Passive stiffness of monoarticular lower leg muscles is influenced by knee joint angle

Explorative study using ultrasound time-harmonic elastography for stiffness-based quantification of skeletal muscle function

Time-harmonic elastography (THE) is an emerging ultrasound imaging technique that allows full-field mapping of the stiffness of deep biological tissues. THE's unique ability to rapidly capture stiffness in multiple tissues has never been applied for imaging skeletal muscle. Therefore, we addressed the lack of data on temporal changes in skeletal muscle stiffness while simultaneously covering stiffness of different muscles. Acquiring repeated THE scans every five seconds we quantified shear-wave speed (SWS) as a marker of stiffness of the long head (LHB) and short head (SHB) of biceps brachii and of the brachialis muscle (B) in ten healthy volunteers. SWS was continuously acquired during a 3-min isometric preloading phase, a 3-min loading phase with different weights (4, 8, and 12 kg), and a 9-min postloading phase. In addition, we analyzed temporal SWS standard deviation (SD) as a marker of muscle contraction regulation. Our results (median [min, max]) showed both SWS at preloading (LHB: 1.04 [0.94, 1.12] m/s, SHB: 0.86 [0.78, 0.94] m/s, B: 0.96 [0.87, 1.09] m/s, p < 0.001) and the increase in SWS with loading weight to be muscle-specific (LHB: 0.010 [0.002, 0.019] m/s/kg, SHB: 0.022 [0.017, 0.042] m/s/kg, B: 0.039 [0.019, 0.062] m/s/kg, p < 0.001). Additionally, SWS during loading increased continuously over time by 0.022 [0.004, 0.051] m/s/min (p < 0.01). Using an exponential decay model, we found an average relaxation time of 27 seconds during postloading. Analogously, SWS SD at preloading was also muscle-specific (LHB: 0.018 [0.011, 0.029] m/s, SHB: 0.021 [0.015, 0.027] m/s, B: 0.024 [0.018, 0.037] m/s, p < 0.05) and increased by 0.005 [0.003, 0.008] m/s/kg (p < 0.01) with loading. SWS SD did not change over loading time and decreased immediately in the postloading phase. Taken together, THE of skeletal muscle is a promising imaging technique for in vivo quantification of stiffness and stiffness changes in multiple muscle groups within seconds. Both the magnitude of stiffness changes and their temporal variation during isometric exercise may reflect the functional status of skeletal muscle and provide additional information to the morphological measures obtained by conventional imaging modalities.

Detecting age-related changes in skeletal muscle mechanics using ultrasound shear wave elastography

Aging leads to a decline in muscle mass and force-generating capacity. Ultrasound shear wave elastography (SWE) is a non-invasive method to capture age-related muscular adaptation. This study assessed biceps brachii muscle (BB) mechanics, hypothesizing that shear elastic modulus reflects (i) passive muscle force increase imposed by length change, (ii) activation-dependent mechanical changes, and (iii) differences between older and younger individuals. Fourteen healthy volunteers aged 60-80 participated. Shear elastic modulus, surface electromyography, and elbow torque were measured at five elbow positions in passive and active states. Data collected from young adults aged 20-40 were compared. The BB passive shear elastic modulus increased from flexion to extension, with the older group exhibiting up to 52.58% higher values. Maximum elbow flexion torque decreased in extended positions, with the older group 23.67% weaker. Significant effects of elbow angle, activity level, and age on total and active shear elastic modulus were found during submaximal contractions. The older group had 20.25% lower active shear elastic modulus at 25% maximum voluntary contraction. SWE effectively quantified passive and activation-dependent BB mechanics, detecting age-related alterations at rest and during low-level activities. These findings suggest shear elastic modulus as a promising biomarker for identifying altered muscle mechanics in aging.

Effect of Whole-body Vibration frequency on muscle tensile state during graded plantar flexor isometric contractions

Background

Acute physiological and biomechanical alterations have been reported following whole-body vibration (WBV). Stiffening of muscles has only been anecdotally reported in response to WBV. Accordingly, this study investigated active plantar flexor muscle stiffness in response to a single WBV bout at four mechanical vibration frequencies.

Methods

Thirteen healthy adults (37.1 ± 14.4 years old) randomly received WBV in 4 different frequencies (6, 12, 24, and 0 Hz control) for 5 min. Shear wave speed (SWS) in longitudinal and transverse projections, architecture, and electric muscle activity were recorded in the medial gastrocnemius (MG) and soleus (SOL) muscle during graded plantar flexor contraction. Subjective rating of perceived muscle stiffness was assessed via Likert-scale.

Results

SWS of the MG at rest was enhanced in response to 5 min of 24 Hz WBV (p = 0.025), while a small reduction in SOL SWS was found during contraction (p = 0.005) in the longitudinal view. Subjective stiffness rating was increased following 12 Hz intervention. After 24 Hz WBV, pennation angle for MG was decreased (p = 0.011) during contraction. As a secondary finding, plantar flexor strength was significantly increased with each visit, which, however, did not affect the study's main outcome because of balanced sequence allocation.

Conclusion

SWS effects were solely limited to 24 Hz mechanical vibration and in the longitudinal projection. The observed effects are compatible with an interpretation by post-activation potentiation, warm-up, and force-distribution within the triceps surae muscles following 5 min WBV. The outcome may suggest SWS as a useful tool for assessing acute changes in muscle stiffness.

