Tendon Tap Research Articles

Low levels of anterior tibial loading enhance knee extensor reflex response characteristics

We examined whether neuromuscular reflexes were altered with anterior loads applied to the tibio-femoral joint. A ligament testing device was modified by attaching a reflex hammer to a steel mounted frame to illicit a patellar tendon tap, while anterior directed loads displaced the tibia on the femur. Five trials were acquired while anterior-directed loads (20, 50, 100 N; counterbalanced) were applied to the posterior tibia between 20 N pre (20 N Pre) and post (20 N Post) baseline conditions on two different days. Surface electromyography (sEMG) recorded mean quadriceps ( Q) and hamstring ( H) reflex time ( R Time = ms) and reflex amplitude ( R Amp = %MVIC). A load cell on the anterior tibia measured the timing (KE Time = ms) and amplitude (KE Amp = N) of the knee extension force, and was used to calculate electromechanical delay (EMD = ms) and peak knee extension moment (KE Mom = N m/kg). Data from 19 recreationally active subjects revealed good to excellent response consistency between test days and between baseline conditions for R Time, R Amp, KE Time and KE Amp. With anterior tibial loading, R Time was faster at 50 N vs. 20 N Post, and R Amp was greater at 20 N Pre vs. 20 N Post ( Q and H) and at 50 N vs. 100 N ( Q only). KE Mom was greater at 20 N Pre and 50 N vs. 20 N Post, and EMD was shorter at 50 N vs. 20 N, 20 N Pre and 20 N Post. These results suggest that knee extensor reflex responses are enhanced with low (50 N) but not moderate (100 N) anterior loading of the knee.

Proprioceptive control of human wrist extensor motor units during an attention-demanding task

The responsiveness of the tonically firing single motor units (SMU) to Ia afferent volleys elicited by either mechanical (T-reflex) or electrical nerve stimulation (H-reflex) was tested in the extensor carpi radialis muscle (ECR) while the subjects were maintaining a steady wrist extension force using visual feedback set either at low or high gain. The aim was to determine whether the proprioceptive control of tonic motoneuronal activity depends on the level of attentiveness required by the behavioural context. The response probability of the SMUs to tendon taps was significantly higher ( p<0.0001) and that to electrical nerve stimulation was lower ( p<0.001) during the more demanding task. Since these changes in SMU responsiveness were not accompanied by any differences in either the motor unit firing patterns or the mean levels of EMG muscle activity, it can be concluded that there were no attention-related changes in the net excitatory drive to the ECR motoneurons. These results are consistent with the idea that fusimotor sensitization of the muscle spindle may have occurred in the more demanding task: an increase in the mechanical sensitivity of the muscle spindles would certainly account for both the T-reflex facilitation and the H-reflex depression observed. The attention-demanding task therefore seemed to involve an independent fusimotor drive activation process. The results of this study suggest that an adaptation of the fusimotor system occurs in humans, depending on the levels of attention and accuracy required to perform the ongoing motor task, as previously reported to occur in animals.

Neuromuscular Efficiency of the Triceps Surae in Induced and Voluntary Contractions: Morning and Evening Evaluations

