Fixed Dystonia in Complex Regional Pain Syndrome: a Descriptive and Computational Modeling Approach

Background  

Complex regional pain syndrome (CRPS) may occur after trauma, usually to one limb, and is characterized by pain and disturbed blood flow, temperature regulation and motor control. Approximately 25% of cases develop fixed dystonia. Involvement of dysfunctional GABAergic interneurons has been suggested, however the mechanisms that underpin fixed dystonia are still unknown. We hypothesized that dystonia could be the result of aberrant proprioceptive reflex strengths of position, velocity or force feedback.     

Directional sensitivity of velocity sense in the lumbar spine

Regulating spinal motion requires proprioceptive feedback. While studies have investigated the sensing of static lumbar postures, few have investigated sensing lumbar movement speed. In this study, proprioceptive contributions to lateral trunk motion were examined during paraspinal muscle vibration. Seventeen healthy subjects performed lateral trunk flexion movements while lying prone with pelvis fixed. A 44.5-Hz vibratory stimulus was applied to the paraspinal muscles at the L3 level. Subjects attempted to match target paces of 9.5, 13.5, and 17.5 deg/s with and without paraspinal muscle vibration. Vibration of the paraspinal musculature was found to result in slower overall lateral flexion. This effect was found to have a greater influence in the difference of directional velocities with vibration applied to the left musculature. These changes reflect the sensitivity of lumbar velocity sense to applied vibration leading to the perception of faster muscle lengthening and ultimately resulting in slower movement velocities. This suggests that muscle spindle organs modulate the ability to sense velocity of motion and are important in the control of dynamic motion of the spine.     

Bifurcation and stability analysis in musculoskeletal systems: a study in human stance

Reflexes are important in the control of such daily activities as standing and walking. The goal of this study is to establish how reflexive feedback of muscle length, velocity, and force can lead to stable equilibria (i.e., posture) and limit cycles (e.g., ankle clonus and gait). The influence of stretch reflexes on the behavior and stability of musculoskeletal systems was examined using a model of human stance. We computed branches of fold and Hopf bifurcations by numerical bifurcation analysis of the model. These fold and Hopf branches divide the parameter space, constructed by the reflexive feedback gains, into regions of different behavior: unstable posture, stable posture, and stable limit cycles. These limit cycles correspond to a neural deficiency, termed ankle clonus. We also linked bifurcation analysis to known biomechanical concepts by linearizing the model: the fold branch corresponds to zero ankle stiffness and defines the minimal muscle length feedback necessary for stable posture; the Hopf branch is related to unstable reflex loops. Crossing the Hopf branch can lead to the above-mentioned stable limit cycles. The Hopf branch reduces with increasing time delays, making the subjects posture more susceptible to unstable reflex loops. This might be one of the reasons why elderly people, or those with injuries to the central nervous system, often have trouble with standing and other posture tasks. The influence of cocontraction and force feedback on the behavior of the posture model was also investigated. An increase in cocontraction leads to an increase in ankle stiffness (i.e., intrinsic muscle stiffness) and a decrease in the effective reflex loop gain. On the one hand, positive force feedback increases the ankle stiffness (i.e., intrinsic and reflexive muscle stiffness); on the other hand it makes the posture more susceptible to unstable reflex loops. For negative force feedback, the opposite is true. Finally, we calculated areas of reflex gains for perturbed stance and quiet stance in healthy subjects by fitting the model to data from the literature. The overlap of these areas of reflex gains could indicate that stretch reflexes are the major control mechanisms in both quiet and perturbed stance. In conclusion, this study has successfully combined bifurcation analysis with the more common biomechanical concepts and tools to determine the influence of reflexes on the stability and quality of stance. In the future, we will develop this line of research to look at rhythmic tasks, such as walking.     