Characterization of Muscle Weakness Due to Myasthenia Gravis Using Shear Wave Elastography

Myasthenia gravis (MG) is often accompanied with muscle weakness; however, little is known about mechanical adaptions of the affected muscles. As the latter can be assessed using ultrasound shear wave elastography (SWE), this study characterizes the biceps brachii muscle of 11 patients with MG and compares them with that of 14 healthy volunteers. Simultaneous SWE, elbow torque and surface electromyography measurements were performed during rest, maximal voluntary contraction (MVC) and submaximal isometric contractions (up to 25%, 50% and 75% MVC) at different elbow angles from flexion to extension. We found that, with increasing elbow angle, maximum elbow torque decreased (p < 0.001), whereas muscle stiffness increased during rest (p = 0.001), MVC (p = 0.004) and submaximal contractions (p < 0.001). Muscle stiffness increased with increasing contraction intensities during submaximal contractions (p < 0.001). In comparison to the healthy cohort, muscle stiffness of MG patients was 2.1 times higher at rest (p < 0.001) but 8.93% lower in active state (75% MVC, p = 0.044). We conclude that (i) increased muscle stiffness shown by SWE during rest might be an indicator of MG, (ii) SWE reflects muscle weakness and (iii) SWE can be used to characterize MG muscle.

Shear wave elastography characterizes passive and active mechanical properties of biceps brachii muscle in vivo

Mechanical characterization of individual muscles in their in vivo environment is not well studied. Shear wave elastography (SWE) as a non-invasive technique was shown to be promising in quantifying the local mechanical properties of skeletal muscles. This study aimed to investigate the mechanics of the biceps brachii muscle (BB) derived from SWE in relation to elbow joint position and contraction intensity during isometric contraction. 14 healthy, young subjects participated in the study and five different joint positions (60°-180° elbow angle) were investigated. Shear elastic modulus and surface electromyography (sEMG) of the BB and elbow torque were measured simultaneously, both in passive (i.e., resting) and active states during slow, sub-maximal isometric ramp contractions up to 25%, 50%, and 75% of the maximum voluntary contraction. At passive state, the shear elastic modulus of the BB increased with increasing elbow angle (p < 0.001). Maximum elbow flexion torque was produced at 60° and it decreased with increasing elbow angle (p = 0.001). During sub-maximal contractions, both elbow angle (p < 0.001) and contraction intensity (p < 0.001) had significant effects on the shear elastic modulus but only contraction intensity (p < 0.001) affected sEMG amplitude of the BB. Although torque was decreased at extended elbow positions (150°, 180°), higher active shear elastic modulus of BB muscle was found compared to flexed positions (60°, 90°). Linear regression of the BB sEMG amplitude over elbow torque showed good agreement for all joint positions (R² between 0.69 and 0.89) while the linear agreement between shear elastic modulus of BB and elbow torque differed between flexed (R² = 0.70 at 60° and R² = 0.79 at 90°) and extended positions (with the lowest R² = 0.57 at 150°). We conclude that using SWE, we can detect length-dependent mechanical changes of BB both in passive and active states. More importantly, SWE can be used to characterize active muscle properties in vivo. The present findings have critical importance for developing muscle stiffness as a measure of individual muscle force to validate muscle models and using SWE in clinical diagnostics.

Botulinum Toxin Intervention in Cerebral Palsy-Induced Spasticity Management: Projected and Contradictory Effects on Skeletal Muscles

Spasticity, following the neurological disorder of cerebral palsy (CP), describes a pathological condition, the central feature of which is involuntary and prolonged muscle contraction. The persistent resistance of spastic muscles to stretching is often followed by structural and mechanical changes in musculature. This leads to functional limitations at the respective joint. Focal injection of botulinum toxin type-A (BTX-A) is effectively used to manage spasticity and improve the quality of life of the patients. By blocking acetylcholine release at the neuromuscular junction and causing temporary muscle paralysis, BTX-A aims to reduce spasticity and hereby improve joint function. However, recent studies have indicated some contradictory effects such as increased muscle stiffness or a narrower range of active force production. The potential of these toxin- and atrophy-related alterations in worsening the condition of spastic muscles that are already subjected to changes should be further investigated and quantified. By focusing on the effects of BTX-A on muscle biomechanics and overall function in children with CP, this review deals with which of these goals have been achieved and to what extent, and what can await us in the future.

Soleus muscle and Achilles tendon compressive stiffness is related to knee and ankle positioning

Changes in fascicle length and tension of the soleus (SOL) muscle have been observed in humans using B-mode ultrasound to examine the knee from different angles. An alternative technique of assessing muscle and tendon stiffness is myometry, which is non-invasive, accessible, and easy to use. This study aimed to estimate the compressive stiffness of the distal SOL and Achilles tendon (AT) using myometry in various knee and ankle joint positions. Twenty-six healthy young males were recruited. The Myoton-PRO device was used to measure the compressive stiffness of the distal SOL and AT in the dominant leg. The knee was measured in two positions (90° of flexion and 0° of flexion) and the ankle joint in three positions (10° of dorsiflexion, neutral position, and 30° of plantar flexion) in random order. A three-way repeated-measures ANOVA test was performed. Significant interactions were found for structure × ankle position, structure × knee position, and structure × ankle position × knee position (p < 0.05). The AT and SOL showed significant increases in compressive stiffness with knee extension over knee flexion for all tested ankle positions (p < 0.05). Changes in stiffness relating to knee positioning were larger in the SOL than in the AT (p < 0.05). These results indicate that knee extension increases the compressive stiffness of the distal SOL and AT under various ankle joint positions, with a greater degree of change observed for the SOL. This study highlights the relevance of knee position in passive stiffness of the SOL and AT.