Variations in force and electromyographic (EMG) activities of skeletal muscles with the time-of-day have been previously described, but not for a postural muscle, submitted to daily postural and locomotor tasks. In this article, mechanical performances, EMGs, and the ratio between these parameters, i.e., the neuromuscular efficiency (NME), were measured on the triceps surae (TS) of eight subjects, two times each day, at 6:00 and 18:00 h. NME was evaluated under different experimental conditions (electrically induced contractions, reflex contractions, maximal and submaximal voluntary isometric contractions, and during a natural movement, a drop jump) to determine whether mechanisms, peripheral or central in origin, were responsible for the eventual changes in NME with time-of-day. To calculate NME in induced conditions (NMEind), a supramaximal electrical stimulus was applied to the tibial nerve, and the maximal M wave of TS (TS Mmax) and the amplitude of the twitch tension (PtMmax) in response to this electrical stimulation were quantified. TS Mmax was significantly lower in the evening (mean gain value −10.7 ± 5.5%, p < 0.05), whereas PtMmax was not significantly modified. NMEind (PtMmax/TS Mmax) was significantly higher in the evening (mean gain of 17.6 ± 5.8%, p < 0.05), and this increase was necessarily peripheral in origin. Secondly, maximal tendon taps were applied to the Achilles tendon in order to quantify at the two times-of-day the reflexes in response to a mechanical stimulus. The maximal reflex, TS Tmax/Mmax (%), the peak amplitude of the twitch tension associated to this tendon jerk (PtTmax), and the corresponding NME (NMEreflex = PtTmax/TS Tmax/Mmax) were not affected by time-of-day, indicating that reflex excitability did not present daytime variations when tested under these conditions. Voluntary isometric contractions were required under maximal (MVC) and submaximal (25% MVC) conditions, and the corresponding torques and TS EMG were measured. MVC was higher in the evening (mean gain: 8.6 ± 2.7%, p < 0.05) and TS EMGmax (normalized with regard to TS Mmax) also increased in the evening but not significantly; thus, NMEMVC was not modified. At 25% of MVC, TS EMG was significantly higher in the evening (mean gain of 23 ± 13.9%, p < 0.05) and a trend for a lower NME25%MVC in the evening was observed, a result probably representative of a higher muscle fatigue state in the evening. Finally, to test the muscle capacities during a natural task, a NME index was calculated during a drop jump (DJ). The NMEDJ was defined as the ratio between jump height and mean amplitude of TS EMG (% of TS Mmax) between the drop and the jump. Both jump height and NMEDJ were significantly higher in the evening (mean gains of 10.9 ± 4.5% and 15.7 ± 7.4%, respectively, p < 0.05). In conclusion, daytime changes in the efficiency of postural muscles seem to depend on both peripheral and central mechanisms. According to the experimental conditions, NME of the postural muscle could increase, remain constant, or even decrease in the evening, and this result may reflect reverse effects of better contractile capacities and higher fatigue state.

Continuous wavelet transform in the evaluation of stretch reflex responses from surface EMG

Objective: This is the first reported use of the continuous wavelet transform (CWT) of the surface EMG (sEMG) to extract the reflex response to muscle stretch. We used a modulus-based method to estimate instantaneous amplitude-envelopes from ridges of the CWT (referred in this work as sEMG intensity) to extract the dynamic reflex response from sEMG. We tested the method on tendon reflexes where excellent temporal resolution is required to identify the different latency components, and on the tonic stretch reflex (tonic SR) response to an ongoing perturbation that characteristically has a low signal to noise ratio. Methods: Eight subjects without neurological impairment were subjected to a series of archilles tendon taps and a 2 min continuous perturbation of the ankle using a pseudo-sinusoidal stretch profile containing frequencies from 0.1 to 8.0 Hz. The tendon reflexes were assessed in the soleus muscle at 10% of MVC and the tonic SR in tibialis anterior while the muscle was relaxed, at 5 and 10% of maximal voluntary contraction. Root mean square (RMS) and wavelet ridge extraction was applied to the sEMG signal to extract sEMG amplitudes (RMS) and intensities for all reflexes. To obtain the tonic SR, these estimates and those from the sEMG-RMS were subsequently cross-correlated with the perturbation record to yield 2 sets of estimates of reflex gain and coherence for comparison. Results: The sEMG intensities were highly correlated with the torques resulting from a ramped voluntary contraction. Following tendon taps, the method resolved the M1, M2, M3 response components at accurate latencies and with more complete reconstruction of the components than RMS-derived estimates. The wavelet ridge estimates extracted the tonic SR from resting and contracting muscles with significantly higher coherence than RMS estimates. Reflex gain, when estimated from sEMG intensity or sEMG-RMS, demonstrated similar relationships to the perturbation frequency and background contraction level. When the sEMG intensity reflex gain estimates from different subjects were pooled, they showed significantly lower variance about the mean than gain estimates derived from the rectified sEMG. Conclusions: Wavelet-ridge extraction provides a valid approach to reflex evaluation from sEMG that does not depend on the absolute amplitude of the potentials measured at the EMG electrodes. This may have substantial advantages in more directly comparing responses between subjects on an absolute frequency scale without the need for normalisation against maximal contraction levels.

