Aberrant protective force generation during neural provocation testing and the effect of treatment in patients with neurogenic cervicobrachial pain

Background: Observation of the occurrence of protective muscle activity is advocated in assessment of the peripheral nervous system by means of neural provocation tests. However, no studies have yet demonstrated abnormal force generation in a patient population. Objectives: To analyze whether aberrations in shoulder girdle-elevation force during neural tissue provocation testing for the median nerve (NTPTI) can be demonstrated, and whether possible aberrations can be normalized following cervical mobilization. Study Design: A single-blind randomized comparative controlled study. Setting: Laboratory setting annex in a manual therapy teaching practice. Participants: Twenty patients with unilateral or bilateral neurogenic cervicobrachial pain. Methods: During the NTPTI, we used a load cell and electrogoniometer to record continuously the shoulder-girdle elevation force in relation to the available range of elbow extension. Following randomization, we analyzed the immediate treatment effects of a cervical contralateral lateral glide mobilization technique (experimental group) and therapeutic ultrasound (control group). Results: On the involved side, the shoulder-girdle elevation force occur-red earlier, and the amount of force at the end of the test was substantially, though not significantly, greater than that on the uninvolved side at the corresponding range of motion. Together with a significant reduction in pain perception after cervical mobilization, a clear tendency toward normalization of the force curve could be observed, namely, a significant decrease in force generation and a delayed onset. The control group demonstrated no differences. Conclusions: Aberrations in force generation during neural, provocation testing are present in patients with neurogenic pain and can be normalized with appropriate treatment modalities.

A pain neuromatrix approach to patients with chronic pain

This paper presents an approach to rehabilitation of pain patients. The fundamental principles of the approach are (i) pain is an output of the brain that is produced whenever the brain concludes that body tissue is in danger and action is required, and (ii) pain is a multisystem output that is produced when an individual-specific cortical pain neuromatrix is activated. When pain becomes chronic, the efficacy of the pain neuromatrix is strengthened via nociceptive and non-nociceptive mechanisms, which means that less input, both nociceptive and non-nociceptive, is required to produce pain. The clinical approach focuses on decreasing all inputs that imply that body tissue is in danger and then on activating components of the pain neuromatrix without activating its output. Rehabilitation progresses to increase exposure to threatening input across sensory and non-sensory domains. (C) 2003 Elsevier Ltd. All rights reserved.

Rehabilitation of pelvic floor muscles utilizing trunk stabilization

The pelvic floor muscles (PFM) are part of the trunk stability mechanism. Their function is interdependent with other muscles of this system. They also contribute to continence, elimination, sexual arousal and intra-abdominal pressure. This paper outlines some aspects of function and dysfunction of the PFM complex and describes the contribution of other trunk muscles to these processes. Muscle pathophysiology of stress urinary incontinence (SUI) is described in detail. The innovative rehabilitation programme for SUI presented here utilizes abdominal muscle action to initiate tonic PFM activity. Abdominal muscle activity is then used in PFM strengthening, motor relearning for functional expiratory actions and finally impact training. (C) 2003 Elsevier Ltd. All rights reserved.

The Effect of Wrist Rests and Forearm Support during Keyboard and Mouse Use

Supporting the forearm on the work surface during keyboard operation may increase comfort, decrease muscular load of the neck and shoulders, and decrease the time spent in ulnar deviation. Wrist rests are used widely in the workplace and are more commonly being incorporated in keyboard design. The aim of this study was to examine the effect of wrist rest use on wrist posture during forearm Support. A laboratory based, experimental study was conducted (subjects n = 15) to examine muscle activity and wrist Postures during keyboard and mouse tasks in each of' two conditions; wrist rest and no wrist rest. There were no significant differences for right wrist flexion/extension between use of a wrist rest and no wrist rest for keyboard or mouse use. Left wrist extension was significantly higher without a wrist rest than with a wrist rest during keyboard use (df = 14; t = 2.95; p = 0.01; d = 0.38). No differences with respect to use of a wrist rest were found for the left or right hand for ulnar deviation For keyboard or mouse use. There were no differences in muscle activity between the test conditions for keyboard use. Relevance to industry Wrist rests are used widely in the workplace and are more commonly being incorporated in keyboard design. Use of a wrist rest in conjunction with forearm support when using a conventional desk does not appear to have any impact on wrist posture or muscle activity during keyboard use. (C) 2004 Elsevier B.V. All rights reserved.

