Pisa syndrome in Parkinson's disease: clinical, electromyographic, and radiological characterization

Abnormal postures of the trunk are a typical feature of Parkinson's disease (PD). These include Pisa syndrome (PS), a tonic lateral flexion of the trunk associated with slight rotation along the sagittal plane. In this study we describe clinical, electromyographic (EMG), and radiological features of PS in a group of 20 PD patients. All patients with trunk deviation underwent EMG and radiological (RX and CT scan) investigation. Clinical characteristics of patients with PS were compared with a control group of PD patients without trunk deviation. PD patients with PS showed a significantly higher score of disease asymmetry compared with the control group. In the majority of patients with PS, trunk bending was contralateral to the side of symptom onset. EMG showed abnormal tonic hyperactivity on the side of the deviation in the paravertebral thoracic muscles and in the abdominal oblique muscles. CT of the lumbar paraspinal muscles showed muscular atrophy more marked on the side of the deviation, with a craniocaudal gradient. PS may represent a complication of advanced PD in a subgroup of patients who show more marked asymmetry of disease and who have detectable hyperactivity of the dorsal paravertebral muscles on the less affected side. This postural abnormality deserves attention and proper early treatment to prevent comorbidities and pain.     

Human muscle fascicle behavior in agonist and antagonist isometric contractions

Introduction: The aim of this study was to compare, at a given level of electromyographic (EMG) activity, the behavior of dorsiflexor and plantarflexor muscles as assessed via their architecture (pennation angle and fiber length) during agonist or antagonist isometric contractions. Methods: Real‐time ultrasonography and EMG activity of gastrocnemius medialis (GM) and tibialis anterior (TA) muscles were obtained while young males performed ramp isometric contractions in dorsi‐ and plantarflexion. Results: For both muscles, at a similar level of EMG activity, fiber length was longer, and pennation angle was smaller, during antagonist than during agonist contractions. Conclusions: These results indicate that, at similar levels of EMG activity, GM and TA muscles elicit a higher mechanical output while acting as an antagonist. These findings have important implications for muscle function testing. They show that estimation of antagonistic force using the common method based on the EMG/net torque relationship yields underestimated values. Muscle Nerve 45: 92–99, 2012     

Coactivation at the ankle joint is not sufficient to estimate agonist and antagonist mechanical contribution

The aim of this study was to assess, via an electromyographic (EMG) biofeedback method, the mechanical contribution of both agonist and antagonist muscles during maximal voluntary contraction (MVC). We compared this original method with the MVC–EMGmax ratio and the torque/EMG relationship method, both of which are commonly used to estimate antagonist torque. The plantarflexion (PF) and dorsiflexion (DF) MVCs were measured simultaneously with EMG activity of triceps surae (TS) and tibialis anterior in 15 young adults (mean age 23 years). Antagonist torques obtained from the torque/EMG relationship and EMG biofeedback methods appeared to be similar. TS antagonist torque had a major mechanical impact on DF MVC (～42%). EMG coactivation is significantly different than normalized antagonist torque. TS antagonist torque is not negligible when maximal DF is assessed, and the EMG biofeedback method is a simple method to estimate antagonist torque. Muscle Nerve, 2010     

Sudden loading perturbation to determine the reflex response of different back muscles: a reliability study

In this study we estimate the reliability of reflex response variables to identify the main sources of variability and to estimate appropriate measurement strategies to obtain more reliable measures. Back muscle surface electromyography (EMG) was recorded in healthy males during anteriorly-directed sudden loading perturbations applied to the trunk. Measures of EMG reflex latency and amplitude were obtained. The generalizability theory was used as a framework to estimate the magnitude of the different variance components and the reliability of the measures corresponding to various simulations of different measurement strategies. Reliability of the different variables was poor to moderate (intraclass correlation coefficient range 0-0.62). Averaging scores across homologous muscles and several trials were strategies to achieve more acceptable reliability. The reflex response of back muscles is inherently variable, and a large measurement effort is necessary to obtain reliable and, consequently, valid and responsive estimations of this neuromuscular function.     

