Presynaptic inhibition of monosynaptic reflexes in the lower limbs of subjects with upper motoneuron disease

Spinal Cord Transcutaneous Stimulation in Cervical Spinal Cord Injury: A Review Examining Upper Extremity Neuromotor Control, Recovery Mechanisms, and Future Directions

Cervical spinal cord injury (SCI) results in significant sensorimotor impairments below the injury level, notably in the upper extremities (UEs), impacting daily activities and quality of life. Regaining UE function remains the top priority for individuals post-cervical SCI. Recent advances in understanding adaptive plasticity within the sensorimotor system have led to the development of novel non-invasive neurostimulation strategies, such as spinal cord transcutaneous stimulation (scTS), to facilitate UE motor recovery after SCI. This comprehensive review investigates the neuromotor control of UE, the typical recovery trajectories following SCI, and the therapeutic potential of scTS to enhance UE motor function in individuals with cervical SCI. Although limited in number with smaller sample sizes, the included research articles consistently suggest that scTS, when combined with task-specific training, improves voluntary control of arm and hand function and sensation. Further, the reported improvements translate to the recovery of various UE functional tasks and positively impact the quality of life in individuals with cervical SCI. Several methodological limitations, including stimulation site selection and parameters, training strategies, and sensitive outcome measures, require further advancements to allow successful translation of scTS from research to clinical settings. This review also summarizes the current literature and proposes future directions to support establishing approaches for scTS as a viable neuro-rehabilitative tool.

Post-activation depression of primary afferents reevaluated in humans

Amplitude variation of Hoffmann Reflex (H-reflex) was used as a tool to investigate many neuronal networks. However, H-reflex itself is a subject to intrinsic changes including post-activation depression (P-AD). We aimed to investigate P-AD and its implication on motor control in humans. Upon tibial nerve stimulation in 23 healthy participants, peak-to-peak amplitude change of H-reflex was investigated using surface electromyography (SEMG) of soleus muscle. Variety of stimulus intensities, interstimulus intervals (ISIs), voluntary contraction levels/types and force recording were used to investigate the nature of P-AD. We have shown that P-AD was significantly stronger in the shorter ISIs. The only exception was the ISI of 200 msecs which had a weaker P-AD than some of the longer ISIs. Sudden muscle relaxation, on the other hand, further increased the effectiveness of the ongoing P-AD. Moreover, P-AD displayed its full effect with the first stimulus when there was no muscle contraction and was efficient to reduce the muscle force output by about 30%. These findings provide insight about the variations and mechanism of P-AD and could lead to improvements in diagnostic tools in neurological diseases.

Preserved gait kinematics during controlled body unloading

Background

Body weight supported locomotor training was shown to improve walking function in neurological patients and is often performed on a treadmill. However, walking on a treadmill does not mimic natural walking for several reasons: absent self-initiation, less active retraction of leg required and altered afferent input. The superiority of overground training has been suggested in humans and was shown in rats demonstrating greater plasticity especially in descending pathways compared to treadmill training. We therefore developed a body weight support system allowing unrestricted overground walking with minimal interfering forces to train neurological patients. The present study investigated the influence of different amounts of body weight support on gait in healthy individuals.

Methods

Kinematic and electromyographic data of 19 healthy individuals were recorded during overground walking at different levels of body weight support (0, 10, 20, 30, 40, and 50%). Upper body inclination, lower body joint angles and multi-joint coordination as well as time-distance parameters were calculated. Continuous data were analyzed with regard to distinct changes within a gait cycle across all unloading conditions.

Results

Temporal gait parameters were most sensitive to changes in body unloading while spatial variables (step length, joint angles) showed modest responses when unloaded by as much as 50% body weight. The activation of the gastrocnemius muscle showed a gradual decrease with increasing unloading while the biceps femoris muscle showed increased activity levels at 50% unloading. These changes occurred during stance phase while swing phase activity remained unaltered.

Conclusions

Healthy individuals were able to keep their walking kinematics strikingly constant even when unloaded by half of their body weight, suggesting that the weight support system permits a physiological gait pattern. However, maintaining a given walking speed using close-to-normal kinematics while being unloaded was achieved by adapting muscle activity patterns. Interestingly, the required propulsion to maintain speed was not achieved by means of increased gastrocnemius activity at push-off, but rather through elevated biceps femoris activity while retracting the leg during stance phase. It remains to be investigated to what extent neurological patients with gait disorders are able to adapt their gait pattern in response to body unloading.

Effect of paralyzed side soleus muscle pressure on the gait of stroke patients as measured by a three-dimensional motion analysis system

[Purpose] The purpose of this study was to examine the effects of muscle belly compression by a supporter on the paralyzed side soleus muscle of patients with cerebrovascular disability, and to determine the intensity of compression that is effective for improving gait. [Subjects] Eleven patients with chronic cerebral vascular disorder. [Methods] Before setting the supporter, standing posture and 6 m free walking were measured 3 times with the three-dimensional motion analysis system, VICON. Then, supporters were placed on the center of the lower leg of the hemiplegic side of the subjects and inflated to 30 or 50 mmHg. Three minutes after wearing the supporters, the subjects walked again for 3 times. The data measured with VICON were processed using Visial3D.V4, and the angles of the ankle, steps of the hemiplegic and non-hemiplegic sides, walking speed, walk rate and cadence were calculated. [Results] Compared to without a supporter, a supporter with 30 mmHg pressure showed a significant reduction in the angle of the knee at Initial Contact (IC), and a significant increase in the power of the knee extension at Loading Response (LR). [Conclusion] The results reveal a supporter with that of the subjects during pressure over 30 mmHg applied for 3 minutes improved the knee angle power and hemiplegia walking.

