Sympathetic skin response in myelopathies

Autonomic dysfunctions cause significant morbidity and mortality among patients with spinal cord disorders. Sympathetic skin response (SSR), a simple, noninvasive electrophysiological technique, may be useful for assessing sympathetic functions in patients with myelopathies. Our aim was to study SSR in patients with myelopathy and correlate it with clinical features, severity of the impairment, somatosensory evoked potentials. and outcome. Thirty patients (15 men, 15 women) 12 to 60 years old with myelopathies of different etiology were studied. Subjects with clinical, electrophysiologic, or radiologic evidence of lesions outside the spinal cord were excluded. Somatosensory evoked potentials (SSEP) were recorded from scalp with median nerve stimulation at the wrist and posterior tibial nerve below the medial malleolus. The SSR was recorded from palm and sole after stimulating the supraorbital nerve at forehead, median nerve at wrist, and posterior tibial nerve below medial malleolus. The SSR was considered abnormal when absent. The sites of the lesions in these patients were cervical (13), thoracic (16), and lumbar (1). The lesion was clinically complete in six patients. Good motor recovery was noted in 16 subjects. SSR was absent from sole in 25 and palm in 10 patients from all three sites of stimulation. In addition, three patients also had absent SSR from palm on posterior tibial nerve (PTN) stimulation. SSEP was absent from median (N₁₉) in three and posterior tibial (N₃₉) in 20 patients. Among 10 patients with absent SSR from palm, only three had a good outcome. Presence of SSR from palm to PTN stimulation correlated with sparing of bladder sensations and good outcome. However, absent SSR from sole did not correlate with clinical features, bladder dysfunction, or outcome.Sympathetic skin response is frequently abnormal in patients with myelopathies. Spinal afferent and efferent tracts for SSR are different and may be affected individually. The afferent pathways are closely related to tracts conveying bladder sensation. Preserved palmar SSR on PTN stimulation may suggest good motor outcome. SSR may be a valuable adjunct in evaluating patients with myelopathies.     

Sympathetic skin response in patients with reflex sympathetic dystrophy

The sympathetic skin response (SSR) originates from synchronized activation of the sweat glands as a response to a volley discharge in efferent sympathetic nerve fibres. The aim of the study was to verify the diagnostic value of SSR in patients with reflex sympathetic dystrophy (RSD). SSR was recorded in 20 normal subjects and in 24 patients with predominantly chronic RSD. In normal subjects inter- and intra-individually different mono-, bi- and triphasic potentials could be recorded without difference of the waveform from side to side. SSR abnormalities were found in 15 patients and correlated with the severity of the disease. In patients with slight dystrophies, SSR was predominantly normal. In intermediate dystrophies, mainly differences of the SSR waveform between sides could be recorded, indicating unilateral sudomotor dysfunction. In severe dystrophies abnormalities of SSR amplitude or latency were found, indicating more serious disturbance of sudomotor activity, possibly due to a lesion of sympathetic fibres. The SSR provides useful information on sudomotor dysfunction in patients with RSD. However, as there is no consensus in the literature for the clinical criteria to diagnose RSD, it is not yet possible to determine the final diagnostic value of SSR for the diagnoses of RSD.     

Sympathetic skin response

Sympathetic skin response (SSR), defined as the momentary change of the electrical potential of the skin, may be spontaneous or reflexively evoked by a variety of internal or by externally applied arousal stimuli. Although the suprasegmental structures influencing the SSR in humans are not well known, SSR has been proposed as a non-invasive approach to investigate the function of the sympathetic system. SSR is easy to apply but current procedures are not sufficiently reliable for diagnostic purposes, and show imperfect correlations both with clinical features and other measurements of autonomic, in particular, sudomotor dysfunction.     