Effects of Kinesio Taping on Muscle Contractile Properties: Assessment Using Tensiomyography

CONTEXT

Although functional effects of kinesio taping (KT) have been widely studied, its effects on contractile properties of the target muscle remain unclear. Tensiomyography is suitable for quantifying muscle stiffness and rate of force development upon imposed twitch contraction.

OBJECTIVE

To test the hypothesis that KT has effects on contractile properties of targeted muscle using tensiomyography.

DESIGN

Prospective cohort study.

SETTINGS

Performance laboratory of a sports rehabilitation center.

PARTICIPANTS

A total of 11 healthy volunteers.

INTERVENTIONS

Tensiomyography measurements before KT facilitation technique applied (pre-KT), 45 minutes, and 24 hours after KT (post-KT1 and post-KT2, respectively) without removing the tape.

MAIN OUTCOME MEASURES

Maximal radial displacement, contraction time, delay time, sustain time, relaxation time, and velocity of contraction.

RESULTS

Significant effects were shown for maximal radial displacement (P = .004), contraction time (P = .013), relaxation time (P = .035), and velocity of contraction (P = .0033), but not for delay time (P = .060) and sustain time (P = .078). Post hoc testing indicated a significant decrease in maximal radial displacement for post-KT1 only (from 6.33 [1.46] to 4.87 [2.14] mm), and a significant increase in contraction time for both post-KT1 and post-KT2 (from 30.87 [11.39] to 39.71 [13.49] ms, and 37.41 [14.73] ms, respectively). Post hoc testing also showed a significant decrease in relaxation time for post-KT2 (from 65.97 [53.43] to 47.45 [38.12] ms), and a significant decrease in velocity of contraction for both post-KT1 and post-KT2 (from 0.22 [0.08] to 0.15 [0.09] mm/s, and 0.16 [0.07] mm/s), respectively.

CONCLUSION

The findings indicate that KT leads to an increased muscle stiffness and a reduced muscle rate of force production despite the facilitation technique applied.

Mechanomyogram amplitude vs. isometric ankle plantarflexion torque of human medial gastrocnemius muscle at different ankle joint angles

The purpose of this study was to investigate the influence of changes in ankle joint angle on the mechanomyogram (MMG) amplitude of the human medial gastrocnemius (MG) muscle during voluntary isometric plantarflexion contractions. Ten healthy individuals were asked to perform voluntary isometric contractions at six different contraction intensities (from 10% to 100%) and at three different ankle joint angles (plantarflexion of 26°; plantarflexion of 10°; dorsiflexion of 3°). MMG signals were recorded from the surface over the MG muscle, using a 3-axis accelerometer. The relations between root mean square (RMS) MMG and isometric plantarflexion torque at different ankle joint angles were characterized to evaluate the effects of altered muscle mechanical properties on RMS MMG. We found that the relation between RMS MMG and plantarflexion torque is changed at different ankle joint angles: RMS MMG increases monotonically with increasing the plantarflexion torque but decreases as the ankle joint became dorsiflexed. Moreover, RMS MMG shows a negative correlation with muscle length, with passive torque, and with maximum voluntary torque, which were all changed significantly at different ankle joint angles. Our findings demonstrate the potential effects of changing muscle mechanical properties on muscle vibration amplitude. Future studies are required to explore the major sources of this muscle vibration from the perspective of muscle mechanics and muscle activation level, attributable to changes in the neural command.

Agonist and antagonist activation at the ankle monitored along the swing phase in hemiparetic gait

BACKGROUND

Descending command in hemiparesis is reduced to agonists and misdirected to antagonists. We monitored agonist and antagonist activation along the swing phase of gait, comparing paretic and non-paretic legs.

METHODS

Forty-two adults with chronic hemiparesis underwent gait analysis with bilateral EMG from tibialis anterior, soleus and gastrocnemius medialis. We monitored ankle and knee positions, and coefficients of agonist activation in tibialis anterior and of antagonist activation in soleus and gastrocnemius medialis over the three thirds of swing phase. These coefficients were defined as the ratio of the root-mean-square EMG from one muscle over any period to the root-mean-square EMG from the same muscle over 100 ms of its maximal voluntary isometric contraction.

FINDINGS

As against the non-paretic side, the paretic side showed lesser ankle dorsiflexion and knee flexion (P < 1.E^-5), with higher coefficients of agonist activation in tibialis anterior (+100 ± 28%, P < 0.05), and of antagonist activation in soleus (+224 ± 41%, P < 0.05) and gastrocnemius medialis (+276 ± 49%, P < 0.05). On the paretic side, coefficient of agonist activation in tibialis anterior decreased from mid-swing on; coefficients of antagonist activation in soleus and gastrocnemius medialis increased and ankle dorsiflexion decreased in late swing (P < 0.05).

INTERPRETATION

During the swing phase in hemiparesis, normalized tibialis anterior recruitment is higher on the paretic than on the non-paretic leg, failing to compensate for a marked increase in plantar flexor activation (cocontraction). The situation deteriorates along swing with a decrease in tibialis anterior recruitment in parallel with an increase in plantar flexor activation, both likely related to gastrocnemius stretch during knee re-extension. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT03119948.

