Spinal Cord Stimulation in Failed Back Surgery Syndrome: Effects on Posture and Gait-A Preliminary 3D Biomechanical Study.

We studied 8 patients with spinal cord stimulation (SCS) devices which had been previously implanted to treat neuropathic chronic pain secondary to Failed Back Surgery Syndrome. The aim of our study was to investigate the effects of SCS on posture and gait by means of clinical scales (Short Form Health Survey-36, Visual Analogue Scale for pain, and Hamilton Depression Rating Scale) and instrumented evaluation with 3D Gait Analysis using a stereophotogrammetric system. The latter was performed with the SCS device turned both OFF and ON. We recorded gait and posture using the Davis protocol and also trunk movement during flexion-extension on the sagittal plane, lateral bending on the frontal plane, and rotation on the transversal plane. During and 30 minutes after the stimulation, not only the clinical scales but also spatial-temporal gait parameters and trunk movements improved significantly. Improvement was not shown under stimulation-OFF conditions. Our preliminary data suggest that SCS has the potential to improve posture and gait and to provide a window of pain-free opportunity to optimize rehabilitation interventions.

Abnormal interaction between vestibular and voluntary head control in patients with spasmodic torticollis.

The functional status of vestibulo-collic reflexes in the sternocleidomastoid (SCM) muscles was investigated in 24 patients with spasmodic torticollis using small, abrupt 'drops' of the head. None had been treated with botulinum toxin injections during at least 4 months preceding the study. Eight of the patients, four of whom had been studied before surgery, were also studied after selective peripheral denervation of neck muscles. The reflex was of normal latency and duration in the 'passive drop' condition, in which subjects were instructed not to oppose the fall of the head. To study voluntary interaction with the reflex response, subjects were then asked to flex the neck as quickly as possible after onset of the head drop ('active drop'). In this condition, voluntary responses in patients were delayed, smaller and less effective in counteracting the head fall than in normal subjects. The same abnormalities were also found in patients after surgery when the head posture was improved. Somatosensory/auditory voluntary reaction times in SCM were normal, as was the latency of the startle reflex. We conclude that voluntary interaction with the vestibulo-collic reflex is disrupted in patients with spasmodic torticollis, a finding which corroborates the patients' aggravation of their symptoms by head or body perturbations. Lack of effective interaction between two major systems controlling head position may contribute to torticollis.

Postural coordination in elderly subjects standing on a periodically moving platform.

OBJECTIVE: To test body segment coordination during dynamic equilibrium on a moving platform, and assess age-related differences in the performance. DESIGN: Subjects had infrared light-emitting diode (LED) markers fixed on their temporomandibularjoint, greater trochanter, and lateral malleolus. Subjects stood upright on a sinusoidally translating platform with both feet, either with eyes open (EO) or eyes closed (EC). The platform was displaced horizontally in an anteroposterior direction at frequencies of 0.2 or 0.6Hz. Each trial, for either visual condition, was repeated twice, lasted 30 seconds, with 30-second intervals, for up to 1 hour. PARTICIPANTS: Fifty-three healthy subjects, aged 17 to 89 years. MAIN OUTCOME MEASURES: Kinematics of head and hip were analyzed by measuring periodic shift of LED markers using an optoelectronic device. Standard deviation on traces of the markers were taken as a comprehensive index of segment placement. Cross-correlation between marker traces was determined to obtain measures of degrees of coupling between body segments. RESULTS: At the low translation frequency (0.2Hz), with EO, subjects behaved like a noninverted pendulum, whereby the head tended to be stabilized more than the hip, and the legs taking up most of the imposed displacement. Aging was associated with greater head stabilization, and a looser coupling between head and hip. With EC, the body attitude changed to an inverted pendulum, whereby the head overshot the platform displacement. Aging was associated with reduced head stabilization, and a stronger coupling between head and hip. When the frequency of the platform translation increased to 0.6Hz, with EC, the general picture was similar to the above, but in older subjects vision was no longer able to counteract the imposed head displacement. At this frequency, with both EO and EC, there was a poor coupling between body segments across all ages. CONCLUSIONS: Periodic shift of the support base may be a valid protocol to test the ability to control balance in the elderly, and may be a useful tool to assess age-related changes of the sensorimotor mechanisms underlying dynamic equilibrium.