Tremor and other oscillations in neuromuscular systems

A model has been analyzed which is based on recent experimental evidence concerning the properties of muscles and the sensory feedback pathways from muscles. Damped oscillations can arise in the absence of sensory feedback due to the interaction of a muscle with inertial loads. These mechanical oscillations can have a wide range of frequencies depending on the inertial and elastic loads that are attached to the muscle. Small amounts of sensory feedback will tend to reduce deviations from a steady muscle length, but larger amounts of feedback can produce oscillations. The frequency of these reflex oscillations is determined by the properties of the muscle and feedback pathway, and is rather independent of load. If the strength of the sensory feedback is sufficient, either the mechanical oscillations or the reflex oscillations or both can grow, rather than decay, with time. The growth of these oscillations is limited by saturation non-linearities in the muscle receptors and the muscle itself, so that the oscillations approach a steady amplitude and frequency. Using typical properties of muscles and spinal reflex pathways, the frequency of reflex oscillations will be within the range 8–12 Hz found for physiological tremor. With the longer latency found for supraspinal reflexes, oscillations will occur in the range 4–6 Hz which is characteristic of Parkinson's and cerebellar diseases. The role of longer latency reflexes in the generation of these tremors is discussed.     

Torso flexion modulates stiffness and reflex response.

Neuromuscular factors that contribute to spinal stability include trunk stiffness from passive and active tissues as well as active feedback from reflex response in the paraspinal muscles. Trunk flexion postures are a recognized risk factor for occupational low-back pain and may influence these stabilizing control factors. Sixteen healthy adult subjects participated in an experiment to record trunk stiffness and paraspinal muscle reflex gain during voluntary isometric trunk extension exertions. The protocol was designed to achieve trunk flexion without concomitant influences of external gravitational moment, i.e., decouple the effects of trunk flexion posture from trunk moment. Systems identification analyses identified reflex gain by quantifying the relation between applied force disturbances and time-dependent EMG response in the lumbar paraspinal muscles. Trunk stiffness was characterized from a second order model describing the dynamic relation between the force disturbances versus the kinematic response of the torso. Trunk stiffness increased significantly with flexion angle and exertion level. This was attributed to passive tissue contributions to stiffness. Reflex gain declined significantly with trunk flexion angle but increased with exertion level. These trends were attributed to correlated changes in baseline EMG recruitment in the lumbar paraspinal muscles. Female subjects demonstrated greater reflex gain than males and the decline in reflex gain with flexion angle was greater in females than in males. Results reveal that torso flexion influences neuromuscular factors that control spinal stability and suggest that posture may contribute to the risk of instability injury.     

Towards a question of formation mechanisms of muscular hand dystonia

Studies on the mechanisms of hand muscle dystonia, as exemplified by writer??s cramp (WC). WC is a specific movement disorder characterized by excessive involuntary muscle contractions leading to abnormal posture during selective motor activity, including skilled repetitive movements. WC pathophysiology remains obscure. Incomplete inhibition at various levels of the sensorimotor system is assumed to be a major mechanism of muscle dystonia. The following approaches are used for studying WC muscle dystonia: genetic and neurophysiologic examinations (transcranial magnetic stimulation, TMS; evoked motor potentials, EMP); and the methods of neuroimaging (functional MRI, positron emission tomography, PET; and three-dimensional kinematic analysis).     

Human gene for torsion dystonia located on chromosome 9q32-q34

Torsion dystonia is a movement disorder of unknown etiology characterized by loss of control of voluntary movements appearing as sustained muscle contractions and/or abnormal postures. Dystonic movements can be caused by lesions in the basal ganglia, drugs, or gene defects. Several hereditary forms have been described, most of which have autosomal dominant transmission with variable expressivity. In the Ashkenazi Jewish population the defective gene frequency is about 1/10,000. Here, linkage analysis using polymorphic DNA and protein markers has been used to locate a gene responsible for susceptibility to dystonia in a large, non-Jewish kinship. Affected members of this family have a clinical syndrome similar to that found in the Jewish population. This dystonia gene (ITD1) shows tight linkage with the gene encoding gelsolin, an actin binding protein, and appears by multipoint linkage analysis to lie in the q32-q34 region of chromosome 9 between ABO and D9S26, a region that also contains the locus for dopamine-beta-hydroxylase.     