Intra-abdominal pressure response to multidirectional support-surface translation

A complex response of the trunk muscles occurs to restore equilibrium in response to movement of the support surface. Intra-abdominal pressure (IAP) is considered to contribute to control of the trunk. This study investigated the contribution of IAP to the postural response to multidirection support-surface translation. IAP was recorded with a thin-film pressure transducer inserted via the nose into the stomach and trunk motion was recorded with an optoelectronic system with markers over the spinous process of L1. A pattern of trunk movement was recorded in response to the support-surface translations that was consistent with a 'hip' strategy of postural control. The trunk moved in a manner appropriate to move the centre of gravity over the new base of support. IAP was increased with movement in each direction, but varied in timing and amplitude between translation directions. In general, the IAP was greater with translations in the sagittal plane compared to the frontal plane and was initiated earlier for translations in the backward direction. These data indicate that IAP contributes to the postural response associated with support-surface translation and suggest that this is consistent with stiffening the spine. (C) 2003 Elsevier B.V. All rights reserved.

Novel strategies in feedforward adaptation to a position-dependent perturbation

To investigate the control mechanisms used in adapting to position-dependent forces, subjects performed 150 horizontal reaching movements over 25 cm in the presence of a position-dependent parabolic force field (PF). The PF acted only over the first 10 cm of the movement. On every fifth trial, a virtual mechanical guide (double wall) constrained subjects to move along a straight-line path between the start and target positions. Its purpose was to register lateral force to track formation of an internal model of the force field, and to look for evidence of possible alternative adaptive strategies. The force field produced a force to the right, which initially caused subjects to deviate in that direction. They reacted by producing deviations to the left, into the force field, as early as the second trial. Further adaptation resulted in rapid exponential reduction of kinematic error in the latter portion of the movement, where the greatest perturbation to the handpath was initially observed, whereas there was little modification of the handpath in the region where the PF was active. Significant force directed to counteract the PF was measured on the first guided trial, and was modified during the first half of the learning set. The total force impulse in the region of the PF increased throughout the learning trials, but it always remained less than that produced by the PF. The force profile did not resemble a mirror image of the PF in that it tended to be more trapezoidal than parabolic in shape. As in previous studies of force-field adaptation, we found that changes in muscle activation involved a general increase in the activity of all muscles, which increased arm stiffness, and selectively-greater increases in the activation of muscles which counteracted the PF. With training, activation was exponentially reduced, albeit more slowly than kinematic error. Progressive changes in kinematics and EMG occurred predominantly in the region of the workspace beyond the force field. We suggest that constraints on muscle mechanics limit the ability of the central nervous system to employ an inverse dynamics model to nullify impulse-like forces by generating mirror-image forces. Consequently, subjects adopted a strategy of slightly overcompensating for the first half of the force field, then allowing the force field to push them in the opposite direction. Muscle activity patterns in the region beyond the boundary of the force field were subsequently adjusted because of the relatively-slow response of the second-order mechanics of muscle impedance to the force impulse.

Intra-abdominal pressure increases stiffness of the lumbar spine

Intra-abdominal pressure (IAP) increases during many tasks and has been argued to increase stability and stiffness of the spine. Although several studies have shown a relationship between the IAP increase and spinal stability, it has been impossible to determine whether this augmentation of mechanical support for the spine is due to the increase in IAP or the abdominal muscle activity which contributes to it. The present study determined whether spinal stiffness increased when IAP increased without concurrent activity of the abdominal and back extensor muscles. A sustained increase in IAP was evoked by tetanic stimulation of the phrenic nerves either. unilaterally or bilaterally at 20 Hz (for 5 s) via percutaneous electrodes in three subjects. Spinal stiffness was measured as the force required to displace an indentor over the L4 or L2 spinous process with the subjects lying prone. Stiffness was measured as the slope of the regression line fitted to the linear region of the force-displacement curve. Tetanic stimulation of the diaphragm increased IAP by 27-61% of a maximal voluntary pressure increase and increased the stiffness of the spine by 8-31% of resting levels. The increase in spinal stiffness was positively correlated with the size of the IAP increase. IAP increased stiffness at L2 and L4 level. The results of this:study provide evidence that the stiffness of the lumbar spine is increased when IAP is elevated. (C) 2004 Elsevier Ltd. All rights reserved.

