Note (by Robert Schleip): The following is a rather technical report about the research of Hubert Godard and his colleagues at the National Cancer Institute of Milano/Italy. It deals specifically with electromyographic research about 3 versions of an "unbendable arm" exercise with women after mastectomy. There is another interesting and more extensive article at our website about Hubert's work at  Kevin Frank: Tonic Function..

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NEUROPHYSIOLOGICAL STUDY OF THE E-MOTION

 

H. Godard*, C. Pirovano°, L. Bedodi°°, A. Cola°°, G. Galperti°°, R.Sensi°° and G. Martino°.

 * Universite de Paris VIII Saint Denis.

 ° METIS - Medicine and Memory - International Center of Studies and Therapies for Women's Health - Milan.

 °° Rehabilitation Dept. - National Cancer Institute - Milan.

    

INTRODUCTION

 Research conducted over the course of twelve years an the physical and psychological damage in women operated on for breast cancer led us to study some inexplicable phenomena related to oncological trauma and to surgery (1,2,3).

  We found post-surgical limitations of the shoulder girdle in daily movement that could not be explained through muscular, articular, electromyographical and radiological examination. In the classical clinical approach, only the force and amplitude of the basic movements of the joint are measured.

  Observation of the subjects while walking and while performing the movements of daily life revealed changes in the coordinative structures (acquired sensory‑motor automatisms) that were not reflected in the voluntary action tests. When walking, 65% of the breast‑operated women showed a loss of pendular motion of the homolateral arm. From the observers' perspective, the arm looked anchored to the trunk or paretic (like dead). When asked to move the arms symmetrically while walking the patients performed the movements without difficulty. In most cases the loss of pendular motion of the arm when walking, causes over time and by compensation, a malfunction of one hip joint.

  A second series of experiments was carried out with patients in the preoperative phase and with a sample of healthy women; 50% of the women with breast cancer in the pre‑surgical period presented reduced pendulousness in comparison with 10% in the healthy group (4). The pendulousness further decreased after surgery, in some cases as far as complete arrest of the arm.

  A third series of experiments was conducted with post‑surgical subjects, without functional or articular deficit, participating in body‑mind therapy groups (immediately post-surgery and during subsequent radiation therapy). We observed that these patients had less ability in space directionality (exteroception) (5), in space projection [ex‑proprioception: Awareness of body positions in reference to the spacial surroundings) (6) and in the ability to anticipate an action with the arm on the side of the operated breast.

  Following Damasio (7), Edelman (8), Reed (9), we suspected a link between emotion, perception and the loss of movement in our oncological patients. Starting from these works we investigated, through a new trial with the EMG, the neurophysiological implications of the emotional situations and of the fluctuations in perception in the context during the movement (e-motion).

  Specifically the aim of this study was:

 MATERIALS AND METHODS

 The experiment was carried out an 10 healthy volunteer subjects: 5 men and 5 women, aged between 28 and 46 years and without previous neuro‑motor deficits.

  We chose to evaluate the overall capacity of extension of the forearm against resistance in several different contexts.

  Strength of extension of the forearm is based an 1he work of the triceps brachii which can be inhibited or facilitated by the action of the antagonist: the biceps brachii. The stronger the work of the antagonist, the weaker the overall capacity of extension. The amount of biceps action is thus taken as the indicator of an inhibition in the movement.

  The triceps could be considered a muscle with a clearly prevailing phasic, alpha mediated activity and it has, as antagonist, the biceps, a tonic muscle implicated in the gravitational equilibrium with an important gamma activity. The two muscles could be considered "pure" antagonists because the articulation of the elbow is structured in way that allows few additional movements during the flexion‑extension of the forearm.

  The neuro‑physiological investigation was carried out with electromyography, by concentric needle electrodes of Adrian and Bronk. The recruitment pattern was recorded continuously during maximum voluntary activity. with sweep speed of 20 msec. and amplitude of motor units of 0.2 mV per division. (Some examples of the electromyographical traces that were recorded are shown below)

  Subjects, in seated position, were asked to support the back of the wrist an a bracket and to maintain the extension of the forearm resisting the examiner's attempt to flex lt. ( test against resistance). 