Hypercapnic impairment of neuromuscular function is related to afferent depression.

Acetazolamide (ACZ), a carbonic anhydrase inhibitor, results in altered neuromuscular function secondary to depressed afferent transmission in intact humans. One effect of ACZ is hypercapnia. Thus, to test if the neuromuscular depression observed following ACZ treatment is related to elevated CO(2), human subjects ( n=10) were exposed to 15 min of room air (0% CO(2)) or hypercapnia (7% inspired CO(2)), and neuromuscular function was evaluated. Isometric force (36.8 to 31.1 N) and peak-to-peak electromyographic amplitude (EMG, 1.5 to 1.0 mV) associated with an Achilles tendon tap, and soleus H(max):M(max) ratio (69.0 to 62.2%) were depressed, while EMG latency (34.8 to 39.8 ms) was increased by hypercapnia. Reflex recovery profiles (following a conditioning tap to the contralateral Achilles tendon), motor nerve conduction velocity, amplitude of the maximum M-wave, and peak twitch tension at M(max) were unaltered by hypercapnia. We conclude that elevated CO(2) impairs neuromuscular function through effects on afferent transmission or synaptic integrity between type Ia fibers of the muscle spindle and the alpha motor neuron, without affecting the muscle spindle, efferent conduction or skeletal muscle force-generating capacity.

The history of contraction of the wrist flexors can change cortical excitability.

Voluntary contractions induce thixotropic changes in intrafusal muscle fibres and hence, by induction or removal of "slack", the background discharge and sensitivity of spindle endings to stretch is altered. This study assessed whether such changes also altered the "excitability" of the motor cortex. Eleven subjects performed a series of voluntary conditioning contractions of the wrist flexors designed to remove slack in the intrafusal fibres (contract and test at intermediate length, termed "contract-test") or to introduce slack (contract at long length and test at intermediate length, termed "contract-long"). Surface electromyographic recordings were made from one wrist flexor, flexor carpi radialis. Subjects relaxed after each contraction, and 10 s later a test stimulus was applied to elicit a tendon tap response, H-reflex, or motor-evoked potential (MEP) to transcranial magnetic stimulation in the flexor carpi radialis. Each of the three test stimuli was applied during 15 consecutive pairs of contractions ("contract-long" and "contract-test"). Three subjects repeated the protocol using transmastoid electrical stimulation as the test stimulus to evoke a cervicomedullary motor-evoked potential (CMEP). For the group of subjects, after conditioning contractions designed to induce slack there was a significant reduction in the amplitude of the tendon reflex, no significant change in the H-reflex, and a small but significant reduction in the amplitude of the MEP. In one subject the CMEP was significantly reduced, while it was unchanged in two others. In the absence of corresponding changes in the H-reflex (or CMEP), changes in the size of the response to motor cortical stimulation suggest that the level of motor cortical "excitability" changes according to naturally induced variations in the discharge of muscle spindle afferents.

