Pediatric Dimensions

Research Article ISSN: 2397-950X

Autogenic inhibition versus reciprocal inhibition

techniques on spastic children
Mohamed Serag Eldein Mahgoub Mohamed Mostafa1 and Mohamed Ali Elshafey2
Associate professor Department of Basic Sciences, Faculty of Physical Therapy, Cairo University, Egypt
1

Associate professor Department of physical Therapy for Growth and Developmental Disorders in Children and it is Surgery - Faculty of Physical Therapy, Cairo University, Egypt
2

Abstract
Background: Studying the result of autogenic inhibition versus reciprocal inhibition techniques on the children spasticity is a strategy for determining which of them
is the most actual in reducing spasticity.
Objective: To investigate the efficacy of autogenic inhibition versus reciprocal inhibition on hemiplegic children spasticity.
Design: Pretest-Posttest trial.
Setting: Laboratories of comprehensive rehabilitation center.
Subjects: Forty spastic hemiplegic children of both genders ranged in age from seven to nine years contributed in this study, they were being randomly selected from
comprehensive rehabilitation center and assigned into two groups of equal number (each group 20 child).
Intervention: Group (A) underwent autogenic inhibition technique while group (B) underwent reciprocal inhibition technique.
Measurements: H\M ratio and Muscle Functional Magnetic Resonance Imaging used to assess muscle spasticity for both groups before and after the intervention.
Results: There were significant reduction in H\M ratio for both groups after intervention immediately in favor of group A and significant improvements in Muscle
Functional Magnetic Resonance Imaging for group A while non-significant for group B.
Conclusions: Autogenic inhibition more effective than reciprocal inhibition technique on decreasing hemiplegic children spasticity.

Introduction of Ia reciprocal inhibition is reduced [5] and its regulation during (the
remaining) voluntary movement is more or less eliminated [6].
Autogenic inhibition reflex is a sudden relaxation of muscle upon
the development of high tension. It is a self-induced, inhibitory, While a significant decrease of reciprocal inhibition is seen in spastic
negative feedback prolong lengthen reaction against tear muscles. patients, it has been difficult to correlate the amount of decrease with the
Golgi tendon organs are receptors responsible for that [1]. clinical severity of spasticity. Nevertheless, some long-term studies may
indicate a positive relationship. One group of researchers reported that
Autogenic inhibition (historically known as the inverse myotatic the Ia inhibition returns with clinical recovery [7]. Another longitudinal
reflex or autogenetic inhibition) shows a decrease in the excitability study of stroke patient found that the development of Autogenetic Ib
of a contracting or stretched muscle that in the past has been merely inhibition, or “non-reciprocal group I inhibition,” has been identified
ascribed to the increased inhibitory input arising from Golgi tendon in humans [8,9]. Through willing contraction of the muscle group, the
organs (GTOs) within the same muscle. The reduced efferent (motor) inhibition seems to be reduced [10]. In animal experiments, this has
send to the muscle through autogenic inhibition is a factor that will been proven that during locomotion, there is not just a reduction of
help muscle elongation [1]. the di-/trisynaptic inhibition but also even the appearance of a “new”
locomotor-related Ib excitation [11]. This could not be confirmed
Reciprocal inhibition process recognized as when the muscle “reflex reversal” in experiments on human locomotion. The reports on
spindle, which is placed within the muscle, tummy and stretches changes in Ib inhibition during spasticity are conflicting. Delwaide and
alongside with the muscle itself. When this occurs, the muscle spindle
is activated and causes a reflexive contraction in the agonist’s muscle
(known as the stretch reflex) and relaxation in the antagonist muscle [1,2]. *Correspondence to: Mohamed Serag, Physical Therapy department of
Basic Sciences, Faculty of Physical Therapy, Cairo University, Egypt, E-mail:
Reciprocal inhibition mediated via the muscle spindle Ia afferents
drsergany_79@hotmail.com
from the antagonist’s muscle was identified and investigated in healthy
subjects [3-5]. The reciprocal Ia inhibition is enhanced throughout Key words: autogenic inhibition, reciprocal inhibition, spasticity, h\m ratio, muscle
voluntary activation of the antagonist, e.g. it prevents stretch reflexes functional, magnetic resonance imaging
in the antagonist’s muscle as the muscle is passively stretched. In Received: August 20, 2018; Accepted: September 15, 2018; Published:
spastic patients, in hemiplegia in addition to paraplegia, the quantity September 19, 2018

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 Serag ME (2018) Autogenic inhibition versus reciprocal inhibition techniques on spastic children

