Methods for estimating numbers of motor units in biceps-brachialis muscles and losses of motor units with aging

Aging of orbicularis oculi: anatomophysiologic consideration in upper blepharoplasty

OBJECTIVE

To investigate the anatomophysiologic aging-related changes in the orbicularis oculi muscle.

METHODS

We examined the full-thickness histologic characteristics of the upper eyelids from cadavers of 30-, 40-, 60-, and 70-year-old men and the muscle interference pattern (IP) of 68 healthy volunteers of both sexes aged 18 to 73 years.

RESULTS

Histologic analysis revealed that in the aging upper eyelid, changes were primarily in the skin and subcutaneous layers with the characteristic loss of collagen elastic fibers; however, the whole muscle layer was histologically intact, with no signs of aging; loss of fibers, loss of adherence to surrounding structure, or ptosis. Neurophysiologic studies of the electromyographic IP of the orbicularis oculi muscle confirmed that the full efficiency of orbicularis oculi function was intact in the age group studied (18-73 years) in both sexes.

CONCLUSION

Our results suggest that the anatomophysiologic characteristics of the orbicularis oculi muscle remain intact through advancement of age.

Motor unit number estimation in the assessment of performance and function in motor neuron disease

Motor unit number estimation (MUNE) is a unique electrophysiologic test used to estimate the number of surviving motor units in a muscle or group of muscles. It is used most frequently to monitor lower motor neuron loss in amyotrophic lateral sclerosis and spinal muscle atrophy. Of particular interest is its use as an endpoint measure in clinical trials for these diseases. This article describes the principles of MUNE and the factors that need to be considered, and reviews several techniques that have been used in clinical trials and in monitoring progression. It then reviews experience with MUNE in clinical trials for amyotrophic lateral sclerosis and spinal muscle atrophy and discusses how MUNE correlates with measures of function.

Quantitative anal sphincter electromyography in primiparous women with anal incontinence

OBJECTIVE

The purpose of this study was to determine whether evidence of denervation/reinnervation of the external anal sphincter is associated with anal incontinence symptoms immediately after delivery.

STUDY DESIGN

After a first vaginal delivery, 42 women completed an anal incontinence questionnaire. They also underwent concentric needle electromyography of the external anal sphincter. For each subject, motor unit action potential and interference pattern parameters were determined.

RESULTS

For the motor unit action potential, no difference was observed between patients with and without anal incontinence symptoms (t-test). For the interference pattern, the amplitude/turn was greater in subjects with fecal urgency (318 +/- 48 [SD] microV) and fecal incontinence (332 +/- 48 microV), compared with those without fecal urgency (282 +/- 38 microV) and fecal incontinence (286 +/- 41 microV; P = .02, t-test).

CONCLUSION

In this group of postpartum women with mild anal incontinence symptoms, interference pattern analysis shows evidence of denervation and subsequent reinnervation.

The effect of handedness on electromyographic activity of human shoulder muscles during movement

The aim of the study was to investigate whether there was a difference in the electromyographic (EMG) activity of human shoulder muscles between the dominant and nondominant side during movement and to explore whether a possible side-difference depends on the specific task. We compared the EMG activity with surface and intramuscular electrodes in eight muscles of both shoulders in 20 healthy subjects whose hand preference was evaluated using a standard questionnaire. EMG signals were recorded during abduction and external rotation. During abduction, the normalized EMG activity was significantly smaller on the dominant side compared to the nondominant side for all the muscles except for infraspinatus and lower trapezius (P <or= 0.002). In contrast, during external rotation, higher EMG activity was seen in the supraspinatus, infraspinatus, lower and upper trapezius and latissimus muscles of the dominant side (P <or= 0.01). We demonstrated a side-difference in shoulder muscle activity, which was dependent on the type of motion carried out, suggesting a qualitative difference in the activation of muscles during the two types of movement. Dynamic abduction has the characteristics of a dominant arm task (i.e., task performed almost exclusively by the dominant arm) and reduced muscle activity for the dominant side during abduction indicates a dominance-related advantage in arm dynamics.

Strength-training exercise in dysphagia rehabilitation: principles, procedures, and directions for future research

Dysphagia rehabilitation, historically, has focused a great deal on various compensations during swallowing to prevent aspiration and/or improve safety and efficiency. Exercise, in general, has been a part of the dysphagia rehabilitation landscape. However, heightened discussions in the field regarding best practices for exercise training, particularly strengthening, raise more questions than answers. The intent of this paper is to (1) explore the overriding principles of neuromuscular plasticity with regard to strength training, (2) evaluate how current exercise-training interventions in dysphagia rehabilitation correspond to these principles, and (3) postulate directions for future study of normal and disordered swallowing and determine how to incorporate these principles into dysphagia rehabilitation.

Rate coding is compressed but variability is unaltered for motor units in a hand muscle of old adults

The discharge of single motor units (n = 34) in the first dorsal interosseus muscle and the fluctuations in force during steady contractions were measured across a range of index finger abduction forces in old adults (77.1 +/- 6.9 yr, n = 20). These results were compared with previously reported data on 38 motor units from young adults (25.7 +/- 5.7 yr). Both minimal and peak discharge rates increased with recruitment threshold, but the strength of these relations was notably weaker for the old adults. Minimal discharge rates were similar for young and old adults (P = 0.77), whereas peak discharge rates were lower for old adults (P < 0.01). Consequently, the range of rate coding for each motor unit was substantially less for the old adults (7.1 pps) compared with the young adults (12.1 pps, P < 0.01). However, the variability in motor-unit discharge was similar for young and old adults; the coefficient of variation of the interspike intervals was similar at recruitment (old: 25.4%, young: 27.1%, P = 0.39) and declined with an increase in discharge rate (old: 13.2%, young: 14.2%, P = 0.21). Furthermore, the fluctuations in force during steady isometric contractions (2-95% of maximal force) were similar for young and old adults, except that the relative variability at the lowest force was greater for the old adults. A computational model of motor-unit recruitment and rate coding incorporated the experimental observations and was able to match the measured and simulated values for force steadiness across the operating range of the muscle.