Deep Tendon Reflexes: A Study Of Quantitative Methods

Objective: The deep tendon reflex (DTR) is routinely used by clinicians to evaluate the nervous system. Depressed and hyperactive DTRs suggest peripheral and central nervous system compromise, respectively. Limitations of DTRs are: qualitative nature of the assessments based upon subjective grading, and limited inter-rater reliability. This preliminary study was undertaken to quantify the tendon tap used by clinicians to elicit DTRs and the reflex response elicited.Methods: Tendon taps were applied to a force transducer in hypo-, normo-, and hyperreflexic ranges by 2 clinicians, using 3 different tendon hammers (Babinski, Queen Square, and Taylor). Patellar DTRs, measured as joint angle excursion with an electrogoniometer, were compared in hyper- and normoreflexic individuals.Results: Median peak tap force was 12.8, 38.0, and 85.2 Newtons (Nt), respectively, for eliciting hyper-, normo-, and hyporeflexic DTRs. Peak tap force was similar in the hyper- and normoreflexic ranges for all 3 hammers; in the hyporeflexic range, peak tap forces with the Taylor hammer were lower. A good distinguishing feature between hyper- and normoreflexic patellar DTRs was briskness, measured as the quotient of knee excursion divided by peak tendon tap force. Knee excursion is a non-linear patellar DTR response, when measured sitting.Conclusions: Peak tap forces used by clinicians fall into 3 ranges: 0–20 Nt for hyperreflexia, 21–50 Nt for normoreflexia, and >50 Nt for hyporeflexia. The Taylor hammer, with small mass and short handle, has a ceiling effect in the hyporeflexic range. We propose a systematic method for DTR testing.

The differential effects of fatigue on reflex response timing and amplitude in males and females

We examined the effects of fatigue on patellar tendon reflex responses in males and females. A spring-loaded reflex hammer elicited a standardized tendon tap with the knee positioned in an isokinetic dynamometer and flexed to 85°. We recorded vastus lateralis activity (SEMG) and knee extension force production at the distal tibia (force transducer). Reflex trials were performed before and after (immediate, 2, 4, and 6 min) an isokinetic fatigue protocol to 50% MVC (90°/s). For each event, pre-motor time (PMT), electromechanical delay (EMD), and total motor time (TMT) were obtained, as well as EMG amplitude (EMG amp), time to peak EMG (EMG tpk), peak force amplitude (F amp), time to peak force (F tpk), EMG:force ratio (E:F), and rate of force production (F rate=N/ms). TMT increased significantly in females following fatigue, while males showed no change. The increased TMT was due to an increased EMD with fatigue, while PMT was unaffected. EMG amp and F amp were somewhat diminished in females yet significantly augmented in males following fatigue, likely accounting for the differential changes in EMD noted. Results suggest males and females may respond differently to isokinetic fatigue, with males having a greater capacity to compensate for contraction force failure when responding to mechanical perturbations.

Warm-up Activities and Their Influences on Neuromuscular and Functional Indices

Introduction: Researchers show that a high intensity warm-up prior to an explosive event, can improve one's performance [Gullich and Schmidtbleicher, 1996]. Post activation potentiation (PAP) is cited as the reason for these increases in performance. It is thought that PAP causes an increase in Ca++ sensitivity within the actomyosin complex [Sweeney, Bowman, and Stull, 1993]. However, it is not known whether it is the warm-up phase occurring before or the intense activity phase of the entire pre-event protocol that causes the neuromuscular changes often cited as post activation potentiation. So, the purpose of this study was to examine neuromuscular and functional outcomes of post activation stimulation caused by distinct phases of voluntary muscular activation. Methods: This study employed two separate oneway repeated measures designs. The sessions were single leg leg extension (LE) and tendon tap reflex (TTR); characterized by performing the activity using a resistance equal to 40% 1repetition maximum (1RM) and the muscle activity recorded within the rectus femoris caused by 6 N force rapidly applied to the patellar tendon respectively. Dependent measures were average rectus femoris EMG (AEMG) during the LE session and AEMG and peak isometric force (PIF) produced during the 120-ms post stimulus period within the TTR session. Data from nine subjects (174.66 ± 10.54 cm; 76.22 ± 13.22 kg; 21.67 ± 1.58 yrs) was collected using Noraxon telemetered EMG hardware and a tensile calibrated load cell integrated by DataPac 2000 software. The EMG signal, from both sessions, was processed (passive demeaning and RMS smoothed (20-msec)). The processed AEMG and the raw PIF were then normalized to their baseline values. The warm-up phase during each session consisted of a series of submaximal high bar parallel back squats: 1 × 5 at 50% of 1RM, 1 × 5 at 65% of 1RM, 1 × 3 at 75% of 1RM, 1 × 1 at 90% of 1RM with a three minute rest interval between sets and a five minute rest interval separating the warm-up phase from the data collection. At the conclusion of the 5-minute rest interval, the subjects began the intense activity phase, which consisted of 5 × 1 at 90% 1-RM with three minutes rest in between sets and a five-minute rest interval at the conclusion of the squat activity. Data collection resumed at the conclusion of this rest interval. Results: Significance was found during the warm-up phase and the intense phase on AEMG compared to baseline during the TTR (P ≤ 0.10). No significant effect was found on the AEMG during the LE session for any phase. PIF was significantly different for the intense phase (P ≤ 0.10). Discussion: PAP can alter segmental reflexive activity via neuromuscular changes and increasing force production. Neuromuscular changes can occur within any type of warm-up activity. Our study confirms that PAP can occur in untrained as well as recreationally trained individuals. Other studies have confirmed that PAP can occur in elite athletes as well [Gullich and Schmidtbleicher, 1996]. Future studies may want to investigate if and how PAP can alter motor unit recruitment patterns.

