Physical Therapy Intervention Effects on Alteration of Spinal Excitability in Patients With Chronic Ankle Instability: A Systematic Review and Meta-analysis.

CONTEXT: Chronic ankle instability (CAI) is a common injury in athletes. Different forms of physical therapy have been applied to the population with CAI to assess their impact on spinal excitability. OBJECTIVE: The purpose of this systematic review and meta-analysis was to investigate the effectiveness of various physical therapy interventions on the alteration of spinal excitability in patients with CAI. DATA SOURCES: Four databases (EMBASE, MEDLINE, Cochrane CENTRAL, and Scopus) were searched from inception to November 2022. STUDY SELECTION: A total of 253 studies were obtained and screened; 11 studies on the effects of physical therapy intervention on the alteration of spinal excitability in patients with CAI were identified for meta-analysis. STUDY DESIGN: Systematic review and meta-analysis. LEVEL OF EVIDENCE: Level 3a. DATA EXTRACTION: A total of 11 studies that included the maximal Hoffmann reflex normalized by the maximal muscle response (H/M ratio) in the peroneus longus and soleus muscles were extracted and summarized. The quality of the studies was assessed using the PEDro scale. RESULTS: The extracted studies had an average PEDro score of 4.7 ± 1.4, indicating that most of them had fair-to-good quality. The physical therapy interventions included cryotherapy, taping, mobilization, proprioceptive training, and dry needling. The overall effects showed that the H/M ratios of the peroneus longus (P = 0.44, I2 = 0%) and soleus (P = 0.56,I2 = 22%) muscles were not changed by physical therapy in patients with CAI. CONCLUSION: The meta-analysis indicated that physical therapy interventions such as cryotherapy, taping, mobilization, proprioceptive training, and dry needling do not alter the spinal excitability in patients with CAI. Given that only 1 study reported ineffective changes in spinal excitability with dry needling, more research is essential to establish and validate its efficacy. PROSPERO REGISTRATION: CRD42022372998.

Local and Non-local Effects of Foam Rolling on Passive Soft Tissue Properties and Spinal Excitability.

In sports and clinical settings, roller massage (RM) interventions are used to acutely increase range of motion (ROM); however, the underlying mechanisms are unclear. Apart from changes in soft tissue properties (i.e., reduced passive stiffness), neurophysiological alterations such as decreased spinal excitability have been described. However, to date, no study has investigated both jointly. The purpose of this trial was to examine RM's effects on neurophysiological markers and passive tissue properties of the plantar flexors in the treated (ROLL) and non-treated (NO-ROLL) leg. Fifteen healthy individuals (23 ± 3 years, eight females) performed three unilateral 60-s bouts of calf RM. This procedure was repeated four times on separate days to allow independent assessments of the following outcomes without reciprocal interactions: dorsiflexion ROM, passive torque during passive dorsiflexion, shear elastic modulus of the medial gastrocnemius muscle, and spinal excitability. Following RM, dorsiflexion ROM increased in both ROLL (+19.7%) and NO-ROLL (+13.9%). Similarly, also passive torque at dorsiflexion ROM increased in ROLL (+15.0%) and NO-ROLL (+15.2%). However, there were no significant changes in shear elastic modulus and spinal excitability (p > 0.05). Moreover, significant correlations were observed between the changes in DF ROM and passive torque at DF ROM in both ROLL and NO-ROLL. Changes in ROM after RM appear to be the result of sensory changes (e.g., passive torque at DF ROM), affecting both rolled and non-rolled body regions. Thus, therapists and exercise professionals may consider applying remote treatments if local loading is contraindicated.

Sex Differences in the Mechanical and Neurophysiological Response to Roller Massage of the Plantar Flexors.

