Treatment of vitamin D deficiency increases lower limb muscle strength in institutionalized older people independently of regular physical activity: a randomized double-blind controlled trial

Aims: To investigate the effects of a 6-month supplementation with calcium and cholecalciferol on biochemical parameters and muscle strength of institutionalized elderly. Methods: This prospective, double-blind, placebo-controlled, randomized trial included Brazilian institutionalized people 6 60 years of age receiving a 6-month supplementation ( December to May) of daily calcium plus monthly placebo (calcium/placebo group) or daily calcium plus oral cholecalciferol (150,000 IU once a month during the first 2 months, followed by 90,000 IU once a month for the last 4 months; calcium/vitamin D group). Fasting blood samples for 25-(OH) D, PTH and calcium determination were collected (n = 56) and muscle tests were performed ( n = 46) to measure the strength of hip flexors (SHF) and knee extensors (SKE) before ( baseline) and after the 6-month intervention ( 6 months). Results: Due to seasonal variations, serum 25( OH) D significantly enhanced in both groups after treatment, but the calcium/vitamin D group had significantly higher 25-(OH) D levels than the calcium/placebo group (84 vs. 33%, respectively; p < 0.0001). No cases of hypercalcemia were observed. While the calcium/placebo group showed no improvement in SHF and SKE at 6 months (p = 0.93 and p = 0.61, respectively), SHF was increased in the calcium/vitamin D group by 16.4% (p = 0.0001) and SKE by 24.6% (p = 0.0007). Conclusions: The suggested cholecalciferol supplementation was safe and efficient in enhancing 25(OH)D levels and lower limb muscle strength in the elderly, in the absence of any regular physical exercise practice. Copyright (C) 2009 S. Karger AG, Basel

Upper limb assessment in tetraplegia: clinical, functional and kinematic correlations

The aim of this study was to correlate clinical and functional evaluations with kinematic variables of upper limp reach-to-grasp movement in patients with tetraplegia. Twenty chronic patients were selected to perform reach-to-grasp kinematic assessment using a target placed at a distance equal to the arm`s length. Kinematic variables (hand peak velocity, movement time, percent time-to-maximal velocity, index of curvature, number of peaks, and joint range of motion) were correlated to clinical (Standard Neurological Classification of Spinal Cord Injury-American Spinal Injury Association) and functional [Functional Independence Measure (FIM) and Spinal Cord Independence Measure II (SCIM II)) evaluation scores. Twenty control participants were also selected to obtain normal reference parameters. There was a positive correlation between total motor index and FIM (r=0.6089; P=0.0044) and SCIM II (r=0.5229; P=0.018). Both functional scores showed positive correlation with each other (r=0.8283; P<0.0001). A correlation was also observed between the right and left motor indices, the motor AM, and the SCIM II in most of the reach-to-grasp kinematic variables studied (hand peak velocity, movement time, index of curvature, and number of peaks). In contrast, for the joint range of motion (shoulder, elbow, and wrist), only the wrist in the horizontal plane showed correlation with clinical variables. This study shows that muscle strength assessed by the American Spinal Injury Association motor index influences the reach-to-grasp kinematic variables of patients with tetraplegia. However, the functional assessments did not present the same influence.

A hybrid system for upper limb movement restoration in quadriplegics

Generally, quadriplegic individuals have difficulties performing object manipulation. Toward satisfactory manipulation, reach and grasp movements must be performed with voluntary control, and for that, grasp force feedback is essential. A hybrid system aiming at partial upper limb sensory-motor restoration for quadriplegics was built. Such device is composed of an elbow dynamic orthosis that provides elbow flexion/extension (range was approximately from 20 degrees to 120 degrees, and average angular speed was approximately 15 degrees/s) with forearm support, a wrist static orthosis and neuromuscular electrical stimulation for grasping generation, and a glove with force sensors that allows grasping force feedback. The glove presents two user interface modes: visual by light emitting diodes or audio emitted by buzzer. Voice control of the entire system (elbow dynamic orthosis and electrical stimulator) is performed by the patient. The movements provided by the hybrid system, combined with the scapular and shoulder movements performed by the patient, can aid quadriplegic individuals in tasks that involve reach and grasp movements.

