Reduced inhibition from quadriceps onto soleus after acute quadriceps fatigue suggests Golgi tendon organ contribution to heteronymous inhibition.

Heteronymous inhibition between lower limb muscles is primarily attributed to recurrent inhibitory circuits in humans but could also arise from Golgi tendon organs (GTOs). Distinguishing between recurrent inhibition and mechanical activation of GTOs is challenging because their heteronymous effects are both elicited by stimulation of nerves or a muscle above motor threshold. Here, the unique influence of mechanically activated GTOs was examined by comparing the magnitude of heteronymous inhibition from quadriceps (Q) muscle stimulation onto ongoing soleus electromyographic at five Q stimulation intensities (1.5-2.5× motor threshold) before and after an acute bout of stimulation-induced Q fatigue. Fatigue was used to decrease Q stimulation evoked force (i.e., decreased GTO activation) despite using the same pre-fatigue stimulation currents (i.e., same antidromic recurrent inhibition input). Thus, a decrease in heteronymous inhibition after Q fatigue and a linear relation between stimulation-evoked torque and inhibition both before and after fatigue would support mechanical activation of GTOs as a source of inhibition. A reduction in evoked torque but no change in inhibition would support recurrent inhibition. After fatigue, Q stimulation-evoked knee torque, heteronymous inhibition magnitude and inhibition duration were significantly decreased for all stimulation intensities. In addition, heteronymous inhibition magnitude was linearly related to twitch-evoked knee torque before and after fatigue. These findings support mechanical activation of GTOs as a source of heteronymous inhibition along with recurrent inhibition. The unique patterns of heteronymous inhibition before and after fatigue across participants suggest the relative contribution of GTOs, and recurrent inhibition may vary across persons.

Quadriceps muscle stimulation evokes heteronymous inhibition onto soleus with limited Ia activation compared to femoral nerve stimulation.

Heteronymous excitatory feedback from muscle spindles and inhibitory feedback from Golgi tendon organs and recurrent inhibitory circuits can influence motor coordination. The functional role of inhibitory feedback is difficult to determine, because nerve stimulation, the primary method used in humans, cannot evoke inhibition without first activating the largest diameter muscle spindle axons. Here, we tested the hypothesis that quadriceps muscle stimulation could be used to examine heteronymous inhibition more selectively when compared to femoral nerve stimulation by comparing the effects of nerve and muscle stimulation onto ongoing soleus EMG held at 20% of maximal effort. Motor threshold and two higher femoral nerve and quadriceps stimulus intensities matched by twitch evoked torque magnitudes were examined. We found that significantly fewer participants exhibited excitation during quadriceps muscle stimulation when compared to nerve stimulation (14-29% vs. 64-71% of participants across stimulation intensities) and the magnitude of heteronymous excitation from muscle stimulation, when present, was much reduced compared to nerve stimulation. Muscle and nerve stimulation resulted in heteronymous inhibition that significantly increased with increasing stimulation evoked torque magnitudes. This study provides novel evidence that muscle stimulation may be used to more selectively examine inhibitory heteronymous feedback between muscles in the human lower limb when compared to nerve stimulation.

Soleus H-reflex modulation during a double-legged drop landing task.

Muscle spindle afferent feedback is modulated during different phases of locomotor tasks in a way that facilitates task goals. However, only a few studies have studied H-reflex modulation during landing. This study aimed to characterize soleus (SOL) H-reflex modulation during the flight and early landing period of drop landings. Since landing presumably involves a massive increase in spindle afferent firing due to rapid SOL muscle stretching, we hypothesized H-reflex size would decrease near landing reflecting neural modulation to prevent excessive motoneuron excitation. The soleus H-reflex was recorded during drop landings from a 30 cm height in nine healthy adults. Electromyography (SOL, tibialis anterior (TA), medial gastrocnemius, and vastus lateralis), ankle and knee joint motion and ground reaction force were recorded during landings. Tibial nerve stimulation was timed to elicit H-reflexes during the flight and early ground contact period (five 30 ms Bins from 90 ms before to 60 ms after landing). The H-reflexes recorded after landing (0-30 and 30-60 ms) were significantly smaller (21-36% less) than that recorded during the flight periods (90-0 ms before ground contact; P ≤ 0.004). The decrease in H-reflex size not occurring until after ground contact indicates a time-critical modulation of reflex gain during the last 30 ms of flight (i.e., time of tibial nerve stimulation). H-reflex size reduction after ground contact supports a probable neural strategy to prevent excessive reflex-mediated muscle activation and thereby facilitates appropriate musculotendon and joint stiffness.