Delayed and prolonged effects of a near threshold EPSP on the firing time of human alpha-motoneurones.

In order to investigate the effects of near-threshold excitatory inputs on the precise timing of the action potentials during the tonic discharge of human motoneurones, the activity of single motor units was recorded in the extensor carpi radialis muscles while tendon taps (indentation, 0.1 mm; duration, 1 ms) were being delivered irregularly at a mean rate of 0.8 s(-1). New methods of analysis, such as the phase response function, were used to study the relative changes in the interspike interval (ISI1) during which the stimulus was being delivered and in the three subsequent intervals (ISI2, ISI3, ISI4) as a percentage of the pre-stimulus interspike interval (ISI0). The consistency of the effects of the actual stimulus as regards the spontaneous variability was assessed by comparing the data with those obtained with virtual stimulation. When the stimulus occurred at the end of ISI1, and triggered a spike, ISI1 and ISI3 were generally shortened, whereas ISI2 was lengthened, probably due to the negative correlation induced by the summation of the after-hyperpolarisations (AHPs). When the stimulus occurred in the middle of ISI1 without triggering a spike, ISI1, ISI2 and more rarely ISI3 were shortened. Lastly, when the stimulus occurred during the AHP scoop in ISI1, ISI2 was shortened although ISI1 remained unchanged. ISI4 was not consistently affected in any of these cases. The present results show that the tendon tap-induced inputs (probably from muscle spindle primary endings) mediated delayed and prolonged shortening effects of the ISIs on most of the alpha-motoneurones tested (n = 16). These effects undetected in classic peri-stimulus histogram analysis may involve long-lasting conductance changes although the contribution of polysynaptic pathways cannot be excluded. The changes in ISI were quite moderate (< 15% of ISI) but highly consistent. Their functional involvement in the synchronisation or desynchronisation processes and/or the mechanisms of optimisation of muscle contraction still remains to be explored.

HEMISPHERIC MODULATORY INFLUENCE ON SKIN RESISTANCE RESPONSE LATENCY: UNILATERAL STIMULATION, BILATERAL RECORDING

In order to evaluate the bilateral asymmetries in evoked electrodermal activity (EDA) and the use of EDA parameters as indices of relative hemispheric activation, skin resistance level (SRL), skin resistance response (SRR), and the SRR latency (L) were examined in 25 right-handed male subjects. We used bilateral recording with a unilateral stimulation (auditory click/patellar tendon tap) to assess the asymmetries of EDA variables related to the side of stimulation and to handedness. Although no significant asymmetry in C = SRRmax/SRL ratio was found, significant differences in latency were observed. Ipsilateral responses were 100 ms faster than contralateral responses for auditory stimulus, a result that can be explained in terms of contralateral delay of neuronal communication on EDA-l pathway. Response latency to reflex-motor activation was 60-100 ms shorter in the dominant hand, regardless of the stimulation site used. This result indicates that the reaction time of the EDA-2 pathway of the left hemisphere was shorter than the right for right-handed subjects. It is concluded that there is hemispheric asymmetry on EDA-2 pathway and that this asymmetry appears to be dependent on the preferred dexterity. These results have implications for the influence of both central and peripheral factors on EDA laterality and principally on laterality of response amplitude. Further, there is no single cortical mechanism modulating the asymmetries in the latency of this response.