Skin vasodilator response to local heating in human chronic spinal cord injury

Local heating evokes an increase in skin blood flow (SkBF), which consists of an initial peak (axon-reflex mediated) followed by a brief nadir and a secondary rise to a plateau. The aim of this study was to investigate whether heat provoked vasodilatation detects sympathetic vasomotor dysfunction and completeness of injury in patients with spinal cord injury (SCI). Twelve (seven complete, and five incomplete; level C4-L4) SCI patients, and nine healthy subjects as controls were studied. Thermostatic laser Doppler probes, which heat the skin locally, were placed on the dorsum of the hand and foot. SkBF was measured by laser Doppler flowmetry at baseline and at the first peak of vasodilatation (SkBF(max)). On the hand, SkBF at baseline and SkBF(max) were similar between the three groups. On the foot, SkBF at baseline was similar between the three groups but SkBF(max) was significantly diminished in complete SCI patients compared with controls (P < 0.01). In conclusion, heat provoked axon-reflex vasodilatation was diminished in the foot, below the level of lesion, in complete SCI. This test, that evaluates localized sympathetic vasomotor dysfunction, may be a useful non-invasive technique to detect completeness of autonomic disruption after SCI.     

Sympathetic skin response in Parkinson's disease

Sudomotor function in 83 patients with Parkinson's disease (PD) was evaluated using the sympathetic skin response (SSR) and sweat response to intradermal acetylcholine (ACh) injection. The incidence of abnormal SSRs (36.1%) increased, and the size of the response decrease with the severity of the illness. Neither the incidence of abnormal SSRs nor the amplitudes of the responses were influenced by levodopa or an anticholinergic agent. The SSR therefore can be used to evaluate the sudomotor efferent pathway in PD patients. In all the patients who had no SSR response, the local sweat response to ACh showed a reduced number of excitable sweat glands and low sweat volume. One patient, whose local sweat response to ACh was markedly impaired, had unmyelinated and acetylcholinesterase-positive fiber densities that were in the normal range in his biopsied sural nerve. The abnormal sweat response to ACh is considered to reflect the dysfunction of postganglionic sympathetic fibers in PD patients.     

Sympathetic skin response in patients with myasthenia gravis★ A comparative analysis

BACKGROUND: The examination of sympathetic skin response is an important index for assessing the autonomic nerve function, and patients with myasthenia gravis are always accompanied by dysautonomia. Therefore, it will be important to know whether sympathetic skin response can be used as the index for the clinical evaluation of myasthenia gravis. OBJECTIVE: To investigate the diagnostic value of sympathetic skin response in the damage of autonomic nerve function of patients with myasthenia gravis. DESIGN: A case-controlled comparative observation. SETTING: Department of Neurology and Room of Nerve Electromyogram, the Affiliated Hospital of North Sichuan Medical College. PARTICIPANTS: Thirty outpatients or inpatients with myasthenia gravis were selected from the Department of Neurology, the Affiliated Hospital of North Sichuan Medical College from May 2006 to May 2007, including 9 males and 21 females, aged 8–72 years with a mean age of (28±5) years old. They were all accorded with the diagnostic standards of myasthenia gravis, accompanied by different severity of autonomic nerve symptoms, including poor skin nutrition, sweating of hands and feet, pyknocardia, persistent hypotension, abdominal pain, constipation, etc. They all had not taken any drug affecting the autonomic nerve function before the examination. Informed consents were obtained from all the patients. Meanwhile, 30 healthy physical examinees were enrolled as the normal control group, including 10 males and 20 females, aged 10–75 years with a mean age of (31±5) years old. Approval was obtained from the hospital ethic committee. METHODS: After admission, the patients were examined with sympathetic skin response using DANTEC keypoint 2.0 electromyography evoked potential apparatus (Danmark). The changes of the latency and wave amplitude of sympathetic skin response were observed. The subjects in the normal control group were examined with the same methods at physical examination. Abnormality was judged by the disappearance of wave form, latency longer than that in the normal control group by Mean±2.5SD, or wave amplitude lower than the average value in the normal control group by 50%. MAIN OUTCOME MEASURES: The results of the latency and wave amplitude of sympathetic skin response were compared between the patients with myasthenia gravis and normal controls. RESULTS: All the 30 patients with myasthenia gravis and 30 healthy physical examinees were involved in the final analysis of results. There were no significant differences between the left and right upper and lower limbs in both the myasthenia gravis group and normal control group (P > 0.05). In the myasthenia gravis group, the abnormal rate of sympathetic skin response was 37% (11/30), the latency was prolonged and the wave amplitude was decreased as compared with those in the normal control group, and there were significant differences (P < 0.01). CONCLUSION: Sympathetic skin response can be used as an electrophysiological index for judging the damages of autonomic nerve function in patients with myasthenia gravis.     