Time, graft, sex, geographic location, and isokinetic speed influence the degree of quadriceps weakness after anterior cruciate ligament reconstruction: a systematic review and meta-analysis.

PURPOSE: Although quadriceps weakness after ACL reconstruction (ACLR) is well documented, the magnitude of reported weakness varies considerably. Such variation raises the possibility that certain patients may be more susceptible to quadriceps weakness after ACLR. This meta-analysis identified factors explaining between-study variability in quadriceps weakness post-ACLR. METHODS: Studies between 2010 and 2020 were screened for the following criteria: human subjects, unilateral ACLR, and strength reported both for the ACLR leg and the uninjured or healthy-control leg. 122 studies met the criteria, resulting in 303 and 152 Cohen's d effect sizes (ESs) comparing ACLR legs to uninjured legs (a total of 4135 ACLR subjects) and to healthy controls (a total of 1,507 ACLR subjects vs. 1-193 healthy controls), respectively. Factors (time, graft, sex, activity, mass/height, geographic area, concomitant injury, and type of strength testing) that may affect study ES were examined. RESULTS: Meta-regressions indicated an association between time post-ACLR and study ESs (P < 0.001) and predicted full recovery (ES = 0) to occur at 54-59 months post-ACLR. When compared to uninjured legs, patients with patellar tendon autografts had greater deficits than studies using hamstring tendon autografts (P = 0.023). When compared to uninjured legs, studies including only males reported greater deficits than studies combining males and females (P = 0.045); whereas when compared to healthy controls, studies combining males and females reported greater deficits than studies with males (P = 0.013). When compared to controls, studies from USA reported greater deficits than studies from Europe (P = 0.003). Increased isokinetic-testing speed was associated with smaller deficits (P ≤ 0.025). Less than 25% of patients achieved a between-limb symmetry in quadriceps strength > 90% between 6 and 12 months post-ACLR. CONCLUSION: Time post-surgery, graft, sex, geographic location, and isokinetic speed influenced the magnitude of post-ACLR quadriceps weakness. Patients with patellar tendon autografts demonstrated greater between-limb asymmetry in quadriceps strength, while female strength deficits were underestimated to a greater extent. A slower isokinetic speed provided a more sensitive assessment of quadriceps strength post-ACLR. The overwhelming majority of patients were returning to sport with significantly impaired quadriceps strength. LEVEL OF EVIDENCE: III.

Terminal knee extension deficit and female sex predict poorer quadriceps strength following ACL reconstruction using all-soft tissue quadriceps tendon autografts.

PURPOSE: The all-soft tissue quadriceps tendon (QT) autograft is becoming increasingly popular for ACL reconstruction (ACLR); however, studies reporting strength recovery and early outcomes after QT autograft are limited with patient samples composed of predominantly males. The primary purpose was to characterize early, sex-specific recovery of strength, range of motion (ROM), and knee laxity in a large cohort of patients undergoing primary ACLR with standardized harvest technique of the all-soft tissue QT autograft. The secondary purpose was to examine the influence of demographic factors and clinical measures on 6-month quadriceps strength. METHODS: Patients 14-25 years who underwent primary, unilateral ACLR with all-soft tissue QT autografts were prospectively followed. Knee laxity and ROM were collected at 6 weeks, 3 and 6 months; while, quadriceps normalized torques and limb symmetry indices (LSI) were collected at 3 and 6 months using isokinetic dynamometry at 60°/s. Two-way ANOVAs with repeated measures were conducted to determine recovery over time and between sexes. Stepwise linear multiple regressions were conducted to determine predictors of 6-month quadriceps strength. RESULTS: Three-hundred and twenty patients were included (18 ± 3 years; 156 males:164 females; BMI = 24 ± 4 kg/m2) with no early graft failures within the study period. For strength, there were significant main effects of time (p < 0.001) and sex (p < 0.001), indicating similar improvement from 3 to 6 months with males demonstrating greater quadriceps LSI (6 months: 72.1 vs 63.3%) and normalized strength (6 months: 2.0 vs 1.6 Nm/kg). A significantly higher proportion of females had knee extension ROM deficits ≥ 5° compared to males at 6 weeks (61 vs 39%; p = 0.002). Female sex and 3-month extension ROM deficits were identified as significant predictors of 6-month quadriceps LSI (R2 = 0.083; p < 0.001). Female sex, BMI, and 6-week extension ROM deficits were identified as significant predictors of 6-month normalized quadriceps strength (R2 = 0.190; p < 0.001). CONCLUSIONS: Females had decreased quadriceps strength and greater extension ROM deficits at 3 and 6 months following ACLR using all-soft tissue QT autografts. Female sex, higher BMI, and loss of extension ROM were independent predictors of poorer quadriceps strength at 6 months. There were no early graft failures, and laxity remained within normal ranges for both males and females. Surgeons and rehabilitation clinicians should be aware of the increased risk of postoperative loss of extension ROM in females and its implications on quadriceps strength recovery. LEVEL OF EVIDENCE: III.