The influence of increased muscle spindle sensitivity on Achilles tendon jerk and H-reflex in relaxed human subjects

Whether the fusimotor system contributes to reflex gain changes during reinforcement maneuvers is re-examined in the light of new data. Recently, from direct recordings of spindle afferent activity originating from ankle flexor muscles, we showed that mental computation increased the muscle spindle mechanical sensitivity in completely relaxed human subjects without concomitant f -motoneuron activation, providing evidence for selective fusimotor drive activation. In the present study, the effects of mental computation were investigated on monosynaptic reflexes elicited in non-contracting soleus muscle either by direct nerve stimulation (Hoffmann reflex, H) or by tendon tap (Tendinous reflex, T). The aim was to relate the time course of the changes in reflex size to the increase in spindle sensitivity during mental task in order to explore whether fusimotor activation can influence the size of the monosynaptic reflex. The results show changes in reflex amplitude that parallel the increase in muscle spindle sensitivity. When T-reflex is consistently facilitated during mental effort, the H-reflex is either depressed or facilitated, depending on the subjects. These findings suggest that the increased activity in muscle spindle primary endings may account for mental computation-induced changes in both tendon jerk and H-reflex. The facilitation of T-reflex is attributed to the enhanced spindle mechanical sensitivity and the inhibition of H-reflex is attributed to post-activation depression following the increased Ia ongoing discharge. This study supports the view that the fusimotor sensitization of muscle spindles is responsible for changes in both the mechanically and electrically elicited reflexes. It is concluded that the fusimotor drive contributed to adjustment of the size of tendon jerk and H-reflex during mental effort. The possibility that a mental computation task may also operate by reducing the level of presynaptic inhibition is discussed on the basis of H-reflex facilitation.

Comparison of spinal myotatic reflexes in human adults investigated with cross-correlation and signal averaging methods

A cross-correlation method for recording spinal myotatic reflexes has been developed to meet the need for brief test periods in babies and children and subjects with central neurological pathology. In normal adult subjects the method has been validated by comparing excitatory and inhibitory reflexes obtained with cross-correlation with those obtained with conventional signal averaging. In the cross-correlation method a pseudo-random binary sequence of 64 brief tendon taps was delivered in <1.5 s, and in the averaging method 20–150 taps at one per second. The reflexes were expressed as unit impulse responses to enable direct, quantitative comparisons to be made. With cross-correlation the responses were slightly expanded in time, had lower peak amplitudes, and onset latencies advanced by 10 ms, the clock period of the pseudo-random binary sequence. The amplitude of biceps phasic stretch reflex increased with muscle contraction in a similar manner with both methods. In tests for stationarity the amplitude of biceps phasic stretch reflex varied <10% in the first six repeats of the pseudo-random binary sequence. The tap force required at threshold for cross-correlation was approximately half that for averaging, but with both methods the magnitude of biceps phasic stretch reflex varied linearly with tap force over the range of one to two times threshold. The validity of responses obtained with cross-correlation was assessed by a statistical procedure. In conclusion, the cross-correlation method is robust and gives similar results to those obtained with averaging.

Basic principles and therapy of spasticity

An acute central nervous system lesion is followed by a phase of "shock" with flaccid muscle tone. After some weeks the syndrome of spastic paresis develops which is characterized by increased muscle tone and exaggerated tendon tap reflexes. During the last years it could be shown that the characteristic spastic movement disorder is mainly due to secondary changes of muscle properties which require a specific treatment. Exaggerated reflexes do only little contribute to the movement disorder.