A systematic review of the effects of pharmacological agents on walking function in people with spinal cord injury

Studies of spinalized animals indicate that some pharmacological agents may act on receptors in the spinal cord, helping to produce coordinated locomotor movement. Other drugs may help to ameliorate the neuropathological changes resulting from spinal cord injury (SCI), such as spasticity or demyelination, to improve walking. The purpose of this study was to systematically review the effects of pharmacological agents on gait in people with SCI. A keyword literature search of articles that evaluated the effects of drugs on walking after SCI was performed using the databases MEDLINE/PubMed, CINAHL, EMBASE, PsycINFO, and hand searching. Two reviewers independently evaluated each study, using the Physiotherapy Evidence Database (PEDro) tool for randomized clinical trials (RCTs), and the modified Downs & Black scale for all other studies. Results were tabulated and levels of evidence were assigned. Eleven studies met the inclusion criteria. One RCT provided Level 1 evidence that GM-1 ganglioside in combination with physical therapy improved motor scores, walking velocity, and distance better than placebo and physical therapy in persons with incomplete SCI. Multiple studies (levels of evidence 1-5) showed that clonidine and cyproheptadine may improve locomotor function and walking speed in severely impaired individuals with incomplete SCI. Gains in walking speed associated with GM-1, cyproheptadine, and clonidine are low compared to those seen with locomotor training. There was also Level 1 evidence that 4-aminopyridine and L-dopa were no better than placebo in helping to improve gait. Two Level 5 studies showed that baclofen had little to no effect on improving walking in persons with incomplete SCI. There is limited evidence that pharmacological agents tested so far would facilitate the recovery of walking after SCI. More studies are needed to better understand the effects of drugs combined with gait training on walking outcomes in people with SCI.

Excitability changes in the sciatic nerve and triceps surae muscle after spinal cord injury in mice

BACKGROUND

From the onset to the chronic phase of spinal cord injury (SCI), peripheral axons and muscles are subjected to abnormal states of activity. This starts with very intense spasms during the first instant of SCI, through a no activity flaccidity phase, to a chronic hyperactivity phase. It remains unclear how the nature of this sequence may affect the peripheral axons and muscles.

METHODS

We set out to investigate the changes in excitability of the sciatic nerve and to characterize the properties of muscle contractility after contusive injury of the mouse thoracic spinal cord.

RESULTS

The following changes were observed in animals after SCI: 1) The sciatic nerve compound action potential was of higher amplitudes and lower threshold, with the longer strength-duration time constant and faster conduction velocity; 2) The latency of the onset of muscle contraction of the triceps surae muscle was significantly shorter in animals with SCI; 3) The muscle twitches expressed slower rising and falling slopes, which were accompanied by prolonged contraction duration in SCI animals compared to controls.

CONCLUSION

These findings suggest that in peripheral nerves SCI promotes hyperexcitability, which might contribute to mechanisms of spastic syndrome.

Suppression of soleus H-reflex amplitude is graded with frequency of rhythmic arm cycling

In humans, rhythmic arm cycling has been shown to significantly suppress the soleus H-reflex amplitude in stationary legs. The specific nature of the relationship between frequency of arm cycling and H-reflex modulation in the legs has not been explored. We speculated that the effect of arm cycling on reflexes in leg muscles is related to the neural control of arm movement; therefore, we hypothesized that a graded increase in arm cycling frequency would produce a graded suppression of the soleus H-reflex amplitude. We also hypothesized that a threshold frequency of arm cycling would be identified at which the H-reflex amplitude significantly differed from static control trials (i.e., the arms were stationary). Soleus H-reflexes were evoked in stationary legs with tibial nerve stimulation during both control and rhythmic arm cycling (0.03-2.0 Hz) trials. The results show a significant inverse linear relation between arm cycling frequency and soleus H-reflex amplitude (P<0.05). Soleus H-reflex amplitude significantly differed from control at an average threshold cycling frequency of 0.8 Hz. The results demonstrate that increased frequency of upper limb movement increases the intensity of interlimb influences on the neural activity in stationary legs. Further, a minimum threshold frequency of arm cycling is required to produce a significant effect. This suggests that achieving a threshold frequency of rhythmic arm movement may be important to incorporate in rehabilitation strategies to engage the appropriate interlimb neural pathways.

Immobilization induces changes in presynaptic control of group Ia afferents in healthy humans

Neural plasticity occurs throughout adult life in response to maturation, use and disuse. Recent studies have documented that H-reflex amplitudes increase following a period of immobilization. To elucidate the mechanisms contributing to the increase in H-reflex size following immobilization we immobilized the left foot and ankle joint for 2 weeks in 12 able-bodied subjects. Disynaptic reciprocal inhibition of soleus (SOL) motoneurons and presynaptic control of SOL group Ia afferents was measured before and after the immobilization as well as following 2 weeks of recovery. Following immobilization, maximal voluntary plantar- and dorsiflexion torque (MVC) was significantly reduced and the maximal SOL H-reflex amplitude increased with no changes in the maximal compound motor response (M(max)). Decreased presynaptic inhibition of the Ia afferents probably contributed to the increase of the H-reflex size, since we observed a significant decrease in the long-latency depression of the SOL H-reflex evoked by peroneal nerve stimulation (D2 inhibition) and an increase in the size of the monosynaptic Ia facilitation of the SOL H-reflex evoked by femoral nerve stimulation. These two measures provide independent evidence of changes in presynaptic inhibition of SOL Ia afferents and taken together suggest that GABAergic presynaptic inhibition of the SOL Ia afferents is decreased following 2 weeks of immobilization. The depression of the SOL H-reflex when evoked at intervals shorter than 10 s (homosynaptic post-activation depression) also decreased following immobilization, suggesting that the activity-dependent regulation of transmitter release from the afferents was also affected by immobilization. We observed no significant changes in disynaptic reciprocal Ia inhibition. Two weeks after cast removal measurements returned to pre-immobilization levels. Together, these observations suggest that disuse causes plastic changes in spinal interneuronal circuitries responsible for presynaptic control of sensory input to the spinal cord. This may be of significance for the motor disabilities seen following immobilization as well as the development of spasticity following central motor lesions.