Ventilatory changes following head-up tilt and standing in healthy subjects

Passive tilting increases ventilation in healthy subjects; however, controversy surrounds the proposed mechanism. This study is aimed to evaluate the possible mechanism for changes to ventilation following passive head-up tilt (HUT) and active standing by comparison of a range of ventilatory, metabolic and mechanical parameters. Ventilatory parameters (V (T), V (E), V (E)/VO2, V (E)/VCO2, f and PetCO(2)), functional residual capacity (FRC), respiratory mechanics with impulse oscillometry; oxygen consumption (VO2) and carbon dioxide production (VCO2) were measured in 20 healthy male subjects whilst supine, following HUT to 70 degrees and unsupported standing. Data were analysed using a linear mixed model. HUT to 70 degrees from supine increased minute ventilation (V (E)) (P < 0.001), tidal volume (V (T)) (P=0.001), ventilatory equivalent for O-2 (V (E)/VO2) (P=0.020) and the ventilatory equivalent for CO2 (V (E)/VCO2) (P < 0.001) with no change in f (P=0.488). HUT also increased FRC (P < 0.001) and respiratory system reactance (X5Hz) (P < 0.001) with reduced respiratory system resistance (R5Hz) (P=0.004) and end-tidal carbon dioxide (PetCO(2)) (P < 0.001) compared to supine. Standing increased V (E) (P < 0.001), V (T) (P < 0.001) and V (E)/VCO2 (P=0.020) with no change in respiratory rate (f) (P=0.065), V (E)/VO2 (P=0.543). Similar changes in FRC (P < 0.001), R5Hz (P=0.013), X5Hz (P < 0.001) and PetCO(2) (P < 0.001) compared to HUT were found. In contrast to HUT, standing increased VO2 (P=0.002) and VCO2 (P=0.048). The greater increase in V (E) in standing compared to HUT appears to be related to increased VO2 and VCO2 associated with increased muscle activity in the unsupported standing position. This has implications for exercise prescription and rehabilitation of critically ill patients who have reduced cardiovascular and respiratory reserve.

Deceleration affects anticipatory and reactive components of triggered postural responses

Understanding the physiological and psychological factors that contribute to healthy and pathological balance control in man has been made difficult by the confounding effects of the perturbations used to test balance reactions. The present study examined how postural responses were influenced by the acceleration-deceleration interval of an unexpected horizontal translation. Twelve adult males maintained balance during unexpected forward and backward surface translations with two different acceleration-deceleration intervals and presentation orders (serial or random). SHORT perturbations consisted of an initial acceleration (peak acceleration 1.3 m s(-2); duration 300 ms) followed 100 ms later by a deceleration. LONG perturbations had the same acceleration as SHORT perturbations, followed by a 2-s interval of constant velocity before deceleration. Surface and intra-muscular electromyography (EMG) from the leg, trunk, and shoulder muscles were recorded along with motion and force plate data. LONG perturbations induced larger trunk displacements compared to SHORT perturbations when presented randomly and larger EMG responses in proximal and distal muscles during later (500-800 ms) response intervals. During SHORT perturbations, activity in some antagonist muscles was found to be associated with deceleration and not the initial acceleration of the support surface. When predictable, SHORT perturbations facilitated the use of anticipatory mechanisms to attenuate early (100-400 ms) EMG response amplitudes, ankle torque change and trunk displacement. In contrast, LONG perturbations, without an early deceleration effect, did not facilitate anticipatory changes when presented in a predictable order. Therefore, perturbations with a short acceleration-deceleration interval can influence triggered postural responses through reactive effects and, when predictable with repeated exposure, through anticipatory mechanisms.

Are the changes in postural control associated with low back pain caused by pain interference?