Updating motor unit number estimation (MUNE)

Motor unit number estimation (MUNE) is a unique electrophysiologic technique that can provide a numeric estimate of the number of axons innervating a muscle or group of muscles. The first technique was first described in 1971, and since then different techniques have been developed to address specific methodologic issues. The field was reviewed in this journal in 2001, and this update covers new information and uses of MUNE over the past five years. These include models of muscles that allow evaluation of MUNE techniques and comparisons between techniques. There have been further investigations of specific technical aspects of MUNE. Modifications to MUNE techniques have been offered that permit more rapid acquisition of data. MUNE has been used in clinical situations to elucidate the pathophysiology features of axonal loss in a number of disorders. There is now more experience with MUNE as endpoint measures in clinical trials.

Efficient control of arm movements in advanced age

The present study addresses the influence of aging on the ability to regulate mechanical effects arising during arm movements due to the multi-joint structure of the arm. Two mechanical factors were considered, interaction torque (IT) and inertial resistance (IR). Regulation of these two factors can be demanding in terms of the timing and magnitude of the required muscle torque (MT), specifically during fast movements. We hypothesized that aging exacerbates the challenge regarding the regulation of these effects with muscular control due to declines in the motor system. This hypothesis was tested by comparing performance of a cyclic line-drawing task in two age groups, young and older adults. Only two joints, the shoulder and elbow, participated in motion. Four orientations of the lines were used to provide variations in the requirements for regulation of IT and IR. Cyclic frequency was manipulated to emphasize the dependence of the mechanical factors on movement speed. Various characteristics of fingertip motion showed that there were no age-related deteriorations in accuracy of line drawing. However, older adults were systematically slower, particularly in the directions of high IR. A detailed analysis of the magnitude of MT and the contribution of this torque to production of net torque at each joint demonstrated that older adults modified joint control and decreased the demands for MT by skillful exploitation of IT in a way specific for each particular line orientation. The results point to a tendency in older adults to decrease the production of muscle force. Nevertheless, older adults also demonstrated an ability to partially compensate for declines in the force production by developing sophisticated strategies of joint control that exploit the multi-joint mechanical structure of the arm. This ability suggests that the internal representation of inter-segmental dynamics and the capability to use it for movement control does not decay with age. The study emphasizes the importance of analysis of joint motion and control characteristics for the investigation of arm movements and for comparison of these movements between different subject populations.

The amplitude of force variability is correlated in the knee extensor and elbow flexor muscles

The purpose of this study was to determine motor output variability for different muscles in the same individuals. Ten young (21.7 +/- 3.4 years) and ten elderly (72.1 +/- 3.9 years) men underwent assessment of maximal isometric (MVC) and dynamic (1-RM) strength, and performed constant-force (2-50% MVC), constant-load (5-50% 1-RM load), and unloaded postural contractions as steadily as possible with the first dorsal interosseus (FDI), elbow flexors (EF), and knee extensors (KE). The coefficient of variation (CV) of force for isometric contractions and the standard deviation (SD) of acceleration for concentric, eccentric, and postural contractions were calculated. The 1-RM load, the CV of force for four of five isometric target forces, and the SD of acceleration during postural contractions were correlated between the EF and KE muscles. MVC force, 1-RM load, and SD of acceleration during postural contractions were not correlated between the FDI/EF or FDI/KE. The CV of force was correlated between the FDI/EF and FDI/KE for two of five isometric target forces. The SD of acceleration during concentric and eccentric contractions was not correlated between muscles. The normalized fluctuations during isometric contractions were greater for the FDI compared with the EF and KE. Elderly adults displayed greater fluctuations only for the FDI during low-force isometric and postural contractions. The dominant frequency of fluctuations was similar for the EF and KE muscles. The correlated fluctuations for the EF and KE muscles, within subjects, suggests that the two motor neuron pools transform the various neural inputs similarly.

Cortical versus spinal dysfunction in amyotrophic lateral sclerosis

Little is known about the possible link between cortical and spinal motor neuron dysfunction in amyotrophic lateral sclerosis (ALS). We correlated the characteristics of the responses to transcranial magnetic stimulation (TMS) with the electromechanical properties and firing pattern of single motor units (MUs) tested in nine ALS patients, three patients with Kennedy's disease, and 15 healthy subjects. In Kennedy's disease, 19 of 22 MUs were markedly enlarged with good electromechanical coupling and discharged with great variability. Their excitatory responses increased with MU size. In ALS, 17 of 34 MUs with excitatory responses behaved as in Kennedy's disease. By contrast, 28 MUs with nonsignificant responses showed poor electromechanical coupling and high firing rates, whereas 28 MUs with inhibitory responses showed moderate functional alterations. This result indicates that in ALS as in Kennedy's disease, sprouting of corticospinal axons may occur on surviving motoneurons. A clear relationship exists between the responsiveness of MUs to TMS and their functional state.

External anal sphincter volume measurements using 3-dimensional endoanal ultrasound

OBJECTIVE

Significant nerve injury to a muscle can be associated with muscle atrophy and volume loss. Three-dimensional (3D) ultrasound can measure muscle volume, but the reproducibility of the technique has not been established for the anal sphincter.

STUDY DESIGN

Using a 10 MHz 360-degree rotating endoanal probe, we performed 3D endoanal ultrasounds on 9 nulliparous and 23 asymptomatic primiparous subjects at 12 weeks' postpartum. Two blinded examiners measured the length of the external anal sphincter (EAS) from a midsagittal image, and the width of the EAS and internal anal sphincter (IAS) from axial images at mid anal canal. The EAS volume was calculated by repetitively outlining only the EAS in each sequential axial view. Both examiners measured the EAS volumes twice, blinded to previous calculations.

RESULTS

The intrarater reliability for EAS volume was 0.79 to 0.89 (intraclass coefficient). The mean difference of the EAS volume between the 2 examiners was 0.5 mL (P = .3, t test). Correlation between the 2 examiners for measuring EAS volume was r = 0.77 (P < .001, Pearson's). The "limits of agreement" (between 2 examiners) varied by as much as 40% of the mean volume.

