Modulation of triceps surae H-reflexes as a function of the reflex activation history during standing and stepping

Results of Intrathecal Baclofen Treatment in Sixteen Spasticity Patients According to Four Different Measurement Scales: A Retrospective Analysis

Introduction

Spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes. It occurs as a result of overstimulation of the stretch reflex and is a component of the upper motor neuron syndrome. Intrathecal Baclofen (ITB) pump administration in patients with a diagnosis of spasticity may be a suitable option for reducing the complaints of the patients and increasing their quality of life. The aim of this study is to analyze clinically and statistically the diagnosis, treatment criteria, and post-treatment results of patients with spasticity who were treated in our clinic.

Materials and Method

Sixteen patients who were diagnosed with spasticity and placed on an intrathecal Baclofen pump between January 2015 and December 2020 were included in this study. An intrathecal Baclofen trial was first applied to patients who were candidates for the Baclofen pump. The spasticity levels of the patients who decided to have an intrathecal Baclofen pump were scored according to the modified Ashworth scale (MAS) and Penn spasm frequency scale (PSFS). In addition, the scaling of the patients' own conditions according to the visual analogue scale (VAS) and ambulation status according to the modified functional ambulation classification (MFAC) were recorded. All these evaluations were repeated in the preoperative, early postoperative, and follow-up periods.

Results

The sex distribution of the patients included in the study was equal to eight women and eight men. The age distribution was between 18 and 76. The average age was 40.62 (standard deviation ±17.79). The average preoperative modified Ashworth scale score was 3.73, and the average Penn spasm frequency scale score of the patients was 3.67. The average preoperative modified functional ambulation classification score was 1.87, and the average visual analogue scale score was 6.67. At the end of the second postoperative week, the average modified Ashworth scale score was 1.80 and the average Penn spasm frequency scale score was 1.67. The modified functional ambulation classification score was 2.60 and the visual analogue scale score was 4.58. The average follow-up period of the patients was 64 months. At the end of the follow-up periods, the average late-period modified Ashworth scale score was 1.87, and the Penn spasm frequency scale score was 1.67. The average modified functional ambulation classification score was 3.00, and the average visual analogue scale score was 4.50. Statistically, there was a significant difference between preoperative and postoperative results in both modified Ashworth scale and Penn spasm frequency scale scores (P<0.05). Modified functional ambulation classification preoperative and postoperative comparison results (P<0.05) and visual analogue scale results (P<0.05) were also statistically significant. No significant difference was found between the early postoperative period and the late postoperative period in all measurements (P=1.00).

Conclusion

Intrathecal Baclofen administration is one of the many treatment options for spasticity. In this way, it has been shown that greater Baclofen efficacy is achieved and its side effects are reduced. It should always be remembered that the process of this treatment is teamwork that requires the participation of more than one specialty branch. Physical therapists, neurologists, pediatricians, and neurosurgeons should be included in this teamwork.

The underlying mechanisms of improved balance after one and ten sessions of balance training in older adults

Training improves balance control in older adults, but the time course and neural mechanisms underlying these improvements are unclear. We studied balance robustness and performance, H-reflex gains, paired reflex depression, and co-contraction duration in ankle muscles after one and ten training sessions in 22 older adults (+65 yrs). Mediolateral balance robustness, time to balance loss in unipedal standing on a platform with decreasing rotational stiffness, improved (33%) after one session, with no further improvement after ten sessions. Balance performance, absolute mediolateral center of mass velocity, improved (18.75%) after one session in perturbed unipedal standing and (18.18%) after ten sessions in unperturbed unipedal standing. Co-contraction duration of soleus/tibialis anterior increased (16%) after ten sessions. H-reflex gain and paired reflex depression excitability did not change. H-reflex gains were lower, and soleus/tibialis anterior co-contraction duration was higher in participants with more robust balance after ten sessions, and co-contraction duration was higher in participants with better balance performance at several time-points. Changes in robustness and performance were uncorrelated with changes in co-contraction duration, H-reflex gain, or paired reflex depression. In older adults, balance robustness improved over a single session, while performance improved gradually over multiple sessions. Changes in co-contraction and excitability of ankle muscles were not exclusive causes of improved balance.

Fatigue, pain, and the recovery of neuromuscular function after consecutive days of full-body resistance exercise in trained men

PURPOSE

This study measured the self-reported level of fatigue, pain, and neuromuscular function of the knee extensor muscles over a three-day period that included two consecutive days of full-body resistance exercises.

METHODS

10 resistance-trained men performed two consecutive days of full-body resistance exercise. Muscle activation (electromyography and voluntary activation), contractility, and presynaptic inhibition of Ia afferents (homosynaptic and GABA mediated presynaptic inhibition) for the quadriceps were examined from femoral and posterior tibial nerve stimulation.

RESULTS

Fatigue and pain were elevated after Day 1, and were not reduced to pre-exercise levels at the start of Day 2 (p < 0.05). Maximal voluntary torque (- 51.4 Nm, 95% CI = 12.4-90.4 Nm, p = 0.005) and rate of torque development (- 469 Nm.s^-1, 95% CI = 109-829 Nm.s^-1, p = 0.006) were reduced after Day 1, had recovered by Day 2, and did not change after the second training session. The maximal amplitude and rate of rise for the quadriceps twitch were reduced after both training sessions (p < 0.01), with recovery 24 h each session. The maximal amplitude and rate of early muscle activation were reduced after Day 1 (p < 0.01), but no changes were observed for voluntary activation, H-reflex size and shape, or measures of Ia presynaptic inhibition.

