**11. EBM**

*Recent Advances in Biomechanics*

(magnetography).

invasiveness [93]:

eters of the body.

**10. Metrological engineering techniques**

Taking into account the above issues, the pursuit of professionalization in the measurement process gains extreme importance, which can be seen in the works of many authors, concerning the static features of the spine using the projection moire, axial spondylometry, as well as changes of these characteristics in various clinical conditions. Much attention was paid to the assessment of the motion range (SFTR), balance, and gait analysis carried out using contact and photogramometric methods. Joints are an area of particular interest—in clinical practice they are most often subjected to endoprosthetic surgery, i.e., knee, hip, shoulder joints, intervertebral discs or other elements of vertebroplasty, and even the joints of the fingers. An interesting combined research began, concerning the synergy of dynamometric tests, the range of foot movement and strength of lower limb muscles, and gnatosomal analyses. There are also attempts to model complex limb functions based on motion measurement data and EMG signals. Measurements using bioengineering techniques have a great impact on the development of clinical metrology. They have many advantages, such as (1) standardization of the measurement conditions (measurement track in particular), (2) repeatability of the body stimulation scaling parameters using electronic systems (3) repeatability of scaling of the measurement parameters, and (4) stability of the calculation and result-interpreting criteria. Noninvasive recording techniques, consist in resting or functional, but contactless monitoring of vital functions, based on registering parameters that are spontaneously emitted by the body, such as infrared radiation (pyrometry, thermography), electric field (electrography), or magnetic field

Contact recording techniques consist in applying a sensor to the skin surface, in order to establish physical contact (often galvanic as well). The skin surface changes a number of its properties depending on the symmetry and specificity of the processes taking place in the internal organs; hence, the registration of parameters at specific points of the marker will give clear information about the phenomena occurring in the internal organs (e.g., thermometry, ECG, EEG, EMG). The essence of measurement techniques is diverse, depending on the degree of

1.*Bilaterally interactive test*, in which the doctor affects the patient's body with a mechanical stimulus that is hard to repeat (e.g., pricking the skin with a probe or strike) and then the patient makes a subjective response assessment, based

2.*Unilaterally interactive test*, in which the doctor is replaced by an electronic device that generates parameterized and repetitive stimuli while the patient subjectively determines their perception threshold (e.g., palestesiometry, audiometry).

recorded—they are based solely on the parameters spontaneously issued by the

4.*Parametric contact test*, involving, for example, fixing a sensor on the body (or unipolar group of sensors), which provides information on selected param-

5.*Bilaterally parametric test*, where the body is influenced by a reproducible, parametric stimulus generated by the technical device (which can either

3.*Parametric telemetry test*, in which parametric responses of the patient are

on which the diagnostic conclusions are being drawn.

body (thermography, electrography, magnetography).

**62**

A huge problem that is still present in movement studies and physiotherapies is the tendency to look at the multidimensional profile of the patient's suffering and dysfunction through the prism of a narrow specialization, causing multithreading and lack of synergy in procedures related to the diagnosis and treatment of a complex locomotor dysfunction. In this context, a complex biomechanical, psychophysical, and clinical problem begins to be seen as the sum of some separate sequences, which are diagnosed and treated fragmentarily in the narrow ranges of specializations of the successive therapists.

It leads to an absurd situation, in which a pain and dysfunction problem is being taken care of by subsequent specialists in physio- and kinesiotherapy and finally in biomechanics. Based on their own experience and simple measurements, they assess the patient's condition and plan a simple treatment program, mainly in the aspect of symptoms and function, not having a full insight into the interpretation of the results of advanced diagnostic tests. Diagnostics, in turn, is carried out by a team of doctors, who have direct contact neither with a variety of procedures in applied physiotherapy nor with their effects. As for issues revolving around the experience of pain, especially against the background of the patient's individual psychophysical characteristics and predispositions, they are estimated by the psychologist, who is deprived of a broader knowledge of the details of diagnosis and therapy specifics.