Maintenance of upright standing posture during trunk rotation elicited by rapid and asymmetrical movements of the arms

Nine healthy subjects standing upright, initiated small, medium and large (S, M and L conditions, respectively) forward movements of their right (Rt) arm together with backward movements of their left (Lt) arm. They also performed medium-size movements while holding a 3 kg dumbbell in each hand (D condition). Movements started with the arm hanging alongside the body and ended when the shoulder reached a desired orientation. The arm and trunk movements were videotaped and recorded by accelerometers taped to the wrists, shoulders, and hips bilaterally. The torque around the vertical axis was measured using a force-plate on which the subjects stood. EMGs were recorded with surface electrodes bilaterally from the shoulder, trunk, and thigh muscles. Trajectories of the center of foot pressure were measured in additional experiments. In association with arm movements, there was a small counterclockwise (ccw: the Rt shoulder forward and the Lt backward) rotation of the trunk, followed by large alternate rotations of the trunk, first clockwise (cw) and subsequently ccw. The intervals from the hand acceleration to the shoulder and hip accelerations were, respectively, 0+/-15 ms (mean and S.D. for all subjects) and -17+/-15 ms. The force-plate showed initial cw and later ccw torques 63+/-41 ms after hand acceleration. The EMGs of the Rt hamstrings (Ham) and Lt rectus femoris (RFem) were followed by those of the Lt Ham and Rt RFem which, respectively preceded the alternate trunk rotations. The integrated EMGs and torques increased with increasing amplitude of arm movement and load. The integrated torques increased in the order of S, M, L, and D conditions. The integrated EMGs of the thigh muscles correlated with the integrated torques (medians: r=0.880, 0.696, 0.785, and 0.688, respectively, in the Rt Ham, Lt Ham, Rt RFem, and Lt RFem). The trajectories of the center of foot pressure showed variations, initially toward the Rt side and then the Lt side which, respectively coincided with the initial and later phases of the trunk rotations and the muscle activation. The trunk muscles were generally coactivated between the Rt and Lt muscles, and the integrated EMGs increased with increasing the integrated torques. Our results showed that alternate rotations of the upper trunk, produced by rapid arm movements, were transmitted to the hip in part due to cocontraction of trunk muscles, and each pair of hip joint muscles contributed to the maintenance of the standing posture by stabilizing the hip joints against alternating trunk rotations.     

Electromyography and mechanomyography of elbow agonists and antagonists in Parkinson disease

The purpose of this study was to assess the electromyographic (EMG) and mechanomyographic (MMG) activities of agonist and antagonist muscles in Parkinson disease patients during maximal isometric elbow contraction in flexion and extension. Ten elderly females with Parkinson disease (average age 75 years) and 10 age‐matched healthy females were tested. The torque and the EMG and MMG signals from biceps brachii and triceps brachii were recorded during sustained maximal voluntary isometric contraction of the elbow flexors and extensors. There were no intergroup differences in the EMG and MMG activities of agonist and antagonist muscles or in torque. This might be because the Parkinson subjects were tested during their medication “ON” phase, or perhaps maximal isometric contraction (MVC) induced greater active muscle stiffness that affected the MMG signal. Muscle Nerve 40: 240–248, 2009     

Electromyographic activity of voluntarily activated trunk flexor and extensor muscles in post-stroke hemiparetic subjects.

OBJECTIVE: To study the EMG activity of selected trunk muscles during self-initiated voluntary flexion and extension of the trunk in post-stroke hemiparetic subjects, and to compare measurement results to corresponding findings in control subjects. METHODS: Using a sample of 50 patients and 30 control subjects, bilateral EMG activity of the rectus abdominis (RA) and external oblique (EO) muscles was studied during direct trunk flexion, and activity of the lumbar erector spinae (ES) and latissimus dorsi (LD) was studied during straight trunk extension. Variables of timing, magnitude, and temporal synchronization between muscle activity on the paretic and non-paretic sides of the body in the patient group were compared with the same measurements taken from the left and right sides of the body in the control group. RESULTS: Activity of the RA and LD muscles on the affected side of the body was reduced and delayed relative to the unaffected side in the patients and relative to the control subjects. Some deterioration was also observed in the function of the EO muscle, whereas the lumbar ES displayed normal activity on both sides of the body. Trunk velocity during both flexion and extension was slower in the patients than in the controls. CONCLUSIONS: Despite the existence of ipsilateral as well as contralateral higher inputs to axial and to a lesser extent also to more lateral trunk muscles, the function of the superficial abdominal muscles and of the LD muscle is adversely affected by a contralateral stroke. Conversely, the lumbar ES, which can be categorized as local trunk extensors, seem to normally fulfill their anti-gravitational task on both sides of the body.     

