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Niu S, Zhang T, Li W, Wen S, Dong L, Wang S, Shi W, Shi C, Shen Y, Huang Q, Tan Y, Xu X, Yu L. Positive effect of deep diaphragmatic breathing training on gastroesophageal reflux-induced chronic cough: a clinical randomized controlled study. Respir Res 2024; 25:169. [PMID: 38637797 PMCID: PMC11027235 DOI: 10.1186/s12931-024-02783-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/21/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVE To explore the efficacy of deep diaphragmatic breathing training (DEP) in patients with gastroesophageal reflux-induced chronic cough (GERC). METHODS A randomized controlled study was conducted involving 60 GERC patients who were divided into the intervention group and the control group (each with 30 patients). Both groups received routine medication treatment for GERC, while the intervention group received DEP training additionally. Both groups were evaluated by cough symptom scores, Hull airway reflux questionnaire (HARQ), gastroesophageal reflux diagnostic questionnaire (GerdQ), generalized anxiety disorder scale-7 (GAD-7), patient health questionnaire-9 (PHQ-9), Pittsburgh sleep quality index (PSQI), the Leicester cough questionnaire (LCQ), as well as capsaicin cough sensitivity testing, B-ultrasound and surface electromyography (sEMG) of the diaphragmatic muscles before and after treatment. The cough resolution rate and changes of the above indictors was compared between the two groups after eight weeks of treatment. RESULTS After eight weeks of treatment, cough symptoms improved in both groups, but the cough resolution rate in the intervention group of 94% was significantly higher than that in the control group of 77% (χ2 = 6.402, P = 0.041). The intervention group showed significant improvements to the control group in GerdQ (6.13(0.35) VS 6.57(0.77)), GAD-7 (0(0;1) VS 1(0;3)), PSQI (2(1;3) VS 4(3;6)), LCQ (17.19(1.56) VS 15.88(1.92)) and PHQ-9 (0(0;0) VS 0(0;3)) after treatment. Compared to control group, sEMG activity of the diaphragmatic muscle was significantly increased in the intervention group after treatment, measured during DEP (79.00(2.49) VS 74.65 (1.93)) and quiet breathing (72.73 (1.96) VS 67.15 (2.48)). CONCLUSION DEP training can improve cough symptoms as an adjunctive treatment in GERC patients. TRIAL REGISTRATION The protocol was registered in February 2, 2022 via the Chinese Clinical Trials Register ( http://www.chictr.org.cn/ ) [ChiCTR2200056246].
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Affiliation(s)
- Shanshan Niu
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
- Department of Oncology, Shanghai Yangzhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), School of Medicine, Tongji University, Shanghai, China
| | - Tongyangzi Zhang
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Wanzhen Li
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Siwan Wen
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Lei Dong
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Shengyuan Wang
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Wenbo Shi
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Cuiqin Shi
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Yuqin Shen
- Department of Cardiac Rehabilitation, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Qianchun Huang
- Department of Cardiac Rehabilitation, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Yaling Tan
- Department of Neurology, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China
| | - Xianghuai Xu
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China.
| | - Li Yu
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China.
- Department of Allergy, Tongji Hospital, School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai, 200065, China.
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Braun P, Rapp J, Hemmert W, Gleich B. Coil efficiency for inductive peripheral nerve stimulation. IEEE Trans Neural Syst Rehabil Eng 2022; 30:2137-2145. [PMID: 35857725 DOI: 10.1109/tnsre.2022.3192761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Magnetic stimulation of peripheral nerves is evoked by electric field gradients caused by high-intensity, pulsed magnetic fields created from a coil. Currents required for stimulation are very high, therefore devices are large, expensive, and often too complex for many applications like rehabilitation therapy. For repetitive stimulation, coil heating due to power loss poses a further limitation. The geometry of the magnetic coil determines field depth and focality, making it the most important factor that determines the current required for neuronal excitation. However, the comparison between different coil geometries is difficult and depends on the specific application. Especially the distance between nerve and coil plays a crucial role. In this investigation, the electric field distribution of 14 different coil geometries was calculated for a typical peripheral nerve stimulation with a 27mm distance between axon and coil. Coil parameters like field strength and focality were determined with electromagnetic field simulations. In a second analysis, the activating function along the axon was calculated, which quantifies the efficiency of neuronal stimulation. Moreover, coil designs were evaluated concerning power efficacy based on ohmic losses. Our results indicate that power efficacy of magnetic neurostimulation can be improved significantly by up to 40% with optimized coil designs.
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Ye H. Finding the Location of Axonal Activation by a Miniature Magnetic Coil. Front Comput Neurosci 2022; 16:932615. [PMID: 35847967 PMCID: PMC9276924 DOI: 10.3389/fncom.2022.932615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 06/03/2022] [Indexed: 11/17/2022] Open
Abstract
Magnetic stimulation for neural activation is widely used in clinical and lab research. In comparison to electric stimulation using an implanted electrode, stimulation with a large magnetic coil is associated with poor spatial specificity and incapability to stimulate deep brain structures. Recent developments in micromagnetic stimulation (μMS) technology mitigates some of these shortcomings. The sub-millimeter coils can be covered with soft, biocompatible material, and chronically implanted. They can provide highly specific neural stimulation in the deep neural structure. Although the μMS technology is expected to provide a precise location of neural stimulation, the exact site of neural activation is difficult to determine. Furthermore, factors that could cause the shifting of the activation site during μMS have not been fully investigated. To estimate the location of axon activation in μMS, we first derived an analytical expression of the activating function, which predicts the location of membrane depolarization in an unmyelinated axon. Then, we developed a multi-compartment, Hodgkin-Huxley (H-H) type of NEURON model of an unmyelinated axon to test the impact of several important coil parameters on the location of axonal activation. The location of axonal activation was dependent on both the parameters of the stimulus and the biophysics properties of the targeted axon during μMS. The activating function analysis predicted that the location of membrane depolarization and activation could shift due to the reversal of the coil current and the change in the coil-axon distance. The NEURON modeling confirmed these predictions. Interestingly, the NEURON simulation further revealed that the intensity of stimulation played a significant role in the activation location. Moderate or strong coil currents activated the axon at different locations, mediated by two distinct ion channel mechanisms. This study reports several experimental factors that could cause a potential shift in the location of neural activation during μMS, which is essential for further development of this novel technology.
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Younis G, El Sawy N, Elnemr R, Madkour D. Differences between diaphragmatic compound muscle action potentials recorded from over the sternum and lateral chest wall in healthy subjects. Sci Rep 2022; 12:8925. [PMID: 35624292 PMCID: PMC9142496 DOI: 10.1038/s41598-022-11930-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/21/2022] [Indexed: 01/15/2023] Open
Abstract
To report normative data for diaphragmatic compound muscle action potentials (DCMAPs) recorded from over the sternum and lateral chest wall (LCW) and highlight factors that may contribute to variations in DCMAP parameters at the two sites. The phrenic nerve of seventy-three healthy subjects was bilaterally stimulated at the posterior border of the sternocleidomastoid muscle. DCMAPs from over the sternum and LCW were recorded (inspiration/expiration). Normative values of sternal and LCW DCMAPs were presented. The mean values of latency of LCW DCMAPs, duration of sternal DCMAPs and area from both recording sites are close to values reported by other studies. The mean values of latency of sternal DCMAPs are higher than that reported by other studies. Significant differences were found between sternal and LCW potentials in the mean latency, amplitude, and area (p < 0.001). The duration did not differ between the two sites. Differences were found between inspiration and expiration, right and left sides, and men and women. Regression analysis showed a relation between latency of sternal and LCW potentials and age. Latency (LCW potentials) and amplitude and area (sternal/LCW potentials) were related to gender. Amplitude (LCW potentials/inspiration) and area (sternal potentials/inspiration) were related to chest circumference (p = 0.023 and 0.013 respectively). Area (sternal potentials/expiration) was related to the BMI (p = 0.019). Our normative values for sternal and LCW DCMAPs are provided. Notable differences in the DCMAPs parameters were detected between the two recording sites, inspiration and expiration, right and left, and men and women. The technique of phrenic nerve should be standardized.