Adaptation to slope in locomotor-trained spinal cats with intact and self-reinnervated lateral gastrocnemius and soleus muscles.

Sensorimotor training providing motion-dependent somatosensory feedback to spinal locomotor networks restores treadmill weight-bearing stepping on flat surfaces in spinal cats. In this study, we examined if locomotor ability on flat surfaces transfers to sloped surfaces and the contribution of length-dependent sensory feedback from lateral gastrocnemius (LG) and soleus (Sol) to locomotor recovery after spinal transection and locomotor training. We compared kinematics and muscle activity at different slopes (±10° and ±25°) in spinalized cats (n = 8) trained to walk on a flat treadmill. Half of those animals had their right hindlimb LG/Sol nerve cut and reattached before spinal transection and locomotor training, a procedure called muscle self-reinnervation that leads to elimination of autogenic monosynaptic length feedback in spinally intact animals. All spinal animals trained on a flat surface were able to walk on slopes with minimal differences in walking kinematics and muscle activity between animals with/without LG/Sol self-reinnervation. We found minimal changes in kinematics and muscle activity at lower slopes (±10°), indicating that walking patterns obtained on flat surfaces are robust enough to accommodate low slopes. Contrary to results in spinal intact animals, force responses to muscle stretch largely returned in both SELF-REINNERVATED muscles for the trained spinalized animals. Overall, our results indicate that the locomotor patterns acquired with training on a level surface transfer to walking on low slopes and that spinalization may allow the recovery of autogenic monosynaptic length feedback following muscle self-reinnervation.NEW & NOTEWORTHY Spinal locomotor networks locomotor trained on a flat surface can adapt the locomotor output to slope walking, up to ±25° of slope, even with total absence of supraspinal CONTROL. Autogenic length feedback (stretch reflex) shows signs of recovery in spinalized animals, contrary to results in spinally intact animals.

Redistribution of inhibitory force feedback between a long toe flexor and the major ankle extensor muscles following spinal cord injury.

Inhibitory pathways from Golgi tendon organs project widely between muscles crossing different joints and axes of rotation. Evidence suggests that the strength and distribution of this intermuscular inhibition is dependent on motor task and corresponding signals from the brainstem. The purpose of the present study was to investigate whether this sensory network is altered after spinal cord hemisection as a potential explanation for motor deficits observed after spinal cord injury (SCI). Force feedback was assessed between the long toe flexor and ankle plantarflexor (flexor hallucis longus), and the three major ankle extensors, (combined gastrocnemius, soleus, and plantaris muscles) in the hind limbs of unanesthetized, decerebrate, female cats. Data were collected from animals with intact spinal cords (control) and lateral spinal hemisections (LSHs) including chronic LSH (4-20 weeks), subchronic LSH (2 weeks), and acute LSH. Muscles were stretched individually and in pairwise combinations to measure intermuscular feedback between the toe flexor and each of the ankle extensors. In control animals, three patterns were observed (balanced inhibition between toe flexor and ankle extensors, stronger inhibition from toe flexor to ankle extensor, and vice versa). Following spinal hemisection, only strong inhibition from toe flexors onto ankle extensors was observed independent of survival time. The results suggest immediate and permanent reorganization of force feedback in the injured spinal cord. The altered strength and distribution of force feedback after SCI may be an important future target for rehabilitation.

Evaluating intermuscular Golgi tendon organ feedback with twitch contractions.