Neuromuscular abnormalities associated with spasticity of upper extremity muscles in hemiparetic stroke

Our objective was to assess the mechanical changes associated with spasticity in elbow muscles of chronic hemiparetic stroke survivors and to compare these changes with those recorded in the ankle muscles of a similar cohort. We first characterized elbow dynamic stiffness by applying pseudorandom binary positional perturbations to the joints at different initial angles, over the entire range of motion, with subjects relaxed. We separated this stiffness into intrinsic and reflex components using a novel parallel cascade system identification technique. In addition, for controls, we studied the nonparetic limbs of stroke survivors and limbs of age-matched healthy subjects as primary and secondary controls. We found that both reflex and intrinsic stiffnesses were significantly larger in the stroke than in the nonparetic elbow muscles, and the differences increased as the elbow was extended. Reflex stiffness increased monotonically with the elbow angle in both paretic and nonparetic sides. In contrast, the modulation of intrinsic stiffness with elbow position was different in nonparetic limbs; intrinsic stiffness decreased sharply from full- to mid-flexion in both sides, then it increased continuously with the elbow extension in the paretic side. It remained invariant in the nonparetic side. Surprisingly, reflex stiffness was larger in the nonparetic than in the normal control arm, yet intrinsic stiffness was smaller in the nonparetic arm. Finally, we compare the angular dependence of paretic elbow and ankle muscles and show that the modulation of reflex stiffness with position was strikingly different.

Rhythmic arm cycling produces a non-specific signal that suppresses Soleus H-reflex amplitude in stationary legs

Rhythmic arm cycling significantly suppresses Hoffmann (H-) reflex amplitude in Soleus muscles of stationary legs. The specific parameters of arm cycling contributing to this suppression, however, are unknown. Between the arms or legs, movement results in suppression of the H-reflex that is specifically related to the phase of movement and the locus of limb movement. We speculated that the effects of arm movement features on H-reflexes in the leg would be similar and hypothesized that the Soleus H-reflex suppression evoked by arm movement would therefore be specifically related to: (1) phase of the movement; (2) the locus of the movement (i.e., ipsilateral or contralateral arm); (3) range of arm motion; and (4) frequency of arm cycling. Participants performed bilateral arm cycling at 1 and 2 Hz with short and long-crank lengths. Ipsilateral and contralateral arm cycling was also performed at 1 Hz with a long-crank length. Soleus H-reflexes were evoked at four equidistant phases and comparisons were made while maintaining similar evoked motor waves and Soleus activation. Our results show that comparable suppressive effects were seen at all phases of the arm movement: there was no phase-dependence. Further, bilateral or unilateral (whether ipsi- or contralateral arm) cycling yielded equivalent suppression of the H-reflex amplitude. Cycling at 2 Hz resulted in a significantly larger suppression than with 1 Hz cycling. We conclude that a general, rather than a specific, signal related to the command to produce rhythmic arm muscle activity mediates the suppression of Soleus H-reflex during arm cycling.

Temporal facilitation of spastic stretch reflexes following human spinal cord injury

Recent evidence suggests that alterations in ionic conductances in spinal motoneurones, specifically the manifestation of persistent inward currents, may be partly responsible for the appearance of hyperexcitable reflexes following spinal cord injury (SCI). We hypothesized that such alterations would manifest as temporal facilitation of stretch reflexes in human SCI. Controlled, triangular wave, ankle joint rotations applied at variable velocities (30-120 deg s(-1)) and intervals between stretches (0.25-5.0 s) were performed on 14 SCI subjects with velocity-dependent, hyperexcitable plantarflexors. Repeated stretch elicited significant increases in plantarflexion torques and electromyographic (EMG) activity from the soleus (SOL) and medial gastrocnemius (MG). At higher velocities (> or = 90 deg s(-1)), reflex torques declined initially, but subsequently increased to levels exceeding the initial response, while mean EMG responses increased throughout the joint perturbations. At lower velocities (< or = 60 deg s(-1)), both joint torques and EMGs increased gradually. Throughout a range of angular velocities, reflex responses increased significantly only at intervals < or = 1 s between stretches and following at least four rotations. Ramp-and-hold perturbations used to elicit tonic stretch reflexes revealed significantly prolonged EMG responses following one or two triangular stretches, as compared to single ramp-and-hold excursions. Post hoc analyses revealed reduced reflex facilitation in subjects using baclofen to control spastic behaviours. Evidence of stretch reflex facilitation post-SCI may reflect changes in underlying neuronal properties and provide insight into the mechanisms underlying spastic reflexes.

Pathophysiology of spastic paresis. II: Emergence of muscle overactivity

In the subacute and chronic stages of spastic paresis, stretch-sensitive (spastic) muscle overactivity emerges as a third fundamental mechanism of motor impairment, along with paresis and soft tissue contracture. Part II of this review primarily addresses the pathophysiology of the various forms of spastic overactivity. It is argued that muscle contracture is one of the factors that cause excessive responsiveness to stretch, which in turn aggravates contracture. Excessive responsiveness to stretch also impedes voluntary motor neuron recruitment, a concept termed stretch-sensitive paresis. None of the three mechanisms of impairment (paresis, contracture, and spastic overactivity) is symmetrically distributed between agonists and antagonists, which generates torque imbalance around joints and limb deformities. Thus, each may be best treated focally on an individual muscle-by-muscle basis. Intensive motor training of the less overactive muscles should disrupt the cycle of paresis-disuse-paresis, and concomitant use of aggressive stretch and focal weakening agents in their more overactive and shortened antagonists should break the cycle of overactivity-contracture-overactivity.

Effects of baclofen on spinal reflexes and persistent inward currents in motoneurons of chronic spinal rats with spasticity