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Affiliation(s)
- Gihan Younis
- grid.7155.60000 0001 2260 6941Physical Medicine, Rheumatology and Rehabilitation Department, Faculty of Medicine, Alexandria University, El-Khartoom Square, Alexandria, 21526 Egypt
| | - Noha El Sawy
- grid.7155.60000 0001 2260 6941Physical Medicine, Rheumatology and Rehabilitation Department, Faculty of Medicine, Alexandria University, El-Khartoom Square, Alexandria, 21526 Egypt
| | - Rehab Elnemr
- grid.7155.60000 0001 2260 6941Physical Medicine, Rheumatology and Rehabilitation Department, Faculty of Medicine, Alexandria University, El-Khartoom Square, Alexandria, 21526 Egypt
| | - Doaa Madkour
- grid.7155.60000 0001 2260 6941Physical Medicine, Rheumatology and Rehabilitation Department, Faculty of Medicine, Alexandria University, El-Khartoom Square, Alexandria, 21526 Egypt
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Welch JF, Nair J, Argento PJ, Mitchell GS, Fox EJ. Acute intermittent hypercapnic-hypoxia elicits central neural respiratory motor plasticity in humans. J Physiol 2022; 600:2515-2533. [PMID: 35348218 DOI: 10.1113/jp282822] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/25/2022] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS The occurrence of respiratory long-term facilitation following acute exposure to intermittent hypoxia is believed to be dependent upon CO2 regulation - mechanisms governing the critical role of CO2 have seldom been explored. We tested the hypothesis that acute intermittent hypercapnic-hypoxia (AIHH) enhances cortico-phrenic neurotransmission in awake healthy humans. The amplitude of diaphragmatic motor-evoked potentials induced by transcranial magnetic stimulation was increased after AIHH, but not the amplitude of compound muscle action potentials evoked by cervical magnetic stimulation. Mouth occlusion pressure (P0.1 , indicator of neural respiratory drive) was also increased after AIHH, but not tidal volume or minute ventilation. Thus, moderate AIHH elicits central neural mechanisms of respiratory motor plasticity, without measurable ventilatory long-term facilitation in awake humans. ABSTRACT Acute intermittent hypoxia (AIH) elicits long-term facilitation (LTF) of respiration. Although LTF is observed when CO2 is elevated during AIH in awake humans, the influence of CO2 on corticospinal respiratory motor plasticity is unknown. Thus, we tested the hypotheses that acute intermittent hypercapnic-hypoxia (AIHH): 1) enhances cortico-phrenic neurotransmission (reflecting volitional respiratory control); and 2) elicits ventilatory LTF (reflecting automatic respiratory control). Eighteen healthy adults completed four study visits. Day 1 consisted of anthropometry and pulmonary function testing. On Days 2, 3 and 4, in a balanced alternating sequence, participants received: AIHH, poikilocapnic AIH, and normocapnic-normoxia (Sham). Protocols consisted of 15, 60-s exposures with 90-s normoxic intervals. Transcranial (TMS) and cervical (CMS) magnetic stimulation were used to induce diaphragmatic motor-evoked potentials and compound muscle action potentials, respectively. Respiratory drive was assessed via mouth occlusion pressure (P0.1 ), and minute ventilation measured at rest. Dependent variables were assessed at baseline and 30-60 min post-exposures. Increases in TMS-evoked diaphragm potential amplitudes were observed following AIHH versus Sham (+28 ± 41%, p = 0.003), but not after AIH. No changes were observed in CMS-evoked diaphragm potential amplitudes. Mouth occlusion pressure also increased after AIHH (+21 ± 34%, p = 0.033), but not after AIH. Ventilatory LTF was not observed after any treatment. We demonstrate that AIHH elicits central neural mechanisms of respiratory motor plasticity and increases resting respiratory drive in awake humans. These findings may have important implications for neurorehabilitation after spinal cord injury and other neuromuscular disorders compromising respiratory motor function. Abstract Figure Legend In a single-blind, cross-over, sham-controlled trial, 18 healthy adults received in a balanced alternating sequence: normocapnic-normoxia (Sham), poikilocapnic acute intermittent hypoxia (AIH), and acute intermittent hypercapnic-hypoxia (AIHH). The study tested the hypothesis that AIHH enhances cortico-phrenic neurotransmission and elicits ventilatory long-term facilitation. Note the increase in the mean amplitude of diaphragmatic motor-evoked potentials (MEP) induced by transcranial magnetic stimulation 60 min after AIHH only, whereas the amplitude of diaphragmatic compound muscle action potentials evoked by cervical (phrenic nerve) stimulation were unchanged after AIHH, AIH and Sham. Traces are composite averages of all participants. Mouth occlusion pressure (P0.1 ), an indicator of resting respiratory drive, was increased after AIHH, but not after AIH or Sham (see yellow shaded area). Traces are mouth pressure at the onset of an occluded inspiration during resting breathing. Finally, tidal volume (VT ) was unchanged 30-60 min after AIHH, AIH and Sham. Our results indicate that moderate AIHH elicits a central neural mechanism of respiratory motor plasticity and increases resting respiratory drive in awake humans, without measurable ventilatory long-term facilitation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Joseph F Welch
- Breathing Research and Therapeutics Centre.,Department of Physical Therapy
| | - Jayakrishnan Nair
- Breathing Research and Therapeutics Centre.,Department of Physical Therapy.,Department of Physical Therapy, Thomas Jefferson University, Philadelphia, PA, USA
| | - Patrick J Argento
- Herbert Wertheim College of Engineering, University of Florida, Gainesville, FL, USA
| | - Gordon S Mitchell
- Breathing Research and Therapeutics Centre.,Department of Physical Therapy
| | - Emily J Fox
- Breathing Research and Therapeutics Centre.,Department of Physical Therapy.,Brooks Rehabilitation, Jacksonville, FL, USA
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Rapp J, Braun P, Hemmert W, Gleich B. Optimal pulse configuration for peripheral inductive nerve stimulation. Biomed Phys Eng Express 2022; 8. [DOI: 10.1088/2057-1976/ac52d8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/08/2022] [Indexed: 11/12/2022]
Abstract
Abstract
Peripheral magnetic stimulation is a promising technique for several applications like rehabilitation or diagnose of neuronal pathways. However, most available magnetic stimulation devices are designed for transcranial stimulation and require high-power, expensive hardware. Modern technology such as rectangular pulses allows to adapt parameters like pulse shape and duration in order to reduce the required energy. Nevertheless, the effect of different temporal electromagnetic field shapes on neuronal structures is not yet fully understood. We created a simulation environment to find out how peripheral nerves are affected by induced magnetic fields and what pulse shapes have the lowest energy requirements. Using the electric field distribution of a Figure-of-8 coil together with an axon model in saline solution, we calculated the potential along the axon and determined the required threshold current to elicit an action potential. Further, for the purpose of selective stimulation, we investigated different axon diameters. Our results show that rectangular pulses have the lowest thresholds at a pulse duration of 20 μs. For sinusoidal coil currents, the optimal pulse duration was found to be 40 μs. Most importantly, with an asymmetric rectangular pulse, the coil current could be reduced from 2.3 kA (cosine shaped pulse) to 600 A. In summary, our results indicate that for magnetic nerve stimulation the use of rectangular pulse shapes holds the potential to reduce the required coil current by a factor of 4, which would be a massive improvement.
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Lee KZ, Liou LM, Vinit S. Diaphragm Motor-Evoked Potential Induced by Cervical Magnetic Stimulation following Cervical Spinal Cord Contusion in the Rat. J Neurotrauma 2021; 38:2122-2140. [PMID: 33899506 DOI: 10.1089/neu.2021.0080] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Cervical spinal injury is typically associated with respiratory impairments due to damage to bulbospinal respiratory pathways and phrenic motoneurons. Magnetic stimulation is a non-invasive approach for the evaluation and modulation of the nervous system. The present study was designed to examine whether cervical magnetic stimulation can be applied to evaluate diaphragmatic motor outputs in a pre-clinical rat model of cervical spinal injury. The bilateral diaphragm was monitored in anesthetized rats using electromyogram at the acute, subchronic, and chronic stages following left mid-cervical contusion. The center of a figure-of-eight coil was placed 20 mm caudal to bregma to stimulate the cervical spinal cord. The results demonstrated that a single magnetic stimulation can evoke significant motor-evoked potentials in the diaphragms of uninjured animals when the animal's head was placed 30 mm right or left from the center of the coil. The spontaneous bursting of the diaphragm was significantly attenuated by contusion injury at all-time-points post-injury. However, the threshold of the diaphragmatic motor-evoked potential was reduced, and the amplitude of the diaphragmatic motor-evoked potential was enhanced in response to cervical magnetic stimulation at the acute injury stage. Moreover, the motor-evoked potentials of the bilateral diaphragm in animals with contusions were generally larger when the coil was placed at the left spinal cord at the subchronic and chronic injury stages. These results suggested that cervical magnetic stimulation can be used to examine the excitability of phrenic motor outputs post-injury, and magnetic stimulation applied more laterally may be more effective for triggering diaphragmatic motor-evoked potentials.
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Affiliation(s)
- Kun-Ze Lee
- Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
- Department of Biomedical Science and Environmental Biology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Min Liou
- Department of Neurology, Kaohsiung Medical University Hospital, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Stéphane Vinit
- Université Paris-Saclay, UVSQ, Inserm, END-ICAP, Versailles, France
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Welch JF, Argento PJ, Mitchell GS, Fox EJ. Reliability of diaphragmatic motor-evoked potentials induced by transcranial magnetic stimulation. J Appl Physiol (1985) 2020; 129:1393-1404. [PMID: 33031020 DOI: 10.1152/japplphysiol.00486.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The diaphragmatic motor-evoked potential (MEP) induced by transcranial magnetic stimulation (TMS) permits electrophysiological assessment of the cortico-diaphragmatic pathway. Despite the value of TMS for investigating diaphragm motor integrity in health and disease, reliability of the technique has not been established. The study aim was to determine within- and between-session reproducibility of surface electromyogram recordings of TMS-evoked diaphragm potentials. Fifteen healthy young adults participated (6 females, age = 29 ± 7 yr). Diaphragm activation was determined by gradually increasing the stimulus intensity from 60 to 100% of maximal stimulator output (MSO). A minimum of seven stimulations were performed at each intensity. A second block of stimuli was delivered 30 min later for within-day comparisons, and a third block was performed on a separate day for between-day comparisons. Reliability of diaphragm MEPs was assessed at 100% MSO using intraclass correlation coefficients (ICC) and 95% limits of agreement (LOA). MEP latency (ICC = 0.984, P < 0.001), duration (ICC = 0.958, P < 0.001), amplitude (ICC = 0.950, P < 0.001), and area (ICC = 0.956, P < 0.001) were highly reproducible within-day. Between-day reproducibility was good to excellent for all MEP characteristics (latency ICC = 0.953, P < 0.001; duration ICC = 0.879, P = 0.002; amplitude ICC = 0.789, P = 0.019; area ICC = 0.815, P = 0.012). Data revealed less precision between-day versus within-day, as evidenced by wider LOA for all MEP characteristics. Large within- and between-subject variability in MEP amplitude and area was observed. In conclusion, TMS is a reliable means of inducing diaphragm potentials in most healthy individuals.NEW & NOTEWORTHY Transcranial magnetic stimulation (TMS) is a noninvasive technique to assess neural impulse conduction along the cortico-diaphragmatic pathway. The reliability of diaphragm motor-evoked potentials (MEP) induced by TMS is unknown. Notwithstanding large variability in MEP amplitude, we found good-to-excellent reproducibility of all MEP characteristics (latency, duration, amplitude, and area) both within- and between-day in healthy adult men and women. Our findings support the use of TMS and surface EMG to assess diaphragm activation in humans.
