Surgery – Diagnostic testing – Measuring anatomical characteristic or force applied to or...
Reexamination Certificate
2001-12-14
2004-02-17
Hindenburg, Max F. (Department: 3736)
Surgery
Diagnostic testing
Measuring anatomical characteristic or force applied to or...
Reexamination Certificate
active
06692449
ABSTRACT:
BACKGROUND OF THE INVENTION
Limb position sense (LPS) is the ability to sense the movement and position of limbs in space. During locomotion, limb position sense is regulated by sensory feedback to the nervous system from proprioceptors, which include cutaneous, vestibular, muscle and joint receptors. Such proprioceptors respond to locomotion and provide the information needed to know the position of a subject's limb(s) in space. (Williams W J. A systems-oriented evaluation of the role of joint receptors and other afferents in position and motion sense.
CRC Critical Reviews in Biomedical Engineering.
1981; 7:23-77.)
Proprioceptive feedback from muscle, joint and cutaneous receptors are essential for the generation of the normal motor pattern. (Gandevia S C, Burke D. Does the nervous system depend on kinesthetic information to control natural limb movements?
Behavioral and Brain Sciences.
1992;15:614-632.) Neural stimulation detected by receptors travels to the central nervous system for integration via cortical and reflex pathways. These mechanoreceptors demonstrate adaptive properties depending on a particular stimulus. Pacinian corpuscles are quick adapting joint mechanoreceptors that decrease their discharge rate to extinction within milliseconds of the onset of a continuous stimulus. It is postulated that they mediate the sensation of joint motion because they are sensitive to changes in position. Slow-adapting mechanoreceptors, including muscle spindle, Golgi tendon organ and Ruffini ending joint receptors, are thought to mediate the sensation of joint position and changes in position because they are maximally stimulated at specific angles. (Lephart S M. Proprioception following ACL reconstruction.
J Sports Rehab.
1992; 1:186-196.) Muscle spindle receptors are found within skeletal muscle and function to measure tension upon stretch of the muscle. Golgi tendon organs are located at the musculotendinous junction and function as a protective mechanism by inhibiting the motor neurons innervating the muscles that were stretched while exciting the motor nerves of the antagonistic muscles.
Various studies have also confirmed the role of these receptors in providing information to the central nervous system about tissue deformation. Other studies by Goodwin et al and Eklund showed that perception of limb position sense and movement is derived from muscle spindle. (Gandevia S C, Burke D. Does the nervous system depend on kinesthetic information to control natural limb movements?
Behavioral and Brain Sciences.
1992; 15:614-632.) In their studies, when vibration was applied to muscles, tendon movement occurred. Direct recordings from human spindle afferents suggest that these movements depend upon signals from primary and secondary spindle endings. Hiebert et al indicated that proprioceptors that signal hip extension might arise from muscle spindle afferents. (Hiebert G W, Whelan P I, Prochazka A, Pearson K G. Contribution of hind limb flexor muscle afferents to the timing of phase transitions in the cat step cycle.
J Neurophysiol.
1996; 75:1126-1137.) Gandevia and Burke, supra, demonstrated that acuity can be diminished with both cutaneous and joint anesthesia, particularly in joints in the hand.
Perception of afferent signals, however, is not required for movement. The spinal cord has complex neural circuitry, which is capable of producing rhythmic, oscillating commands to the musculature, even in the absence of sensory input. Central motor programs alone are sufficient to control simple learned movements. For example, Gandevia et al, supra, showed that subjects can recruit and grade the motor drive to a paralyzed muscle in the absence of feedback from that muscle. Grillner et al described research performed on animals (Grillner S. Locomotion in vertebrates: Central mechanisms and reflex interaction.
Physiol Reviews.
1975; 55:247-304): The spinal cord of cats is cut at a level below the brain so that the higher centers cannot influence lower ones, and the cord is deafferented below the level of the cut. When the cord is stimulated, the cat produces stepping movements that resemble normal locomotion in cats without feedback from the limbs.
Afferent feedback, however, is critical in providing the central nervous system with input, especially when involving small, precise contractions during phase transitions or disturbances. Afferent signals, for example, are required to modulate the central pattern generator of the locust and thus for its nervous system to generate the appropriate motor pattern. When deafferented, the locust cannot maintain the normal flight rhythm despite a wind stimulus to its head. The authors explain that the change in flight behavior is associated with significant changes in the profile of synaptic activation in many interneurons in deafferented preparations and with alterations in the motor pattern.
Feedback during active and passive movements is more functional than during static positioning. Studies using microneurography of the human hand during active and passive movement show a response from cutaneous, joint and muscle afferents. During both active and passive movements, the majority of afferents from all classes of cutaneous receptors alter their discharge rates. In a static position, however, there is little background discharge in any of the cutaneous receptors. (Gandevia S C, Burke D. Ibid.)
In a review article spanning the past 20 years, Duysens and colleagues show the importance of proprioceptive feedback in triggering events in the gait cycle. (Duysens J, Clarac F, Cruse H. Load-regulating mechanisms in gait and posture: Comparative aspects.
Physiol Reviews.
2000; 80:83-133.) They discuss research with spinal cats on a treadmill whereby they found that at end stance the cat's limb is extended and unloaded whereas at end swing the cat's limb is flexed and beginning to unload. Researchers then questioned what triggered these transitions. They postulated that the transition from stance to swing was triggered by load and the transition from flexion to extension was triggered by limb position sense.
Afferent feedback provides information about human movement and can influence normal movement. Sharma et al studied knee joints with and without osteoarthritis and identified two possible directions in the relationship between impaired proprioception and knee osteoarthritis: 1) that proprioceptive impairment contributes to the development of knee osteoarthritis; or 2) that knee position sense impairment results from osteoarthritic pathologic processes at the joint. (Sharma L, Pai Y-C, Holtkamp K, Rymer W Z. Is knee joint proprioception worse in the arthritic knee versus the unaffected knee in unilateral knee osteoarthritis?
Arthritis
&
Rheumatism.
1997; 40:1518-1525.) They concluded that within the patients with osteoarthritis, proprioception was not worse in the arthritic knees than in the unaffected knees. These results suggest that impaired proprioception is not exclusively a local result of disease in knee osteoarthritis; rather, impaired proprioception may contribute to knee osteoarthritis.
LPS activity is measured in order to determine if a person is capable of accurately placing a limb in key positions during functional movements. Clinical measurement of proprioception is currently, in the prior art, determined by two methods: 1) single joint position placement and/or 2) mirroring. In the former, the therapist places a limb in either flexion or extension and the patient verbally indicates the position of his/her limb or duplicates the position with the contralateral limb. In the latter, the patient mimics the movement of the therapist and attempts to mirror that same movement with the contralateral limb. Also, movement detection is tested by slowly moving the limb until the person indicates a sense the limb is moving. These are static, single joint measurements that do not signify how proprioception effects movement—contrary to the above-cited research which indicates that limb position sense beco
Hindenburg Max F.
Northwestern University
Reinhart Boerner Van Deuren s.c.
Szmal Brian
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