CONCLUSION

Resistance exercise in the presence of elevated fatigue and pain from a previous training session does not worsen recovery, or lead to significant alterations in quadriceps neuromuscular function. Reduction in muscle contractility, in the absence of declines in muscle activation, does not lead to decreased voluntary torque.

Gamma somatosensory cortical oscillations are attenuated during the stance phase of human walking

It is well appreciated that processing of peripheral feedback by the somatosensory cortices plays a prominent role in the control of human motor actions like walking. However, very few studies have actually quantified the somatosensory cortical activity during walking. In this investigation, we used electroencephalography (EEG) and beamforming source reconstruction methods to quantify the frequency specific neural oscillations that are induced by an electrical stimulation that is applied to the right tibial nerve under the following experimental conditions: 1) sitting, 2) standing in place, and 3) treadmill walking. Our experimental results revealed that the peripheral stimulation induced a transient increase in theta-alpha (4-12 Hz; 50-350 ms) and gamma (40-80 Hz; 40-100 ms) activity in the leg region of the contralateral somatosensory cortices. The strength of the gamma oscillations were similar while sitting and standing, but were markedly attenuated while walking. Conversely, the strength of the theta-alpha oscillations were not different across the respective experimental conditions. Prior research suggests the afferent feedback from the Ia sensory fibers are likely attenuated during walking, while afferent feedback from the β polysynaptic sensory fibers are not. We suggest that the attenuated gamma oscillations seen during walking reflect the gating of the Ia afferents, while the similarity of theta-alpha oscillations across the experimental conditions is associated with the afferent information from the type II (Aα and β) polysynaptic sensory fibers.

Changes in the quadriceps spinal reflex pathway after repeated sprint cycling are not influenced by ischemic preconditioning

PURPOSE

We examined the effect of ischemic preconditioning (IPC) on changes in muscle force, activation, and the spinal reflex pathway during and after repeated sprint cycling.

METHODS

Eight recreationally active men (high-intensity cardiorespiratory training > 3 times per week, > 6 months) completed two exercise sessions (5 sets of 5 cycling sprints, 150% max W), preceded by either IPC (3 × 5 min leg occlusions at 220 mmHg) or SHAM (3 × 5 min at 20 mmHg). Knee extensor maximal force and rate of force were measured before (PRE), immediately post (POST), 1H, and 24H after cycling. Twitch interpolation and resting potentiated twitches were applied to estimate voluntary activation and muscle contractility, respectively. Quadriceps H-reflex recruitment curves were collected at all time-points using 10 Hz doublet stimulation to allow estimation of H-reflex post-activation depression. Surface electromyograms and tissue oxygenation (via near-infrared spectroscopy) were continuously recorded during cycling.

RESULTS

IPC did not affect any measure of neuromuscular function or performance during cycling. Maximal force and muscle contractility were significantly lower at POST and 1H compared to PRE and 24H by up to 50% (p < 0.01). Maximal force was lower than PRE at 24H by 8.7% (p = 0.028). Voluntary activation and rate of force were unchanged. A rightwards shift was observed for the H-reflex recruitment curve POST, and post-activation depression was higher than all other time-points at 24H (p < 0.05). Muscle activation and oxygenation decreased during cycling.

CONCLUSIONS

IPC has a nominal effect on mechanisms associated with neuromuscular function during and after exercise in healthy populations.

Modulation of H-Reflex Depression with Paired-Pulse Stimulation in Healthy Active Humans

Depression of the Hoffman reflex (H-reflex) is used to examine spinal control mechanisms during exercise, fatigue, and vibration and in response to training. H-reflex depression protocols frequently use trains of stimuli; this is time-consuming and prevents instantaneous assessment of motor neuronal excitability. The purpose of this study was to determine if paired-pulse H-reflex depression is reproducible and whether paired-pulse stimulation adequately estimates the depression induced by the more traditional ten-pulse train. H-reflexes were elicited via ten-pulse trains at 0.1, 0.2, 1, 2, and 5 Hz in ten neurologically intact individuals on two separate days. We measured the depression elicited by the second pulse (H2) and the mean depression elicited by pulses 2–10 (Hmean). H2 was consistent at all frequencies on both days (r² = 0.97, p < 0.05, and ICC_(3,1) = 0.81). H2 did not differ from Hmean (p > 0.05). The results indicate that paired-pulse H-reflex depression has high between-day reliability and yields depression estimates that are comparable to those obtained via ten-pulse trains. Paired-pulse H-reflex depression may be especially useful for studies that require rapid assessment of motor neuronal excitability, such as during exercise, fatigue, and vibration, or to establish recovery curves following inhibition.

Relationships between presynaptic inhibition and static postural sway in subjects with and without diabetic neuropathy

[Purpose] Diabetic peripheral neuropathy can often lead to balance impairment. The spinal reflex is a mechanism that is reportedly important for balance, but it has not been investigated in diabetic peripheral neuropathy patients. Moreover, inhibitory or facilitatory behavior of the spinal reflex—known as presynaptic inhibition—is essential for controlling postural sway. The purpose of this study was to compare the differences in as presynaptic inhibition and balance in subjects with and without diabetic peripheral neuropathy to determine the influence of presynaptic inhibition on balance in diabetic peripheral neuropathy patients. [Subjects and Methods] Presynaptic inhibition and postural sway were tested in eight patients (mean age, 58±6 years) and eight normal subjects (mean age, 59±7 years). The mean percent difference in conditioned reflex amplitude relative to the unconditioned reflex amplitude was assessed to calculate as presynaptic inhibition. The single-leg balance index was measured using a computerized balance-measuring device. [Results] The diabetic peripheral neuropathy group showed lower presynaptic inhibition (47±30% vs. 75±22%) and decreased balance (0.65±0.24 vs. 0.38±0.06) as compared with the normal group. No significant correlation was found between as presynaptic inhibition and balance score (R=0.37). [Conclusion] Although the decreased as presynaptic inhibition observed in diabetic peripheral neuropathy patients may suggest central nervous system involvement, further research is necessary to explore the role of presynaptic inhibition in decreased balance in diabetic peripheral neuropathy patients.