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Affiliation(s)
- Joseph F Welch
- Breathing Research and Therapeutics Center, Department of Physical Therapy, University of Florida, Gainesville, Florida
| | - Patrick J Argento
- Herbert Wertheim College of Engineering, University of Florida, Gainesville, Florida
| | - Gordon S Mitchell
- Breathing Research and Therapeutics Center, Department of Physical Therapy, University of Florida, Gainesville, Florida
| | - Emily J Fox
- Breathing Research and Therapeutics Center, Department of Physical Therapy, University of Florida, Gainesville, Florida.,Brooks Rehabilitation, Jacksonville, Florida
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Spiesshoefer J, Henke C, Herkenrath S, Randerath W, Brix T, Young P, Boentert M. Assessment of Central Drive to the Diaphragm by Twitch Interpolation: Normal Values, Theoretical Considerations, and Future Directions. Respiration 2020; 98:283-293. [PMID: 31352459 DOI: 10.1159/000500726] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 04/30/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The twitch interpolation technique is a promising tool for assessing central drive to the diaphragm. It is used to quantify the degree of voluntary diaphragm activation during predefined breathing maneuvers. OBJECTIVES This study was designed to (a) determine reference values for the level of voluntary activation of the diaphragm using the twitch occlusion technique in healthy adults and (b) explore the association between central drive to the diaphragm and volitional tests of respiratory muscle strength. METHODS Twenty-seven healthy volunteers aged 26 ± 14 years (18 male) were enrolled. Twitch transdiaphragmatic pressure (Pdi) was determined at relaxed functional residual capacity in response to cervical magnetic stimulation (CMS) of the phrenic nerves. The subjects were then instructed to gradually increase voluntary activation of the diaphragm, and the effects of superimposed magnetic stimuli on voluntary Pdi were assessed. RESULTS The twitch Pdi amplitude following CMS linearly decreased with increasing inspiratory effort. The resulting diaphragm voluntary activation index (DVAI) during maximal voluntary contraction was 75 ± 15% irrespective of gender or age. Twitch duration, half relaxation time, and area under the curve of superimposed Pdi deflections did not show a linear but an exponential association with increasing voluntary activation of the diaphragm. More than 2/3 of the decrease in the above values was evident after 1/3 of voluntary diaphragm contraction. Forced vital capacity (FVC) was inversely correlated with the DVAI. CONCLUSIONS Twitch interpolation allows for assessment of central drive to the diaphragm. The maximum DVAI is independent of gender or age, and significantly related to FVC but not to maximum inspiratory pressure or Pdi as direct measures of diaphragm strength.
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Affiliation(s)
- Jens Spiesshoefer
- Respiratory Physiology Laboratory, Department of Neurology with Institute for Translational Neurology, University of Münster, Münster, Germany,
| | - Carolin Henke
- Respiratory Physiology Laboratory, Department of Neurology with Institute for Translational Neurology, University of Münster, Münster, Germany
| | - Simon Herkenrath
- Bethanien Hospital gGmbH Solingen, Solingen, Germany.,Institute of Pneumology, University of Cologne, Solingen, Germany
| | - Winfried Randerath
- Bethanien Hospital gGmbH Solingen, Solingen, Germany.,Institute of Pneumology, University of Cologne, Solingen, Germany
| | - Tobias Brix
- Institute of Medical Informatics, University of Münster, Münster, Germany
| | - Peter Young
- Medical Park Klinik Reithofpark, Bad Feilnbach, Germany
| | - Matthias Boentert
- Respiratory Physiology Laboratory, Department of Neurology with Institute for Translational Neurology, University of Münster, Münster, Germany
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Spiesshoefer J, Henke C, Herkenrath SD, Randerath W, Brix T, Görlich D, Young P, Boentert M. Noninvasive Prediction of Twitch Transdiaphragmatic Pressure: Insights from Spirometry, Diaphragm Ultrasound, and Phrenic Nerve Stimulation Studies. Respiration 2019; 98:301-311. [PMID: 31387103 DOI: 10.1159/000501171] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 05/26/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Twitch transdiaphragmatic pressure (twPdi) following magnetic stimulation (MS) of the phrenic nerves is the gold standard for non-volitional assessment of diaphragm strength. Expiratory muscle function can be investigated using MS of the abdominal muscles and measurement of twitch gastric pressure (twPgas). OBJECTIVES To investigate whether twitch pressures following MS of the phrenic and lower thoracic nerve roots can be predicted noninvasively by diaphragm ultrasound parameters and volitional tests of respiratory muscle strength. METHODS Sixty-three healthy subjects underwent standard spirometry, measurement of maximum inspiratory (PImax) and expiratory pressure (PEmax), and diaphragm ultrasound. TwPdi following cervical MS of the phrenic nerve roots and twPgas after lower thoracic MS (twPgas-Thor) were measured using esophageal and gastric balloon catheters inserted transnasally. Using surface electrodes, compound muscle action potentials (CMAP) were simultaneously recorded from the diaphragm or obliquus abdominis muscles, respectively. RESULTS Forced expiratory flow (FEF25-75) was significantly correlated with twPdi (r = 0.37; p = 0.003) and its components (twPgas and twitch esophageal pressure, twPes). Diaphragm excursion velocity during tidal breathing was correlated to twPes (r = 0.44; p = 0.02). No prediction of twitch pressures was possible from CMAP amplitude, forced vital capacity (FVC), or PImax. TwPgas-Thor was correlated with FEF25-75 (r = 0.46; p = 0.05) and diaphragm thickness at total lung capacity (r = 0.38; p = 0.04) but could not be predicted from CMAP amplitude, FVC, or PEmax. CONCLUSIONS TwPdi and twPgas-Thor cannot be predicted from volitional measures of respiratory muscle strength, diaphragm and abdominal CMAP, or diaphragm ultrasound. Invasive recording of esophageal and gastric pressures following MS remains indispensable for objective assessment of respiratory muscle strength.
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Affiliation(s)
- Jens Spiesshoefer
- Respiratory Physiology Laboratory, Department of Neurology with Institute for Translational Neurology, University of Muenster, Muenster, Germany,
| | - Carolin Henke
- Respiratory Physiology Laboratory, Department of Neurology with Institute for Translational Neurology, University of Muenster, Muenster, Germany
| | - Simon Dominik Herkenrath
- Institute for Pneumology, University of Cologne, Solingen, Germany.,Bethanien Hospital gGmbH, Solingen, Germany
| | - Winfried Randerath
- Institute for Pneumology, University of Cologne, Solingen, Germany.,Bethanien Hospital gGmbH, Solingen, Germany
| | - Tobias Brix
- Institute of Medical Informatics, University of Muenster, Muenster, Germany
| | - Dennis Görlich
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Peter Young
- Medical Park Klinik Reithofpark, Bad Feilnbach, Germany
| | - Matthias Boentert
- Respiratory Physiology Laboratory, Department of Neurology with Institute for Translational Neurology, University of Muenster, Muenster, Germany
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Spiesshoefer J, Henke C, Herkenrath S, Brix T, Randerath W, Young P, Boentert M. Transdiapragmatic pressure and contractile properties of the diaphragm following magnetic stimulation. Respir Physiol Neurobiol 2019; 266:47-53. [DOI: 10.1016/j.resp.2019.04.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/12/2019] [Accepted: 04/23/2019] [Indexed: 11/28/2022]
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Electrophysiological Properties of the Human Diaphragm Assessed by Magnetic Phrenic Nerve Stimulation: Normal Values and Theoretical Considerations in Healthy Adults. J Clin Neurophysiol 2019; 36:375-384. [PMID: 31145172 DOI: 10.1097/wnp.0000000000000608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE This study determined normal values for motor evoked potentials (MEPs) and compound muscle action potentials (CMAPs) of the diaphragm following cortical and cervical magnetic stimulation (COMS and CEMS) of the phrenic nerves in healthy adults. METHODS Using surface electrodes, diaphragmatic MEP and CMAP were recorded in 70 subjects (34 ± 13 years, 25 men) following supramaximal cortical magnetic stimulation and CEMS at functional residual capacity and using a standardized inspiratory pressure trigger (-0.5 kPa). All healthy volunteers underwent standard spirometry and measurement of maximum inspiratory and expiratory pressure. RESULTS At functional residual capacity, upper limit of normal for MEP latency was 25 ms in men and 23 ms in women (p < 0.05), and upper limit of normal for CMAP latency was 6 ms. In contrast to MEP and CMAP amplitude, corresponding latencies showed little interindividual and intraindividual variability. Use of an inspiratory pressure trigger enhanced reproducibility and amplitude of diaphragm MEP. Diaphragm responses to both cortical and cervical magnetic stimulation were symmetrical and independent of age (in our cohort), with higher values for latency and amplitude in men (each p < 0.05). Diaphragm CMAP amplitude showed weak-moderate correlations with forced vital capacity (r = 0.47; p < 0.01), maximum inspiratory pressure (r = 0.39; p < 0.01), and maximum expiratory pressure (r = 0.32; p < 0.01). CONCLUSIONS Combination of cortical magnetic stimulation and CEMS of the phrenic nerves is feasible and allows noninvasive assessment of both central and peripheral conductivity of the diaphragm and the inspiratory pathway.
