Imperial College London

DrPaulStrutton

Faculty of MedicineDepartment of Surgery & Cancer

Senior Lecturer
 
 
 
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Contact

 

+44 (0)20 7594 3239p.strutton

 
 
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Location

 

205Building E - Sir Michael UrenWhite City Campus

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Summary

 

Publications

Publication Type
Year
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73 results found

Mehesz E, Karoui H, Strutton PH, Hughes SWet al., 2021, Exposure to an Immersive Virtual Reality Environment can Modulate Perceptual Correlates of Endogenous Analgesia and Central Sensitization in Healthy Volunteers, JOURNAL OF PAIN, Vol: 22, Pages: 707-714, ISSN: 1526-5900

Journal article

Bonsu AN, Nousi S, Lobo R, Strutton PH, Arshad Q, Bronstein AMet al., 2021, Vestibulo-perceptual influences upon the vestibulo-spinal reflex, EXPERIMENTAL BRAIN RESEARCH, Vol: 239, Pages: 2141-2149, ISSN: 0014-4819

Journal article

Deane JA, Lim AKP, McGregor AH, Strutton PHet al., 2021, Understanding the impact of lumbar disc degeneration and chronic low back pain: a cross-sectional electromyographic analysis of postural strategy during predicted and unpredicted postural perturbations, PLoS One, Vol: 16, ISSN: 1932-6203

People with chronic low back pain (LBP) exhibit changes in postural control. Stereotypical muscle activations resulting from external perturbations include anticipatory (APAs) and compensatory (CPAs) postural adjustments. The aim and objective of this study was to determine differences in postural control strategies (peak amplitude, APAs and CPAs) between symptomatic and asymptomatic adults with and without Lumbar Disc Degeneration (LDD) using surface electromyography during forward postural perturbation. Ninety-seven subjects participated in the study (mean age 50 years (SD 12)). 3T MRI was used to acquire T2 weighted images (L1-S1). LDD was determined using Pfirrmann grading. A bespoke translational platform was designed to deliver horizontal perturbations in sagittal and frontal planes. Electromyographic activity was analysed bilaterally from 8 trunk and lower limb muscles during four established APA and CPA epochs. A Kruskal-Wallis H test with Bonferroni correction for multiple comparisons was conducted. Four groups were identified: no LDD no pain (n = 19), LDD no pain (n = 38), LDD pain (n = 35) and no LDD pain (n = 5). There were no significant differences in age or gender between groups. The most significant difference between groups was observed during forward perturbation. In the APA and CPA phases of predictable forward perturbation there were significant differences ankle strategy between groups (p = 0.007–0.008); lateral gastrocnemius and tibialis anterior activity was higher in the LDD pain than the LDD no pain group. There were no significant differences in the unpredictable condition (p>0.05). These findings were different from the remaining groups, where significant differences in hip strategy were observed during both perturbation conditions (p = 0.004–0.006). Symptomatic LDD patients exhibit different electromyographic strategies to asymptomatic LDD controls. Future LBP electromyographic research should benefit from considering asses

Journal article

Bogomolova K, Sam AH, Misky AT, Gupte CM, Strutton PH, Hurkxkens TJ, Hierck BPet al., 2021, Development of a Virtual Three-Dimensional Assessment Scenario for Anatomical Education, ANATOMICAL SCIENCES EDUCATION, Vol: 14, Pages: 385-393, ISSN: 1935-9772

Journal article

Hughes SW, Basra M, Chan C, Parr C, FelyxWong, Gomes S, Strutton PHet al., 2021, Capsaicin-Induced Changes in Electrical Pain Perception Threshold Can Be Used to Assess the Magnitude of Secondary Hyperalgesia in Humans (vol 21, pg 2830, 2020), PAIN MEDICINE, Vol: 22, Pages: 237-237, ISSN: 1526-2375

Journal article

Hughes SW, Basra M, Chan C, Parr C, Wong F, Gomez S, Strutton PHet al., 2020, Capsaicin-induced changes in electrical pain perception threshold can be used to assess the magnitude of secondary hyperalgesia in humans., Pain Medicine, Vol: 21, Pages: 2830-2838, ISSN: 1526-2375

OBJECTIVES: Areas of secondary hyperalgesia can be assessed using quantitative sensory testing (QST). Delivering noxious electrocutaneous stimulation could provide added benefit by allowing multiple measurements of the magnitude of hyperalgesia. We aimed to characterize the use of electrical pain perception (EPP) thresholds alongside QST as a means by which to measure changes in pain thresholds within an area of secondary mechanical hyperalgesia. METHODS: EPP and heat pain thresholds (HPTs) were measured at five distinct points at baseline and following 1% capsaicin cream application, one within a central zone and four within a secondary zone. Areas of secondary mechanical hyperalgesia were mapped using QST. In a further 14 participants, capsaicin-induced reduction in EPP thresholds was mapped using a radial lines approach across 24 points. RESULTS: There was a reduction in EPP threshold measured at the four points within the secondary zone, which was within the mapped area of mechanical secondary hyperalgesia. The magnitude of secondary hyperalgesia could be split into a mild (∼4% reduction) and severe (∼21% reduction) area within an individual subject. There was no reduction in HPT within the secondary zone, but there was a reduction in both HPT and EPP threshold within the primary zone. EPP mapping revealed differences in the magnitude and spread of hyperalgesia across all subjects. CONCLUSIONS: Measuring capsaicin-induced reduction in EPP thresholds can be used to map hyperalgesic areas in humans. This semi-automated approach allows rapid assessment of the magnitude of hyperalgesia, both within an individual subject and across a study population.

