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  • 1
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    German Medical Science GMS Publishing House; Düsseldorf
    In:  Deutscher Kongress für Orthopädie und Unfallchirurgie; 73. Jahrestagung der Deutschen Gesellschaft für Unfallchirurgie, 95. Tagung der Deutschen Gesellschaft für Orthopädie und Orthopädische Chirurgie, 50. Tagung des Berufsverbandes der Fachärzte für Orthopädie; 20091021-20091024; Berlin; DOCPO11-675 /20091015/
    Publication Date: 2009-10-16
    Keywords: ddc: 610
    Language: German
    Type: conferenceObject
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  • 2
    Publication Date: 2019-06-18
    Description: Introduction: Pain is a prominent complication in spinal cord injury (SCI). It can either occur as a direct or as an indirect consequence of SCI and it often heavily influences the quality of life of affected individuals. In SCI, nociceptive and neuropathic pain can equally emerge at the same time above or below the level of injury. Thus, classification and grading of pain is frequently difficult. Effective treatment of SCI-related pain in general and of neuropathic pain in particular is challenging. Current treatment options are sparse and their evidence is considered to be limited. Considering these aspects, a clinical practice guideline was developed as basis for an optimized, comprehensive and standardized pain management in SCI-related pain.Methods: The German-Speaking Medical Society for Spinal Cord Injury (Deutschsprachige Medizinische Gesellschaft für Paraplegiologie - DMGP) developed a clinical practice guideline that received consensus from seven further German-speaking medical societies and one patient organization. The evidence base from clinical trials and meta-analyses was summarized and subjected to a structured consensus-process in accordance with the regulations of the Association of Scientific Medical Societies in Germany (AWMF) and the methodological requirements of the "German instrument for methodological guideline appraisal".Results: This consensus-based guideline (S2k classification according to the AWMF guidance manual and rules) resulted in seven on-topic statements and 17 specific recommendations relevant to the classification, assessment and therapy of pain directly or indirectly caused by SCI. Recommended therapeutic approaches comprise pharmacological (e.g. nonsteroidal anti-inflammatory drugs or anticonvulsants) and non-pharmacological (e.g. physical activity or psychotherapeutic techniques) strategies for both nociceptive and neuropathic pain.Discussion: Assessment of SCI-related pain is standardized and respective methods in terms of examination, classification and grading of pain are already in use and validated in German language. In contrast, valid, evidence-based and efficient therapeutic options are limited and ask for further clinical studies, ideally randomized controlled trials and meta-analyses.
    Description: Einleitung: Schmerzen sind eine höchst relevante Komplikation nach erlittener Querschnittlähmung. Sie können als eine direkte oder indirekte Folge auftreten und erheblichen Einfluss auf die Lebensqualität Betroffener haben. Nach einer Querschnittlähmung können nozizeptive und neuropathische Schmerzen gleichermaßen und zeitgleich sowohl oberhalb als auch unterhalb des Lähmungsniveaus auftreten. Deshalb erscheinen Klassifikation und Einordnung der Schmerzen häufig problematisch. Die Behandlung dieser Schmerzen ist generell schwierig und insbesondere für neuropathische Schmerzen herausfordernd. Dies ergibt sich nicht zuletzt aus den wenig vorhandenen und kaum evidenzbasierten Behandlungsmöglichkeiten. In Anbetracht dessen soll die Leitlinie als valide Basis für ein optimiertes, umfassendes und standardisiertes Schmerzmanagement dienen.Methoden: Sieben deutschsprachige medizinische Fachgesellschaften mit thematischem Bezug zur Leitlinie und eine Fördergemeinschaft Betroffener entwickelten unter Federführung der Deutschsprachigen Medizinischen Gesellschaft für Paraplegiologie (DMGP) diese Leitlinie mittels einer strukturierten Konsensfindung nach den Maßgaben des Regelwerks der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) sowie in Übereinstimmung mit dem deutschen Instrument zur methodischen Leitlinienbewertung.Ergebnisse: Diese Leitlinie (S2k-Klassifikation gemäß dem Regelwerk der AWMF) ergab einen einstimmigen Konsens für sieben Kernaussagen und 17 spezifische Empfehlungen mit Bezug zur Klassifikation, Untersuchung/Beurteilung und Therapie von direkt oder indirekt infolge einer Querschnittlähmung auftretender Schmerzen. Empfohlene Therapien umfassen sowohl medikamentöse (z.B. nicht-steroidale Antirheumatika und Antikonvulsiva), als auch nicht-medikamentöse (z.B. körperliche Aktivität und psychotherapeutische Maßnahmen) Ansätze und betreffen nozizeptive wie auch neuropathische Schmerzen.Diskussion: Es existieren diverse standardisierte und verlässliche Methoden zur Beurteilung und Untersuchung von Schmerzen nach Querschnittlähmung, die auch häufig in deutscher Sprache validiert sind. Demgegenüber sind evidenzbasierte und effektive schmerztherapeutische Möglichkeiten stark begrenzt und bedürfen weiterer wissenschaftlicher Auseinandersetzung, die sich im Idealfall aus randomisierten kontrollierten Studien und Metaanalysen ergibt.