Reflex activity and muscle tone during elbow movements in patients with spastic paresis.

Reflex behavior and tension development in upper limb muscles were analyzed and comparisons made between the unaffected and spastic sides of patients with spastic hemiparesis. During sinusoidal (0.3-Hz) isometric or isotonic elbow tracking, with a control either of joint position or of torque, randomly timed displacements were induced (at one of three velocities) stretching either the activated flexor or the extensor muscles. On the spastic side, exaggerated short-latency reflexes were apparent, but in contrast, the amplitude of long-latency electromyography (EMG) responses was reduced. The latter responses were differentially modulated on the unaffected side, predominantly by the acceleration signal during control of position and more by the velocity signal during control of torque, while the mode of muscle contraction (isometric or isotonic) had little influence on this behavior. This difference in reflex modulation was lost on the spastic side. The functional consequence of this reduced EMG modulation could be difficulty in performing finely controlled arm movements. The ratio of torque to EMG activity during displacements was higher for both background and reflex-induced EMG on the spastic limb than on the unaffected side. This effect was more pronounced for the flexor than for the extensor muscles. Consequently, the development of spastic muscle hypertonia cannot be attributed to an increase in EMG activity. It is suggested that secondary to a supraspinal lesion, mechanical muscle properties change in such a way that the activated spastic muscle develops more tension when it is stretched.     

A comparison of monopolar and bipolar recording techniques for examining the patterns of responses for electromyographic amplitude and mean power frequency versus isometric torque for the vastus lateralis muscle

The purpose of the present study was to compare monopolar and bipolar recording techniques for the patterns of responses and mean values for absolute and normalized electromyographic (EMG) amplitude and mean power frequency (MPF) versus isometric torque for the vastus lateralis muscle. Ten healthy men (mean+/-S.D. age=23.6+/-3.0 years; body weight=80.9+/-15.6 kg) volunteered to perform submaximal to maximal isometric muscle actions of the dominant leg extensors. Monopolar and bipolar surface EMG signals were detected simultaneously from the vastus lateralis with an eight-channel linear electrode array. The results indicated that in 70-80% of the cases, monopolar and bipolar recording techniques resulted in the same patterns of responses for absolute and normalized EMG amplitude and MPF versus isometric torque. There were, however, differences between the two techniques for mean absolute EMG amplitude and MPF values, but not for the normalized values. Thus, these results supported the practice of normalization, and suggested that comparisons can be made between monopolar and bipolar recording methods for the patterns of responses and mean values for normalized (but not absolute) EMG amplitude and MPF versus isometric torque.     

Activation of selected trunk muscles during symmetric functional activities in poststroke hemiparetic and hemiplegic patients

OBJECTIVE: To compare the EMG activity between the recti abdominii muscles and between the lumbar erector spinae muscles in hemiparetic and hemiplegic patients during functional symmetric trunk movements and to compare patients' EMG activity profiles with those of healthy controls. METHODS: EMG activity from the selected muscles was recorded during three symmetric and time controlled trunk exercises. Data analysis was based on values of cross correlations and of ratios between EMG activity of the bilateral corresponding muscles. RESULTS: In all groups, the highest cross correlations were obtained for both muscles when the muscles acted as prime movers. For the recti abdominii muscles, these values in the patients were comparable with those of the healthy subjects, whereas for the extensor muscles, the highest synchronous activity was displayed in healthy subjects and the lowest in hemiplegic patients. Laterality differences in the amount of EMG activity of the recti abdominii muscles were not biased towards one side. For the extensor muscles, in the controls, the activation levels were higher in the left erector spinae muscle than in the right one in two of the three exercises. Similarly, in the extensor muscles of the hemiparetic patients, activity on the paretic side was higher than on the non-paretic side in two exercises. CONCLUSIONS: In patients with a supratentorial poststroke hemiparesis or hemiplegia, bilateral corresponding axial trunk muscles co-contract during symmetric trunk activities. Synchronous activation is at its highest level during voluntary dynamic tasks and is greater in the recti abdominii than in the erector spinae muscles. For both muscles, EMG activation levels on the paretic side were not lower than on the non-paretic side. Thus, the assertion that the muscles on the paretic side are activated to a lesser extent than their counterparts on the non-paretic side during symmetric trunk movements was not confirmed.     