CONCLUSION

Quantitative 3D ultrasound of the anal sphincter is moderately reproducible.

Within-subject reliability of motor unit number estimates and quantitative motor unit analysis in a distal and proximal upper limb muscle

OBJECTIVE

To establish within-subject reliability of motor unit number estimates (MUNEs) and quantitative MU analysis using decomposition-based quantitative electromyography (DQEMG).

METHODS

Following the acquisition of a maximum M-wave, needle and surface-detected EMG signals were collected during contractions of the first dorsal interrosseous (FDI) and biceps brachii (BB). DQEMG was used to extract motor unit potential (MUP) trains and surface-detected MUPs associated with each train, the mean size of which was divided into the maximum M-wave to obtain a MUNE. Retests were performed following the initial test to evaluate reliability.

RESULTS

Subjects test-retest MUNEs were highly correlated (r=0.72 FDI; 0.97 BB) with no significant differences between test and retest MUNE values (P>0.10). Ninety-five percent confidence intervals were calculated to establish the range of expected retest MUNE variability and were +/-41 MUs for the FDI and BB. Quantitative information pertaining to MU size, complexity and firing rate were similar for both tests.

CONCLUSION

MUNEs and quantitative MU data can be obtained reliably from the BB and FDI using DQEMG in individual subjects.

SIGNIFICANCE

Establishing within-subject reliability of MUNEs and quantitative MU analysis allow clinicians to longitudinally follow changes in the MU pool of individuals with disorders of the central or peripheral nervous system in addition to assessing their response to treatments.

The stimulus–response curve and motor unit variability in normal subjects and subjects with amyotrophic lateral sclerosis

The behavior and stability of motor units (MUs) in response to electrical stimulation of different intensities can be assessed with the stimulus-response curve, which is a graphical representation of the size of the compound muscle action potential (CMAP) in relation to stimulus intensity. To examine MU characteristics across the whole stimulus range, the variability of CMAP responses to electrical stimulation, and the differences that occur between normal and disease states, the curve was studied in 11 normal subjects and 16 subjects with amyotrophic lateral sclerosis (ALS). In normal subjects, the curve showed a gradual increase in CMAP size with increasing stimulus intensity, although one or two discrete steps were sometimes observed in the upper half of the curve, indicating the activation of large MUs at higher intensities. In ALS subjects, large discrete steps, due to loss of MUs and collateral sprouting, were frequently present. Variability of the CMAP responses was greater than baseline variability, indicating variability of MU responses, and at certain levels this variability was up to 100 microVms. The stimulus-response curve shows differences between normal and ALS subjects and provides information on MU activation and variability throughout the curve.

Recovery and prognosticators of paralysis in West Nile virus infection

Previous studies have demonstrated that lesions of the anterior horn motor neurons are the primary pathology in patients with paralysis due to West Nile virus (WNV) infection. To characterize recovery and identify prognostic factors for the recovery of paralysis, we investigated 11 patients with electrophysiology testing and muscle biopsy, and one with autopsy. We found that limb weakness was markedly asymmetric and differed between upper and lower extremities, suggesting focal or segmental involvement of the spinal cord anterior horn. This was supported by segmental depletion of spinal motor neurons at autopsy. Clinical recovery was variable during a 21-month follow-up period. To explain variability, we performed motor unit number estimation (MUNE) in six patients. MUNE values and strength were correlated in tested muscles. We also detected motor nerve terminal damages in muscle biopsies, suggesting another possible mechanism for transient weakness and variable recovery. We conclude that the type of pathological lesions may vary in paralytic WNV infection, and different degrees or combinations of motor neuron loss and motor nerve terminal changes may account for the observed degrees of weakness and recovery.

Effects of an eight-week stretching program on the passive-elastic properties and function of the calf muscles of older women

BACKGROUND

Calf muscle stretching programs are used to increase dorsiflexion range of motion at the ankle, yet the effects of the stretching programs on the passive properties of aged calf muscles and on standing and ambulatory function have not been studied. This initial study examined the effects of an eight-week stretching program on the passive-elastic properties of the calf muscles of older women and on selected functional activities.

METHODS

Nineteen women aged 65-89 years with limited dorsiflexion range of motion first completed a timed agility course, a timed 10-m walk and a standing functional reach test. A dynamometer then moved the right ankle from plantarflexion to maximal dorsiflexion and back to plantarflexion at 5 deg s(-1) to measure calf muscle passive properties. The women were randomly assigned to a group that stretched three-times a week for eight-weeks (n=10) or to a control group (n=9) that did not. The tests were repeated after the stretching program.

FINDINGS

The stretching group showed increased maximal dorsiflexion range of motion, passive resistive forces (Newtons [N]), and the absorbed and retained passive-elastic energy (deg N) (P<0.05). They also had decreased times for the agility course and the 10-m walk (P<0.05). The functional reach test did not change for either group.

INTERPRETATION

The eight-week stretching program most likely increased the maximal length, length extensibility and passive resistive forces of the calf muscles. Adaptations of other ankle and leg structures also may have contributed. The passive adaptations were associated with enhanced performances of ambulatory functional activities.

Viscoelastic properties of short calf muscle-tendon units of older women: effects of slow and fast passive dorsiflexion stretches in vivo

Changes in connective tissues of the skeletal muscle-tendon unit (MTU) of aging animal muscles have been associated with increased passive viscoelastic properties. This study examined whether similar changes in the viscoelastic properties were present in short calf MTUs of older women in vivo. Fifteen women 68-87 years of age with short calf MTUs, as represented by limited active dorsiflexion (DF) range of motion (ROM) of < or =5 degrees, and 15 women 20-26 years of age without decreased DF ROM participated. A Kin-Com dynamometer stretched the MTU from plantarflexion to maximal DF at the slow velocity of 5 degrees s(-1) (0.087 rad s(-1)) and the fast velocity of 120 degrees s(-1) (2.094 rad s(-1)) with minimal surface electromyogram activity in the soleus, gastrocnemius, and tibialis anterior muscles. Two-way analysis of variance (ANOVA) tests for repeated measures (Velocity x Group) indicated that all women showed greater passive torque, average passive elastic stiffness, and total absorbed passive elastic energy for the fast stretch than for the slow stretch (P < 0.001). The older women had greater percent increases for the average passive torque (30%) and total absorbed passive elastic energy (26%) for the fast stretch than the younger women (P < 0.05), who had 17.5 and 13% increases, respectively. The older women had less maximal and average passive torque (Nm) and total absorbed passive elastic energy (degrees Nm), but greater average passive elastic stiffness (Nm degrees (-1)) at both stretch velocities (P < 0.001). The results indicated that short calf MTUs of older women have increased passive viscoelastic properties that could have implications for balance and ambulatory function.