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Laveneziana P, Albuquerque A, Aliverti A, Babb T, Barreiro E, Dres M, Dubé BP, Fauroux B, Gea J, Guenette JA, Hudson AL, Kabitz HJ, Laghi F, Langer D, Luo YM, Neder JA, O'Donnell D, Polkey MI, Rabinovich R, Rossi A, Series F, Similowski T, Spengler C, Vogiatzis I, Verges S. ERS statement on respiratory muscle testing at rest and during exercise. Eur Respir J 2019; 53:13993003.01214-2018. [DOI: 10.1183/13993003.01214-2018] [Citation(s) in RCA: 227] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 02/18/2019] [Indexed: 12/12/2022]
Abstract
Assessing respiratory mechanics and muscle function is critical for both clinical practice and research purposes. Several methodological developments over the past two decades have enhanced our understanding of respiratory muscle function and responses to interventions across the spectrum of health and disease. They are especially useful in diagnosing, phenotyping and assessing treatment efficacy in patients with respiratory symptoms and neuromuscular diseases. Considerable research has been undertaken over the past 17 years, since the publication of the previous American Thoracic Society (ATS)/European Respiratory Society (ERS) statement on respiratory muscle testing in 2002. Key advances have been made in the field of mechanics of breathing, respiratory muscle neurophysiology (electromyography, electroencephalography and transcranial magnetic stimulation) and on respiratory muscle imaging (ultrasound, optoelectronic plethysmography and structured light plethysmography). Accordingly, this ERS task force reviewed the field of respiratory muscle testing in health and disease, with particular reference to data obtained since the previous ATS/ERS statement. It summarises the most recent scientific and methodological developments regarding respiratory mechanics and respiratory muscle assessment by addressing the validity, precision, reproducibility, prognostic value and responsiveness to interventions of various methods. A particular emphasis is placed on assessment during exercise, which is a useful condition to stress the respiratory system.
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Abstract
Respiratory failure is common during acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). Phrenic nerve conduction (PNC), transcranial magnetic stimulation (TMS), and cervical magnetic stimulation (CMS) are of great value in identifying the feature and site of AE-COPD.PNC, TMS, and CMS were performed in 20 AE-COPD patients with respiratory failure, and re-examined after weaning. Latencies and amplitudes of the diaphragmatic compound muscle action potential (dCMAP), motor evoked potential of the diaphragm (dMEP) evoked by TMS and CMS, and central motor conduction time (CMCT) were measured. Blood gas analysis and serum electrolyte levels were also evaluated. The results were compared with those from 20 healthy subjects.AE-COPD patients showed prolonged CMCT and latencies of dCMAP and dMEP, decreased amplitudes of dCMAP and dMEP evoked by CMS, while CMCT and the latency of dMEP evoked by TMS were shortened after weaning. Significant correlation was identified between arterial blood gas analysis, serum electrolyte levels, disease duration, the duration of mechanical ventilation and the electrophysiological findings in AE-COPD patients prior to weaning.The central and peripheral respiratory pathway is involved in AE-COPD. Central respiratory pathway function is improved after weaning in AE-COPD patients with respiratory failure.
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Affiliation(s)
- Yu Wang
- Department of Neurology, Third Central Hospital of Tianjin
- Tianjin Institute of Hepatobiliary Disease
- Tianjin Key Laboratory of Artificial Cell
- Artificial Cell Engineering Technology Research Center of Public Health Ministry, Tianjin, China
| | - Na Liu
- Department of Neurology, Third Central Hospital of Tianjin
- Tianjin Institute of Hepatobiliary Disease
- Tianjin Key Laboratory of Artificial Cell
- Artificial Cell Engineering Technology Research Center of Public Health Ministry, Tianjin, China
| | - Zhecheng Zhang
- Department of Neurology, Third Central Hospital of Tianjin
- Tianjin Institute of Hepatobiliary Disease
- Tianjin Key Laboratory of Artificial Cell
- Artificial Cell Engineering Technology Research Center of Public Health Ministry, Tianjin, China
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Türk M, Weber I, Vogt-Ladner G, Schröder R, Winterholler M. Diaphragmatic dysfunction as the presenting symptom in neuromuscular disorders: A retrospective longitudinal study of etiology and outcome in 30 German patients. Neuromuscul Disord 2018; 28:484-490. [DOI: 10.1016/j.nmd.2018.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 03/16/2018] [Accepted: 04/03/2018] [Indexed: 10/17/2022]
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17
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Welch JF, Mildren RL, Zaback M, Archiza B, Allen GP, Sheel AW. Reliability of the diaphragmatic compound muscle action potential evoked by cervical magnetic stimulation and recorded via chest wall surface EMG. Respir Physiol Neurobiol 2017; 243:101-106. [PMID: 28571976 DOI: 10.1016/j.resp.2017.05.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/23/2017] [Accepted: 05/25/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Stimulation of the phrenic nerve via cervical magnetic stimulation (CMS) elicits a compound muscle action potential (CMAP) that allows for assessment of diaphragm activation. The reliability of CMS to evoke the CMAP recorded by chest wall surface EMG has yet to be comprehensively examined. METHODS CMS was performed on healthy young males (n=10) and females (n=10). Surface EMG electrodes were placed on the right and left hemi-diaphragm between the 6-8th intercostal spaces. CMAPs were analysed for: latency, duration, peak-to-peak amplitude, and area. Reliability within and between experimental sessions was assessed using intraclass correlation coefficients (ICC). Bilateral (right-left) and sex-based (male-female) comparisons were also made (independent samples t-test). RESULTS All CMAP characteristics demonstrated high reproducibility within (ICCs>0.96) and between (ICCs>0.89) experimental sessions. No statistically significant bilateral or sex-based differences were found (p>0.05). DISCUSSION CMS is a reliable and non-invasive method to evaluate phrenic nerve conduction.
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Affiliation(s)
- Joseph F Welch
- School of Kinesiology, University of British Columbia, Vancouver, BC, Canada.
| | - Robyn L Mildren
- School of Kinesiology, University of British Columbia, Vancouver, BC, Canada
| | - Martin Zaback
- School of Kinesiology, University of British Columbia, Vancouver, BC, Canada
| | - Bruno Archiza
- Department of Physical Therapy, Federal University of Sao Carlos, Sao Carlos, SP, Brazil
| | - Grayson P Allen
- School of Kinesiology, University of British Columbia, Vancouver, BC, Canada
| | - A William Sheel
- School of Kinesiology, University of British Columbia, Vancouver, BC, Canada
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Leung A, Shukla S, Lee J, Metzger-Smith V, He Y, Chen J, Golshan S. Effect of low frequency transcutaneous magnetic stimulation on sensory and motor transmission. Bioelectromagnetics 2015; 36:410-9. [PMID: 25989482 DOI: 10.1002/bem.21921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 04/05/2015] [Indexed: 11/06/2022]
Abstract
Peripheral nerve injury diminishes fast conducting large myelinated afferent fibers transmission but enhances smaller pain transmitting fibers firing. This aberrant afferent neuronal behavior contributes to development of chronic post-traumatic peripheral neuropathic pain (PTP-NP). Non-invasive dynamic magnetic flux stimulation has been implicated in treating PTP-NP, a condition currently not adequately addressed by other therapies including transcutaneous electrical nerve stimulation (TENS). The current study assessed the effect of low frequency transcutaneous magnetic stimulation (LFTMS) on peripheral sensory thresholds, nerve conduction properties, and TENS induced fast afferent slowing effect as measured by motor and sensory conduction studies in the ulnar nerve. Results indicated sham LFTMS with TENS (Sham + TENS) significantly (P = 0.02 and 0.007, respectively) reduces sensory conduction velocity (CV) and increases sensory onset latency (OL), and motor peak latency (PL) whereas, real LFTMS with TENS (Real + TENS) reverses effects of TENS on sensory CV and OL, and significantly (P = 0.036) increases the sensory PL. LFTMS alone significantly (P < 0.05) elevates sensory PL and onset-to-peak latency. LFTMS appears to reverse TENS slowing effect on fast conducting fibers and casts a selective peripheral modulatory effect on slow conducting pain afferent fibers.
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Affiliation(s)
- Albert Leung
- Department of Anesthesiology, University of California, School of Medicine, San Diego, California.,Veterans Administration San Diego Healthcare System (California), San Diego, California
| | - Shivshil Shukla
- Department of Anesthesiology, University of California, School of Medicine, San Diego, California.,Veterans Administration San Diego Healthcare System (California), San Diego, California
| | | | | | - Yifan He
- University of California, San Diego, California
| | - Jeffrey Chen
- Department of Anesthesiology, University of California, School of Medicine, San Diego, California.,Veterans Administration San Diego Healthcare System (California), San Diego, California
| | - Shahrokh Golshan
- Department of Psychiatry, University of California, School of Medicine, San Diego, California
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Does trans-spinal direct current stimulation alter phrenic motoneurons and respiratory neuromechanical outputs in humans? A double-blind, sham-controlled, randomized, crossover study. J Neurosci 2015; 34:14420-9. [PMID: 25339753 DOI: 10.1523/jneurosci.1288-14.2014] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Although compelling evidence has demonstrated considerable neuroplasticity in the respiratory control system, few studies have explored the possibility of altering descending projections to phrenic motoneurons (PMNs) using noninvasive stimulation protocols. The present study was designed to investigate the immediate and long-lasting effects of a single session of transcutaneous spinal direct current stimulation (tsDCS), a promising technique for modulating spinal cord functions, on descending ventilatory commands in healthy humans. Using a double-blind, controlled, randomized, crossover approach, we examined the effects of anodal, cathodal, and sham tsDCS delivered to the C3-C5 level on (1) diaphragm motor-evoked potentials (DiMEPs) elicited by transcranial magnetic stimulation and (2) spontaneous ventilation, as measured by respiratory inductance plethysmography. Both anodal and cathodal tsDCS induced a progressive increase in DiMEP amplitude during stimulation that persisted for at least 15 min after current offset. Interestingly, cathodal, but not anodal, tsDCS induced a persistent increase in tidal volume. In addition, (1) short-interval intracortical inhibition, (2) nonlinear complexity of the tidal volume signal (related to medullary ventilatory command), (3) autonomic function, and (4) compound muscle action potentials evoked by cervical magnetic stimulation were unaffected by tsDCS. This suggests that tsDCS-induced aftereffects did not occur at brainstem or cortical levels and were likely not attributable to direct polarization of cranial nerves or ventral roots. Instead, we argue that tsDCS could induce sustained changes in PMN output. Increased tidal volume after cathodal tsDCS opens up the perspective of harnessing respiratory neuroplasticity as a therapeutic tool for the management of several respiratory disorders.
