Age and sex dependency of the Achilles tendon reflex

Variability in the clinical diagnosis of diabetic peripheral neuropathy

AIMS

The aims of this study are to assess the variability in the prevalence of diabetic peripheral neuropathy (DPN), according to the diagnostic and clinical guidelines used.

METHODS

A cross-sectional observational study was conducted of 111 patients with diabetes mellitus. The presence/absence of DPN was determined according to 12 different criteria stipulated in various clinical guidelines (ADA 2018, IWGDF 2016, IDF 2012 and CONUEI 2018). The Cohen's kappa coefficient (κ) was performed to determine the degree of agreement for DPN diagnosis among the different criteria.

RESULTS

The recorded prevalence of DPN ranged from 13.1% (criterion ADA 2018) to 68.5% (criterion IDF 2012). The sensory parameter that was most commonly affected was the non-perception of vibration (68.5%) and the absence of Achilles reflexes (59.4%). IWGDF, based on the use of a monofilament, cotton wisp and tuning fork, was the test with more agreements, presenting good agreement with 2 criteria from ADA 2018 (k=0.845), 1b2 (k=0.817), 2 criteria from IWGDF 2016 (k=0.933), (k=0.817), 1 criteria from IDF 2012 (k=0.845) and 1 criteria from CONUEI 2018 (k=0.860), all p<0.001.

CONCLUSION

The IWGDF criterion based on the use of a monofilament, cotton wisp and tuning fork for the diagnosis presented the highest level of concordance with the other criteria (>0.8).

Development and aging of human spinal cord circuitries

The neural motor circuitries in the spinal cord receive information from our senses and the rest of the nervous system and translate it into purposeful movements, which allow us to interact with the rest of the world. In this review, we discuss how these circuitries are established during early development and the extent to which they are shaped according to the demands of the body that they control and the environment with which the body has to interact. We also discuss how aging processes and physiological changes in our body are reflected in adaptations of activity in the spinal cord motor circuitries. The complex, multifaceted connectivity of the spinal cord motor circuitries allows them to generate vastly different movements and to adapt their activity to meet new challenges imposed by bodily changes or a changing environment. There are thus plenty of possibilities for adaptive changes in the spinal motor circuitries both early and late in life.

Motion analysis of normal patellar tendon reflex

BACKGROUND

Reflex assessment, an essential element in the investigation of the motor system, is currently assessed through qualitative description, which lacks of normal values in the healthy population. This study quantified the amplitude and latency of patellar tendon reflex in normal subjects using motion analysis to determine the factors affecting the reflex amplitude.

METHODS

100 healthy volunteers were recruited for patellar tendon reflex assessments which were recorded using a motion analysis system. Different levels of input strength were exerted during the experiments.

RESULTS

A linear relationship was found between reflex input and reflex amplitude (r = 0.50, P <0.001). The left knee was found to exhibit 26.3% higher reflex amplitude than the right (P <0.001). The Jendrassik manoeuvre significantly increased reflex amplitude by 34.3% (P = 0.001); the effect was especially prominent in subjects with weak reflex response. Reflex latency normality data were established, which showed a gradual reduction with increasing input strength.

CONCLUSION

The quantitative normality data and findings showed that the present method has great potential to objectively quantify deep tendon reflexes.

Analyse du mouvement du réflexe rotulien normal.

Influence of age on patellar tendon reflex response

Background

A clinical parameter commonly used to assess the neurological status of an individual is the tendon reflex response. However, the clinical method of evaluation often leads to subjective conclusions that may differ between examiners. Moreover, attempts to quantify the reflex response, especially in older age groups, have produced inconsistent results. This study aims to examine the influence of age on the magnitude of the patellar tendon reflex response.

Methodology/Principal Findings

This study was conducted using the motion analysis technique with the reflex responses measured in terms of knee angles. Forty healthy subjects were selected and categorized into three different age groups. Patellar reflexes were elicited from both the left and right patellar tendons of each subject at three different tapping angles and using the Jendrassik maneuver. The findings suggested that age has a significant effect on the magnitude of the reflex response. An angle of 45° may be the ideal tapping angle at which the reflex can be elicited to detect age-related differences in reflex response. The reflex responses were also not influenced by gender and were observed to be fairly symmetrical.

Conclusions/Significance

Neurologically normal individuals will experience an age-dependent decline in patellar reflex response.