Journal article

Chiou S-Y, Strutton PH, 2020, Crossed corticospinal facilitation between arm and trunk muscles correlates with trunk control after spinal cord injury, Frontiers in Human Neuroscience, Vol: 14, Pages: 1-11, ISSN: 1662-5161

Objective: To investigate whether crossed corticospinal facilitation between arm and trunk muscles is preserved following spinal cord injury (SCI) and to elucidate these neural interactions for postural control during functional arm movements.Methods: Using transcranial magnetic stimulation (TMS) in 22 subjects with incomplete SCI motor evoked potentials (MEPs) in the erector spinae (ES) muscle were examined when the contralateral arm was at rest or performed 20% of maximal voluntary contraction (MVC) of biceps brachii (BB) or triceps brachii (TB). Trunk function was assessed with rapid shoulder flexion and forward-reaching tasks.Results: MEP amplitudes in ES were increased during elbow flexion in some subjects and this facilitatory effect was more prominent in subjects with thoracic SCI than in the subjects with cervical SCI. Those who showed the increased MEPs during elbow flexion had faster reaction times and quicker anticipatory postural adjustments of the trunk in the rapid shoulder flexion task. The onset of EMG activity in ES during the rapid shoulder flexion task correlated with the trunk excursion in forward-reaching.Conclusions: Our findings demonstrate that crossed corticospinal facilitation in the trunk muscles can be preserved after SCI and is reflected in trunk control during functional arm movements.

Journal article

Mullington CJ, Low DA, Strutton PH, Malhotra Set al., 2020, A mechanistic study of the tremor associated with epidural anaesthesia for intrapartum caesarean delivery, International Journal of Obstetric Anesthesia, Vol: 43, Pages: 56-64, ISSN: 0959-289X

BackgroundIt is not known if the tremor associated with an epidural top-up dose for intrapartum caesarean delivery is thermoregulatory shivering. A tremor is only shivering if it has the same frequency profile as cold stress-induced shivering. Thermoregulatory shivering is a response to a reduction in actual body temperature, whereas non-thermoregulatory shivering may be triggered by a reduction in sensed body temperature. This mechanistic study aimed to compare: 1. the frequency profiles of epidural top-up tremor and cold stress-induced shivering; and 2. body temperature (actual and sensed) before epidural top-up and at the onset of tremor.MethodsTwenty obstetric patients received an epidural top-up for intrapartum caesarean delivery and 20 non-pregnant female volunteers underwent a cold stress. Tremor, surface electromyography, core temperature, skin temperature (seven sites) and temperature sensation votes (a bipolar visual analog score ranging from −50 to +50 mm) were recorded.ResultsThe mean (SD) primary oscillation (9.9 (1.9) Hz) frequency of epidural top-up tremor did not differ from that of cold stress-induced shivering (9.0 (1.6) Hz; P=0.194), but the mean (SD) burst frequency was slower (6.1 (1.2) × 10−2 Hz vs 6.9 (0.7) × 10−2 Hz, respectively; P=0.046). Before the epidural top-up dose, the mean (SD) core temperature was 37.6 (0.6) °C. Between the epidural top-up dose and the onset of tremor the mean (SD) core temperature did not change (–0.1 (0.1) °C; P=0.126), the mean (SD) skin temperature increased (+0.4 (0.4) °C; P=0.002) and the mean (SD) temperature sensation votes decreased (−12 (16) mm; P=0.012).ConclusionThese results suggest that epidural top-up tremor is a form of non-thermoregulatory shivering triggered by a reduction in sensed body temperature.

Journal article

Moniri A, Terracina D, Rodriguez-Manzano J, Strutton P, Georgiou Pet al., 2020, Real-time forecasting of sEMG features for trunk muscle fatigue using machine learning, IEEE Transactions on Biomedical Engineering, Vol: 68, Pages: 718-727, ISSN: 0018-9294

Objective: Several features of the surface electromyography (sEMG) signal are related to muscle activity and fatigue. However, the time-evolution of these features are non-stationary and vary between subjects. The aim of this study is to investigate the use of adaptive algorithms to forecast sMEG feature of the trunk muscles. Methods: Shallow models and a deep convolutional neural network (CNN) were used to simultaneously learn and forecast 5 common sEMG features in real-time to provide tailored predictions. This was investigated for: up to a 25 second horizon; for 14 different muscles in the trunk; across 13 healthy subjects; while they were performing various exercises. Results: The CNN was able to forecast 25 seconds ahead of time, with 6.88% mean absolute percentage error and 3.72% standard deviation of absolute percentage error, across all the features. Moreover, the CNN outperforms the best shallow model in terms of a figure of merit combining accuracy and precision by at least 30% for all the 5 features. Conclusion: Even though the sEMG features are non-stationary and vary between subjects, adaptive learning and forecasting, especially using CNNs, can provide accurate and precise forecasts across a range of physical activities. Significance: The proposed models provide the groundwork for a wearable device which can forecast muscle fatigue in the trunk, so as to potentially prevent low back pain. Additionally, the explicit realtime forecasting of sEMG features provides a general model which can be applied to many applications of muscle activity monitoring, which helps practitioners and physiotherapists improve therapy.