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Hamaoui A, Hudson AL, Laviolette L, Nierat MC, Do MC, Similowski T. Postural disturbances resulting from unilateral and bilateral diaphragm contractions: a phrenic nerve stimulation study. J Appl Physiol (1985) 2014; 117:825-32. [PMID: 25150226 DOI: 10.1152/japplphysiol.00369.2014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Thoracoabdominal breathing movements are a complex source of postural disturbance, but there are contradictory reports in the literature with inspiration described as having either a backward or a forward disturbing effect. To elucidate the mechanisms underlying this phenomenon, the present study studied the postural disturbance caused by isolated contractions of the diaphragm. Eight male and four female healthy subjects followed an original paradigm of phrenic nerve stimulation (bilateral and unilateral) and "diaphragmatic" voluntary sniff maneuvers in the seated and standing postures. Center of gravity (CG) acceleration was calculated from force plate recordings, and respiratory kinematics were assessed with thoracic and abdominal sensor belts. CG and respiratory signals revealed that, while seated, bilateral phrenic stimulation and sniff maneuvers consistently produced expansion of the abdomen associated with a forward peak of CG acceleration. In the standing posture, the direction of the CG peak was reversed and always directed backward. Unilateral phrenic stimulation induced an additional medial-lateral acceleration of the CG, directed toward the nonactive side while seated, but in the opposite direction while standing. These results suggest that isolated diaphragmatic contractions produce a constant disturbing pattern for a given posture, but with opposite effects between standing and seated postures. This could be related to the different biomechanical configuration of the body in each posture, corresponding to distinct kinematic patterns of the osteoarticular chain. In addition, the lateral component of the CG acceleration induced by unilateral diaphragm contractions could be clinically relevant in patients with hemidiaphragm paralysis.
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Affiliation(s)
- Alain Hamaoui
- Laboratory of Posture and Movement Physiology, University Champollion, Albi, France;
| | - Anna L Hudson
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1158 "Neurophysiologie Respiratoire Expérimentale et Clinique", Paris, France; INSERM, UMR_S 1158 "Neurophysiologie Respiratoire Expérimentale et Clinique", Paris, France; Neuroscience Research Australia and University of New South Wales, Sydney, Australia
| | - Louis Laviolette
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1158 "Neurophysiologie Respiratoire Expérimentale et Clinique", Paris, France; INSERM, UMR_S 1158 "Neurophysiologie Respiratoire Expérimentale et Clinique", Paris, France; Centre de Recherche clinique de l'Institut Universitaire de Cardiologie et Pneumologie de Québec (CRIUCPQ), Quebec, Canada; and
| | - Marie-Cécile Nierat
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1158 "Neurophysiologie Respiratoire Expérimentale et Clinique", Paris, France; INSERM, UMR_S 1158 "Neurophysiologie Respiratoire Expérimentale et Clinique", Paris, France
| | - Manh-Cuong Do
- CIAMS Laboratory, UFR STAPS, University Paris-Sud, Orsay, France
| | - Thomas Similowski
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1158 "Neurophysiologie Respiratoire Expérimentale et Clinique", Paris, France; INSERM, UMR_S 1158 "Neurophysiologie Respiratoire Expérimentale et Clinique", Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
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Alar T, Degirmenci Y, Ozisik Karaman HI. Lightning strike: a first case of unilateral diaphragmatic paralysis. Clin Pract 2011; 1:e94. [PMID: 24765394 PMCID: PMC3981430 DOI: 10.4081/cp.2011.e94] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Accepted: 10/09/2011] [Indexed: 11/23/2022] Open
Abstract
Lightning injury is the second most common cause of weather-related deaths in the United States. Despite the several neurological complications such as polyneuropathy, myelopathy, spinal cord injury, motor neuron disease due to the lightning-induced injury, there is no documented case of unilateral diaphragmatic paralysis. We describe the case of a patient with a history of lightning strike at childhood period, prior the onset of isolated, diaphragmatic paralysis, unilaterally. Clinical and electrophysiological findings suggest an injury restricted to the phrenic nerve, unilaterally.
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Affiliation(s)
| | - Yildiz Degirmenci
- Neurology Department, Canakkale Onsekiz Mart University, Canakkale, Turkey
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22
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Adler D, Gottfried SB, Bautin N, Mirkovic T, Schmidt M, Raux M, Pavlovic D, Similowski T, Demoule A. Repetitive magnetic stimulation of the phrenic nerves for diaphragm conditioning: a normative study of feasibility and optimal settings. Appl Physiol Nutr Metab 2011; 36:1001-8. [PMID: 22014178 DOI: 10.1139/h11-095] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Electrical stimulation can enhance muscle function. We applied repetitive cervical magnetic phrenic stimulation (rCMS) to induce diaphragm contractions in 7 healthy subjects (800 ms trains; transdiaphragmatic pressure (Pdi) measurements; tolerance ratings). Each rCMS train produced a sustained diaphragm contraction. Sixty-five percent of the maximal available output at 15 Hz proved the best compromise between Pdi and discomfort with nonfatiguing contractions. rCMS appears feasible and should be investigated for diaphragm conditioning in appropriate clinical populations.
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Affiliation(s)
- Dan Adler
- Service de Pneumologie et Réanimation et Centre de Neurostimulation Respiratoire, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
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Identification of prolonged phrenic nerve conduction time in the ICU: magnetic versus electrical stimulation. Intensive Care Med 2011; 37:1962-8. [PMID: 22005823 DOI: 10.1007/s00134-011-2374-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Accepted: 08/31/2011] [Indexed: 10/16/2022]
Abstract
PURPOSE Retrospective study of prospectively collected data to assess the reliability of cervical magnetic stimulation (CMS) to detect prolonged phrenic nerve (PN) conduction time at the bedside. Because PN injuries may cause diaphragm dysfunction, their diagnosis is relevant in intensive care units (ICU). This is achieved by studying latency and amplitude of diaphragm response to PN stimulation. Electrical stimulation (ES) is the gold standard, but it is difficult to perform in the ICU. CMS is an easy noninvasive tool to assess PN integrity, but co-activates muscles that could contaminate surface chest electromyographic recordings. METHODS In a first set of 56 ICU patients with suspected PN injury, presence and latency of compound motor action potentials elicited by CMS and ES were compared. With ES as the reference method, CMS was evaluated as a test designed to indicate presence or absence of PN injury. In eight additional patients, intramuscular diaphragm recordings were compared with surface diaphragm recordings and with the electromyograms of possible contamination sources. RESULTS The sensitivity of CMS to diagnose abnormal PN conduction was 0.91, and specificity was 0.84, whereas positive and negative predictive values were 0.81 and 0.92, respectively. Passing-Bablok regression analysis suggested no differences between the two measures. The correlation between PN latency in response to CMS and ES was significant. The "diaphragm surface" and "needle" latencies were close, and were significantly different from those of possibly contaminating muscles. One hemidiaphragm showed likely signal contamination. CONCLUSION CMS provides an easy reliable tool to detect prolonged PN conduction time in the ICU.
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Cartography of human diaphragmatic innervation: Preliminary data. Respir Physiol Neurobiol 2011; 176:68-71. [DOI: 10.1016/j.resp.2010.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 11/03/2010] [Indexed: 11/23/2022]
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Jammes Y, Budin-Poirier C, Brégeon F. Electromyographic tools to assess hemidiaphragm paralysis. Clin Physiol Funct Imaging 2010; 30:107-15. [DOI: 10.1111/j.1475-097x.2009.00911.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Morélot-Panzini C, Fournier E, Donzel-Raynaud C, Dubourg O, Willer JC, Similowski T. Conduction velocity of the human phrenic nerve in the neck. J Electromyogr Kinesiol 2009; 19:122-30. [PMID: 17888682 DOI: 10.1016/j.jelekin.2007.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2007] [Revised: 06/27/2007] [Accepted: 06/27/2007] [Indexed: 10/22/2022] Open
Abstract
PURPOSE To measure phrenic nerve conduction velocity in the neck in humans. SCOPE We studied 15 healthy subjects (9 men, 32.4+/-6.7). We performed bipolar electrical phrenic stimulation in the neck, from a distal and a proximal stimulation site, and recorded diaphragm electromyographic responses on the surface of the chest. The ratio of the between-site distance to the latency difference provided phrenic velocities. Ulnar motor velocity was assessed similarly. In addition, five homogeneous patients with Charcot-Marie-Tooth disease type 1A (CMT1A) were studied for validation purposes. We obtained diaphragmatic responses from the two stimulation sites in all cases. The distal latencies (anterior axillary line recording) were 6.51+/-0.63ms (right) and 6.13+/-0.64ms (left). The minimal between site distance was 39mm. Phrenic motor velocity was 55.2+/-6.3ms(-1) (right) and 56.3+/-7.2ms(-1) (left). In CMT1A, phrenic velocities were 17.1+/-8.1ms(-1) (from 7 to 32ms(-1)) and were similar to ulnar and median velocities. CONCLUSIONS Phrenic nerve velocities can be estimated in humans and compare with upper limb motor conduction velocities. This should refine the investigation of phrenic function in peripheral neuropathies.
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Affiliation(s)
- Capucine Morélot-Panzini
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Laboratoire de Physiopathologie Respiratoire du Service de Pneumologie et Réanimation, Paris, France
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Abstract
The usefulness of diaphragm electromyography recorded from an oesophageal electrode depends on a reliable signal which is free of artefact. The diaphragm EMG (electromyogram) recorded from chest wall surface electrodes may be unreliable because of signal contamination from muscle activity other than the diaphragm. Initially, the oesophageal electrode catheter for human studies had only one electrode pair, which could be difficult to position accurately and was influenced by a change in lung volume. Recently, a multipair oesophageal electrode has been developed which allows a high-quality EMG to be recorded. In the present review, the progress of oesophageal electrode design is outlined. The effects of signal contamination, electrode movement and particularly the effect of change in lung volume on the diaphragm EMG are discussed. The diaphragm EMG, recorded from a multipair oesophageal electrode, is useful to assess neural respiratory drive and diaphragm function in different groups of patients with respiratory disease, including patients with neuromuscular disease and sleep-disordered breathing, and those in the intensive care unit. When combined with cervical and cranial magnetic stimulation, an oesophageal electrode can be used to partition the central respiratory response time and phrenic nerve conduction time.