Self-massage using foam rollers, sticks, or balls has become a popular technique to enhance joint range of motion (ROM). Although increases are reported to be larger in females than males, the mechanisms of this observation are unclear. The present study aimed to investigate the effect of roller massage (RM) on ROM, passive tissue stiffness, and neurophysiological markers as a function of sex. Males (n = 15, 22.8 ± 2.9 yrs.) and females (n = 14, 21.1 ± 0.7 yrs.) performed three 60-second bouts of calf RM. Outcomes assessed pre-, and post-intervention included passive dorsiflexion (DF) ROM, passive tissue stiffness, passive torque, DF angle at the first stretch sensation, shear elastic modulus, and spinal excitability. DF ROM (+35.9 %), passive torque at DF ROM (+46.4 %), DF angle at first stretch sensation (+32.9 %), and pain pressure threshold (+25.2 %) increased in both groups (p<.05) with no differences between males and females (p > 0.05). No changes were observed for passive stiffness, shear elastic modulus, and spinal excitability (p > 0.05). Roller massage may increase ROM independently of sex, which, in the present study, could not be ascribed to alterations in passive stiffness or neurophysiological markers. Future studies may further elucidate the role of sensory alterations as possible factors driving RM-induced changes in flexibility.

Long-term Inhibition of Soleus H-reflex with Epidural Adhesiolysis and Pulsed Radiofrequency in Lumbosacral Neuropathic Pain.

INTRODUCTION: Scientific data about neurophysiological changes subsequent to pulsed radiofrequency (PRF) are still lacking. The goal of this study was to evaluate sural nerve conduction and Hoffmann reflex (H-reflex) in soleus muscle following adhesiolysis and PRF in patients with unilateral chronic lumbosacral L5-S1 neuropathic radiating pain. METHODS: Seventeen patients received two cycles of 240 seconds high-voltage PRF and epidural adhesiolysis. Sural nerve action potential (SNAP) and the ratio of maximum H-reflex to maximum M response (H/M ratio) as well as pain scores were collected in both lower limbs before, immediately following, and 1 month after the treatment. RESULTS: At follow-up, a significant reduction in numeric rating scale (NRS) and Douleur Neuropathique 4 Questions (DN4) scores was observed in 53% of patients reporting pain improvement of ≥ 30% over baseline. The H/M ratio was decreased in the affected limb following PRF (P = 0.01) and 1 month after the treatment (P = 0.04). A direct correlation was observed between H/M ratio variation and NRS score at follow-up in the treated limb (P = 0.04). No significant difference in sural nerve latency, amplitude, and velocity was detected between affected and normal side after treatment and at follow-up. CONCLUSIONS: Epidural adhesiolysis and PRF of the dorsal root ganglion seem to significantly affect spinal reflexes in patients with lumbosacral neuropathic radiating pain.

Cannabinoids in multiple sclerosis: A neurophysiological analysis.

OBJECTIVES: To investigate the action of cannabinoids on spasticity and pain in secondary progressive multiple sclerosis, by means of neurophysiological indexes. MATERIAL AND METHODS: We assessed 15 patients with progressive MS (11 females) using clinical scales for spasticity and pain, as well as neurophysiological variables (H/M ratio, cutaneous silent period or CSP). Testing occurred before (T0) and during (T1) a standard treatment with an oral spray containing delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). Neurophysiological measures at T0 were compared with those of 14 healthy controls of similar age and sex (HC). We then compared the patient results at the two time points (T1 vs T0). RESULTS: At T0, neurophysiological variables did not differ significantly between patients and controls. At T1, spasticity and pain scores improved, as detected by the Modified Ashworth Scale or MAS (P = .001), 9-Hole Peg Test or 9HPT (P = .018), numeric rating scale for spasticity or NRS (P = .001), and visual analogue scale for pain or VAS (P = .005). At the same time, the CSP was significantly prolonged (P = .001). CONCLUSIONS: The THC-CBD spray improved spasticity and pain in secondary progressive MS patients. The spray prolonged CSP duration, which appears a promising tool for assessing and monitoring the analgesic effects of THC-CBD in MS.

A diagnostic strategy for Lewy body disease using DAT-SPECT, MIBG and Combined index.