Journal article

Hughes SW, Hellyer PJ, Sharp DJ, Newbould RD, Patel MC, Strutton PHet al., 2020, Diffusion tensor imaging of lumbar spinal nerves reveals changes in microstructural integrity following decompression surgery associated with improvements in clinical symptoms: A case report, Magnetic Resonance Imaging, Vol: 69, Pages: 65-70, ISSN: 0730-725X

The outcomes from spinal nerve decompression surgery are highly variable with a sizable proportion of elderly foraminal stenosis patients not regaining good pain relief. A better understanding of nerve root compression before and following decompression surgery and whether these changes are mirrored by improvements in symptoms may help to improve clinical decision-making processes. This case study used a combination of diffusion tensor imaging (DTI), clinical questionnaires and motor neurophysiology assessments before and up to 3 months following spinal decompression surgery. In this case report, a 70-year-old women with compression of the left L5 spinal nerve root in the L5-S1 exit foramina was recruited to the study. At 3 months following surgery, DTI revealed marked improvements in left L5 microstructural integrity to a similar level to that seen in the intact right L5 nerve root. This was accompanied by a gradual improvement in pain-related symptoms, mood and disability score by 3 months. Using this novel multimodal approach, it may be possible to track concurrent improvements in pain-related symptoms, function and microstructural integrity of compressed nerves in elderly foraminal stenosis patients undergoing decompression surgery.

Journal article

Hughes SW, Ward G, Strutton PH, 2020, Anodal transcranial direct current stimulation over the primary motor cortex attenuates capsaicin-induced dynamic mechanical allodynia and mechanical pain sensitivity in humans., European Journal of Pain, Vol: 24, Pages: 1130-1137, ISSN: 1090-3801

BACKGROUND: Anodal transcranial direct current stimulation over the primary cortex has been shown to activate regions of the brain involved in the descending modulation of pain sensitivity. However, more research is required in order to dissect the spinal cord analgesic mechanisms associated with the development of central sensitisation. METHODS: In this randomised, double blind, cross over study 12 healthy participants had baseline mechanical stimulus response (S/R) functions measured before and after the development of capsaicin-induced ongoing pain sensitivity. The effects of 20 min of either real or sham transcranial direct current stimulation (tDCS, 2 mA) over the primary motor cortex on dynamic mechanical allodynia (DMA) and mechanical pain sensitivity (MPS) was then investigated. RESULTS: Topical application of capsaicin resulted in an increase in area under the pain ratings curve for both DMA (p < .01) and MPS (p < .01). The effects of tDCS on the area under the curve ratio (i.e. post/pre-treatment) revealed significant analgesic effects over DMA (p < .05) and MPS (p < .05) when compared to sham. CONCLUSIONS: This study demonstrates that anodal tDCS over the primary motor cortex can reduce both dynamic and static forms of mechanical pain sensitivity associated with the development of DMA and MPS, respectively. The use of tDCS may provide a novel mechanism-driven therapy in chronic pain patients with altered mechanical S/R functions.

Journal article

Terracina D, Moniri A, Rodriguez-Manzano J, Strutton PH, Georgiou Pet al., 2019, Real-time forecasting and classification of trunk muscle fatigue using surface electromyography, IEEE Biomedical Circuits and Systems Conference (BioCAS), Publisher: IEEE, Pages: 1-4, ISSN: 2163-4025

Low Back Pain (LBP) affects the vast majority of the population at some point in their lives. People with LBP show altered trunk muscle activity and enhanced fatigability of trunk muscles is associated with the development and future risk of LBP. Therefore, a system that can forecast trunk muscle activity and detect fatigue can help subjects, practitioners and physiotherapists in the diagnosis, monitoring and recovery of LBP. In this paper, we present a novel approach in order to determine whether subjects are fatigued, or transitioning to fatigue, 25 seconds ahead of time using surface Electromyography (sEMG) from 14 trunk muscles. This is achieved using a three-step approach: A) extracting features related to fatigue from sEMG, B) forecasting the features using a real-time adaptive filter and C) performing dimensionality reduction (from 70 to 2 features) and then classifying subjects using a supervised machine learning algorithm. The forecasting classification accuracy across 13 patients is 99.1% ± 0.004 and the area under the micro and macro ROC curve is 0.935 ± 0.036 and 0.940 ±0.034 as determined by 10-fold cross validation. The proposed approach enables a computationally efficient solution which could be implemented in a wearable device for preventing muscle injury.