KEY POINTS: Golgi tendon organ feedback has been evaluated most frequently using electrical stimulation of peripheral nerves, which is not a physiological or selective stimulus for Golgi tendon organs. Golgi tendon organs are most responsive to active muscle contractions. This study provides evidence that muscle stimulation evoked twitches - a physiological stimulus for Golgi tendon organs - induces intermuscular effects most likely due to mechanical activation of Golgi tendon organ feedback and not direct activation of sensory axons. The results demonstrate that twitch contractions are a feasible non-invasive approach that can be used to advance understanding of the functional role of Golgi tendon organ feedback. ABSTRACT: Force feedback from Golgi tendon organs (GTOs) has widespread intermuscular projections mediated by interneurons that share inputs from muscle spindles, among others. Because current methods to study GTO circuitry (nerve stimulation or muscle stretch) also activate muscle spindle afferents, the selective role of GTOs remains uncertain. Here, we tested the hypothesis that intramuscular stimulation evoked twitch contractions could be used to naturally bias activation of GTOs and thus evaluate their intermuscular effects in decerebrate cats. This was achieved by comparing the effects of twitch contractions and stretches as donor inputs onto the motor output of recipient muscles. Donor-recipient pairs evaluated included those already known in the cat to receive donor excitatory muscle spindle feedback only, inhibitory GTO feedback only, and both excitatory spindle and inhibitory GTO effects. Muscle stretch, but not twitch contractions, evoked excitation onto recipient muscles with muscle spindle afferent inputs only. Both donor muscle stretch and twitch contractions inhibited a recipient muscle with GTO projections only. In a recipient muscle that receives both muscle spindle and GTO projections, donor muscle stretch evoked both excitatory and inhibitory effects, whereas twitch contractions evoked inhibitory effects only. These data support the hypothesis that muscle stimulation evoked contractions can induce intermuscular effects most consistent with mechanical GTO receptor activation and not direct activation of sensory axons. We propose this approach can be used to evaluate GTO circuitry more selectively than muscle stretch or nerve stimulation and can be adapted to study GTO feedback non-invasively in freely moving cats and humans.

Patterns of intermuscular inhibitory force feedback across cat hindlimbs suggest a flexible system for regulating whole limb mechanics.

Prior work has suggested that Golgi tendon organ feedback, via its distributed network linking muscles spanning all joints, could be used by the nervous system to help regulate whole limb mechanics if appropriately organized. We tested this hypothesis by characterizing the patterns of intermuscular force-dependent feedback between the primary extensor muscles spanning the knee, ankle, and toes in decerebrate cat hindlimbs. Intermuscular force feedback was evaluated by stretching tendons of selected muscles in isolation and in pairwise combinations and then measuring the resulting force-dependent intermuscular interactions. The relative inhibitory feedback between extensor muscles was examined, as well as symmetry of the interactions across limbs. Differences in the directional biases of inhibitory feedback were observed across cats, with three patterns identified as points on a spectrum: pattern 1, directional bias of inhibitory feedback onto the ankle extensors and toe flexors; pattern 2, convergence of inhibitory feedback onto ankle extensors and mostly balanced inhibitory feedback between vastus muscle group and flexor hallucis longus, and pattern 3, directional bias of inhibitory feedback onto ankle and knee extensors. The patterns of inhibitory feedback, while different across cats, were symmetric across limbs of individual cats. The variable but structured distribution of force feedback across cat hindlimbs provides preliminary evidence that inhibitory force feedback could be a regulated neural control variable. We propose the directional biases of inhibitory feedback observed experimentally could provide important task-dependent benefits, such as directionally appropriate joint compliance, joint coupling, and compensation for nonuniform inertia. NEW & NOTEWORTHY Feedback from Golgi tendon organs project widely among extensor motor nuclei in the spinal cord. The distributed nature of force feedback suggests these pathways contribute to the global regulation of limb mechanics. Analysis of this network in individual animals indicates that the strengths of these pathways can be reorganized appropriately for a variety of motor tasks, including level walking, slope walking, and landing.

Self-reinnervated muscles lose autogenic length feedback, but intermuscular feedback can recover functional connectivity.

