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• Journal article
  Pearce AP, Bull AMJ, Clasper JC, 2017,

  Mediastinal injury is the strongest predictor of mortality in mounted blast amongst UK deployed forces.

  , Injury, Vol: 48, Pages: 1900-1905, ISSN: 0020-1383

  BACKGROUND: Blast injury has been the most common cause of morbidity and mortality encountered by UK forces during recent conflicts. Injuries sustained by blast are categorised by the injuring component of the explosion and depend upon physical surroundings. Previous work has established that head injuries and intra cavity haemorrhage are the major causes of death following exposure to under body (mounted) blast but has yet to explore the precise nature of these torso injuries nor the effect of particular injuries upon survival. This study examines the patterns of torso injury within the mounted blast environment in order to understand the effect of these injuries upon survivability. METHODS: This retrospective study examined the UK Joint Theatre Trauma Registry to determine precise injury patterns of mounted blast casualties within a 13year period of UK military deployments. Survival rates of individual injuries were compared and a multivariable logistic regression model was developed in order to assess the effect that each injury had upon likelihood of death. RESULTS: 426 mounted casualties were reviewed of whom 129 did not survive. Median NISS and ISS for non-survivors was found to be 75. Torso injuries were significantly more common amongst non-survivors than survivors and high case fatality rates were associated with all haemorrhagic torso injuries. Multivariable analysis shows that mediastinal injuries have the largest odds ratio for mortality (20.4) followed by lung laceration and head injury. CONCLUSIONS: Non-compressible torso haemorrhage is associated with mortality amongst mounted blast. Of this group, mediastinal injury is the strongest predictor of death and could be considered as a surrogate marker of lethality. Future work to link blast loading characteristics with specific injury patterns will inform the design of mitigating strategies in order to improve survivability of underbody blast.

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• Journal article
  Panagiotakis E, Mok K-M, Fong DT-P, Bull AMJet al., 2017,

  Biomechanical analysis of ankle ligamentous sprain injury cases from televised basketball games: Understanding when, how and why ligament failure occurs

  , Journal of Science and Medicine in Sport, Vol: 20, Pages: 1057-1061, ISSN: 1440-2440

  OBJECTIVES: Ankle sprains due to landing on an opponent's foot are common in basketball. There is no analysis to date that provides a quantification of this injury mechanism. The aim of this study was to quantify the kinematics of this specific injury mechanism and relate this to lateral ankle ligament biomechanics. DESIGN: Case series. METHODS: The model-based image-matching technique was used to quantify calcaneo-fibular-talar kinematics during four ankle inversion sprain injury incidents in televised NBA basketball games. The four incidents follow the same injury pattern in which the players of interest step onto an opponent's foot with significant inversion and a diagnosed ankle injury. A geometric analysis was performed to calculate the in vivo ligament strains and strain rates for the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). RESULTS: Despite the controlled selection of cases, the results show that there are two distinct injury mechanisms: sudden inversion and internal rotation with low levels of plantarflexion; and a similar mechanism without internal rotation. The first of these mechanisms results in high ATFL and CFL strains, whereas the second of these strains the CFL in isolation. CONCLUSIONS: The injury mechanism combined with measures of the ligament injury in terms of percentage of strain to failure correlate directly with the severity of the injury quantified by return-to-sport. The opportunity to control excessive internal rotation through proprioceptive training and/or prophylactic footwear or bracing could be utilised to reduce the severity of common ankle injuries in basketball.

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• Journal article
  Fratini A, Bonci T, Bull AM, 2016,

  Whole body vibration treatments in postmenopausal women can improve bone mineral density: results of a stimulus focussed meta-analysis.