Pennisi [12,13] stated that the Ib inhibition is reduced (and can even be Instrumentation
reversed into facilitation), and the decline is associated with the degree
of spasticity. Furthermore, they [13] describe that tizanidine reduces Hanson professional scale was used to measure weight and height
both spasticity and enhances the Ib inhibition. [25]. Electromyography apparatus (A TeleMyo 2400 G2 Telemetry
System, made in the USA) to measure H\M ratio and MRI was
Downes and others [14] could not approve a decrease in Ib performed on a 3-T magnet (Siemens Magnetom Trio a Tim System
inhibition in spasticity and show that the evident differences may with Syngo MR B13. Erlangen Germany).
depend on pathophysiological differences in cerebral and spinal
spasticity. To summarize, the Ib inhibition has not been investigated Procedure
as extensively in relation to spasticity as has reciprocal inhibition and a) Assessment procedures: The assessors were blinded folded to
presynaptic inhibition, and the results are conflicting. It is clear that group allocation.
further investigations, both on the normal function in motor control
and the role in regulating muscle tone following supraspinal and spinal I- weight and height assessment: The weight and height of both
lesions, were warranted. groups were measured by the Hanson professional scale before the
intervention.
Hemiplegia accounts for approximately 30-40% of all people who
are born with cerebral palsy [15,16]. Hemiplegic children had problems II- EMG Studies: H\M ratio for Bicepsbrachii from the upper limb
in proceeding fine motor hand activities and had abnormal upper limb was evaluated by EMG before, immediately after intervention and
posturing during walk and in any activities needed effort [17]. after 2min post intervention on the spastic side of each children. The
technical steps of the electro diagnostic test application EMG including;
Using muscle functional Magnetic Resonance Imaging (mfMRI) electrode placement, skin temperature correction, determination of
in healthy and non-healthy people is an innovative, post-exercise, nerve stimulation intensity and analysis of the evoked neuro- electrical
evaluation method to assess the quantity of metabolic muscle activity response. The system comprises an electronic monitor and a report
by quantifying shifts in T2-relaxation times of muscle water upon
generation system. The archive stores all electrophysiological data
exercise [18,19]. Few studies are available investigating the muscle
including raw waveforms and limited demographic information (age,
performance during activities these studies are solely based on EMG
height, weight and gender). Official clinical staffs that undergo training
measurements therefore Magnetic resonance imaging (MRI) has
by the manufacture typically perform the EMG tests. Each study is coded
the potential to provide a more reliable and objective assessment of
with the primary clinical indication for the (Biceps brachii muscle). For
muscle function than surface EMG [20]. Muscle functional MRI is an
innovative technique that enables investigation of the activity pattern Hoffmann reflex of Biceps brachii muscle. Prior to electrode placement,
of muscles. The method relies on an acute activity-induced increase in the skin on the right upper arm was lightly rubbed with and cleaned
transverse relaxation time (T2) of muscle water [21-23]. This increase with scrubbing alcohol to reduce signal impedance at the skin surface.
in T2 causes an enhancement in signal intensity of activated muscles The motor point was then specified for electrode placement. The
[24]. Despite its widespread use for evaluation of skeletal muscle and motor point is defined as a muscle region in which the lowest possible
soft tissue elsewhere in the body. incentive will produce minimum muscle contraction. The motor point
of the biceps brachii (BB) was located approximately midway between
There is a lack in the literature concerning the effect of autogenetic the glenohumeral joint and the cubital crease. The cathode portion of
inhibition versus reciprocal inhibition on children spasticity. We the stimulating probe was placed in the predictable motor point region.
hypothesize that there was no significant difference on children With the train rate on the stimulator set at 10 pps, and the stimulus
spasticity between autogenetic inhibition and reciprocal inhibition duration set at 1 msec [26], the cathode was moved around belly of
techniques. the muscle to find the motor point. Prior to placing the recording (G2)
and reference (Gl) electrodes, skin impedance was measured (Grass
Subjects, materials and methods
EZM Electrode Impedance Meter, Astro-Med Inc., Warwick, RI) and
Study design maintained below 10 kΩ. The G2 electrode was placed directly above
the motor point of the BB muscle. The Gl electrode was placed on the
The design of the study was pre-test post-test design. The
biceps tendon. Both Gl and G2 were standard size (20 mm diameter)
procedures followed agreed with the Institutional Ethical Committee
Ag/AgCl electrodes (Grass FE9- 40-5, Astro-Med Inc., Warwick, RI).
Clearance (PACTR201801002940240), and written informed consent
On the upper portion of the biceps muscle a self-adhesive ground
was taken from their legal guardians of the children.
electrode was placed, between G2 and the point of stimulation on the
Subjects musculocutaneous nerve. The EMG system (Grass, P511, Astro-Med
Inc., W Warwick, RI) amplified the evoked potentials (1000×) before
This study was conducted in the laboratories of comprehensive
they were band-passed filtered (3–1000 Hz). the biceps brachii H-wave
rehabilitation center. Forty spastic hemiplegic CP children of both sexes
that was recorded by EMG and then stimulation with higher intensities
(22 B -18G) were assigned randomly into two equal groups of equal
to activate axons of alphamotor neurons and M-response was recorded
number (each group 20 child) randomly selected from comprehensive
before placing the electrodes [27].
rehabilitation center according to the following criteria: Their ages
were ranged from 7 to 9 years. They had grade 1 or 1+ according to III- MRI:- MRI-images were obtained under 2 consecutive
modified ashworth scale and grade II or III according to Manual Ability conditions [28]: 1] at rest (T2- rest) after 30min of supine lying, 2]
Classification Scale (MACS), they can understand and follow verbal immediately following exercise to avoid regain the resting metabolic
commands and instructions included in the test. Children’s in Group condition of the muscles. According to Cagnie, et al. [18], a rest period
(A) consisted of 20 children (11 B and 9G) were received autogenetic of 45 min is required, which allows _98% of the T2 shifts to be recovered.
inhibition technique, Children’s in Group (B) consisted of 20 children There were five transaxial slices before and after the intervention,
(9 B and 11 G) were received reciprocal inhibition technique. 5-mm thick with 10-mm space between each slice, including one at