Background: Voluntary limb movements are associated with involuntary and automatic postural adjustments of the trunk muscles. These postural adjustments occur prior to movement and prevent unwanted perturbation of the trunk. In low back pain, postural adjustments of the trunk muscles are altered such that the deep trunk muscles are consistently delayed and the superficial trunk muscles are sometimes augmented. This alteration of postural adjustments may reflect disruption of normal postural control imparted by reduced central nervous system resources available during pain, so-called pain interference, or reflect adoption of an alternate postural adjustment strategy. Methods: We aimed to clarify this by recording electromyographic activity of the upper (obliquus extemus) and lower (transversus abdominis/obliquus internus) abdominal muscles during voluntary arm movements that were coupled with painful cutaneous stimulation at the low back. If the effect of pain on postural adjustments is caused by pain interference, it should be greatest at the onset of the stimulus, should habituate with repeated exposure, and be absent immediately when the threat of pain is removed. Sixteen patients performed 30 forward movements of the right arm in response to a visual cue (control). Seventy trials were then conducted in which arm movement was coupled with pain (pain trials) and then a further 70 trials were conducted without the pain stimulus (no pain trials). Results: There was a gradual and increasing delay of transversus abdominis/obliquus internus electromyograph and augmentation of obliquus externus during the pain trials, both of which gradually returned to control values during the no pain trials. Conclusion: The results suggest that altered postural adjustments of the trunk muscles during pain are not caused by pain interference but are likely to reflect development and adoption of an alternate postural adjustment strategy, which may serve to limit the amplitude and velocity of trunk excursion caused by arm movement.

Further evaluation of an EMG technique for assessment of the deep cervical flexor muscles

A novel surface electromyographic (EMG) technique was recently described for the detection of deep cervical flexor muscle activity. Further investigation of this technique is warranted to ensure EMG activity from neighbouring muscles is not markedly influencing the signals recorded. This study compared deep cervical flexor (DCF) muscle activity with the activity of surrounding neck and jaw muscles during various anatomical movements of the neck and jaw in 10 volunteer subjects. DCF EMG activity was recorded with custom electrodes inserted via the nose and fixed by suction to the posterior mucosa of the oropharynx. Surface electrodes were placed over the sternocleidomastoid, anterior scalene, masseter and suprahyoid muscles. Positioned in supine, subjects performed isometric cranio-cervical flexion, cervical flexion, right and left cervical rotation,jaw clench and resisted jaw opening. Across all movements examined, EMG amplitude of the DCF muscles was greatest during neck movements that would require activity of the DCF muscles, particularly during cranio-cervical flexion, their primary anatomical action. The actions of jaw clench and resisted jaw opening demonstrated significantly less DCF EMG activity than the cranio-cervical flexion action (p < 0.05). Across all other movements, the neighbouring neck and jaw muscles demonstrated greatest EMG amplitude during their respective primary anatomical actions, which occurred in the absence of increased EMG amplitude recorded from the DCF muscles. The finding of substantial EMG activity of the DCF muscles only during neck actions that would require their activity, particularly cranio-cervical flexion, and not during actions involving the jaw, provide further assurance that the majority of myoelectric signals detected from the nasopharyngeal electrode are from the DCF muscles. (C) 2005 Elsevier Ltd. All rights reserved.

Towards evidence-based guidelines for wise use of computers by children

This paper argues for the systematic development and presentation of evidence-based guidelines for appropriate use of computers by children. The currently available guidelines are characterised and a proposed conceptual model presented. Five principles are presented as a foundation to the guidelines. The paper concludes with a framework for the guidelines, key evidence for and against guidelines, and gaps in the available evidence, with the aim of facilitating further discussion. Relevance to industry The current generation of children in affluent countries will typically have over 10 years of computer experience before they enter the workforce. Consequently, the primary prevention of computer-related health disorders and the development of good productivity skills for the next generation of workers needs to occur during childhood. (c) 2006 Elsevier B.V. All rights reserved.