Convergence in Reflex Pathways from Multiple Cutaneous Nerves Innervating the Foot Depends upon the Number of Rhythmically Active Limbs during Locomotion

Neural output from the locomotor system for each arm and leg influences the spinal motoneuronal pools directly and indirectly through interneuronal (IN) reflex networks. While well documented in other species, less is known about the functions and features of convergence in common IN reflex system from cutaneous afferents innervating different foot regions during remote arm and leg movement in humans. The purpose of the present study was to use spatial facilitation to examine possible convergence in common reflex pathways during rhythmic locomotor limb movements. Cutaneous reflexes were evoked in ipsilateral tibialis anterior muscle by stimulating (in random order) the sural nerve (SUR), the distal tibial nerve (TIB), and combined simultaneous stimulation of both nerves (TIB&SUR). Reflexes were evoked while participants performed rhythmic stepping and arm swinging movement with both arms and the leg contralateral to stimulation (ARM&LEG), with just arm movement (ARM) and with just contralateral leg movement (LEG). Stimulation intensities were just below threshold for evoking early latency (<80 ms to peak) reflexes. For each stimulus condition, rectified EMG signals were averaged while participants held static contractions in the stationary (stimulated) leg. During ARM&LEG movement, amplitudes of cutaneous reflexes evoked by combined TIB&SUR stimulation were significantly larger than simple mathematical summation of the amplitudes evoked by SUR or TIB alone. Interestingly, this extra facilitation seen during combined nerve stimulation was significantly reduced when performing ARM or LEG compared to ARM&LEG. We conclude that locomotor rhythmic limb movement induces excitation of common IN reflex pathways from cutaneous afferents innervating different foot regions. Importantly, activity in this pathway is most facilitated during ARM&LEG movement. These results suggest that transmission in IN reflex pathways is weighted according to the number of limbs directly engaged in human locomotor activity and underscores the importance of arm swing to support neuronal excitability in leg muscles.     

Spasticity and spastic dystonia: the two faces of velocity-dependent hypertonia

BackgroundSpasticity and spastic dystonia are two separate phenomena of the upper motor neuron syndrome. Spasticity is clinically defined by velocity-dependent hypertonia and tendon jerk hyperreflexia due to the hyper-excitability of the stretch reflex. Spastic dystonia is the inability to relax a muscle leading to a spontaneous tonic contraction. Both spasticity and spastic dystonia are present in patients who are at rest; however, only patients with spasticity are actually able to kept their muscles relaxed prior to muscle stretch. The idea that has inspired the present work is that also in patients with spastic dystonia the stretch reflex is likely to be hyper-excitable. Therefore, velocity-dependent hypertonia could be mediated not only by spasticity, but also by spastic dystonia.MethodsTonic stretch reflexes in the rectus femoris muscle were evoked in 30 patients with multiple sclerosis showing velocity-dependent hypertonia of leg extensors and the habituation of the reflex was studied. Moreover, the capability of relax the muscle prior to muscle stretch (spastic dystonia) was also investigated.ResultsA tonic stretch reflex was evoked in all the enrolled patients. 73% of the patients were able to relax their rectus femoris muscle prior to stretch (spasticity). In the overwhelming majority of these patients, the tonic stretch reflex decreased during repeated stretches. In the remaining 27% of the subjects, the muscle was tonically activated prior to muscle stretch (spastic dystonia). In the patients in whom spastic dystonia progressively increased over the subsequent stretches (50% of the subjects with spastic dystonia), the habituation of the reflex was replaced by a progressive reflex facilitation.DiscussionThis study shows for the first time that velocity-dependent hypertonia can be caused by two distinct phenomena: spasticity and spastic dystonia. The habituation of the tonic stretch reflex, which is a typical feature of spasticity, is replaced by a reflex facilitation in the half of the subject with spastic dystonia. These preliminary findings suggest that differentiating the two types of velocity-dependent muscle hypertonia (spasticity and spastic dystonia) could be clinically relevant.     

