Feedforward activity of the cervical flexor muscles during voluntary arm movements is delayed in chronic neck pain

The objective of this study was to compare onset of deep and superficial cervical flexor muscle activity during rapid, unilateral arm movements between ten patients with chronic neck pain and 12 control subjects. Deep cervical flexor (DCF) electromyographic activity (EMG) 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 (SCM) and anterior scalene (AS) muscles. While standing, subjects flexed and extended the right arm in response to a visual stimulus. For the control group, activation of DCF, SCM and AS muscles occurred less than 50 ms after the onset of deltoid activity, which is consistent with feedforward control of the neck during arm flexion and extension. When subjects with a history of neck pain flexed the arm, the onsets of DCF and contralateral SCM and AS muscles were significantly delayed (p<0.05). It is concluded that the delay in neck muscle activity associated with movement of the arm in patients with neck pain indicates a significant deficit in the automatic feedforward control of the cervical spine. As the deep cervical muscles are fundamentally important for support of the cervical lordosis and the cervical joints, change in the feedforward response may leave the cervical spine vulnerable to reactive forces from arm movement.     

Experimental muscle pain changes motor control strategies in dynamic contractions

This study investigated the effect of muscle pain on muscle activation strategies during dynamic exercises. Ten healthy volunteers performed cyclic elbow flexion/extension movements at maximum speed for 2 min after injection of (1) hypertonic (painful) saline in the biceps brachii, (2) hypertonic saline in both biceps brachii and triceps brachii, and (3) isotonic (nonpainful) saline in the biceps brachii muscle. Surface electromyographic (EMG) signals were collected from the upper trapezius, biceps brachii, triceps brachii, and brachioradialis muscles (to estimate EMG amplitude) and with an electrode arrays from biceps brachii (to estimate muscle fiber conduction velocity [CV]). In all conditions, the acceleration of the movement decreased throughout the exercise, and kinematic parameters were not altered by pain. With respect to the control condition, pain induced a decrease of the biceps brachii (mean ± SE, –23±4%) and brachioradialis (–10±0.4%) integrated EMG (IEMG) in the beginning of the exercise, and an increase (45±3.5%) of the upper trapezius IEMG at all time points during the exercise. The biceps brachii IEMG decreased over time during the nonpainful exercises (–11±0.6%) while it remained constant in the painful condition. Biceps brachii CV decreased during painful conditions (–12.8±2.2%) while it remained constant during the nonpainful condition. In conclusion, muscle pain changes the motor control strategy to sustain the required dynamic task both in the relative contribution between synergistic muscles and in the motor unit activation within the painful muscle. Such a changed motor strategy may be highly relevant in models of occupational musculoskeletal pain conditions.     

Larger center of pressure minus center of gravity in the elderly induces larger body acceleration during quiet standing

When an inverted pendulum approximates quiet standing, it is assumed that the distance between the center of pressure and the vertical projection of the center of mass on the ground (COP–COG) reflects the relationship between the controlling and controlled variables of the balance control mechanism, and that the center of mass acceleration (ACC) is proportional to COP–COG. As aging affects the control mechanism of balance during quiet standing, COP–COG must be influenced by aging and, as a result, ACC is influenced by aging as well. The purpose of this study was to test the hypotheses that aging results in an increased COP–COG amplitude and, as a consequence, that ACC becomes larger in the elderly than the young. Fifteen elderly and 11 young subjects stood quietly on a force platform with their eyes open or closed. We found that (1) the standard deviations of COP–COG and ACC were larger in the elderly than in the young, irrespective of the eye condition; (2) COP–COG is proportional to ACC in both age groups, i.e., the inverted pendulum assumption holds true for quiet standing. The results suggest that a change in the control strategy that is due to aging causes a larger COP–COG in the elderly and, as a consequence, that ACC becomes larger as well.     