Sympathetic skin response in premenstrual syndrome

Abstract Premenstrual syndrome is a term which includes a broad group of emotional, behavioral and physical symptoms that occur for several days before menses and subside following the menstrual period. Many women experience premenstrual syndrome symptoms, particularly physical ones such as breast tenderness and swelling. Approximately 5–10% women suffer from severe premenstrual syndrome and another 30–40% have moderate symptoms. Premenstrual syndrome continues to be an unsolved problem.In this study, we evaluated 24 premenstrual syndrome patients and 20 healthy women in the control group. The ages of the women were 22–34 years (mean ± SD: 25±3) for the premenstrual syndrome group and 23–34 (25±3) for the control group. The sympathetic skin response was recorded from the palms, soles and genital regions by using electrical stimuli to the median nerve at the wrist.The sympathetic skin response was recorded twice, in the follicular and late luteal phases of menstruation.The follicular and late luteal phase sympathetic skin response of the two groups were compared. The amplitudes and latency values of the late luteal and follicular phase sympathetic skin response from the premenstrual syndrome group and control group women were statistically similar. We also did not find any latency or amplitude difference in the sympathetic skin response obtained from the three regions of the premenstrual syndrome patients and the control group.We checked sympathetic skin response in the symptomatic (late luteal phase) and asymptomatic (follicular phase) periods of patients with premenstrual syndrome, a disorder known to have many autonomic symptoms, to determine whether there was sudomotor sympathetic involvement.The results of our PMS patients indicate at the very least that there is no difference with the control subjects as regards peripheral sudomotor functions.     

不完全性脊髓缺血损伤动物模型的建立及价值

目的 探讨不完全性脊髓缺血损伤动物模型的建立方法,为不完全性脊髓缺血损伤机制研究提供理想的载体. 方法 24只新西兰大白兔按照随机数字表法分为对照组及3根组、4根组,每组8只.对照组用于排除麻醉和手术对运动诱发电位的影响;3根组、4根组分别结扎3根、4根腰动脉.各组麻醉后记录基线诱发电位,手术/结扎后30 min、2d、7d记录诱发电位;麻醉清醒后、手术/结扎后2d、7d进行运动功能评分;手术/结扎后7d后取缺血中心区标本进行HE染色,镜下观察. 结果 3根组动物结扎后30 min诱发电位波幅与对照组比较差异有统计学意义(P＜0.05),结扎后2d、7d与对照组比较差异无统计学意义(P＞0.05);4根组动物结扎后30 min、2d、7d3个时间点诱发电位波幅与对照组比较差异均有统计学意义(P＜0.05).3组动物手术/结扎后30min、2d、7d3个时间点的潜伏期与对照组比较差异均无统计学意义(P＞0.05).各组动物运动功能评分结果与诱发电位波幅变化一致. 结论 结扎3根腰动脉可以造成可逆性不完全性脊髓缺血损伤,结扎4根腰动脉可以造成不可逆性不完全性脊髓缺血损伤.     