Conference paper

Hughes S, Zhao H, Auvinet E, Strutton Pet al., 2019, Attenuation of capsaicin-induced ongoing pain and secondary hyperalgesia during exposure to an immersive virtual reality environment, PAIN Reports, Vol: 4, Pages: e790-e790, ISSN: 2471-2531

Introduction: There is growing evidence that virtual reality (VR) can be used in the treatment of chronic pain conditions. However, further research is required in order to better understand the analgesic mechanisms during sensitised pain states. Objectives: We examined the effects of an immersive polar VR environment on capsaicin-induced ongoing pain and secondary hyperalgesia. We also investigated whether the degree of analgesia was related to baseline conditioned pain modulation (CPM) responses. Methods: Nineteen subjects had baseline CPM and electrical pain perception (EPP) thresholds measured prior to the topical application of capsaicin cream. Visual analogue scale (VAS) ratings were measured to track the development of an ongoing pain state and EPP thresholds were used to measure secondary hyperalgesia. The effects of a passive polar VR environment on ongoing pain and secondary hyperalgesia were compared to sham VR (i.e. 2D monitor screen) in responders to capsaicin (n=15). Results: VR was associated with a transient reduction in ongoing pain and an increase in EPP thresholds in an area of secondary hyperalgesia. Baseline CPM measurements showed a significant correlation with VR-induced changes in secondary hyperalgesia, but not with VR-induced changes in ongoing pain perception. There was no correlation between VR-induced changes in pain perception and VR-induced changes in secondary hyperalgesia. Conclusions: Virtual reality can reduce the perception of capsaicin-induced ongoing pain perception and secondary hyperalgesia. We also show that CPM may provide a means by which to identify individuals likely to respond to VR therapy.

Journal article

To M, Strutton P, Alexander C, 2019, Central fatigue is greater than peripheral fatigue in people with Joint Hypermobility Syndrome, Journal of Electromyography and Kinesiology, Vol: 48, Pages: 197-204, ISSN: 1050-6411

Purpose: People with Joint Hypermobility Syndrome (JHS) suffer with fatigue. The purpose of this project was to investigate the contribution of central and peripheral fatigue.Methods: Electrical stimulation of the musculocutaneous nerve to biceps brachii, and transcranial magnetic stimulation over the motor cortex supplying biceps brachii were used. Peripheral and central fatigue were assessed during a control, fatiguing and recovery phase protocol. Results: JHS participants perceived greater fatigue during the protocol compared to a control group and did not recover. Central and peripheral fatigue did not occur in the control group. However, the JHS group showed central fatigue. MEP amplitude increased in the JHS group during the fatiguing protocol (p<0.01) before recovering. Superimposed twitch amplitude increased in the JHS group during the fatiguing protocol and stayed elevated during the recovery phase (p<0.04). Time to peak (TTP) amplitude of the torque generated by the TMS was longer in the JHS group (p<0.05). RMS during MVCs decreased during the fatiguing protocol reaching significance during the recovery phase (p<0.01).Conclusion: JHS participants suffered central but not peripheral fatigue. A modified strength programme to target this is discussed.

Journal article

Hughes S, Grimsey S, Strutton PH, 2019, Primary motor cortex transcranial direct current stimulation modulates temporal summation of the nociceptive withdrawal reflex in healthy subjects, Pain Medicine, Vol: 20, Pages: 1156-1165, ISSN: 1526-2375

Objective: Transcranial direct current stimulation (tDCS) over the primary motor cortex (M1) has shown efficacy in a number of chronic pain conditions. Despite attempts to dissect the analgesic mechanisms, it is unknown whether M1 tDCS modulates the central integration of spinal nociception. To test this, we investigated the top-down modulation of spinal excitability using temporal summation (TS) of the nociceptive withdrawal reflex (NWR). Methods: In this randomized, blinded, cross-over study, eight healthy subjects received electrically evoked TS of the NWR, which was delivered at 5 Hz at a threshold and a suprathreshold (1.1× threshold) to elicit TS resulting in different levels of pain. Subjects were asked to rate their pain after each stimulation. Changes in the TS of the NWR and pain ratings were investigated following 20 minutes of 2-mA anodal tDCS or sham stimulation applied over M1. Results: Baseline recordings showed that TS of the NWR was induced with both threshold and suprathreshold stimulation. Suprathreshold stimulation was also associated with a higher pain intensity rating. After brain stimulation, there was no effect over the lower-intensity TS of the NWR or pain ratings in both the tDCS and sham conditions. However, tDCS reduced TS of the NWR and associated pain ratings following higher-intensity suprathreshold stimulation. Conclusions: These results indicate that M1 tDCS can indirectly modulate the central integration of suprathreshold nociceptive processing in the spinal cord. It is possible that the analgesic efficacy of tDCS is dependent on plasticity induced within pain pathways following repeated, high-intensity stimulation, which may explain the beneficial effects seen in chronic pain patients.

