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Galgiani JE, French MA, Morton SM. Acute pain impairs retention of locomotor learning. J Neurophysiol 2024; 131:678-688. [PMID: 38381551 DOI: 10.1152/jn.00343.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 02/05/2024] [Accepted: 02/18/2024] [Indexed: 02/23/2024] Open
Abstract
Despite abundant evidence that pain alters movement performance, considerably less is known about the potential effects of pain on motor learning. Some of the brain regions involved in pain processing are also responsible for specific aspects of motor learning, indicating that the two functions have the potential to interact, yet it is unclear if they do. In experiment 1, we compared the acquisition and retention of a novel locomotor pattern in young, healthy individuals randomized to either experience pain via capsaicin and heat applied to the lower leg during learning or no stimulus. On day 1, participants learned a new asymmetric walking pattern using distorted visual feedback, a paradigm known to involve mostly explicit re-aiming processes. Retention was tested 24 h later. Although there were no differences in day 1 acquisition between groups, individuals who experienced pain on day 1 demonstrated reduced retention on day 2. Furthermore, the degree of forgetting between days correlated with pain ratings during learning. In experiment 2, we examined the effects of a heat stimulus alone, which served as a control for (nonpainful) cutaneous stimulation, and found no effects on either acquisition or retention of learning. Thus, pain experienced during explicit, strategic locomotor learning interferes with motor memory consolidation processes and does so most likely through a pain mechanism and not an effect of distraction. These findings have important implications for understanding basic motor learning processes and for clinical rehabilitation, in which painful conditions are often treated through motor learning-based interventions.NEW & NOTEWORTHY Pain is a highly prevalent and burdensome experience that rehabilitation practitioners often treat using motor learning-based interventions. Here, we showed that experimental acute pain, but not a heat stimulus, during locomotor learning impaired 24-h retention of the newly learned walking pattern. The degree of retention loss was related to the perceived pain level during learning. These findings suggest important links between pain and motor learning that have significant implications for clinical rehabilitation.
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Affiliation(s)
- Jessica E Galgiani
- Department of Physical Therapy, University of Delaware, Newark, Delaware, United States
- Interdisciplinary Graduate Program in Biomechanics and Movement Science, University of Delaware, Newark, Delaware, United States
| | - Margaret A French
- Department of Physical Therapy, University of Delaware, Newark, Delaware, United States
- Interdisciplinary Graduate Program in Biomechanics and Movement Science, University of Delaware, Newark, Delaware, United States
| | - Susanne M Morton
- Department of Physical Therapy, University of Delaware, Newark, Delaware, United States
- Interdisciplinary Graduate Program in Biomechanics and Movement Science, University of Delaware, Newark, Delaware, United States
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2
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Sperling EL, Hulett JM, Sherwin LB, Thompson S, Bettencourt BA. The effect of mindfulness interventions on stress in medical students: A systematic review and meta-analysis. PLoS One 2023; 18:e0286387. [PMID: 37796866 PMCID: PMC10553303 DOI: 10.1371/journal.pone.0286387] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 05/16/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Medical students have high levels of stress, which is associated with higher incidents of burnout, depression, and suicide compared to age-matched peers. Mindfulness practices have been shown to reduce stress among medical students. PURPOSE The purpose of this systematic review and meta-analysis was to examine if mindfulness interventions have an overall effect on stress outcomes in the high-stress population of medical students globally, particularly given the wide variety of interventions. Any intervention designed to promote mindfulness was included. METHODS A comprehensive literature search was completed to include multiple databases, ancestry, and hand-searching and 35 studies were included. Standardized mean difference effect sizes (ES) were synthesized across studies using a random-effects model for changes in stress levels in medical students ≥ 18. Moderator analyses were performed to explore variations in effects by participant and intervention characteristics. RESULTS Mindfulness interventions significantly improved stress among medical students in both the two-arm studies (d = 0.370, k = 19, n = 2,199, 95% CI 0.239-0.501, p < .001) and one-arm pre-post studies (d = 0.291, k = 30, n = 18 (two cohorts from Dyrbye et al), 95% CI 0.127-0.455, p = 0.001). Moderator analyses found trends in less hours and less required practice resulted in better improvement in stress. CONCLUSIONS This study further confirms that despite a wide variety of mindfulness interventions for medical students around the world, they produce an overall small-to-moderate effect on stress reduction. Future research looking at the most effective protocols for high-stress medical students would be beneficial.