Relating reflex gain modulation in posture control to underlying neural network properties using a neuromusculoskeletal model

During posture control, reflexive feedback allows humans to efficiently compensate for unpredictable mechanical disturbances. Although reflexes are involuntary, humans can adapt their reflexive settings to the characteristics of the disturbances. Reflex modulation is commonly studied by determining reflex gains: a set of parameters that quantify the contributions of Ia, Ib and II afferents to mechanical joint behavior. Many mechanisms, like presynaptic inhibition and fusimotor drive, can account for reflex gain modulations. The goal of this study was to investigate the effects of underlying neural and sensory mechanisms on mechanical joint behavior. A neuromusculoskeletal model was built, in which a pair of muscles actuated a limb, while being controlled by a model of 2,298 spiking neurons in six pairs of spinal populations. Identical to experiments, the endpoint of the limb was disturbed with force perturbations. System identification was used to quantify the control behavior with reflex gains. A sensitivity analysis was then performed on the neuromusculoskeletal model, determining the influence of the neural, sensory and synaptic parameters on the joint dynamics. The results showed that the lumped reflex gains positively correlate to their most direct neural substrates: the velocity gain with Ia afferent velocity feedback, the positional gain with muscle stretch over II afferents and the force feedback gain with Ib afferent feedback. However, position feedback and force feedback gains show strong interactions with other neural and sensory properties. These results give important insights in the effects of neural properties on joint dynamics and in the identifiability of reflex gains in experiments.     

Moving muscle points provide accurate curved muscle paths in a model of the cervical spine

Muscle paths in musculoskeletal models have been modeled using several different methods; however, deformation of soft tissue with changes in posture is rarely accounted for, and often only the neutral posture is used to define a muscle path. The objective of this study was to model curved muscle paths in the cervical spine that take into consideration soft tissue deformation with changes in neck posture. Two subject-specific models were created from magnetic resonance images (MRI) in 5 different sagittal plane neck postures. Curved paths of flexor and extensor muscles were modeled using piecewise linear lines-of-action in two ways; (1) using fixed via points determined from muscle paths in the neutral posture and (2) using moving muscle points that moved relative to the bones determined from muscle paths in all 5 postures. Accuracy of each curved modeled muscle path was evaluated by an error metric, the distance from the anatomic (centroid) muscle path determined from the MRI. Error metric was compared among three modeled muscle path types (straight, fixed via and moving muscle point) using a repeated measures one-way ANOVA (α=0.05). Moving muscle point paths had 21% lower error metric than fixed via point paths over all 15 pairs of neck muscles examined over 5 postures (3.86 mm vs. 4.88 mm). This study highlights the importance of defining muscle paths in multiple postures in order to properly define the changing curvature of a muscle path due to soft tissue deformation with posture.     

Enhanced stretch reflex excitability in the soleus muscle during passive standing posture in humans

The purpose of this study was to test whether the spinal reflex excitability of the soleus muscle is modulated as posture changes from a supine to a passive upright position. Eight healthy subjects (29.6 ± 5.4 yrs) participated in this study. Stretch and H-reflex responses were elicited while the subjects maintained passive standing (ST) and supine (SP) postures. The passive standing posture was accomplished by using a gait orthosis to which a custom-made device was mounted to elicit stretch reflex in the soleus muscle. This orthosis makes it possible to elicit stretch and H-reflexes without background muscle activity in the soleus muscle. The results revealed that the H-reflex amplitude in the ST was smaller than that in the SP condition, which is in good agreement with previous reports. On the other hand, the stretch reflex was significantly larger in the ST than in the SP condition. Since the experimental conditions of both the stretch and H-reflex measurements were exactly the same, the results were attributed to differences in the underlying neural mechanisms of the two reflex systems: different sensitivity of the presynaptic inhibition onto the spinal motoneuron pool and/or a change in the muscle spindle sensitivity.     