Gait Pattern Adaptation for an Active Lower-Limb Orthosis Based on Neural Networks

This work deals with neural network (NN)-based gait pattern adaptation algorithms for an active lower-limb orthosis. Stable trajectories with different walking speeds are generated during an optimization process considering the zero-moment point (ZMP) criterion and the inverse dynamic of the orthosis-patient model. Additionally, a set of NNs is used to decrease the time-consuming analytical computation of the model and ZMP. The first NN approximates the inverse dynamics including the ZMP computation, while the second NN works in the optimization procedure, giving an adapted desired trajectory according to orthosis-patient interaction. This trajectory adaptation is added directly to the trajectory generator, also reproduced by a set of NNs. With this strategy, it is possible to adapt the trajectory during the walking cycle in an on-line procedure, instead of changing the trajectory parameter after each step. The dynamic model of the actual exoskeleton, with interaction forces included, is used to generate simulation results. Also, an experimental test is performed with an active ankle-foot orthosis, where the dynamic variables of this joint are replaced in the simulator by actual values provided by the device. It is shown that the final adapted trajectory follows the patient intention of increasing the walking speed, so changing the gait pattern. (C) Koninklijke Brill NV, Leiden, 2011

Excitability changes in human forearm corticospinal projections and spinal reflex pathways during rhythmic voluntary movement of the opposite limb

Rhythmic movements brought about by the contraction of muscles on one side of the body give rise to phase-locked changes in the excitability of the homologous motor pathways of the opposite limb. Such crossed facilitation should favour patterns of bimanual coordination in which homologous muscles are engaged simultaneously, and disrupt those in which the muscles are activated in an alternating fashion. In order to examine these issues, we obtained responses to transcranial magnetic stimulation (TMS), to stimulation of the cervicomedullary junction (cervicomedullary-evoked potentials, CMEPs), to peripheral nerve stimulation (H-reflexes and f-waves), and elicited stretch reflexes in the relaxed right flexor carpi radialis (FCR) muscle during rhythmic (2 Hz) flexion and extension movements of the opposite (left) wrist. The potentials evoked by TMS in right FCR were potentiated during the phases of movement in which the left FCR was most strongly engaged. In contrast, CMEPs were unaffected by the movements of the opposite limb. These results suggest that there was systematic variation of the excitability of the motor cortex ipsilateral to the moving limb. H-reflexes and stretch reflexes recorded in right FCR were modulated in phase with the activation of left FCR. As the f-waves did not vary in corresponding fashion, it appears that the phasic modulation of the H-reflex was mediated by presynaptic inhibition of Ia afferents. The observation that both H-reflexes and f-waves were depressed markedly during movements of the opposite indicates that there may also have been postsynaptic inhibition or disfacilitation of the largest motor units. Our findings indicate that the patterned modulation of excitability in motor pathways that occurs during rhythmic movements of the opposite limb is mediated primarily by interhemispheric interactions between cortical motor areas.

Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limb

The temporal parameters of the response of the trunk muscles associated with movement of the lower limb were investigated in people with and without low back pain (LBP). The weight shift component of the task was completed voluntarily prior to a stimulus to move to allow investigation of the movement component of the response. In the control subjects the onset of electromyographic (EMG) activity of all trunk muscles preceded that of the muscle responsible for limb movement, thus contributing to the feed forward postural response. The EMG onset of transversus abdominis was delayed in the LBP subjects with movement in each direction, while the EMG onsets of rectus abdominis, erector spinae, and oblique abdominal muscles were delayed with specific movement directions. This result provides evidence of a change in the postural control of the trunk in people with LBP.

Preparatory trunk motion accompanies rapid upper limb movement

Evaluation of trunk movements, trunk muscle activation, intra-abdominal pressure and displacement of centres of pressure and mass was undertaken to determine whether trunk orientation is a controlled variable prior to and during rapid bilateral movement of the upper limbs. Standing subjects performed rapid bilateral symmetrical upper limb movements in three directions (flexion, abduction and extension). The results indicated a small (0.4-3.3 degrees) but consistent initial angular displacement between the segments of the trunk in a direction opposite to that produced by the reactive moments resulting from limb movement. Phasic activation of superficial trunk muscles was consistent with this pattern of preparatory motion and with the direction of motion of the centre of mass. In contrast, activation of the deep abdominal muscles was independent of the direction of limb motion, suggesting a non-direction specific contribution to spinal stability. The results support the opinion that feedforward postural responses result in trunk movements, and that orientation of the trunk and centre of mass are both controlled variables in relation to rapid limb movements.