Is spinal excitability of the triceps surae mainly affected by muscle activity or body position?

The aim of this study was to determine how muscle activity and body orientation contribute to the triceps surae spinal transmission modulation, when moving from a sitting to a standing position. Maximal Hoffmann-reflex (Hmax) and motor potential (Mmax) were evoked in the soleus (SOL), medial and lateral gastrocnemius in 10 male subjects and in three conditions, passive sitting, active sitting and upright standing, with the same SOL activity in active sitting and upright standing. Moreover volitional wave (V) was evoked in the two active conditions (i.e., active sitting and upright standing). The results showed that SOL Hmax/Mmax was lower in active sitting than in passive sitting, while for the gastrocnemii it was not significantly altered. For the three plantar flexors, Hmax/Mmax was lower in upright standing than in active sitting, whereas V/Mmax was not modulated. SOL H-reflex is therefore affected by the increase in muscle activity and change in body orientation, while, in the gastrocnemii, it was only affected by a change in posture. In conclusion, passing from a sitting to a standing position affects the Hmax/Mmax of the whole triceps surae, but the mechanisms responsible for this change differ among the synergist muscles. The V/Mmax does not change when upright stance is assumed. This means that the increased inhibitory activity in orthostatic position is compensated by an increased excitatory inflow to the α-motoneurons of central and/or peripheral origin.

Manual therapy directed at the knee or lumbopelvic region does not influence quadriceps spinal reflex excitability

Manual therapies, directed to the knee and lumbopelvic region, have demonstrated the ability to improve neuromuscular quadriceps function in individuals with knee pathology. It remains unknown if manual therapies may alter impaired spinal reflex excitability, thus identifying a potential mechanism in which manual therapy may improve neuromuscular function following knee injury.

AIM

To determine the effect of local and distant mobilisation/manipulation interventions on quadriceps spinal reflex excitability.

METHODS

Seventy-five individuals with a history of knee joint injury and current quadriceps inhibition volunteered for this study. Participants were randomised to one of five intervention groups: lumbopelvic manipulation (grade V), lumbopelvic manipulation positioning (no thrust), grade IV patellar mobilisation, grade I patellar mobilisation, and control (no treatment). Changes in spinal reflex excitability were quantified by assessing the Hoffmann reflex (H-reflex), presynaptic, and postsynaptic excitability. A hierarchical linear-mixed model for repeated measures was performed to compare changes in outcome variables between groups over time (pre, post 0, 30, 60, 90 min).

RESULTS

There were no significant differences in H-reflex, presynaptic, or postsynaptic excitability between groups across time.

CONCLUSIONS

Manual therapies directed to the knee or lumbopelvic region did not acutely change quadriceps spinal reflex excitability. Although manual therapies may improve impairments and functional outcomes the underlying mechanism does not appear to be related to changes in spinal reflex excitability.

Temporal depression of the soleus H-reflex during passive stretch

Synaptic efficacy associated with muscle spindle feedback is regulated via depression at the Ia-motoneurone synapse. The inhibitory effects of repetitive Ia afferent discharge on target motoneurones of different sizes were investigated during a passive stretch of ankle extensors in humans. H-reflex recruitment curves were collected from the soleus muscle for two conditions in ten subjects. H-reflexes were elicited during passive stretch at latencies of 50, 100, 300, and 500 ms after a slow (20°/s) dorsiflexion about the right ankle (from 100 to 90°). Control H-reflexes were recorded at corresponding static (without movement) ankle angles of 99, 98, 94, and 90° of flexion. The slope of the H-reflex recruitment curves (Hslp) was then calculated for both conditions. H-reflex values were similar for the static and passive stretch conditions prior to 50-100 ms, not showing the early facilitation typical of increased muscle spindle discharge rates. However, the H-reflex was significantly depressed by 300 ms and persisted through 500 ms. Furthermore, less than 300 ms into the stretch, there was significantly greater H-reflex depression with a lower stimulus intensity (20 % Mmax) versus a higher stimulus intensity (Hmax), though the effects begin to converge at later latencies (>300 ms). This suggests there is a distinct two-stage temporal process in the depression observed in the Ia afferent pathway for all motoneurones during a passive stretch. Additionally, there is not a single mechanism responsible for the depression, but rather both heterosynaptic presynaptic inhibition and homosynaptic post-activation depression are independently influencing the Ia-motoneurone pathway temporally during movement.