Spinal and supraspinal effects of activity in ligament afferents.

In this paper available knowledge on effects from joint and ligament afferents on spinal neurones and pathways are briefly reviewed, and possible functional implications discussed. Ligament afferents may contribute to joint stability, muscle coordination and proprioception through direct polysynaptic reflex effects onto ascending pathways and skeletomotoneurones, and/or indirectly via reflex actions on the gamma-muscle spindle system. Theoretical and experimental evidence indicate that ligament afferents, together with afferents from other joint structures, muscles and the skin, provide the CNS with information on movements and posture through ensemble coding mechanisms, rather than via modality specific private pathways. The existence and functional relevance of ligamentomuscular protective reflexes, that are triggered when the ligament is threatened by potentially harmful loads, has been seriously questioned. It seems more likely that peripheral sensory inputs from ligament afferents participate in a continuous control of the muscle activity through feedforward, or preprogramming, mechanisms. In line with these ideas it has been suggested that ligament mechanoreceptors have an important role in muscle coordination and in the reflex regulation of the functional joint stability, by contributing to the preprogramming of the muscle stiffness through reflex modulation of the gamma-muscle spindle system.     

Torsion dystonia genes in two populations confined to a small region on chromosome 9q32-34.

Idiopathic torsion dystonia (ITD) is characterized by sustained, involuntary muscle contractions, frequently causing twisting and repetitive movements or abnormal postures. Most familial forms of ITD display autosomal dominant inheritance with reduced penetrance. Linkage analysis has been previously used to localize a dystonia gene to the 9q32-34 region in a large non-Jewish family and in a group of Ashkenazi Jewish families. Utilizing GT repeat polymorphisms from this region, here we demonstrate that the gene causing dystonia in Ashkenazi Jews can be localized to the 11-cM interval between AK1 and D9S10. Linkage analysis in the non-Jewish family is also consistent with occurrence of the gene in this region, although positive lod scores extend over a greater than 20-cM interval in that family. These results set the stage for positional cloning of the dystonia gene. Currently there are no known candidate genes in this region.     

Responses to agonistic postures by the spider crab Microphrys bicornutus †

Models were presented to 102 specimens of the spider crab Microphrys bicornutus to test the importance of several appendage and body postures, which occur during agonistic interactions. The double first ambulatory raise posture and the cheliped spread posture both elicited a significant number of agonistic responses. Multiple ambulatory raise postures and raised or lowered body postures did not elicit significantly different response spectra. Size and sex of test animals seemed to have little effect on their responses.     

Integration of Sensory Force Feedback Is Disturbed in CRPS-Related Dystonia

Complex regional pain syndrome (CRPS) is characterized by pain and disturbed blood flow, temperature regulation and motor control. Approximately 25% of cases develop fixed dystonia. The origin of this movement disorder is poorly understood, although recent insights suggest involvement of disturbed force feedback. Assessment of sensorimotor integration may provide insight into the pathophysiology of fixed dystonia. Sensory weighting is the process of integrating and weighting sensory feedback channels in the central nervous system to improve the state estimate. It was hypothesized that patients with CRPS-related dystonia bias sensory weighting of force and position toward position due to the unreliability of force feedback. The current study provides experimental evidence for dysfunctional sensory integration in fixed dystonia, showing that CRPS-patients with fixed dystonia weight force and position feedback differently than controls do. The study shows reduced force feedback weights in CRPS-patients with fixed dystonia, making it the first to demonstrate disturbed integration of force feedback in fixed dystonia, an important step towards understanding the pathophysiology of fixed dystonia.     