Assessment of limb muscle and adipose tissue by dual-energy X-ray absorptiometry using magnetic resonance imaging for comparison

OBJECTIVE: To use magnetic resonance imaging (MRI) to validate estimates of muscle and adipose tissue (AT) in lower limb sections obtained by dual-energy X-ray absorptiometry (DXA) modelling. DESIGN: MRI measurements were used as reference for validating limb muscle and AT estimates obtained by DXA models that assume fat-free soft tissue (FFST) comprised mainly muscle: model A accounted for bone hydration only; model B also applied constants for FFST in bone and skin and fat in muscle and AT; model C was as model B but allowing for variable fat in muscle and AT. SUBJECTS: Healthy men (n = 8) and women (n = 8), ages 41 - 62 y; mean (s.d.) body mass indices (BMIs) of 28.6 (5.4) kg/m(2) and 25.1 (5.4) kg/m2, respectively. MEASUREMENTS: MRI scans of the legs and whole body DXA scans were analysed for muscle and AT content of thigh (20 cm) and lower leg (10 cm) sections; 24 h creatinine excretion was measured. RESULTS: Model A overestimated thigh muscle volume (MRI mean, 2.3 l) substantially (bias 0.36 l), whereas model B underestimated it by only 2% (bias 0.045 l). Lower leg muscle (MRI mean, 0.6 l) was better predicted using model A (bias 0.04 l, 7% overestimate) than model B (bias 0.1 l, 17% underestimate). The 95% limits of agreement were high for these models (thigh,+/- 20%; lower leg,+/- 47%). Model C predictions were more discrepant than those of model B. There was generally less agreement between MRI and all DXA models for AT. Measurement variability was generally less for DXA measurements of FFST (coefficient of variation 0.7 - 1.8%) and fat (0.8 - 3.3%) than model B estimates of muscle (0.5-2.6%) and AT (3.3 - 6.8%), respectively. Despite strong relationships between them, muscle mass was overestimated by creatinine excretion with highly variable predictability. CONCLUSION: This study has shown the value of DXA models for assessment of muscle and AT in leg sections, but suggests the need to re-evaluate some of the assumptions upon which they are based.

Can tissue drug concentrations be monitored by microdialysis during or after isolated limb perfusion for melanoma treatment?

Isolated limb perfusion (ILP) with melphalan is used to treat recurrent melanoma. This study aimed to develop a microdialysis technique for melphalan tissue concentration measurement during ILP. The effects of melphalan concentration (50-600 mu g/ml), microdialysis flow rate (0.55-17.5 mu l/min), probe length (5-50 mm) and temperature (25-41.5 degrees C) on in vitro recovery were studied. In addition, in vivo recovery was measured in rat hindlimbs perfused with melphalan using 50 mm microdialysis probes implanted subcutaneously and into muscle. Both dialysate and tissue sample melphalan concentrations were determined by high performance liquid chromatography. The in vitro recovery of melphalan was not affected by melphalan concentration or temperature, but increased with probe length and decreased with flow rate. The melphalan concentrations in subcutaneous and muscle dialysates were not significantly different. A linear relationship was found between tissue dialysate concentrations and actual tissue concentrations of melphalan (r(2) = 0.97). Microdialysis is a potential method for tissue drug monitoring which may assist in the efficacious use of cytotoxics in human ILP. (C) 2000 Lippincott Williams & Wilkins.

Three dimensional preparatory trunk motion precedes asymmetrical upper limb movement

Three-dimensional trunk motion. trunk muscle electromyography and intra-abdominal pressure were evaluated to investigate the preparatory control of the trunk associated with voluntary unilateral upper limb movement. The directions of angular motion produced by moments reactive to limb movement in each direction were predicted using a three-dimensional model of the body. Preparatory motion of the trunk occurred in three dimensions in the directions opposite to the reactive moments. Electromyographic recordings from the superficial trunk muscles were consistent with preparatory trunk motion. However, activation of transversus abdominis was inconsistent with control of direction-specific moments acting on the trunk. The results provide evidence that anticipatory postural adjustments result in movements and not simple rigidification of the trunk. (C) 2000 Elsevier Science B.V. All rights reserved.