Motor unit action potential topography and its use in motor unit number estimation

High-density multichannel electromyography (EMG) recordings add spatial information to the temporal information content of the surface EMG (sEMG) signal. This study explores the potential value of such multichannel information at a single motor unit level, in particular for the improvement of motor unit number estimation (MUNE) techniques. It is shown that multichannel recordings make it easier to distinguish motor unit action potentials (MUAPs) and that MUAP combinations can be better resolved. Furthermore, the spatiotemporal information allows a quantitative assessment of the representativity of the mean of the recorded MUAPs in relation to the maximum CMAP, i.e., for the muscle as a whole. In general, this is practically impossible on the basis of temporal information alone. For these reasons, we expect that high-density sEMG has the potential to address several methodological limitations of single channel surface EMG recordings. This is specifically illustrated in this study for one of the MUNE techniques in use, the F-response method.

Motor unit number estimates in the tibialis anterior muscle of young, old, and very old men

The rate of motor unit (MU) loss and its influence on the progression of sarcopenia is not well understood. Therefore, the main purpose of this study was to estimate and compare numbers of MUs in the tibialis anterior (TA) of young men ( approximately 25 years) and two groups of older men ( approximately 65 years and >/=80 years). Decomposition-enhanced spike-triggered averaging was used to collect surface and intramuscular electromyographic signals during isometric dorsiflexions at 25% of maximum voluntary contraction. The mean surface-MU potential size was divided into the maximum M wave to calculate the motor unit number estimate (MUNE). The MUNE was significantly reduced in the old (91) compared to young (150) men, and further reduced in the very old men (59). Despite the smaller MUNE at age 65, strength was not reduced until beyond 80 years. This suggests that age-related MU loss in the TA does not limit function until a critical threshold is reached.

Quantitative electromyography of the anal sphincter after uncomplicated vaginal delivery

OBJECTIVE

Fecal incontinence in women is thought to be associated with sphincter laceration or pudendal nerve damage. A prolonged pudendal nerve terminal motor latency is evidence of profound nerve damage, but pudendal nerve terminal motor latency can be normal even when nerve injury has been sustained. We performed quantitative electromyography (EMG) to compare multiple motor unit action potential parameters between recently postpartum women and nulliparous women.

METHODS

Standardized examinations were prospectively performed on 2 groups: 1) healthy nulliparous women without pelvic floor disorders (n = 28) and 2) asymptomatic women who were postpartum following vaginal delivery of their first child (n = 23). The examinations included pelvic organ prolapse quantification measurements, endoanal ultrasonography, pudendal nerve terminal motor latency, sacral reflexes, and concentric needle EMG using multiple motor unit action potential analysis.

RESULTS

A mean of 11.5 (standard deviation [sd] 1.1) weeks had elapsed since first vaginal deliveries in the postpartum group. The mean fetal weight at delivery was 3,495 (sd 458) grams. There were no sphincter defects seen by ultrasonography. Compared with the nulliparous women, pudendal nerve terminal motor latency and sacral reflexes (clitoral-anal reflex, urethral-anal reflex) were not increased in the postpartum group. Each of the quantitative parameters (duration, amplitude, area, turns, and phases), measured from motor unit action potentials in the postpartum group, were larger than in the nulliparous group (P < or =.004, nested analysis of variance [ANOVA]).

CONCLUSION

Quantitative EMG using multiple motor unit action potential analysis can detect the presence after vaginal childbirth of subtle nerve injury not demonstrable by pudendal nerve terminal motor latency. Even asymptomatic women show evidence of pelvic floor nerve injury after uncomplicated deliveries.

The Consequences of Resistance Training for Movement Control in Older Adults

Older adults who undertake resistance training are typically seeking to maintain or increase their muscular strength with the goal of preserving or improving their functional capabilities. The extent to which resistance training adaptations lead to improved performance on tasks of everyday living is not particularly well understood. Indeed, studies examining changes in functional task performance experienced by older adults following periods of resistance training have produced equivocal findings. A clear understanding of the principles governing the transfer of resistance training adaptations is therefore critical in seeking to optimize the prescription of training regimes that have as their aim the maintenance and improvement of functional movement capacities in older adults. The degenerative processes that occur in the aging motor system are likely to influence heavily any adaptations to resistance training and the subsequent transfer to functional task performance. The resulting characteristics of motor behavior, such as the substantial decline in the rate of force development and the decreased steadiness of force production, may entail that specialized resistance training strategies are necessary to maximize the benefits for older adults. In this review, we summarize the alterations in the neuromuscular system that are responsible for the declines in strength, power, and force control, and the subsequent deterioration in the everyday movement capabilities of older adults. We examine the literature concerning the neural adaptations that older adults experience in response to resistance training, and consider the readiness with which these adaptations will improve the functional movement capabilities of older adults.

Slow passive stretch and release characteristics of the calf muscles of older women with limited dorsiflexion range of motion

OBJECTIVE

Examine the slow passive stretch and release characteristics of the calf muscles of older women with limited dorsiflexion range of motion.

DESIGN

A cross-sectional comparative design.

BACKGROUND

The passive stretch and release characteristics of the calf muscles of older women with limited dorsiflexion range of motion have not been studied.