·         Initially the request was to exert the maximum possible extension of the forearm against resistance (test A).

extending with a horizontal aim in space before and during the movement in order

to modify the intentional perception within the context ("Imagine that your fingers

lengthen out to reach the wall of the room" or using other visual‑kinesthetic

modality. "that your fingers emit a beam of light that reaches the wall "). As in the

first test, during this trial the examiner tried to flex the arm of the subject (test B).

projection, by interposing an obstacle between the subject's arm and the wall. An

examiner passed through the aiming field of the subject (test C).

   

RESULTS

During maximum voluntary activity (test A): In the 10 subjects examined the electromyographic examination highlighted an unexpected, clean activity of biceps brachii (antagonist of the movement) while the examiner registered the strength of the extension of the forearm against resistance. The recruitment pattern changed from discrete activity to a reduced interference.

  With a spatial projective aim (test B), in all the examined subjects, the electromyographic data and the examiner's perception of the strength of extension clearly changed. The examiner perceived an "invincible" resistance, 3-4 times stronger than in the A-test , while the EMG showed a clear reduction in the recruitment of motor units in the biceps with patterns of single unit potentials and at times complete electrical silence. '

  Setting an obstacle to modify the spatial context (test C): In all the examined subjects the EMG activity in the biceps brachii reappeared although in a moderate way relative to test A. There were patterns of discrete activity and the strength against resistance was also somewhat reduced.

 

 

DISCUSSION

 In the A-test the electrical activity registered in the biceps brachii (antagonist muscle during the maximum extension of the forearm) could not be caused by the will of the subject who is actively trying to obtain the maximum motor Performance. The electrical activity of the biceps could be explained by the tonic-emotional arousal (increase of the gamma tone) linked to the context of struggle during the extension of the forearm which modifies the proprioceptive/exproprioceptive balance necessary for efficient movement. Without an exproprioceptive reference, the subject no longer perceives the reality of the actual context (which includes the external) but only the relationship with the examiner.(a‑test:emotion) Since the two muscles contract together, a Part of the pure extensor activity of the triceps is lost in the conflict with the flexion of the forearm induced by the biceps. In other words, a Part of the potential energy of the triceps has been transformed into caloric, not productive energy (entropy) instead of being used for the movement.

In the B-test the addition of a clear exproprioception before and during the movement ameliorates immediately and often completely the situation in the observed subjects. Clinically the examiner registers the maximum strength of the triceps and the EMG reports the electrical' silence of the biceps. This is due to a better relationship between proprio /ex-proprioception.

  When we introduce the projective and aiming element we suppress or clearly reduce the gamma activity of the biceps, while the triceps becomes wholly constituted from kinetic pure energy . We can say that the ability to project in the space suppresses the unconscious inhibition, the unaware activity that conflicts with the voluntarily programmed action. The relationship is then triangulated for the examinees who feel their arm, face the examiner and relate to the surrounding. This situation brings them to the maximum potential of action (B test : ex-motion).

  In the C-test, the evidence, in most cases, a reactivation in the biceps brachii simultaneously with the reduction of the spatial projection, confirms the influence of the subject's evaluation of the context and the symbolic dimension (conscious and unconscious) an the tensional organization of the shoulder girdle. Over time this situation of poor spatial projection (absence of projects for a part of the body) decreases the sensorial afference stimuli and leads to a structural modification of the related primary sensory cortex's territory. Merzenich et al. (10,11) demonstrated the rapidity of the transformation of these territories in absence of the afferent stimuli. The impoverishment of the sensory cortex then decreases, in its turn, the ability of the motor cortex's retroactive loops linked with the sensory area. The work of these retroactive loops represents, according to Weisendanger (12), 98.5% of motor cortex activity. Thus a vicious circle is formed which can progress as far as the complete disappearance of a motor activity without any evident somatic injury.

  CONCLUSION

 We registered, with EMG, the different potentiality of the muscular activity submitting the subjects to motor resistance in various perceptive/projective tests.

  When we ask the subject to only counteract the examiner we noticed a paradoxal electrical activity in the antagonist muscle which reduced the strength potentiality and brought rapid fatigue. The relationship was only oppositional and dual because of poor ex‑proprioceptive references (emotion).

  Without spatial attention, a weak force was registered. This is due to the emotional situation that elicited a lost of spacial references and an accentuation of the gamma activity increasing the spindle response (modification of the firing point of the stretch reflex by the gamma loop) of the antagonist muscle.