In the months after spinal cord injury, motoneurons develop large voltage-dependent persistent inward currents (PICs) that cause sustained reflexes and associated muscle spasms. These muscle spasms are triggered by any excitatory postsynaptic potential (EPSP) that is long enough to activate the PICs, which take > 100 ms to activate. The PICs are composed of a persistent sodium current (Na PIC) and a persistent calcium current (Ca PIC). Considering that Ca PICs have been shown in other neurons to be inhibited by baclofen, we tested whether part of the antispastic action of baclofen was to reduce the motoneuron PICs as opposed to EPSPs. The whole sacrocaudal spinal cord from acute spinal rats and spastic chronic spinal rats (with sacral spinal transection 2 mo previously) was studied in vitro. Ventral root reflexes were recorded in response to dorsal root stimulation. Intracellular recordings were made from motoneurons, and slow voltage ramps were used to measure PICs. Chronic spinal rats exhibited large monosynaptic and long-lasting polysynaptic ventral root reflexes, and motoneurons had associated large EPSPs and PICs. Baclofen inhibited these reflexes at very low doses with a 50% inhibition (EC50) of the mono- and polysynaptic reflexes at 0.26 +/- 0.07 and 0.25 +/- 0.09 (SD) microM, respectively. Baclofen inhibited the monosynaptic reflex in acute spinal rats at even lower doses (EC50 = 0.18 +/- 0.02 microM). In chronic (and acute) spinal rats, all reflexes and EPSPs were eliminated with 1 microM baclofen with little change in motoneuron properties (PICs, input resistance, etc), suggesting that baclofen's antispastic action is presynaptic to the motoneuron. Unexpectedly, in chronic spinal rats higher doses of baclofen (20-30 microM) significantly increased the total motoneuron PIC by 31.6 +/- 12.4%. However, the Ca PIC component (measured in TTX to block the Na PIC) was significantly reduced by baclofen. Thus baclofen increased the Na PIC and decreased the Ca PIC with a net increase in total PIC. By contrast, when a PIC was induced by 5-HT (10-30 microM) in motoneurons of acute spinal rats, baclofen (20-30 microM) significantly decreased the PIC by 38.8 +/- 25.8%, primarily due to a reduction in the Ca PIC (measured in TTX), which dominated the total PIC in these acute spinal neurons. In summary, baclofen does not exert its antispastic action postsynaptically at clinically achievable doses (< 1 microM), and at higher doses (10-30 microM), baclofen unexpectedly increases motoneuron excitability (Na PIC) in chronic spinal rats.

Outcome Assessment for Spasticity Management in the Patient With Traumatic Brain Injury

The objective of this article was to (1) review the engineering and medical literature to structure the available information concerning the assessment of spasticity in the neurological population; (2) to discuss the strengths and weaknesses of the different methods currently in use in spasticity assessment; and (3) make recommendations for future efforts in spasticity outcome assessment. Spasticity textbooks, Web sites, and OVID, IEEE, and Medline searches from 1966 through 2003 of spasticity, quantitative measure, or outcome assessment in the rehabilitation population were used as data sources. Over 500 articles were reviewed. Articles that discussed outcome measures used to assess interventions and evaluation of spasticity were included. Authors reviewed the articles looking at inclusion criteria, data collection, methodology, assessment methods, and conclusions for validity and relevance to this article. Issues such as clinical relevance, real-world function and lack of objectivity, and time consumed during performance are important issues for spasticity assessment. Some measures such as the Ashworth Scale remain in common use secondary to ease of use despite their obvious functional limitations. More functional outcome goals are plagued by being more time consuming and a general inability to demonstrate changes after an intervention. This may be secondary to the other factors that combine with spasticity to cause dysfunction at that level. Quantitative metrics can provide more objective measurements but their clinical relevance is sometimes problematic. The assessment of spasticity outcome is still somewhat problematic. Further work is necessary to develop measures that have real-world functional significance to both the individuals being treated and the clinicians. A lack of objectivity is still a problem. In the future it is important for clinicians and the engineers to work together in the development of better outcome measures.

Spinal interneurones; how can studies in animals contribute to the understanding of spinal interneuronal systems in man?

The first part of this review deals with arguments that the essential properties and organization of spinal interneuronal systems in the cat and in man are similar. The second part is concerned with the possibility that some interneuronal systems may be responsible for motor disturbances caused by spinal cord injuries and that these interneurones may be defined. This possibility is discussed with respect to the hyperexcitability of alpha-motoneurones and the exaggeration of stretch reflexes in spastic patients. To this end, what is known about cat spinal interneurones and about the neuronal basis and pharmacological treatment of spasticity, is put together. Interneurones in di- and trisynaptic reflex pathways from group II muscle afferents are singled out, since they are depressed by the alpha(2) noradrenaline receptor agonists clonidine and tizanidine, which is a critical feature of interneurones expected to contribute to exaggerated stretch reflexes which are reduced by alpha(2) noradrenaline receptor agonists. Recent observations that reflex excitation of extensor motoneurones from group II afferents is enhanced in spastic patients and that the pathologically strong reflex actions of group II afferents are reduced by clonidine and tizanidine support this proposal. On the other hand, a lack of effect of clonidine and tizanidine upon other types of excitatory or inhibitory interneurones argues against any major contribution of such interneurones to the abnormally strong responses of alpha-motoneurones to muscle stretch.

Sensitivity of qualitative and quantitative spasticity measures to clinical treatment with cryotherapy

This study examined the extent to which a battery of tests could detect a reduction of plantarflexor spasticity resulting from cryotherapy. The tests included a traditional qualitative spasticity scale, three potential quantitative spasticity measures and a measure of voluntary ankle muscle function. Twenty-six adult traumatic-brain-injured subjects were examined; these included 22 males and 4 females. The mean age was 28.15 years (range: 18-57, SD 10.78). The five tests were performed in random sequence on both ankles of each subject, before and after a 20 minute cold pack application to the calf. Tests were: modified Ashworth scale (MAS) scoring; H-reflex testing with and without dorsiflexor contraction (Hdf/Hctrl ratio); H-reflex testing with and without Achilles tendon vibration (Hvib/Hctrl ratio); reflex threshold angle (RTA) and timed toe tapping (TIT). Cryotherapy resulted in lowered MAS scores consistent with a reduction in spasticity. Doubly multivariate repeated measures ANOVA revealed a significant difference (F = 24.16, P < 0.001) in test scores between the pre- and post-cryotherapy test batteries. Significant pre- and post-cryotherapy differences (P < or = 0.03) for all dependent measures contributed to the main effect for cryotherapy. However, among the potential quantitative measures of spasticity only the RTA test demonstrated appropriate sensitivity to the reduction in spasticity. In spite of spasticity reduction, TIT performance was impaired following muscle cooling. Failure of the H-reflex ratios to show a reduction consistent with reduced spasticity was attributed to competing alpha and gamma motoneuron effects resulting from peripheral cooling.