    Keywords: neuropathic pain ; nociceptive pain ; central pain syndrome ; clinical practice guideline ; spinal cord injury ; pain management ; drug therapy ; non-pharmacological pain therapy ; neuropathische Schmerzen ; nozizeptive Schmerzen ; zentrales Schmerzsyndrom ; medizinische Leitlinie ; Querschnittlähmung ; Schmerzmanagement ; Pharmakotherapie ; nicht-medikamentöse Schmerztherapie ; ddc: 610
    Language: English
    Type: article
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  • 3
    ISSN: 1432-1106
    Keywords: Vestibulo-spinal reflexes ; Motor control ; Regulation of stance and gait ; Head tilt ; Man
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Summary Sudden tilts of the head to the front or rear were induced during stance, balancing, gait and during perturbations of gait. The most prominent response in the leg muscle electromyogram (e.m.g.) to head tilt occurred in the tibialis anterior muscle (latency about 55 ms) following a backward tilt induced during balancing. During stance and gait, the e.m.g. activity related to head tilt was only a minor component of the leg muscle activity normally occurring during gait. When the head tilt was induced shortly after a perturbation of gait (treadmill acceleration impulse), the compensatory reaction in the leg muscles did not significantly differ from that seen after the gait perturbation alone. In addition, the rate of acceleration of the head was tested against the compensatory e.m.g. responses: No correlation of influence could be discerned. The results indicate that sudden head tilts and the resulting head acceleration have little influence on the e.m.g. patterns that occur during gait and perturbations of gait. It is assumed that these patterns are regulated by central programs, and that the compensation for leg perturbation is achieved mainly by spinal reflex mechanisms. It is discussed whether the lack of head tilt responses is the result of an antagonistic vestibularneck interaction, or whether it indicates a reduced effectiveness of vestibulo- and cervico-spinal reflexes during gait.
    Type of Medium: Electronic Resource
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  • 4
    ISSN: 1432-1106
    Keywords: Tendon reflex ; Quadriceps ; Presynaptic inhibition ; Gait ; Ia afferents ; Human
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Summary Amplitude modulation of the quadriceps tendon jerk reflex was investigated during the step cycle in normal human subjects. Reflex amplitude was compared with that obtained during a control stance condition, with “equivalent” levels of EMG activity and limb position. During gait there was a progressive decrease in the reflex amplitude early in the stance phase, i.e. during yielding of the knee, and it remained reduced throughout the step cycle. This pattern of changes in reflex amplitude correlated with neither the quadriceps EMG activity nor with the knee joint movements. The behavior of the tendon reflex was similar to that described for the modulation of the quadriceps H-reflex during the early stages of the stance phase of gait. In the latter study it was argued that changes in presynaptic inhibition of quadriceps la terminals could account for the amplitude modulation. We conclude that there is no dramatic change in the gamma drive to quadriceps muscle spindles: tendon reflexes are modulated during the step cycle in much the same way as H-reflexes, in spite of the peripheral and central differences between them. Similar behavior has been described for the soleus H-reflex and Achilles tendon reflex during gait although the modulation of these reflexes followed a different pattern than that seen in the quadriceps.