Velocity Control of a Bounding Quadruped via Energy Control and Vestibular Reflexes

In this paper a bio-inspired approach of velocity control for a quadruped robot running with a bounding gait on compliant legs is set up. The dynamic properties ofa sagittal plane model of the robot are investigated. By analyzing the stable fixed points based on Poincare map, we find that the energy change of the system is the main source for forward velocity adjustment. Based on the analysis of the dynamics model of the robot, a new simple linear running controller is proposed using the energy control idea, which requires minimal task level feedback and only controls both the leg torque and ending impact angle. On the other hand, the functions of mammalian vestibular reflexes are discussed, and a reflex map between forward velocity and the pitch movement is built through statistical regression analysis. Finally, a velocity controller based on energy control and vestibular reflexes is built, which has the same structure as the mammalian nervous mechanism for body posture control. The new con- troller allows the robot to run autonomously without any other auxiliary equipment and exhibits good speed adjustment capa- bility. A series simulations and experiments were set to show the good movement agility, and the feasibility and validity of the robot system.     

Abnormal motor patterns in the framework of the equilibrium-point hypothesis: a cause for dystonic movements?

Until now, the equilibrium-point hypothesis (λ model) of motor control has assumed nonintersecting force-length characteristics of the tonic stretch reflex for individual muscles. Limited data from animal experiments suggest, however, that such intersections may occur. We have assumed the possibility of intersection of the characteristics of the tonic stretch reflex and performed a computer simulation of movement trajectories and electromyographic patterns. The simulation has demonstrated, in particular, that a transient change in the slope of the characteristic of an agonist muscle may lead to temporary movement reversals, hesitations, oscillations, and multiple electromyographic bursts that are typical of movements of patients with dystonia. The movement patterns of three patients with idiopathic dystonia during attempts at fast single-joint movements (in the elbow, wrist, and ankle) were recorded and compared with the results of the computer simulation. This approach considers that motor disorders in dystonia result from faulty control patterns that may not correlate with any morphological or neurophysiological changes. It provides a basis for the high variability of dystonic movements. The uniqueness of abnormal motor patterns in dystonia, that precludes statistical analysis across patients, may result from subtle differences in the patterns of intersecting characteristics of the tonic stretch reflex. The applicability of our analysis to disordered multijoint movement patterns is discussed. Received: 26 July 1993/Accepted in revised form: 22 December 1993     

Meta level concept versus classic reflex concept for the control of posture and movement

Postural reflexes are replaced soon after birth by automatic reactions that allow for volition and cognition. It is still an enigma how this change in postural control is achieved. We suggest that the change involves the formation of a sensory processing level (meta level) that becomes interleaved in between the tight sensor-actuator coupling of the classic reflexes. We assume that the brain applies at this level intersensory interactions to reconstruct the physical stimuli which are causing the physiological stimuli and sensory signals. The thus derived estimates of the physical stimuli are then used as feedback signals in the posture control system. We present this concept on the background of the classic reflex concept and earlier attempts in the literature to overcome it. The earlier attempts were often motivated by the question how the brain prevents voluntary movements from being hampered by reflexive stabilisation of posture (so-called posture-movement problem). We compare our new concept with the classic reflex concept in a theoretical approach, by implementing both concepts into simple postural control models. In simulations of the two models we superimpose external perturbations (the physical stimuli) and a voluntary body lean movement. We show that it is possible to achieve successful stimulus compensation and unperturbed lean movement with both, the model derived from the new concept and the one of the classic reflex concept. With both approaches, the posture-movement problem does not arise. Based on preliminary considerations that include experimental findings from the literature, however, we conclude that the new concept provides more explanatory power than the classic reflex concept.     

Paying the price at the pump: dystonia from mutations in a Na+/K+ -ATPase

Dystonia is a disorder of involuntary sustained muscle contraction, which usually affects a focal region of the body but may be generalized and results in twisting contorted movements or abnormal postures. Several clinical subtypes of dystonia have been delineated and many have a strong inherited basis. In this issue of Neuron, de Carvalho Aguiar and colleagues report the identification of missense mutations in the gene for the Na+/K+ -ATPase alpha3 subunit (ATP1A3) as a cause of rapid-onset dystonia-parkinsonism (RDP, DYT12).