In this context, there was a need for a systemic change in quality, and thus also the effectiveness and image of modern physiotherapy, beginning from function in analogy to the principles of EBM presented above, as evidence-based physiotherapy (EBP). The trend initiated a few years ago was reflected in the literature, in the form of interesting publications, displaying various aspects of this issue. One of the first, conceptually well-structured works was a manual [96], then a collective work [97], which postulate that a physiotherapist performing direct, manual diagnostic and rehabilitation activities in a patient, should use the results of advanced clinical diagnostics to clarify any doubts arising from direct observation of the patient. In 2001, the World Confederation of Physical Therapy (WCPT) Expert Meeting on

Evidence Based Practice in London 2001 was founded in London. An important initiative here was to create a PEDro system database accessible via the Internet.

In this new approach, EBP is a collection of clinical procedures that aim at the best possible, holistic use of the therapist's clinical experiences, supported by (verified and available in practice) scientific evidences of image, laboratory, and functional and psychological diagnosis, whose application and integration in one personalized clinical picture increase the effectiveness of medical procedures and patient's safety in the process of the musculoskeletal system's diagnosis, shaping the highest possible level of physiotherapeutic treatment [97]. It can be noticed that the presented definition is quite convergent with the Polish model of the rehabilitation team, promoted since the 1970s (Milanowska, Dega), which uses the consular way of disciplinary knowledge of a rehabilitation doctor, physiotherapist, psychologist, and social worker in order to find a comprehensive solution to the problem of motor organ dysfunction in a medical, psychological, rehabilitation, and social aspect. The cited textbook is particularly recommendable due to the fact that the authors have made a very comprehensive summary of the existing literature on the subject, outlining a very clear picture of the issue. Thus, EBP is shaping a directional model for the development of new science of movement disorders, which are the essence of many medical and physiotherapy specialties, aiming at replacing the currently dominant profile of the assessment of movement disorders implemented by means of distributed sequences, narrowly specialized engineering research, and general medical procedures for the creation of multidimensional and a personalized image reflecting the tangle of causative problems of pain with parametric disorders of biomechanics of movement, combined with metrology of psychological and social consequences.

It is therefore of the utmost importance that the professional evolution of specialists dealing with the musculoskeletal system does not stop at specialized, narrow clinical, or metrological competences but aims at increasing interdisciplinary competences, which will result in the ability to perceive parametric body movement disorders against the background of causative phenomena and above all their adaptive and clinical consequences. In such a new situation, a physiotherapist with broadly formatted practical and theoretical knowledge will not only receive but will also be able to use access to team knowledge, including clinical information on the etiology of the disease, as well as to the results of detailed imaging and clinometric tests. The planned treatment strategy will gain a new, more pragmatic parametric foundation, which in addition to diagnosis offers the possibility of metrological supervision of the effects of therapy, including psychological clinimetry. It is important to remember about the changes in the patient's psyche who is suffering from pain, as well as limiting the implementation of his/her priorities on personal, professional, and social grounds. It is also very important that the technical specialist who formulates the equations of movement does not limit his interest only to the movement of markers in three-dimensional space or tribological relations on the rolling surfaces of the joint, but be aware of the causative phenomena of movement, as well as various consequences for specific parametric intervals. Extending technical knowledge with a biological dimension will certainly result in the improvement of existing and the use of new mathematical applications.

#### **12. Quantitative assessment of the observation**

The ability to make an effective, quality diagnosis of the patient is a kind of subjective and highly individualized diagnostician's skill, which combines the elements of systemic, scientific knowledge with acquired experience and intuition into one

**65**

*Biomechanics as an Element of the Motion Clinimetry System*

coherent system. During the professional development period (of a physician, for instance), this trait evolves as a result of one's dominant character, the amount of acquired theoretical knowledge, and the number of known clinical cases. A unique element—human nature—is therefore a modulator in the way of perceiving subsequent clinical situations, in particular seeing them through the prism of acquired

Many years clinical experience has been reflected in the creation of more and more specific criterial systems, being a scientific generalization of practical observations of many generations of doctors. These systems provide high sensitivity and specificity of diagnosis in terms of quality. At the moment it can be said that for the diseases with well-known etiologies and mechanisms, criterial systems do serve their purpose. An experienced doctor, while examining a patient, easily sees the qualitative characteristics of compensative asymmetries in patient's profile of motor dysfunction. For example, he/she notices asymmetry and direction of compensation in statokinetic reflexes in the Romberg test, draws attention to the asymmetry in the SFTR measurements, differences in temperature and humidity of the limbs, differences of the skin sensitivity to pain and touch, and asymmetry of myotatic reflexes, but **has difficulties in estimating the quantitative characteristics of** 