Subjective perception of body sway.

OBJECTIVES AND METHOD: The relation between body sway recorded through a stabilometric platform and the subjective report of steadiness was studied in 20 young and 20 elderly subjects and 20 neuropathic and 20 parkinsonian patients standing upright. The trials were performed under two stances (feet apart, feet together) and two visual conditions (eyes open, eyes closed). At the end of each trial, subjects scored their performance on a scale from 10 (complete steadiness) to 0 (fall). RESULTS: In all subjects, independently of the stance conditions, the larger the body sway the smaller the reported score. The function best fitting this relation was linear when sway was expressed on a logarithmic scale. The scoring reproducibility proved high both within and across subjects. Despite the different body sways and scores recorded under the different visual and postural conditions (eyes closed>eyes open, feet together>feet apart) in all groups of subjects and patients, the slopes of the relations between sway and score were broadly superimposable. In the normal subjects, the scores were slightly higher during eyes open than eyes closed trials for corresponding body sways. This was interpreted as a sign of perception of greater stability when vision was allowed. Parkinsonian patients swayed to a similar extent as normal subjects, and their scores were accordingly similar, both with eyes open and eyes closed. Neuropathic patients swayed to a larger extent than normal subjects, and their scores were matched appropriately. Although the slope of their relation with eyes closed was not different from that of normal subjects, with eyes open it was steeper and similar to that with eyes closed, suggesting that these patients did not feel more stable when they could take advantage of vision. CONCLUSIONS: The subjective evaluation of body sway, irrespective of stance condition, age, neuropathy, and basal ganglia disease, reflects the actual sway, and is inversely proportional to the logarithm of the sway value. The remarkable similarity of the relation between score and sway across the various groups of subjects with eyes closed indicates a common mode of sway evaluation, possibly based on integration of several sensory inputs. All groups except neuropathic patients seem to take advantage of the redundancy of the inputs. Basal ganglia integrity does not seem to have a role in the evaluation of sway.

Standing on a continuously moving platform: is body inertia counteracted or exploited?

We describe the characteristics of displacement of the head and hip in normal young subjects standing on a moving platform undergoing continuous sinusoidal horizontal translation in the antero-posterior direction, at frequencies ranging from 0.1-1 Hz. The head, hip and malleolus were marked by light-emitting diodes (LEDs), and the displacement of each LED was quantified by (1) the measure of the shift during each cycle of translation, (2) the standard deviation (SD) of the path travelled during the whole trial, (3) the power spectrum (PS) of the signal and (4) the cross-correlation (CC) between pairs of LED signals. At each frequency of translation, with eyes open (EO), the displacement of head was smaller than that of hip, and the displacement of hip was smaller than that of malleolus. With eyes closed (EC), this order was reversed. The peak value of the CC functions of the pairs malleolus/head, malleolus/hip and hip/head decreased by passing from low to high frequency of translation, under both visual conditions, and decreased more for the pair malleolus/head than malleolus/hip. The lags between body segment displacements ranged between 30 ms and 150 ms, on average, the former segment of each pair preceding the latter. The fast Fourier transformation of hip and head displacement showed a power spectrum peak at the frequency imposed by the platform translation. The peak was larger with EC than EO. With EC, another peak appeared at 0.2 Hz, possibly corresponding to the respiratory frequency. We conclude that, when vision was allowed, subjects behaved as a non-rigid, noninverted pendulum, and stabilised head in space. When vision was denied, head oscillated more than the platform, especially at low translation frequencies. Therefore, the strategy of balance control shifted from a pendulum to an inverted-pendulum behaviour, passing from active head-and-trunk control to maximal body compliance to the perturbation.

The effects of hyperventilation on postural control mechanisms.