The effect of operant-conditioning balance training on the down-regulation of spinal H-reflexes in a spastic patient

Spasticity in chronic hemiparetic stroke patients has primarily been treated pharmacologically. However, there is increasing evidence that physical rehabilitation can help manage hyper-excitability of reflexes (hyperreflexia), which is a primary contributor to spasticity. In the present study, one chronic hemiparetic stroke patient operantly conditioned the soleus H-reflex while training on a balance board for two weeks. The results showed a minimal decrease in the Hmax-Mmax ratio for both the affected and unaffected limb, indicating that the H-reflex was not significantly altered with training. Alternatively, paired-reflex depression (PRD), a measure of history-dependent changes in reflex excitability, could be conditioned. This was evident by the rightward shift and decreased slope of reflex excitability in the affected limb. The non-affected limb decreased as well, although the non-affected limb was very sensitive to PRD initially, whereas the affected limb was not. Based on these results, it was concluded that PRD is a better index of hyperreflexia, and this measurement could be more informative of synapse function than simple H-reflexes. This study presents a novel and non-pharmacological means of managing spasticity that warrants further investigation with the potential of being translated to the clinic.

Postactivation depression and recovery of reflex transmission during repetitive electrical stimulation of the human tibial nerve

H-reflexes are progressively depressed, relative to the first response, at stimulation frequencies above 0.1 Hz (postactivation depression; PAD). Presently, we investigated whether H-reflexes "recover" from this depression throughout 10-s trains of stimulation delivered at physiologically relevant frequencies (5-20 Hz) during functionally relevant tasks (sitting and standing) and contraction amplitudes [relaxed to 20% maximum voluntary contraction (MVC)]. When participants held a 10% MVC, reflex amplitudes did not change during 5-Hz stimulation. During stimulation at 10 Hz, reflexes were initially depressed by 43% but recovered completely by the end of the stimulation period. During 20-Hz stimulation, reflexes were depressed to 10% and recovered to 36% of the first response, respectively. This "postactivation depression and recovery" (PAD&R) of reflex amplitude was not different between sitting and standing. In contrast, PAD&R were strongly influenced by contraction amplitude. Reflexes were depressed to 10% of the first response during the relaxed condition (10-Hz stimulation) and showed no depression during a 20% MVC contraction. A partial recovery of reflex amplitude occurred when participants were relaxed and during contractions of 1-5% MVC. Surprisingly, reflexes could recover completely by the third pulse within a stimulation train when participants held a contraction between 5 and 10% MVC during stimulation at 10 Hz, a finding that challenges classical ideas regarding PAD mechanisms. Our results support the idea that there is an ongoing interplay between depression and facilitation when motoneurons receive trains of afferent input. This interplay depends strongly on the frequency of the afferent input and the magnitude of the background contraction but is relatively insensitive to changes in task.

INTERSESSION RELIABILITY OF A PROTOCOL TO ASSESS REFLEX ACTIVATION HISTORY IN THE VASTUS MEDIALIS

The purpose of this study was to determine the reliability of a protocol to assess reflex activation history in the vastus medialis. Eight subjects reported to the laboratory on two occasions. Reflex activation history was assessed by delivering two stimuli of the same intensity 80 ms apart. The dependent variable evaluated was the percentage of the unconditioned reflex amplitude. Eight trials were elicited and averaged on each day. An intraclass correlation coefficient (ICC 2,1) was used to estimate intersession reliability. The ICC for the protocol was found to be 0.9647. The results of this investigation indicate that this technique can reliably estimate reflex activation history in the vastus medialis.

Sensorimotor function as a predictor of chronic ankle instability

BACKGROUND

Recurrent ankle injury occurs in 70% of individuals experiencing a lateral ankle sprain. The cause of this high level of recurrence is currently unknown. Researchers have begun to investigate sensorimotor deficits as one possible cause with inconclusive and often conflicting results. The purpose of this study was to further the understanding of the role of sensorimotor deficits in the chronically unstable ankle by establishing which specific measures best distinguish between chronically unstable and healthy ankles.

METHODS

Twenty-two participants with chronic ankle instability and 21 healthy matched controls volunteered. Twenty-five variables were measured within four sensorimotor constructs: joint kinesthesia (isokinetic dynamometer), static balance (force plate), dynamic balance (Star Excursion Balance Test) and motoneuron pool excitability (electromyography).

FINDINGS

The above variables were evaluated using a discriminant function analysis [Wilks'Lambda=0.536 chi(2)(7, N=43)=22.118, P=0.002; canonical correlation=0.681]. The variables found to be significant were then used to assess group discrimination. This study revealed that seven separate variables from the static balance (anterior/posterior and medial/lateral displacement and velocity) and motoneuron pool excitability constructs (single-legged recurrent inhibition and single- and double-legged paired reflex depression) accurately classified over 86% of participants with unstable ankles.

INTERPRETATION

These results suggest that a multivariate approach may be necessary to understand the role of sensorimotor function in chronic ankle instability, and to the development of appropriate rehabilitation and prevention programs. Out of the four overall constructs, only two were needed to accurately classify the participants into two groups. This indicates that static balance and motoneuron pool excitability may be more clinically important in treatment and rehabilitation of chronic ankle instability than functional balance or joint kinesthesia.

Muscle and bone plasticity after spinal cord injury: review of adaptations to disuse and to electrical muscle stimulation

The paralyzed musculoskeletal system retains a remarkable degree of plasticity after spinal cord injury (SCI). In response to reduced activity, muscle atrophies and shifts toward a fast-fatigable phenotype arising from numerous changes in histochemistry and metabolic enzymes. The loss of routine gravitational and muscular loads removes a critical stimulus for maintenance of bone mineral density (BMD), precipitating neurogenic osteoporosis in paralyzed limbs. The primary adaptations of bone to reduced use are demineralization of epiphyses and thinning of the diaphyseal cortical wall. Electrical stimulation of paralyzed muscle markedly reduces deleterious post-SCI adaptations. Recent studies demonstrate that physiological levels of electrically induced muscular loading hold promise for preventing post-SCI BMD decline. Rehabilitation specialists will be challenged to develop strategies to prevent or reverse musculoskeletal deterioration in anticipation of a future cure for SCI. Quantifying the precise dose of stress needed to efficiently induce a therapeutic effect on bone will be paramount to the advancement of rehabilitation strategies.