Reliability and validity of a scale for measurement of trunk mobility in Parkinson's disease: Trunk Mobility Scale

Axial rigidity is an important motor manifestation in Parkinson's disease (PD). Trunk mobility impairment can cause gait, balance and postural problems. However, only few instruments analyze the trunk mobility in PD patients. The aim of this study is to present a new Trunk Mobility Scale (TMS) and its validation in PD. The TMS constituted of dynamic tests involving trunk movements in sagittal, transversal and coronal planes. Ninety eight PD patients and 31 normal controls were analyzed. A strong correlation was found between the TMS scores and the Hoehn & Yahr staging scale (r: 0.72; p<0.01), motor Unified Parkinson's Disease Rating Scale (r: 0.84; p<0.01) and Schwab and England Activities of Daily Living (r: -0.72; p<0.01). The scale showed a satisfactory reliability rate (αCronbach: 0.85, ICC: 099). TMS is a simple and reliable instrument to evaluate trunk mobility impairment in patients with PD.     

Effects of velocity on maximal torque production in poststroke hemiparesis

Impaired torque production is a major physical impairment following stroke, and has been studied extensively in isometric conditions. However, functional use of a limb requires torque production during movement, and the effects of velocity on maximal torque production may be abnormally enhanced in the paretic limb. The purpose of this study was to quantify the effects of movement velocity on maximal torque production during isokinetic, concentric flexion and extension of the elbow in poststroke subjects. Three speeds were tested (30, 75, 120 deg/s) over a 100-deg range of motion. To control for strength variations between subjects and limbs, isokinetic torques were normalized by peak isometric torque. As flexion velocity increased, paretic limb torque decreased at a greater rate than in the unaffected limb. During extension, paretic limb torque was much lower than torque in the unaffected limb at all speeds. In both flexion and extension, the disparity between limbs in the constant-velocity torque-angle curves became more pronounced as velocity increased. Torque decreased 44% +/- 7% in flexion and 63% +/- 9% in extension as velocity increased from 30 to 120 deg/s, whereas the corresponding decreases in the unaffected limb were only 9% +/- 5% in flexion and 16% +/- 4% in extension. No electromyographic (EMG) abnormalities were observed during flexion. During extension, EMG data provided evidence for abnormally increased antagonist coactivation in brachioradialis and markedly reduced activation in triceps as potential contributors to the decreased extension torques. The finding that movement velocity produces large deficits in maximal torque might explain why functional use of the paretic limb is often impaired even though isometric strength appears adequate.     

Long-term botulinum toxin treatment of cervical dystonia--EMG changes in injected and noninjected muscles.

OBJECTIVE: To evaluate changes in quantitative EMG of injected and noninjected sternocleidomastoid muscles following long-term unilateral botulinum toxin treatment of cervical dystonia. METHODS: We investigated 27 patients with cervical dystonia, who received repeated unilateral botulinum toxin injections of the sternocleidomastoid muscle, with quantitative EMG at rest and at maximal voluntary contraction. The patients had on the average 7.1 botulinum toxin treatments and the follow-up period was on the average 31 months (SD 16). RESULTS: After the first treatment, the injected sternocleidomastoid muscles showed a significant decrease in turns/s (mean 45%) and amplitude (mean 52%) at rest, and in amplitude at maximal flexion (mean 24%) and rotation (mean 39%). Except for a reduction in turns/s at rotation (mean 19%) no further reductions in EMG parameters were seen after long-term treatment. The contralateral noninjected sternocleidomastoid muscles showed no significant change in EMG activity after the first BT treatment, but after long-term treatment a significant reduction in turns/s and amplitude at both maximal flexion (turns: mean 28%; amplitude: mean 25%) and rotation (turns/s: mean 32%; amplitude: mean 25%) were seen as compared to pretreatment values. CONCLUSION: The results indicate that there seems to be no cumulative chemodenervation by repeated botulinum toxin injections of sternocleidomastoid muscles measured by quantitative EMG. Contralateral noninjected sternocleidomastoid muscles however, seem to be affected following long-term treatment. The mechanism behind this finding is unknown.     