In this study, we sought to identify sensory circuitry responsible for motor deficits or compensatory adaptations after peripheral nerve cut and repair. Self-reinnervation of the ankle extensor muscles abolishes the stretch reflex and increases ankle yielding during downslope walking, but it remains unknown whether this finding generalizes to other muscle groups and whether muscles become completely deafferented. In decerebrate cats at least 19 wk after nerve cut and repair, we examined the influence of quadriceps (Q) muscles' self-reinnervation on autogenic length feedback, as well as intermuscular length and force feedback, among the primary extensor muscles in the cat hindlimb. Effects of gastrocnemius and soleus self-reinnervation on intermuscular circuitry were also evaluated. We found that autogenic length feedback was lost after Q self-reinnervation, indicating that loss of the stretch reflex appears to be a generalizable consequence of muscle self-reinnervation. However, intermuscular force and length feedback, evoked from self-reinnervated muscles, was preserved in most of the interactions evaluated with similar relative inhibitory or excitatory magnitudes. These data indicate that intermuscular spinal reflex circuitry has the ability to regain functional connectivity, but the restoration is not absolute. Explanations for the recovery of intermuscular feedback are discussed, based on identified mechanisms responsible for lost autogenic length feedback. Functional implications, due to permanent loss of autogenic length feedback and potential for compensatory adaptations from preserved intermuscular feedback, are discussed.

Heteronymous feedback from quadriceps onto soleus in stroke survivors.

Background: Recent findings suggest increased excitatory heteronymous feedback from quadriceps onto soleus may contribute to abnormal coactivation of knee and ankle extensors after stroke. However, there is lack of consensus on whether persons post-stroke exhibit altered heteronymous reflexes and, when present, the origin of increased excitation (i.e. increased excitation alone and/or decreased inhibition). This study examined heteronymous excitation and inhibition from quadriceps onto soleus in paretic, nonparetic, and age-matched control limbs to determine whether increased excitation was due to excitatory and/or reduced inhibitory reflex circuits. A secondary purpose was to examine whether heteronymous reflex magnitudes were related to clinical measures of lower limb recovery, walking-speed, and dynamic balance. Methods: Heteronymous excitation and inhibition from quadriceps onto soleus were examined in fourteen persons post-stroke and fourteen age-matched unimpaired participants. Heteronymous feedback was elicited by femoral nerve and quadriceps muscle stimulation in separate trials while participants tonically activated soleus at 20% max. Fugl-Myer assessment of lower extremity, 10-meter walk test, and Mini-BESTest were assessed in stroke survivors. Results: Heteronymous excitation and inhibition onsets, durations, and magnitudes were not different between paretic, nonparetic or age-matched unimpaired limbs. Quadriceps stimulation elicited excitation that was half the magnitude of femoral nerve stimulation. Femoral nerve elicited paretic limb heteronymous excitation was positively correlated with walking speed but did not reach significance because only a subset of paretic limbs exhibited excitation (n = 8, Spearman r = 0.69, P = 0.058). Conclusions: Heteronymous feedback from quadriceps onto soleus assessed in a seated posture was not impaired in persons post-stroke. Despite being unable to identify whether reduced inhibition contributes to abnormal excitation reported in prior studies, our results indicate quadriceps stimulation may allow a better estimate of heteronymous inhibition in those that exhibit exaggerated excitation. Heteronymous excitation magnitude in the paretic limb was positively correlated with self-selected walking speed suggesting paretic limb excitation at the higher end of a normal range may facilitate walking ability after stroke. Future studies are needed to identify whether heteronymous feedback from Q onto SOL is altered after stroke in upright postures and during motor tasks as a necessary next step to identify mechanisms underlying motor impairment.

Differential effect of heteronymous feedback from femoral nerve and quadriceps muscle stimulation onto soleus H-reflex.

Excitatory feedback from muscle spindles, and inhibitory feedback from Golgi tendon organs and recurrent inhibitory circuits are widely distributed within the spinal cord to modulate activity between human lower limb muscles. Heteronymous feedback is most commonly studied in humans by stimulating peripheral nerves, but the unique effect of non-spindle heteronymous feedback is difficult to determine due to the lower threshold of excitatory spindle axons. A few studies suggest stimulation of the muscle belly preferentially elicits non-spindle heteronymous feedback. However, there remains a lack of consensus on the differential effect of nerve and muscle stimulation onto the H-reflex, and the relation of the heteronymous effects onto H-reflex compared to that onto ongoing EMG has not been determined. In this cross-sectional study, we compared excitatory and inhibitory effects from femoral nerve and quadriceps muscle belly stimulation onto soleus H-reflex size in 15 able-bodied participants and in a subset also compared heteronymous effects onto ongoing soleus EMG at 10% and 20% max. Femoral nerve stimulation elicited greater excitation of the H-reflex compared to quadriceps stimulation. The differential effect was also observed onto ongoing soleus EMG at 20% max but not 10%. Femoral nerve and quadriceps stimulation elicited similar inhibition of the soleus H-reflexes, and these results were better associated with soleus EMG at 20%. The results support surface quadriceps muscles stimulation as a method to preferentially study heteronymous inhibition at least in healthy adults. The primary benefit of using muscle stimulation is expected to be in persons with abnormal, prolonged heteronymous excitation. These data further suggest heteronymous feedback should be evaluated with H-reflex or onto ongoing EMG of at least 20% max to identify group differences or modulation of heteronymous feedback in response to treatment or task.