Experimental jaw-muscle pain does not change heteronymous H-reflexes in the human temporalis muscle

Muscle pain generally has an inhibitory effect on voluntary orofacial motor function. However, it is not known whether muscle pain causes direct or indirect changes in motoneuron excitability. In this study a monopolar needle stimulation technique was used to evoke the direct motor response (M-response) in the left masseter muscle and the heteronymous H-reflex in the left temporalis muscle as an indirect measure of motoneuron excitability. Series of 20 repeated electrical stimuli were delivered at 50% of maximal voluntary contraction (MVC) before, during, and after periods with experimental jaw-muscle pain in 11 healthy subjects. Pain was induced by standardized infusion of hypertonic (5%) saline into the mid-portion of the right masseter muscle. The mean pain intensity rating on a 100-mm visual analog scale was 42±5 mm. The short-latency responses (less than 6 ms) could be evoked in all subjects. Analysis of the latency and amplitude of the temporal H-reflex indicated no significant effect of jaw-muscle pain. The amplitude of the masseteric M-response was significantly smaller in the postpain condition than in the pain conditions (ANOVA, P=0.018), but no differences were found between the prepain and postpain conditions. In nine subjects, poststimulus periods (mean offset latency, 69.6±8.6 ms) with significantly (more than 50%) suppressed EMG activity were detected in the ipsilateral masseter muscle following the M-response (mean offset latency, 5.5±0.2 ms). These reflex responses did not show a systematic change during the pain conditions. In conclusion, acute contralateral jaw-muscle pain does not seem to modulate the motoneuron excitability as measured by the heteronymous H-reflex. Received: 7 November 1997 / Accepted: 16 February 1998     

Age-related changes in open-loop and closed-loop postural control mechanisms

In an earlier posturographic investigation (Collins and De Luca 1993) it was proposed that open-loop and closed-loop control mechanisms are involved in the regulation of undisturbed, upright stance. In this study, stabilogram-diffusion analysis was used to examine how the natural aging process affects the operational characteristics of these control mechanisms. Stabilogram-diffusion analysis leads to the extraction of repeatable center-of-pressure (COP) parameters that can be directly related to the steady-state behavior and functional interaction of the neuromuscular mechanisms underlying the maintenance of erect posture. Twenty-five healthy young males (aged 19–30 years) and twenty-five elderly males (aged 71–80 years) who were free of major gait and postural disorders were included in the study. An instrumented force platform was used to measure the time-varying displacements of the COP under each subject's feet during quiet standing. The COP trajectories were analyzed as one-dimensional and two-dimensional random walks, according to stabilogram-diffusion analysis. Using this technique, it was demonstrated cross-sectionally that healthy aging is associated with significant changes in the quasi-static dynamics of the postural control system. (It was also shown that more traditional posturographic analyses, i.e., summary statistics, were not sensitive enough to detect these age-related differences.) It was found that the steady-state behavior of the open-loop postural control mechanisms in the elderly is more positively correlated and therefore perhaps more unstable, i.e., the output of the overall system has a greater tendency to move or drift away from a relative equilibrium point over the short term. In contrast with this result, it was also found that the steady-state behavior of the closed-loop postural control mechanisms in the elderly is more negatively correlated and therefore perhaps more stable, i.e., over the longer term, there is an increased probability that movements away from a relative equilibrium point will be offset by corrective adjustments back towards the equilibrium position. In addition, it was demonstrated that the elderly utilize open-loop control schemes for longer time intervals and correspondingly larger COP displacements during periods of undisturbed stance. This result suggests that in the elderly there is a greater delay, on average, before closed-loop feedback mechanisms are called into play. Finally, it was shown that there is an increased heterogeneity of postural control abilities in healthy older adults.     

Experimental muscle pain results in reorganization of coordination among trapezius muscle subdivisions during repetitive shoulder flexion

The aim of the study was to examine the effect of experimental unilateral upper trapezius muscle pain on the relative activation of trapezius muscle subdivisions bilaterally during repetitive movement of the upper limb. Surface EMG signals were detected from nine healthy subjects from the upper, middle and lower divisions of trapezius during a repetitive bilateral shoulder flexion task. Measurements were performed before and after injection of 0.5 ml hypertonic (pain condition) and isotonic (control) saline into the upper division of the right trapezius muscle in two experimental sessions. On the painful side, upper trapezius showed decreased EMG amplitude (average rectified value, ARV) and lower trapezius increased ARV throughout the entire task following the injection of hypertonic saline (40.0 ± 22.2 vs. 26.0 ± 17.4 μV, and 12.5 ± 7.6 vs. 25.6 ± 14.8 μV, respectively, at the beginning of the contraction). On the side contralateral to pain, greater estimates of ARV were identified for the upper division of trapezius as the task progressed (37.4 ± 20.2 vs. 52.7 ± 28.4 μV, at the end of the contraction). Muscle fiber conduction velocity did not change with pain in all three divisions of the right trapezius muscle. The results suggest that local elicitation of nociceptive afferents in the upper division of the trapezius induces reorganization in the coordinated activity of the three subdivisions of the trapezius in repetitive dynamic tasks.     