    Type of Medium: Electronic Resource
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  • 5
    ISSN: 1432-1106
    Keywords: Human gait ; Sural nerve ; Soleus ; Gas trocnemius ; Cutaneous reflexes ; Differential recruitment
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Summary Phase-dependent reflex modulation was studied by recording the electromyographic (EMG) responses in soleus (SOL) and gastrocnemius medialis (GM) to a 20 ms train of 5 electrical pulses, applied to the sural or tibial nerve at the ankle, in 14 volunteers walking or running on a treadmill. Although both the spontaneous activity and the reflex responses were usually similar for both muscles, instances were identified in which separate control was evident. During walking (4 km/h), activity in SOL started earlier in the stance phase than GM activity. Correspondingly, the amplitude of the reflex responses was larger in SOL than in GM in early stance, both ipsi- and contralateral to the side of stimulation. In some cases, the same stimulus could elicit contralaterally a suppression of GM in synchrony with a facilitation of SOL. These crossed extensor reflexes had a low threshold (1.2 × T) and a latency ranging from 72 to 105 ms. During running (8 km/h or more), responses were seen selectively in GM instead, without concomitant responses in SOL. Such responses had a latency ranging from 82 to 158 ms and they appeared during the first extension phase, at the end of the swing phase. In addition, selective GM responses, with latencies above 200 ms, were seen near the transition from stance to swing during running. These instances of separate reflex control of SOL and GM were correlated with step cycle periods during which the motoneurones of either one of these muscles received more spontaneous activation than the other. Nevertheless, it is argued that premotoneuronal gating must also be involved since the increased amplitude of the crossed SOL responses (in early stance) and of GM responses (at end swing) was not strictly linked to an elevated amount of spontaneous activity during these parts of the step cycle as compared to other parts.
    Type of Medium: Electronic Resource
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  • 6
    ISSN: 1432-1106
    Keywords: Vestibular ; Posture ; Head stabilization ; Somatosensory ; Human
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract The relative contribution of vestibular and somatosensory information to triggering postural responses to external body displacements may depend on the task and on the availability of sensory information in each system. To separate the contribution of vestibular and neck mechanisms to the stabilization of upright stance from that of lower body somatosensory mechanisms, responses to displacements of the head alone were compared with responses to displacements of the head and body, in both healthy subjects and in patients with profound bilateral vestibular loss. Head displacements were induced by translating two 1-kg weights suspended on either side of the head at the level of the mastoid bone, and body displacements were induced translating the support surface. Head displacements resulted in maximum forward and backward head accelerations similar to those resulting from body displacements, but were not accompanied by significant center of body mass, ankle, knee, or hip motions. We tested the effect of disrupting somatosensory information from the legs on postural responses to head or body displacements by sway-referencing the support surface. The subjects' eyes were closed during all testing to eliminate the effects of vision. Results showed that head displacements alone can trigger medium latency (48–84 ms) responses in the same leg and trunk muscles as body displacements. Nevertheless, it is unlikely that vestibular signals alone normally trigger directionally specific postural responses to support surface translations in standing humans because: (1) initial head accelerations resulting from body and head displacements were in opposite directions, but were associated with activation of the same leg and trunk postural muscles; (2) muscle responses to displacements of the head alone were only one third of the amplitude of responses to body displacements with equivalent maximum head accelerations; and (3) patients with profound bilateral vestibular loss showed patterns and latencies of leg and trunk muscle responses to body displacements similar to those of healthy subjects. Altering somatosensory information, by sway-referencing the support surface, increased the amplitude of ankle muscle activation to head displacements and reduced the amplitude of ankle muscle activation to body displacements, suggesting context-specific reweighting of vestibular and somatosensory inputs for posture. In contrast to responses to body displacements, responses to direct head displacements appear to depend upon a vestibulospinal trigger, since trunk and leg muscle responses to head displacements were absent in patients who had lost vestibular function as adults. Patients who lost vestibular function as infants, however, had near normal trunk and leg response to head displacements, suggesting a substitution of upper trunk and neck somatosensory inputs for missing vestibular inputs during development.
    Type of Medium: Electronic Resource
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  • 7
    ISSN: 1432-1106
    Keywords: Presynaptic inhibition ; Ia fibres ; Spinal reflexes ; Gait ; Human
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Modulation of presynaptic inhibition of Ia afferents projecting monosynaptically to soleus motoneurones was investigated during human gait. Changes in presynaptic inhibition of Ia afferents were deduced from alterations in the amount of heteronymous soleus H-reflex facilitation evoked by a constant femoral nerve stimulation. It has been shown that this facilitation is mediated through a monosynaptic Ia pathway and that during its first 0.5 ms it is still uncontaminated by any polysynaptic effect and can be used to assess ongoing presynaptic inhibition of Ia terminals to soleus motoneurones. During gait, heteronymous facilitation was reduced with respect to its control value (rest during sitting) and modulated during the step cycle: it reached its maximum at mid-stance and decreased to near zero by the end of stance. At the same time the H-reflex amplitude was to some extent similarly modulated. It is argued that this decrease in heteronymous Ia facilitation and in H-reflex amplitude reflects an increased, ongoing presynaptic inhibition of Ia terminals projecting onto soleus motoneurones, which could be from central and/or peripheral origin. D1 inhibition, i.e. the late and long-lasting inhibition of the soleus H-reflex evoked by a train of stimuli to the common peroneal nerve, was used as another method to assess presynaptic inhibition. This D1 inhibition was decreased during gait, and it is argued that this decrease might reflect an occlusion in presynaptic pathways or increased presynaptic inhibition of pathways mediating the conditioning volley.