Perturbed upper limb movements cause short-latency postural responses in trunk muscles

Addition of a load to a moving upper limb produces a perturbation of the trunk due to transmission of mechanical forces. This experiment investigated the postural response of the trunk muscles in relation to unexpected limb loading. Subjects performed rapid, bilateral shoulder flexion in response to a stimulus. In one third of trials, an unexpected load was added bilaterally to the upper limbs in the first third of the movement. Trunk muscle electromyography, intra-abdominal pressure and upper limb and trunk motion were measured. A short-latency response of the erector spinae and transversus abdominis muscles occurred similar to 50 ms after the onset of the limb perturbation that resulted from addition of the load early in the movement and was coincident with the onset of the observed perturbation at the trunk. The results provide evidence of initiation of a complex postural response of the trunk muscles that is consistent with mediation by afferent input from a site distant to the lumbar spine, which may include afferents of the upper limb.

Contraction of the pelvic floor muscles during abdominal maneuvers

Objective: To determine whether voluntary abdominal muscle contraction is associated with pelvic floor muscle activity. Design: Pelvic floor muscle activity was recorded during contractions of the abdominal muscles at 3 different intensities in supine and standing positions. Setting: Research laboratory. Participants: Six women and 1 man with no histories of lower back pain. Interventions: Not applicable. Main Outcome Measures: Electromyographic activity of the pelvic floor muscles was recorded with surface electrodes inserted into the anus and vagina. These recordings were corroborated by measurements of anal and vaginal pressures. Gastric pressure was recorded in 2 subjects. Results: Pelvic floor muscle electromyography increased with contraction of the abdominal muscles. With strong abdominal contraction, pelvic floor muscle activity did not differ from that recorded during a maximal pelvic floor muscle effort. The pressure recordings confirmed these data. The increase in pressure recorded in the anus and vagina preceded the pressure in the abdomen. Conclusions: In healthy subjects, voluntary activity in the abdominal muscles results in increased pelvic floor muscle activity. The increase in pelvic floor pressure before the increase in the abdomen pressure indicates that this response is preprogrammed. Dysfunction of the pelvic floor muscles can result in urinary and fecal incontinence. Abdominal muscle training to rehabilitate those muscles may be useful in treating these conditions.

Trichomonas vaginalis is associated with pelvic inflammatory disease in women infected with human immunodeficiency virus

We assessed the association between the causative agents of vaginal discharge and pelvic inflammatory disease (PID) among women attending a rural sexually transmitted disease clinic in South Africa; the role played by coinfection with human immunodeficiency virus type 1 (HIV-1) was studied. Vaginal and cervical specimens were obtained to detect Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and bacterial vaginosis. HIV-1 infection was established by use of serum antibody tests. A total of 696 women with vaginal discharge were recruited, 119 of whom had clinical PID. Patients with trichomoniasis had a significantly higher risk of PID than did women without trichomoniasis (P = .03). PID was not associated with any of the other pathogens. When the patients were stratified according to HIV-1 status, the risk of PID in HIV-1-infected patients with T. vaginalis increased significantly (P = .002); no association was found in patients without HIV-1. T. vaginalis infection of the lower genital tract is associated with a clinical diagnosis of PID in HIV-1-infected women.

Assessment of image quality of a standard and two dose-reducing protocols in paediatric pelvic CT

Background: Concerns exist regarding the effect of radiation dose from paediatric pelvic CT scans and the potential later risk of radiation-induced neoplasm and teratogenic outcomes in these patients. Objective: To assess the diagnostic quality of CT images of the paediatric pelvis using either reduced mAs or increased pitch compared with standard settings. Materials and methods: A prospective study of pelvic CT scans of 105 paediatric patients was performed using one of three protocols: (1) 31 at a standard protocol of 200 mA with rotation time of 0.75 s at 120 kVp and a pitch factor approximating 1.4; (2) 31 at increased pitch factor approaching 2 and 200 mA; and (3) 43 at a reduced setting of 100 mA and a pitch factor of 1.4. All other settings remained the same in all three groups. Image quality was assessed by radiologists blinded to the protocol used in each scan. Results: No significant difference was found between the quality of images acquired at standard settings and those acquired at half the standard mAs. The use of increased pitch factor resulted in a higher proportion of poor images. Conclusions: Images acquired at 120 kVp using 75 mAs are equivalent in diagnostic quality to those acquired at 150 mAs. Reduced settings can provide useful imaging of the paediatric pelvis and should be considered as a standard protocol in these situations.