Assessment of post-stroke elbow flexor spasticity in different forearm positions

Abstract

Purpose/Aim: There have been conflicting results regarding which muscle contribute most to the elbow spastic flexion deformity. This study aimed to investigate whether flexor spasticity of the elbow changed according to the position of the forearm, and to determine the muscle or muscles that contributed most to the elbow spastic flexion deformity by clinical examination.

Methods: This study is a single group, observational and cross-sectional study. Sixty patients were assessed for elbow flexor spasticity in different forearm positions (pronation, neutral and supination) with Modified Tardieu Scale. The primary outcome measure was a domain of the Modified Tardieu Scale, the dynamic component of spasticity (spasticity angle).

Results: In general, there was a significant difference between forearm positions regarding spasticity angle (p?<?.001). In pairwise comparisons, median spasticity angles in pronation (70 degrees) and neutral position (60 degrees) were significantly higher than those in supination (57.5 degrees) (adjusted p?<?.001 and adjusted p?=?.003, respectively). However, median spasticity angle in pronation did not differ significantly from those in neutral position in favour of pronation (adjusted p?=?.274).

Conclusions: The severity of spasticity changes according to the elbow position which suggests that the magnitude of contribution of each elbow flexor muscle to spastic elbow deformity is different. Reduction of spasticity from pronation to supination leads us to consider brachialis as the most spastic muscle. Since biceps was suggested to be the least spastic muscle in this study, and also to avoid spastic pronation deformity of the forearm, it should be rethought before performing chemodenervation into biceps muscle.     

Influence of forearm orientation on biceps brachii tendon mechanics and elbow flexor force steadiness

Achilles tendon mechanics influence plantar flexion force steadiness (FS) and balance. In the upper limb, elbow flexor FS is greater in supinated and neutral forearm orientations compared to pronated, with contributions of tendon mechanics remaining unknown in position-dependent FS. This study investigated whether distal biceps brachii (BB) tendon mechanics across supinated, neutral and pronated forearm orientations influence position-dependent FS of the elbow flexors. Eleven males (23 ± 3 years) performed submaximal isometric elbow flexion tasks at low (5, 10% maximal voluntary contraction (MVC)) and high (25, 50, 75% MVC) force levels in supinated, neutral and pronated forearm orientations. Distal BB tendon elongation and CSA were recorded on ultrasound to calculate mechanics of tendon stress, strain and stiffness. Relationships between FS, calculated as coefficient of variation (CV) of force, and tendon mechanics were evaluated with multiple regressions. Supinated and neutral were ∼50% stronger and ∼60% steadier than pronated (p < 0.05). Tendon stress was ∼52% greater in supinated and neutral compared to pronated, tendon strain was ∼36% greater in neutral than pronated (p < 0.05), while tendon stiffness (267.4 ± 78.9 N/mm) did not differ across orientations (p > 0.05). At low forces, CV of force was predicted by MVC (r²: 0.52) in supinated, and MVC and stress in neutral and pronated (r²: 0.65–0.81). At high force levels, CV of force was predicted by MVC and stress in supinated (r²: 0.49), and MVC in neutral (r²: 0.53). Absolute strength and tendon mechanics influence the ability of the BB tendon to distribute forces, and thus are key factors in position-dependent FS.     

Four forearm flexor muscles of the horse, Equus caballus: anatomy and histochemistry.

Two of the forearm flexors of the horse, the superficial and deep digital flexor muscles, are critical to support the digital and fetlock joints, exhibit differing insertions, and are passively supported by the proximal and distal check ligaments, respectively. These two muscles differ in histochemical composition and architecture. The differences are correlated with the different stress levels transmitted through their tendons, and the different frequencies of clinical breakdown that have been reported. Both muscles contain type I and type IIa fibers. A few type IIb fibers occurred in the deep digital flexor. The superficial digital flexor contained approximately 56% type I fibers, extremely short muscle fibers, and extensive connective tissue investment. In contrast, the deep digital flexor had three muscle heads: ulnar, radial, and "long" and "short" regions of the humeral head. The "long" and "short" regions of the humeral head contained 33% and 44% type I fibers, respectively, fiber lengths three to four times as long as those in the superficial digital flexor, and relatively less connective tissue investment. Flexor carpi radialis and flexor carpi ulnaris compared most closely with the humeral head of the deep digital flexor. These data suggest a correlation of the unique architecture of superficial digital flexor with its proposed elastic storage properties during locomotion in horses, and an explanation for the frequent breakdown of the superficial digital flexor in athletic horses.     