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Affiliation(s)
- Edie L. Sperling
- Medical Anatomical Sciences, College of Osteopathic Medicine of the Pacific–Northwest, Western University of Health Sciences, Lebanon, Oregon, United States of America
- Sinclair School of Nursing, University of Missouri, Columbia, Missouri, United States of America
| | - Jennifer M. Hulett
- Sinclair School of Nursing, University of Missouri, Columbia, Missouri, United States of America
- Ellis Fischel Cancer Center, University of Missouri, Columbia, Missouri, United States of America
| | - LeeAnne B. Sherwin
- Sinclair School of Nursing, University of Missouri, Columbia, Missouri, United States of America
| | - Sarah Thompson
- Sinclair School of Nursing, University of Missouri, Columbia, Missouri, United States of America
| | - B. Ann Bettencourt
- Department of Psychological Sciences, University of Missouri, Columbia, Missouri, United States of America
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Johnson KA, Petrie MA, Shields RK. Biomarkers for rapid H-reflex operant conditioning among females. J Neurophysiol 2023; 129:685-699. [PMID: 36791051 PMCID: PMC10010925 DOI: 10.1152/jn.00188.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 02/05/2023] [Accepted: 02/07/2023] [Indexed: 02/16/2023] Open
Abstract
Operant conditioning of a spinal monosynaptic pathway using the Hoffman reflex (H-reflex) is well established in animal and human studies. There is a subset within the human population (∼20% nonresponders) who are unable to up train this pathway suggesting some distinct or unique identifying characteristics. Importantly, females, who have a nine times higher rate of injury during human performance activities than men, have been understudied in areas of CNS neuroplasticity. Our long-term goal is to understand if innate ability to rapidly up train the H-reflex is predictive of future performance-based injury among females. In this study, we primarily determined whether healthy, young females could rapidly increase the H-reflex within a single session of operant conditioning and secondarily determined if electro-physiological, humoral, cognitive, anthropometric, or anxiety biomarkers distinguished the responders from nonresponders. Eighteen females (mean age: 24) participated in the study. Overall, females showed a group main effect for up training the H-reflex (P < 0.05). Of the cohort, 10 of 18 females met the criteria for up training the H-reflex (responders). The responders showed lower levels of estradiol (P < 0.05). A multivariate stepwise regression model supported that extracellular to intracellular water ratio (ECW/ICW) and H-max/M-max ratio explained 60% of the variation in up training among females. These findings support that females can acutely upregulate the H-reflex with training and that electro-physiological and hormonal factors may be associated with the up training.NEW & NOTEWORTHY Young females who acutely increase their H-reflexes with operant conditioning had lower levels of estradiol. However, the best predictors of those who could up-train the H-reflex were baseline H-reflex excitability (H-max/M-max) and extracellular to intracellular water ratio (ECW/ICW). Future studies are warranted to understand the complex relationship between operant conditioning, human performance, and injury among active young females.
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Affiliation(s)
- Kristin A Johnson
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, Iowa, United States
| | - Michael A Petrie
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, Iowa, United States
| | - Richard K Shields
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, Iowa, United States
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Kelty-Stephen DG, Lee J, Cole KR, Shields RK, Mangalam M. Multifractal Nonlinearity Moderates Feedforward and Feedback Responses to Suprapostural Perturbations. Percept Mot Skills 2023; 130:622-657. [PMID: 36600493 DOI: 10.1177/00315125221149147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
An adaptive response to unexpected perturbations requires near-term and long-term adjustments over time. We used multifractal analysis to test how nonlinear interactions across timescales might support an adaptive response following an unpredictable perturbation. We reanalyzed torque data from 44 young and 24 older adults who performed a single-leg squat task challenged by an unexpected mechanical perturbation and a secondary visual-cognitive task. We report three findings: (a) multifractal nonlinearity interacted with pre-perturbation torque production and task error to presage greater pre-voluntary feedforward increases and greater voluntary reductions, respectively, in post-perturbation task error; (b) multifractal nonlinearity presaged relatively smaller task error than standard deviations of both pre-perturbation torques and pre-perturbation task error; and (c) increased task demand (e.g., age-related changes in dexterity and dual-task settings) led to multifractal nonlinearity presaging reduced task error. All these results were consistent with our expectations, except that a pre-perturbation knee torque-dependent increase in post-perturbation task error appeared later for older than for younger participants. This correlational multifractal modeling offered theoretical clarity on the possible roles of nonlinear interactions across timescales, moderating both feedforward and feedback processes, and presaging greater stability when the standard deviation is relatively large and task demands are strong. Thus, multifractal nonlinearity usefully describes movement variability even when paired with classical descriptors like the standard deviation. We discuss potential insights from these findings for understanding suprapostural dexterity and developing rehabilitative interventions.