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 Serag ME (2018) Autogenic inhibition versus reciprocal inhibition techniques on spastic children

the proximal half of the muscle (biceps brachii) and two slices above significant difference between groups in gender distribution, spasticity,
and two slices below this point. For T2 calculation, a multi-spin-echo affected side and MACS as Chi-squared value was 0.65, 0.52 and 0.42
sequence was used: repetition time of 2,500 ms; echo times 10–161.6 respectively (P > 0.05).
ms with steps of 10.1 ms (16echos), field of view 256 mm, matrix 128
x128, and voxel size 2 x 2 x 5 mm. Total acquisition time was 5 min, Pretreatment comparison between the two groups
12 s. Imaging procedures were identical for the resting scan and the There was no significant difference between the two groups in all
scan after exercise. T2 increase values, which are known as the change measured variables before intervention (P > 0.05) as illustrated in table 2.
between T2 values at rest and after exercise.
Pre-post treatment comparison for each group
b) Training procedures: I- Group (A): received autogenetic
inhibition technique in form of maximum isometric muscle contraction As illustrated in table 3 there was significance difference for
(MIC) hold for 6 seconds and then relax for 6 seconds for the agonist both groups in H\M ratio when comparing pre and post immediate
muscle (biceps brachii) repeated 5 times using isokinetic dynamometer intervention and immediately and after 2 m of interventions (P < 0.05)
from setting position with the elbow angle constant at 120° during the with no significance difference during comparing Before and after 2
isometric contraction [29,] Rok et al ,2008). H\M ratio was done to m of intervention (P > 0.05).There was significant difference in pre
biceps brachii muscle before, directly after intervention and after 2 min and immediate post intervention comparison in T2 values for biceps
post intervention. MRI done before the intervention at rest and directly brachii musclein-group (A) (P < 0.05), with no significant difference
after intervention. for group (B) (P > 0.05) as illustrated in table 4.
II-Group (B): received reciprocal inhibition technique in form of Comparison between the two groups immediately after
maximum isometric muscle contraction (MIC) hold for 6 seconds and intervention and 2 minutes post interventions
then relax for 6 seconds for the antagonist muscles (Triceps brachii)
repeated 5 times using isokinetic dynamometer from setting position There was a significant difference in favor of group A immediately
with the elbow angle constant at 120° during the isometric contraction after intervention in H\M ratio and T2 values for biceps brachii
[29,30]. H\M ratio was done to biceps brachii muscle before, directly muscle. (P < 0.05) and there was no significant difference between the
after intervention and after 2 min postintervention. MRI done before two groups after 2 minutes of interventions in H\M ratio (P >0.05) as
the intervention at rest and directly after intervention to the biceps illustrated in table 5.
brachii muscle.
Discussion
c) Data management: After scanning, the images were transferred
to a computer for calculation of muscle T2 value using ImageJ, a The result of this study demonstrated that there was a significant
Java-based version of the public domain NIH Image software. USA difference between both groups post intervention in H\M ratio of
(Research Services Branch, National Institutes of Health). Regions spastic muscle in favor of autogenic inhibition technique. This comes