A comparison of clinical and laboratory measures of spasticity

Clinical evaluation of spasticity was performed in lower extremities in 35 ambulatory multiple sclerosis patients and compared with the soleus stretch reflex and the Hoffman reflex. There was no relation between the muscle tone score of dorsiflexion of the foot and the biomechanical/electrophysiological parameters. In contrast, the Achilles tendon reflex score was significantly related to the amplitude (rho = 0.411, P < 0.05) and the slope of the stretch reflex (rho = 0.523, P < 0.01). The clinical examination at the ankle joint revealed 33% normal reflex examinations but only 7% normal muscle tone examinations. In contrast, the number of normal examinations of patellar reflex and muscle tone at the knee joint were similar. It is concluded that the muscle tone score overestimates the amount of spasticity because of changes in the non-reflex properties of the spastic extremity and that a reflex score should be used as a clinical measure of spasticity. In addition, biomechanical/electrophysiological evaluation of spasticity at the ankle joint relates to the over-all total muscle tone and reflex scores of lower extremities in this group of MS patients.

Correlation of quantitative measures with the modified Ashworth scale in the assessment of plantar flexor spasticity in patients with traumatic brain injury

This study of plantar flexor spasticity describes relationships among a traditional qualitative spasticity scale, three potential quantitative spasticity measures and a measure of voluntary ankle muscle function. Thirty-four volunteer adult patients with traumatic brain injuries participated. There were 28 males and 6 females; the mean age was 30.3 years. A battery of five randomly sequenced tests was performed for each subject on one ankle. Tests were: modified Ashworth scale (MAS) scoring; H-reflex testing with and without Achilles tendon vibration; H-reflex testing with and without dorsiflexor contraction; reflex threshold angle and timed toe tapping (TTT). Twenty-six subjects returned to have the second ankle tested, resulting in 60 ankles for the analyses. Spearman's coefficients for correlation of quantitative spasticity measures with MAS scores ranged from 0.39 to 0.49 with associated probabilities < or = 0.002. Pearson coefficients for correlation of quantitative spasticity measures with TTT scores were lower but also significant (P < or = 0.07). Multiple correlation for the set of quantitative measures yielded R = 0.614 (P < 0.001) with MAS scores and R = 0.365 (P = 0.045) with TTT scores. These findings reveal statistically significant relationships of low to moderate strength among potential quantitative spasticity measures, a traditional qualitative spasticity scale and a simple measure of voluntary ankle muscle function. Understanding these relationships is an essential part of the ongoing search for quantitative spasticity measures.

Influence of physiotherapeutic facilitation techniques on motor evoked potentials in centrally paretic hand extensor muscles

In the rehabilitation of stroke patients, various facilitation techniques are applied to reduce weakness in centrally paretic muscles and to improve functional motor capacity. The present investigation compared the facilitatory effect of 5 different physiotherapeutic approaches onto the centrally paretic extensor carpi radialis muscle in 30 stroke patients classified into 3 groups according to the individual degree of paresis. In order to quantify the influence of the respective facilitation manoeuvre, single transcranial magnetic stimuli were applied before and during the application of cutaneous/proprioceptive stimuli, a weight bearing task, contraction of the affected and the non-affected extensor carpi radialis muscle and during proximal preinnervation on the affected side. All procedures, indeed, enhanced the frequency of occurrence of muscular response potentials and their amplitudes while diminishing their response latencies. The most prominent effects were observed when the muscle itself was voluntarily activated. A similarly strong facilitation was obtained in the most severely affected patients with cutaneous and proprioceptive stimuli, but such stimuli had inhibitory effects in the healthy control group. The present study illustrates the interaction of cortically evoked motor potentials with peripherally or centrally generated inputs, contributes to the understanding of the neurophysiological mechanisms underlying physiotherapeutic facilitation techniques and helps in providing rational criteria to decide about the most appropriate facilitation method.

Presynaptic inhibition of soleus Ia afferent terminals in Parkinson's disease

The possible role of changes in presynaptic inhibition of muscle spindle primary afferent terminals in Parkinson's disease was investigated. The pathway from tibialis anterior Ia afferents to soleus Ia terminals was assessed in 20 patients with Parkinson's disease and in 17 age matched controls, both at rest and during maintenance of tonic plantar flexing torques about the ankle. At all torques less presynaptic inhibition was present in the patients with Parkinson's disease than in the controls. The difference was significant at rest (p < 0.03) and at 2 Nm (p < 0.05) but not at 5 Nm and 7 Nm torque. The amount of presynaptic inhibition did not change with torque in either group. The observed alteration in presynaptic inhibition in Parkinson's disease is likely to make only a small contribution to the rigidity and impaired movement control.

Impaired afferent control in patients with spastic hemiplegia at different recovery stages: contribution to gait disorder

The cerebral somatosensory potentials (SEP) evoked by electrical stimulation of the tibial nerve on the affected and unaffected limbs during stance and gait were recorded in 50 patients with spastic hemiplegia. On the unaffected side, the onset of the cortical activation during gait was 15 to 20ms later, and the amplitude was about 50% smaller than that recorded during stance condition. This was attributed to blocking of Ia afferent fibers during gait. SEPs recorded on the affected side during gait were, in general, of smaller amplitude and appeared with a shorter latency than in the unaffected side. During gait, 22 affected limbs showed a "Ia" blocking pattern of SEPs whereas another 28 showed a nonblocking pattern. The behavior of SEPs was analyzed with respect to three clinical identifiable recovery stages of voluntary movements in the spastic limbs (namely synergistic, isolated, and useful movements). The blocking pattern during gait was usually present in good functioning limbs, whereas the nonblocking pattern was usually present in poorly functioning limbs. It is concluded that the change in the gait pattern of hemiparetic patients represents a shift from good relevant functioning group II-afferent system to a predominance of functionally ineffective group I-afferent system.

H-reflex changes during contractions of the ankle extensors in spastic patients

Soleus H-reflexes during tonic contractions and isometric ramp contractions of the ankle extensors in spastic and healthy subjects were measured. During the tonic contractions, the H-reflex increased with the contraction level. The increase was highest in the patients (p < 0.001). The facilitation of the H-reflex during a ramp contraction is due to a static component resulting from the increased excitation level and a dynamic component resulting from the modulation of the H-reflex. The dynamic H-reflex facilitation during the ramp contraction was decreased in the patients (p < 0.05). The findings suggest that there is a decreased H-reflex control in spastic patients and this could be explained by a decreased presynaptic inhibition or by postsynaptic changes.