Tendon structural and mechanical properties do not differ between genders in a healthy community-dwelling elderly population

Elderly women are reportedly at higher risk of falling than their male counterparts. Postural balance is highly associated with fall risk and is also correlated with tendon structural and mechanical properties. Gender differences in tendon properties could partly explain the discrepancy in fall risk. Thus the purpose of this study was to investigate the possible gender difference in tendon properties in the elderly. The properties of the patellar tendon of 55 elderly (men n = 27, aged 72 +/- 1 years, women n = 28, aged 70 +/- 1 years) participants were tested. Tendon stiffness (K), length (L), and cross-sectional area (CSA) were measured using B-mode ultrasonography, dynamometry, and electromyography during ramped isometric knee extensions. There were no significant differences (p > 0.05) between men and women in tendon stiffness (elderly men 550.9 +/- 29.2 vs. women 502.9 +/- 44.9 Nmm(-1)) or in Young's modulus (elderly men 0.32 +/- 0.02 vs. women 0.36 +/- 0.04 GPa). This elderly group had similar tendon structural and mechanical properties. The comparable characteristics in gender-specific tendon properties in an elderly population exhibiting similar lifestyle characteristics to the current sample may not explain the reports in the literature regarding increased fall risk in elderly women relative to that seen in men of a similar age.

Patellar tendon reflex as a predictor of improving motor paralysis in complete paralysis due to cervical cord injury

STUDY DESIGN

A retrospective study.

OBJECTIVE

We have encountered several cases of complete sensorimotor paralysis in which patellar tendon reflex (PTR) was demonstrated approximately 3 days after injury and improvement of motor paralysis was subsequently achieved. We considered that PTR apparent in the early stage after injury may offer an index to predict improvements in motor paralysis.

MATERIALS AND METHODS

A total of 142 patients assessed as ASIA Impairment Scale A on admission from 1979 to 1998 were included in the study. The patients who demonstrated PTR within 72 h after injury were classified as the PTR(+) group and those who did not constituted the PTR(-) group. With regard to the method of motor paralysis assessment at about 6 months after injury, patients assessed as ASIA Impairment Scale A or B (that is, complete motor paralysis) were classified as 'Non-recovered', whereas those assessed as ASIA Impairment Scale C, D or E (that is, showing obvious improvement of motor paralysis) were considered as 'Recovered'.

RESULTS

A significant difference was noted between groups, with the Recovered group including 16 of the 17 PTR(+) patients (94.1%) and 11 of the 115 PTR(-) patients (9.6%) (P<0.0001).

CONCLUSION

The results obtained indicate that motor paralysis recovery could be expected at a very high rate among patients demonstrating PTR within 72 h of injury. As all physicians should be familiar with the PTR, this seems to represent a simple and highly useful sign to predict improvements in motor paralysis during the acute stage of cervical cord injury.

Aging-related neuromuscular changes characterized by tendon reflex system properties

OBJECTIVE

To quantitatively evaluate changes in neuromuscular reflex system properties that are associated with aging.

DESIGN

Controlled, experimental.

SETTING

Research laboratory in a rehabilitation hospital.

PARTICIPANTS

Fourteen elderly (age, 69.4+/-7.1 y) and 18 young (age, 29.9+/-6.5 y) healthy subjects.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

With the subject relaxed, an instrumented reflex hammer was used to tap the Achilles tendon and record the tapping force, whereas the ankle plantarflexion torque and plantarflexor muscle electromyographic activity were recorded isometrically as measures of the reflex responses. Tendon reflex system properties were evaluated by using system identification techniques. Tendon tapping force was designated as system input and reflex-mediated torque and electromyographic activity as outputs. The dynamic relations between input and output were characterized by the system parameters of reflex-mediated torque and electromyographic gains, contraction and excitation rate, reflex-mediated torque and electromyographic delays, and electromechanic delay.

RESULTS

Various aging-related changes were found in the tendon reflex system properties, including decreased tendon reflex gain ( P =.029), slower contraction and half-relaxation rates ( P </=.018), and longer electromyographic activation delay, electromechanical delay and overall torque reflex delay ( P </=.025). In contrast, changes in the electromyographic properties were not significant, except for the longer electromyographic activation delay.

CONCLUSIONS

Aging is associated with significant changes in the neuromuscular reflex system properties. The changes were mainly associated with weaker and slower muscle force generation but not with significant decrease in motoneuronal excitability.

Stretch reflex excitability of the anti-gravity ankle extensor muscle in elderly humans

AIM

To examine whether the stretch reflex excitability of the soleus muscle changes with age, stretch reflexes at rest (REST) and during weak voluntary contractions (ACT) were elicited in 18 older and 14 younger subjects.

METHOD

The amplitude of the stretch reflex responses and gain, defined as the gradient of the regression line for the relation between stretch reflex responses against the angular velocity of the applied perturbation, were evaluated in each short-latency (M1) and two long-latency components (M2 and M3).

RESULTS

It was found that in the older group, both the amplitude and gain of the M1 component did not change from the REST to the ACT conditions, whereas in the younger group both variables significantly increased from the REST to ACT conditions. The latency of the M1 component was significantly shorter under the REST condition (older vs. younger: 51.8 +/- 7.37 vs. 55.1 +/- 8.69 ms), while no group differences were found in those variables under the ACT condition, suggesting that the muscle-tendon complexes of SOL muscles of the older subjects were less elastic and had less slack, probably due to age-related histochemical alterations. Further, the Hoffman reflex (H-reflex), elicited during the REST condition in 10 older and 11 younger subjects showed no significant differences, suggesting that the soleus motoneuron response to the Ia input was comparable between the two subject groups.

CONCLUSION

The histochemical alterations occurring with the ageing process might augment the short-latency stretch reflex in the SOL muscle without enhancement of motoneuronal excitability, and this effect might be masked when the muscle is voluntarily activated.

Age-dependent variations in the directional sensitivity of balance corrections and compensatory arm movements in man

We investigated the effects of ageing on balance corrections induced by sudden stance perturbations in different directions. Effects were examined in biomechanical and electromyographic (EMG) recordings from a total of 36 healthy subjects divided equally into three age groups (20-34, 35-55 and 60-75 years old). Perturbations consisted of six combinations of support-surface roll (laterally) and pitch (forward-backward) each with 7.5 deg amplitude (2 pure pitch, and 4 roll and pitch) delivered randomly. To reduce stimulus predictability further and to investigate scaling effects, perturbations were at either 30 or 60 deg s(-1). In the legs, trunk and arms we observed age-related changes in balance corrections. The changes that appeared in the lower leg responses included smaller stretch reflexes in soleus and larger reflexes in tibialis anterior of the elderly compared with the young. For all perturbation directions, onsets of balance correcting responses in these ankle muscles were delayed by 20-30 ms and initially had smaller amplitudes (between 120-220 ms) in the elderly. This reduced early activity was compensated by increased lower leg activity after 240 ms. These EMG changes were paralleled by comparable differences in ankle torque responses, which were initially (after 160 ms) smaller in the elderly, but subsequently greater (after 280 ms). Findings in the middle-aged group were generally intermediate between the young and the elderly groups. Comparable results were obtained for the two different stimulus velocities. Stimulus-induced trunk roll, but not trunk pitch, changed dramatically with increasing age. Young subjects responded with early large roll movements of the trunk in the opposite direction to platform roll. A similarly directed but reduced amplitude of trunk roll was observed in the middle-aged. The elderly had very little initial roll modulation and also had smaller stretch reflexes in paraspinals. Balance-correcting responses (over 120-220 ms) in gluteus medius and paraspinals were equally well tuned to roll in the elderly, as in the young, but were reduced in amplitude. Onset latencies were delayed with age in gluteus medius muscles. Following the onset of trunk and hip balance corrections, trunk roll was in the same direction as support-surface motion for all age groups and resulted in overall trunk roll towards the fall side in the elderly, but not in the young. Protective arm movements also changed with age. Initial arm roll movements were largest in the young, smaller in the middle aged, and smallest in the elderly. Initial arm roll movements were in the same direction as initial trunk motion in the young and middle aged. Thus initial roll arm movements in the elderly were directed oppositely to those in the young. Initial pitch motion of the arms was similar across age groups. Subsequent arm movements were related to the amplitude of deltoid muscle responses which commenced at 100 ms in the young and 20-30 ms later in the elderly. These deltoid muscle responses preceded additional arm roll motion which left the arms directed 'downhill' (in the direction of the fall) in the elderly, but 'uphill' (to counterbalance motion of the pelvis) in the young. We conclude that increased trunk roll stiffness is a key biomechanical change with age. This interferes with early compensatory trunk movements and leads to trunk displacements in the direction of the impending fall. The reversal of protective arm movements in the elderly may reflect an adaptive strategy to cushion the fall. The uniform delay and amplitude reduction of balance-correcting responses across many segments (legs, hips and arms) suggests a neurally based alteration in processing times and response modulation with age. Interestingly, the elderly compensated for these 'early abnormalities' with enlarged later responses in the legs, but no similar adaptation was noted in the arms and trunk. These changes with age provide an insight into possible mechanisms underlying falls in the elderly.