Can exercise interventions reduce external knee adduction moment during gait? A systematic review and meta-analysis.

BACKGROUND: An increased external knee adduction moment has been identified as a factor contributing to the progression of medial knee osteoarthritis. Interventions that reduce knee adduction moment may help prevent knee osteoarthritis onset and progression. While exercise interventions have been commonly used to treat knee osteoarthritis, whether exercises can modulate knee adduction moment in knee osteoarthritis patients remains unknown. This systematic review and meta-analysis aimed to determine if exercise interventions are effective in reducing knee adduction moment during gait. METHODS: Study reports published through May 2023 were screened for pre-specified inclusion/exclusion criteria. Nine studies met the eligibility criteria and yielded 24 effect sizes comparing the reduction in knee adduction moment of the exercise intervention groups to the control groups. Moderator/experimental variables concerning characteristics of the exercise interventions and included subjects (e.g., sex, BMI, type of exercise, muscle group targeted, training volume, physical therapist supervision) that may contribute to variation among studies were explored through subgroup analysis and meta-regression. FINDINGS: The effect of exercise intervention on modulating knee adduction moment during gait was no better than control (ES = -0.004, P = 0.946). Sub-group analysis revealed that the effect sizes of studies containing only females (positive exercise effect) were significantly greater than studies containing both males and females. INTERPRETATION: Exercise may not be effective in reducing knee adduction moment during gait. Clinicians aiming to decrease knee adduction moment in patients with medial knee osteoarthritis should consider alternative treatment options. Exploring the underlying mechanism(s) regarding a more positive response to exercises in females may help design more effective exercise interventions.

Associations of Strength and Spatiotemporal Gait Variables With Knee Loading During Gait After Anterior Cruciate Ligament Reconstruction.

CONTEXT: Altered knee moments are common during gait in patients after anterior cruciate ligament reconstruction (ACLR). Modifiable factors that influence knee moments and are feasible to record in clinical settings such as strength and spatiotemporal values (eg, step length, step width) have not been identified in persons after ACLR. OBJECTIVE: To identify strength and spatiotemporal gait values that can predict knee moments in persons after ACLR. DESIGN: Cross-sectional study. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty-three individuals with ACLR (14.4 ± 17.2 months post-ACLR). MAIN OUTCOME MEASURE(S): Peak knee-flexion and -adduction moments were measured while the participants walked at self-selected speeds. Peak isokinetic knee-extensor strength (60°/s) was recorded on a dynamometer, and spatiotemporal gait values were recorded using a pressure walkway. Pearson coefficients were calculated to examine the association of peak knee moments with strength and gait values. Variables correlated with peak knee-flexion and -adduction moments were entered into a stepwise regression model. RESULTS: Knee-extensor strength and step width were the strongest predictors of knee-flexion moment, accounting for 44% of the variance, whereas stance-phase time and step width were the strongest predictors of knee-adduction moment, explaining 62% of the variance. CONCLUSIONS: The identified spatiotemporal variables could be clinically feasible targets for biofeedback to improve gait after ACLR.

A preliminary investigation of the effects of patellar displacement on brain activation and perceived pain in young females with patellofemoral pain.