Soleus H-reflex modulation and paired reflex depression from prone to standing and from standing to walking

Patterns of soleus H-reflex modulation as a function of posture, task, and reflex activation history were assessed with three experimental paradigms: lying prone compared with standing unsupported; standing compared with the initiation of walking; and standing compared with the mid stance phase of walking. Paired H-reflexes, 80 ms apart, were evoked under each condition. The paired reflex depression (PRD), the percentage depression of the second H-reflex relative to the first H-reflex, was modulated independently of the first H-reflex across the postures and tasks. These results reveal divergent patterns of segmental reflex modulation and support the idea that segmental reflexes are controlled by multiple mechanisms.

Modulation of soleus H-reflex by presynaptic spinal mechanisms during varying surface and ankle brace conditions

AIMS

Reflex excitability is modulated in part by presynaptic spinal mechanisms. Presynaptic inhibition may prevent an over-response of the motoneuron pool to afferent information. A paired-reflex depression (PRD) conditioning protocol can be used to monitor reflex plasticity. Manipulation of stance, surface, and external bracing are common methods of rehabilitating and treating lower extremity musculoskeletal injuries. The intent of this study was to evaluate changes in PRD of the soleus H-reflex during single-leg stance under varying stability conditions.

METHODS

Seven trials were completed for each condition in ten healthy volunteers (age=23+/-1.8 yr, weight 65.0+/-11.3 kg, height=168.7+/-28.0 cm). The conditioning stimuli were composed of soleus H-reflex pairs evoked 80 ms apart at an equal intensity. The mean percent decrease of the second H-reflex relative to the first represented PRD.

RESULTS

A 2 x 2 repeated measures ANOVA (P<0.05) was used to evaluate influence of surface (foam, no foam) and support (semi-rigid ankle brace, no ankle brace) on PRD. Main effects testing revealed a significantly greater soleus PRD (P=.034) for the foam surface (62.5%) compared the flat surface (57.5%). Ankle brace application did not influence soleus PRD (P=0.63).

CONCLUSION

The increase in soleus PRD during the foam condition suggests depression of the motoneuron pool. This may lessen postural over-corrections while maintaining upright stance during less stable conditions. No change in PRD during the ankle brace condition suggests that mechanical reinforcement provided an increase in ankle stability, decreasing the demand on the motoneuron pool.

Failed excitability of spinal motoneurons induced by prolonged running exercise

The main purpose of this study was to investigate the modulations in H-reflex and V-wave responses (spinal loop properties) induced by prolonged locomotion activities. The second purpose was to compare the development of central fatigue between continuous and intermittent running modes. Eleven males randomly performed two 90-min running exercises either continuously (CONT, first ventilatory threshold) or intermittently (INT, 150 s at a velocity 20% higher than that during CONT/30 s of recovery). Neuromuscular tests of the plantar flexors [including M-wave and H-reflex at rest and M-wave and V-wave during maximal voluntary contraction (MVC)] were performed before and 5 and 30 min after the running exercises. During MVC, the torque significantly decreased (P < 0.05) from preexercise to 5 and 30 min postexercise (-11 and -9%, respectively), as did the RMS/M ratio (-11 and -13%, respectively) and the V/M ratio (-19 and -37%, respectively) for the soleus muscle. At rest, the H/M ratio also decreased significantly (P < 0.001) from preexercise to 5 and 30 min postexercise (-61 and -55%, respectively). Last, no difference in the alteration of spinal loop properties was noted between CONT and INT. In conclusion, the results regarding H-reflex and V-wave suggest for the first time a modulation in spinal loop properties after prolonged running.

Influence of posture and stimulus parameters on post-activation depression of the soleus H-reflex in individuals with chronic spinal cord injury

In non-disabled (ND) individuals, reflexes are modulated by influences related to physiologic state (e.g., posture, joint position, load) and activation history. Repeated activation of the H-reflex results in post-activation depression (PAD) of the response amplitude. The modulation associated with physiologic state and activation history is suppressed or abolished in individuals with spinal cord injury (SCI). While posture is known to affect H-reflex amplitude and PAD in non-disabled individuals, the effect of posture on PAD in SCI individuals is not known. Further, while the amount of PAD is also known to be influenced by the stimulus rate and by the amplitude of the evoked reflex, the interaction of posture with stimulus parameters has not been previously investigated in either group. We investigated differences in PAD of the soleus H-reflex between SCI subjects and ND subjects during sitting versus supported standing. Subjects were tested using paired conditioning-test stimulus pulses of 2.5s and 5s interpulse intervals (ISI) and with stimulus intensity adjusted to evoke reflex responses of 20% and 40% of the maximum motor response. We found standing posture to be associated with significantly less PAD in SCI subjects compared to ND subjects. In both groups, shorter ISIs and smaller reflex amplitudes were associated with greater PAD of the H-reflex. These results indicate that postural influences on post-activation modulation, while present, are impaired in individuals with chronic incomplete SCI.

