Thien ngo md pgy 3 uk pm r 5 22 2012 advisors drs lumy sawaki oscar ortiz
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Thien Ngo MD PGY – 3 UK PM&R 5/22/2012 Advisors: Drs. Lumy Sawaki & Oscar Ortiz. Identification of Sural Nociceptive flexion reflex index in adult Males 20-40 years of age. Outline. Introduction Revised proposed objectives from 2011 Method First Set of Result Discussion

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Identification of Sural Nociceptive flexion reflex index in adult Males 20-40 years of age

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Thien ngo md pgy 3 uk pm r 5 22 2012 advisors drs lumy sawaki oscar ortiz

Thien Ngo MD

PGY – 3

UK PM&R

5/22/2012

Advisors: Drs. Lumy Sawaki & Oscar Ortiz

Identification of SuralNociceptive flexion reflex index in adult Males 20-40 years of age


Outline

Outline

  • Introduction

  • Revised proposed objectives from 2011

  • Method

  • First Set of Result

  • Discussion

  • Timeline Revision

  • References


Introduction 1

Introduction 1

  • Pain is a subjective experience, and its measurement has been traditionally based on self reported instruments.

  • Absence of objective instruments

  • Quantitative sensory testing and nociceptive flexion reflex (NFR) threshold have been explored as options to measure pain more objectively


Introduction 2

Introduction 2

  • NFR in theory

    • The NFR is a polysynaptic spinal reflex subserving withdrawal from potentially noxious stimuli.

    • Provide indirect evidence of supraspinal modulation

      • The higher the threshold the more inhibition of spinal nociceptive transmission


Introduction 3

Introduction 3

  • NFR threshold is defined by the lowest noxious stimulation intensity required to trigger a reflex motor response in the biceps femoris muscle.


Introduction 4

Introduction 4

Central hyperexcitability as measured with nociceptive flexor reflex threshold in chronic musculoskeletal pain: a systematic review.

Lim EC, Sterling M, Stone A, Vicenzino B.

Pain. 2011 Aug;152(8):1811-20. Epub 2011 Apr 27


Introduction 5

Introduction 5

  • Promising results in multiples experimental studies.

    • Reliable, reproducible, and correlated well with clinical findings within subjects

    • Significant variability between subjects, despite efforts for standardization, makes it unsuitable for clinical use or establishment of normal values.


Introduction 6

Introduction 6

Sural SNAP amplitude using NFRT stimulus

NFRI =

x 100

Sural SNAP amplitude (supramaximal)

  • Propose alternative standardized method to measure NFR that avoid variability (mostly due to changes in skin resistance).


Objectives

Objectives

  • The goal of this pilot study is to begin to establish normative data of NFRI in young male adults. Our proposed study has 2 specific aims:

  • Specific Aim #1:Identify the suralnociceptive flexion reflex threshold (NRFT) and the suralnociceptive flexion reflex index (NFRI) in male adults of 20 to 40 years of age.

  • Specific Aim #2:Measure the correlation between the NFRI and level of pain as measured by Visual Analogue Scale (VAS).


Experimental design

Experimental Design

  • Recruitment: Flyers and volunteer subjects

  • Screening process and informed consent

  • Inclusion Criteria:

    • Healthy male 20-40

  • Exclusion Criteria:

    • Avoiding confounding factors of NFR and NFRT recording

      • Head injury, alcohol/drug abuse, psychiatric illness, on psychiatric/pain medications, neurological disorder, chronic pain, h/o cancer, and peripheral neuropathy


Method step 1 sural sensory nerve action potential

Method (Step 1) (Sural sensory nerve action potential)


Emg machine

EMG Machine


Method step 2 nociceptive flexion reflex

Method (Step 2) (Nociceptive Flexion Reflex)


Emg machine biceps femoris reflex

EMG machine - Biceps Femoris Reflex


Method step 3 nociceptive flexion reflex index

Method (Step 3) Nociceptive Flexion Reflex Index


Emg machine nrfi

EMG machine – NRFI


First set of result

First Set of Result

  • SNAP – 28 mAmp

  • NFR – 28 mAmp

  • NFR Index – 100%

  • VAS - 45 mm (range 0-100 mm)


Future outlook

Future outlook:

Timeline

- June 2012 – May 2013: recruiting and obtaining ten sets of data

- June 2012 – May 2013: will compare with VA research for age group of 40-60

- May 2013

- Present comparison between the two population


References

References

  • 1.) Giorgio, S. et al. “The lower limb flexion reflex in humans”. (2005) Progress in Neurobiology 77: 353-395.

  • 2.) Rhudy, J. & France, C. “Defining the nociceptive flexion reflex (NFR) threshold in human participants: A comparison of different scoring criteria”. (2007) Pain 128: 244-253.

  • 3.) France, C. et al. “Using normalized EMG to define the nociceptive flexion reflex (NFR) threshold: Further evaluation of standardized NFR scoring criteria”. (2009) Pain 145: 211-218.

  • 4.) Terry, E. et al. “Standardizing procedures to study sensitization of human spinal nociceptiveprocesses: Comparing parameters for temporal summation of the nociceptiveflexionreflex (TS-NFR)”. (2011) International Journal of Psychophysiology 81: 263-274.

  • 5.) Micalos, P. et al. “Reliability of the nociceptive flexor reflex (RIII) threshold and association with Pain threshold”. (2009) Eur J ApplPhysio 105: 55-62.


Thank you

Thank you!


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