Temporal response of canine flexor tendon to limb suspension

Tendon disuse, or stress deprivation, frequently accompanies clinical disorders and treatments, yet the metabolism of tendons subject to stress deprivation has rarely been investigated systematically. The effects of stress deprivation on canine flexor tendon were investigated in this study. One adult canine forepaw was suspended for 21 or 42 days. Control forepaws were collected from dogs that had no intervention on their limbs and paws. The expression of collagen I and III was not significantly altered in the tendons disused for 21 days but was significantly decreased at 42 days (P < 0.03). The expression of collagen II, aggrecan, decorin, and fibronectin was significantly decreased in the tendons in the suspended limbs at 21 days (P < 0.002) and further reduced at 42 days. With stress deprivation, the expression of matrix metalloproteinase 2 (MMP2) was significantly increased (P < 0.004) at 21 and 42 days. The expression of MMP3 was significantly decreased at 21 and 42 days (P < 0.03). The expression of MMP13 was not altered with stress deprivation at 21 and 42 days. The expression of MMP14 was significantly increased at 21 days (P = 0.0015) and returned to the control level at 42 days. Tissue inhibitor of metalloproteinase 1 (TIMP1) expression was decreased after the limbs were suspended for 42 days (P = 0.0043), but not 21 days. However, TIMP2 expression was not significantly different from control at 21 or 42 days. Furthermore, the cross-sectional area of the stress-deprived tendons at 42 days was decreased compared with the control group (P < 0.01). The intervention method in this study did not result in any alteration of stiffness of the tendon. Our study demonstrated that stress deprivation decreases the anabolic process and increases the catabolic process of extracellular matrix in flexor tendon.     

Fatigue effect on cross-talk in mechanomyography signals of extensor and flexor forearm muscles during maximal voluntary isometric contractions

Objective:This paper presents the analyses of the fatigue effect on the cross-talk in mechanomyography (MMG) signals of extensor and flexor forearm muscles during pre- and post-fatigue maximum voluntary isometric contraction (MVIC).Methods:Twenty male participants performed repetitive submaximal (60% MVIC) grip muscle contractions to induce muscle fatigue and the results were analyzed during the pre- and post-fatigue MVIC. MMG signals were recorded on the extensor digitorum (ED), extensor carpi radialis longus (ECRL), flexor digitorum superficialis (FDS) and flexor carpi radialis (FCR) muscles. The cross-correlation coefficient was used to quantify the cross-talk values in forearm muscle pairs (MP1, MP2, MP3, MP4, MP5 and MP6). In addition, the MMG RMS and MMG MPF were calculated to determine force production and muscle fatigue level, respectively.Results:The fatigue effect significantly increased the cross-talk values in forearm muscle pairs except for MP2 and MP6. While the MMG RMS and MMG MPF significantly decreased (p<0.05) based on the examination of the mean differences from pre- and post-fatigue MVIC.Conclusion:The presented results can be used as a reference for further investigation of cross-talk on the fatigue assessment of extensor and flexor muscles’ mechanic.     

Evidence of a myogenic response in vasomotor control of forearm and palm cutaneous microcirculations.

Previous investigations of autoregulatory mechanisms in the control of skin blood flow suffer from the possibility of interfering effects of the autonomic nervous system. To address this question, in 11 subjects cutaneous vascular responses were measured during acute changes in perfusion pressure (using Valsalva maneuver; VM) before and after ganglionic blockade via systemic trimethaphan infusion. Cutaneous vascular conductance at baseline (CVC(base)) and during the last 5 s of the VM (CVC(VM)) were measured from forearm (nonglabrous) and palm (glabrous) skin. During the VM without ganglionic blockade, compared with CVC(base), CVC(VM) decreased significantly at the palm [0.79 +/- 0.17 to 0.55 +/- 0.17 arbitrary units (AU)/mmHg; P = 0.002] but was unchanged at the forearm (0.13 +/- 0.02 to 0.16 +/- 0.02 AU/mmHg; P = 0.50). After ganglionic blockade, VM induced pronounced decreases in perfusion pressure, which resulted in significant increases in CVC(VM) at both forearm (0.19 +/- 0.03 to 0.31 +/- 0.07 AU/mmHg; P = 0.008) and palm (1.84 +/- 0.29 to 2.76 +/- 0.63 AU/mmHg; P = 0.003) sites. These results suggest that, devoid of autonomic control, both glabrous and nonglabrous skin are capable of exhibiting vasomotor autoregulation during pronounced reductions in perfusion pressure.     

Facilitation of baroreceptor reflex response by endogenous somatostatin in the rat.

We evaluated the potential participation of endogenous brain somatostatin-14 (SOM) in central cardiovascular regulation, using adult male Sprague-Dawley rats anesthetized with pentobarbital sodium (40 mg/kg, i.p.). Intracerebroventricular (i.c.v.) application of SOM (2 or 4 nmol) promoted a significant elevation in baroreceptor reflex (BRR) response, induced by phenylephrine (5 micrograms kg, i.v.). Blocking the endogenous SOM activity with its specific receptor antagonist, cyclo-[7-aminoheptanoyl-Phe-D-Trp-Lys-Thr(Bzl)] (2 or 4 nmol, i.c.v.) or antiserum against SOM (1:20, i.c.v.), on the other hand, appreciably attenuated the same response. These modulatory effects on the BRR response were essentially duplicated upon bilateral microinjections of SOM (320 pmol), SOM antagonist (320 pmol) or anti-SOM (1:20) into the caudal portion of the nucleus of tractus solitarius (NTS), the terminal site for baroreceptor afferents. These results suggest that neurons that contain SOM may participate in cardiovascular control by tonically facilitating the BRR, possibly by exerting an influence on the neurons at the NTS.     

The Role of CaV2.1 Channel Facilitation in Synaptic Facilitation

1. Download high-res image (146KB)
2. Download full-size image

     

Plant Facilitation on a Mine Tailings Dump

Facilitation is a potentially useful tool in restoration efforts. We investigated the causes of facilitation in planted Picea mariana seedlings in an unvegetated mine tailings dump. Clusters of plants doubled the survival rate in the first growing season compared to single plants. In the first year mycorrhizal inoculation had no effect on survival, but by the second growing season only mycorrhizal inoculated plants survived, most of these being in plant clusters. This suggests that facilitation in this environment is partly the result of interactions with mycorrhizae.     

Input-output relation in a flexor reflex

Observations have been made upon a typical flexor reflex with the aim of disclosing the changes in amount, latency, and temporal configuration of reflex discharge that take place as afferent input is varied from zero to maximal for the band of cutaneous myelinated afferent fibers that extends upward from approximately 6 µ in diameter (group II fibers). Reflex threshold is reached at 6 to 12 per cent maximal afferent input. From threshold to maximal input the relation between input and amount of output is essentially linear, latency on the average decreases, the shorter central paths in general gain preference, but the known minimum pathway, one of three neurons, does not transmit unless aided by convergent activity. Flexor reflex discharge may occur in several bursts suggesting the existence of closed chain connections in the internuncial pools of the spinal cord. At any given input there is, in successively elicited reflexes, little correlation between latency and amount of discharge, at first sight a surprising result for each variable can be taken as a measure of excitability status of the motoneuron population. However, latency of discharge indicates excitability at the beginning of the reflex event whereas amount of discharge is an expression of excitability over the entire period of discharge. Given a constantly and rapidly fluctuating excitability absence of correlation between these variables would be an anticipated result.     

Physiological response in the forearm during and after isometric intermittent handgrip

The aim of the present paper was to study the development of fatigue during isometric intermittent handgrip exercise. Using a handgrip dynamometer, four combinations of contraction-relaxation periods were studied (10 + 10, 10 + 5, 10 + 2 s and continuous contraction) at three contraction intensities (10, 25 and 40% maximum voluntary contraction, MVC). Local blood flow (BF) in the forearm (venous occlusion plethysmography) was followed before, during and after the exercise period. Electromyography (EMG) (frequency analysis) and the perceived effort and pain were recorded during the exercise period. Forearm BF is insufficient even at isometric contractions of low intensity (10% MVC). The results indicate that vasodilating metabolites play an active role for BF in low-intensity isometric contractions. It is shown that maximal BF in the forearm during relaxation periods (25-30 ml.min-1.100 ml-1) is already reached at 25% MVC. Only intermittent exercise at 10% MVC and (10 + 5 s) and (10 + 10 s) at 25% MVC was considered acceptable with regard to local fatigue, which was defined as a switch of local BF to the post-exercise period, a decrease in the number of zero-crossings (EMG) and marked increases in subjective ratings.     

Neural control of the forearm cutaneous vasoconstrictor response to dynamic exercise.

This study was designed to evaluate the relative importance of intended effort ("central command") and of the absolute intensity of dynamic exercise to the cutaneous vasoconstrictor response to the onset of exercise in humans. Skin blood flow (laser-Doppler flowmetry) was measured from the forearm in six healthy individuals during 3-min periods of high- and low-intensity exercise with and without partial neuromuscular blockade. Cutaneous vascular conductance (CVC) was calculated from the ratio of skin blood flow to mean arterial pressure and expressed as a percent change from rest. A rating of perceived exertion (RPE) was expressed as a subjective measure of intended effort. Under control conditions, CVC decreased by 22% (median; range 7-42%, P less than 0.05) during high-intensity exercise [218 (186-268) W; RPE 16 (14-19) exertion units]. In contrast, during control low-intensity exercise [106 (88-128) W; RPE 10 (9-14) exertion units], during low-level exercise with curare [77 (54-98) W; RPE 13 (11-16) exertion units], and during maximal exercise with curare [106 (88-124) W; RPE 19 (18-20) exertion units], CVC did not change significantly. These results suggest that factors related to the activity of the exercising muscle and its metabolism rather than intended effort determine the cutaneous vasoconstrictor response to the initiation of intense dynamic exercise in humans.     

The mechanical behavior of the human forearm in response to transient perturbations

Static and dynamic components of mechanical impedance of human forearm were evaluated by applying two kinds of perturbations: 1) large viscoelastic loads, and 2) small pseudo-random perturbations. When the task involved the active resistance of the perturbations, both stiffness and viscosity increased relatively to their values in the passive task, the increment in stiffness being larger than that in viscosity. The time course of such changes was investigated during the transition between the two operating points defined by the instructions do not resist and resist the applied perturbations. The changes in stiffness and viscosity were relatively slow, those in the latter lagging behind those in the former.     

Joint kinetic response during unexpectedly reduced plantar flexor torque provided by a robotic ankle exoskeleton during walking

During human walking, plantar flexor activation in late stance helps to generate a stable and economical gait pattern. Because plantar flexor activation is highly mediated by proprioceptive feedback, the nervous system must modulate reflex pathways to meet the mechanical requirements of gait. The purpose of this study was to quantify ankle joint mechanical output of the plantar flexor stretch reflex response during a novel unexpected gait perturbation. We used a robotic ankle exoskeleton to mechanically amplify the ankle torque output resulting from soleus muscle activation. We recorded lower-body kinematics, ground reaction forces, and electromyography during steady-state walking and during randomly perturbed steps when the exoskeleton assistance was unexpectedly turned off. We also measured soleus Hoffmann- (H-) reflexes at late stance during the two conditions. Subjects reacted to the unexpectedly decreased exoskeleton assistance by greatly increasing soleus muscle activity about 60 ms after ankle angle deviated from the control condition (p<0.001). There were large differences in ankle kinematic and electromyography patterns for the perturbed and control steps, but the total ankle moment was almost identical for the two conditions (p=0.13). The ratio of soleus H-reflex amplitude to background electromyography was not significantly different between the two conditions (p=0.4). This is the first study to show that the nervous system chooses reflex responses during human walking such that invariant ankle joint moment patterns are maintained during perturbations. Our findings are particularly useful for the development of neuromusculoskeletal computer simulations of human walking that need to adjust reflex gains appropriately for biomechanical analyses.     

