Relationship between muscle output and functional MRI-measured brain activation.

The relationship between functional MRI (fMRI)-measured brain signal and muscle force and or electromyogram (EMG) is critical in interpreting fMRI data and understanding the control mechanisms of voluntary motor actions. We designed a system that could record joint force and surface EMG online with fMRI data. High-quality force and EMG data were obtained while maintaining the quality of the fMRI brain images. Using this system, we determined the relationship between fMRI-measured brain activation and handgrip force and between fMRI-measured brain signal and EMG of extrinsic finger muscles. Ten volunteers participated in the experiments (only seven subjects' data were analyzed due to excessive noise in the fMRI data of three subjects). The participants exerted 20%, 35%, 50%, 65%, and 80% of the maximal force. During each contraction period, handgrip force, surface EMG of the finger flexor and extensor muscles, and fMRI brain images were acquired. The degree of muscle activation (force and EMG) was directly proportional to the amplitude of the brain signal determined by fMRI in the entire brain and in a number of motor function-related cortical fields, including primary motor, sensory regions, supplementary motor area, premotor, prefrontal, parietal and cingulate cortices, and cerebellum. All the examined brain areas demonstrated a similar relationship between the fMRI signal and force. A stronger fMRI signal during higher force indicates that more cortical output neurons and/or interneurons may participate in generating descending commands and/or processing additional sensory information. The similarity in the relationship between muscle output and fMRI signal in the cortical regions suggests that correlated or networked activation among a number of cortical fields may be necessary for controlling precise static force of finger muscles.

Greater movement-related cortical potential during human eccentric versus concentric muscle contractions.

Despite abundant evidence that different nervous system control strategies may exist for human concentric and eccentric muscle contractions, no data are available to indicate that the brain signal differs for eccentric versus concentric muscle actions. The purpose of this study was to evaluate electroencephalography (EEG)-derived movement-related cortical potential (MRCP) and to determine whether the level of MRCP-measured cortical activation differs between the two types of muscle activities. Eight healthy subjects performed 50 voluntary eccentric and 50 voluntary concentric elbow flexor contractions against a load equal to 10% body weight. Surface EEG signals from four scalp locations overlying sensorimotor-related cortical areas in the frontal and parietal lobes were measured along with kinetic and kinematic information from the muscle and joint. MRCP was derived from the EEG signals of the eccentric and concentric muscle contractions. Although the elbow flexor muscle activation (EMG) was lower during eccentric than concentric actions, the amplitude of two major MRCP components-one related to movement planning and execution and the other associated with feedback signals from the peripheral systems-was significantly greater for eccentric than for concentric actions. The MRCP onset time for the eccentric task occurred earlier than that for the concentric task. The greater cortical signal for eccentric muscle actions suggests that the brain probably plans and programs eccentric movements differently from concentric muscle tasks.

Skilled finger movement exercise improves hand function.

BACKGROUND: Aging is accompanied by a marked decline in muscle strength and ability to maintain steady submaximal force. Studies have shown that exercise programs can improve age-related regression of hand function in elderly individuals. The purpose of this study was to train elderly subjects to perform skilled finger movements and to evaluate the changes in hand function involving skillful use of finger pinch. METHODS: Grip strength, maximum pinch force (MPF), steadiness of pinch force at 5%, 10%, and 20% MPF, M wave, and Hoffman (H) reflex were measured. Fourteen elderly subjects were trained with skilled finger movements, and their performance involving finger pinch was measured. RESULTS: Compared with untrained elderly subjects, the trained older adults significantly (p <.05) improved their ability to control submaximal pinch force, to maintain a steady hand posture, and to relocate a small object quickly with finger grip. The amplitude of H reflex increased significantly for the trained group. CONCLUSIONS: Skilled finger movement training improves the ability to control submaximal pinch force, hand steadiness, and manual speed in elderly subjects; these improvements may be due to training-induced adaptations in the central and peripheral nervous systems.

Validation test for climate control on air-loss supports.

