Internal hydraulic exoskeleton theory and the sanomechanics® system as for prevention of osteoarthritis after unilateral lower limb amputation

Authors:

Prof. Pitkin, M.R. Dr. Tech. Sci. Tufts University, Boston, MA 02111, USA. Phone 617-636-7000, e-mail: mpitkin@tuftsmedicalcenter.org

Annotation:

Introduction. After unilateral amputation of the lower limb, the preserved leg experiences asymmetrically greater loads during walking than before the operation. Overloading of its joints leads to the development of posttraumatic osteoarthritis, which negatively affects the effectiveness of prosthetic rehabilitation, significantly reducing the patient’s quality of life. A new approach to rehabilitation techniques is proposed in order to increase their effectiveness in preventing joint overload as one of the causes of posttraumatic osteoarthritis.
This approach consists of the introduction of the elements of Sanomechanics®, developed by the author, as a general strengthening system of psychophysical exercises into existing rehabilitation methods. A distinctive feature of Sanomechanics is its focus on maintaining and restoring a previously undetectable physiological system that protects articular cartilage from overload. The system, called “internal hydraulic exoskeleton,” encompasses the entire bony skeleton and includes the bursae, periosteum, entheses, and subperiosteal fluid.

Aim. The aim of the work was to propose a minimum number of exercises that develop a patient’s ability to withstand jumping loads for inclusion in the rehabilitation methods of a prosthetics clinic, as well as to modify training systems to help patients without prior athletic training to master the recommended exercises in a short time and help them make these exercises part of their daily practice.

Materials and methods. The connection of muscles with the bones of the skeleton, which could be associated with the structure and operation of the “internal hydraulic exoskeleton” system, were investigated. The concept of the internal hydraulic exoskeleton was used as a semantic filter for the analysis of well-known traditional methods of physical improvement associated with extreme loads of the jumping type. The analysis set two tasks: to select the minimum number of exercises that develop the ability to withstand jumping loads, which can be recommended for inclusion in the rehabilitation methods of a prosthetics clinic; to offer a training system to help patients with no prior athletic training to master the recommended exercises in a short time and to help them to practice these exercises daily.

Results. Despite differences in the analyzed training systems, the general theme consistent with the concept of the internal hydraulic exoskeleton was the development of flexibility in the pelvic region. Selected exercises for performance in the sagittal plane: longitudinal split, “cobra” yoga pose, “child” yoga pose. In the frontal plane, this is the transverse split. These exercises have been modified so that they can be performed in bed after waking up according to the Sanomechanics method. It is proposed to teach the technique while the patient is in the clinic before and after prosthetics services.

Conclusion. An additional element of rehabilitation methods in the prosthetics clinic, consisting of the method of psychophysical training of the internal exoskeleton system, is proposed for discussion and verification.
The technique consists of exercises to reduce intra-articular pressures by maintaining and restoring hydrostatic transmission and pressure distribution in the subperiosteal layer between the pelvis and extremities, and between the pelvis and the spine.

List of cited literature:

1. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, Shibuya K, Salomon J.A, Abdalla S, Aboyans V. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. The lancet. 2012;380(9859):2163-96.

2. Struyf PA, Heugten CM van, Hitters MW, Smeets RJ. The prevalence of osteoarthritis of the intact hip and knee among traumatic leg amputees. Archives of physical medicine and rehabilitation. 2009;90(3):440-6.

3. Burke M, Roman V, Wright V. Bone and joint changes in lower limb amputees. Annals of the rheumatic diseases. 1978;37(3):252-4.

4. Esquenazi A, Geriatric amputee rehabilitation. Clinics in geriatric medicine 1993;9(4):731-43.

5. Kohn MD, Sassoon AA, Fernando ND. Classifications in brief: Kellgren-Lawrence classification of osteoarthritis. Springer, 2016.

6. Smirnova LM. Biomekhanicheskie pokazateli peregruzki sohrannoj konechnosti u pacientov s amputaciej goleni, bedra ili vychleneniem v tazobedrennom sustave [Biomechanical indicators of the overload of the preserved limb in patients with amputation of the lower leg, hip or hip joint]. Genij Ortopedii [The genius of Orthopedics]. 2018;24(1):50-6. (In Russian).

7. Lew HL, Otis JD., Tun C, Kerns RD, Clark ME, Cifu DX. Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: polytrauma clinical triad. J Rehabil Res Dev. 2009;46(6):697-702.

8. Clark ME, Walker R., Gironda RJ, Scholten JD. Comparison of pain and emotional symptoms in soldiers with polytrauma: unique aspects of blast exposure. Pain medicine (Malden, Mass.). 2009;10(3):447-55.

9. Dominick KL, Golightly YM, Jackson GL. Arthritis prevalence and symptoms among US non-veterans, veterans, and veterans receiving Department of Veterans Affairs Healthcare.The Journal of rheumatology. 2006;33(2):348-54.

10. Rivera JC, Wenke JC, Buckwalter JA, Ficke JR, Johnson AE. Posttraumatic osteoarthritis caused by battlefield injuries: the primary source of disability in warriors.
Journal of the American Academy of Orthopaedic Surgeons. 2013;20(suppl):S64-S69.

11. Pitkin MR. Teoriya vnutrennego gidravlicheskogo ezoskeletona i sistema Sanomekhanika (Sanomechanics®) v primenenii k profilaktike osteoartrita posle odnostoronnej amputacii nizhnej konechnosti [Detection of Intra-Articular Pressure Transmission Between Knees: A Confirmation of the “Internal Hydraulic Exoskeleton” System That Protects Articular Cartilage from Overloading]. Fizicheskaya i reabilitacionnaya medicina. [Physkal and Rehabilitation Medicine]. 2020;2(4):8-19. DOI: 10.26211/2658-4522- 2020-2-4-8-19 (In Russian).