Age-related muscle stiffness: predominance of non-reflex factors

This study was aimed at assessing the contribution of reflex and non-reflex factors to the muscle tone of old female Wistar rats. The hind foot of a rat was flexed or extended at the ankle joint by 25 degrees over 250 ms. The resistance of the foot to passive movements (torque, mechanomyogram), as well as the reflex electromyographic activity in the gastrocnemius and tibialis anterior muscles, were recorded simultaneously. Moreover, the impact of the blockade of the reflex activity caused by the local anesthetic lignocaine (1-2 ml of a 2% solution, injected in the vicinity of the sciatic nerve) on the muscle tone was investigated. Additionally, old rats' hind leg muscle samples were analysed using fluorescent microscopy for the expression of fibronectin, which is an early marker of connective tissue formation. It has been shown that old rats are characterized by (i) a substantially increased resistance of flexor muscle stiffness (measured during extension) and unchanged resistance of extensors (measured during flexion), (ii) the loss of a major part of the reflex electromyographic activity and (iii) the increased content of fibronectin in muscles. Moreover, it has been shown that lignocaine, which completely blocked the electromyographic reflex activity in the gastrocnemius and tibialis anterior muscles in young animals, was unable to counteract the resistance of these muscles to passive movements in old rats. The present results suggest that the muscle stiffness seen in old rats is not due to a reflex response, but depends mainly on non-reflex factors--chiefly on a large overgrowth of non-elastic connective tissue replacing degenerated active muscle fibers.

Age-dependent effects of muscle vibration and the Jendrassik maneuver on the patellar tendon reflex response

OBJECTIVE

To explore possible effects of aging on the excitability of spinal reflexes.

DESIGN

Using a cross-sectional design, the influences of muscle vibration and the Jendrassik maneuver on patellar tendon reflex function were compared between 30 young adults and 15 older adults.

SETTING

Motor control research laboratory.

SUBJECTS

The young adults were volunteers of college age. The older adults (74.5 +/- 4.14 yr) were volunteers from the local community. All subjects were free of medications and neurological conditions that would affect normal neuromuscular responses.

MAIN OUTCOME MEASURES

A force-time curve analysis of the patellar tendon reflex response was used to assess the inhibition and facilitation of spinal reflexes. In the experimental protocol to assess spinal reflex inhibition, 100 Hz vibration was applied to the right quadriceps muscle. In another experimental protocol, spinal reflex facilitation was assessed using the Jendrassik maneuver. To perform the Jendrassik maneuver, subjects were instructed to grasp their hands together and to pull as hard as possible while breathing normally. After a 2-second count, the tendon tap was delivered to the right leg and the subject was instructed to relax. In both experimental protocols, control patellar tendon reflexes were collected.

RESULTS

Analysis of variance for reflex peak force revealed a significant 30% reduction in the amount of vibration-induced reflex inhibition with increasing age, and a similar 33% reduction in the amount of Jendrassik maneuver facilitation observed for the older adults as compared with the younger adults.

CONCLUSION

These results support the hypothesis that inhibitory and excitatory influences acting on the alpha motoneuron pool are different in young and older adults.

EMG study on the effect of ageing on the human masseteric jaw-jerk reflex

The effect of age on the masseteric jaw-jerk reflex was investigated in 22 young (11 males and 11 females with mean age 23.2 years) and 22 older dentate subjects (11 males and 11 females with mean age 61.3 years). Electromyographic (EMG) recordings were obtained, after chin taps, from the relaxed masseter muscle of the preferred chewing side, by use of a computerised recording and analysis system. With increasing age the occurrence of the reflex was reduced, the latency was increased, while the amplitude was decreased. Those findings are probably related to the general age related changes in the muscular tissue, the sense organs, the peripheral nerves and especially the central nervous system. Increased biological variance was also observed in the older subjects, as in most aspects of performance in the latent years. Furthermore, the effects of ageing were generally similar in men and women. The age-related decrement in the monosynaptic reflex response is indicative of a generalised decline in the motor performance of the stomatognathic system and the decreased ability of the older dental patient to easily adapt to any dramatic changes in the sensory input.

