Gain modulation of the middle latency cutaneous reflex in patients with chronic joint instability after ankle sprain

Reliability of reflex measurements and perceived instability following cutaneous stimulation during gait

Individuals with chronic ankle instability (CAI) exhibit a variety of sensorimotor deficits which contribute to long-term health risks and lower overall health-related quality of life. Recent literature finds abnormal cutaneous reflex characteristics and perceptions of instability during gait among those with CAI. These may serve as important patient-specific outcome measures in diagnosing and monitoring the condition, however, the test-retest reliability of these measurements is still undetermined. Therefore, the purpose of this study is to assess reliability of cutaneous reflex amplitudes and variability and perceived instability following perturbation in those with CAI and healthy controls during gait. Subjects walked on a treadmill while receiving random, non-noxious sural nerve stimulations throughout the stance phases of gait. Muscle activity was measured via electromyography for the peroneus longus, and medial and lateral gastrocnemius. Subjects reported their perceived instability following each stimulation. Cutaneous reflex amplitudes and perceived instability throughout the stance phases of gait can be reliably measured within the same day and over a 1-week period while reflex variability may be a less reliable measure. Our findings support the use of these variables as clinical outcome measures to identify and monitor neuromuscular recovery.

Middle and Long Latency Cutaneous Reflexes During the Stance Phase of Gait in Individuals with and Without Chronic Ankle Instability

BACKGROUND/OBJECTIVES

Lower limb cutaneous reflex amplitudes can modulate across gait, which helps humans adjust rhythmic motor outputs to maintain balance in an ever-changing environment. Preliminary evidence suggests people who suffer from repetitive ankle sprains and residual feelings of giving way demonstrate altered cutaneous reflex patterns in the gastrocnemius. However, before cutaneous reflex assessment can be implemented as a clinical outcome measure, there is a need to substantiate these early findings by measuring reflex amplitudes across longer latency periods and exploring the variability of reflexes within each subject.

METHODS

Forty-eight subjects with and without chronic ankle instability (CAI) walked on a treadmill at 4 km/h while activity of the lateral gastrocnemius (LG) was measured via surface electromyography. Non-noxious stimulations were elicited randomly to the ipsilateral sural nerve at the mid-stance phase of gait, and reflex amplitudes were calculated offline by comparing muscle activity during unstimulated and stimulated gait cycles. Two primary outcome measures were compared between groups at the middle latency (MLR: 80-120 ms) and late latency (LLR: 120-150 ms) time windows: (1) average reflex amplitudes and (2) standard deviation of reflex amplitudes for each subject across 10 trials.

RESULTS

Both groups demonstrated an equal amount of LG inhibition at the MLR and LG facilitation at the LLR. However, subjects with CAI showed significantly higher variability in LLR amplitude across trials than healthy controls.

CONCLUSIONS

Increased variability of cutaneous reflex amplitudes may relate to symptoms associated with CAI. These findings suggest that reflex variability following sural nerve stimulation could serve as an objective measure to track treatment progress in patients with CAI, offering clinicians a new tool for conducting rehabilitation assessments in a controlled environment.

Neurophysiologic inhibitory factors influencing subsequent ankle sprain in collegiate male athletes: a prospective cohort study

Many athletes with recurrent ankle sprains complain of neurophysiological deficits related to chronic ankle instability (CAI). However, it remains unclear how changes in the corticospinal pathway affect the potential risk of subsequent ankle sprains. The purpose of this study was to investigate whether the corticospinal excitability (input-output properties) and silent period (SP) could be related to the risk of subsequent ankle sprains among athletes. Forty-three male collegiate basketball athletes were enrolled, and 82 ankles were finally sorted into four ankle groups based on symptoms (CAI, sub-CAI, copers, and normal). The neurophysiological data was recorded in both ankles using transcranial magnetic stimulation (TMS) as baseline assessments. Subsequently, we prospectively followed the occurrence of subsequent ankle sprain injuries for 24 months (SG, subsequent ankle sprain group; NSG, non-sprain group). In the baseline assessment, we confirmed that the threshold of the input-output properties in the CAI group was higher than those in the normal group. After the follow-up, 22 ankles sustained subsequent ankle sprains (SGs). We also found that SGs exhibited a significantly longer SP at the middle and high stimulus intensities of TMS compared to NSGs (60 ankles) (middle: p = 0.012, Cohen's d = 0.644, and high: p = 0.020, Cohen's d = 0.590). These findings suggest that a prolonged SP could be a crucial factor affecting subsequent ankle sprains in athletes. To prevent further recurrent sports injuries, neurophysiologic probes, particularly a longer SP, might be a potential assessment tool to return to the field.

Contralateral cutaneous reflex modulation during gait in individuals with and without chronic ankle instability

INTRODUCTION

Chronic ankle instability (CAI), a common seqeula to ankle injury is characterized by a variety of sensorimotor deficits extending beyond the previously injured limb. Cutaneous reflexes have been identified as a potential contributor to these functional limitations with recent studies identifying alterations in reflex patterns following sural nerve stimulation among those with CAI. To date, no studies have measured cutaneous reflexes of the unaffected limb in this population, therefore, the objective of this study was to measure contralateral cutaneous reflexes during gait in individuals with unilateral CAI and healthy controls.

METHODS

Muscle activity of 6 lower limb muscles was measured in nineteen participants while receiving random, non-noxious sural nerve stimulations during a walking task.

RESULTS

Control reflex patterns were generally well-aligned with previous literature while CAI patterns varied from controls in several muscles throughout the gait cycle. Namely, a lack of lateral gastrocnemius facilitation during late stance and medial gastrocnemius inhibition at midstance. Additionally, a lack of significant BF facilitation throughout contralateral swing was noted. These results indicate reflex alterations extend beyond the affected limb in those with unilateral CAI indicating changes at the spinal level following lateral ankle sprains (LAS). Considering the symptom variability in CAI, the lack of significant reflexes exhibited by the CAI group may be due to increased variability in motor output between subjects or between stimulation trials.

CONCLUSIONS

These findings highlight the importance of identifying reflex alterations arising from LAS and subsequently treating these limitations through rehabilitation targeting systemic neural pathways rather than local deficits.

The role of sural nerve reflexes during drop-landing in subjects with and without chronic ankle instability

The purpose of this study was to investigate the functional role of cutaneous reflexes during a single-leg drop-landing task among healthy, neurologically intact adults, and to identify whether individuals with chronic ankle instability (CAI) demonstrate altered reflexes and subsequent ankle kinematics. All subjects were physically active adults and were categorized as control (n = 10, Male = 6, Female = 4) or CAI (n = 9, Male = 4, Female = 5) depending on whether they scored a 0 or ≥ 11 on the Identification of Functional Ankle Instability questionnaire, respectively. Subjects performed 30-40 single-leg drop-landing trials from a platform set to the height of their tibial tuberosity. Muscle activity of four lower leg muscles was collected via surface electromyography, while ankle kinematics were recorded via an electrogoniometer. Non-noxious stimulations were elicited randomly to the ipsilateral sural nerve at two unique phases of the drop-landing task (takeoff and landing). Unstimulated and stimulated trials were used to calculate middle latency reflex amplitudes (80-120 ms) and net ankle kinematics (140-220 ms) post-stimulation. Mixed-factor ANOVAs were used to identify significant reflexes within groups and differences in reflex amplitudes between groups. Unlike the CAI group, the control group experienced significant facilitation of the Peroneus Longus (PL) and inhibition of the Lateral Gastrocnemius (LG) when stimulated at takeoff, resulting in eversion immediately prior to landing. When stimulated at landing, the control group experienced significantly more inhibition of the PL compared to the CAI group (p = 0.019). These results suggest lower neural excitability for individuals with CAI, which may predispose them to recurrent injury during similar functional tasks.

Misencoding of ankle joint angle control system via cutaneous afferents reflex pathway in chronic ankle instability

This study aimed to investigate how the cutaneous reflexes in the peroneus longus (PL) muscle are affected by changing the ankle joint position in patients with chronic ankle instability (CAI). We also investigated the correlation between the degree of reflex modulation and angle position sense of the ankle joint. The participants were 19 patients with CAI and 20 age-matched controls. Cutaneous reflexes were elicited by applying non-noxious electrical stimulation to the sural nerve at the ankle joint in the neutral standing and eversion/inversion standing positions. The suppressive middle latency cutaneous reflex (MLR; ~ 70-120 ms) and angle position sense of the ankle joint were assessed. During neutral standing, the gain of the suppressive MLR was more prominent in the CAI patients than in controls, although no significant difference was seen during 30° inversion standing. In addition, the ratios of the suppressive MLR and background electromyography in a neutral position were significantly larger than those at the 15°, 25°, and 30° inversion positions in CAI patients. No such difference was seen in control individuals. Furthermore, the correlations between reflex modulation degree and position sense error were quite different in CAI patients compared to controls. These findings suggest that the sensory-motor system was deteriorated in CAI patients due to changes in the PL cutaneous reflex pathway excitability and position sense of the ankle joint.

Cointegration of single-transistor neurons and synapses by nanoscale CMOS fabrication for highly scalable neuromorphic hardware

Cointegration of multistate single-transistor neurons and synapses was demonstrated for highly scalable neuromorphic hardware, using nanoscale complementary metal-oxide semiconductor (CMOS) fabrication. The neurons and synapses were integrated on the same plane with the same process because they have the same structure of a metal-oxide semiconductor field-effect transistor with different functions such as homotype. By virtue of 100% CMOS compatibility, it was also realized to cointegrate the neurons and synapses with additional CMOS circuits. Such cointegration can enhance packing density, reduce chip cost, and simplify fabrication procedures. The multistate single-transistor neuron that can control neuronal inhibition and the firing threshold voltage was achieved for an energy-efficient and reliable neural network. Spatiotemporal neuronal functionalities are demonstrated with fabricated single-transistor neurons and synapses. Image processing for letter pattern recognition and face image recognition is performed using experimental-based neuromorphic simulation.

Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021

This revised clinical practice guideline (CPG) addresses the distinct but related lower extremity impairments of those with a first-time lateral ankle sprain (LAS) and those with chronic ankle instability (CAI). Depending on many factors, impairments may continue following injury. While most individuals experience resolution of symptoms, complaints of instability may continue and are defined as CAI. The aims of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. J Orthop Sports Phys Ther 2021;51(4):CPG1-CPG80. doi:10.2519/jospt.2021.0302.

Effect of ankle taping on postural control measures during grasp and release task in patients with chronic ankle instability

OBJECTIVE

The aim of this study was to examine the effect of Mulligan ankle taping on center of pressure (COP) parameters during performance of a functional upper limb task in patients with chronic ankle instability (CAI).

METHODS

A clinical controlled trial study designed between 4 ankle conditions: untaped and taped, CAI and healthy subjects. Fifteen subjects with CAI and 15 healthy controls were asked to grasp an object at their waist level and release it above shoulder level in an oblique pattern during performance of single-leg stance balance test. All the subjects performed 3 trials of single-leg stance with eyes opened before and after Mulligan taping on a force plate during performance of functional upper limb task. The mean displacement (mdCOP), range of COP excursion (rangeCOP) and average speed of COP (velCOP) in anteroposterior (AP) and mediolateral (ML) directions were analysed for differences between groups.

RESULTS

mdCOP and rangeCOP in AP direction were significantly increased (P= 0.04 and 0.03, respectively) in the CAI group. Mulligan taping significantly reduced velCOP in AP and ML directions (P= 0.02).

CONCLUSION

In CAI patients Mulligan ankle taping can improve postural control by decreasing velCOP, therefore Mulligan taping can have immediate positive effects on postural parameters and maintenance of dynamic postural control.

High lateral plantar pressure is related to an increased tibialis anterior/fibularis longus activity ratio in patients with recurrent lateral ankle sprain

Introduction

Center of pressure (COP) is a sudden displacement at the time of a lateral ankle sprain (LAS). It has been suggested that the distribution of plantar pressure and the quantity of COP displacement are important for assessing the risk of LAS. Therefore, we evaluated the plantar pressure during a single-leg balance test with eyes closed (SLB-C) to identify the factors and characteristics of plantar pressure in people with repeated cases of LAS.