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Chien MY, Wu YT, Chang YJ. Assessment of Diaphragm and External Intercostals Fatigue from Surface EMG using Cervical Magnetic Stimulation. SENSORS (BASEL, SWITZERLAND) 2008; 8:2174-2187. [PMID: 27879816 PMCID: PMC3673412 DOI: 10.3390/s8042174] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Accepted: 03/14/2008] [Indexed: 11/17/2022]
Abstract
This study was designed: (1) to test the reliability of surface electromyography (sEMG) recording of the diaphragm and external intercostals contractions response to cervical magnetic stimulation (CMS), (2) to examine the amount and the types of inspiratory muscle fatigue that developed after maximum voluntary ventilation (MVV) maneuvers.Ten male college students without physical disability (22.1±2.0 years old) participated in the study and each completed a control (quiet breathing) trial and a fatigue (MVV maneuvers) trial sequentially. In the quiet breathing trial, the subjects maintained quiet breathing for five minutes. The subjects performed five maximal static inspiratory efforts and received five CMS before and after the quiet breathing. In the MVV trial, subjects performed five maximal inspiratory efforts and received five CMS before, immediately after, and ten minutes after two sets of MVV maneuvers performed five minutes apart. Maximal inspiratory pressure (PImax), sEMG of diaphragm and external intercostals during maximal static inspiratory efforts and during CMS were recorded. In the quiet breathing trial, high intraclass correlation coefficients (ICC=0.95-0.99) were observed in all the variables. In the MVV trial, the PImax, the EMG amplitude and the median power frequency during maximal static inspiratory efforts significantly decreased in both the diaphragm and the external intercostals immediately after the MVV maneuvers (P0.05). It is concluded that the sEMG recordings of the diaphragm during maximal static inspiratory efforts and in response to CMS allow reproducible sequential assessment of diaphragm contractility. MVV maneuvers resulted in inspiratory muscles fatigue, possibly central fatigue.
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Affiliation(s)
- Meng-Yueh Chien
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ying-Tai Wu
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ya-Ju Chang
- Department of Physical Therapy, Chang Gung University, 259 Wen-Hwa 1st Road, Kwei-Shan Tao-Yuan 333, Taiwan.
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Short-term training-dependent plasticity of the corticospinal diaphragm control in normal humans. Respir Physiol Neurobiol 2008; 160:172-80. [DOI: 10.1016/j.resp.2007.09.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2007] [Revised: 09/12/2007] [Accepted: 09/14/2007] [Indexed: 11/19/2022]
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Popescu EA, Popescu M, Bennett TL, Lewine JD, Drake WB, Gustafson KM. Magnetographic assessment of fetal hiccups and their effect on fetal heart rhythm. Physiol Meas 2007; 28:665-76. [PMID: 17664620 DOI: 10.1088/0967-3334/28/6/005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Fetal hiccups emerge as early as nine weeks post-conception, being the predominant diaphragmatic movement before 26 weeks of gestation. They are considered as a programmed isometric inspiratory muscle exercise of the fetus in preparation for the post-natal respiratory function, or a manifestation of a reflex circuitry underlying the development of suckling and gasping patterns. The present paper provides the first evidence of non-invasive biomagnetic measurements of the diaphragm spasmodic contractions associated with fetal hiccups. The magnetic field patterns generated by fetal hiccups exhibit well-defined morphological features, consisting of an initial high frequency transient waveform followed by a more prolonged low frequency component. This pattern is consistent across recordings obtained from two fetal subjects, and it is confirmed by signals recorded in a neonatal subject. These results demonstrate that fetal biomagnetometry can provide insights into the electrophysiological mechanisms of diaphragm motor function in the fetus. Additionally, we study the correlation between hiccup events and fetal cardiac rhythm and provide evidence that hiccups may modulate the fetal heart rate during the last trimester of pregnancy.
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Affiliation(s)
- E A Popescu
- Hoglund Brain Imaging Center, University of Kansas Medical Center, Kansas City, KS 66160, USA.
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Verin E, Marie JP, Tardif C, Denis P. Spontaneous recovery of diaphragmatic strength in unilateral diaphragmatic paralysis. Respir Med 2006; 100:1944-51. [PMID: 16618539 DOI: 10.1016/j.rmed.2006.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2005] [Revised: 03/07/2006] [Accepted: 03/07/2006] [Indexed: 10/24/2022]
Abstract
The aim of the present study was to evaluate diaphragmatic strength in patients with unilateral diaphragmatic paralysis and to determine whether patients with recent diaphragm paralysis develop lower inspiratory pressure than patients with longstanding diaphragmatic paralysis. Twenty patients (16 men and 4 women, 62+/-12 years) and six control subjects were included (4 men and 2 women, 53+/-15 years) in the study. Esophageal pressure during sharp sniff (Pes,sniff), bilateral cervical phrenic nerve magnetic stimulation (Pes,cms) and unilateral phrenic nerve stimulation (Pes,ums) (in nine patients) were measured. Sixteen patients presented right diaphragmatic paralysis and four, left diaphragmatic paralysis. Pes,sniff was higher in control subjects than in patients with diaphragmatic paralysis (respectively 110+/-22 cmH2O and 82+/-24 cmH2O, P<0.05). There was no difference in Pes,cms between patients with diaphragmatic paralysis and control subjects (14+/-7 cmH2O vs. 16+/-4 cmH2O; ns). Pes,ums after stimulation of the affected phrenic nerve was less than 4 cmH2O, was 8+/-2 cmH2O after stimulation of the intact phrenic nerve and was correlated to Pes,cms (R=0.87, P<0.01). There was a positive correlation between Pes,cms, Pes,ums of the intact hemidiaphragm, Pes,sniff and the time from the onset of symptoms and the diaphragmatic explorations (respectively R=0.86, P<0.0001; R=0.72, P<0.05; R=0.48, P<0.05). In conclusion, diaphragmatic strength after unilateral diaphragmatic paralysis seems to improve with time.
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Affiliation(s)
- Eric Verin
- Service de Physiologie digestive, urinaire, respiratoire et sportive, CHU de ROUEN-1 rue de Germont, 76031 ROUEN Cedex, France.
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Miscio G, Gukov B, Pisano F, Mazzini L, Baudo S, Salvadori A, Mauro A. The cortico-diaphragmatic pathway involvement in amyotrophic lateral sclerosis: neurophysiological, respiratory and clinical considerations. J Neurol Sci 2006; 251:10-6. [PMID: 17078971 DOI: 10.1016/j.jns.2006.05.059] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2005] [Revised: 05/18/2006] [Accepted: 05/19/2006] [Indexed: 11/23/2022]
Abstract
Cortico-diaphragmatic pathway was investigated by means of transcranial magnetic stimulation (TMS), in 14 patients affected by definite amyotrophic lateral sclerosis (ALS) without clinical signs of respiratory impairment. Spirometry, gas analysis, and measurement of static inspiratory and expiratory pressures were performed in all patients. Forced vital capacity, forced expiratory volume at the first and second peak expiratory flow, sniff effort from FRC level (SNIP), maximal inspiratory and expiratory pressure at mouth (MIP/MEP), maximal transdiaphragmatic pressure (Pdimx) were considered. TMS was performed, recording by surface electrodes from hemidiaphragm, bilaterally. Latency of cortical and spinal motor-evoked potentials (Cx-MEP/Sp-MEP) and central motor conduction time (CMCT) were measured. None of the patients showed altered spirometry and gas levels. Seven patients showed decreased Pdimx and eight of MEP values. Four patients showed a delayed Sp-MEP. In one patient the Cx-MEP was abolished while the mean values of both Cx-MEP and CMCT were significantly increased (19.2+/-4.1 ms, P<0.0001; 10.8+/-4.8 ms, P<0.0001). Cx-MEP and CMCT did not show significant correlations with any of the respiratory measures. The patients with prolonged Sp-MEP, showed longer disease duration, lower Norris score, lower Pdimx and MEP values. In conclusion, cortico-diaphragmatic study is a sensitive measure to reveal subclinical diaphragmatic impairment although not correlated to respiratory measures.
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Affiliation(s)
- Giacinta Miscio
- Department of Neurology and Neurorehabilitation, Istituto Auxologico Italiano, IRCCS, Piancavallo (VB), Italy.
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Pereira MC, Mussi RFM, Massucio RADC, Camino AM, Barbeiro ADS, Villalba WDO, Paschoal IA. Paresia diafragmática bilateral idiopática. J Bras Pneumol 2006. [DOI: 10.1590/s1806-37132006000500017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Relata-se o caso de um paciente com dispnéia intensa ao se deitar, em que foram excluídas doenças pulmonares, neuromusculares ou cardíacas, cuja investigação revelou paresia diafragmática bilateral. Um sinal chave para o diagnóstico foi a evidência de respiração paradoxal com o doente em decúbito supino. Havia piora da oxigenação e da capacidade vital forçada com a mudança da posição ortostática para supina. A fluoroscopia ortostática foi normal. A pressão inspiratória máxima estava muito reduzida. A estimulação elétrica transcutânea do diafragma foi normal, e a eletroestimulação do nervo frênico mostrou ausência de resposta, permitindo o diagnóstico de paresia bilateral do diafragma.