  , PLOS One, Vol: 11, ISSN: 1932-6203

  Whole body vibration treatment is a non-pharmacological intervention intended to stimulate muscular response and increase bone mineral density, particularly for postmenopausal women. The literature related to this topic is controversial, heterogeneous, and unclear despite the prospect of a major clinical effect.The aim of this study was to identify and systematically review the literature to assess the effect of whole body vibration treatments on bone mineral density (BMD) in postmenopausal women with a specific focus on the experimental factors that influence the stimulus. Nine studies fulfilled the inclusion criteria, including 527 postmenopausal women and different vibration delivery designs. Cumulative dose, amplitudes and frequency of treatments as well as subject posture during treatment vary widely among studies. Some of the studies included an associated exercise training regime. Both randomized and controlled clinical trials were included. Whole body vibration was shown to produce significant BMD improvements on the hip and spine when compared to no intervention. Conversely, treatment associated with exercise training resulted in negligible outcomes when compared to exercise training or to placebo. Moreover, side-alternating platforms were more effective in improving BMD values than synchronous platforms and mechanical oscillations of magnitude higher than 3 g and/or frequency lower than 25 Hz were also found to be effective. Treatments with a cumulative dose over 1000 minutes in the follow-up period were correlated to positive outcomes.Our conclusion is that whole body vibration treatments in elderly women can reduce BMD decline.However, many factors (e.g., amplitude, frequency and subject posture) affect the capacity of the vibrations to propagate to the target site; the adequate level of stimulation required to produce these effects has not yet been defined. Further biomechanical analyses to predict the propagation of the vibration waves along the body a

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• Journal article
  Rane L, Bull AMJ, 2016,

  Functional electrical stimulation of gluteus medius reduces the medial joint reaction force of the knee during level walking

  , Arthritis Research & Therapy, Vol: 18, ISSN: 1478-6354

  Background: By altering muscular activation patterns, internal forces acting on the human body during dynamic activity may be manipulated. The magnitude of one of these forces, the medial knee joint reaction force (JRF), is associated with disease progression in patients with early osteoarthritis (OA), suggesting utility in its targeted reduction. Increased activation of gluteus medius has been suggested as a means to achieve this. Methods: Motion capture equipment and forceplate transducers were used to obtain kinematic and kinetic data for 15 healthy subjects during level walking, with and without the application of functional electrical stimulation (FES) to gluteus medius. Musculoskeletal modelling was employed to determine the medial knee JRF during stance phase for each trial. A further computer simulation of increased gluteus medius activation was performed using data from normal walking trials by a manipulation of modelling parameters. Relationships between changes in the medial knee JRF, kinematics and ground reaction force were evaluated. Results: In simulations of increased gluteus medius activity, the total impulse of the medial knee JRF was reduced by 4.2% (p=0.003) compared to control. With real-world application of FES to the muscle, the magnitude of this reduction increased to 12.5% (p<0.001), with significant inter-subject variation. Across subjects, the magnitude of reduction correlated strongly with kinematic (p<0.001) and kinetic (p<0.001) correlates of gluteus medius activity. Conclusions: The results support a major role for gluteus medius in the protection of the knee for patients with OA, establishing the muscle’s central importance to effective therapeutic regimes. FES may be used to achieve increased activation in order to mitigate distal internal loads, and much of the benefit of this increase can be attributed to resulting changes in kinematic parameters and the ground reaction force. The utility of interventions targeting g

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• Journal article
  Cheong VS, Karunaratne A, Amis AA, Bull AMJet al., 2016,

  Strain rate dependency of fractures of immature bone

  , Journal of the Mechanical Behavior of Biomedical Materials, Vol: 66, Pages: 68-76, ISSN: 1751-6161

  Radiological features alone do not allow the discrimination between accidental paediatric long bone fractures or those sustained by child abuse. Therefore, there is a clinical need to elucidate the mechanisms behind each fracture to provide a forensic biomechanical tool for the vulnerable child. Four-point bending and torsional loading tests were conducted at more than one strain rate for the first time on immature bone, using a specimen-specific alignment system, to characterise structural behaviour at para-physiological strain rates. The bones behaved linearly to the point of fracture in all cases and transverse, oblique, and spiral fracture patterns were consistently reproduced. The results showed that there was a significant difference in bending stiffness between transverse and oblique fractures in four-point bending. For torsional loading, spiral fractures were produced in all cases with a significant difference in the energy and obliquity to fracture. Multiple or comminuted fractures were seen only in bones that failed at a higher stress or torque for both loading types. This demonstrates the differentiation of fracture patterns at different strain rates for the first time for immature bones, which may be used to match the case history given of a child and the fracture produced.