Negligible epimuscular myofascial force transmission between the human rectus femoris and vastus lateralis muscles in passive conditions

PURPOSE

There have been contradictory reports of the effects of epimuscular myofascial force transmission in humans. This study investigated the transmission of myofascial force to the human vastus lateralis muscle by determining whether vastus lateralis slack angle changed with hip angle. Since the distance between the origin and insertion of the vastus lateralis muscle does not change when hip angle changes, any change in vastus lateralis slack angle with hip position can be attributed to epimuscular myofascial force transmission.

METHODS

Nineteen young adults were tested in hip flexed ([Formula: see text]) and neutral ([Formula: see text]) positions. Ultrasound images of the vastus lateralis muscle were obtained as the knee was passively flexed at [Formula: see text]/s. The knee angle at which vastus lateralis muscle fascicles began to lengthen was used to identify muscle slack angle.

RESULTS

Overall, there was a negligible effect of hip position on vastus lateralis slack angle ([Formula: see text] [[Formula: see text] to 1.9]; mean [95% confidence interval]). However, a small and variable effect was noted in 3/19 participants.

CONCLUSION

This result indicates that, over the range of joint angles tested here, there is little or no epimuscular myofascial force transmission between the vastus lateralis muscle and neighbouring bi-articular structures under passive conditions. More broadly, this result provides additional evidence that epimuscular myofascial force transmission tends to be small and variable under passive conditions in healthy human muscle.

Intramuscular pressure of human tibialis anterior muscle detects age-related changes in muscle performance

Intramuscular pressure (IMP) reflects forces produced by a muscle. Age is one of the determinants of skeletal muscle performance. The present study aimed to test whether IMP mirrors known age-related muscular changes. We simultaneously measured the tibialis anterior (TA) IMP, compound muscle action potential (CMAP), and ankle torque in thirteen older adults (60-80 years old) in vivo by applying different stimulation intensities and frequencies. We found significant positive correlations between the stimulation intensity and IMP and CMAP. Increasing stimulation frequency caused ankle torque and IMP to increase. The electromechanical delay (EMD) (36 ms) was longer than the onset of IMP (IMPD) (29 ms). Compared to the previously published data collected from young adults (21-40 years old) in identical conditions, the TA CMAP and IMP of older adults at maximum intensity of stimulation were 23.8% and 39.6% lower, respectively. For different stimulation frequencies, CMAP, IMP, as well as ankle torque of older adults were 20.5%, 24.2%, and 13.2% lower, respectively. Surprisingly, the EMD did not exhibit any difference between young and older adults and the IMPD was consistent with the EMD. Data supporting the hypotheses suggest that IMP measurement is an indicator of muscle performance in older adults.

Influence of Bias in the Assessment of Patellar Tendon Stiffness: A Systematic Review and Meta-analysis

The aim of the present study was to provide a systematic review and meta-analysis of the main biases in practical applications of the different types of elastography in assessment of the stiffness of healthy patellar tendons. A literature search on four databases (Scopus, Web of Science, Pubmed and SportDiscus) was conducted on March 25, 2020. After analysis of 1,052 resultant articles, studies were included if they met two inclusion criteria: (1) studies were observational or randomized controlled trials; (2) studies included outcomes of patellar tendon stiffness. Twenty-one studies met the inclusion criteria and were included in this meta-analysis. Four meta-analyses were performed with respect to assessment procedure and participant characteristics. This meta-analysis found a low effect of examined portion of patellar tendon (standardized mean difference [SMD] = 0.27, 95% confidence interval [CI]: 0.01-0.54, n = 379, Z = 2.01, p = 0.04) and a high effect of knee flexion angle during assessment (SMD = -2.12; 95% CI: -2.67 to -1.58, n = 97, Z = 7.68, p < 0.01) in stiffness outcomes. The risk of bias was generally low, but the heterogenicity of the results downgraded the level of evidence. There is evidence in the elastography assessment of patellar tendon suggesting that the knee position and patellar tendon portion evaluated influence stiffness outcomes for patellar tendon in healthy volunteers.

Epimuscular myofascial force transmission from biarticular rectus femoris elongation increases shear modulus of monoarticular quadriceps muscles

This study aimed to examine the effect of rectus femoris (RF) elongation with passive hip angle change on the shear moduli of the vastus lateralis (VL) and medialis (VM) to verify whether Epimuscular myofascial force transmission (EMFT) occurs in the human quadriceps. Fourteen healthy men participated in this study. The shear moduli of the RF, VL, and VM were measured in four hip positions: flexion (Flex), extension and abduction (Ext-Abd), extension (Ext), and extension and adduction (Ext-Add). As the behavior of shear moduli may differ depending on the parts of the vasti muscles, we measured the medial and lateral parts of the VL (Medial-VL and Lateral-VL) and VM (Medial-VM and Lateral-VM). The shear moduli at the Ext and Ext-Add positions were higher than at the Flex position in the RF, VL, and VM. The shear moduli during Ext and Ext-Add were higher than at the Ext-Abd in the RF, VL, and Lateral-VM. Moreover, the shear modulus of the Lateral-VM was higher than of the Medial-VM (Flex: 8.5% higher; Ext-Abd: 15.6%; Ext: 30.2%; Ext-Add: 32.6%). The shear moduli of the VL and VM, which are monoarticular muscles of the knee, increased with passive hip extension or adduction with extension, even when the knee angle was kept constant. The results suggest that EMFT occurs in the quadriceps, and EMFT had a great impact in the Lateral-VM, which is anatomically adjacent to the RF, but it had little effect in the Medial-VM, which is further away from the RF.