Sympathetic skin response in monomelic amyotrophy

OBJECTIVES: Monomelic amyotrophy (MMA) a variant of motor neuron disease, has the characteristic features of wasting and weakness usually confined to a single upper or lower limb occurring predominantly in young males and a benign outcome. Symptoms of increased sweating, coldness and cyanosis have been observed in a few patients. The objective was to evaluate the involvement of the sympathetic nervous system in MMA by measuring sympathetic skin response. METHODS: Electromyography, motor and sensory nerve conduction studies were done in all the four limbs of 9 patients with atrophy of one upper limb. Stimulation at Erb's point, and above and below elbow was done to look for evidence of conduction block. The sympathetic skin response (SSR) was recorded in all the limbs of these patients. Wasting and weakness of right upper limb in 7 patients and left upper limb in 2 patients was seen. The mean age was 28.3+/-10.1 years. Twenty-five age matched (24.8+/-4.8 years) healthy subjects served as controls. RESULTS: The mean SSR latency in the affected upper limbs of 9 patients was prolonged compared to the 25 control subjects (1.51+/-0.07 s vs 1.42+/-0.19 s, P=0.03). The mean value of SSR latency in 18 upper limbs of the 9 patients which included atrophied and unatrophied limbs was also prolonged compared to the controls (1.50+/-0.08 s vs 1.42+/-0.19 s, P=0.05). There was no significant difference of the mean latency of SSR between the atrophied upper limbs and the clinically normal upper limbs (1.51+/-0.07 s vs 1.49+/-0.09 s, P=0.51). The mean SSR latency in the lower limbs of the patients (2.09+/-0.09 s) did not significantly differ from the control subjects (1.97+/-0.28 s, P=0.09). Motor and sensory nerve conduction was normal and there was no evidence of conduction block. CONCLUSION: In MMA the sympathetic nervous system is involved in the atrophic upper limb and also in the clinically unaffected upper limb but not in the lower limbs.     

Sympathetic skin response in Guillain-Barré syndrome

Dysautonomia is a common feature of Guillain—Barré (GB) syndrome and is sometimes the cause of significant morbidity and death. Changes in sympathetic skin response (SSR) may be one of the accompaniments of dysautonomia. An attempt was made to correlate SSR changes with clinical and electrophysiologic features in a group of 24 patients with GB syndrome fulfilling NINDS (National Institute of Neurological Disorders and Stroke) criteria. A total of nine patients had absent SSR. Thirteen patients had clinical dysautonomia, of whom five had absent SSR. Five patients had features of predominant axonal damage and preserved SSR. A trend towards correlation of SSR abnormalities with common peroneal nerve conduction parameters (velocity and compound muscle action potential amplitude) was noted. We conclude that SSR abnormalities are common in GB syndrome and may be complementry to bed-side tests for autonomic dysfunction.

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Sympathetic skin response in Guillain-Barré syndrome

     

促甲状腺释放激素类似物YM-14673对大鼠脊髓损伤后水肿的影响

目的研究促甲状腺释放激素（ＴＲＨ）类似物,ＹＭ－１４６７３大鼠脊髓损伤后水肿的影响。方法用改良Ａｌｌｅｎ氏法建立大鼠脊髓损伤模型,分设正常组、对照组和治疗组,治疗组在损伤后１５分钟注射ＹＭ－１４６７３,用称重法测量脊髓的水含量,公式：（湿重－干重）÷湿重×１００％。结果对照组示伤后２４小时脊髓水肿,治疗组显示在２４小时脊髓水肿减轻。结论早期应用ＴＲＨ类似物,ＹＭ-１４６７３可减轻脊髓损伤后的脊随水肿。     