Altered cardiovascular/pain regulatory relationships in chronic pain

In healthy individuals, there is an inverse relationship between resting blood pressure (BP) and pain sensitivity. This study examined possible dysregulation of this adaptive relation in chronic pain patients, and tested whether the extent of this dysregulation is a function of pain duration, Continuous resting BP_s were assessed for 5 min after a 5-min rest period in 121 chronic benign pain patients. Unlike the inverse relationship observed previously in normals, mean resting diastolic BP_s during the assessment period were correlated positively with ratings of pain severity. A Pain Duration x Systolic BP i nteraction emerged (p > .05) such that the magnitude of the BP-pain relation was greatest in patients with the longest duration of pain, r(38) = .50, p > .001. A hypothesized progressive alteration in endogenous pain regulatory systems in chronic pain patients was supported. A possible role of endogenous opioid dysfunction in accounting for these alterations is discussed. This investigation was supported by Grant BRSG S07 RR05366-28. awarded to John W. Burns by the Biomedical Research Grant Program, Division of Research Resources, National Institutes of Health. We thank Kathleen Kiselica and Ronald Pawl for allowing access to their patients at the Center for Rehabilitation at Lake Forest Hospital in Lake Forest, IL.     

Influence of skin temperature on heat pain threshold in humans

We compared the effect of skin temperature on the critical threshold temperature eliciting heat pain with the effect of skin temperature on the response latency to the first heat pain sensation in healthy human subjects. Also, we determined the effect of the duration of a heat stimulus ramp on pain threshold. Furthermore, we determined the effect of skin temperature on mechanically induced pain. We found that the latency to the first pain sensation induced by a radiant heat stimulus was significantly decreased with an increase in the skin temperature (25–35 °C). However, independent of the rate of the stimulus rise (3–10 °C/s) and independent of the stimulus location (hairy vs glabrous skin), the threshold temperature for eliciting the heat pain sensation, determined with a contact thermostimulator, was not changed by a change in the skin temperature in the same subjects. With a fast rate of stimulus rise, a higher pain threshold was obtained than with a slow rise of stimulus temperature. However, this difference was found only with subject-controlled ascending stimuli (method of limits) but not with experimenter-controlled, predetermined stimulus ramps (method of levels). The heat pain threshold was higher in the glabrous skin of the hand than in the hairy skin of the forearm. With increasing stimulus duration (2.5–10s), the threshold temperature eliciting the heat pain sensation was significantly decreased. The mechanically induced pain threshold was not influenced by the skin temperature. The results indicate that the critical temperature for eliciting heat pain is independent of the skin temperature in humans. However, a change in skin temperature is an important source of an artefactual change in heat pain sensitivity when the radiant heat method (latency or energy) is used as an index of pain sensitivity. With a method dependent on reaction time (the method of limits), the heat pain threshold was artefactually increased, with fast rates of stimulus rise due to the long delay of slowly conducting heat pain signals in reaching the brain. With an increase in the duration of the heat stimulus, the critical temperature for eliciting pain sensation was significantly decreased, which may be explained by central neuronal mechanisms (temporal summation).     

Center of pressure displacement characteristics differentiate fall risk in older people: A systematic review with meta-analysis

Falling is the second most prevalent cause of accidental death in the world. Currently available clinical tests to assess balance in older people are insufficiently sensitive to screen for fall risk in this population. Laboratory tests that record the center of pressure (COP) trajectory could overcome this problem but despite their widespread use, the choice of COP trajectory features for use as a biomarker of fall risk lacks consensus. This systematic review and meta-analysis aimed at identifying the best COP characteristics to predict risk of falling in older adults. More than 4000 articles were screened; 44 (7176 older adults) were included in this study. Several COP parameters emerged as good indices to discriminate fallers from non-fallers. From sensitivity analysis, Sway area per unit time, anteroposterior mean velocity, and radial mean velocity were the best traditional features. In this study, identification of older people with a high fall risk was demonstrated using quiet-standing recordings. Such screening would also be useful for routine follow-up of balance changes in older fallers in clinical practice.     