of interest (ROI) were identified on the T2 images: on the base of its in accordance with Herbert M. How stated that during muscular
clearest visualization on the bulkiest area of the muscle. When defining contraction, autogenic inhibition is initiated in parallel (with the motor
a ROI, non-muscular tissue within the ROI, such as fat, fascia, and excitation), via the interneuron’s that are activated by the Golgi tendon
vessels, was avoided. organs (GTO). It appears that when an excessive force is applied to or
exerted by a muscle at varying lengths (extensions), the GTO inhibition
Statistical analysis regulates not only the frequency of discharge but also the range of firing
Descriptive statistics (mean and standard deviation) were of the motor neurons. Inhibition of gamma and alpha motor neurons
computed for all data. Friedman test was conducted to compare the resulting in muscle relaxation [31]. Golgi tendon organs functionally
mean differences in the outcome measures scores within both groups known as B-receptors recording active or passive tension and are
at three occasions (before intervention, immediately after intervention, sensitive to the rate of increase of tension [32].
and after 2minutes of intervention). The post hoc test was used for
In addition, it comes in agreement with Stuart et al., and Goslow
pairwise comparison. The Mann-Whitney U test was conducted to
et al. [33,34] they stated that the functional significance of GTO’s in
compare the mean differences between groups. The level of significance
moment to moment regulatory mechanisms has become increasingly
for all statistical tests was set at P less than 0.05. All statistical analyses
evident [33,34]. Muscular contraction does elicit autogenic postsynaptic
were performed with the Statistical Package for Social Sciences version
20 for windows.
Table 1. Physical characteristics of the subjects at the beginning of the study
Results Group (A) Group (B) Significant
Characteristics
Χ ± SD Χ ± SD (P-value)
Pilot study Age (year) 8.3 ± 0.83 8.6 ± 0.57 0.61**
Before the beginning of the study, pilot study was performed on 15 Weight 27.8 ± 5.4 28.4 ± 3.5 0.55**
RT. Hemiplegic children. Statistical analysis of the pilot study revealed height 120.7 ± 6.2 121.6 ± 4.8 0.46**
that there was no need for control group as there is no intervention Χ : Mean; SD: Standard deviation; p-value: Level of significance; **: Non-significant
and no significance difference for the control group. Power analysis
was initially done for the pilot study to calculate the sample size. These Table 2. Pretreatment comparison between the groups
assumptions created a sample size of fifteen children for each group. Group(A) Group (B)
Variables P-value
Χ ± SD Χ ± SD
Demographic characteristics T2 values for biceps brachii muscle (ms). 41.07 ± 3.17 40.89 ± 3.43 0.45**
H\M ratio 0.77 ± 0.05 0.73 ± 0.08 0.39**
There was no significant difference between the two groups in age
weight and height (P > 0.05) as illustrated in table 1. There was no Χ : Mean SD: standard deviation p-value: level of significance **: non-significant

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 Serag ME (2018) Autogenic inhibition versus reciprocal inhibition techniques on spastic children

Table 3. Pairwise comparison for both groups in H\M ratio immediately after intervention and after 2 m. of intervention
Group (A) Group (B)
Variables Immediately after Immediately after
Before and immediately Before and Before and immediately Before and
interventions and after interventions and after
after intervention after 2 m of intervention after intervention after 2 m of intervention
2 m. 2 m.
H\M ratio 0.001 * 0.015** 0.001** 0.001* 0.21** 0.001**
*: significant; **: non-significant