Differences between flexion and extension synergy-driven coupling at the elbow,wrist, and fingers of individuals with chronic hemiparetic stroke

ObjectiveThe flexion and extension synergies were quantified at the paretic elbow, forearm, wrist, and finger joints within the same group of participants for the first time. Differences in synergy expression at each of the four joints were examined, as were the ways these differences varied across the joints.MethodsTwelve post-stroke individuals with chronic moderate-to-severe hemiparesis and six age-matched controls participated. Participants generated isometric shoulder abduction (SABD) and shoulder adduction (SADD) at four submaximal levels to progressively elicit the flexion and extension synergies, respectively. Isometric joint torques and EMG were recorded from shoulder, elbow, forearm (radio-ulnar), wrist, and finger joints and muscles.ResultsSABD elicited strong wrist and finger flexion torque that increased with shoulder torque level. SADD produced primarily wrist and finger flexion torque, but magnitudes at the wrist were less than during SABD. Findings contrasted with those at the elbow and forearm, where torques and EMG generated due to SABD and SADD were opposite in direction.ConclusionsFlexion and extension synergy expression are more similar at the hand than at the shoulder and elbow. Specific bulbospinal pathways that may underlie flexion and extension synergy expression are discussed.SignificanceWhole-limb behavior must be considered when examining paretic hand function in moderately-to-severely impaired individuals.     

Isokinetic strength and power deficits in the hand following stroke

ObjectiveThe purpose of this study was to compare the torque production in the paretic and non-paretic hands during isokinetic tasks following stroke.MethodsWe compared torque and power production at the MCP joint of chronic stroke survivors during isometric and isokinetic tasks. We also recorded surface electromyography (EMG) activity in the forearm muscles.ResultsIsokinetic torque production at all velocities was less than that produced during isometric trials. Both torque and power produced by the paretic hand was substantially impaired. Deficits were substantially greater in extension than flexion trials. EMG data suggests that excessive co-contraction of agonist and antagonist muscles does not greatly affect isokinetic torque production at the MCP joint.ConclusionsThe fact that movement velocity produces larger deficits in torque and power production may explain why patients who have limited strength impairments still experience functional deficits.SignificanceThis study demonstrates that strength testing of stroke survivors under isometric conditions may underestimate the overall level of impairment.     

Impairment of voluntary control of finger motion following stroke: role of inappropriate muscle coactivation

Subjects with chronic hemiplegia following stroke attempted to perform voluntary isometric, isokinetic, and free contractions of the extensor muscles of the metacarpophalangeal (MCP) joints. We recorded torque, metacarpophalangeal joint angle and velocity, and electromyographic (EMG) activity of the extrinsic extensors and flexors and the first dorsal interosseous (FDI). We found that voluntary MCP joint extension in hemiparetic subjects was greatly impaired in comparison with control subjects: only two of the 11 stroke subjects were able to generate even 0.21 N-m of isometric extension torque, only two could produce positive finger extension with no load, and none could develop an isokinetic concentric extension. Deficits seemed to result from a combination of coactivation of the finger flexor and extensor muscles and decreased voluntary excitation of the extensors, as normalized flexor and FDI EMG activity were greater for stroke than for control subjects (P < 0.001), but normalized extensor activity was reduced (P < 0.001).     

MRI volume of the amygdala: a reliable method allowing separation from the hippocampal formation.