12. Pitkin M. New Training System Based on the Discovery of Subperiosteal Transmission of Pressures Between Joint Capsules. Mil Med. 2021;186(S_1):814819. Available from: https://doi.org/10.1093/milmed/ usaa476. PMID: 33499550.

13. Pitkin M, Cassidy C, Muppavarapu R, Pitkin E. Subperiosteal Transmission of Intra-Articular Pressure Between Articulated and Stationary Joints, Nature. Scientific Reports. 2015:8103. Available from: https://www.nature. com/articles/srep08103. DOI: 10.1038/srep08103.

14. Pitkin M. Biomechanics for Life. Introduction to Sanomechanics. Heidelberg, Dondrecht, London, New York: Springer, 2011. Available from: http://www.springer. com/medicine/orthop edic s/ book/978-3-642-17176-5.

15. Schiffman JM, Gregorczyk KN, Bensel CK., Hasselquist L, Obusek JP. The effects of a lower body exoskeleton load carriage assistive device on limits of stability and postural sway. Ergonomics. 2008;51(10):1515-29.

16. Hill D, Holloway CS, Ramirez DZM, Smitham P, Pappas Y. What are user perspectives of exoskeleton technology? A literature review, 2017.

17. Pitkin M. New Training System – Sanomechanics – Based on the Discovery of Subperiosteal Transmission of Pressures Between Joint Capsules. Military Health System Research Symposium. MHSRS-19-00181. Kissime, FL, 2019:182.

18. Greene WB, Netter FH. Netter’s orthopaedics, 1st ed. Philadelphia, PA: Saunders Elsevier, 2006.

19. Dwek JR. The periosteum: what is it, where is it, and what mimics it in its absence? Skeletal radiology. 2010;39(4):319-323.

20. Duhamel HL. Sur le developpement et la crue des os des animaux, Mem Acad R Sci. 55(1742):354-370.

21. Bilkay U, Tokat C, Helvaci E, Ozek C, Zekioglu O, Onat T, Songur E. Osteogenic capacities of tibial and cranial periosteum: a biochemical and histologic study. J Craniofac Surg. 2008;19(2):453-8.

22. Carpenter RD, Carter DR. The mechanobiological effects of periosteal surface loads. Biomech Model Mechanobiol. 20087(3):227-42.

23. Balabanova RM. Entezity: diagnostika, lechenie [Enteritis: diagnosis, treatment]. RMZh [Russian Medical Journal]. 2021;11:538 (In Russian).

24. Benjamin M, Kumai T, Milz S, Boszczyk BM, Boszczyk AA, Ralphs JR. The skeletal attachment of tendons– tendon «entheses». Comp Biochem Physiol A Mol Integr Physiol. 2002;133(4):931-45.

25. Lu HH, Thomopoulos S. Functional attachment of soft tissues to bone: development, healing, and tissue engineering. Annu Rev Biomed Eng. 2013;15: 201-26.

26. Benjamin M, Moriggl B, Brenner E, Emery P, McGonagle D, Redman S. The “enthesis organ” concept: why enthesopathies may not present as focal insertional disorders. Arthritis & Rheumatism. 2004;50(10): 3306-13.

27. Slobodin G, Rozenbaum M, Boulman N, Rosner I. Varied presentations of thesopathy. Seminars in arthritis and rheumatism. Elsevier. 2007:119-26.

28. Tan AL, Grainger AJ, Tanner SF, Shelley DM, Pease C, Emery P, McGonagle D. High-resolution magnetic resonance imaging for the assessment of hand osteoarthritis. Arthritis Rheum. 2005;52(8):2355-65.

29. Hunter DJ. Insights from imaging on the epidemiology and pathophysiology of osteoarthritis, Radiologic Clinics. 2009;47(4):539-51.

30. Brandt K, Radin E, Dieppe P, Van De Putte L. Yet more evidence that osteoarthritis is not a cartilage disease. BMJ Publishing Group Ltd, 2006.

31. Rogers J, Shepstone L, Dieppe P. Is osteoarthritis a systemic disorder of bone? Arthritis & Rheumatism: Official Journal of the American College of Rheumatology. 2004;50(2):452-7.

32. Dorfl J. Migration of tendinous insertions. I. Cause and mechanism. J Anat. 1980;131(Pt 1):179-95.

33. McBride SH, Evans SF, Knothe ML. Tate, Anisotropic mechanical properties of ovine femoral periosteum and the effects of cryopreservation. J Biomech. 2011;44(10):1954-9.

34. Reid H, Wood S. Achilles Tendinopathy: Advice and Management. Oxford University Hospitals NHS Foundation Trust, 2015. Available from: https://www.ouh.nhs.uk/patient-guide/leaflets/ files/11924Ptendinopathy.pdf

35. Deshikachar T. Serdce jogi (sovershenstvovanie individual’noj praktiki), [The Heart of Yoga (improving individual practice)]. M.: Sofiya [Moscow: Sofia], 2003 (In Russian).

36. Pitkin M. Sanomechanics. In: Biomechanics for Life. Introduction to Sanomechanics. Heidelberg, Dordrecht, London, New York: Springer, 2011:25-36.

37. Freud S. Introductory lectures on psycho-analysis: a course of twenty eight lectures delivered at the University of Vienna. Rev. ed. London: Allen & Unwin, 1929.

38. Coue Ё. How to practice suggestion and autosuggestion. New York: American library service, 1923.

39. Luthe W, Schultz JH. Autogenic therapy. New York: Grune & Stratton, 1969.

40. Lyubinskaya SM. Ot zaikaniya k svobodnoj rechi [From stuttering to free speech]. M.: Prosveshchenie [Moscow: Education]. 1970. (In Russian).