Journal article

Hughes SW, Hellyer PJ, Sharp DJ, Newbould RD, Patel MC, Strutton PHet al., 2019, Diffusion tensor imaging reveals changes in microstructural integrity along compressed nerve roots that correlate with chronic pain symptoms and motor deficiencies in elderly stenosis patients, NeuroImage: Clinical, Vol: 23, ISSN: 2213-1582

Age-related degenerative changes in the lumbar spine frequently result in nerve root compression causing severe pain and disability. Given the increasing incidence of lumbar spinal disorders in the aging population and the discrepancies between the use of current diagnostic imaging tools and clinical symptoms, novel methods of nerve root assessment are needed. We investigated elderly patients with stenosis at L4-L5 or L5-S1 levels. Diffusion tensor imaging (DTI) was used to quantify microstructure in compressed L5 nerve roots and investigate relationships to clinical symptoms and motor neurophysiology. DTI metrics (i.e. FA, MD, AD and RD) were measured at proximal, mid and distal segments along compressed (i.e. L5) and intact (i.e. L4 or S1) nerve roots. FA was significantly reduced in compressed nerve roots and MD, AD and RD were significantly elevated in the most proximal segment of the nerve root studied. FA was significantly correlated with electrophysiological measures of root function: minimum F-wave latency and peripheral motor conduction time (PMCT). In addition, FA along the compressed root also correlated with leg pain and depression score. There was also a relationship between RD and anxiety, leg pain and disability score and AD correlated with depression score. Taken together, these data show that DTI metrics are sensitive to nerve root compression in patients with stenosis as a result of age-related lumbar degeneration. Critically, they show that the changes in microstructural integrity along compressed L5 nerve roots are closely related to a number of clinical symptoms associated with the development of chronic pain as well as neurophysiological assessments of motor function. These inherent relationships between nerve root damage and phenotype suggest that the use DTI is a promising method as a way to stratify treatment selection and predict outcomes.

Journal article

Mullington CJ, Low DA, Strutton PH, Malhotra Set al., 2018, Body temperature, cutaneous heat loss and skin blood flow during epidural anaesthesia for emergency caesarean section, Anaesthesia, Vol: 73, Pages: 1500-1506, ISSN: 0003-2409

It is not clear how converting epidural analgesia for labour to epidural anaesthesia for emergency caesarean section affects either cutaneous vasomotor tone or mean body temperature. We hypothesised that topping up a labour epidural blocks active cutaneous vasodilation (cutaneous heat loss and skin blood flow decrease), and that as a result mean body temperature increases. Twenty women in established labour had body temperature, cutaneous heat loss and skin blood flow recorded before and after epidural top‐up for emergency caesarean section. Changes over time were analysed with repeated measures ANOVA. Mean (SD) mean body temperature was 36.8 (0.5)°C at epidural top‐up and 36.9 (0.6)°C at delivery. Between epidural top‐up and delivery, the mean (SD) rate of increase in mean body temperature was 0.5 (0.5) °C.h−1. Following epidural top‐up, chest (p < 0.001) and forearm (p = 0.004) heat loss decreased, but head (p = 0.05), thigh (p = 0.79) and calf (p = 1.00) heat loss did not change. The mean (SD) decrease in heat loss was 15 (19) % (p < 0.001). Neither arm (p = 0.06) nor thigh (p = 0.10) skin blood flow changed following epidural top‐up. Despite the lack of change in skin blood flow, the most plausible explanation for the reduction in heat loss and the increase in mean body temperature is blockade of active cutaneous vasodilation. It is possible that a similar mechanism is responsible for the hyperthermia associated with labour epidural analgesia.

Journal article

Chiou S-Y, Strutton PH, Perez MA, 2018, Crossed corticospinal facilitation between arm and trunk muscles in humans, Journal of Neurophysiology, Vol: 120, Pages: 2595-2602, ISSN: 0022-3077

A voluntary contraction of muscles with one arm increases corticospinal excitability of projections to the contralateral resting arm, a phenomenon known as crossed facilitation. Although many motor tasks engage simultaneous activation of the arm and trunk, interactions between corticospinal projections targeting these segments remain largely unknown. Using transcranial magnetic stimulation over the trunk representation of the primary motor cortex we examined motor evoked potentials (MEPs) in the resting erector spinae (ES) muscle when the contralateral arm remained at rest or performed 20% of isometric maximal voluntary contraction (MVC) into index finger abduction, thumb abduction, elbow flexion and elbow extension. We found that MEP size in the ES increased during all voluntary contractions, with greater facilitation occurring during elbow flexion and index finger abduction. To further examine the origin of changes in MEP size we measured short-interval intracortical inhibition (SICI) and cervicomedullary MEPs (CMEPs) in the ES muscle during elbow flexion and index finger abduction and when the arm remained at rest. Notably, SICI decreased and CMEPs remained unchanged in the ES during both voluntary contractions compared with rest, suggesting a cortical origin for the effects. Our findings reveal crossed facilitatory interactions between trunk extensor and proximal and distal arm muscles, particularly for elbow flexor and index finger muscles, likely involving cortical mechanisms. These interactions might reflect the different role of these muscles during functionally relevant arm and trunk movements.