The posture-related interaction between Ia-afferent and descending input on the spinal reflex excitability in humans

The separate and combined depressive effects induced by vibration and standing on the soleus H-reflex have been studied by administering Achilles' tendon vibration in prone position and during stance. Without vibration, H-reflex amplitude was larger under prone than standing condition. Vibration reduced the reflex both in prone position and even more during stance. When vibration was superimposed to inclined stance (greater EMG background), the reflex was reduced of the same absolute amount as when it was superimposed to normal stance. When vibration was superimposed on stance with minimal or no background EMG, the reflex disappeared. These results confirm that both upright posture and vibration have a strong depressive effect on the H-reflex. They also show that muscle activity during stance is enough for overcoming the reflex depression. These findings provide information about the origin of the disfacilitatory effects on the monosynaptic reflex pathway, contribute to the understanding of the posture-related mechanisms responsible for the modulation of the spinal reflex excitability, and allow arguing in favour of a minor but adaptable role for the short latency stretch reflex in the control of quiet unperturbed stance.

Pharmacotherapy of spasticity in children with cerebral palsy

Spasticity is one of the most common symptoms presented by neurologic patients. Apart from surgical management, drug therapy is an important treatment of children suffering from spasticity. In this review, recent advances in the pharmacologic armamentarium are reported in detail. In particular, there are oral medications (benzodiazepines, baclofen, dantrolene sodium, alpha 2 adrenergic agonists) and parenteral medications (botulinum toxin type A and B, alcohol). Moreover, there is also baclofen that can be administered intrathecally. There are some reports supporting the use of intramuscular alcohol (45% and/or 5-7% phenol) to reduce spasticity without the loss of voluntary movement or loss of sensation. Among these drugs, intrathecal baclofen is one of the most effective substances that can reduce spasticity significantly in the upper and lower extremities. Finally, the effectiveness of therapy with botulinum toxin type A in the management of spasticity is analyzed. Botulinum toxin type A reduces hypertonia in the injected muscles for a period of 2 to 4 months without important side effects. The purpose of this article is to provide an overview of available oral and parenteral drugs for treatment of spasticity in cerebral palsy and to outline indications and contraindications.

Pre-synaptic modulation of quadriceps arthrogenic muscle inhibition

Arthrogenic muscle inhibition (AMI) impedes rehabilitation following knee joint injury by preventing activation of the quadriceps. AMI has been attributed to neuronal reflex activity in which altered afferent input originating from the injured joint results in a diminished efferent motor drive to the quadriceps muscles. Beginning to understand the mechanisms responsible for muscle inhibition following joint injury is vital to control or eliminate this phenomenon. Therefore, the purpose of this investigation is to determine if quadriceps AMI is mediated by a presynaptic regulatory mechanism. Eight adults participated in two sessions: in one session their knee was injected with saline and in the other session it was not. The maximum Hoffmann reflex (H-reflex), M-wave, reflex activation history, plasma epinephrine, and norepinephrine were recorded at: baseline, post needle stick, post lidocaine, and 25 and 45 min post effusion. Measures for the control condition were matched to the effusion condition. The percent of the unconditioned reflex amplitude for reflex activation history and the maximum H-reflex were decreased at 25 and 45 min post effusion as compared to measures taken at baseline, post needle stick, and post lidocaine (P<0.05). No differences were noted for the maximum M-wave or plasma epinephrine and norepinephrine levels in either the effusion or noneffusion admission (P>0.05). No differences were detected at any time interval for any measure during the control admission (P>0.05). Quadriceps AMI elicited via an experimental knee joint effusion is, at least in part, mediated by a presynaptic mechanism.

Modulation of cutaneous reflexes in hindlimb muscles during locomotion in the freely walking rat: A model for studying cerebellar involvement in the adaptive control of reflexes during rhythmic movements

This study aims to demonstrate stepphase-dependent modulation in the gain of cutaneously triggered reflexes in the freely locomoting rat. Electromyographic recordings of biceps femoris (mainly involved in knee flexion) and gastrocnemius (mainly involved in ankle extension) muscles were continuously monitored during locomotion and cutaneous reflexes were induced by subcutaneously placed stimulation electrodes in the lateral malleolal region. The results show that the reflex responses in both muscles during locomotion were generally reduced compared to reflexes induces in rest. For the biceps femoris reduction of reflex gain was highest during the stance phase whereas for the gastrocnemius the period of highest depression was found during the swing phase. We conclude that stepphase-dependent modulation of peripheral reflexes can be measured in freely locomoting rats and generally concur with previous studies in cat and man that this type of modulation may be functionally important for maintaining and adjusting gait. Moreover, although the mechanism of inducing and maintaining this modulation is not fully known, it is now open to experimental investigation in rodents.

Arthrogenic muscle response induced by an experimental knee joint effusion is mediated by pre- and post-synaptic spinal mechanisms

Knee joint effusion results in quadriceps inhibition and is accompanied by increased excitability in the soleus musculature. The purpose of this study was to determine if soleus arthrogenic muscle response is regulated by pre- or post-synaptic spinal mechanisms. Ten healthy adults (two females and eight males) were measured on two occasions. At the first session, subjects had their knee injected with 60 ml of saline and in the other session they did not. Pre- and post-synaptic spinal mechanisms were measured at baseline, immediately following a needle stick, immediately following a Xylocaine injection, and 25 and 45 min post-saline injection. A mixed effects model for repeated measures was used to analyze each dependent variable. The a priori alpha level was set a P < or = 0.05. The percentage of the unconditioned reflex amplitude for recurrent inhibition (P < 0.0001) and reflex activation history (P < 0.0001) significantly increased from baseline at 25 and 45 min post-effusion. Soleus arthrogenic muscle response seen following knee joint effusion is mediated by both pre- and post-synaptic mechanisms. In conclusion, the arthrogenic muscle response seen in the soleus musculature following joint effusion is regulated by both pre- and post-synaptic control mechanisms. Our data are the first step in understanding the neural networks involved in the patterned muscle response that occurs following joint effusion.