OBJECTIVES: To identify the neural substrates of a clinician-based test and associated pain perception in young female athletes with patellofemoral pain. DESIGN: Cross-sectional. METHODS: Females with patellofemoral pain (n = 14; 14.3 ±â€¯3.2 years) completed a patella displacement test during brain functional magnetic resonance imaging. The neuroimaging protocol included 18 s of interspersed rest/test blocks during which an experimenter manually applied intermittent frontal plane stress to the patella during test blocks. Patients rated their pain unpleasantness and pain intensity immediately after testing using a visual analog scale. RESULTS: During the patella displacement test, increased activation was observed in previously identified sensorimotor and neural pain regions, including the primary and secondary somatosensory cortices, primary motor cortex, prefrontal cortex, cerebellum, and other cognitive-related brain regions (z's > 4.4, p's < 0.05). Furthermore, pain unpleasantness during the test was positively correlated with increased activation of the posterior cerebellum (z = 4.51, p = 0.02), which is involved in both motor and pain processing as well as cognitive and affective feedback. CONCLUSIONS: These preliminary findings suggest that the posterior cerebellum may represent a critical modulator in the cognitive appraisal of pain in patellofemoral pain through cortico-cerebellar loops, which may have downstream effects on motor function. However further exploration of task-based functional connectivity between the posterior cerebellum and cortical regions is necessary to support these novel findings and associated interpretations.

Identification of strength and spatiotemporal gait parameters associated with knee loading during gait in persons after anterior cruciate ligament reconstruction.

CONTEXT: Altered knee moments are common during gait in patients following anterior cruciate ligament reconstruction (ACLR). Modifiable factors that influence knee moments and are feasible to record in clinical settings such as strength and spatiotemporal parameters (e.g. step length, step width) have not been identified in persons after ACLR. OBJECTIVE: The objective was to identify strength and spatiotemporal gait parameters that can predict knee moments in persons after ACLR. DESIGN: Cross-Sectional Study Setting: Laboratory Patients: Twenty-three participants with ACLR (14.4 ± 17.2 months post-ACLR) participated. MAIN OUTCOME MEASURES: Peak knee flexion and adduction moments were measured while walking at self-selected speeds. Spatiotemporal gait parameters were recorded with a pressure walkway, and peak isokinetic knee extensor strength (60°/s) was recorded on a dynamometer. Pearson coefficients were used to examine the association of peak knee moments with strength and gait parameters. Variables correlated with peak knee flexion and adduction moments were entered into a stepwise regression model. RESULTS: Step width and knee extensor strength were the strongest predictors of knee flexion moment accounting for 44% of data variance, whereas stance phase time and step width were the strongest predictors of knee adduction moment explaining 62% of data variance. CONCLUSIONS: The spatiotemporal variables that were identified could be clinically feasible targets for biofeedback to improve gait after ACLR.

Musculotendon adaptations and preservation of spinal reflex pathways following agonist-to-antagonist tendon transfer.

Tendon transfer surgeries are performed to restore lost motor function, but outcomes are variable, particularly those involving agonist-to-antagonist muscles. Here, we evaluated the possibility that lack of proprioceptive feedback reorganization and musculotendon adaptations could influence outcomes. Plantaris-to-tibialis anterior tendon transfer along with resection of the distal third of the tibialis anterior muscle belly was performed in eight cats. Four cats had concurrent transection of the deep peroneal nerve. After 15-20 weeks, intermuscular length and force-dependent sensory feedback were examined between hindlimb muscles, and the integrity of the tendon-to-tendon connection and musculotendon adaptations were evaluated. Three of the transferred tendons tore. A common finding was the formation of new tendinous connections, which often inserted near the original location of insertion on the skeleton (e.g., connections from plantaris toward calcaneus and from tibialis anterior toward first metatarsal). The newly formed tissue connections are expected to compromise the mechanical action of the transferred muscle. We found no evidence of changes in intermuscular reflexes between transferred plantaris muscle and synergists/antagonists whether the tendon-to-tendon connection remained intact or tore, indicating no spinal reflex reorganization. We propose the lack of spinal reflex reorganization could contribute the transferred muscle not adopting the activation patterns of the host muscle. Taken together, these findings suggest that musculotendon plasticity and lack of spinal reflex circuitry reorganization could limit functional outcomes after tendon transfer surgery. Surgical planning and outcomes assessments after tendon transfer surgery should consider potential consequences of the transferred muscle's intermuscular spinal circuit actions.

Relationship of physical examination findings and self-reported symptom severity and physical function in patients with degenerative lumbar conditions.