To sum up, one of the major problems of musculoskeletal medicine is the difficulty of a reliable, quantitative estimation of biomechanical parameters of the asymmetry of the patient's adaptive dysfunction profile and the subjective dimension of his suffering that occurs in the course of a qualitatively diagnosed disease. It should be remembered that without a reliable assessment of the patient's initial biomechanical parameters, it is difficult to talk about proper assessment of treatment effects and prognoses. Currently, in the evaluation of the musculoskeletal system, estimated methods are still in use—they are based on mutually subjective relationship between the patient and the physician, with examples such as the Lovett and WAS scales or (more recent) quality of life scales. Metrology-wise, the use of simple measuring tools dominates and is rarely supplemented with individual cases of only

locally available (and usually unique), advanced measurement technology.

Methods of converting specific (but descriptive) clinical criteria (that are specific for different disease units) into the form of bioengineering parameters, which would finally allow for a quantitative monitoring of disease parameters, are being actively searched for. Another question is whether a principle that is obvious for the angular, vector, and time parameters used in biomechanics can be applied in the description of results of medical imaging, pathology, and electrodiagnostics. There is a lack of a supervisory system that would function as a standard, inter-center way of presenting well-known measurement technologies enriched with a quantitative aspect adjusted to this standard, designed for communication and capable of assimilating new diagnostic solutions to suit the presentation and systemic work.

An important element of bioengineering research is the correct location of the body marker points, thereafter subjected to a static 3D parameterization, with the possibility of tracking, associated with the movement of the parametric drift in the dynamic graphic analysis or in telemetric analysis of radio markers. A characteristic feature of these points must be location stability as a common feature of

scientific knowledge and gradually collected capital of experience.

*DOI: http://dx.doi.org/10.5772/intechopen.92757*

**his/her observations**.

**13. Clinimetry**

**13.1 Movement marking**

#### *Biomechanics as an Element of the Motion Clinimetry System DOI: http://dx.doi.org/10.5772/intechopen.92757*

*Recent Advances in Biomechanics*

consequences.

Evidence Based Practice in London 2001 was founded in London. An important initiative here was to create a PEDro system database accessible via the Internet. In this new approach, EBP is a collection of clinical procedures that aim at the best possible, holistic use of the therapist's clinical experiences, supported by (verified and available in practice) scientific evidences of image, laboratory, and functional and psychological diagnosis, whose application and integration in one personalized clinical picture increase the effectiveness of medical procedures and patient's safety in the process of the musculoskeletal system's diagnosis, shaping the highest possible level of physiotherapeutic treatment [97]. It can be noticed that the presented definition is quite convergent with the Polish model of the rehabilitation team, promoted since the 1970s (Milanowska, Dega), which uses the consular way of disciplinary knowledge of a rehabilitation doctor, physiotherapist, psychologist, and social worker in order to find a comprehensive solution to the problem of motor organ dysfunction in a medical, psychological, rehabilitation, and social aspect. The cited textbook is particularly recommendable due to the fact that the authors have made a very comprehensive summary of the existing literature on the subject, outlining a very clear picture of the issue. Thus, EBP is shaping a directional model for the development of new science of movement disorders, which are the essence of many medical and physiotherapy specialties, aiming at replacing the currently dominant profile of the assessment of movement disorders implemented by means of distributed sequences, narrowly specialized engineering research, and general medical procedures for the creation of multidimensional and a personalized image reflecting the tangle of causative problems of pain with parametric disorders of biomechanics of movement, combined with metrology of psychological and social