Table 4. Pre-and immediate after intervention comparison for both groups in T2 values for or even the speed of the task [39-41]. Furthermore, quadriceps undergo
biceps brachii muscle
a varying degree of reflex facilitation and inhibition as the knee moves
Variables Group (A) Group (B) through the gait cycle [42]. Although this finding is interesting from
T2 values for biceps brachii muscle (ms). 0.001* 0.38** a clinical perspective. Clinicians may use RI as a clarification for the
*: significant; **: non-significant. effect of some manual therapy handlings such as some techniques of
muscle energy and PNF. In hypothesizing the mechanism of effect,
Table 5. Post treatment comparison between the two groups immediately after interventions
and 2 minutes post interventions
clinicians should question any presumption that reciprocal inhibition
is equal and opposite between any agonist-antagonist muscle pair
Group(A) Group (B)
Variables P-value during every task [38]. Our data are supported by Neha and Sheila
Χ ± SD Χ ± SD
T2 values for biceps brachii muscle (ms). 48.14 ± 2.96 42.20 ± 2.22 0.001* [43] whom reported that reciprocal inhibition was absent and replaced
H\M ratio (immediately) 0.51 ± 0.06 0.59 ± 0.05 0.001* by reciprocal facilitation in 10 of 15 chronic post-stroke hemiparesis
H\M ratio (2 min post) 0.69 ± 0.05 0.72 ± 0.08 0.61** individuals. Reciprocal facilitation was associated with low Fugl-Meyer
scores and slow walking speeds but not with overactive Achilles tendon
Χ : Mean; SD: standard deviation; P-value: level of significance; *: significant; **: Non- reflexes. Decreased RI is not a constant finding post-stroke and is more
significant relevant related to walking ability and movement impairment than
inhibition in both extensors and flexors [35]. Furthermore, if a to spasticity. Phenomena other than decreased RI may contribute to
motoneuron is not driven by the primaries and the muscle is under post-stroke spasticity. Furthermore our results reinforced by Moore
some tension, an increase in membrane potential may be expected due and Kukulka [44] whom concluded that after voluntary contraction
to autogenic inhibition from the tendon organs [36]. H-reflex amplitudes were strongly depressed (mean maximum decrease
= 83.3%) indicating a reduction in alpha MN reflex excitability, indicate
In the present study, our choice to use autogenic inhibition was that proprioceptive neuromuscular facilitation techniques (eg, hold-
supported by Herbert who reported that the level of force applied to, relax) purported to produce a phase of relaxation following voluntary
or exerted by a muscle, as well as its rate of change, determine the contraction do appear to produce a strong, but brig neuromuscular
discharge frequency of its firing motor units and that of the GTO’s. inhibition that may be clinically useful for applying stretch.
In addition, the thresholds of the interneuron’s in the intermediate
nucleus to natural (tension and stretch/extension) and electrical stimuli The results of this study show that muscle functional MRI was used
suggest that their excitation is dependent on group Ib afferents, which to illustrate the specific activation levels and recruitment patterns of the
is an essential function of GTO recruitment [31]. muscles after contraction. According to the data analysis in the current
study, the results of autogenic inhibition group revealed that there was
Concerning the results of reciprocal inhibition group, the results of a significant increasing of post-intervention in transverse relaxation
our study come in accordance with Gyan and Gerald [37] whom stated time (T2) than reciprocal inhibition group it come in agreement with
that excitation of primary spindle afferent fibers from the gastrocnemius [45] whom concluded that muscle functional MRI can be used to
and soleus muscles may produce a period of electrical silence on both characterize the specific activation levels and recruitment patterns of
homonymous and antagonistic muscle groups. The silence of the the superficial and deep cervical flexors during different cervical flexion
antagonist is due to reciprocal inhibition over neural pathways within exercises. In addition, it come in agreement with Danneels et al. [46].
the spinal cord. The homonymous silence is also initiated by spinal Whom demonstrated that Quantitative T2-images (muscle functional
mechanisms, but the extended duration of this silence is determined by MRI) used to evaluate low back pain on lumbar muscle activities which
mechanical factors of the contracting muscle [37]. concluded that T2-values were significantly higher in the exercise
condition (without pain) compared to the resting condition and T2-
According to the data analysis in the current study, the results
shift was significantly lower in the exercise-with-pain compared to the
of autogenic inhibition group revealed that there was a significant
exercise-without pain condition for all muscles.
reduction of post-intervention muscular spasticity than reciprocal
inhibition group. It comes in agreement with Karen and Caroline [38] The result of this study demonstrated that there was a significant
they concluded that as the results of short-latency inhibition to both difference between both groups post intervention in T2-value MRI
the quadriceps and hamstrings upon stimulation of their respective images in spastic muscle in favor of autogenic inhibition group that
antagonist nerve. Group I afferents seem likely to be responsible for result in increased the T2-values than reciprocal inhibition group, it
the early part of this inhibition suggesting that disynaptic Ia inhibition was supported by Shellock et al [47], who reported that Five subjects
can be evoked to both the quadriceps and hamstrings. In addition, performed exhaustive exercise by doing isolated concentric actions
disynaptic Ia inhibition occurred more regularly and with greater (raising a dumbbell, flexing at the elbow) and eccentric muscle actions
amplitude in the hamstrings compared with the quadriceps, indicating (lowering a dumbbell, extending the contra lateral arm). T2-weighted
that the disynaptic Ia inhibition present in the quadriceps and MR images of the arms were obtained immediately before and after
hamstrings is not equivalent in both directions and is consequently not exercise. Muscles that achieved concentric actions had increases in
actually ‘reciprocal’. