Quadriceps muscle function following anterior cruciate ligament reconstruction: systemic differences in neural and morphological characteristics.

Quadriceps muscle dysfunction is common following anterior cruciate ligament reconstruction (ACLR). Data considering the diversity of neural changes, in-concert with morphological adaptations of the quadriceps muscle, are lacking. We investigated bilateral differences in neural and morphological characteristics of the quadriceps muscle in ACLR participants (n = 11, month post-surgery: 69.4 ± 22.4) compared to controls matched by sex, age, height, weight, limb dominance, and activity level. Spinal reflex excitability was assessed using Hoffmann reflexes (H:M); corticospinal excitability was quantified via active motor thresholds (AMT) and motor-evoked potentials (MEP) using transcranial magnetic stimulation. Cortical activation was assessed using a knee flexion/extension task with functional magnetic resonance imaging (fMRI). Muscle volume was quantified using structural MRI. Muscle strength and patient-reported outcomes were also collected. 2 × 2 RM ANOVAs were used to evaluate group differences. Smaller quadriceps muscle volume (total volume, rectus femoris, vastus medialis, and intermedius) and lower strength were detected compared to contralateral and control limbs. Individuals with ACLR reported higher levels of pain and fear and lower levels of knee function compared to controls. No differences were observed for H:M. ACLR individuals demonstrated higher AMT bilaterally and smaller MEPs in the injured limb, compared to the controls. ACLR participants demonstrated greater activation in frontal lobe areas responsible for motor and pain processing compared to controls, which were associated with self-reported pain. Our results suggest that individuals with ACLR demonstrate systemic neural differences compared to controls, which are observed concurrently with smaller quadriceps muscle volume, quadriceps muscle weakness, and self-reported dysfunction.

Implications of Thoracic Epidural Analgesia on Hospital Charges in Rib Fracture Patients.

Objective: Rib fractures are present in more than 150,000 patients admitted to US trauma centers each year. Those who fracture two or more ribs are typically treated with oral analgesic drugs and are discharged with few complications. The cost of this care generally reflects its brevity. When a patient fractures three or more ribs, there is an elevated risk of complication. In response, treatments are often broadened and their durations prolonged; this affects cost. While health, function, and survival have been widely explored, patient billing has not. Thus, we evaluated the financial implications of one mode of treatment for patients with rib fractures: thoracic epidural analgesia (TEA). Methods: We retrospectively analyzed the registry of a level II trauma center. All patients who fractured one or more ribs (n = 1,344) were considered; 382 of those patients were not candidates for epidural placement and were eliminated from analyses. Epidural placement was determined by individual clinicians. We used multiple linear regressions to determine predictors of cost. Results: After eliminating patients who were not eligible to receive TEA, the average patient bill was $59,123 ($10,631 per day of treatment). The administration of TEA predicted a 25% reduction in total billing (99% CI = -$21,429.55- -$7,794.66) and a 24% reduction in per-day billing (99% CI = -$3,745.99- -$1,276.14). Conclusions: Patients who received TEA were more severely injured and required longer treatments; controlling for these variables, the use of TEA associated with reductions in the cost of receiving care. From an administrative and insurance perspective, more frequent reliance on TEA may be indicated.

Improved Outcomes Associated with the Liberal Use of Thoracic Epidural Analgesia in Patients with Rib Fractures.

OBJECTIVE: Each year, more than 150,000 patients with rib fractures are admitted to US trauma centers; as many as 10% die. Effective pain control is critical to survival. One way to manage pain is thoracic epidural analgesia. If this treatment reduces mortality, more frequent use may be indicated. METHODS: We analyzed the patient registry of a level II trauma center. All patients admitted with one or more rib fractures (N = 1,347) were considered. Patients who were not candidates for epidural analgesia (N = 382) were eliminated. Mortality was assessed with binary logistic regressions. RESULTS: Across the total population, mortality was 6.7%; incidence of pneumonia was 11.1%; mechanical ventilation was required in 23.8% of patients, for an average duration of 10.0 days; average stay in the hospital was 7.7 nights; and 49.7% of patients were admitted to the ICU for an average of 7.2 nights. Epidural analgesia was administered to 18.4% of patients. After matching samples for candidacy, patients who received epidurals were 3.7 years older, fractured 2.6 more ribs, had higher injury severity scores, and were more likely to present with bilateral fractures, flail segments, pulmonary contusions, hemothoraces, and pneumothoraces. Despite greater injury severity, mortality among these patients was lower (0.5%) than those who received alternative care (1.9%). Controlling for age, injury severity, and use of mechanical ventilation, epidural analgesia predicted a 97% reduction in mortality. CONCLUSION: Thoracic epidural analgesia associates with reduced mortality in rib fracture patients. Better care of this population is likely to be facilitated by more frequent reliance on this treatment.

Laterality of quiet standing in old and young.

"Quiet standing" is standing without intended movement. To the naked eye, a person "quiet standing" on a rigid surface of support is stationary. In the laboratory quiet standing is indexed by behavior (at the millimeter scale) of the center of pressure (COP), the point location of the vertical ground reaction force vector (GRF). We asked whether quiet standing is lateralized and whether the COP dynamics of the right and left legs differ. In answer, we reexamined a previous quiet standing experiment (Kinsella-Shaw et al. in J Mot Behav 38:251-264, 2006) that used dual, side-by-side, force plates to investigate effects of age and embedding environment. All participants, old (M age = 72.2 ± 4.90 years) and young (M age = 22.8 ± 0.83 years), were right handed and right footed. Cross-recurrence quantification of the anterior-posterior and mediolateral coordinates of each COP revealed that, independent of age, and with no right GRF bias, right-leg coordination was (1) more dynamically stable and less noisy than left-leg coordination and (2) more responsive to changes in degree of visible structure. The results are considered in the context of theories of laterality inclusive of lateralized differences in postural dynamics.

Effects of footedness and stance asymmetry confirm an inter-leg metastable coordination dynamics of standing posture.

We investigated the patterns of coordination between the left and right legs that support the task of maintaining an upright standing posture. We used cross-wavelet analyses to assess coordination between the centers of pressure under the left and right feet. We recruited participants with a lateralized functional preference for their right leg, and we manipulated whether these participants stood with symmetric/asymmetric stances and whether their eyes were open or closed. Our hypotheses were derived from the Haken-Kelso-Bunz (HKB) model of interlimb coordination dynamics. Consistent with HKB model predictions, we observed (1) coordination taking the form of metastable, transient epochs of stable phase relations, (2) preferences for in-phase and anti-phase coordination patterns, and (3) changes in pattern stability and phase leads associated with both stance asymmetry and right-side lateral preference. The form and stability of observed coordination patterns were mediated by the availability of visual information. Our findings confirm the existence of a metastable coordination dynamic associated with the task of maintaining upright stance. We discuss the implications of these findings in the context of evaluating the utility of the HKB model for understanding the functional organization of the posture system.

Reliability and validity of pendulum test measures of spasticity obtained with the Polhemus tracking system from patients with chronic stroke.

BACKGROUND: Spasticity is a common impairment accompanying stroke. Spasticity of the quadriceps femoris muscle can be quantified using the pendulum test. The measurement properties of pendular kinematics captured using a magnetic tracking system has not been studied among patients who have experienced a stroke. Therefore, this study describes the test-retest reliability and known groups and convergent validity of the pendulum test measures obtained with the Polhemus tracking system. METHODS: Eight patients with chronic stroke underwent pendulum tests with their affected and unaffected lower limbs, with and without the addition of a 2.2 kg cuff weight at the ankle, using the Polhemus magnetic tracking system. Also measured bilaterally were knee resting angles, Ashworth scores (grades 0-4) of quadriceps femoris muscles, patellar tendon (knee jerk) reflexes (grades 0-4), and isometric knee extension force. RESULTS: Three measures obtained from pendular traces of the affected side were reliable (intraclass correlation coefficient > or = .844). Known groups validity was confirmed by demonstration of a significant difference in the measurements between sides. Convergent validity was supported by correlations > or = .57 between pendulum test measures and other measures reflective of spasticity. CONCLUSION: Pendulum test measures obtained with the Polhemus tracking system from the affected side of patients with stroke have good test-retest reliability and both known groups and convergent validity.

Haptic selective attention by foot and by hand.

Nonvisual perceptions of a wielded object's spatial properties are based on the quantities expressing the object's mass distribution, quantities that are invariant during the wielding. The mechanoreceptors underlying the kind of haptic perception involved in wielding - referred to as effortful, kinesthetic, or dynamic touch - are those embedded in the muscles, tendons, and ligaments. The present experiment's focus was the selectivity of this muscle-based form of haptic perception. For an occluded rod grasped by the hand at some intermediate position along its length, participants can attend to and report selectively the rod's full length, its partial lengths (fore or aft of the hand), and the position of the grip. The present experiment evaluated whether participants could similarly attend selectively when wielding by foot. For a given rod attached to and wielded by foot or attached to (i.e. grasped) and wielded by hand, participants reported (by magnitude production) the rod's whole length or fractional length leftward of the point of attachment. On measures of mean perceived length, accuracy, and reliability, the degree of differentiation of partial from full extent achieved by means of the foot matched that achieved by means of the hand. Despite their neural, anatomical, and experiential differences, the lower and upper limbs seem to abide by the same principles of selective muscle-based perception and seem to express this perceptual function with equal facility.

Comparison of dynamic (effortful) touch by hand and foot.

Spatial perception by dynamic touch is a well-documented capability of the hand and arm. Morphological and physiological characteristics of the foot and leg suggest that such a capability may not generalize to that putatively less dexterous limb. The authors examined length perception by dynamic touch in a task in which weighted aluminum rods were grasped by the hand and wielded about the wrist or secured to the foot and wielded about the ankle. Participants' (N = 10) upper and lower extremities were comparable in terms of (a) the accuracy and consistency of length perception and (b) their sensitivity to manipulations of the moments of the mass distribution of the rods. The authors discuss those results in terms of the field-like structure of the haptic perceptual system, an organization that may underlie what appears to be functional, rather than anatomical, specificity.

Towards an ecologically grounded functional practice in rehabilitation.

According to the International Classification of Functioning, Disability and Health, effective rehabilitation requires interventions that go beyond minimizing pathological conditions and associated symptoms. The scope of practice must include promoting an individual's activity within relevant contexts. We argue that best practice requires decisions that are not only evidence-based but also theory-based. Perception and action theories are essential for interpreting evidence and clinical phenomena as well as for developing new interventions. It is our contention that rehabilitation goals can best be achieved if inspired by the ecological approach to perception and action, an approach that focuses on the dynamics of interacting constraints of performer, task and environment. This contrasts with organism-limited motor control theories that have important influence in clinical practice. Parallels between such theories and the medical model of care highlight their fundamental inconsistency with the current understanding of functioning. We contend that incorporating ecological principles into rehabilitation research and practice can help advance our understanding of the complexity of action and provide better grounding for the development of effective functional practice. Implications and initial suggestions for an ecologically grounded functional practice are outlined.

Peripheral neuropathy and object length perception by effortful (dynamic) touch: a case study.

The spatial extents of hand-held objects can be perceived nonvisually by wielding them. This ability of effortful or dynamic touch to exploit the mass moments of an object to perceive its length was evaluated with a 40-years old right-handed woman with surgically treated Arnold-Chiari Type 1 Malformation and cervical syrinx. At the time of the experiment she presented with loss of discriminative touch in the left arm but no comparable sensory deficits in the right arm or the lower extremities. She could neither identify objects in her left hand nor tell that they were in the hand while manipulating them. She could, however, grasp an object tightly and wield it on request. In the experiment she wielded weighted rods of 45, 60, and 80cm length about the wrist. There were two main results. First, her nonvisual perception of rod length by the insensate left arm scaled systematically with rod moment of inertia. The scaling matched that of the intact right arm and the nondominant arm of haptically unimpaired controls tested with rods of similar dimensions. Second, her right arm was superior in accuracy and reliability than her insensate left arm and was equal to or better than the dominant arm of the control group on key measures of nonvisual length perception. The first result was evaluated in respect to the notions of numb touch and differences in the neural bases of discriminative and effortful touch. The second result was discussed in terms of contralateral cortical enhancement by deafferentation.

Effects of visual environment on quiet standing by young and old adults.

The authors manipulated the circumstances in which individuals are typically embedded when standing upright by manipulating the intensity of light and the stationary structure of the environment. They expected that the manipulations would affect 12 older participants (aged 65-82 years) more than it would 12 younger participants (aged 22-24 years). Linear (e.g., total path length) and nonlinear (e.g., maximum line length of recurrent points in phase space) measures of the center of pressure time series confirmed that expectation. Moreover, for some measures, there was a suggestion that participants' visual contrast sensitivity (an index of neurophysiological age) was a more important contributing factor overall than was their chronological age. In the Discussion, the authors highlight the significance of interactive effects of environmental, organismic, and task constraints on quiet standing.

Haptic perceptual intent in quiet standing affects multifractal scaling of postural fluctuations.

Research on dynamic touch has shown that when a rod strapped to the shoulders is wielded via axial rotations, flexions-extensions, and lateral bending of the trunk, participants can selectively perceive whole rod length and partial rod length (e.g., a leftward segment) with precision comparable to wielding by hand (Palatinus, Carello & Turvey, 2011). The present research addressed whether this haptic ability is preserved in quiet standing, when postural control is limited to center of pressure (COP) fluctuations at the mm/ms scale, and, if so, whether the intentions ("perceive partial," "perceive whole") are distinguishable within the fluctuations. Given standard manipulations of rod length and attached mass, participants provided significantly distinct, appropriately scaled, whole and partial estimates of rod length. COP displacement time series were subjected to multifractal, detrended fluctuation analysis. The resultant spectrum of fractal scaling exponents for gradually different-sized fluctuations revealed that "perceive partial" was manifest as larger exponents for progressively smaller fluctuations than "perceive whole." Our results indicate (a) that the significant mechanical variables for haptically perceiving object extent are available in the small scale of normal body sway, and (b) that these seemingly "passive" movements reflect the intention of the perceiver.

Interleg coordination in quiet standing: influence of age and visual environment on noise and stability.

The authors reexamined reported effects of age, illumination, and stationary visible structure on the net center of pressure (COP) derived from dual, side-by-side force plates (J. Kinsella-Shaw, S. Harrison, C. Colon-Semenza, & M. Turvey, 2006 ) from the perspective of axial postural control. They questioned how left and right COP(x)(t), COP(y)(t), and vertically oriented ground reactive force, GRF(z)(t), coordinated during quiet standing. The Cross-recurrence Quantification (CRQ) revealed that coordination was primarily between fluctuations of similar direction, with coordination of left and right COP(y) (t) (anteroposterior fluctuations) dominant. CRQ also revealed that (a) illumination and structure affected the interlimb dynamics of older (M age = 72.2 ± 4.90 years) participants more than their younger (M age = 22.8 ± 0.83 years) counterparts, and (b) older participants exhibited greater interlimb entrainment (dynamical stability) in the presence of greater interlimb noise.

Deterministic and stochastic postural processes: effects of task, environment, and age.

Upright standing is always environmentally embedded and typically co-occurs with another (suprapostural) activity. In the present study, the authors investigate how these facts affect postural dynamics in an experiment in which younger (M age = 20.23 years, SD = 2.02 years) and older (M age = 75.26 years, SD = 4.87 years) participants performed a task of detecting letters in text or maintaining gaze within a target while standing upright in a structured or nonstructured stationary environment. They extracted the coefficients of drift (indexing attractor strength) and diffusion (indexing noise strength) from the center of pressure (COP) time series in anteroposterior (AP) and mediolateral (ML) axes. COP standard deviation decreased with drift and increased with diffusion. The authors found that structure reduced AP diffusion for both groups and that letter detection reduced younger SDAP (primarily by diffusion decrease) and increased older SDML (primarily by drift decrease). For older and younger participants, ML drift was lower during letter detection. Further, in older letter detection, larger visual contrast sensitivity was associated with larger ML drift and smaller SDML, raising the hypotheses that ML sway helps information detection and reflects neurophysiological age.