The effect of hyperventilation on postural balance was investigated. Voluntary hyperventilation increased body sway in normal subjects, particularly in the sagittal plane. The possibility that this hyperventilation-induced unsteadiness is due to interference with lower limb somatosensory input, vestibular reflexes or cerebellar function was assessed. (i) The effect of hyperventilation on peripheral compound sensory action potentials (SAPs) and somatosensory evoked potentials (SEPs) (recorded centrally, from the scalp) elicited by electrical stimulation of the sural nerve was measured in six normal adults. A reduction in the scalp SEP amplitude and an increase in the peripheral SAP amplitude were observed during hyperventilation, which reversed during the recovery period. These changes indicate increased peripheral neural excitability which could lead to a higher level of ectopic activity; the latter would interfere with central reception of peripheral input. (ii) The click-evoked vestibulo-collic reflex was recorded to study the effect of hyperventilation on vestibulo-spinal activity. EMG recordings from both sternocleidomastoid muscles of six healthy subjects were made in response to loud clicks presented to either ear. Neither the amplitude nor the latency of the response were altered significantly by hyperventilation. (iii) Eye-movement recordings were obtained in the six normal subjects to assess the effect of hyperventilation on the vestibulo-ocular reflex and its visual suppression, the latter being a function largely mediated by the cerebellum; no changes were detected. (iv) Three-dimensional eye-movement recordings and body-sway measurements were obtained in six patients with longstanding unilateral vestibular loss in order to evaluate if hyperventilation disrupts vestibular compensation. In all patients, a horizontal nystagmus either appeared or was significantly enhanced for > or = 60 s after voluntary hyperventilation. Sway was also enhanced by hyperventilation in these patients, particularly in the frontal plane. This study suggests that hyperventilation disrupts mechanisms mediating vestibular compensation. The increase in sway may be, at least partly, mediated by deranged peripheral and central somatosensory signals from the lower limbs. Hyperventilation seems to spare vestibular reflex activity and cerebellar-mediated eye movements.

The functional effectiveness of neck muscle reflexes for head-righting in response to sudden fall.

Reflex head-righting in normal and labyrinthine-defective (LD) subjects was compared to identify the relative functional effectiveness of vestibular-collic and cervico-collic myotactic reflexes. To restrict stimuli largely to the head and neck, subjects lay supine, supported up to the shoulders on a horizontal bed with their head supported in a sling over the edge. The head fell freely as the sling was released with an electromagnetic catch. Head drops were delivered with the subjects instructed to relax and accept the fall passively or to actively right the head as fast as possible. With both instructions, righting responses in normal subjects commenced with electromyographic (EMG) bursts in the sternocleidomastoid (SCM) at 24.5 ms latency, which was reflected in a deceleration of the downwards head velocity. The latency of the earliest EMG responses in LD subjects was 67.4 ms, accompanied by similar deceleration. It is assumed that the earliest response in normal subjects is vestibular, whereas in LDs the SCM stretch reflex is the earliest response. These reflexes are followed at circa 100 ms by more intense EMG activity due to voluntary movement, but braking of head fall is evident before voluntary activity takes effect. Righting was more effective in normal subjects than in LDs, and when "active" normal subjects made more vigorous righting responses than when "passive"; whereas active righting in LDs was no better than passive. The results demonstrate that reflex responses contribute significantly to head-righting. The vestibular contribution gives an advantage over stretch reflexes alone and also assists in voluntary enhancement of reflex responses.

Reflex (unloading) and (defensive capitulation) responses in human neck muscle.

1. We studied unloading and stretch responses in human neck muscle during manoeuvres in which the head pulled against a 2-3 kg weight which could be abruptly released or applied electromagnetically. 2. During head tracking in pitch, unloading of the weight induced inhibition of EMG in the contracting sternocleidomastoid at a mean latency of 24.9 ms in normal subjects and at 41 ms in bilateral labyrinthine-defective subjects, with antagonist (trapezius) excitation at 30.5 and 41.3 ms, respectively. During tracking in yaw, unloading induced inhibition in the contracting splenius capitis (SpC) at a mean latency of 20.4 ms in normal subjects and 25 ms in labyrinthine-defective subjects, with excitation in the antagonist SpC at 22.2 and 24 ms, respectively. 3. If subjects tried to resist an unexpected sideways tug on the head a burst occurred in the stretched SpC at a mean latency of 53.5 ms. When subjects relaxed there was excitation of the shortening of SpC at 75.9 ms, which assisted the imposed motion and is possibly a "defensive reflex".

Unilateral displacement of lower limb evokes bilateral EMG responses in leg and foot muscles in standing humans.