METHODS

Fifteen older women (mean 79 years) with active dorsiflexion < or =10 degrees and 15 younger women (mean 24 years) without limited dorsiflexion were tested. The right ankle was stretched from plantarflexion to maximal dorsiflexion and released into plantarflexion at 5 degrees /s with minimal surface EMG activity in the soleus, gastrocnemius, and tibialis anterior muscles. Length, passive-elastic stiffness and stored passive-elastic energy were examined.

RESULTS

The older women had less maximal passive dorsiflexion, a greater initial stretch angle, and less angular change than the younger women (P < 0.05). The maximal passive resistive force (Newtons) of the stretch phase, and the stored passive-elastic energy ( degrees N) during both stretch and release phases were also less (P < 0.001). The older women had greater passive-elastic stiffness at 0 degrees and 5 degrees of dorsiflexion (P < 0.001).

CONCLUSIONS

The older women had decreased calf muscle length, extensibility, maximal passive resistive force, stored passive-elastic energy, but greater angle-specific-stiffness at 0 and 5 degrees of passive dorsiflexion.

RELEVANCE

Older women with limited dorsiflexion range of motion have decreased calf muscle length, passive resistive forces and stored passive-elastic energy that may impact static and dynamic standing balance activities. Greater passive-elastic stiffness within their ambulatory dorsiflexion range of motion may partially compensate for the deficits.

Comparison of conventional and decomposition-enhanced spike triggered averaging techniques

OBJECTIVE

Spike triggered averaging (STA) is a technique to extract an estimate of a recurring motor unit potential from a complex electromyographic (EMG) signal. In conventional STA (C-STA), potentials related to the discharges of single intramuscular motor units are isolated and used to trigger an averager to obtain an individual surface-detected motor unit potential (S-MUP) from an EMG signal. In decomposition-enhanced STA (DE-STA), EMG signal decomposition algorithms determine discharges of a number of different motor units (4 to 10) that can be used to trigger an averager to obtain their corresponding S-MUPs. We tested the accuracy of extracting and averaging S-MUPs using DE-STA compared to C-STA for the same EMG signals.

METHODS

We compared the intramuscular potentials used for triggering and the resultant averaged S-MUPs that were common in both techniques.

RESULTS

We found no statistically significant differences in the metrics used to describe the triggering potentials and S-MUPs.

CONCLUSIONS

We conclude that DE-STA is an accurate and efficient method to obtain a large number of intramuscular motor unit potentials and their corresponding S-MUP in proximal and distal muscles.

Motor unit number estimation by decomposition-enhanced spike-triggered averaging: Control data, test-retest reliability, and contractile level effects

Decomposition-enhanced spike-triggered averaging (DE-STA) has been developed as a method for obtaining a motor unit number estimate (MUNE). We describe the method and report control data for the first dorsal interosseous/adductor pollicis and thenar muscles and reliability in the thenar muscles. Seventeen subjects (ages 20-50 years) took part in the study. The maximum M potential was elicited with supramaximal stimulation of the ulnar or median nerve at the wrist. Surface and intramuscularly detected electromyographic signals were then collected simultaneously during mild to moderate contractions. Decomposition algorithms were used to detect and sort the individual motor unit potential (MUP) occurrences of several concurrently active motor units in the needle-detected signals. The MUP occurrences were used as triggering sources to estimate their corresponding surface-detected MUPs (S-MUPs) using STA. The mean S-MUP size was calculated and divided into the maximum M-potential size to derive a MUNE. The MUNE values were consistent with those previously reported with other methods, and thenar MUNEs for the two trials were similar (249 +/- 78 and 246 +/- 90), with high test-retest reliability (r = 0.94, P < 0.05). DE-STA thus appears to be a valid and reliable method to obtain MUNEs.

Motor unit number estimation: new techniques and new uses

MUNE is a unique neurophysiologic tool because it can quantitatively estimate the number of motor neurons innervating a muscle or group of muscles. All other neurophysiologic techniques are influenced by collateral reinnervation and provide only a qualitative estimate of motor unit loss. Further, the S-MUPs obtained with MUNE provide quantitative information about the whole motor unit. Other routine neurophysiologic techniques provide information restricted to a portion of the motor unit. These unique features of MUNE have been applied to neurogenic disorders to yield a better understanding of disease processes. Various modifications are being developed that will provide more data and ease of use. It is anticipated that the availability of MUNE on EMG machines will grow and it use will expand from a research tool to a routine neurophysiologic test.

Assessment of axonal loss in Charcot–Marie–Tooth neuropathies

Sensory loss and weakness in Charcot-Marie-Tooth (CMT) neuropathy is due to axonal loss. However, the pattern and degree of axonal loss cannot be accurately determined from routine electrodiagnostic or strength testing due to collateral reinnervation. We sought to quantify axonal loss in two upper extremity muscles in CMT1A and CMT2 subjects using the electrophysiologic endpoint measure of motor unit number estimation (MUNE). Hypothenar and biceps-brachialis muscle groups were studied in 9 CMT1A, 9 CMT2, and 10 control subjects. The spike-triggered averaging (STA) technique was used to collect surface motor unit potentials for MUNE calculations, and a needle electrode was used to collect corresponding intramuscular data. Maximal voluntary hypothenar and handgrip strength was measured quantitatively, while biceps-brachialis strength was measured qualitatively. Compared to normal subjects, CMT1A and CMT2 subjects had significantly lower MUNE values in hypothenar muscles. Biceps-brachialis MUNE values were reduced in CMT2 but not in CMT1A subjects. In support of proximal axonal loss in CMT2 subjects, surface motor unit and intramuscular potential amplitudes were higher in biceps-brachialis muscles compared to controls. Correlations between quantitative strength and MUNE were significant for hypothenar but not for grip muscle groups. Axonal loss is demonstrated in distal muscles in CMT1A and CMT2 supporting a length-dependent axonopathy. Despite clinical findings of normal or near-normal strength and small reductions in compound muscle action potential (CMAP) amplitude, MUNE values were significantly lower in CMT2 subjects in proximal muscles, consistent with more diffuse denervation. These data indicate that subclinical axonal loss is present that cannot be appreciated using clinical examination or routine electrodiagnostic techniques.