Conditioning Ia-afferent stimulation reduces the soleus Hoffman reflex in humans when muscle spindles are assumed to be inactive

Despite higher neural activation during active as compared to passive muscle shortening, Hoffman reflexes (H-reflexes) are similar. This may be explained by homosynaptic post-activation depression (HPAD) of Ia-afferents being present during active shortening. Accordingly, it was investigated whether conditioning electrical stimulation of the tibial nerve reduced the H-reflex less during active than passive shortening. The effects of two conditioning modes (0.2 and 1 Hz) were compared to a control mode without conditioning. H-reflexes and M-waves were elicited as the ankle passed 90 degrees with the soleus muscle undergoing passive or active (20% MVC) lengthening or shortening. Conditioning had no effect during active shortening. In contrast, during passive shortening, the H:M of the 1 Hz mode was significantly less than that of the 0.2 Hz and control modes. In lengthening, H:M was unaffected by conditioning. These findings support that HPAD reduces the synaptic efficacy of Ia-afferents during active shortening, active and passive lengthening, but not passive shortening.

Central and peripheral contributions to fatigue in relation to level of activation during repeated maximal voluntary isometric plantar flexions

This study aimed to investigate central and peripheral contributions to fatigue during repeated maximal voluntary isometric plantar flexions (MVCs). Changes in joint torque, level of activation (LOA), resting twitch amplitude (RT), electromyographic signals (EMG), and presynaptic inhibition of Ia afferents were investigated during 9 bouts of 10 MVCs. MVCs lasted for 2 s and were separated by 1 s. The interval between bouts was 10 s. Electrical stimulation was applied to the tibial nerve; at rest to evoke RTs, M waves, and two (1.5-s interval) H reflexes; with the soleus EMG at 30% of that during MVC to evoke M waves and two H reflexes; and during MVCs to measure LOA. Over the nine bouts, LOA decreased by 12.6% and RT by 16.2%. EMG root mean square during MVCs remained unchanged for the soleus and tibialis anterior muscles, but it decreased for medial gastrocnemius. Peripheral fatigue (decrease in RT) was positively correlated to LOA, whereas central fatigue (decrease in LOA) was not. Depression of both H reflexes suggests that presynaptic inhibition after the first bout was partly induced by homosynaptic postactivation depression of the Ia terminal. The H-reflex-to-M-wave ratio increased with fatigue in both passive and active states, with no change in the ratio of the second H reflex to the first, thereby indicating a decrease of presynaptic inhibition during fatigue. The results indicate that both central and peripheral mechanisms contributed to the fatigue observed during repeated MVCs and that the development of peripheral fatigue was influenced by the level of voluntary activation and initial plantar flexor torque.

Pre- and post-synaptic control of motoneuron excitability in athletes

PURPOSE

The purpose of this study was to examine the efficacy of two spinal mechanisms in gating motoneuron excitability in power-trained athletes (N = 9), endurance-trained athletes (N = 9), and untrained subjects (N = 9).

METHODS

The dependent variable for each protocol was the peak-to-peak amplitude of the conditioned soleus Hoffmann reflex (H-reflex). Modulations of the test reflex amplitude were evaluated for each subject by using two experimental conditioning protocols: recurrent inhibition (RI) and paired-reflex depression (PRD). Also, to assess the effects of different levels of input on motoneuron excitability, two H-reflex stimulus intensities were used (10% and 30% of maximal motor response (M-max)). For each protocol, seven conditioned H-reflex trials were obtained from each subject during quiet stance. The RI protocol consisted of two reflex responses that were separated by 10 ms. The first was of the same intensity as the unconditioned trials. The second stimulus was of an intensity great enough to elicit a supramaximal motor response. The PRD protocol utilized two reflex stimuli of the same intensity separated by 80 ms. A group by intensity (3 x 2) analysis of variance was performed to determine group differences within each condition.

RESULTS

For both protocols, increases in stimulus intensity resulted in significantly greater inhibition. Significant differences were observed between the trained groups for both the RI and the PRD protocols. For the RI protocol, the endurance-trained athletes demonstrated significantly less RI than either the power-trained athletes or the untrained subjects. For the PRD protocol, the endurance-trained athletes demonstrated significantly greater PRD than either the power-trained athletes or the untrained subjects.

CONCLUSIONS

These observations indicate differential control of motoneuron excitability as a result of segmental reflex pathways among differently trained athletes.