Studies of MRI-derived volume of the amygdala have been mostly performed on coronal sections where its boundaries with the hippocampus and the entorhinal cortex are indistinct. To date, all reports of in vivo amygdala volume have consistently overestimated the size of the structure. We have developed a method for the MRI-based in vivo measurement of the amygdala volume which allows a better separation of the amygdala from the adjoining hippocampal formation. In nine normal volunteers we obtained three-dimensional spoiled gradient recalled acquisition, 1.3-mm thick, T1 weighted sagittal MR images and created electronically linked reformatted images in the coronal and axial planes. On the original sagittal and the reformatted axial planes, where it is more readily apparent, we delineated the boundaries between the amygdala and the hippocampus and the amygdala and the hippocampo-amygdala transition area, respectively. We then projected those markings onto the coronal plane, where the other boundaries of the amygdala are more easily seen. Using these markings as a guide and utilizing extra-amygdalar coronal landmarks for the anterior end, we outlined the whole amygdala on the coronal plane and determined its volume. We observed that 45% of the coronal slices that contained amygdala also contained some hippocampus. The amygdala measurement had high test-retest reliability, with an intra-class correlation coefficient (rICC) of 0.99 for the total volume and an rICC of 0.93 for the measurement at the level of the individual slice. The average amygdala volume was 1.05 +/- 0.17 cm3 on the right and 1.14 +/- 0.15 cm3 on the left. Our amygdala volumes are in agreement with those reported in postmortem studies, which provides the reported method with face validity.     

Trunk movement in Parkinson's disease during rising from seated position.

Parkinson's disease (PD) is associated with particular difficulties rising from a seated position. Little is known about the mechanisms of sit-to-stand in this condition. We sought to define trunk movement during sit-to-stand in a group of patients with PD. Six patients and seven normal volunteers were studied using a six camera ELITE motion analysis system (BTS, Milan, Italy), which permitted data collection in the coronal, sagittal, and transverse planes. Retroreflective markers were positioned along the spine at C7, T3, T6, T9, T12, L3, and the sacrum. Whole-trunk kinematics and the movement at the six different trunk markers were recorded during rising. PD patients have a significantly greater degree of trunk flexion than controls, showing a significant increase in angular velocity of the trunk in the sagittal plane. The total range of movement of trunk rotation was significantly smaller in the PD group, but lateral movement in the trunk was greater than normal. These data suggest that patients with early PD compensate for their difficulties rising from a chair by generating greater trunk flexion at higher angular velocity, thus developing greater forward momentum. This process results in a decrease in the duration of the unstable transitional phase of sit-to-stand, allowing PD patients to reach the upright position as easily and safely as possible. Small rotational movements are an effective way to maintain the centre of mass within the base of support during sit-to-stand. This mechanism appears to be denied to the PD patients who may use increased movements in the coronal plane as an alternative strategy.     

Effect of moderate dehydration on torque,electromyography, and mechanomyography

The purpose of the present investigation was to test the hypotheses that the mechanomyographic (MMG) signal would be affected by hydration status due to changes in the intra- and extracellular fluid content (which could affect the degree of fluid turbulence), changes in the filtering properties of the tissues between the MMG sensor and muscle, and changes in torque production that may accompany dehydration. Ten subjects (age 22.5 +/- 1.6 years) were tested for maximal isometric (MVC), submaximal isometric (25, 50, and 75%MVC), and maximal concentric isokinetic muscle strength of the biceps brachii in either a euhydrated or dehydrated state while the electromyographic (EMG) and MMG signals were recorded. Separate three-way and two-way ANOVAs indicated no change in torque, EMG amplitude, EMG mean power frequency (MPF), MMG amplitude, and MMG MPF with dehydration. The lack of dehydration effect suggests that MMG may be more reflective of the intrinsic contractile processes of a muscle fiber (torque production) or the motor control mechanisms (reflected by the EMG) than the tissues and fluids surrounding the muscle fiber.     

Strength training in old age: adaptation of antagonist muscles at the ankle joint

The purpose of this study was to determine whether strength training could reduce the deficit in plantarflexion (PF) maximal voluntary contraction (MVC) torque observed in previous studies in older subjects relative to young adults. Accordingly, the effects of a 6-month strength training program on the muscle and neural properties of the major muscle groups around the ankle were examined. PF and dorsiflexion (DF) isometric MVC torques were measured and surface electromyographic activity of the triceps surae and tibialis anterior muscles was recorded. The strength training program was very effective in improving strength in PF (+24.5%), and it thus reduced the DF-to-PF MVC torque ratio; in addition, it also induced gains in DF (+7.6%). Thus, there must be an improvement in ankle joint stability. In PF, gains were due particularly to a modification of the agonist neural drive; in DF, the gains appeared to be the consequence of a reduction in antagonist coactivation. Our findings indicate that the investigation of one muscle group should always be accompanied by examination of its antagonist muscle group.