The neurotoxic effects of enzyme inhibitors at the neuromuscular junction

Current knowledge of the long-term, low dose effects of carbamate (CB) anti-cholinesterases on skeletal muscle or on the metabolism and regulation of the molecular forms of acetylcholinesterase (AChE) is limited. This is largely due to the reversible nature of these inhibitors and the subtle effects they induce which has generally made their study difficult and preliminary investigations were conducted to determine suitable study methods. A sequential extraction technique was used to rapidly analyse AChE molecular form activity at the mouse neuromuscular junction and also in peripheral parts of muscle fibres. AChE in the synaptic cleft involved in the termination of cholinergic transmission was successfully assessed by the assay method and by an alternative method using a correlation equation which represented the relationship between synaptic AChE and the prolongation of extra-cellular miniature endplate potentials. It was found that inhibition after in vivo Carbamate (CB) dosing could not be maintained during tissue analysis because CB-inhibited enzyme complexes decarbamoylated vary rapidly and could not be prevented even when maintained on ice. The methods employed did not therefore give a measure of inhibition but presented a profile of metabolic responses to continual, low dose CB treatment. Repetitive and continual infusion with low doses of the CBs: pyridostigmine and physostigmine induced a variety of effects on mouse skeletal muscle. Both compounds induced a mild myopathy in the mouse diaphragm during continual infusion which was characterised by endplate deformation without necrosis; such deformation persisted on termination of treatment but had recovered slightly 14 days later. Endplate and non-endplate AChE molecular forms displayed selective responses to CB treatment. During treatment endplate AChE was reduced whereas non-endplate AChE was largely unaffected, and after treatment, endplate AChE recovered, whereas non-endplate AChE was up-regulated. The mechanisms by which these responses become manifest are unclear but may be due to CB-induced effects on nerve-mediated muscle activity, neurotrophic factors or morphological and physiological changes which arise at the neuromuscular junction. It was concluded that, as well as inhibiting AChE, CBs also influence the metabolism and regulation of the enzyme and induce persistent endplate deformation; possible detrimental effects of long-term, low-dose determination requires further investigation.

Injectable hydrogels with high fixed charge density and swelling pressure for nucleus pulposus repair:biomimetic glycosaminoglycan analogues

The load-bearing biomechanical role of the intervertebral disc is governed by the composition and organization of its major macromolecular components, collagen and aggrecan. The major function of aggrecan is to maintain tissue hydration, and hence disc height, under the high loads imposed by muscle activity and body weight. Key to this role is the high negative fixed charge of its glycosaminoglycan side chains, which impart a high osmotic pressure to the tissue, thus regulating and maintaining tissue hydration and hence disc height under load. In degenerate discs, aggrecan degrades and is lost from the disc, particularly centrally from the nucleus pulposus. This loss of fixed charge results in reduced hydration and loss of disc height; such changes are closely associated with low back pain. The present authors developed biomimetic glycosaminoglycan analogues based on sulphonate-containing polymers. These biomimetics are deliverable via injection into the disc where they polymerize in situ, forming a non-degradable, nuclear "implant" aimed at restoring disc height to degenerate discs, thereby relieving back pain. In vitro, these glycosaminoglycan analogues possess appropriate fixed charge density, hydration and osmotic responsiveness, thereby displaying the capacity to restore disc height and function. Preliminary biomechanical tests using a degenerate explant model showed that the implant adapts to the space into which it is injected and restores stiffness. These hydrogels mimic the role taken by glycosaminoglycans in vivo and, unlike other hydrogels, provide an intrinsic swelling pressure, which can maintain disc hydration and height under the high and variable compressive loads encountered in vivo. © 2013 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.

Relevance of motion artifact in electromyography recordings during vibration treatment

Electromyography readings (EMGs) from quadriceps of fifteen subjects were recorded during whole body vibration treatment at different frequencies (10-50 Hz). Additional electrodes were placed on the patella to monitor the occurrence of motion artifact, triaxial accelerometers were placed onto quadriceps to monitor motion. Signal spectra revealed sharp peaks corresponding to vibration frequency and its harmonics, in accordance with the accelerometer data. EMG total power was compared to that associated with vibration harmonics narrow bands, before and during vibration. On average, vibration associated power resulted in only 3% (±0.9%) of the total power prior to vibration and 29% (±13.4%) during vibration. Often, studies employ surface EMG to quantitatively evaluate vibration evoked muscular activity and to set stimulation frequency. However, previous research has not accounted for motion artifacts. The data presented in this study emphasize the need for the removal of motion artifacts, as they consistently affect RMS estimation, which is often used as a concise muscle activity index during vibrations. Such artifacts, rather unpredictable in amplitude, might be the cause of large inter-study differences and must be eliminated before analysis. Motion artifact filtering will contribute to thorough and precise interpretation of neuromuscular response to vibration treatment. © 2008 Elsevier Ltd. All rights reserved.