The effect of baclofen on the transmission in spinal pathways in spastic multiple sclerosis patients

Objectives: To measure the effect of baclofen on the transmission in different spinal pathways to soleus motoneurones in spastic multiple sclerosis patients.Methods: Baclofen was administered orally in 14 and intrathecally in 8 patients. Hmax/Mmax, presynaptic inhibition by biceps femoris tendon tap of femoral nerve stimulation, depression of the soleus H-reflex following previous activation of the Ia afferents from the soleus muscle (i.e. postactivation depression), disynaptic reciprocal Ia inhibition of the soleus H-reflex and the number of backpropagating action potentials in primary afferents, which may be a sign of presynaptic inhibition, were examined.Results: Baclofen depressed the soleus Hmax/Mmax ratio significantly following oral and intrathecal baclofen. None of the two tests of presynaptic inhibition, or the postactivation depression or the disynaptic reciprocal Ia inhibition of the soleus H-reflex were affected by baclofen administration. Also the action potentials of the primary afferents were unchanged during baclofen administration.Conclusions: The antispastic effect of baclofen is not caused by an effect on the transmitter release from Ia afferents or on disynaptic reciprocal Ia inhibition. One possible explanation of the depression of the H-reflex by baclofen is suggested to be a direct depression of motoneuronal excitability.

Spastic movement disorder.

This review deals with the neuronal mechanisms underlying spastic movement disorder, assessed by electrophysiological means with the aim of first, a better understanding of the underlying pathophysiology and second, the selection of an adequate treatment. For the patient usually one of the first symptoms of a lesion within the central motor system represents the movement disorder, which is most characteristic during locomotion in patients with spasticity. The clinical examination reveals exaggerated tendon tap reflexes and increased muscle tone typical of the spastic movement disorder. However, today we know that there exists only a weak relationship between the physical signs obtained during the clinical examination in a passive motor condition and the impaired neuronal mechanisms being in operation during an active movement. By the recording and analysis of electrophysiological and biomechanical parameters during a functional movement such as locomotion, the significance of, for example, impaired reflex behaviour or pathophysiology of muscle tone and its contribution to the movement disorder can reliably be assessed. Consequently, an adequate treatment should not be restricted to the cosmetic therapy and correction of an isolated clinical parameter but should be based on the pathophysiology and significance of the mechanisms underlying the disorder of functional movement which impairs the patient.

Hyperactive tendon reflexes in spastic multiple sclerosis: Measures and mechanisms of action

Zhang L-Q, Wang G, Nishida T, Xu D, Sliwa JA, Rymer WZ. Hyperactive tendon reflexes in spastic multiple sclerosis: measures and mechanisms of action. Arch Phys Med Rehabil 2000;81:901-9. Objective: To develop new measures of tendon reflexes and evaluate hyperactive reflexes in patients with spastic multiple sclerosis (MS). Design: With the subject relaxed, a hand-held instrumented hammer was used to tap the patellar tendon and record the tapping force, while knee extension torque and quadriceps EMG were recorded isometrically as measures of the reflex response. Setting: Research laboratory in a rehabilitation hospital. Subjects: Ten spastic MS and 14 healthy subjects. Main Outcome Measures: Tendon tapping force (designated as system input), reflex torque (as output), their dynamic relationship (characterized as system parameters tendon reflex gain, contraction rate, and reflex loop delay), Ashworth scale, and tendon reflex scale. Results: The system parameters provide more repeatable measures than do input or output parameters alone because they quantify the input and output simultaneously and dynamically. Compared with control subjects, MS patients had a significantly lower threshold in tapping force (p =.026), yet their evoked reflex torque was significantly higher (p =.033). Despite significant quadriceps weakness (p ≤.0001), MS patients had a significantly higher reflex gain (p =.0002) and contraction rate (p =.0002), and shorter reflex loop delay (p =.0046), indicating hyperexcitability of motoneurons and peripheral receptors, and indicating that relatively more of the muscle was activated reflexively, with greater recruitment of larger fast-twitch fibers. Both the reflex gain and rate measures correlated more closely with the Ashworth scale and tendon reflex scale than did the output measures, indicating their potential clinical value. Conclusions: With appropriate simplification, the method may be used in clinical practice to quantify more precisely the tendon jerk than is currently feasible with standard clinical tests. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Ia presynaptic inhibition after muscle twitch in the arm.