Inhomogeneous and anisotropic mechanical properties of the triceps surae muscles and aponeuroses in vivo during submaximal muscle contraction

This study aimed to identify characteristics of the triceps surae muscles and aponeuroses stiffness in vivo, during graded isometric submaximal plantarflexion efforts. A total of twelve healthy male subjects (age: 27 ± 4 years) participated and were required to stay at rest (0% MVC) and perform isometric submaximal plantar flexion contractions (20%, 40%, 60% of MVC) on a dynamometer. Young's modulus of triceps surae muscles and the adjoining aponeuroses between gastrocnemii and soleus at the proximal and distal sites were obtained in the longitudinal direction (along muscle's line of action) during at rest and submaximal plantar flexions. Additionally, Young's modulus of adjoining aponeuroses in the transverse direction at the distal sites was also calculated. Young's modulus of LG (lateral gastrocnemius), SOL-lat (lateral part of soleus) and LPS (superficial aponeurosis of LG) at the proximal site showed significant (p < 0.001) graded increase response to the submaximal contraction levels. Besides, in the lateral side, significant differences in the Young's modulus of aponeuroses were observed between longitudinal and transverse directions at rest and during contractions (p < 0.002). Changes of aponeuroses length were significantly correlated with Young's modulus changes of the proximal gastrocnemii muscle bellies (r = 0.43-0.45, p = 0.006-0.008) and superficial aponeuroses (r = 0.49-0.60, p < 0.002). The results further indicate that the triceps surae muscles and aponeuroses showed inhomogeneous and anisotropic mechanical properties during submaximal muscle contractions, and the stiffening effect of muscle belly possibly make influence on the mechanical properties of aponeuroses during muscle contractions, especially for the lateral gastrocnemius.

Principles of the Mechanism for Epimuscular Myofascial Loads Leading to Non-uniform Strain Distributions Along Muscle Fiber Direction: Finite Element Modeling

Sarcomere lengths and their changes are key determinants of muscle active force production. Recent studies indicate inhomogeneity of sarcomere lengths within the muscle. Studies utilizing magnetic resonance imaging (MRI) analyses for quantifying local muscle tissue strains and diffusion tensor imaging (DTI) analyses allowing for determination of their components along muscle fascicles show that those length changes can be non-uniform. Specifically, two questions arise regarding the muscle’s length change heterogeneities along the muscle fiber direction: (1) How can a passively lengthened muscle show shortened regions? (2) How can an isometric contracting muscle show lengthened parts? Using finite element modeling and studying principles of the mechanism of strain heterogeneity along the muscle fiber direction, the aim was to test the following hypothesis: epimuscular myofascial loads can lead locally to strains opposing those elsewhere within the muscle that are determined by the globally imposed conditions. The geometry of the model was defined by the contour of a longitudinal slice of the rat extensor digitorum longus (EDL) muscle belly. Three models were studied: (1) isolated muscle (muscle modeled fully isolated from its surroundings) and models aiming at representing the principles of a muscle in its in vivo context including (2) extramuscularly connected muscle (muscle’s connections to non-muscular structures are modeled exclusively) and (3) epimuscularly connected muscle (additionally muscle’s connections to neighboring muscle are modeled). Three cases were studied: passive isometric muscle with imposed relative position change (Case I), passive lengthened muscle (Case II), and active isometric muscle with imposed relative position change (Case III). The findings indicated non-uniform strains for all models except for zero strain in model (1) in Case I, but models (2) and (3) also showed strains opposing the imposed effect. Case I: model (3) showed shortened and lengthened sections (up to 35.3%), caused exclusively by imposed relative position change. Case II: models (2) and (3) showed shortened sections (up to 12.7 and 19.5%, respectively) in addition to lengthened sections. Case III: models (2) and (3) showed lengthened sections (up to 5 and 23.4%, respectively) in addition to shortened sections. These effects get more pronounced with stiffer epimuscular connections. Assessments of forces exerted on the muscle by the epimuscular connections showed that such strain heterogeneities are ascribed to epimuscular myofascial loads determined by muscle relative position changes.

Long-Term Effects With Potential Clinical Importance of Botulinum Toxin Type-A on Mechanics of Muscles Exposed