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• Conference paper
  Grigoriadis G, Carpanen D, Bull AMJ, Masouros SDet al., 2016,

  A finite element model of the foot and ankle for prediction of injury in under-body blast

  , International Research Council on the Biomechanics of Injury, Publisher: IRCOBI, Pages: 457-458, ISSN: 2235-3151
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• Journal article
  Nolte D, Tsang CK, Zhang KY, Ding Z, Kedgley AE, Bull AMJet al., 2016,

  Non-linear scaling of a musculoskeletal model of the lower limb using statistical shape models

  , Journal of Biomechanics, Vol: 49, Pages: 3576-3581, ISSN: 1873-2380

  Accurate muscle geometry for musculoskeletal models is important to enable accurate subject-specific simulations. Commonly, linear scaling is used to obtain individualised muscle geometry. More advanced methods include non-linear scaling using segmented bone surfaces and manual or semi-automatic digitisation of muscle paths from medical images. In this study, a new scaling method combining non-linear scaling with reconstructions of bone surfaces using statistical shape modelling is presented. Statistical Shape Models (SSMs) of femur and tibia/fibula were used to reconstruct bone surfaces of nine subjects. Reference models were created by morphing manually digitised muscle paths to mean shapes of the SSMs using non-linear transformations and inter-subject variability was calculated. Subject-specific models of muscle attachment and via points were created from three reference models. The accuracy was evaluated by calculating the differences between the scaled and manually digitised models. The points defining the muscle paths showed large inter-subject variability at the thigh and shank – up to 26 mm; this was found to limit the accuracy of all studied scaling methods. Errors for the subject-specific muscle point reconstructions of the thigh could be decreased by 9% to 20% by using the non-linear scaling compared to a typical linear scaling method. We conclude that the proposed non-linear scaling method is more accurate than linear scaling methods. Thus, when combined with the ability to reconstruct bone surfaces from incomplete or scattered geometry data using statistical shape models our proposed method is an alternative to linear scaling methods.

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• Journal article
  Grigoriadis G, Newell N, Carpanen D, Christou A, Bull AMJ, Masouros Set al., 2016,

  Material properties of the heel fat pad across strain rates

  , Journal of the Mechanical Behavior of Biomedical Materials, Vol: 65, Pages: 398-407, ISSN: 1751-6161

  The complex structural and material behaviour of the human heel fat pad determines the transmission of plantar loading to the lower limb across a wide range of loading scenarios; from locomotion to injurious incidents. The aim of this study was to quantify the hyper-viscoelastic material properties of the human heel fat pad across strains and strain rates. An inverse finite element (FE) optimisation algorithm was developed and used, in conjunction with quasi-static and dynamic tests performed to five cadaveric heel specimens, to derive specimen-specific and mean hyper-viscoelastic material models able to predict accurately the response of the tissue at compressive loading of strain rates up to 150 s−1. The mean behaviour was expressed by the quasi-linear viscoelastic (QLV) material formulation, combining the Yeoh material model (C10=0.1MPa, C30=7MPa, K=2GPa) and Prony׳s terms (A1=0.06, A2=0.77, A3=0.02 for τ1=1ms, τ2=10ms, τ3=10s). These new data help to understand better the functional anatomy and pathophysiology of the foot and ankle, develop biomimetic materials for tissue reconstruction, design of shoe, insole, and foot and ankle orthoses, and improve the predictive ability of computational models of the foot and ankle used to simulate daily activities or predict injuries at high rate injurious incidents such as road traffic accidents and underbody blast.

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• Book
  Southgate DFL, Childs PRN, Bull AMJ, 2016,

  Introduction

  , ISBN: 9781786340429
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• Book chapter
  Eftaxiopoulou T, Chaillot V, Bull AMJ, 2016,

  Interaction between equipment and athlete performance in racket sports: A cricketing story

  , Sports Innovation, Technology and Research, Pages: 43-62
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