Methods

We recruited 22 collegiate athletes and divided them into an instability group (IG; n=11) and a control group (CG; n=11). We measured the distribution of plantar pressure and lower extremity muscle activity during a SLB-C along with static alignment and isometric ankle strength.

Results

The fibularis longus (FL) activity was significantly lower in the IG than in the CG. The lateral plantar pressure (LPP)/medial plantar pressure (MPP) ratio was also higher in the IG than in the CG. In addition, the LPP/MPP ratio was correlated with the tibialis anterior (TA)/FL ratio.

Conclusion

These results suggest that increased lateral plantar pressure is related to decreased FL activity and increased TA/FL ratio.

History-dependent changes in the recovery process of the middle latency cutaneous reflex gain after ankle sprain injury

PURPOSE

We previously reported that suppressive middle latency cutaneous reflexes (MLRs) in the peroneus longus (PL) are exaggerated in subjects with chronic ankle instability, and the changes are related to functional instability. However, the time-varying history of these neurophysiological changes after an ankle sprain is yet to be elucidated. Therefore, in the present study, we investigated the time course of the changes in the PL MLR after an ankle sprain in relation to the number of sprain recurrences.

METHODS

Twenty-three subjects with ankle sprain were classified into 3 groups according to their history of ankle sprain: first ankle sprain, 2-3 ankle sprains, and ≥4 ankle sprains. Twenty-three age-matched control subjects also participated. The PL MLRs were elicited by stimulating the sural nerve while the subjects performed different levels of isometric ankle eversion. Gain of MLR was estimated using linear regression analysis (slope value) of the amplitude modulation of MLRs obtained from graded isometric contractions.

RESULT

The gain of MLRs first increased 4 weeks after the injury. In subjects with their first ankle sprain, the MLRs returned to almost baseline levels after 3 months. In contrast, the increase in MLR gain persisted even after 3 months in subjects with recurrent ankle sprains. In addition, the MLR gains were closely related to functional recovery of the ankle joint.

CONCLUSIONS

Our findings suggest that the recovery process of MLR gains were strongly affected by the history of ankle sprains as well as the functional recovery of the ankle joint.

Strength-Duration Curves of the Common Fibular Nerve Show Hypoexcitability in People With Functional Ankle Instability

BACKGROUND

Some motor impairments, such as decreased reaction of peroneal muscles, altered kinematics, or poor postural control, have been described in people with functional ankle instability. Evidence shows a possible relationship between fibular nerve impairments and functional ankle instability.

OBJECTIVE

To investigate the electrophysiologic excitability of the common fibular nerve, as measured by strength-duration curves, in subjects with functional ankle instability compared with a control group without ankle impairment.

DESIGN

A cross-sectional study.

SETTING

University Research laboratory.

PARTICIPANTS

Fifty subjects with functional ankle instability (35 men, 15 women; ages 24.36 ± 5.01 years) and 63 uninjured control patients (44 men, 19 women; ages 22.67 ± 4.85 years) were recruited by convenience sampling.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Strength-duration curves of the common fibular nerve were made in all participants. Rheobase, chronaxie, Bawen index, accommodation index, galvano-tetanic threshold, and intensity thresholds for different pulse durations were obtained and compared between the 2 groups.

RESULTS

Subjects with functional ankle instability show increased values of chronaxie (0.58 ± 0.24 ms versus 0.47 ± 0.16 ms; P = .004), Bawen index (1.53 ± 0.24 versus 1.39 ± 0.21; P = .002), and intensity thresholds for pulse durations ≤2 ms both for rectangular and triangular pulse wave forms. The accommodation index was smaller in subjects with functional ankle instability than controls (3.7 ± 0.72 versus 4.05 ± 0.98; P = .036). The remaining parameters did not show significant differences between groups.

CONCLUSIONS

These findings suggest that subjects with functional ankle instability show a decreased excitability in their common fibular nerve when compared with subjects without ankle injuries.