Botulinum toxin type-A (BTX-A) is widely used for spasticity management and mechanically aims at reducing passive resistance at the joint and widening joint range of movement. However, recent experiments on acute BTX-A effects showed that the injected rat tibialis anterior (TA) muscle’s passive forces increased, and the length range of active force exertion (l_range) did not change. Additionally, BTX-A was shown to spread into non-injected muscles in the compartment and affect their mechanics. Whether those effects persist in the long term is highly important, but unknown. The aim was to test the following hypotheses with experiments conducted in the anterior crural compartment of the rat: In the long term, BTX-A (1) maintains l_range, (2) increases passive forces of the injected TA muscle, and (3) spreads into non-injected extensor digitorum longus (EDL) and the extensor hallucis longus (EHL) muscles, also affecting their active and passive forces. Male Wistar rats were divided into two groups: BTX-A and Control (0.1 units of BTX-A or only saline was injected into the TA). Isometric forces of the muscles were measured simultaneously 1-month post-injection. The targeted TA was lengthened, whereas the non-targeted EDL and EHL were kept at constant length. Hydroxyproline analysis was done to quantify changes in the collagen content of studied muscles. Two-way ANOVA test (for muscle forces, factors: TA length and animal group) and unpaired t or Mann-Whitney U test (for l_range and collagen content, where appropriate) were used for statistical analyses (P < 0.05). BTX-A caused significant effects. TA: active forces decreased (maximally by 75.2% at short and minimally by 48.3%, at long muscle lengths), l_range decreased (by 22.9%), passive forces increased (by 12.3%), and collagen content increased (approximately threefold). EDL and EHL: active forces decreased (up to 66.8%), passive force increased (minimally by 62.5%), and collagen content increased (approximately twofold). Therefore, hypothesis 1 was rejected and 2 and 3 were confirmed indicating that previously reported acute BTX-A effects persist and advance in the long term. A narrower l_range and an elevated passive resistance of the targeted muscle are unintended mechanical effects, whereas spread of BTX-A into other compartmental muscles indicates the presence of uncontrolled mechanical effects.

Structural and Functional Changes in the Coupling of Fascial Tissue, Skeletal Muscle, and Nerves During Aging

Aging is a one-way process associated with profound structural and functional changes in the organism. Indeed, the neuromuscular system undergoes a wide remodeling, which involves muscles, fascia, and the central and peripheral nervous systems. As a result, intrinsic features of tissues, as well as their functional and structural coupling, are affected and a decline in overall physical performance occurs. Evidence from the scientific literature demonstrates that senescence is associated with increased stiffness and reduced elasticity of fascia, as well as loss of skeletal muscle mass, strength, and regenerative potential. The interaction between muscular and fascial structures is also weakened. As for the nervous system, aging leads to motor cortex atrophy, reduced motor cortical excitability, and plasticity, thus leading to accumulation of denervated muscle fibers. As a result, the magnitude of force generated by the neuromuscular apparatus, its transmission along the myofascial chain, joint mobility, and movement coordination are impaired. In this review, we summarize the evidence about the deleterious effect of aging on skeletal muscle, fascial tissue, and the nervous system. In particular, we address the structural and functional changes occurring within and between these tissues and discuss the effect of inflammation in aging. From the clinical perspective, this article outlines promising approaches for analyzing the composition and the viscoelastic properties of skeletal muscle, such as ultrasonography and elastography, which could be applied for a better understanding of musculoskeletal modifications occurring with aging. Moreover, we describe the use of tissue manipulation techniques, such as massage, traction, mobilization as well as acupuncture, dry needling, and nerve block, to enhance fascial repair.

Ankle Motion Is Associated With Soft Tissue Displacement in the Dorsal Thigh: An in vivo Investigation Suggesting Myofascial Force Transmission Across the Knee Joint

Experiments in cadavers have demonstrated significant mechanical interactions between constituents of myofascial chains. However, evidence for such force transmission effects is scarce under in vivo conditions. The purpose of this trial was to examine the impact of ankle motion on soft tissue displacement of the dorsal thigh. Eleven healthy active individuals (26.8 ± 4.3 years, six males), in prone position and with the knee extended, underwent passive calf stretches (ankle dorsal extension) imposed by an isokinetic dynamometer. High-resolution ultrasound was used to simultaneously capture the displacement of the semimembranosus muscle, which was quantified by means of cross-correlation analysis. Inactivity of the leg muscles was controlled using surface electromyography (EMG). One participant had to be excluded due to major EMG activity during the experiment. According to a one-sample t test testing the difference to the neutral zero position, ankle dorsal extension induced substantial caudal muscle displacements (5.76 ± 2.67 mm, p < 0.0001). Correlation analysis (Spearman), furthermore, revealed a strong association between maximal dorsal extension and semimembranosus motion (rho = 0.76, p = 0.02). In conclusion, the present trial provides initial in vivo evidence for a mechanical force transmission between serially connected skeletal muscles. This means that local alterations of the mechanical tissue properties may modify flexibility in neighboring (superior or inferior) joints.

A Review of the Theoretical Fascial Models: Biotensegrity, Fascintegrity, and Myofascial Chains

The fascial tissue includes solid and liquid fascia (body fluids such as blood and lymph). The fascia's nomenclature is the subject of debate in the academic world, as it is classified starting from different scientific perspectives. This disagreement is not a brake but is, in reality, the real wealth of research, the multidisciplinarity of thought and knowledge that leads to a deeper understanding of the topic. Another topic of discussion is the fascial model to conceptualize the human body, that is, how the fascial tissue fits into the living. Currently, there are some models: biotensegrity, fascintegrity, and myofascial chains. Biotensegrity is a mechanical model, which takes into consideration the solid fascia; fascintegrity considers the solid and the liquid fascia. Myofascial chains converge attention on the movement and transmission of force in the muscle continuum. The article is a reflection on fascial models and how these are theoretical-scientific visions that need to be further investigated.