PURPOSE: The functional imaging methods widely used for the diagnosis of Lewy body disease (LBD) are 123I-N-ω-fluoropropyl-2ß-carbomethoxy-3ß-(4-iodophenyl) nortropan (FP-CIT) with dopamine transporter single photon emission computed tomography (DAT-SPECT) and 123I-iodobenzylguanidine (MIBG) myocardial scintigraphy. The aim of this study was to determine whether DAT-SPECT or 123I-MIBG myocardial scintigraphy should be examined first and to evaluate whether the combined use of DAT-SPECT and MIBG myocardial scintigraphy is superior to using either modality alone for diagnosing suspected LBD. METHODS: In this retrospective study, a total of 117 patients suspected of having LBD underwent DAT-SPECT imaging followed by MIBG myocardial scintigraphy. The delayed heart-to-mediastinum (H/M) ratio of MIBG scintigraphy, and the specific binding ratio (SBR) of DAT-SPECT imaging, and Combined index (defined as SBR mean × H/M in the delayed phase) were used as semi-quantitative measures. The diagnostic ability was evaluated using these indexes. RESULTS: The sensitivity, specificity, and accuracy of diagnosing Lewy body disease were 59.6%, 71.4%, and 67.5% by SBR mean of DAT-SPECT, 85.1%, 91.4%, and 88.9% by delayed H/M ratio of MIBG myocardial scintigraphy, 76.6%, 74.3%, and 75.2% by Combined index, respectively. CONCLUSION: In the diagnosis of LBD, DAT-SPECT, MIBG myocardial scintigraphy, and Combined index may be reliable indices. In particular, MIBG myocardial scintigraphy was the specific modality for LBD diagnosis. Understanding the effectiveness and limits of DAT-SPECT and MIBG myocardial scintigraphy and using both properly will lead to a more accurate diagnosis and better treatment.

Left-ventricular innervation assessed by 123I-SPECT/CT is associated with cardiac events in inherited arrhythmia syndromes.

AIMS: Impaired myocardial sympathetic innervation assessed by 123Iodine-Metaiodobenzylguanidine (123I-MIBG) scintigraphy is associated with cardiac events. Since regional disparities of structural abnormalities are common in inherited arrhythmia syndromes (iAS), a chamber-specific innervation assessment of the right (RV) and left ventricle (LV) could provide important insights for a patient-individual therapy. Aim of this study was to evaluate chamber-specific patterns of autonomic innervation by Single-photon emission computed tomography/computed tomography (SPECT/CT) in patients with iAS with respect to clinical outcome regarding cardiac events. METHODS AND RESULTS: We assessed ventricular sympathetic innervation (LV, RV and planar heart/mediastinum-ratios, and washout-rates) by 123I-MIBG-SPECT/CT in 48 patients (arrhythmogenic right ventricular cardiomyopathy [ARVC], n = 26; laminopathy, n = 8; idiopathic ventricular fibrillation [iVF], n = 14) in relation to a composite clinical endpoint (ventricular arrhythmia; cardiac death; cardiac hospitalization). RV tracer uptake was lower in patients with ARVC than in laminopathy and iVF patients (1.7 ± 0.4 vs. 2.1 ± 0.7 and 2.1 ± 0.5, respectively). Over a median follow-up of 2.2 years, the combined endpoint was met in 18 patients (n = 12 ventricular tachyarrhythmias, n = 5 hospitalizations, n = 1 death). LV, but not RV H/M ratio was associated with the combined endpoint (hazard-ratio 2.82 [1.30-6.10], p < 0.01). After adjustment for LV and RV function, LV H/M-ratio still remained a significant predictor for cardiac events (hazard-ratio 2.79 [1.06-7.35], p = 0.04). CONCLUSION: We demonstrated that chamber-specific 123MIBG-SPECT/CT imaging is feasible and that reduced LV sympathetic innervation was associated with worse outcome in iAS. These findings provide novel insights into the potential role of regional autonomic nervous system heterogeneity for the evolution of life-threatening cardiac events in iAS.