The effects of unilateral medial arch support stimulation on plantar pressure and center of pressure adjustment in young gymnasts

The purpose of this study was to examine the contribution of tactile afferents from the medial arch of the foot on postural control. The center of pressure (CoP) position and right/left plantar pressure distributions of 13 gymnasts, with and without a medial arch support, were recorded by a force platform coupled with a baropedometry analysis. Stimulation of the subject's plantar sole was accomplished using a 3 mm thick medial arch insert. Right arch stimulation induced an ipsilateral increase of plantar pressure and a contralateral displacement of the CoP to the left. Left arch support also resulted in an ipsilateral increase in plantar pressure and displacement of the CoP to the right. Stimulation of the plantar arch may induce a perception that the body's center of mass has shifted toward the stimulated foot. To maintain stability, individuals may then shift their CoP in the opposite direction. This response may involve compensatory muscle activation strategies to adjust posture. Clinicians may apply these results in their use of foot orthoses to address postural anomalies in patients.     

Electrical stimulation of the gastrocnemius muscle in the spontaneously hypertensive rat increases the pain threshold: role of different serotonergic receptors

In a previous study, prolonged low-frequency muscle stimulation in the hind leg of the fully conscious spontaneously hypertensive rat (SHR) was shown to induce a long-lasting reduction of blood pressure. It was also shown that opioid and serotonergic (5-HT) systems were involved. More recently, we have shown that the 5-HT₁ receptors are involved in the post-stimulatory decrease in blood pressure. In the present study, the influence of this type of muscle stimulation on the pain threshold was investigated. Pain perception was measured as the squeak threshold to noxious electric pulses. After cessation of the stimulation, an analgesic response was elicited within 60 min and peak analgesia developed after 120 min, being 139 ±10% (P < 0.01) of the prestimulatory control value. The increased pain threshold lasted for another 2 h. One group of SHR was pretreated with PCPA, a serotonin synthesis blocker, which completely abolished the post-stimulatory analgesia. To analyse further the involvement of different serotonin systems, drugs with selective affinity for 5-HT receptors were used. In one group a prestimulatory dose of metitepine maleate (a 5-HT_1&2 receptor antagonist) abolished the post-stimulatory elevation of the pain threshold. The prolonged analgesic response was still present after prestimulatory treatment with ritanserin or ICS 205–930 (5-HT₂ and 5-HT₃ blocking agents respectively). In another group of experiments, the serotonin receptor antagonists were administered post-stimulation to animals with fully elicited analgesia. None of the antagonists used could reverse the elevation of pain threshold towards prestimulatory levels. Thus, intact 5-HT systems were necessary to elicit the analgesia to muscle stimulation and the response was mediated by the 5-HT₁ receptor. However, the results indicate that serotonin is not required to maintain the analgesia once it has been elicited.     

Learned maintenance of pain: muscle tension reduces central nervous system processing of painful stimulation in chronic and subchronic pain patients.

The effect of level of muscle tension on the perception of painful stimuli was assessed in 13 chronic back pain patients, 14 subjects at high risk for chronic back pain, and 14 matched healthy controls. Subjects received painful intracutaneous electric stimuli to the forearm or the lower back while they produced either high or low muscle tension levels. Visual analog scale (VAS) ratings of acute pain were obtained after each trial. Electroencephalograms, electromyograms, skin conductance levels, and blood pressure were measured during the trials. Although subjective pain ratings were not significantly affected by muscle tension levels, the chronic pain patients displayed elevated N150 and N150/P260 amplitudes of the somatosensory-evoked potentials in the low as compared to the high muscle tension condition. The high risk group showed a trend toward higher N150 amplitudes in the low as compared to the high tension condition. The results of this study partially support the hypothesis that increases in muscle tension might serve as a pain-reducing mechanism in chronic pain patients and those at risk for chronicity, thus leading to a vicious pain-tension cycle.     

The effect of low-load exercise on joint pain,function, and activities of daily living in patients with knee osteoarthritis

Background

Knee osteoarthritis has a lifetime risk of nearly one in two, with obese individuals being most susceptible. While exercise is universally recognized as a critical component for management, unsafe or ineffective exercise frequently leads to exacerbation of joint symptoms.