OBJECTIVE: To develop a simple, reproducible validation test protocol for classification of air-loss support systems. DESIGN: Simultaneous experimental measurement of moisture loss and temperature reduction at the air-loss support surface-human body equivalent interface from a sweating human skin analogue. SETTING: A hospital department of physical medicine and rehabilitation. OTHER PARTICIPANTS: These 3 manufacturers contributed 14 support surfaces. INTERVENTIONS: Test support surfaces and a standard foam mattress were placed on a hospital bed. Water was circulated to a loading gauge, placed on a dry moisture reservoir, and connected to a water bath to keep the interface at 37 degrees +/- 0.5 degrees C. The loading gauge and support surface was adjusted 23cm below the water bath level and the air flow through the interface initiated. After the dry moisture reservoir came to temperature equilibrium for 30 minutes, it was replaced with a wet one that was saturated with 36g of saline. The temperature change and evaporation rate were recorded throughout a 90-minute test period. MAIN OUTCOME MEASURES: Temperature of support surface interface and evaporation rate. RESULTS: Clustered data from temperature reduction and standardized rate of moisture loss yielded 3 groups of support surfaces in categories of no air loss (control), low air loss (LAL), and high air loss. The mean values of the characteristic temperature reduction and rate of moisture loss differed significantly between the groups. By multiple comparisons with Bonferroni's adjustment, the group means differed significantly for average temperature reduction (p <.017) and for standardized rate of moisture loss (p =.0001). The measured temperature change at any instant of time reflected the effect of evaporation and the opposing effect of thermal conductivity. CONCLUSION: Measurements of support interface climate change allowed for selective grouping of LAL surfaces according to rate of moisture evaporation and the resulting temperature reduction. Neither temperature change nor evaporation rate alone was sufficient to determine the microclimate characteristics of the support surface. Combined, these characteristics can effectively describe the performance of any LAL support system and may be used to define standards of performance.

Effects of aging on hand function.

OBJECTIVES: The purpose of this study was to quantify age-induced changes in handgrip and finger-pinch strength, ability to maintain a steady submaximal finger pinch force and pinch posture, speed in relocating small objects with finger grip, and ability to discriminate two identical mechanical stimuli applied to the finger tip. DESIGN: A cross-sectional study. SETTINGS: Greater Cleveland area of Ohio. PARTICIPANTS: Healthy, independent, young (n = 27, range 20-35 years) and older (n = 28, range 65-79 years) subjects. MEASUREMENTS: Handgrip strength, maximum pinch force (MPF), ability to maintain a steady pinch force at three relative force levels (5%, 10%, and 20% MPF) and three absolute force levels (2.5 Newtons (N), 4 N, and 8 N), ability to maintain a precision pinch posture, speed in relocating pegs from a nearby location onto the pegboard, and the shortest distance for discriminating two stimuli were measured in both young and older groups. RESULTS: Compared with young subjects, the older group's handgrip force was 30% weaker (P < .001), MPF was 26% lower (P < .05), and ability to maintain steady submaximal pinch force and a precision pinch posture was significantly less (P < .05). The time taken to relocate the pegs and the distance needed to discriminate two identical stimuli increased significantly with age (P < .01). The decrease in the ability to maintain steady submaximal pinch force was more pronounced in women than men. CONCLUSION: Aging has a degenerative effect on hand function, including declines in hand and finger strength and ability to control submaximal pinch force and maintain a steady precision pinch posture, manual speed, and hand sensation.

Electrical stimulation for pressure sore prevention and wound healing.

This paper reviews applications of therapeutic electrical stimulation (ES) specific to wound healing and pressure sore prevention. The application of ES for wound healing has been found to increase the rate of healing by more than 50%. Furthermore, the total number of wounds healed is also increased. However, optimal delivery techniques for ES therapy have not been established to date. A study of stimulation current effects on wound healing in a pig model has shown that direct current (DC) stimulation is most effective in wound area reduction and alternating current (AC) stimulation for wound volume reduction at current densities of 127 microA/cm2 and 1,125 microA/cm2, respectively. Preliminary studies have been carried out at two research centers to assess the role of ES in pressure sore prevention. Surface stimulation studies have shown that ES can produce positive short-term changes in tissue health variables such as regional blood flow and pressure distribution. The use of an implanted stimulation system consisting of intramuscular electrodes with percutaneous leads has been found to produce additional long-term changes. Specifically, gluteal muscle thickness increased by 50% with regular long-term ES application concurrent with a 20% decrease in regional interface pressures and increased tissue oxygen levels. These findings indicate that an implantable ES system may have great potential for pressure sore prevention, particularly for individuals who lack sensation or who are physically unable to perform regular independent pressure relief.