    Type of Medium: Electronic Resource
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  • 8
    ISSN: 1432-1106
    Keywords: Stance perturbation ; Cerebral potential ; Leg muscle e.m.g. response ; Spinal reflexes ; Motor control
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Summary In order to investigate the neuronal mechanisms underlying the compensatory movements following stance disturbance, leg muscle e.m.g. responses and cerebral potentials evoked by a treadmill acceleration impulse were analysed. It was found that the displacement was followed by a cerebral potential of a latency of 40–45 ms and EMG responses in the calf muscles at a latency of 65–70 ms. The e.m.g. responses represented specific compensatory reactions to the mode of perturbation (with a gastrocnemius activation following positive acceleration but a tibialis ant. activation following negative acceleration). The cerebral potentials, however, showed a common pattern to both conditions. In addition, the leg muscle e.m.g. reactions were not altered by learning effects and by forewarning of displacement onset, while the amplitude of the cerebral potentials was significantly smaller in these conditions compared to those produced in response to randomly induced perturbations. It was therefore concluded that the leg muscle e.m.g. reactions are mediated by a polysynaptic spinal reflex pathway which depends on a supraspinal control. The cerebral potentials seem to represent afferent signals which can be supposed to be subjected to modification and processing by supraspinal motor centres, according to the actual requirements.
    Type of Medium: Electronic Resource
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  • 9
    ISSN: 1432-1106
    Keywords: Tibial nerve ; Sural nerve ; Reflex modulation ; Reflex reversal ; Flexor reflex ; Human gait
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Summary Phase-dependent reflex modulation was studied by recording the electromyographic (EMG) responses in ankle flexors (Tibialis Anterior, TA) and extensors (Gastrocnemius Medialis, GM and Soleus, SOL) to a 20 ms train of electrical pulses, applied to the tibial or sural nerve at the ankle, in human volunteers walking on a treadmill at 4 km/h. For low intensity stimuli (i.e. 1.6 times perception threshold), given during the swing phase, the most common response was a suppression of the TA activity with a latency of 67 to 118 ms. With high intensity of stimulation (i.e. 2.8 × T), a facilitatory response appeared in TA with a latency of 74 ms. This latter response was largest during the middle of the swing phase, when it was correlated with exaggerated ankle dorsiflexion. The TA reflex amplitude was not a simple function of the level of spontaneous ongoing activity. During stance, TA responses were small or absent and accompanied by a suppression of the GM activity with a latency ranging from 62 to 101 ms. A few subjects showed an early facilitatory, instead of a suppressive, GM response (88 to 136 ms latency). They showed a phase-dependent reflex reversal from a dominant TA response during swing to a facilitatory GM response with an equivalent latency during stance. The GM facilitation occurred exclusively during the early stance phase and habituated more than the TA responses. It is concluded that phase-dependent gating of reflexes occurs in ankle muscles of man, but only when vigorous extensor reflexes are present. More commonly, a phase-dependent modulation is seen, both of facilitatory and suppressive responses.
    Type of Medium: Electronic Resource
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  • 10
    ISSN: 1432-1106
    Keywords: Stance regulation ; Compensatory EMG responses ; Rotational/translational perturbations ; Load receptors ; Postural reflexes ; Human
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Summary According to recent observations, influence of body load has to be taken into account for the neuronal control of upright stance in addition to the systems known to be involved in this regulation (e.g. afferent input from vestibular canals, visual and muscle stretch receptors). The modulation of compensatory leg muscle electromyographic (EMG) responses observed during horizontal body posture indicates the existence of a receptor system which responds to loading of the body against the supporting platform. This receptor should be located within the extensor muscles because a compensatory EMG response and a loading effect on this response was only present following translational, but not rotational impulses. As the EMG responses were identical to those obtained during upright stance, it is argued that these load receptors activate postural reflexes. According to recent observations in the spinal cat, this afferent input probably arises from Golgi tendon organs and represents a newly discovered function of these receptors in the regulation of stance and gait.
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