Journal article

Hughes SW, Ali M, Sharma P, Insan N, Strutton PHet al., 2018, Frequency-dependent top-down modulation of temporal summation by anodal transcranial direct-current stimulation of the primary motor cortex in healthy adults, European Journal of Pain, Vol: 22, Pages: 1494-1501, ISSN: 1090-3801

BackgroundTranscranial direct‐current stimulation (tDCS) applied over the primary motor cortex has been shown to be effective in the treatment of a number of chronic pain conditions. However, there is a lack of understanding of the top‐down analgesic mechanisms involved.MethodIn this study, we investigated the effects of tDCS on the facilitation of subjective sensory and pain scores using a transcutaneous electrically evoked measure of temporal summation. In this randomized, blinded, cross‐over study healthy subjects received a single stimulus given at 0.9× pain threshold (pTh) over the L5 dermatome on the lateral aspect of the right leg, followed by a train of 5 stimuli given at 0.5, 1, 5 and 20 Hz before and after 20 min of sham or anodal tDCS (2 mA) applied over the primary motor cortex. Ratings of sensation and pain intensity were scored on a visual analogue scale (VAS).ResultsTemporal summation leading to pain only occurred at higher frequencies (5 and 20 Hz). Sham or real tDCS had no effect over temporal summation evoked at 5 Hz; however, there was a significant analgesic effect at 20 Hz. Sham or real tDCS had no effect over acute, single stimuli‐evoked responses.ConclusionThese results indicate that anodal tDCS applied to the primary motor cortex preferentially modulates temporal summation induced by high‐frequency electrical stimulation‐induced pain. The inhibitory effects of tDCS appear to be dynamic and dependent on the degree of spinal cord excitability and may explain the higher analgesic efficacy in patients with moderate to severe chronic pain symptoms.SignificanceThe analgesic effects of tDCS are dependent on spinal cord excitability. This work provides insight into top‐down modulation during acute pain and temporal summation. This knowledge may explain why tDCS has a higher analgesic efficacy in chronic pain patients.

Journal article

Chiou S-Y, Hurry M, Reed T, Quek JX, Strutton PHet al., 2018, Cortical contributions to anticipatory postural adjustments in the trunk, JOURNAL OF PHYSIOLOGY-LONDON, Vol: 596, Pages: 1295-1306, ISSN: 0022-3751

Voluntary limb movements are associated with increases in trunk muscle activity, some of which occur within a time window considered too fast to be induced by sensory feedback; these increases are termed anticipatory postural adjustments (APAs). Although it is known that the function of APAs is to maintain postural stability in response to perturbations, excitability of the corticospinal projections to the trunk muscles during the APAs remains unclear. Thirty‐four healthy subjects performed rapid shoulder flexion in response to a visual cue in standing and lying positions. Transcranial magnetic stimulation (TMS) was delivered over the trunk motor cortex to examine motor evoked potentials (MEPs) in erector spinae (ES) and in rectus abdominis (RA) muscles at several time points prior to the rise in electromyographic activity (EMG) of anterior deltoid (AD) muscle. TMS was also used to assess short‐interval intracortical inhibition (SICI) and cervicomedullary MEPs (CMEPs) in ES in the standing position. MEPs in ES were larger at time points closer to the rise in AD EMG in both standing and lying positions, whereas MEPs in RA did not differ over the time course examined. Notably, SICI was reduced at time points closer to the rise in AD EMG, with no change in CMEPs. Our results demonstrate that increasing excitability of corticospinal projections to the trunk muscles prior to a voluntary limb movement is likely to be cortical in origin and is muscle specific.

Journal article

Chiou S, Koutsos E, Georgiou P, Strutton PHet al., 2018, Association between spectral characteristics of paraspinal muscles and functional disability in low back pain patients: a cohort study, BMJ Open, Vol: 8, ISSN: 2044-6055

Objectives. Characteristics of muscle activity, represented by surface electromyography (EMG), have revealed differences between patients with low back pain and healthy adults; how they relate to functional and clinical parameters remains unclear. The purpose of the current study was to examine the correlation between frequency characteristics of EMG (analysed using continuous wavelet transform (CWT) analysis) and patients’ self-rated score of disability. Design and setting. This is a case control study with fifteen patients with mechanical low back pain (LBP) without radicular symptoms. Patients were recruited from the orthopaedic clinic at Charing Cross Hospital. Ten healthy adults were recruited from the staff working in the hospital and associated university. Patients completed the Roland-Morris Disability Questionnaire (RMDQ) and bilateral EMG activity was obtained from erector spinae at vertebral levels L4 and T12. Subjects performed 3 brief maximal isometric voluntary contractions (MVCs) of the back extensors and the torque was measured using a dynamometer. CWT was applied to the EMG signals of each muscle in a 200ms window centred around the peak torque obtained during the MVCs. The ratio (low/high frequencies) of the energy, the peak power, and the frequency of the peak power were calculated for each recording site, averaged and correlated with the individual’s RMDQ score. Results. Patients had lower peak power (T12 and L4) and lower frequency of the peak power (at T12) than the healthy adults. Additionally, RMDQ positively correlated to the average ratio of energy at T12 (rho=0.63; p=0.012), i.e. greater self-rated disability corresponded to a dominant distribution of energy in the lower frequencies. Conclusion. The current findings reveal alterations in EMG profile and its association with self-related back pain disability, suggesting that spectral characteristics of EMG reflect muscle function.