  When we ask the subject to extend the forearm with a directionality and a spatial projection of the hand, we registered the full strength of the agonist muscle, with absence of activity of the antagonist. The action by the exteroceptive and exproprioceptive references became triangulated and therefore potentially maximized (ex‑motion).

  This EMG study helps us to understand why many of the oncological patients that we observed lost some basics movements, like pendular motion of the arm, without clinical explanation. This loss came from the reduced capacity to have movement projects of a part of the body due to the physical and emotional trauma in this part. Over time, the repetition of this situation transforms sensory territory and organization (transformation of the body image) and then motor capacity.

  Our neuro-physiological results emphasize the importance of considering the role of sensory activity in motor rehabilitation; clarify the relationship between the quantity of muscular strength and the quality of the projection in the space (proprioception and emotion / ex-proprioception and ex-motion); calls into question the value of the standard approach of studies using EMG that disregard the importance of the context during clinical evaluation; emphasizes the importance of a program of rehabilitation that gives attention to the patient's emotional / perceptual organization.

   

  REFERENCES

  1. Martino G., Prevenzione e terapia degli esitt. In U. Veronesi (Ed.) : Manuale di senologia oncologica. Miiano: Masson, 1993, pp. 431‑442.

  2. Martino G.,II recupero del paziente oncologico: aspetti psicologici e riabilitativi. In G. Beretta, E. Ghislandi, G. Luporini, A. Scanni (eds.) Atti del XV Corso di Aggiornamento in Oncologia Medica. Milano, 26‑29 giugno 1994. Milano: AIOM, 1994, pp. 439‑443.

  3. Merson M.. Pirovano C., Balzarini A., Luini A., Biasi S., Galimberti V., Genitoni V., MuscoUno G., Veronesi P., The preservation of minor pectoralis muscle in axillary dissection for breast cancer: functional and cosmetic evaluation. Eur.J. Surg. Oncol. 18, 215‑218, 1992.

  4. Godard H., Le geste manquant. In: Revue Internationale de Psychanalyse, Etats corps, Ed. érès, Paris, 5, 1994, pp. 63‑75.

  5. Lee D.N., On the functions of vision. In: H. Pick and E. Saltzman (Eds.): Modes of perceiving. Hillsdale, N.J.: Lawrence Erlbaum Associates, 1978.

  6. Fitch H.L., Tuller B., Turvey M.T., The Bernstein Perspective: III. Tuning of Coordi­native Structures with Special Reference to Perception. In J.A. Scott Kelso(ed.) Human Motor Behaviour: An Introduction. Hillsdale, N.J.: Lawrence Erlbaum Associates,1982.

  7. Damasio A. R., L'erreur de Descartes, Editions Odile Jacob, Paris, 1995.

  8. Edelman G. M., Biologie de la Conscience, Editions Odile Jacob, Paris, 1992

  9. Reed E. S., An Outline of a Theory of Action System, Journal of Motor Behavior, Vol.14 No 2, 98‑134, 1982.

  10. Wall J.T., Kaas J.H., Sur M., Nelson R.J., Felleman ‑D. J. and Merzenich M.M., Functional reorganization in somatosensory cortical areas 3b and 2 of adult monkeys after median nerve repair: possible relationships to sensory recovery in humans. J. Neuroscience 6, 218‑233, 1986.

  11. Merzenich, M.M., Recanzone, G. H., Jenkins, W.M., and Nudo, R.J. How the brain functionally rewires itsef in Arbib, M.A., Robinson,J.A. :Natural and Atipical Parallel Computation Mit‑Press Cambrige* 1990 , pp 177‑210.

  12. Weisendanger M., Contröie cortical des mouvements et régulation par les afférences proprioceptives, Journal de physiologie, Paris, 1976.

  All the Authors have worked (and some are still working) at the Rehabilitation Department of the National Cancer Institute of Milan where for more than twelve years they have worked to ameliorate the quality of life of people with cancer. Hubert Godard directed a seven year training program for the rehabilitation team of the INT on bio-mechanical, functional and symbolic aspects of movement. He led this research which was coordinated by Gemma Martino and financed by the CNRA.C.R.0. n. 92.02361 .

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