Cortical mechanisms underlying point localization of pain spot as studied by event-related potentials following CO2 laser stimulation in man

To elucidate cortical mechanisms underlying point localization of a pain spot, we investigated event-related potentials (ERPs) while using a CO₂ laser beam to apply a pain stimulus to the hand dorsum in 16 healthy men. The stimulus spot (pain spot) was shifted for each stimulus, while the subject was requested to identify the stimulated spot as accurately as possible and to use a pointer in the non-stimulated hand to indicate the corresponding spot on a figure of a hand that was projected onto a screen (localization condition). For the control condition, the subject pointed to a single predetermined spot, regardless of the location of the stimulation (control motor task condition). Electroencephalograms were recorded from 21 electrodes, referenced to the linked earlobes, and were averaged time-locked to the stimulus onset for each task separately. Under the control rest condition (neither point localization nor motor task), only two early components (N2 and P2) were recorded. During the control motor task condition (no point localization), in addition to N2 and P2, a steep negative-going slope was recorded at the fronto-central region. Exclusively during the localization condition, a positive peak (647 ms, 5.6 μV for the left and 634 ms, 5.7 μV for the right hand stimulation) was identified; this was maximal at the midline centro-parietal area and distributed symmetrically over the scalp. It is suggested that the late positive component detected exclusively during the localization task is related to the somatotopic point localization of the pain spot. From the distribution of this ERP, the task most likely involves bilateral activation of the superior parietal cortices. Received: 4 September 1998 / Accepted: 22 February 1999     

Effects of an over-ground exoskeleton on external knee moments during stance phase of gait in healthy adults

Background

Physical activity and exercise is central to conservative management of knee osteoarthritis (KOA), but is often difficult for patients with KOA to maintain over the decade or more prior to surgical management. Better approaches are needed for maintaining physical function and health in this population that can also address the patho-biomechanics of the osteoarthritic knee.The objective of the study is to quantify how a lower-extremity robotic exoskeleton (dermoskeleton) modifies the external knee moments during over-ground walking in a sample of healthy adults, and to evaluate these biomechanical modifications in the context of the osteoarthritic knee.

Safety and effectiveness of enzyme replacement therapy with agalsidase alfa in patients with Fabry disease: Post-marketing surveillance in Japan

Fabry disease is a rare X-linked inherited multisystem disorder resulting from deficiency of the lysosomal enzyme alpha-galactosidase A. Currently, specific therapies, including enzyme replacement therapies, are available for Fabry disease, but clinical trials provide limited information on long-term safety and effectiveness.Agalsidase alfa was approved in Japan in 2006. The post-marketing surveillance study of all patients receiving agalsidase alfa to evaluate its long-term safety and effectiveness as a mandatory condition for its approval had been conducted for 8 years (from February 2007 to March 2015).A total of 493 patients were included in this analysis of safety and effectiveness. The overall mean follow-up period was 3.5 years (range, 0.0–7.9 years). The percentage of patients with adverse drug reactions was 24.5% (121/493) and 12.6% had infusion-related reactions (62/493). In the 256 patients without prior enzyme replacement therapy whose IgG antibody data were available, 17 were IgG antibody positive (6.6%). However, the chronological correlation between seroconversion and the incidence of infusion-related reactions was not clear.The mean brief pain inventory score of the worst pain decreased in patients with moderate and severe pain at baseline. Plasma Gb₃ and urine sediment Gb₃ in males with classical Fabry disease without prior enzyme replacement therapy significantly decreased. The mean yearly changes in eGFR (mL/min/1.73 m²) ranged from ?2.88 to +1.00 in males with classical Fabry disease, from ?2.04 to ?0.95 in males with non-typical variant and from ?2.64 to ?1.02 in females. The lower eGFR or the more proteinuria at baseline, the faster the decrease in eGFR of the patients was observed. There was no substantial difference in cardiac parameters (left ventricular mass index, E/A wave ratio, ejection fraction, and QRS duration).In conclusion, agalsidase alfa, 0.2 mg/kg every other week, was well tolerated and controlled the progression of symptoms (especially renal and cardiac) of Fabry disease in adults. Enzyme replacement therapy should be started in Japanese patients before cardiac and/or renal symptoms of Fabry disease develop.