Simultaneous measurement of human joint force, surface electromyograms, and functional MRI-measured brain activation.

Functional magnetic resonance imaging (fMRI) has been increasingly used in studying human brain function given its non-invasive feature and good spatial resolution. However, difficulties in acquiring data from peripheral (e.g. information from muscle) during fMRI studies of motor function hinder interpretation of fMRI data and designing more sophisticated investigations. Here we describe a system that was designed to concurrently measure handgrip force, surface electromyograms (EMG) of finger flexor and extensor muscles, and fMRI of human brain. The system included a pressure transducer built in a hydraulic environment, a heavily shielded EMG recording element, and a visual feedback structure for online monitoring of force and/or EMG signal, by the subject positioned in the scanner during an fMRI experiment. System evaluation and subsequent fMRI motor function studies have indicated that by using this system, high quality force and EMG signals can be recorded without sacrificing the quality of the fMRI data.

Relationship between motor activity-related cortical potential and voluntary muscle activation.

The purpose of this study was to investigate the relationship between EEG-derived motor activity-related cortical potential (MRCP) and voluntary muscle activation. Eight healthy volunteers participated in two experimental sessions. In one session, subjects performed isometric elbow-flexion contractions at four intensity levels [10%, 35%, 60%, and 85% maximal voluntary contraction (MVC)]. In another session, a given elbow-flexion force (35% MVC) was generated at three different rates (slow, intermediate, and fast). Thirty to 40 contractions were performed at each force level or rate. EEG signals were recorded from the scalp overlying the supplementary motor area (SMA) and contralateral sensorimotor cortex, and EMG signals were recorded from the skin surface overlying the belly of the biceps brachii and brachioradialis muscles during all contractions. In each trial, the force was used as the triggering signal for MRCP averaging. MRCP amplitude was measured from the beginning to the peak of the negative slope. The magnitude of MRCP from both EEG recording locations (sensorimotor cortex and SMA) was highly correlated with elbow-flexion force, rate of rising of force, and muscle EMG signals. These results suggest that MRCP represents cortical motor commands that scale the level of muscle activation.

Brain activation during human finger extension and flexion movements.

Corticospinal projections to the motor neuron pool of upper-limb extensor muscles have been reported to differ from those of the flexor muscles in humans and other primates. The influence of this difference on the central nervous system control for extension and flexion movements is unknown. Cortical activation during thumb extension and flexion movements of eight human volunteers was measured using functional magnetic resonance imaging (fMRI), which detects signal changes caused by an alteration in the local blood oxygenation level. Although the relative activity of the extensor and flexor muscles of the thumb was similar, the brain volume activated during extension was substantially larger than that during flexion. These fMRI results were confirmed by measurements of EEG-derived movement-related cortical potential. Higher brain activity during thumb extension movement may be a result of differential corticospinal, and possibly other pathway projections to the motoneuron pools of extensor and flexor muscles of upper the extremities.

Measurement of tissue electrical impedance confirms stereotactically localized internal segment of the globus pallidus during surgery.

Lesions surgically made in the internal segment of the posteroventral globus pallidus (Gpi) reduce many medically intractable symptoms in patients with Parkinson's disease. The Gpi is localized for pallidotomy by stereotactic procedures. We sought to confirm the stereotactically localized Gpi segment by measuring impedance between the tip of an active electrode that was advanced toward the target and a remote reference electrode. A stereotactic instrument was used to place an active electrode in 53 conscious patients undergoing pallidotomy. The electrode was manually advanced slowly toward the Gpi segment by a microdrive. Impedance was measured every 10 mm initially and every 1 mm in the final 10 mm of the electrode's advancement, using an impedance monitor interconnected with a lesion generator. Measurements were continued for several millimeters after each patient's target was reached. Impedance values ranged from 250 to 350 ohms throughout of the electrode passage. Impedance increased by 25-35 ohms at 1-3 mm before the center of the target and then dropped abruptly when the electrode passed the target. Impedance values depended strongly on the electrode's configuration. The impedance measurement confirmed the location of each surgical target identified by stereotactic navigation. The accuracy of the impedance measurement is acceptable, and the procedure can be recommended as an aid to confirm the stereotactically localized Gpi during neurological surgery.

Evidence of inability to fully activate human limb muscle.