Clinical and electrophysiological investigation of spastic muscle overactivity in patients with disorders of consciousness following severe brain injury.

OBJECTIVE: The clinical and electrophysiological profile of spastic muscle overactivity (SMO) is poorly documented in patients with disorders of consciousness (DOC) following severe cortical and subcortical injury. We aim at investigating the link between the clinical observations of SMO and the electrophysiological spastic over-reactivity in patients with prolonged DOC. METHODS: We prospectively enrolled adult patients with DOC at least 3 months post traumatic or non-traumatic brain injury. The spastic profile was investigated using the Modified Ashworth Scale and the Hmax/Mmax ratio. T1 MRI data and impact of medication were analyzed as well. RESULTS: 21 patients were included (mean age: 41 ±â€¯11 years; time since injury: 4 ±â€¯5 years; 9 women; 10 traumatic etiologies). Eighteen patients presented signs of SMO and 11 had an increased ratio. Eight patients presented signs of SMO but no increased ratio. We did not find any significant correlation between the ratio and the MAS score for each limb (all ps > 0.05). The presence of medication was not significantly associated with a reduction in MAS scores or Hmax/Mmax ratios. CONCLUSIONS: In this preliminary study, the Hmax/Mmax ratio does not seem to reflect the clinical MAS scores in patients with DOC. This supports the fact they do not only present spasticity but other forms of SMO and contracture. SIGNIFICANCE: Patients with DOC are still in need of optimized tools to evaluate their spastic profile and therapeutic approaches should be adapted accordingly.

Combined use of dopamine transporter imaging (DAT-SPECT) and 123I-metaiodobenzylguanidine (MIBG) myocardial scintigraphy for diagnosing Parkinson's disease.

BACKGROUND: To examine whether combined use of 123I-FP-CIT dopamine transporter single photon emission computed tomography (DAT-SPECT) and 123I-MIBG myocardial scintigraphy (MIBG) is superior to either modality alone for diagnosing Parkinson's disease (PD). METHODS: Patients with probable PD (n=120) who underwent both DAT-SPECT and MIBG myocardial scintigraphy within short intervals were enrolled. Specific binding ratio (SBR) of DAT-SPECT images and heart-to-mediastinum (H/M) ratio of MIBG images were used as quantitative measures. We classified patients into 4 groups based on SBR value and H/M ratio, or into two groups based on the striatal asymmetry index (SAI) of DAT-SPECT, and examined the clinical features of each group. We also investigated the characteristics of SWEDDs (scans without evidence of dopaminergic deficits) patients. Finally, we calculated the sensitivity and specificity of each method and the combined method. RESULTS: SBR value was significantly correlated with both early and delayed H/M ratio values. Motor complications and hallucinations were observed at high frequency in the group with both lower SBR and H/M ratio, and hallucinations appeared in the group with larger SAI. SWEDDs were observed 8.3% of patients. The sensitivity and specificity of diagnosing PD were 91.7% and 15.0% by SBR of DAT-SPECT, 78.3% and 90.0% by H/M ratio of MIBG uptake, and 74.2% and 95.0% by the combined modalities, respectively. CONCLUSIONS: Combined use of DAT-SPECT and MIBG myocardial scintigraphy increases the specificity of PD diagnosis, and is helpful for understanding the clinical features or predicting complications.

Effect of shock wave therapy on ankle plantar flexors spasticity in stroke patients.

BACKGROUND: Large number of patients with first-ever stroke developed spasticity. Spasticity can reduce the range of motion, hinder voluntary movements, provoke pain, and result in impairment of functional activities of daily living. OBJECTIVE: Demonstrate the effect of shock wave therapy on ankle plantar flexors spasticity in stroke patients. METHODS: We included forty ischemic stroke patients divided into 2 groups; group I were subjected to the selected physical therapy program and shock wave therapy whereas group II received the selected physical therapy program as well as placebo shock wave for six weeks. Both groups were subjected to pre- and post-treatment assessment by H/M ratio, dorsiflexion active range of motion, and time of ten-meters walking. RESULTS: Baseline characteristics showed no significant difference between the two groups regarding the grades of spasticity. Whereas After treatment, there were a highly significant difference between both groups regarding the grades of spasticity according to the 3 parameters, H/M ratio, dorsiflexion active range of motion, and time of ten-meters walking test (P values; <0.001, 0.006, and 0.009 respectively). CONCLUSIONS: Shock wave therapy is effective in controlling spasticity, increase dorsiflexion active range of motion of ankle and improving ten- meters walking test in stroke patients.