大鼠脊髓损伤后巢蛋白表达

目的探讨成年大鼠脊髓损伤后损伤区局部巢蛋白（nestin）的表达及意义。方法应用Allen＇s法建立大鼠脊髓拟伤模型，行为学评分采用BBB评分（Basso，Beattie＆Bresnahan locomotor rating scale，BBB scale），观察局部病理组织学改变及用免疫荧光组织化学方法检测局部脊髓在不同时段nestin的阳性表达变化。结果伤后1w BBB评分最低，随后增加，到4w以后达到最高并进入平台期。常规病理学检查显示拟伤模型类似于临床常见的脊髓损伤。损伤后1W，可见损伤区附近nestin表达升高，2W达高峰，4W后nestin表达明显下调。结论脊髓损伤可诱导损伤区周围短暂的nestin阳性表达，后者可能存在脊髓损伤后的再生与修复中起重要作用。     

Sympathetic skin response in amyotrophic lateral sclerosis

Objectives– The aim of our study was to verify the usefulness of the sympathetic skin response (SSR) as an instrument for assessing autonomic involvement in amyotrophic lateral sclerosis (ALS). Material and methods– We studied palmar and plantar SSR in 31 patients with ALS (mean age: 58.4±9.3 years); 48 age-matched healthy subjects constituted the control group. Results– Palmar SSR was elicitable in all patients, and its latency and amplitude did not significantly differ from that of the controls. Plantar response was evoked in all but 7 patients. The lack of response was significantly related to the functional disability and duration of the disease. Conclusions– We conclude that SSR, even the plantar response, cannot be considered a useful tool for detecting early autonomic involvement in ALS.     

脊髓缺血再灌注损伤时血清及脊髓组织一氧化氮水平的动态变化及意义

目的 观察一氧化氮(NO)在脊髓缺血再灌注损伤(SCIRI)时血清及脊髓组织中的变化,探讨其在SCIRI中的意义. 方法 采用Zivin法建立家兔SCIRI模型,动态观察NO在血清和脊髓组织中的表达. 结果 血清NO在缺血再灌注(IRI)组缺血末期明显上升,IRI后2 h达到峰值,与缺血前比较差异有统计学意义(P<0.05),IRI后6 h、12 h明显降低,与缺血前及Sham组比较差异有统计学意义(P<0.05);脊髓组织中NO在缺血末期明显升高并达到峰值,缺血再灌注后2h、6 h逐渐下降,与Sham组比较差异有统计学意义(P<0.05),缺血再灌注后12 h下降到Sham组水平. 结论 NO在SCIRI后血清和脊髓组织中表达增高,可能在SCIRI病理过程神经元损伤与修复中发挥一定作用.     

Melatonin and cortisol in individuals with spinal cord injury

Study objectivesThe aim of this study was to investigate circadian rhythm and sleep complaints in individuals with spinal cord injury (SCI) as determined by diurnal saliva melatonin and cortisol as well as activity measurements and subjective sleep quality.MethodsFourteen patients with cervical SCI (cSCI), six patients with thoracic SCI (tSCI) and eight able-bodied controls all underwent two consecutive weeks wearing a wrist actigraph in addition to filling out a sleep diary. During one 24-h period, cortisol and melatonin were measured at 4-h intervals. Furthermore, participants’ sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and their overall daytime sleepiness was assessed using the Epworth Sleepiness Scale (ESS).ResultsThe cSCI group demonstrated lower melatonin levels compared with the tSCI group and the controls at the 24:00 and 04:00 time points. Moreover, at one time point the tSCI group had a higher cortisol level than the cSCI group and the controls. In addition, baseline systolic blood pressure and oxygen saturation were significantly lower in the cSCI group. No differences were found in activity measurements or self-reported sleep quality.ConclusionsIndividuals with cSCI demonstrate reduced melatonin secretion compared with tSCI individuals, but not in other circadian measures. This supports an involvement of melatonergic cervical fibers associated with the cervical lesion.     

Neuromuscular constraints on muscle coordination during overground walking in persons with chronic incomplete spinal cord injury

Objective

Incomplete spinal cord injury (iSCI) disrupts motor control and limits the ability to coordinate muscles for overground walking. Inappropriate muscle activity has been proposed as a source of clinically observed walking deficits after iSCI. We hypothesized that persons with iSCI exhibit lower locomotor complexity compared to able-body (AB) controls as reflected by fewer motor modules, as well as, altered module composition and activation.