Journal article

Chiou SY, Hellyer PJ, Sharp DJ, Newbould RD, Patel MC, Strutton PHet al., 2017, Relationships between the integrity and function of lumbar nerve roots as assessed by diffusion tensor imaging and neurophysiology, NEURORADIOLOGY, Vol: 59, Pages: 893-903, ISSN: 0028-3940

PurposeDiffusion tensor imaging (DTI) has shown promise in the measurement of peripheral nerve integrity, although the optimal way to apply the technique for the study of lumbar spinal nerves is unclear. The aims of this study are to use an improved DTI acquisition to investigate lumbar nerve root integrity and correlate this with functional measures using neurophysiology.MethodsTwenty healthy volunteers underwent 3 T DTI of the L5/S1 area. Regions of interest were applied to L5 and S1 nerve roots, and DTI metrics (fractional anisotropy, mean, axial and radial diffusivity) were derived. Neurophysiological measures were obtained from muscles innervated by L5/S1 nerves; these included the slope of motor-evoked potential input-output curves, F-wave latency, maximal motor response, and central and peripheral motor conduction times.ResultsDTI metrics were similar between the left and right sides and between vertebral levels. Conversely, significant differences in DTI measures were seen along the course of the nerves. Regression analyses revealed that DTI metrics of the L5 nerve correlated with neurophysiological measures from the muscle innervated by it.ConclusionThe current findings suggest that DTI has the potential to be used for assessing lumbar spinal nerve integrity and that parameters derived from DTI provide quantitative information which reflects their function.

Journal article

Chiou S-Y, Gottardi SE, Hodges PW, Strutton PHet al., 2016, Corticospinal Excitability of Trunk Muscles during Different Postural Tasks, PLoS One, Vol: 11, ISSN: 1932-6203

Evidence suggests that the primary motor cortex (M1) is involved in both voluntary, goal-directed movements and in postural control. Trunk muscles are involved in both tasks, however, the extent to which M1 controls these muscles in trunk flexion/extension (voluntary movement) and in rapid shoulder flexion (postural control) remains unclear. The purpose of this study was to investigate this question by examining excitability of corticospinal inputs totrunk muscles during voluntary and postural tasks. Twenty healthy adults participated. Transcranial magnetic stimulation was delivered to the M1 to examine motor evoked potentials (MEPs) in the trunk muscles (erector spinae (ES) and rectus abdominis (RA)) during dynamic shoulder flexion (DSF), static shoulder flexion (SSF), and static trunk extension (STE). The level of background muscle activity in the ES muscles was matched across tasks. MEP amplitudes in ES were significantly larger in DSF than in SSF or in STE; however, this was not observed for RA. Further, there were no differences in levels of muscleactivity in RA between tasks. Our findings reveal that corticospinal excitability of the ES muscles appears greater during dynamic anticipatory posture-related adjustments than during static tasks requiring postural (SSF) and goal-directed voluntary (STE) activity. These results suggest that task-oriented rehabilitation of trunk muscles should be considered for optimal transfer of therapeutic effect to function.

Journal article

Evans DR, Williams KJ, Strutton PH, Davies AHet al., 2016, The comparative hemodynamic efficacy of lower limb muscles using transcutaneous electrical stimulation., Journal of vascular surgery. Venous and lymphatic disorders, Vol: 4, Pages: 206-214, ISSN: 2213-3348

BACKGROUND: Circulation in the limbs can be augmented using transcutaneous electrical stimulation devices. The optimum muscle stimulation sites for enhancement of vascular hemodynamic parameters have not been identified. METHODS: Seven suitable anatomic sites were identified within the right leg. Twelve healthy participants were recruited (mean age, 23.1 ± 3 years; body mass index, 23.1 ± 3 kg/m(2)). Muscles were stimulated by transcutaneous bipolar electrodes at a current twice their motor threshold, at 1 Hz, for 5 minutes. Hemodynamic ultrasound measurements were taken from the right femoral vein. Laser Doppler measurements from the feet of the stimulated and nonstimulated sides were obtained. Baseline measurements were compared with readings after 5 minutes of stimulation, with device active. Discomfort experienced for stimulation of each muscle was rated out of 100. RESULTS: Hemodynamic changes displayed large intersubject variation, with no muscle statistically superior to the others. All muscles increased peak velocity; contraction of medial gastrocnemius increased time-averaged maximum velocity and volume flow. All muscles increased foot fluximetry (P < .05). Discomfort correlated weakly with current applied. Tibialis anterior and vastus lateralis were most tenable. CONCLUSIONS: Transcutaneous stimulation increases hemodynamic parameters significantly, locally and systemically. No optimum stimulation site has been identified, and it is limited by comfort and variability in the subject's response. Gastrocnemius, tibialis anterior, and vastus lateralis all provoke large changes in hemodynamic parameters, but clinical efficacy in disease prevention and management has not been explored.