Effects of Selective Dorsal Rhizotomy on Ankle Joint Function in Patients With Cerebral Palsy

Selective dorsal rhizotomy (SDR) is a neurosurgical technique performed to reduce muscle spasticity and improve motor functions in children with cerebral palsy (CP). In long term, muscle contractures were observed even after SDR. To better understand what is contributing to contracture formation, it is necessary to assess the effects of SDR on joint stiffness. We hypothesized that ankle passive range of motion (ROM) increases and the quasi-stiffness of the ankle joint decreases after SDR in children with CP. This retrospective study included 10 children with diplegic CP (median age 6 years 2 months) who had undergone SDR and for whom gait analysis data were collected 3 months before (Pre-SDR) and 13 months after (Post-SDR) surgery. Additional to clinical measures, ankle quasi-stiffness (the slope of the ankle moment vs. ankle angle plot) was analyzed from gait data. Passive ankle ROM at 0° (p < 0.0001) and 90° knee angles (p < 0.0001) increased after SDR. Dynamic EMG analysis showed improved phasic gastrocnemius activity (p < 0.0001). Equinus gait was improved with the reduction of peak plantar flexion (p < 0.0001), as well as an increase in peak dorsiflexion (p = 0.006) during walking was observed. Ankle joint quasi-stiffness (Pre- and post-SDR median = 0.056 Nm/kg/° and 0.051 Nm/kg/°, and interquartile range: 0.031 Nm/kg/° and 0.019 Nm/kg/°, respectively) decreased significantly (p = 0.0017) after SDR. Moreover, even though the total time of the gait cycle did not change (p = 0.99), the time interval from maximum dorsiflexion to maximum plantar flexion (Pre- and post-SDR median = 0.125 s and 0.156 s, and interquartile range: 0.153 and 0.253 s, respectively) increased significantly (p = 0.0068) after SDR. In conclusion, the decreased ankle quasi-stiffness and the enhanced time interval in the gait cycle due to SDR indicate better motor control and joint stability. Our findings suggest that the long-term contracture formation occurring even after surgical interventions may be related to the stiffening of non-contractile structures.

Intraoperative experiments combined with gait analyses indicate that active state rather than passive dominates the spastic gracilis muscle's joint movement limiting effect in cerebral palsy

BACKGROUND

In cerebral palsy, spastic muscle's passive forces are considered to be high but have not been assessed directly. Although activated spastic muscle's force-joint angle relations were studied, this was independent of gait relevant joint positions. The aim was to test the following hypotheses intraoperatively: (i) spastic gracilis passive forces are high even in flexed knee positions, (ii) its active state forces attain high amplitudes within the gait relevant knee angle range, and (iii) increase with added activations of other muscles.

METHODS

Isometric forces (seven children with cerebral palsy, gross motor function classification score = II) were measured during surgery from knee flexion to full extension, at hip angles of 45° and 20° and in four conditions: (I) passive state, after gracilis was stimulated (II) alone, (III) simultaneously with its synergists, and (IV) also with an antagonist.

FINDINGS

Directly measured peak passive force of spastic gracilis was only a certain fraction of the peak active state forces (maximally 26%) measured in condition II. Conditions III and IV caused gracilis forces to increase (for hip angle = 45°, by 32.8% and 71.9%, and for hip angle = 20°, by 24.5% and 45.1%, respectively). Gait analyses indicated that intraoperative data for knee angles 61-17° and 33-0° (for hip angles 45° and 20°, respectively) are particularly relevant, where active state force approximates its peak values.

INTERPRETATION

Active state muscular mechanics, rather than passive, of spastic gracilis present a capacity to limit joint movement. The findings can be highly relevant for diagnosis and orthopaedic surgery in individuals with cerebral palsy.

Influence of low muscle activation levels on the ankle torque and muscle shear modulus during plantar flexor stretching

During stretching studies, surface electromyography (sEMG) is used to ensure the passive state of the muscle, for the characterization of passive muscle mechanical properties. Different thresholds (1%, 2% or 5% of maximal) are indifferently used to set "passive state". This study aimed to investigate the effects of a slight activity on the joint and muscle mechanical properties during stretching. The joint torque and muscle shear modulus of the triceps surae muscles were measured in fifteen healthy volunteers during ankle dorsiflexions: (i) in a "fully relaxed" state, (ii) during active conditions where participants were asked to produce an sEMG amplitude of 1%, 2% or 5% of their maximal sEMG amplitude of the triceps surae. The 1% condition was the only that did not result in significant differences in joint torque or shear modulus compared to the relaxed condition. In the 2% condition, increases in joint torque were found at 80% of the maximal angle in dorsiflexion, and in the shear modulus of gastrocnemius medialis and gastrocnemius lateralis at the maximal angle in dorsiflexion. During the 5% condition, joint torque and the shear modulus of gastrocnemius medialis were higher than during relaxed condition at angles larger than 40% of maximal angle in dorsiflexion. The results provide new insights on the thresholds that should be considered for the design of stretching studies. A threshold of 1% seems much more appropriate than a 2% or 5% threshold in healthy participants. Further studies are required to define similar thresholds for patients.