The purpose of this study was to determine whether muscle activation level estimated by twitch interpolation technique was different when an electrical stimulus was applied during a dynamic force (DF; force rising) task from that when the stimulus was applied during a static force (SF; constant force) task. Fourteen subjects performed voluntary SF and DF contractions involving isometric elbow flexion at seven voluntary force levels. At each level, the electrical stimulation was applied to the surface of the biceps brachii muscle when the force was steady (SF task) and when the force was rising (DF task). The voluntary activation level of the biceps brachii muscle during the SF maximal voluntary contraction (MVC) was 98.5% and that during the DF MVC task was significantly lower (94.5%; P < 0.05). The motoneurons and/or muscle fibers may become more excitable during the DF task so that the same stimulus can recruit those that are otherwise less excitable during the SF task.

Experimental wound healing with electrical stimulation.

The effect of alternating current (AC) and direct current (DC) stimulation was studied on experimental pressure ulcer healing in a new monoplegic pig model. The study was conducted in 30 healthy young Hanford minipigs. The rate of wound healing, histology, vascularization, collagen formation, microbiology, perfusion, and the mechanical strength of the healed wounds were studied. Normal pigskin was compared to denervated control and denervated AC and DC stimulated healed skin. Hind limb denervation was by right unilateral extradural rhizotomies from the L2 to S1 nerve roots. Reproducible uniformly controlled Stage III or higher tissue ulcers were created. When compared to the control wounds, both the AC and DC stimulated wounds showed reduced healing time and increased perfusion in the early phases of healing. DC stimulation reduced the wound area more rapidly than AC, but AC stimulation reduced the wound volume more rapidly than DC. The electrical stimulation did not reduce the strength of the healing wounds below those of the nonstimulated controls. The applied current appears to orient new collagen formation even in the absence of neural influences.

Older adults exhibit a reduced ability to fully activate their biceps brachii muscle.

BACKGROUND: Voluntary muscle strength declines significantly in older adults. One contributing factor to the strength loss is muscle atrophy developed in old age. Whether the ability to maximally activate the muscle decreases with age, however, is unknown. This study was intended to determine if the central nervous system command to maximally activate the biceps brachii muscle deteriorates with age. METHODS: Electrical stimulation pulses were applied to the skin overlying the biceps brachii muscle during maximal voluntary elbow-flexion contractions. The magnitude of force evoked on the maximal voluntary force was measured to determine the activation level (AL) of the muscle. RESULTS: The AL was 94% for the elderly group and 97% for the young group (100% AL indicates complete activation). The AL for both the elderly and young groups was significantly (p<.05) lower than 100%. The AL of the elderly group was significantly (p<.05) lower than that of the young group. CONCLUSIONS: The loss of voluntary strength in older adults is a mixed result of muscle atrophy and a reduced ability to fully activate muscle.

Quinupristin/dalfopristin (RP 59500) therapy for vancomycin-resistant Enterococcus faecium aortic graft infection: case report.

A 46-year-old woman was admitted to the hospital with severe peripheral vascular disease, requiring multiple vascular surgical procedures. During the sixth hospital week, after prior therapy with multiple antibiotics, Enterococcus faecium was isolated as the only organism from an operating room culture of an infected aortic graft. Histological examination of the graft showed infiltration with polymorphonuclear leukocytes. Subsequently, cultures of an infected inguinal wound yielded Enterococcus faecium with mixed bacterial growth. Both isolates of Enterococcus faecium were resistant to all available antimicrobials, including ampicillin, vancomycin, tetracycline, chloramphenicol, and ciprofloxacin. Compassionate use therapy with quinupristin/dalfopristin (RP59500) was administered for 25 days, the patient's clinical condition improved, and wound healing occurred. Transient elevation of serum alkaline phosphatase was noted. This case demonstrates successful eradication of deep VREF infection by quinupristin/dalfopristin with good tolerance of prolonged therapy.

Shunting in chronic post-traumatic hydrocephalus: demonstration of neurophysiologic improvement.