Correction of collimator-dependent differences in the heart-to-mediastinum ratio in 123I-metaiodobenzylguanidine cardiac sympathetic imaging: Determination of conversion equations using point-source imaging.

BACKGROUND: Septal penetration causes collimator-dependent differences in the heart-to-mediastinum (H/M) ratio in 123I-metaiodobenzylguanidine (MIBG) cardiac imaging. We investigated generally applicable methods to correct such differences. METHODS AND RESULTS: Four hours after 123I-MIBG injection, 40 patients underwent anterior chest imaging successively with medium-energy (ME) and various non-ME collimators. The H/M ratios obtained with the non-ME collimators before and after 123I-dual-window penetration correction were compared with the ME-derived standard values to determine patient-based conversion equations for empiric and combined corrections, respectively. A 123I point source was imaged with various collimators, and the central ratio, the ratio of count in a small central region of interest to count in a large one, was calculated. The method of predicting the conversion equations from the central ratios was determined. Correction using the patient-based conversion equations removed systematic underestimation of the H/M ratios obtained with the non-ME collimators, and combined correction depressed residual random errors to some degree. Point-source-based equations yielded results comparable to the patient-based equations. CONCLUSIONS: Empiric and combined corrections effectively reduce collimator-dependent differences in the H/M ratio. The conversion equations can be predicted from simple point-source imaging, which would allow to apply these corrections to data obtained with various collimators.

Acquisition protocols and correction methods for estimation of the heart-to-mediastinum ratio in 123I-metaiodobenzylguanidine cardiac sympathetic imaging.

UNLABELLED: Septal penetration of high-energy photons affects quantitative results in imaging of (123)I-labeled tracers. We investigated acquisition protocols (collimator choice and energy window setting) and correction methods for estimating the heart-to-mediastinum (H/M) ratio in cardiac (123)I-metaiodobenzylguanidine (MIBG) imaging. METHODS: Four hours after (123)I-MIBG injection, 40 patients successively underwent planar anterior chest imaging with the medium-energy (ME) (ME method) and low-energy high-resolution (LEHR) (LEHR method) collimators. A 20% energy window was used for both collimators. Another 40 patients were imaged successively with the ME collimator and a 20% window (ME method), the low-medium-energy (LME) collimator and a 20% window (LME20 method), and the LME collimator and a 15% window (LME15 method). The H/M ratios obtained by the LEHR, LME20, and LME15 methods were corrected using their correlations with the H/M ratio obtained by the ME method (empiric correction). The (123)I-dual-window (IDW) correction was also applied to remove the influence of high-energy photons. RESULTS: Without correction, severe underestimation of the H/M ratio was shown for the LEHR method using the ME method as a standard, and this underestimation increased with increasing H/M ratios. Underestimation substantially decreased using the LME20 method and further using the LME15 method. Empiric correction reduced the error in the H/M ratio by the LEHR method, but the error was still evident. After empiric correction, the H/M ratios with the LME collimator were comparable to those with the ME collimator. The IDW correction only partially reduced underestimation by the LEHR method and caused a small overestimation for the LME15 method. CONCLUSION: The use of an LME collimator appears to be acceptable for cardiac (123)I-MIBG imaging as an alternative to an ME collimator, and the application of a 15% energy window is recommended when an LME collimator is used. Empiric correction is also expected to improve exchangeability between H/M ratios calculated with ME and LME collimators. Neither the use of an LEHR collimator nor the use of IDW correction is recommended.