Muscle strength, power and adaptations to resistance training in older people

Muscle strength and, to a greater extent, power inexorably decline with ageing. Quantitative loss of muscle mass, referred to as "sarcopenia", is the most important factor underlying this phenomenon. However, qualitative changes of muscle fibres and tendons, such as selective atrophy of fast-twitch fibres and reduced tendon stiffness, and neural changes, such as lower activation of the agonist muscles and higher coactivation of the antagonist muscles, also account for the age-related decline in muscle function. The selective atrophy of fast-twitch fibres has been ascribed to the progressive loss of motoneurons in the spinal cord with initial denervation of fast-twitch fibres, which is often accompanied by reinnervation of these fibres by axonal sprouting from adjacent slow-twitch motor units (MUs). In addition, single fibres of older muscles containing myosin heavy chains of both type I and II show lower tension and shortening velocity with respect to the fibres of young muscles. Changes in central activation capacity are still controversial. At the peripheral level, the rate of decline in parameters of the surface-electromyogram power spectrum and in the action-potential conduction velocity has been shown to be lower in older muscle. Therefore, the older muscle seems to be more resistant to isometric fatigue (fatigue-paradox), which can be ascribed to the selective atrophy of fast-twitch fibres, slowing in the contractile properties and lower MU firing rates. Finally, specific training programmes can dramatically improve the muscle strength, power and functional abilities of older individuals, which will be examined in the second part of this review.

Invited review: Aging and sarcopenia

Aging is associated with progressive loss of neuromuscular function that often leads to progressive disability and loss of independence. The term sarcopenia is now commonly used to describe the loss of skeletal muscle mass and strength that occurs in concert with biological aging. By the seventh and eighth decade of life, maximal voluntary contractile strength is decreased, on average, by 20-40% for both men and women in proximal and distal muscles. Although age-associated decreases in strength per unit muscle mass, or muscle quality, may play a role, the majority of strength loss can be accounted for by decreased muscle mass. Multiple factors lead to the development of sarcopenia and the associated impact on function. Loss of skeletal muscle fibers secondary to decreased numbers of motoneurons appears to be a major contributing influence, but other factors, including decreased physical activity, altered hormonal status, decreased total caloric and protein intake, inflammatory mediators, and factors leading to altered protein synthesis, must also be considered. The prevalence of sarcopenia, which may be as high as 30% for those >/=60 yr, will increase as the percentage of the very old continues to grow in our populations. The link between sarcopenia and disability among elderly men and women highlights the need for continued research into the development of the most effective interventions to prevent or at least partially reverse sarcopenia, including the role of resistance exercise and other novel pharmacological and nutritional interventions.

Statistical motor unit number estimation: from theory to practice

Statistical motor unit number estimation (MUNE) is one of several experimental techniques used to estimate the number of lower motor neurons innervating a given muscle. All are fairly reproducible and have been applied successfully in monitoring neurogenic disease progression. Quantitating the number of lower motor neurons is important, since the compound muscle action potential (CMAP) and strength may not change as rapidly over time due to the confounding effect of reinnervation. MUNE techniques differ in the way they obtain samples of surface-recorded motor unit potentials (SMUP). Statistical MUNE is based on Poisson statistics, uses surface stimulation, and is useful in testing distal, superficial nerves. This review focuses on the theory behind the development of the technique, critiques the publications resulting from applying the technique in control and disease subjects, and discusses the future developments needed for clinical utility.

Motor unit number estimate of distal and proximal muscles in Charcot-Marie-Tooth disease

In order to determine the utility of motor unit number estimation (MUNE) in assessing axonal loss in chronic inherited neuropathies, we determined MUNEs in 54 patients with Charcot-Marie-Tooth (CMT) disease (29 patients with CMT-1A, 13 with CMT-X, and 12 with CMT-2) by using spike-triggered averaging (STA) of the ulnar-innervated abductor digiti minimi/hypothenar muscles (ADM) and the musculo-cutaneous innervated biceps/brachialis (BB) muscles. MUNEs were analyzed in relationship to the corresponding compound muscle action potential (CMAP) amplitudes as well as to clinical strength. Proximal muscles, which appeared strong clinically, had evidence of chronic denervation/reinnervation, although to a lesser extent than weak distal hand muscles, supporting the concept that axonal loss in CMT occurs in a length-dependent fashion. The reduction in ADM-MUNE strongly correlated with clinical weakness in the hand. Both the ADM-MUNE and BB-MUNE were abnormal more often than CMAP amplitude, probably reflecting extensive motor unit reconfiguration and enlargement that maintains CMAP amplitude despite severe motor unit loss. This study suggests that MUNE can assess motor unit loss in CMT and may better reflect axonal loss than CMAP amplitude. The STA technique of MUNE may be useful in longitudinal studies of proximal and distal motor unit changes in CMT.

Pathophysiological changes in the elderly

Demographic data indicate an increasing workload of geriatric anaesthesia due to advancing life expectancy and reduced thresholds for high-invasive and high-risk surgery in the elderly. Chronological and biological age may be inconsistent, and the existence of age-related changes may vary between organ systems in the same individual. Age itself is not an illness, but is the most important contributing factor for perioperative complications and adverse outcome when the overall narrowed margins of organ function reserve are transgressed during the perioperative period. Age-related changes in the cardiovascular, pulmonary, nervous, metabolic and locomotive systems that are frequently present in the elderly are discussed with regard to their potential relevance to anaesthesiology. In conclusion, listing current diagnoses will not be sufficient in the assessment of the geriatric patient because age-related changes do not necessarily manifest as pathological entities. Rather, pre-operative examination should focus on determination of individual margins of organ function reserve.

