow 12, 13).
The result of this analysis therefore suggests that, also in the acquisition of lower arm focal dystonia and repetitive strain injuries, pronator teres muscle might play only a minor role.
Figure 4 Figure 5 Figure 6
Figure 7
Fig. 4 Human lower arm: m. pronator teres (arrows) from humerus (yellow) and ulna (blue) inserts at radius (red) Brand-Hollister ('93) essentially adapted
Fig. 5 Arm anatomical specimen, X-ray, lead markers indicate m. pronator teres
Fig. 6 In positive, pro-supination-axis (red) and m. pronator teres' course added
Fig. 7 Triangle represents "pronation-path", plus m. pronator teres' vector (red)
HANDS AND FINGERS - COMPARATIVE ANATOMICAL ASPECTS
Experimental studies on the brain primary somatosensory cortex in primates, as related to repetitive strain injuries, made use of the hands of a New World primate, Aotus in particular 14). With regard to the use of fingers in such genera however, the next remarks must be kept in mind.
The fingers of primates of the New World have a compact extensor assembly without a distinct distribution into bundles as in higher primates, including man 16). This was demonstrated in the fingers of Callitrichidae and Cebidae, especially in Aotus (Figure 8). In these primates it was expected that, in proximal interphalangeal flexion the lateral parts (l p, Fig. 8) of their compact extensor assembly would not be displaced palmarward as easily, respective to its medial part (m p, Fig. 8), as in higher primates including man 17). Absence of coupled interphalangeal flexion in some kinds of grips would be the result.
In their behaviour these New World primates do show hand postures, in which proximal in-
terphalangeal flexion is coupled notably to distal interphalangeal extension or even hyperextension, leading to an effective adhesion of the hands to large branches 19) (Figure 9). In prosimians too, the extensor assembly is compact 18, 20). This supports the existence of a relationship between a simple structure of the extensor assembly and the prosimian-like nature of interphalangeal coupling.
Fig. 8 Aotus finger transverse 0 at proximal interphalangeal (PlP)-level, see text
Fig. 9 Aotus adhesive grip: distal interphalangeal (DlP)-extension & PlP-flexion
THE FREELY MOVING HUMAN FINGER
A functional analysis of the human extensor assembly in relation to coupled interphalangeal motion was made by means of a kinematic model. In this model, the two interphalangeal joints can be flexed simultaneously, as normally occurs in various types of grips and precision handling. A movie-sequence of simulation by mathematical modelling of such finger flexion was recently published 21, 22). One initial frame from this sequence in particular is depicted in the diagram of the slightly bowed finger, in a stabilized position (Figure 10). Such stability of the freely moving finger is essential for finely tuned finger movements, e.g. by practising musicians. Any muscular imbalance may eventually lead to focal hand dystonia 23, 24).
Apart from practising of various musical instruments, finger scrolling while handling a computer mouse also requires such finger stability. Recent studies dedicated to this subject have underlined the general importance of this topic, in finger stability as well as finger mobility 25, 27).
Figure 8
Figure 9
Figure 10
Fig. 10 Kinematic model: stable human finger in slightly bowed position, lines representing tendons - extensor assembly distributed into separate bundles
THE FINGER IN NEUROPATHY - DIAGNOSTIC ASPECTS
Part of muscular imbalance in hand and finger may result from compression neuropathies in which one or more motor nerves are damaged, leading to paralysis of the muscles concerned. Apart from PC workers, musicians may be the subjects of such disorders 23, 26). With regard to hand and fingers, incoordination of interphalangeal motion may be present too, in such neuropathies.
To analyse the finger motor patterns before and after therapy, forward and reverse modelling by means of the abovementioned kinematic finger model was successfully applied 28).
UPPER EXTREMITY REPETITIVE STRAIN INJURIES - THERAPEUTIC ASPECTS
To conclude, we wish to refer to a pilot study after the effects of vibration therapy on subjects suffering RSI symptoms of the upper extremity, in comparison to classical rehabilitation therapy. 5 subjects in the control group underwent classical rehabilitation, 5 subjects in the experimental group received vibration therapy. A pre-post design was used to measure upper extremity movements for strength, and the McGill pain questionnaire for pain sensation. During 4 weeks, both groups received 8 sessions of therapy consisting of strength exercises. As a result, there was an average strength increase for both groups during the intervention. Indications of pain sensation decreased for both groups, though more significantly so for the group receiving vibration therapy. Vibration therapy can therefore be a significant adjunctive therapy for RSI.
In increasing strength and decreasing pain, it is more significant than classical rehabilitation
CONCLUDING REMARKS
The present overview, highlighting some of the possible anatomical backgrounds of upper extremity repetitive strain injuries and dystonias, has left many questions unanswered. An obvious need is felt also to gather data on a person's ability to manage the relatively monotonous handling of a computer. Such studies may advantageously include anatomical aspects, e.g. anthropometric measurements and highly sensitive registrations of finely tuned hand movements.
The abovementioned presentation clearly shows that until now univocal explanations are hard to deliver. This is generally so in diagnostics, and also in pathophysiology and therapy. Thorough kinematical analyses might be able to unravel some more of the enigmas still existing.
Recently, some doubt arose regarding the effectiveness of vibration therapies in systemic neuropathies 30). Nevertheless, strong indications currently exist, that peripheral and local pain and muscular weakness can be effectively treated with the help of local vibration training, respectively by application of electrovibrostimulation, in a proper way ad modum Zinkovsky 31).
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A. V. Zinkovsky1, K. J. van Zwieten2, K. P. Schmidt2, I. A. Zoubova1, P.L. Lippens2 ELECTRO-VIBROSTIMULATION IN TRAINING AND RECUPERATION OF THE HUMAN SKELETAL-MUSCULAR APPARATUS 1. St. Petersburg State Polytechnic University, Russia;
2. University of Hasselt, Belgium
INTRODUCTION
In daily practice often appears the necessity to correct the functional state of the human skeletal-muscular apparatus (SMA) in order to increase the contraction force of the muscles and the mobility of the joints. This is often necessary in sports and ballet, in long-term space flights for the compensation of hypodynamics and hypokinesy effects, and for the rehabilitation of invalids, including the elimination of post-operative excessive muscles contraction. However, traditional methods require a long period of time to achieve a high functional state of SMA or to restore functions lost after trauma. Therefore, in recent years various new methods and technical means for human SMA stimulation have been developed, in particular electrostimulation and vibrostimulation. Our report describes the methodology and results of simultaneous electro-vibro-stimulation of the SMA in the active and passive insufficiency zones of the muscles.
METHODS
In order to improve the condition of the human SMA, simultaneous electro- and vibrostimulation of the muscles is performed. Antagonist muscles are subjected to vibrostimulation, synergist muscles to electrostimulation. Vibrostimulation helps the antagonistic muscles to relax and is accompanied by an increase of their lengths. Electrostimulation increases the contractile power of the synergistic muscles. For the electrovibrostimulation (EVS) methods and devices were used, which were developed by the authors of the report (Zinkovsky 1987)1). A wide range of variation of the parameters of the electro and vibro impulses in the developed devices allows the selection of their