Journal article

Chiou SY, Jeevathol A, Odedra A, Strutton PHet al., 2015, Voluntary activation of trunk extensors appears normal in young adults who have recovered from low back pain, European Journal of Pain, Vol: 19, Pages: 1506-1515, ISSN: 1090-3801

BackgroundLow back pain (LBP) is associated with alterations in control of trunk movements and changes within central nervous system (CNS). Evidence shows that some of these alterations within the CNS are reversible when the symptoms are relieved, whereas other shows the opposite. Therefore, the purpose of the current study was to investigate whether alterations in voluntary activation (VA) of central neural drive, as assessed using twitch interpolation to measure VA, are present in subjects with a history of low back pain (HLBP), who are free from pain at the time of experiment.MethodsTwelve adults with HLBP and 12 controls participated. Bilateral electromyographic recordings were obtained from erector spiane muscles at two vertebral levels (T12 and L4) and from rectus abdominis. Participants performed a series of brief isometric back extensions (50–100% maximum voluntary contraction) during which transcranial magnetic stimulation was delivered. The sizes of the evoked (superimposed) twitches were measured using dynamometry and VA was derived. The amplitude of motor evoked potentials (MEPs) and duration of cortical silent period (CSP) in erector spinae muscles were calculated; questionnaires were used to evaluate disability, levels of physical activity, quality of life and pain.ResultsThe level of VA was not significantly different between HLBP and control groups. Additionally, there were no between‐group differences in the time‐to‐peak amplitudes of the twitches, MEP amplitudes or duration of CSP.ConclusionsThe ability to voluntarily activate back extensor muscles maximally does not appear to be impaired in subjects with a history of LBP during pain‐free episodes.

Journal article

Mullington C, Wrench C, He J, Low D, Strutton P, Malhotra Set al., 2014, Thermal gradient: the primary driver of thermal perception?, Annual Congress of the Association-of-Anaesthetists-of-Great-Britain-and-Ireland (AAGBI), Publisher: WILEY-BLACKWELL, Pages: 38-38, ISSN: 0003-2409

Conference paper

Chiou SY, Shih YF, Chou LW, McGregor AH, Strutton PHet al., 2014, Impaired neural drive in patients with low back pain, European Journal of Pain, Vol: 18, Pages: 794-802, ISSN: 1090-3801

BackgroundControl of trunk movement relies on the integration between central neuronal circuits and peripheral skeletomuscular activities and it can be altered by pain. There is increasing evidence that there are deficits within the central nervous system controlling the trunk muscles in people with low back pain (LBP). However, it is unclear how LBP impacts upon neural drive to back muscles at different levels of voluntary contraction. Therefore, the purpose of this study was to investigate if neural drive is impaired in these patients.MethodsSeventeen patients with LBP and 11 healthy controls were recruited. Bilateral electromyographic (EMG) recordings were obtained from the erector spinae (ES) muscles at two vertebral levels (T12 and L4). Participants performed a series of brief isometric back extensions (50–100% maximum voluntary contraction – MVC), during which transcranial magnetic stimulation was delivered. The size of the evoked (superimposed) twitch was measured using dynamometry.ResultsThe size of the superimposed twitch decreased linearly with increasing contraction strength in the controls; however, this linear relationship was not observed in the patients. Additionally, patients had larger superimposed twitches and longer time‐to‐peak amplitudes during MVCs than those observed in controls. Furthermore, patients had lower MVC and root‐mean‐square EMG activity of ES muscles during MVCs.ConclusionsA decline of central neural drive to the back muscles at high level of voluntary contraction was observed in patients with LBP. These results suggest that it might be pertinent to include neuromuscular facilitation programmes and therapeutic exercise utilizing high voluntary contractions for patients with LBP.

Journal article

Jones P, Sorinola I, Strutton PH, 2014, Effect of dual tasking on postural responses to rapid lower limb movement while seated on an exercise ball, GAIT & POSTURE, Vol: 40, Pages: 297-304, ISSN: 0966-6362

Journal article

Nicotra A, King NKK, Catley M, Mendoza N, McGregor AH, Strutton PHet al., 2013, Evaluation of corticospinal excitability in cervical myelopathy, before and after surgery, with transcranial magnetic stimulation: a pilot study, EUROPEAN SPINE JOURNAL, Vol: 22, Pages: 189-196, ISSN: 0940-6719

Journal article

Bottle E, Strutton PH, 2012, Relationship between back muscle endurance and voluntary activation, JOURNAL OF ELECTROMYOGRAPHY AND KINESIOLOGY, Vol: 22, Pages: 383-390, ISSN: 1050-6411

Journal article

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