Methods

Eight persons with iSCI and eight age-matched AB controls walked overground at prescribed cadences. Electromyograms of fourteen single leg muscles were recorded. Non-negative matrix factorization was used to identify the composition and activation of motor modules, which represent groups of consistently co-activated muscles that accounted for 90% of variability in muscle activity.

Results

Motor module number, composition, and activation were significantly altered in persons with iSCI as compared to AB controls during overground walking at self-selected cadences. However, there was no significant difference in module number between persons with iSCI and AB controls when cadence and assistive device were matched.

Conclusions

Muscle coordination during overground walking is impaired after chronic iSCI.

Significance

Our results are indicative of neuromuscular constraints on muscle coordination after iSCI. Altered muscle coordination contributes to person-specific gait deficits during overground walking.     

白细胞介素-10在脊髓损伤中的研究进展

一、白细胞介素-10(IL-10)概述 IL-10是一种免疫调节因子,人类内源IL-10产生的主要细胞是巨噬细胞和单核细胞.     

Randomized trial of 4-aminopyridine in patients with chronic incomplete spinal cord injury

Objective To test the efficacy of 4-aminopyridine (4-AP) on functional status, walking speed and vibration perception in patients with chronic, incomplete spinal cord injury. Methods Twenty SCI patients were randomized in a trial with a double-blind, crossover design to receive four weeks of orally administered 4-AP, followed by a two-week wash-out period and four weeks of placebo, or vice versa. The total daily dose of 4-AP during the four weeks of treatment was systematically increased to a maximum of 0.5 mg/kg body weight. Evaluation of (side-)effects took place at the beginning, after one week, and at the end of each four-week study period. Results No significant benefit was found on functional status (COOP-WONCA). A statistically significant treatment effect was found on the vibration perception threshold (VPT) in the left fingers, during the first study period. On average, patients receiving 4-AP treatment responded less favourably (mean increase in VPT of 0.29 (0.31) μm) than patients receiving placebo (mean decrease in VPT of 0.05 (0.35) μm) (p=0.04). Neither comfortable nor maximum walking speed altered significantly following 4-AP treatment. Conclusions No statistically significant, functional benefit from 4-AP was found for patients in the present study. Furthermore, no support was found for the possibility that an a priory selection of responsive patients would have yielded more favourable results. Received: 13 June 2000 / Received in revised form: 9 January 2001 / Accepted: 30 January 2001     

Effectiveness of virtual reality on balance ability in individuals with incomplete spinal cord injury: A systematic review

BackgroundBalance dysfunctions are one of the most prevalent impairments post incomplete spinal cord injury (SCI). The evidence has proposed that the rehabilitation can be efficacious in treating balance dysfunctions in patients with SCI. Virtual reality (VR) is a computer technology designate 3-D setting which provides immersed users to generate numerous feedbacks such as visual, audio, and haptic.ObjectiveTo investigate the effects of VR on balance ability in individuals with incomplete SCI and to identify efficient training protocol.MethodsWe searched in SCOPUS, PEDro, PUBMED, REHABDATA, EMBASE, and web of science for experimental trials studying impacts of VR training on balance in patients with incomplete SCI that published in English. Physiotherapy Evidence Database (PEDro) scale was used to evaluate the methodological quality for selected studies.ResultsFive pilot studies were met the inclusion criteria. The PEDro scores ranged from 2 to 3, with a median of 2. All selected studies enrolled less than 20 patients. The findings showed beneficial effects of VR in improving balance ability in patients with incomplete SCI.ConclusionsThe preliminary findings showed that the influence of VR training on the balance ability in patients with incomplete SCI is promising. Applying 12 to 20 sessions of 30 to 60 min of VR training may show meaningful effects. Further randomized controlled trials strongly needed.