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Beck J, Weinberg J, Hamnegård CH, Spahija J, Olofson J, Grimby G, Sinderby C. Diaphragmatic function in advanced Duchenne muscular dystrophy. Neuromuscul Disord 2006; 16:161-7. [PMID: 16488607 DOI: 10.1016/j.nmd.2006.01.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2005] [Revised: 09/06/2005] [Accepted: 01/03/2006] [Indexed: 10/25/2022]
Abstract
The aim of this study was to assess diaphragm electrical activation and diaphragm strength in patients with advanced Duchenne muscular dystrophy during resting conditions. Eight patients with advanced Duchenne muscular dystrophy (age of 25 +/- 2 years) were studied during tidal breathing, maximal inspiratory capacity, maximal sniff inhalations, and magnetic stimulation of the phrenic nerves. Six patients were prescribed home mechanical ventilation (five non-invasive and one tracheotomy). Transdiaphragmatic pressure and diaphragm electrical activation were measured using an esophageal catheter. During tidal breathing (tidal volume 198 +/- 83 ml, breathing frequency 25 +/- 7), inspiratory diaphragm electrical activation was clearly detectable in seven out of eight patients and was 12 +/- 7 times above the noise level, and represented 45 +/- 19% of the maximum diaphragm electrical activation. Mean inspiratory transdiaphragmatic pressure during tidal breathing was 1.5 +/- 1.2 cmH2O, and during maximal sniff was 7.6 +/- 3.6 cmH2O. Twitch transdiaphragmatic pressure deflections could not be detected. This study shows that despite near complete loss of diaphragm strength in advanced Duchenne muscular dystrophy, diaphragm electrical activation measured with an esophageal electrode array remains clearly detectable in all but one patient.
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Affiliation(s)
- Jennifer Beck
- Department of Newborn and Developmental Pediatrics, Sunnybrook and Women's College Health Sciences Center, Women's College Compus, No. 440-76 Grenville Street, Toronto, Ont., Canada M5S 1B2.
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Mehiri S, Straus C, Arnulf I, Attali V, Zelter M, Derenne JP, Similowski T. Responses of the diaphragm to transcranial magnetic stimulation during wake and sleep in humans. Respir Physiol Neurobiol 2006; 154:406-18. [PMID: 16406377 DOI: 10.1016/j.resp.2005.12.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2005] [Revised: 11/17/2005] [Accepted: 12/05/2005] [Indexed: 10/25/2022]
Abstract
UNLABELLED The human ventilation depends on bulbospinal and corticospinal commands. This study assessed their interactions in five healthy volunteers (two men, age 25-35) through the description of diaphragm and abductor pollicis brevis (APB) motor potentials (DiMEPs, abpMEPs) evoked by transcranial magnetic stimulation (TMS) during relaxed expiration and tidal inspiration and during wake and sleep. NREM decreased corticospinal excitability and REM further did so, for both the diaphragm and the APB. During wake, inspiration shortened supine DiMEPs latencies (expiration 18.56+/-1.90ms; inspiration 17.37+/-1.48ms, P<0.001). This persisted during sleep in an augmented manner (expiration: 21.05+/-1.39ms; inspiration 18.69+/-1.17ms, P=0.002). Inspiration had no effect on apbMEPs during wake and sleep. IN CONCLUSION (1) the tidal bulbospinal input to phrenic motoneurones is sufficient to modulate the throughput of the corticospinal pathway to these neurones; (2) this modulation is best seen after the sleep related removal of corticospinal and/or afferent inputs.
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Affiliation(s)
- Selma Mehiri
- Laboratoire de Physiopathologie Respiratoire, Service de Pneumologie, Groupe Hospitalier Pitié Salpétrière, Assistance Publique-Hôpitaux de Paris, Paris, France
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Mouroux J, Venissac N, Leo F, Alifano M, Guillot F. Surgical treatment of diaphragmatic eventration using video-assisted thoracic surgery: a prospective study. Ann Thorac Surg 2005; 79:308-12. [PMID: 15620964 DOI: 10.1016/j.athoracsur.2004.06.050] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND This study seeks to evaluate results regarding the repair of diaphragmatic eventration using video-assisted thoracic surgery (VATS). METHODS We performed a prospective observational study including patients referred to us for surgical treatment of diaphragmatic eventration during a 12-year period. Clinical, radiologic, and functional data were prospectively recorded. VATS was performed with two thoracoports and a 4-cm mini-thoracotomy. Diaphragmatic plication was performed using two nonresorbable running sutures from periphery to the cardio-phrenic angle. Follow-up data (clinical examination, chest roentgenogram, lung function tests at 3, 6, 12 months, and annually thereafter) were also prospectively recorded. RESULTS Twelve patients (4 male adults, mean age 57.7 +/- 14.8 years) were operated on between 1992 and 2003. The left side was involved in 8 patients and the mean height of diaphragm elevation was 7.5 +/- 1.8 cm. All patients experienced symptoms related to the disease; in 2 patients the operation was carried out to achieve weaning from mechanical ventilation. The etiologic mechanism could be identified in 11 out of 12 patients (trauma, n = 9; Charcot-Marie disease, n = 1; calcified para-aortic nodes, n = 1). Mean operative time, drainage output, and hospital stay were 77 +/- 15 minutes, 0.8 +/- 04 L, and 3.4 +/- 0.7 days, respectively. No mortality was observed; 1 patient experienced postoperative pneumonia, which was treated using antibiotics. All patients experienced amelioration of symptoms and long-term lung function tests revealed a marked improvement of both the forced volume capacity and the forced expiratory volume at 1 second. No relapses were observed at follow-up chest roentgenogram. CONCLUSIONS Treatment using VATS is a safe and effective alternative to conventional surgery. Functional improvement persists at long-term follow-up.
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Affiliation(s)
- Jérôme Mouroux
- Service de Chirurgie Thoracique, CHU de Nice, Hôpital Pasteur, Nice, France
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37
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Vérin E. Quelles explorations spécialisées pour les muscles respiratoires : de la stimulation magnétique à l’imagerie. Rev Mal Respir 2005. [DOI: 10.1016/s0761-8425(05)85462-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Demoule A, Similowski T. Techniques électrophysiologiques d’évaluation fonctionnelle des muscles respiratoires : données récentes (1998-2004). Rev Mal Respir 2005; 22:163-8. [PMID: 15968773 DOI: 10.1016/s0761-8425(05)85451-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- A Demoule
- Service de Pneumologie et Réanimation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique, Hôpitaux de Paris et UPRES EA 2397, Université Pierre et Marie Curie Paris VI, Paris, France
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Teixeira A, Cherin P, Demoule A, Levy-Soussan M, Straus C, Verin E, Zelter M, Derenne JP, Herson S, Similowski T. Diaphragmatic dysfunction in patients with idiopathic inflammatory myopathies. Neuromuscul Disord 2005; 15:32-9. [PMID: 15639118 DOI: 10.1016/j.nmd.2004.09.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2004] [Revised: 09/15/2004] [Accepted: 09/15/2004] [Indexed: 11/29/2022]
Abstract
Polymyositis, dermatopolymyositis, and inclusion body myositis imply chronic inflammation of skeletal muscles. Pulmonary complications include aspiration pneumonia, interstitial pneumonitis, or respiratory muscle myositis. This study aims at better describing their impact on respiratory muscle. Twenty-three consecutive patients (12 PM, 5 DM, 6 IBM) were studied (static inspiratory and expiratory pressures; diaphragm function in terms of the mouth and transdiaphragmatic pressure responses to bilateral phrenic stimulation). Pulmonary parenchymatous abnormalities were mild (6 cases) or absent. The mouth pressure produced by phrenic stimulation was 6.83+/-3.01 cm H2O, with 18 patients (78%) diagnosed with diaphragm weakness (<10 cm H2O) and lower values in DM (4.35+/-1.48 cm H2O) than in IBM and in PM (P<0.05). Diaphragm weakness is frequent and probably overlooked in inflammatory myopathies. Further studies are needed to delineate the clinical relevance of these results.
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Affiliation(s)
- Antonio Teixeira
- UPRES EA 2397, Université Pierre et Marie Curie Paris VI, Paris, France
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41
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Demoule A, Similowski T. Évaluation de la force des muscles respiratoires : données récentes (1998-2004). Rev Mal Respir 2004; 21:1177-82. [PMID: 15767967 DOI: 10.1016/s0761-8425(04)71597-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- A Demoule
- Service de Pneumologie et Réanimation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique - Hôpitaux de Paris. UPRES EA 2397, Université Pierre et Marie Curie Paris VI, Paris, France
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Straus C, Locher C, Zelter M, Derenne JP, Similowski T. Facilitation of the diaphragm response to transcranial magnetic stimulation by increases in human respiratory drive. J Appl Physiol (1985) 2004; 97:902-12. [PMID: 15133007 DOI: 10.1152/japplphysiol.00989.2003] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The human respiratory neural drive has an automatic component (bulbospinal pathway) and a volitional component (corticospinal pathway). The aim of this study was to assess the effects of a hypercapnia-induced increase in the automatic respiratory drive on the function of the diaphragmatic corticospinal pathway as independently as possible of any other influence. Thirteen healthy volunteers breathed room air and then 5 and 7% hyperoxic CO2. Cervical (cms) and transcranial (tms) magnetic stimulations were performed during early inspiration and expiration. Transdiaphragmatic pressure (Pdi) and surface electromyogram of the diaphragm (DiEMG) and of the abductor pollicis brevis (apbEMG) were recorded in response to cms and tms. During inspiration, Pdi,cms was unaffected by CO2, but Pdi,tms increased significantly with 7% CO2. During expiration, Pdi,cms was significantly reduced by CO2, whereas Pdi,tms was preserved. DiEMG,tms latencies decreased significantly during early inspiration and expiration (air vs. 5% CO2 and air vs. 7% CO2). DiEMG,tms amplitude increased significantly in response to early expiration-tms (air vs. 5% CO2 and air vs. 7% CO2) but not in response to early inspiration-tms. DiEMG,cms latencies and amplitudes were not affected by CO2 whereas 7% CO2 significantly increased the apbEMG,cms latency. The apbEMG,tms vs. apbEMG,cms latency difference was unaffected by CO2. In conclusion, increasing the automatic drive to breathe facilitates the response of the diaphragm to tms, during both inspiration and expiration. This could allow the corticospinal drive to breathe to keep the capacity to modulate respiration in conditions under which the automatic respiratory control is stimulated.