Age related decline in postural control mechanisms

In order to study voluntary and reflexive mechanisms of postural control, young and elderly persons were given large-fast and small-slow ankle-rotation postural disturbances while standing on a movable platform capable of measuring ground reaction forces. Large-fast rotations were employed to activate long-loop reflexes, and small-slow rotations were employed to tap the higher level sensory integration aspects of postural control. Overall, the elderly persons exhibited more perturbation induced sway and showed a slowing in voluntary, as opposed to reflexive mechanisms of correcting postural disturbance. For both age groups, reflexive mechanisms were found to be relatively intact. When small perturbations were given, the elderly persons swayed more than young participants and produced sporadic reflexive activity. Moreover, elderly persons did not adapt to the small perturbations and exhibited increased postural sway to repetitive presentation of the perturbation, whereas young participants substantially decreased their postural sway. These data demonstrate that elderly persons are at some disadvantage when posture is under the control of slower, higher level sensory integrative mechanisms.

Contralateral influences on patellar tendon reflexes in young and old adults

In an effort to more fully investigate age-related changes in spinal reflex parameters, we measured force-time characteristics of the patellar tendon reflex in aged subjects and contrasted these with data obtained from college-age individuals. We also conditioned the tendon jerk with a tap to the contralateral tendon. The results showed a marked tendon reflex enhancement in the old group, consisting of greater overall reflex force produced by the quadriceps. In both groups, the contralateral conditioning stimulus produced a short-latency inhibition (at 25 msec) followed by a longer-latency facilitation (beginning at 75 msec). Both the early inhibition and the later reflex enhancement were greater in the aged subjects. We suggest that some age-related change may occur at the spinal level to compensate for decrements in more complex motor functioning.

Plantarflexor muscle function in young and elderly women

Contractile properties of the ankle plantarflexor muscles were compared between groups of young (means = 26 y) and elderly (means = 82 y) women. The H-reflex muscle contraction in the elderly group was characterized by a significant slowing of torque generation, as compared to the young women (means for average rate of torque development were young = 0.16 Nm ms-1 +/- 0.02 (SE), elderly = 0.09 Nm ms-1 +/- 0.02, P less than 0.05). However, the proportion of the total motor unit pool activated by the reflex was similar for the young and elderly groups at 63% and 70%, respectively. Maximal voluntary isometric torques were significantly lower (71%) in the elderly (young means = 135.3 Nm +/- 9.3, elderly means = 39.2 Nm +/- 2.9, P less than 0.01). These results are consistent with, and extend, previous reports showing decreased strength and speed of contraction in elderly muscle. Given that the average body weight was similar for the young and elderly groups, it was concluded that the aged plantarflexor muscles exhibited considerable impairment in ability to generate stabilizing torques about the ankle joint.

Aging and posture control: changes in sensory organization and muscular coordination

The following study examined two aspects of balance control in the older adult: the coordination of the timing and the amplitude of muscle responses to postural perturbations, and the ability of the participant to reorganize sensory inputs and subsequently modify postural responses as a consequence of changing environmental conditions. Coordination of muscle activity in postural responses of twelve elderly (sixty-one to seventy-eight years) participants were compared to those of young (nineteen to thirty-eight years) adults using a movable platform and recording the electromyographic activity of muscles of the legs. The following changes were noted in the timing and amplitude of muscle activity within a postural response synergy: increases in the absolute latency of distal muscle responses were observed in all older adults; in five of the twelve older adults temporal reversals of proximal and distal muscle response onset were observed; and there was a breakdown in the correlation of the amplitude of responses within a synergy. The ability of the older adult to balance under conditions of reduced or conflicting sensory information was also impaired. When confronted with functionally inappropriate visual and/or somatosensory inputs, half of the older group lost balance. In most instances, however, the older participants were able to maintain stability during subsequent responses to conflicting stimuli.