It is therefore of the utmost importance that the professional evolution of specialists dealing with the musculoskeletal system does not stop at specialized, narrow clinical, or metrological competences but aims at increasing interdisciplinary competences, which will result in the ability to perceive parametric body movement disorders against the background of causative phenomena and above all their adaptive and clinical consequences. In such a new situation, a physiotherapist with broadly formatted practical and theoretical knowledge will not only receive but will also be able to use access to team knowledge, including clinical information on the etiology of the disease, as well as to the results of detailed imaging and clinometric tests. The planned treatment strategy will gain a new, more pragmatic parametric foundation, which in addition to diagnosis offers the possibility of metrological supervision of the effects of therapy, including psychological clinimetry. It is important to remember about the changes in the patient's psyche who is suffering from pain, as well as limiting the implementation of his/her priorities on personal, professional, and social grounds. It is also very important that the technical specialist who formulates the equations of movement does not limit his interest only to the movement of markers in three-dimensional space or tribological relations on the rolling surfaces of the joint, but be aware of the causative phenomena of movement, as well as various consequences for specific parametric intervals. Extending technical knowledge with a biological dimension will certainly result in the improvement

The ability to make an effective, quality diagnosis of the patient is a kind of subjective and highly individualized diagnostician's skill, which combines the elements of systemic, scientific knowledge with acquired experience and intuition into one

of existing and the use of new mathematical applications.

**12. Quantitative assessment of the observation**

**64**

coherent system. During the professional development period (of a physician, for instance), this trait evolves as a result of one's dominant character, the amount of acquired theoretical knowledge, and the number of known clinical cases. A unique element—human nature—is therefore a modulator in the way of perceiving subsequent clinical situations, in particular seeing them through the prism of acquired scientific knowledge and gradually collected capital of experience.

Many years clinical experience has been reflected in the creation of more and more specific criterial systems, being a scientific generalization of practical observations of many generations of doctors. These systems provide high sensitivity and specificity of diagnosis in terms of quality. At the moment it can be said that for the diseases with well-known etiologies and mechanisms, criterial systems do serve their purpose. An experienced doctor, while examining a patient, easily sees the qualitative characteristics of compensative asymmetries in patient's profile of motor dysfunction. For example, he/she notices asymmetry and direction of compensation in statokinetic reflexes in the Romberg test, draws attention to the asymmetry in the SFTR measurements, differences in temperature and humidity of the limbs, differences of the skin sensitivity to pain and touch, and asymmetry of myotatic reflexes, but **has difficulties in estimating the quantitative characteristics of his/her observations**.

To sum up, one of the major problems of musculoskeletal medicine is the difficulty of a reliable, quantitative estimation of biomechanical parameters of the asymmetry of the patient's adaptive dysfunction profile and the subjective dimension of his suffering that occurs in the course of a qualitatively diagnosed disease. It should be remembered that without a reliable assessment of the patient's initial biomechanical parameters, it is difficult to talk about proper assessment of treatment effects and prognoses. Currently, in the evaluation of the musculoskeletal system, estimated methods are still in use—they are based on mutually subjective relationship between the patient and the physician, with examples such as the Lovett and WAS scales or (more recent) quality of life scales. Metrology-wise, the use of simple measuring tools dominates and is rarely supplemented with individual cases of only locally available (and usually unique), advanced measurement technology.

### **13. Clinimetry**

Methods of converting specific (but descriptive) clinical criteria (that are specific for different disease units) into the form of bioengineering parameters, which would finally allow for a quantitative monitoring of disease parameters, are being actively searched for. Another question is whether a principle that is obvious for the angular, vector, and time parameters used in biomechanics can be applied in the description of results of medical imaging, pathology, and electrodiagnostics. There is a lack of a supervisory system that would function as a standard, inter-center way of presenting well-known measurement technologies enriched with a quantitative aspect adjusted to this standard, designed for communication and capable of assimilating new diagnostic solutions to suit the presentation and systemic work.

#### **13.1 Movement marking**

An important element of bioengineering research is the correct location of the body marker points, thereafter subjected to a static 3D parameterization, with the possibility of tracking, associated with the movement of the parametric drift in the dynamic graphic analysis or in telemetric analysis of radio markers. A characteristic feature of these points must be location stability as a common feature of

individuals that belong to the same species. Thus, a body construction property, acting as a geometrically distinctive feature for a given species, is called the marker point. A convenient starting procedure is to perform the erosion of the body image (loss conversion), in order to expose the main limb axes, at the same time indicating their joint connections (bonds). The next step is to flag the selected markers at the coordinate system obtained and to draw the vectors showing the acceleration, velocity, and direction of motion. The procedure requires a considerable computing power of the computer system.