Stretch responses to ankle rotation in multiple sclerosis patients with spasticity

In 13 spastic patients with multiple sclerosis and 10 control subjects, electromyographic (EMG) and mechanical responses to stretch of the ankle extensors and ankle flexors during maintained contraction were measured. The reflex EMG responses in the extensors were divided into a phasic response (40-140 msec after onset of stretch) and a tonic response (200-400 msec after onset of stretch). In the control subjects, both the onset and peak latency of the phasic EMG response decreased with the contraction level (0.01 < P < 0.02 and P < 0.002 respectively) in the extensors. In the patients the latency of the phasic EMG response in the extensors was independent of the voluntary contraction level. This could be attributed to a disruption of the normal recruitment of the motor units according to the size principle. The phasic EMG response was larger in the patients than in the control subjects (P < 0.01). The tonic EMG response was of equal size in the two groups. The larger phasic EMG response in the patients was not followed by an increase in the reflex mediated mechanical stretch response. This shows that proposed changes in the muscle function in spastic patients based on changes in EMG stretch responses must be made with caution. In the ankle flexors all patients had reduced or absent EMG responses to stretch, consistent with earlier findings of an absent mechanical reflex mediated response.

Soleus H-reflex tests and clinical signs of the upper motor neuron syndrome

Soleus H-reflex tests are used for elucidating pathophysiological mechanisms in motor control. The cumulative vibratory inhibition of the soleus H-reflex, the ratio of the reflex to direct muscle potential (H to M ratio) and the recovery curve of the soleus H-reflex were studied in 38 patients with varying signs of the upper motor neuron syndrome for a possible relation with clinical features. The results were compared with those obtained from a group of healthy volunteers. The magnitude of vibratory inhibition decreased with increase of hypertonia. The H to M ratio increased as the activity of the tendon reflex was enhanced and correlated to a lesser degree with muscle tone. Both the H to M ratio and late facilitation of the soleus H-reflex recovery curve were elevated in clonus. The findings suggest that alterations in the results of soleus H-reflex tests relate to specific clinical features of the upper motor neuron syndrome. Possible pathophysiological implications are discussed.

The limitations of the tendon jerk as a marker of pathological stretch reflex activity in human spasticity

The motor disorders associated with human spasticity arise, partly from a pathological increase in the excitability of muscle stretch reflexes. In clinical practice, reflex excitability is commonly assessed by grading the reflex response to a blow delivered to the tendon of a muscle. This is a much simpler response than the complex patterns of activity which may be elicited following muscle stretch caused by active or passive movement. Changes in the biceps brachii tendon jerk response have been followed over the first year after stroke in a group of hemiparetic patients and compared with changes in short and medium latency reflex responses elicited by imposed elbow flexion of initially relaxed spastic muscle and with the development of the late reflex responses which contribute to spastic hypertonia. A progressive increase in tendon jerk responses occurred over the first year following stroke, whereas reflex responses to imposed displacement, in particular the late reflex responses contributing to muscle hypertonia, reached their peak excitability one to three months after stroke, with a subsequent reduction in activity. The tendon jerk reflex therefore provides an incomplete picture of the pathological changes in the reflex responses in spasticity.

Patients with spastic hemiplegia at different recovery stages: evidence of reciprocal modulation of early/late reflex responses

Reflex electromyographic (EMG) muscle responses were recorded from abductor pollicis brevis (APB) and tibialis anterior (TA) muscles of fifty patients with spastic hemiplegia. Responses in the muscles were evoked during voluntary muscle contraction (about 20% of maximum voluntary effort) by submaximal but suprathreshold electrical stimulation of the median (at the wrist) and common peroneal (at the neck of the fibula) nerves respectively. Three EMG peaks (R1, R2 and R3) could be recorded after the direct muscle response (M). There was only a slight difference in R1-R2 latency interval of about 5 ms between upper and lower limbs on the unaffected side of the patients making it unlikely that this late response of the lower limb involves a long loop pathway, although this possibility cannot be discounted for the later, R3, response. Reflex behaviour was analysed for three clinical identifiable recovery stages of voluntary movements in the spastic limbs (synergistic, isolated and useful movements). The major finding was that an increase in the amplitude of the early response "R1" was associated with a decreased amplitude and delayed latency of the late response "R2" on the spastic side. The amplitude of R1 in the three different recovery stages decreased significantly, whereas the amplitude of R2 increased significantly with improvement of the functional stage of the limb. A significant negative linear correlation was found between R1 and R2 amplitude changes in upper as well as lower limbs. A refractoriness of the motor neuron pool as a possible explanation for the decreased R2 amplitude could be discounted. These findings together with recent work on reflex development in children support the hypothesis of reciprocal modulation of early and late reflex signals by supraspinal motor centers.

Cortical modulation of transmission in spinal reflex pathways of man

1. The motor actions in the lower limb of transcranial electrical stimulation of the motor cortex have been studied in sitting human subjects. 2. Cortical stimulation induced a short latency inhibition of H reflexes evoked in soleus motoneurones both at rest and during small voluntary contractions of soleus. 3. Spatial interaction between cortical inhibition of soleus motoneurons and inhibition evoked through identified spinal reflex machinery was investigated. 4. Interactions were found between cortically evoked inhibition and spinal Ia reciprocal inhibition, group I non-reciprocal inhibition and higher threshold components of longer latency reciprocal inhibition (D1 and D2 inhibitions). 5. Interactions were facilitatory when cortical and spinal inhibitory actions were weak and reversed to occlusion when both actions were strong. 6. It is concluded that the corticospinal pathway converges on the interneurones which subserve Ia reciprocal, group I non-reciprocal, D1 and D2 inhibition of soleus motoneurones. 7. No significant interaction was found under the present experimental conditions between cortical stimulation and group Ia-Ia presynaptic inhibition of soleus afferents. 8. The statistical significance of spatial interactions observed with H reflex conditioning was investigated using a control experiment.