Motor unit number estimation

Since its introduction 30 years ago, MUNE techniques have increasingly been refined and applied to a wide variety of neuromuscular disorders. Differences of opinion remain among MUNE investigators as to which method is best; however, statistical and MPS MUNE are currently the most widely used. Numerous methodologic issues remain, including the development of detailed universal standards for each technique and the implementation of modifications for the enhancement of reproducibility. These issues are the subjects of ongoing investigation. Despite technical variability, the MUNE values obtained using different methods show good agreement in studies of normal subjects and in patients with a variety of neurogenic processes. MUNE has been applied most successfully to patients with amyotrophic lateral sclerosis and to animal models of motor neuron disease, providing significant insight into the pathophysiology of these disorders. These techniques are increasingly being incorporated into clinical therapeutic trials. MUNE offers promise in the study of neuromuscular disease, enabling the collection of novel data in the living patient unobtainable by any other method.

Effect of ageing on the electrical and mechanical properties of human soleus motor units activated by the H reflex and M wave

This study was designed to investigate the effect of ageing on the mechanical and electromyographic (EMG) characteristics of the soleus motor units (MUs) activated by the maximal Hoffmann reflex (Hmax) and by the direct muscle compound action potential (Mmax). Eleven young (mean age 25 +/- 4 years) and ten elderly (mean age 73 +/- 5 years) males took part in this investigation. The senior group presented lower amplitudes of Mmax (-57 %, P < 0.001) and Hmax (-68 %, P < 0.001) waves compared to the younger population. These were associated with a depression of relative twitch torque of the plantar flexors. The average values of the Hmax/Mmax ratio did not statistically differ between the two populations, despite a tendency for lower values (~23 %) in the senior group. However, the older adults showed a greater relative amplitude of the sub-maximal M wave evoked at Hmax (MatHmax) than did the younger males (young 5 % vs. elderly 29 % of the Mmax, P < 0.01). This finding suggests an increased homogeneity between the excitability threshold of sensory and motor axons. The twitch torque at Hmax (PtH-M) was subsequently calculated by subtraction from the total twitch torque of the mechanical contamination associated with MatHmax. The resulting PtH-M was significantly lower in the elderly (-59 %, P < 0.001). Despite a discrepancy of 20 % between the two groups, the mechanical ratio (PtH-M/PtM; PtM, twitch tension related to the Mmax compound action potential), like the EMG ratio, did not statistically differ between the young and older individuals. Nevertheless, the senior subjects exhibited a higher twitch/EMG ratio for the reflexively activated MUs (PtH-M/Hmax) than the younger individuals (+40 %, P < 0.05). This finding suggests an on-going neuromuscular remodelling, resulting in an increased innervation ratio. The neural rearrangement may be viewed as a compensatory adaptation of the motor system to preserve the mechanical efficiency of the surviving MUs, despite the age-related impairment of the segmental reflex system. This phenomenon is confirmed by the maintenance, with senescence, of the approximately constant values of the twitch/EMG ratio for the entire motor pool (PtM/Mmax).

Motor Unit Estimate Number in the Anterior Tibial Muscle: Normative Data versus Findings in Critically Ill Patients in Intensive Care Units

OBJECTIVES

To determine the number of motor units (MUNEs) in the anterior tibial muscle of normal subjects for comparison with those of severely paretic or paralytic muscles of critically ill patients in intensive care units.

RESULTS

The mean MUNE for 24 normal subjects (194 +/- 5; mean +/- standard deviation) was similar to that of the 22 patients with critical illness (184 +/- 10). However, both the mean amplitude of the evoked compound muscle action potential (CMAP) and of the single motor unit action potential (S-MUAP) among patients were approximately one third of those in normal subjects.

CONCLUSION

Critically ill patients in this study demonstrated normal MUNEs with reduced CMAP and S-MUAP amplitudes in the setting of severe clinical weakness, suggestive of predominantly myopathic injury. MUNE may provide a valuable tool for distinguishing between neuropathy and myopathy in critically ill patients.

Effect of age on muscle functions investigated with surface electromyography

The purpose of this study was to investigate changes in the surface electromyographic (EMG) signal as a means of defining age-related central and peripheral mechanisms affecting muscle fatigue. Spectral and temporal variables of the surface EMG signal were studied during voluntary isometric contractions of the dominant biceps brachii muscle in a group of 8 healthy elderly men (age range 67-86 years) and a group of 10 healthy young men (age range 23-34 years). The maximal torque developed and the rate of decrease (slope) of spectral variables and conduction velocity (CV) were statistically higher in the young subjects than in the elderly subjects. Motor unit (MU) CV distribution was also estimated from the surface EMG signal and no statistical difference was observed in its variance between the two groups. These results confirm previous findings from the tibialis anterior muscle. Thus, changes in fiber type distribution and decrease in MU firing rate with aging may be factors determining the decrease in maximal voluntary contraction torque and in myoelectric manifestations of muscle fatigue.

Aging of the human neuromuscular system

Loss of cells from the motor system occurs during the normal aging process, leading to reduction in the complement of motor neurons and muscle fibers. The latter age-related decrease in muscle mass has been termed "sarcopenia" and is often combined with the detrimental effects of a sedentary lifestyle in older adults, leading to a significant reduction in reserve capacity of the neuromuscular system, which is the primary subject of this review. Clear evidence of this aging effect is seen when voluntary or stimulated muscle strength is compared across the adult lifespan, with a steady decline of approximately 1-2% per year occurring after the sixth decade. Interestingly, when compared with isometric contractions, the effect of aging is more pronounced for concentric movements and less for eccentric movements (i.e., muscle shortening versus lengthening). This phenomenon appears to be linked to the stiffer muscle structures and prolonged myosin crossbridge cycles of aged muscles. It is encouraging that the capability of physiological adaptations in the motor pathways remains into very old age--when an appropriate exercise stimulus is given--and long-term prevention strategies are advocated to avoid excessive physical impairments and activity restrictions in this age group.