Biphasic responses of the brachial artery diameter following forearm occlusion: a blunted response in the elderly

Background

The purpose was to examine the temporal response of the brachial artery diameter following 5 minutes of forearm occlusion in young men. A secondary objective was to compare the main features of the temporal pattern between young and old.

Methods

Sixteen young (28 ± 8 yrs) and fifteen older (85 ± 8 yrs) men underwent high-resolution ultrasonography of the brachial artery before and after five minutes of forearm occlusion.

Results

Following release of the pressure cuff the brachial artery diameter exhibits a temporal biphasic response. Initially, there is a significant reduction in brachial diameter (NIL) compared to baseline (BASE), followed by a rapid increase to a PEAK at 41 sec post release. When comparing the magnitude of the decrease in diameter and the Brachial Artery Flow Mediated Dilation (BAFMD) between Young and Old, older subjects demonstrated a blunted response (Magnitude of Decrease: Young: 2.0%; Old: 0.4%, p = 0.015, and BAFMD: Young: 7.7%; Old: 2.3%, p = 0.001). Finally, a significant relationship was noted between the magnitude of decrease and BAFMD (r = -0.44, p = 0.04).

Conclusion

Examination of the temporal response of the brachial artery diameter following 5 minutes of forearm occlusion reveals a biphasic pattern in all participants. Specific features of this pattern are blunted in older adults compared with younger subjects. Finally, the magnitude of the drop in diameter following forearm occlusion correlates with the magnitude of the BAFMD.

     

Facilitation by previous activity in a pacinian corpuscle

A period of supernormal excitability is left by a propagated impulse in a Pacinian corpuscle. The increase in excitability is found 6 to 10 msec. after an impulse occurs in the corpuscle. Supernormality is produced by either mechanically elicited dromic impulses, or by electrically excited antidromic impulses. Generator potentials do not cause supernormality. Local potentials discharged spontaneously by the corpuscle, and which fall on the supernormal trail left by an antidromic impulse, become enhanced in amplitude, an eventually are turned into propagated dromic potentials. The supernormal period is interpreted as caused by a negative after-potential left at the first intracorpuscular node of Ranvier which outlasts both the recovery time of the firing level and that of the generator potential during the corpuscle's relative refractory period.     

Effect of nerve block on response of forearm blood flow to local temperature

To determine the role of neurotransmitter in the response of forearm blood flow (ABF) to local (forearm) skin temperature (Tsk) we measured ABF of six subjects at Tsk from 25 to 40 degrees C before (control) and after brachial plexus block (BPB). Control experiments were conducted in an ambient temperature of 27-29 degrees C, adjusted to minimize the subject's overall thermal sensation. Tsk was regulated by blowing a controlled-temperature airstream through a plastic bag enclosing the arm. We first lowered Tsk to 25 degrees C and after 20 min began to measure ABF with Whitney strain gauges. We then raised Tsk by 2.5 degrees C steps to 40 degrees C and measured ABF every 30 s for at least 10 min at each level of Tsk. Mean ABF rose from 1.1 ml X 100 ml-1 X min-1 at Tsk of 25 degrees C to 2.1 ml X 100 ml-1 X min-1 at 32.5 degrees C to 13.7 ml X 100 ml-1 X min-1 at 40 degrees C in control experiments and from 2.8 to 4.4 to 14.8 ml X 100 ml-1 X min-1 after BPB. The effect of Tsk on ABF was highly significant (P less than 0.0001) but the effect of BPB was not (P approximately equal to 0.2). At thermoneutrality, the effect of Tsk on ABF is largely independent of neural activity, since this effect is unaffected by nerve block.