A comparative study of methods for estimation of presynaptic inhibition

The influence of vibration on the H-reflex and on the tendon reflex amplitudes was compared and the efficacy of both methods for the assessment of the presynaptic inhibition was studied. One hundred and twenty patients with post-stroke spastic hemiparesis were investigated. Muscle tone, muscle force and tendon reflexes were assessed. The H-reflex and the Achilles tendon reflex (TA) were recorded under identical experimental conditions. Vibration at a frequency of 100 Hz and an amplitude of 2 mm was applied to the TA. Just after vibration the maximal amplitudes of both reflexes were measured. The ratios of reflex amplitudes after vibration to normal maximal reflex amplitudes (Hvibr/Hmax and TAvibr/TAmax) were evaluated. In all patients with hemiparesis the healthy side was used as a control. Our results revealed significantly increased amplitude ratios on the spastic side. Hence it is concluded that presynaptic inhibition is decreased in spasticity. The amplitude ratios on the healthy and the spastic side were consistent. There was good positive correlation between Hvibr/Hmax and TAvibr/TAmax ratios, suggesting that they provide similar and reliable estimates of presynaptic inhibition.

Objective quantification of spastic hypertonia: correlation with clinical findings

To develop a reliable and objective technique for quantifying spastic hypertonia, ten chronically hemiplegic patients with varying degrees of spasticity were studied on three occasions during several weeks. The modified Ashworth scale, a clinical assessment of extremity tone, was performed before and after each of the following objective tests: (1) torque and EMG measurements during ramp and hold angular displacement about the elbow, (2) pendulum test of the lower extremity, and (3) H/M ratio studies of upper and lower extremities. Subject motor function was also quantified using the Fugl-Meyer motor assessment scale. A regression analysis was performed to determine how successfully each of the objective measures correlated with the clinical yardstick, the modified Ashworth scale. A similar correlation between the objective measures and the Fugl-Meyer motor assessment scale was performed. Temporal reproducibility of a test for a given subject was evaluated by performing an ANOVA of repeated measures for each test over the three study sessions in a given subject. We conclude that (1) both the ramp and hold threshold measurements and pendulum test offer acceptable objective measures of spastic hypertonia since they correlate closely with clinical perception, (2) the Fugl-Meyer motor assessment scale also correlates closely with the severity of spastic tone, and (3) objective measures of spastic hypertonia are often surprisingly reproducible when repeatedly applied to a selected group of chronic hemiplegic patients with long-standing spasticity.

Reflex activity and muscle tone during elbow movements in patients with spastic paresis

Reflex behavior and tension development in upper limb muscles were analyzed and comparisons made between the unaffected and spastic sides of patients with spastic hemiparesis. During sinusoidal (0.3-Hz) isometric or isotonic elbow tracking, with a control either of joint position or of torque, randomly timed displacements were induced (at one of three velocities) stretching either the activated flexor or the extensor muscles. On the spastic side, exaggerated short-latency reflexes were apparent, but in contrast, the amplitude of long-latency electromyography (EMG) responses was reduced. The latter responses were differentially modulated on the unaffected side, predominantly by the acceleration signal during control of position and more by the velocity signal during control of torque, while the mode of muscle contraction (isometric or isotonic) had little influence on this behavior. This difference in reflex modulation was lost on the spastic side. The functional consequence of this reduced EMG modulation could be difficulty in performing finely controlled arm movements. The ratio of torque to EMG activity during displacements was higher for both background and reflex-induced EMG on the spastic limb than on the unaffected side. This effect was more pronounced for the flexor than for the extensor muscles. Consequently, the development of spastic muscle hypertonia cannot be attributed to an increase in EMG activity. It is suggested that secondary to a supraspinal lesion, mechanical muscle properties change in such a way that the activated spastic muscle develops more tension when it is stretched.

Trends in the pathophysiology and pharmacotherapy of spasticity

Spasticity develops after supraspinal or spinal lesions of descending motor systems, with obligate involvement of the corticospinal tract. Spasticity is characterized by an increase in muscle tone, which, in contrast to many other types of enhanced muscle tone, shows a marked velocity-dependent increase when the muscle is passively stretched. The pathophysiological mechanisms underlying this spastic muscle tone remain obscure. Three major causes are currently considered possible: (1) changes in the excitability of spinal interneurones; (2) receptor hypersensitivity; (3) formation of new synapses by sprouting. The latter mechanism could account for the long time course over which spastic muscle tone develops in hemiplegic or paraplegic patients, but there is no experimental evidence for this hypothesis. The electromyographic (EMG) gait analysis of patients with spasticity has thrown doubt on the common belief that the velocity-dependent increase in spastic muscle tone is evoked by stretch reflex activity and has led to the idea that spastic muscle tone resides in the muscle fibres themselves. While such a mechanism may contribute to the slowness of active movements in spastic patients, recent experiments on patients with spastic arm paresis have confirmed the classical view that the spastic muscle tone is related to the EMG activity evoked in the passively stretched muscle. This pathological EMG activity is seen during the entire range of the dynamic phase of the stretch, during which a normal muscle exhibits only an early, phasic burst at the highest stretch velocities employed. For the pharmacological treatment of spasticity, substances with different central or peripheral actions are available. Their assumed receptor actions are described, together with their main indications and side-effects.(ABSTRACT TRUNCATED AT 250 WORDS)

Vibration insensitivity of a short latency reflex linking the lower leg and the active knee extensor muscles in humans

The study indirectly investigated the afferent source of a human lower limb reflex that spans two joints and may link limb muscular activity during movement. Low threshold (motor nerve threshold (MT) to 1.6 MT) single, 1 msec, pulses were delivered to the common peroneal nerve at caput fibula. Heteronymous excitatory responses were observed in the elctromyogram of the knee extensor muscle vastus medialis (VM), when the latter was prior contracted. The briefest latency for the VM reflex was 24.2 msec. The distal belly and tendon of the tibialis anterior muscle were vibrated for 20 min at a frequency of 105 Hz, amplitude 1-2 mm, to inhibit the reflex potential evoked by group Ia afferent fibres from that muscle. This significantly reduced the amplitude of the group Ia mediated Hoffmann (H) reflex in TA. Such vibration did not depress the amplitude of the heteronymous reflex to VM, when initially the latter was at peak amplitude or at its mid-range for amplitude. Reflex latency, threshold, and stimulation current for peak expression suggested that group II fibres were unlikely to be the major initiators of the reflex. The results support the view that this human reflex is primarily Ib mediated.