Variations in the soleus H-reflex as a function of activation during controlled lengthening and shortening actions

The effect of soleus activation on the soleus H-reflex was investigated during controlled lengthening and shortening of the plantar flexor muscles. Maximal H-reflexes and M-waves were evoked at the same muscle length (ankle angle 90 degrees ) during lengthening and shortening (ankle angular velocity 5 degrees s(-1)) with soleus either passive or with its electromyographic activity at 10, 20 and 30% of that during a maximal voluntary isometric plantar flexion. In passive trials, the H(MAX):M(MAX) ratio during lengthening was lower than during shortening. In active trials at 10 and 20%, the H(MAX):M(MAX) ratio tended to be lower during lengthening than shortening. Within the active trials, H(MAX):M(MAX) ratios were not different between the three levels of soleus activation, neither for lengthening nor shortening actions. When all active trials were pooled, the lengthening H(MAX):M(MAX) ratio was significantly lower than the shortening one. In lengthening, the H(MAX):M(MAX) ratio increased in the active with respect to the passive condition, whereas no change occurred in active with respect to the passive shortening. These results indicate action type specificity in the way the Ia-excitatory effect is modulated as the soleus muscle is voluntarily activated.

Soleus H-reflex gain in healthy elderly and young adults when lying, standing, and balancing

Soleus Hoffman-reflex (H-reflex) gain was compared at the same background level of electromyographic activity across lying, natural standing, and tandem stance postures, in 12 young and 16 elderly adults. When compared to a lying posture, young adults significantly depressed soleus H-reflex gain when in a natural standing (19% decrease) and a tandem stance position (30% decrease; p <.0125 for both positions). For elderly adults, there was no significant decrease in H-reflex gain while standing naturally, but there was a significant 28% decrease when performing tandem stance (p <.0125). The data indicate that, although the mild motor control challenge of natural standing does not induce a decrease in soleus H-reflex gain in the elderly adults, as it does in young adults, in the more difficult task of tandem stance, soleus H-reflex gain is significantly decreased in both young and elderly adults.

Modulations of soleus H-reflex excitability during gait initiation: central versus peripheral influences

Soleus and tibialis anterior electromyogram (EMG) and soleus H-reflexes were recorded from the stance limb of an individual who suffered a traumatic peroneal nerve injury and of four nonimpaired individuals during gait initiation. The control subjects also initiated walking after swaying forward (sway-gait initiation), which eliminated the initial tibialis anterior activation. During the initial period of gait initiation, H-reflexes were depressed to 43% of standing values during normal-gait initiation and 86% during sway-gait initiation in the nonimpaired subjects. H-reflexes of the nerve-injured subject were depressed to 37%, even though no tibialis anterior EMG was observed. The findings support the view that reciprocal inhibition of the soleus during a task, which normally involves tibialis anterior activation, is due to a centrally mediated process.

Spasticity management: an overview

Recent developments in therapeutic interventions for children with spasticity have complicated managerial decision making. A simplified paradigm for the pathophysiology of spasticity is presented, which emphasizes the ways in which treatment modalities disrupt hyperexcitable segmental spinal reflex arcs. Various techniques for the management of spasticity are reviewed, along with factors relevant to proper patient selection for therapeutic intervention. Potential goals for spasticity management are considered as are outcome measures for assessing the efficacy of these technologies.

Effect of a reduced base of support in standing and balance training on the soleus H-reflex

The present study provides evidence that a reflex at the segmental level can adapt over a two hour experiment in a functionally appropriate manner in response to a balance training task. Subjects (N=9) received soleus (S) H-reflexes in blocks of seven trials while free standing on a normal base-of-support (NBOS) and while standing on a plafform with a reduced base-of-support (RBOS) in the sagittal plane. During the RBOS condition, the H-reflex served as a postural perturbation. Subjects were instructed to suppress the H-reflex when it was evoked, as an attempt to maintain a balanced state. Background EMG from the S and tibialis anterior muscles, the S M-wave, and stimulus current were maintained at a constant level during the experiment. Subjects initially received a block of NBOS trials, followed by 4 RBOS blocks (training), a second NBOS block, four additional RBOS blocks, and a third NBOS block with the protocol repeated on three different days (D1, D2 and D3) within the same week. The S H/M ratio was depressed 9% upon standing on the RBOS. With training the S H/M ratio decreased by 22% on Dl, 18% on D2 and 6% on D3. The ratio between the H-reflex and background S EMG (H-reflex gain) decreased 10% on D1, 40% on D2 and 23% on D3 when the first NBOS and first RBOS blocks were compared. Due to a slight increase in the S EMG across blocks, the H-reflex gain decreased considerably more across blocks than the H/M ratio. Although the S H/M ratio underwent an 7% decrease from D1 to D3, the differences were not significant. Individually, however, six of the nine subjects decreased their H/M ratios from 12-42% across days. The results may reflect the inception of longer-term adaptations of the segmental stretch reflex system.

Scientific basis of spasticity: insights from a laboratory model

A variety of central nervous system injuries, diseases, and developmental deficits can lead to motor disorders that present complex mixtures of symptoms. Those that have a fundamental similarity characterized by the appearance of exaggerated velocity-dependent resistance to the lengthening of skeletal muscles are called spasticity. Reports based on clinical observations of motor disorders have and continue to provide the essential database of information regarding the range and distribution of unifying and discordant features of spasticity. Laboratory investigations employing animal models of motor disorders following experimental lesions of the central nervous system have reproduced some of the neurophysiologic changes that accompany injury of the central nervous system in humans. Those experimental lesions produced by spinal cord contusion/compression reproduce many of the histopathologic features displayed in traumatic injury of the human spinal cord as well. Studies using this model have revealed not only changes in reflex threshold and amplitude but also alterations in fundamental rate-modulation processes that regulate reflex excitability during repetitive stimulation. This report characterizes insights obtained from a laboratory investigation in search of fundamental mechanisms that contribute to the development of spasticity and provides a vantage point for understanding therapeutic strategies for treatment of spasticity.