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Affiliation(s)
- C Straus
- UPRES EA 2397, Faculté de Médecine Pitié-Salpêtrière, Université Paris VI Pierre et Marie Curie, Paris, France
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43
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44
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Electrodiagnostic assessment of respiratory dysfunction in motor neuron disease. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/s1567-4231(04)04029-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Hemmerling TM, Donati F. Neuromuscular blockade at the larynx, the diaphragm and the corrugator supercilii muscle: a review. Can J Anaesth 2003; 50:779-94. [PMID: 14525816 DOI: 10.1007/bf03019373] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To review recent findings concerning neuromuscular blockade and monitoring at the larynx, the diaphragm, and the corrugator supercilii muscle. SOURCE This narrative review is based on recent publications. PRINCIPAL FINDINGS Neuromuscular blockade at the larynx and the diaphragm is less intense than at the adductor pollicis muscle; the onset and offset of neuromuscular blockade is more rapid. The corrugator supercilii muscle reflects better the time course of neuromuscular blockade of the larynx than the adductor pollicis muscle, is better suited to monitor the onset of neuromuscular blockade for intubation, and should give a better reflection of the time course and degree of neuromuscular blockade of the larynx or the diaphragm. Recovery of neuromuscular function at the end of any procedure is best reflected at the adductor pollicis muscle where neuromuscular transmission is last restored. Clinical monitoring of the larynx or the diaphragm is still limited by the absence of a simple method. Acceleromyography of the corrugator supercilii muscle is prone to artifacts that do not occur during monitoring of the adductor pollicis muscle. Phonomyography, a new method of monitoring that is currently being tested, is based on the phenomenon that muscle contraction creates low-frequency sound waves, which can be detected using special microphones to quantify neuromuscular blockade. This method seems promising because it can be easily used on all muscles of interest. CONCLUSION Research during the last 15 years has greatly enhanced our knowledge about how muscles react differently to muscle relaxants and has enabled us to achieve better surgical conditions with safer use of muscle relaxants. Interesting technologies have been developed to reliably monitor neuromuscular blockade at the larynx and the diaphragm, but are currently restricted to research settings. Our increased understanding should help us in ongoing efforts to develop the "ideal" muscle relaxant and the "ideal" method of neuromuscular monitoring.
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Affiliation(s)
- Thomas M Hemmerling
- Department of Anesthesiology, Hôtel-Dieu, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada.
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Bolton CF, Zifko U, Bird SJ. Clinical neurophysiology in the intensive care unit. SUPPLEMENTS TO CLINICAL NEUROPHYSIOLOGY 2003; 53:29-37. [PMID: 12740974 DOI: 10.1016/s1567-424x(09)70135-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Affiliation(s)
- C F Bolton
- London Health Science Center, London, ON N6A 5A5, Canada.
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Demoule A, Verin E, Ross E, Moxham J, Derenne JP, Polkey MI, Similowski T. Intracortical inhibition and facilitation of the response of the diaphragm to transcranial magnetic stimulation. J Clin Neurophysiol 2003; 20:59-64. [PMID: 12684560 DOI: 10.1097/00004691-200302000-00008] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Respiratory muscles respond to a subcortical automatic command and to a neocortical voluntary command. In diseases such as stroke or motor neurone disease, an abnormal diaphragmatic response to single transcranial magnetic stimuli can identify a central source for respiratory disorders, but this is not likely to be the case in disorders affecting intracortical inhibitory and facilitatory mechanisms. This study describes the response of the diaphragm to paired transcranial magnetic stimulation. Thirteen normal subjects were studied (age range, 22 to 43 years; 7 men; phrenic conduction, <6.8 msec; latency of diaphragmatic motor evoked potential, <20.5 msec). Motor evoked potentials in response to paired stimulation were obtained in eight subjects only, with the motor threshold in the remaining five subjects too high to absorb the loss of power inherent in the double-stimulation montage. Interstimulus intervals less than 5 msec resulted in a statistically significant inhibition (p < 0.01 for interstimulus intervals of 1 and 3 ms), whereas intervals longer than 6 msec were facilitatory (maximal, 15 msec). The diaphragmatic pattern matched that of the biceps brachii. The authors conclude that it is possible to study intracortical inhibition and facilitation of diaphragmatic control, although not in all subjects. Technical improvement should alleviate current limitations and make paired transcranial magnetic stimulation a tool to study respiratory muscle abnormalities in settings in which intracortical interactions are important, such as movement disorders.
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Affiliation(s)
- Alexandre Demoule
- Laboratoire de Physiopathologie Respiratoire et Unité de Réanimation, Service de Pneumologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, France
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48
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Demoule A, Verin E, Locher C, Derenne JP, Similowski T. Validation of surface recordings of the diaphragm response to transcranial magnetic stimulation in humans. J Appl Physiol (1985) 2003; 94:453-61. [PMID: 12391044 DOI: 10.1152/japplphysiol.00581.2002] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The integrity of the central efferent motor pathways to the diaphragm can be assessed by using transcranial magnetic stimulation to measure the latency of the corresponding motor evoked potentials with surface electrodes. Because transcranial magnetic stimulation does not activate the diaphragm alone, signal contamination is a potential problem. To evaluate this issue, surface diaphragmatic motor-evoked potential latencies were compared with latencies recorded from diaphragm needle in 9 healthy volunteers. Surface latencies of muscles likely to contaminate the diaphragm signals (serratus anterior, pectoralis major, and tranversus abdominis) were also recorded. The latencies in response to nonfocal transcranial stimulation from surface electrodes were not significantly different from the needle ones (17 +/- 1.3 vs. 17.2 +/- 1.1 ms, respectively) but were significantly different from the latencies of the other muscles. In two cases, signal contamination appeared likely (serratus anterior in 1 case, abdominal muscles in 1 case). It is possible to reliably measure the latency of the diaphragm response to transcranial magnetic stimulation with adequately positioned surface electrodes.
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Affiliation(s)
- Alexandre Demoule
- Laboratoire de Physiopathologie Respiratoire, Service de Pneumologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique, Hôpitaux de Paris, France
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Perrin C, Unterborn JN, Ambrosio CD, Hill NS. Pulmonary complications of chronic neuromuscular diseases and their management. Muscle Nerve 2003; 29:5-27. [PMID: 14694494 DOI: 10.1002/mus.10487] [Citation(s) in RCA: 151] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Chronic neuromuscular diseases may affect all major respiratory muscles groups including inspiratory, expiratory, and bulbar, and respiratory complications are the major cause of morbidity and mortality. Untreated, many of these diseases lead inexorably to hypercapnic respiratory failure, precipitated in some cases by chronic aspiration and secretion retention or pneumonia, related to impairment of cough and swallowing mechanisms. Many measures are helpful including inhibition of salivation, cough-assist techniques, devices to enhance communication, and physical therapy. In addition, ventilatory assistance is an important part of disease management for patients with advanced neuromuscular disease. Because of its comfort, convenience, and portability advantages, noninvasive positive pressure ventilation (NPPV) has become the modality of first choice for most patients. Patients to receive NPPV should be selected using consensus guidelines, and initiation should be gradual to maximize the chances for success. Attention should be paid to individual preferences for interfaces and early identification of cough impairment that necessitates the use of cough-assist devices. For patients considered unsuitable for noninvasive ventilation, invasive mechanical ventilation should be considered, but only after a frank but compassionate discussion between the patient, family, physician, and other caregivers.
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Affiliation(s)
- Christophe Perrin
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts-New England Medical Center, Tufts University School of Medicine, 750 Washington Street, Boston, Massachusetts 02111-1526, USA
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Miscio G, Guastamacchia G, Priano L, Baudo S, Mauro A. Are the neurophysiological techniques useful for the diagnosis of diaphragmatic impairment in multiple sclerosis (MS)? Clin Neurophysiol 2003; 114:147-53. [PMID: 12495775 DOI: 10.1016/s1388-2457(02)00339-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To characterize cortico-diaphragmatic pathway involvement in multiple sclerosis (MS) by means of transcranial magnetic stimulation (TMS), and verify its clinical impact. METHODS TMS from diaphragm (Dia), and abductor digiti minimi (AbdV degrees ) was performed in 26 MS patients. Phrenic nerve (PN) conduction study was also performed. Expanded disability status scale (EDSS) and fatigue descriptive scale (FDS) were measured. Forced vital capacity (FVC), forced expiratory volume at the first second (FEV1), peak expiratory flow (PEF) were tested: the predicted percentage value (% pred) was considered. RESULTS Cortical motor evoked potential (Cx-MEP) latency and central motor conduction time (CMCT) were prolonged, respectively, in 31 and 23% of patients from Dia, in 76 and 79% from AbdV degrees. PN-compound motor action potential (CMAP) was normal. EDSS correlated to Cx-MEP from AbdV degrees (P<0.01), and PN-CMAP amplitude (P<0.05), FEV1 % pred (P<0.01), PEF % pred (P<0.01). PN-CMAP amplitude correlated to FVC % pred P=0.05, FEV1 % pred P<0.01, PEF % pred P<0.01. Fatigue was related to AbdV degrees Cx-MEP and CMCT (P<0.05 and P<0.01). CONCLUSIONS Cortico-diaphragmatic pathway is impaired only in a minority of MS patients. Lack of correlation between TMS findings from Dia and respiratory tests argues against its routinary use to detect subclinical respiratory alterations. Fatigue seems to be related to the motor impairment rather than to respiratory distress.
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Affiliation(s)
- G Miscio
- Department of Neurology and Neurorehabilitation, Istituto Auxologico Italiano, IRCCS, 'San Giuseppe' Hospital, Stada L. Cadorna 90, 28824 (VB), Piancavallo - Oggebbio, Italy.
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