The effects of lesions on autogenetic inhibition in the decerebrate cat

1. The effects of spinal and brain lesions on autogenetic inhibition from contraction receptors were studied in the decerebrate cat. Inhibitory feedback gain was estimated by measuring the effect of tension perturbations on reflex contractions of the soleus muscle. Tendon vibration was used to clamp the firing rate of primary spindle afferents, to prevent spindle unloading from disfacilitating the reflex contraction. In addition, secondary spindle afferents could be selectively excited by stimulating fusimotor fibres during muscle vibration. 2. Following an acute contralateral or bilateral dorsal transection of the spinal cord at L3, the vibration reflex tension fell by between 50 and 74% in three decerebrate animals. This was accompanied by a variable increase in inhibitory feedback, ranging between 180 and 360%. 3. In two animals, selective stimulation of fusimotor fibres supplying soleus muscle was without effect in the presence of muscle vibration both before and after the spinal lesion. In the third animal, a small and variable reduction in tension could be obtained only after the lesion, implying that an inhibitory pathway from homonymous secondary spindle afferents to alpha-motoneurones was released. 4. In a separate series of experiments, contralateral cerebral lesions were made 2-12 months prior to the acute inhibitory feedback measurement. Inhibitory feedback gain was increased, on average twofold in decerebrate animals with chronic cerebral lesions, when compared to control decerebrate animals. 5. Selective stimulation of fusimotor fibres to excite spindle secondary afferents was uniformly without effect in decerebrate animals with chronic cerebral lesions. In one animal spinal transection had only a minor effect on extensor tone and on inhibitory feedback gain, in contrast to the control decerebrate cats. 6. The implications of these findings are discussed in relation to the use of animals with spinal and supraspinal lesions as models of spasticity.

Electromyography in disorders of muscle tone

No single clinical electrophysiological test can evaluate disorders of muscle tone. These disorders, symptomatic of a variety of diseases have a multifactorial physiological basis. The several tests used are complimentary each aiming to study different aspects of spinal and supraspinal reflexes which become deranged. The H reflex and F wave (H max/M max and F max/M max ratios) measure motoneuron pool excitability in general. The tendon reflex includes spindle mechanisms bypassed by the H reflex and, with limitations, comparison of H max/M max and T max/M max yields information about the gamma system. Tonic vibration of a tendon inhibits the H reflex from the same muscle. The TVR measures autogenous presynaptic inhibition exerted by the Ia afferents of the muscle. Recurrent inhibition via Renshaw cells is evaluated by studying the effect of collision on the H reflex. Reciprocal inhibition of the Ia afferents can be assessed by measuring H reflex change induced by stimulating Ia afferents from antagonists. Changes in the H reflex recovery cycle measure polysynaptic influences on spinal motoneuron excitability. Cutaneo-muscular (flexor) reflexes measure poly- and oligosynaptic excitatory drive to spinal motoneurons and the blink reflex evaluates the excitatory drive to brainstem motoneurons. Long loop (segmental) responses can be evaluated by limb pertubation using a torque motor or electrical stimulation applied during voluntary muscle contraction. Finally needle electromyography is a more relevant test in several disorders of muscle tone such as the stiff-man syndrome and Isaacs' syndrome.

Changes in presynaptic inhibition of Ia fibres at the onset of voluntary contraction in man

1. Two independent methods were used, in man, to assess changes in presynaptic inhibition of I a terminals at the onset of selective voluntary contractions: (1) measurement of the amount of heteronymous monosynaptic I a facilitation (from the quadriceps muscle to soleus motoneurones) to provide an assessment of the amount of ongoing presynaptic inhibition exerted on the I a fibres responsible for the facilitation; (2) measurement of the inhibition of H reflexes 40-60 ms after a short vibration to the tibialis anterior tendon to estimate the excitability of the interneurones mediating presynaptic inhibition from tibialis anterior I a afferents to the I a afferents of the test H reflex (soleus or quadriceps). 2. At the onset of an isolated voluntary plantar flexion of the foot (gastrocnemius-soleus contraction) the heteronymous facilitation from quadriceps to soleus was increased, reflecting a decreased presynaptic inhibition of the quadriceps I a terminals on soleus motoneurones. Vibratory inhibition of the soleus H reflex was decreased, reflecting an inhibition of transmission of presynaptic inhibition to homonymous soleus I a afferent terminals. 3. At the onset of the same gastrocnemius-soleus contraction there was, on the contrary, an increased vibratory inhibition of the quadriceps H reflex indicating a facilitation of transmission of presynaptic inhibition to homonymous quadriceps I a afferent terminals. 4. At the onset of an isolated voluntary knee extension (quadriceps contraction) the opposite pattern was seen: the heteronymous facilitation from quadriceps to soleus was decreased and the vibratory inhibition of a soleus H reflex was increased, whereas the vibratory inhibition of the quadriceps H reflex was decreased. 5. These results indicate that presynaptic inhibition of I a afferent terminals on motoneurones of contracting muscles is decreased, permitting I a activity to contribute to excitation of voluntarily activated motoneurones. On the contrary, presynaptic inhibition of I a fibres to motoneurones of muscles not involved in the contraction is increased. It is argued that the former must be supraspinal in origin. 6. It is concluded that the control of presynaptic inhibition of I a fibres at the onset of movement may be organized so as to aid in achieving selectivity of muscle activation, i.e. so as to increase motor contrast.

Inhibition of monosynaptic reflexes in the human lower limb

1. Presynaptic inhibition of muscle spindle Ia afferents by afferents from the same and other muscles has been studied in the human lower limb. The experiments have utilized conditioning of test monosynaptic reflexes by vibration of both the test and other muscles. 2. The pattern of inhibition invariably includes autogenetic actions. 3. There are powerful effects from flexor to extensor Ia afferents. Actions from flexor to flexor, and from extensor to extensor, are weaker. Actions from extensors to flexors are very weak. 4. The strength of presynaptic inhibition from one muscle type to another weakens as the muscles considered become more anatomically distant. 5. The inhibition studied both by vibration and by electrical conditioning stimulation of nerves becomes weaker during voluntary isometric contraction of the test muscle. It is strongest at rest and during antagonist contraction. 6. Evidence is provided suggesting that descending control is the primary cause of this modulation of inhibition during contraction. 7. Stimulation of afferents in cutaneous nerves reduces group I presynaptic inhibition of Ia afferents.