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Affiliation(s)
- Damian G Kelty-Stephen
- Department of Psychology, 14821State University of New York at New Paltz, New Paltz, NY, USA
| | - Jinhyun Lee
- Department of Physical Therapy and Rehabilitation Sciences, 573932University of Iowa, Iowa City, IA, USA
| | - Keith R Cole
- Department of Health, Human Function, and Rehabilitation Science, 50430George Washington University, Washington, DC, USA
| | - Richard K Shields
- Department of Physical Therapy and Rehabilitation Sciences, 573932University of Iowa, Iowa City, IA, USA
| | - Madhur Mangalam
- Division of Biomechanics and Research Development, Department of Biomechanics, and Center for Research in Human Movement Variability, 14720University of Nebraska at Omaha, Omaha, NE, USA
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Trunk Angle Modulates Feedforward and Feedback Control during Single-Limb Squatting. J Funct Morphol Kinesiol 2021; 6:jfmk6040082. [PMID: 34698186 PMCID: PMC8544525 DOI: 10.3390/jfmk6040082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/30/2021] [Accepted: 10/03/2021] [Indexed: 11/16/2022] Open
Abstract
Trunk positioning and unexpected perturbations are high-risk conditions at the time of anterior cruciate ligament injury. The influence of trunk positioning on motor control responses to perturbation during dynamic performance is not known. We tested the influence of trunk position on feedforward and feedback control during unexpected perturbations while performing a novel single-limb squatting task. We also assessed the degree that feedforward control was predictive of feedback responses. In the flexed trunk condition, there were increased quadriceps (p < 0.026) and gluteus medius long-latency reflexes (p < 0.001) and greater quadriceps-to-hamstrings co-contraction during feedforward (p = 0.017) and feedback (p = 0.007) time bins. Soleus long-latency reflexes increased more than 100% from feedforward muscle activity regardless of trunk condition. Feedforward muscle activity differentially predicted long-latency reflex responses depending on the muscle (R2: 0.47-0.97). These findings support the concept that trunk positioning influences motor control responses to perturbation and that feedback responses may be invariant to the feedforward control strategy.
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Cole KR, Yen CL, Dudley-Javoroski S, Shields RK. NIH Toolbox Cognition Battery in Young and Older Adults: Reliability and Relationship to Adiposity and Physical Activity. J Geriatr Phys Ther 2021; 44:51-59. [PMID: 31567883 PMCID: PMC7093212 DOI: 10.1519/jpt.0000000000000244] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Executive function in normal aging may be modulated by body habitus and adiposity, both factors modified by physical therapist prescriptions. This study measured between-day reliability of executive function metrics in young and older individuals and examined associations between cognition, adiposity, and physical activity. METHODS Forty-three young and 24 older participants underwent executive function assessment via the National Institutes of Health Toolbox Cognition Battery (Dimensional Change Card Sort, Flanker Inhibitory Control and Attention [Flanker], and List Sorting Working Memory [List Sorting]) at 7-day intervals. Between-day reliability was assessed via intraclass correlation (ICC). Responsiveness was assessed via between-day effect size and Cohen's d. Forward stepwise linear regression examined associations between cognition and age, body mass index, percent body fat, and a self-report measure of physical activity (International Physical Activity Questionnaire Short Form). RESULTS AND DISCUSSION Executive function scores were higher for young participants than for older participants (all P < .002), consistent with typical age-related cognitive decline. Reliability of cognitive metrics was higher for older participants (ICC = 0.483-0.917) than for young participants (ICC = 0.386-0.730). Between-day effect sizes were approximately 50% smaller for older participants. Percent body fat significantly correlated with the Flanker Unadjusted Scale (P = .004, R2 = 0.0772). Neither vigorous nor total physical activity correlated with any cognitive metric. CONCLUSIONS Older participants demonstrated greater between-day reliability for executive function measures, while young participants showed greater capacity to improve performance upon repeat exposure to a cognitive test (especially Flanker). Percent body fat correlated significantly with Flanker scores, while body mass index (an indirect measure of body fat) did not. Self-reported physical activity did not correlate with executive function. Cognitive response to physical therapist-prescribed exercise is a fertile ground for future research.