The neuronal metabolic state that forms the cellular basis for cognitive functioning and motor behavior is dependent on cerebral perfusion. As intracerebral pressure increases, cerebral perfusion is compromised. The management of acute hydrocephalus after head trauma has been extensively described. In this article, we present evidence of clinical, cerebral perfusion, and neurophysiologic improvement in a 19-year-old patient with chronic post-traumatic hydrocephalus. Lethargy, gaze palsy, torticollis, and triplegia were noted 2 years postinjury in a neurologically stable patient. Computed axial tomography (CAT) scan confirmed marked enlargement of the third and fourth ventricles with a prominent subgaleal fluid collection. Intraoperative cerebral spinal fluid pressure was 26cm H2O despite hyperventilation. A ventriculo-peritoneal shunt was placed. Postoperatively, marked improvement in clinical exam, cerebral perfusion (SPECT scan), and evoked potentials correlated with the reemergence of the cerebral mantle on CAT scan and magnetic resonance imaging (MRI). Chronic obstructive hydrocephalus should be suspected and aggressively pursued in chronic head injury.

Amantadine-induced coma.

Amantadine has found use primarily as an antiviral agent and in the symptomatic treatment of parkinsonism. However, the use of amantadine for the subjective alleviation of fatigue in multiple sclerosis and in the treatment of agitated aggressive behavior in the traumatic brain injured patient has also been described. Side effects of amantadine are primarily related to the central nervous system and include hallucinations, confusion, and nightmares. Toxic manifestations include acute psychosis, coma, cardiovascular toxicity, and death. Amantadine toxicity is a particular problem in patients with renal insufficiency because 90% of an oral dose is excreted unchanged in the urine. We present a case of amantadine-induced coma in a patient with multiple sclerosis and end-stage renal disease. Moreover, this degree of amantadine toxicity was profoundly apparent at a drug level usually not associated with such a severe presentation.

Multichannel cochlear implantation in the rehabilitation of post-traumatic sensorineural hearing loss.

Although there is a 17% to 56% incidence of sensorineural hearing loss following head injury, to our knowledge cochlear implants have not been used in treatment of this problem in patients with cognitive deficits and aphasia. We report our experience with multichannel cochlear implantation in one such patient. The patient is a 26-year-old man with bitemporal lobe damage and T-11 paraplegia. The clinical profile showed emotional lability, perseveration of thought, impulsivity, good visuospatial orientation, and adequate use of oral and written language in conveying basic needs. Audiologic evaluation showed profound sensorineural hearing loss. Middle latency responses suggested intact thalamocortical pathways. The patient was provided with a multichannel cochlear implant with improvement in his speech recognition and functional skills. We conclude that the cochlear implant should be considered in patients with traumatic sensorineural hearing loss with relatively intact cognitive skills.

Effects of denervation on laryngeal muscles: a canine model.

The purpose of this study was to chronologically evaluate the changes in functional and histomorphometry of denervated laryngeal muscles. In 14 adult mongrel dogs, a 2.5-cm segment of the right recurrent laryngeal nerve was excised. Videolaryngoscopy and electromyography were performed at 1, 2, 3, 4, 5, 6, and 9 months under intravenous sedation. The animals were then killed, and the laryngeal muscles were processed for histochemical reactions. The mean muscle fiber diameter, standard deviation, and muscle fiber type composition were determined. The findings indicate that, following recurrent laryngeal nerve sectioning, the canine intrinsic laryngeal muscles undergo denervation atrophy for approximately 3 months, after which reinnervation occurs. The source of reinnervation appears to be from regenerated nerve fibers of the sectioned recurrent laryngeal nerve. The nerve fibers nonselectively reinnervated the abductor and adductor muscles of the larynx.

Morphometric studies of normal muscle mitochondria.

The study describes mitochondrial morphometry in normal adult limb muscles of various mammalian species. The size, area, shape, and volume of mitochondria were compared in two regions (subsarcolemmal and intermyofibrillary) and fiber types (type 1 and type 2) of the 1) human and monkey quadriceps, 2) cat soleus and caudofemoralis-CF, and 3) rat soleus and extensor digitorum longus-EDL. The Z band width showed distinct differences between the two types of fibers in all muscles. The mitochondrial size and volume varied in different muscles but the shape remained oval throughout. The human quadriceps mitochondria were the smallest in size and volume. The monkey and rat muscles showed higher mitochondrial volume which was not significantly different between the two fiber types. The cat soleus and EDL muscles showed significant difference in the mitochondrial volume of two fiber types and also significant correlation between the Z band width and the mitochondrial volume, the soleus being pure type 1 fibers and the EDL being pure type 2B fibers. We conclude that only the shape of mitochondria, but not the size and volume, is independent of the species, the type of muscle and the region of a fiber.