BACKGROUND AND PURPOSE: Limited data are available to assist clinicians in clinical decision making. The purpose of this study was to examine the relationships of symptom provocation during physical examination (PE) procedures and self-report of symptom severity and function in patients with degenerative lumbar conditions. SUBJECTS: Twenty-four men and 50 women with chronic low back pain (CLBP) (>6 months duration) were recruited from a university hospital (median age=64.2 years, mean=66.8, SD=12.4, range=55.7-97.8). METHODS: Demographic information, medical history, PE findings, and data from 2 self-report measures of symptom severity and function (Lumbar Spinal Stenosis [LSS] questionnaire and Medical Outcomes Study 36-Item Short-Form Health Survey [SF-36]) were collected. RESULTS: Patients had moderate symptoms of degenerative lumbar conditions (mean LSS symptom score=2.67, SD=0.71) and reported some difficulties with low back function (mean LSS function score=1.99, SD=0.61). The most frequent physical examination findings were a positive quadrant test (70%), followed by lower-extremity muscle weakness (64%), abnormal reflexes (62%), and active lumbar extension (61%). Patients who were symptomatic during the quadrant test, patients who had pain with lateral flexion, and patients who had lower-extremity weakness had higher self-reported LSS symptom severity (t=-3.06, P=.003; t=-2.96, P=.004; and t=-3.2, P=.002, respectively). Pain with lumbar extension was moderately correlated with LSS symptom severity (Spearman rho=.31, P=.007). No lumbar PE procedure was associated with decreased condition-specific function. The quadrant test was the strongest predictor of symptom severity (beta=.54, r(2)=.21, P=.0009). DISCUSSION AND CONCLUSION: The association between PE findings and self-reported symptom severity in this sample is consistent with the pathoanatomy of degenerative spinal conditions and indicates that movement that narrows the foraminal space contributes to symptom severity. The quadrant test distinguished those subjects with clinically meaningful low back symptom severity but was not predictive of impaired function. This study illustrates the potential benefit of identifying clinical PE measures that are reflective of condition severity and back-specific function in patients with similar clinical syndromes.

Control of dynamic foot-ground interactions in male and female soccer athletes: females exhibit reduced dexterity and higher limb stiffness during landing.

Controlling dynamic interactions between the lower limb and ground is important for skilled locomotion and may influence injury risk in athletes. It is well known that female athletes sustain anterior cruciate ligament (ACL) tears at higher rates than male athletes, and exhibit lower extremity biomechanics thought to increase injury risk during sport maneuvers. The purpose of this study was to examine whether lower extremity dexterity (LED)--the ability to dynamically control endpoint force magnitude and direction as quantified by compressing an unstable spring with the lower limb at submaximal forces--is a potential contributing factor to the "at-risk" movement behavior exhibited by female athletes. We tested this hypothesis by comparing LED-test performance and single-limb drop jump biomechanics between 14 female and 14 male high school soccer players. We found that female athletes exhibited reduced LED-test performance (p=0.001) and higher limb stiffness during landing (p=0.008) calculated on average within 51 ms of foot contact. Females also exhibited higher coactivation at the ankle (p=0.001) and knee (p=0.02) before landing. No sex differences in sagittal plane joint angles and center of mass velocity at foot contact were observed. Collectively, our results raise the possibility that the higher leg stiffness observed in females during landing is an anticipatory behavior due in part to reduced lower extremity dexterity. The reduced lower extremity dexterity and compensatory stiffening strategy may contribute to the heightened risk of ACL injury in this population.

The lower extremity dexterity test as a measure of lower extremity dynamical capability.

The capability of the lower extremity to dynamically interact with the ground is important for skilled locomotor performance. However, there is currently no test method designed to specifically quantify this sensorimotor ability, which we refer to as lower extremity dexterity. We describe a new method to quantify lower extremity dexterity, examine its reliability (n=10), and evaluate the extent to which it is associated with lower extremity strength and anthropometry in healthy young adults (n=38). The lower extremity dexterity test (LED-test)-an adaptation of the Strength-Dexterity test for the fingers-consists of using the isolated lower extremity to compress a slender spring prone to buckling at low forces. The goal of the LED-test is to sustain the highest compression force possible. Applying higher forces makes the spring increasingly unstable, thus achieving higher compression forces represents better ability to dynamically control instability at low force levels. As such, the LED-test provides a novel way to quantify the capability of the lower extremity to regulate dynamic and unstable foot-ground interactions at submaximal forces. LED-test performance ranged between 88.6 and 119.6N, test-retest reliability was excellent (ICC(2,3)=0.94), and the minimal detectable difference was 5.5N. Performance was not correlated with strength or height (r(2)≤0.053, p>0.05), and only weakly with body mass (r(2)=0.116, p=0.04). We propose that the unique lower extremity capability quantified by the LED-test could be informative of skilled locomotor performance and injury risk.