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Affiliation(s)
- Keith R Cole
- Department of Health, Human Function, and Rehabilitation Sciences, The George Washington University, Washington, District of Columbia
| | - Chu-Ling Yen
- Department of Neurology, Division of Cerebrovascular Diseases, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Shauna Dudley-Javoroski
- Department of Physical Therapy and Rehabilitation Science, The University of Iowa, Iowa City
| | - Richard K Shields
- Department of Physical Therapy and Rehabilitation Science, The University of Iowa, Iowa City
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Lu S, Wei F, Li G. The evolution of the concept of stress and the framework of the stress system. Cell Stress 2021; 5:76-85. [PMID: 34124582 PMCID: PMC8166217 DOI: 10.15698/cst2021.06.250] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 12/13/2022] Open
Abstract
Stress is a central concept in biology and has now been widely used in psychological, physiological, social, and even environmental fields. However, the concept of stress was cross-utilized to refer to different elements of the stress system including stressful stimulus, stressor, stress response, and stress effect. Here, we summarized the evolution of the concept of stress and the framework of the stress system. We find although the concept of stress is developed from Selye's "general adaptation syndrome", it has now expanded and evolved significantly. Stress is now defined as a state of homeostasis being challenged, including both system stress and local stress. A specific stressor may potentially bring about specific local stress, while the intensity of stress beyond a threshold may commonly activate the hypothalamic-pituitary-adrenal axis and result in a systematic stress response. The framework of the stress system indicates that stress includes three types: sustress (inadequate stress), eustress (good stress), and distress (bad stress). Both sustress and distress might impair normal physiological functions and even lead to pathological conditions, while eustress might benefit health through hormesis-induced optimization of homeostasis. Therefore, an optimal stress level is essential for building biological shields to guarantee normal life processes.
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Affiliation(s)
- Siyu Lu
- Center for Aging Biomedicine, Key Laboratory of Protein Chemistry and Developmental Biology of Fish of Ministry of Education, College of Life Sciences, Hunan Normal University, Changsha, Hunan 410081, China
| | - Fang Wei
- Center for Aging Biomedicine, Key Laboratory of Protein Chemistry and Developmental Biology of Fish of Ministry of Education, College of Life Sciences, Hunan Normal University, Changsha, Hunan 410081, China
- National & Local Joint Engineering Laboratory of Animal Peptide Drug Development, College of Life Sciences, Hunan Normal University, Changsha, Hunan 410081, China
| | - Guolin Li
- Center for Aging Biomedicine, Key Laboratory of Protein Chemistry and Developmental Biology of Fish of Ministry of Education, College of Life Sciences, Hunan Normal University, Changsha, Hunan 410081, China
- National & Local Joint Engineering Laboratory of Animal Peptide Drug Development, College of Life Sciences, Hunan Normal University, Changsha, Hunan 410081, China
- Key Laboratory of Hunan Province for Model Animal and Stem Cell Biology, School of Medicine, Hunan Normal University, Changsha, Hunan 410081, China
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Coffman CR, Capaday C, Darling WG. Proprioceptive Acuity is Enhanced During Arm Movements Compared to When the Arm is Stationary: A Study of Young and Older Adults. Neuroscience 2021; 466:222-234. [PMID: 33905823 DOI: 10.1016/j.neuroscience.2021.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/09/2021] [Accepted: 04/18/2021] [Indexed: 11/19/2022]
Abstract
Proprioception in old age is thought to be poorer due to degeneration of the central (CNS) and peripheral nervous systems (PNS). We tested whether community-dwelling older adults (65-83 years) make larger proprioceptive errors than young adults (18-22 years) using a natural reaching task. Subjects moved the right arm to touch the index fingertip to the stationary or moving left index fingertip. The range of locations of the target index fingertip was large, sampling the natural workspace of the human arm. The target arm was moved actively by the subject or passively by the experimenter and reaching arm movements towards the target were made under visual guidance, or with vision blocked (proprioceptive guidance). Subjects did not know the direction or speed of upcoming target hand motion in the passive conditions. Mean 3D distance errors between the right and left index finger tips were small in both groups and only slightly larger when vision was blocked than when allowed, but averaged 2-5 mm larger in older than in younger adults in moving (p = 0.002) and stationary (p = 0.07) conditions, respectively. Variable errors were small and similar in the two groups (p > 0.35). Importantly, clearly larger errors were observed for reaching to the stationary than to the moving index fingertip in both groups, demonstrating that dynamic proprioceptive information during movement permits more accurate localization of the endpoint of the moving arm. This novel finding demonstrates the importance of dynamic proprioceptive information in movement guidance and bimanual coordination.