Multiscale modeling of the neuromuscular system: Coupling neurophysiology and skeletal muscle mechanics

Mathematical models and computer simulations have the great potential to substantially increase our understanding of the biophysical behavior of the neuromuscular system. This, however, requires detailed multiscale, and multiphysics models. Once validated, such models allow systematic in silico investigations that are not necessarily feasible within experiments and, therefore, have the ability to provide valuable insights into the complex interrelations within the healthy system and for pathological conditions. Most of the existing models focus on individual parts of the neuromuscular system and do not consider the neuromuscular system as an integrated physiological system. Hence, the aim of this advanced review is to facilitate the prospective development of detailed biophysical models of the entire neuromuscular system. For this purpose, this review is subdivided into three parts. The first part introduces the key anatomical and physiological aspects of the healthy neuromuscular system necessary for modeling the neuromuscular system. The second part provides an overview on state-of-the-art modeling approaches representing all major components of the neuromuscular system on different time and length scales. Within the last part, a specific multiscale neuromuscular system model is introduced. The integrated system model combines existing models of the motor neuron pool, of the sensory system and of a multiscale model describing the mechanical behavior of skeletal muscles. Since many sub-models are based on strictly biophysical modeling approaches, it closely represents the underlying physiological system and thus could be employed as starting point for further improvements and future developments. This article is categorized under: Physiology > Mammalian Physiology in Health and Disease Analytical and Computational Methods > Computational Methods Models of Systems Properties and Processes > Organ, Tissue, and Physiological Models.

Development of a novel multiphysical approach for the characterization of mechanical properties of musculotendinous tissues

At present, there is a lack of well-validated protocols that allow for the analysis of the mechanical properties of muscle and tendon tissues. Further, there are no reports regarding characterization of mouse skeletal muscle and tendon mechanical properties in vivo using elastography thereby limiting the ability to monitor changes in these tissues during disease progression or response to therapy. Therefore, we sought to develop novel protocols for the characterization of mechanical properties in musculotendinous tissues using atomic force microscopy (AFM) and ultrasound elastography. Given that TIEG1 knockout (KO) mice exhibit well characterized defects in the mechanical properties of skeletal muscle and tendon tissue, we have chosen to use this model system in the present study. Using TIEG1 knockout and wild-type mice, we have devised an AFM protocol that does not rely on the use of glue or chemical agents for muscle and tendon fiber immobilization during acquisition of transversal cartographies of elasticity and topography. Additionally, since AFM cannot be employed on live animals, we have also developed an ultrasound elastography protocol using a new linear transducer, SLH20-6 (resolution: 38 µm, footprint: 2.38 cm), to characterize the musculotendinous system in vivo. This protocol allows for the identification of changes in muscle and tendon elasticities. Such innovative technological approaches have no equivalent to date, promise to accelerate our understanding of musculotendinous mechanical properties and have numerous research and clinical applications.

Significance of epimuscular myofascial force transmission under passive muscle conditions

In the past 20 yr, force transmission via connective tissue linkages at the muscle belly surface, called epimuscular myofascial force transmission, has been studied extensively. In this article, the effects of epimuscular linkages under passive muscle conditions are reviewed. Several animal studies that included direct (invasive) measurements of force transmission have shown that different connective tissue structures serve as an epimuscular pathway and that these tissues have sufficient stiffness, especially at supraphysiological muscle lengths and relative positions, to transmit substantial passive forces (up to 15% of active optimal force). Exact values of lumped tissue stiffness for different connective tissue structures have not yet been estimated. Experiments using various imaging techniques (ultrasound, MRI, shear wave elastography) have yielded some, but weak, evidence of epimuscular myofascial force transmission for passive muscles in humans. At this point, the functional consequences of epimuscular pathways for muscle and joint mechanics in the intact body are still unknown. Potentially, however, these pathways may affect sensory feedback and, thereby, neuromuscular control. In addition, altered epimuscular force transmission in pathological conditions may also contribute to changes in passive range of joint motion.

Intramuscular Pressure of Human Tibialis Anterior Muscle Reflects in vivo Muscular Activity

Intramuscular pressure (IMP) is the fluid hydrostatic pressure generated within a muscle and reflects the mechanical forces produced by a muscle. By providing accurate quantification of interstitial fluid pressure, the measurement of IMP may be useful to detect changes in skeletal muscle function not identified with established techniques. However, the relationship between IMP and muscle activity has never been studied in vivo in healthy human muscles. To determine if IMP is able to evaluate electromechanical performance of muscles in vivo, we tested the following hypotheses on the human tibialis anterior (TA) muscle: (i) IMP increases in proportion to muscle activity as measured by electrical [Compound Muscle Action Potential (CMAP)] and mechanical (ankle torque) responses to activation by nerve stimulation and (ii) the onset delay of IMP (IMPD) is shorter than the ankle torque electromechanical delay (EMD). Twelve healthy adults [six females; mean (SD) = 28.1 (5.0) years old] were recruited. Ankle torque, TA IMP, and CMAP responses were collected during maximal stimulation of the fibular nerve at different intensity levels of electrical stimulation, and at different frequencies of supramaximal stimulation, i.e., at 2, 5, 10, and 20 Hz. The IMP response at different stimulation intensities was correlated with the CMAP amplitude (r² = 0.94). The area of the IMP response at different stimulation intensities was also significantly correlated with the area of the CMAP (r² = 0.93). Increasing stimulation intensity resulted in an increase of the IMP response (P < 0.001). Increasing stimulation frequency caused torque (P < 0.001) as well as the IMP (P < 0.001) to increase. The ankle torque EMD [median (interquartile range) = 41.8 (14.4) ms] was later than the IMPD [33.0 (23.6) ms]. These findings support the hypotheses and suggest that IMP captures active mechanical properties of muscle in vivo and can be used to detect muscular changes due to drugs, diseases, or aging.