During upright stance, foot dorsiflexion induced by the movement of a supporting platform elicits a short- (SLR) and a medium-latency response (MLR) in both the soleus and the flexor digitorum brevis muscles; foot plantarflexion elicits a MLR in the tibialis anterior. The SLR is the counterpart of the stretch reflex, but no general agreement exists about the origin of the MLR, though recent results suggest that it is transmitted through group II afferent fibres. Animal studies have shown that group II fibres impinge on interneurones projecting contralaterally as well as ipsilaterally, whereas group I fibres impinge on interneurones which project mainly ipsilaterally. Therefore, we compared the changes in amplitude and latency of the SLRs and MLRs in the right and left limb during postural perturbations induced while subjects maintained both feet on the platform (both-on condition) or while they maintained only one foot on the platform and the other on firm ground (one-on condition). Under the both-on condition, the pattern of EMG responses described above occurred bilaterally. Under the one-on condition, both SLRs and MLRs occurred in the displaced leg. However, whereas the SLRs did not change in amplitude compared with the both-on condition, the MLRs decreased in amplitude to about 50%. MLRs were also present in the non-displaced leg. They were not preceded by any SLR but showed a further decrease in size with respect to the corresponding responses in the perturbed leg. Latency of the MLRs of the perturbed leg increased by about 5 ms passing from the both-on to the one-on condition. In the latter condition, a further increase of 5 ms was observed in the nonperturbed leg with respect to the displaced one. The occurrence of the MLRs but not of the SLRs in the contralateral non-displaced leg is in keeping with the notion that crossed neural pathways fed by spindle group II afferent fibres subserve the MLRs. The changes in latency of the MLRs under the one-on condition compared with both-on give a cue about the synaptic delays along the neural circuit and the time taken by the afferent impulses to cross the spinal cord.

Neck muscle responses to abrupt free fall of the head: comparison of normal with labyrinthine-defective human subjects.

1. EMG responses from sternocleidomastoid (SCM) and orbicularis oculi were recorded in subjects who lay supine with their heads cradled in a sling. When the sling released abruptly, their heads fell freely. Normal and bilateral labyrinthine-defective subjects (LDs) were studied. 2. The normal response in SCM was a small burst of excitation at 22-25 ms latency, of 18 ms duration. This merged into a larger, later burst. The drop also produced eye blinks at 22-38 ms. 3. The onset of the SCM response in LDs was delayed (56-73 ms) even though the latency of their eye blinks was normal. 4. We conclude that the early response at approximately 22 ms in normal subjects is mediated by a vestibulocollic reflex. The delayed activity in LDs may be a stretch reflex. This is the first demonstration of the latency of the vestibulocollic pathway to natural stimulation in man.

Selective depression of medium-latency leg and foot muscle responses to stretch by an alpha 2-agonist in humans.

1. In standing humans, toe-up rotation of a platform induces a short-latency (SLR) and a medium-latency response (MLR) in both soleus (Sol) and flexor digitorum brevis (FDB) muscles. Toe-down rotation evokes a MLR in the tibialis anterior (TA). The SLR is the counterpart of the monosynaptic stretch reflex, but the origin of the MLR is still debated. By means of tizanidine (an alpha 2-adrenergic receptor agonist) we tested the hypothesis that the MLR is relayed by group II afferent fibres, since animal data indicate that tizanidine or stimulation of monoaminergic brainstem centres decrease the excitability of spinal interneurones supplied by those fibres. In addition, we compared the effect of the drug on these responses with that induced by stabilization of posture. 2. Eight subjects received tizanidine (150 micrograms kg-1 orally) or placebo, in a single-blind design. Platform rotations were delivered prior to administration and for 3 h afterwards. Both TA- and FDB-MLRs decreased in size, starting from about 1 h after tizanidine administration. Sol-SLR was unaffected. Response latencies were unchanged. Placebo induced no changes in any response. In each subject, the extent of TA-MLR depression induced by holding onto a frame and by tizanidine was superimposable. 3. The selective effect of tizanidine on MLR supports the notion that it is relayed through group II afferent fibres. The similar effects of holding and tizanidine on the response suggests that it is modulated by monoaminergic centres.