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Affiliation(s)
- Christopher R Coffman
- Department of Health and Human Physiology Motor Control Laboratory, University of Iowa 225 S Grand Ave, Iowa City, IA 52242 United States
| | - Charles Capaday
- Department of Health and Human Physiology Motor Control Laboratory, University of Iowa 225 S Grand Ave, Iowa City, IA 52242 United States
| | - Warren G Darling
- Department of Health and Human Physiology Motor Control Laboratory, University of Iowa 225 S Grand Ave, Iowa City, IA 52242 United States.
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Petrie M, Johnson K, McCue P, Shields RK. Neuromuscular Electrical Stimulation Primes Feedback Control During a Novel Single Leg Task. J Mot Behav 2020; 53:409-418. [PMID: 32633214 DOI: 10.1080/00222895.2020.1789052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
FMRI studies support that neuromuscular electrical stimulation can modulate the excitability of the somatosensory cortex. We studied whether practice and electrical stimulation of the quadriceps would enhance learning during a weight-bearing task. 20 healthy individuals (10 male) and 8 control subjects participated in a 2-day study. Day 1 consisted of a pretest, a training session, and a post-test; day 2 consisted of a pretest, 2 bouts of electrical stimulation to the quadriceps muscles, and a post-test. The single limb squat task was performed at varying knee resistance and target velocities and a random unexpected perturbation was administered. Feedforward error was calculated during a 50 ms time window before the unexpected event. Feedback error was calculated during a 150 ms window after the unexpected event. Peak error score decreased by 2.98 degrees (p < 0.001) immediately following training. Error was improved by 1.78 degrees (p < 0.001) during the feedforward phase and 1.44 degrees (p < 0.001) during the feedback phase. All subjects plateaued after day 1; except for the electrical stimulation group that showed a decrease of 1.206 degrees during the perturbed cycles (p = 0.024). Electrical stimulation triggered additional learning, beyond practice, during the unexpected event at a latency associated with the transcortical reflex.
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Affiliation(s)
- Michael Petrie
- Department of Physical Therapy and Rehabilitation Science, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Kristin Johnson
- Department of Physical Therapy and Rehabilitation Science, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Patrick McCue
- Department of Physical Therapy and Rehabilitation Science, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Richard K Shields
- Department of Physical Therapy and Rehabilitation Science, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
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Shields RK, Lee J, Buelow A, Petrie M, Dudley-Javoroski S, Cross S, Gutmann L, Nopoulos PC. Myotonic dystrophy type 1 alters muscle twitch properties, spinal reflexes, and perturbation-induced trans-cortical reflexes. Muscle Nerve 2019; 61:205-212. [PMID: 31773755 DOI: 10.1002/mus.26767] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/20/2019] [Accepted: 11/23/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Neurophysiologic biomarkers are needed for clinical trials of therapies for myotonic dystrophy (DM1). We characterized muscle properties, spinal reflexes (H-reflexes), and trans-cortical long-latency reflexes (LLRs) in a cohort with mild/moderate DM1. METHODS Twenty-four people with DM1 and 25 matched controls underwent assessment of tibial nerve H-reflexes and soleus muscle twitch properties. Quadriceps LLRs were elicited by delivering an unexpected perturbation during a single-limb squat (SLS) visuomotor tracking task. RESULTS DM1 was associated with decreased H-reflex depression. The efficacy of doublet stimulation was enhanced, yielding an elevated double-single twitch ratio. DM1 participants demonstrated greater error during the SLS task. DM1 individuals with the least-robust LLR responses showed the greatest loss of spinal H-reflex depression. CONCLUSIONS DM1 is associated with abnormalities of muscle twitch properties. Co-occurring alterations of spinal and trans-cortical reflex properties underscore the central nervous system manifestations of this disorder and may assist in gauging efficacy during clinical trials.
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Affiliation(s)
- Richard K Shields
- Department of Physical Therapy and Rehabilitation Science, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Jinhyun Lee
- Department of Physical Therapy and Rehabilitation Science, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Aaron Buelow
- Department of Physical Therapy and Rehabilitation Science, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Michael Petrie
- Department of Physical Therapy and Rehabilitation Science, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Shauna Dudley-Javoroski
- Department of Physical Therapy and Rehabilitation Science, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Stephen Cross
- Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Laurie Gutmann
- Department of Neurology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Peggy C Nopoulos
- Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
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