Medical technology assessment. Electrodiagnosis in motor neuron diseases and amyotrophic lateral sclerosis

In motor neuron diseases/amyotrophic lateral sclerosis (MND-ALS), electrodiagnostic techniques are essential in supporting the diagnosis and excluding other conditions that clinically resemble MND-ALS. Electrodiagnostic techniques can also monitor disease progression and provide prognostic information. Electromyography has an important role in the diagnosis of MND-ALS, but some drawbacks should be borne in mind. Although internationally accepted electrophysiological criteria have been defined to support MND-ALS diagnosis, differences in different laboratories can raise unexpected difficulties in application of diagnosis criteria. Much work needs to be done to increase standardisation of the electrodiagnosis of MND-ALS in order to improve quality. Differential diagnosis with motor axonal neuropathies may be particularly difficult. EMG is an essential tool for the early diagnosis of MND-ALS, which increases potential benefit of therapeutic interventions. A wide discussion among neurophysiologists from different schools could create a sound consensus on early diagnosis of MND-ALS.

Depletion and sizes of motor units in spinal muscular atrophy

Motor unit number estimation (MUNE) was applied to the biceps brachii muscles of 13 young patients (age 5--24 years) with spinal muscular atrophy (SMA) and the results compared with those of healthy control subjects matched for age and gender. In the SMA patients, all motor unit (MU) estimates fell below the control range, and there was good correspondence between the values for the two arms in the same subject. No correlation could be found between the MUNEs and the severity of the weakness. This unexpected result was attributed to the presence of small and normal-sized MUs in the muscles of patients, in addition to MUs that appeared to be considerably enlarged. The threefold mean increase in MU potential size was insufficient to compensate for the MU loss. In addition, the study confirmed that there are, on average, approximately 130 MUs in the healthy biceps brachii muscle.

Decline in motor functions in aging is related to the loss of NMDA receptors

The aim of the study was to assess the contribution of central dopaminergic and glutamatergic systems to the age-dependent loss of motor functions in rats. Rats of three age groups were compared: young (3-5-month-old), middle-aged (20-21-month-old) and old (29-31-month-old). The obtained results showed an age-dependent decline in the electromyographic (EMG) resting and reflex activities in the gastrocnemius and tibialis anterior muscles, as well as in the T-maze performance. Although these disturbances were accompanied with significant age-dependent decreases in the binding to NMDA, AMPA and dopamine D2 receptors, and a decline in the number of nigral dopamine neurons, they were significantly correlated with the loss of the binding to NMDA receptors only. The reduction in T-maze performance with aging was additionally correlated with a decrease in motor functions (EMG activity). The study suggests a crucial role of the loss of NMDA receptors in age-dependent motor disabilities, as well as in disturbances measured in the T-maze.

Motor unit number estimation in human neurological diseases and animal models

Motor unit number estimation (MUNE) was introduced in 1971 as a way of providing an objective and meaningful estimate of axon loss in diseases affecting the motor system. Over the last 30 years, different methods of MUNE have been proposed, with each having specific strengths and limitations. The goal of this paper is to review the available methods, and to present data generated using MUNE in a variety of disease entities. The incremental, multiple point stimulation, spike-triggered averaging, F-wave, and statistical methods of MUNE are reviewed, along with data obtained using these methods in patients with neuropathy, motor neuron disorders, and muscle disease. All methods reviewed have theoretical concerns associated with them. However, with the exception of the spike-triggered averaging method, all give results in normal subjects that are quite similar. MUNE has been of great value in assessing progression of motor neuron disease, and has also shown promise in the assessment of generalized neuropathy. Despite the lack of a perfect method for performing MUNE, it has great clinical value in the assessment of progressive motor axon loss. Further refinements in the method will likely increase its utility in the future.

Electrophysiologic endpoint measures in a multicenter ALS drug trial

We report the analysis of a battery of secondary electrophysiologic measurements to assess the progression of amyotrophic lateral sclerosis (ALS) in a two center, six month, double-blind, three arm trial comparing branched chain amino acids to L-threonine with pyridoxal 5-phosphate to placebo. The endpoint measurements were chosen to separately assess the effects of lower motor neuron loss and collateral reinnervation. For tests of inter-center reliability, we found no differences that could not be readily explained by variations in electrophysiologic testing techniques. Since the drug study was negative for the primary endpoint measure (muscle strength), we combined data from both centers and the three treatment arms. For measures of progression, all measures changed in the expected direction during the 6 months of the trial. We conclude that a battery of electrophysiologic measures can be used in a multicenter ALS drug trial to provide information on changes in lower motor neuron numbers and the effects of collateral reinnervation.

Fatigue of elbow flexor muscles in younger and older adults

The aim of this study was to assess differences in the behavior of fatigue-related measures of neuromuscular function between younger (n = 10; 20-35 years) and older (n = 11; >65 years) healthy adults. Measures reflecting changes in voluntary activation, neuromuscular propagation, metabolite build-up, and excitation-contraction coupling processes were taken before, during, and after a sustained maximum elbow-flexion fatigue task. We found a greater role for a failure in voluntary activation (central fatigue) in about half of the older subjects compared with none of the younger subjects to explain the decrease in force-generating capacity with sustained activity. In contrast, similar behaviors in measures reflecting changes in peripheral mechanisms were noted for the two age groups. These results point to a potential shift in fatigue mechanisms with age, with a greater contribution of central fatigue in some older adults.

Correlation between quantitative EMG and muscle MRI in patients with axonal neuropathy

The aim of the study was to investigate whether there are correlations between electromyography (EMG) data and findings in muscle magnetic resonance imaging (MRI). Quantitative EMG data and the amount of pathologic spontaneous activity (PSA) were compared with MRI signal intensities of the tibialis anterior muscles of 20 patients with axonal polyneuropathy and 14 healthy subjects. Using hierarchical regression analysis, the mean motor unit action potential (MUAP) size index (SI) and the amount of PSA were accurate predictors of T1-weighted signal intensity in MRI, an expression of fatty degeneration. The MUAP SI was superior to MUAP amplitude in explaining the variance of T1 signal intensity. Age was not a relevant factor. A high correlation was found between the amount of PSA and the T2-weighted signal intensity in short tau inversion recovery sequence. Magnetic resonance imaging demonstrates the structural changes and thus visualizes the outcome of the functional changes of denervation and reinnervation detected by EMG.