Contraction of upper limb muscles in healthy subjects was used to investigate presynaptic inhibition at spinal level. The H reflex recorded in the forearm flexor muscles in response to median nerve stimulation was depressed in amplitude from 400 ms to 1 s after a muscle twitch induced by transcranial stimulation, root stimulation, direct biceps stimulation, and triceps tendon tap. Stimulation of the cutaneous branch of musculocutaneous nerve, ipsilateral triceps and contralateral biceps, and biceps tendon tap did not alter H-reflex size. Forearm flexor H-reflex amplitude is therefore related to changes in proprioceptive inflow secondary to the biceps muscle twitch. Root and direct muscle stimulation both failed to reduce the size of the motor evoked potential (MEP) after transcranial magnetic stimulation, suggesting that the inhibition acts at presynaptic level. Attenuation of H-reflex amplitude was related to the size of the muscle twitch and was less pronounced during an isometric twitch than during free joint movement. Our results suggest that the biceps muscle twitch produces long-lasting inhibition of the Ia afferents from forearm flexor muscles. This is an important and a simple mechanism for suppressing proprioceptive input during movement.

From spinal shock to spasticity

To investigate the adaptational changes in excitability of spinal neuronal circuits below the level of lesion from spinal shock to spasticity in patients with spinal cord injury (SCI). More than 6 months after an acute SCI, clinical follow-up examinations were paralleled by electrophysiologic recordings with tibial nerve stimulation (M-wave, F-wave, H-reflex, and flexor reflex). During spinal shock, the loss of tendon tap reflexes and flaccid muscle tone were associated with low persistence of F-waves and loss of flexor reflexes, whereas H-reflexes were already elicitable. During the transition to spasticity, the reappearance of tendon tap reflexes and muscle tone and the occurrence of spasms was associated with the recovery of F-waves and flexor reflex excitability, whereas the H-to-M ratio remained about stable over months. At later stages (2 to 6 months after SCI) when clinical signs of spasticity became established, the electrophysiologic measures showed little change. In paraplegic patients, in contrast to tetraplegic patients, M-wave and flexor reflex amplitudes even decreased. The late decrease in M-wave and flexor reflex amplitude in paraplegic patients suggests a secondary impairment/degeneration of premotoneuronal circuits and of motoneurons. The divergent course of clinical signs of spasticity and their probable neuronal correlates indicates the occurrence of non-neuronal changes contributing to spasticity.

Hyper-reflexia without spasticity after unilateral infarct of the medullary pyramid

Whether or not a lesion confined to the pyramidal tract produces spasticity in humans remains an unresolved controversy. We have studied a patient with an ischemic lesion of the right medullary pyramid, using objective measures of hyper-reflexia, spasticity, and weakness. Electromyographic activity (EMG) of the biceps muscles was recorded under the following conditions: (1) in response to a tendon tap with an instrumental reflex hammer, (2) in response to imposed quick stretch with motion analysis, and (3) during an isometric holding task. Hyper-reflexia of the involved arm in response to tendon tap was shown to be due primarily to an increase in the gain of the reflex arc. No velocity-dependent increase in the response to quick stretch of the involved arm was present. This was consistent with the absence of detectable spasticity on the clinical exam. These findings suggest that a lesion confined to the medullary pyramid can give rise to weakness and hyper-reflexia without causing spasticity. Moreover, these findings suggest that different anatomical substrates may underlie the clinical phenomena of hyper-reflexia and spasticity.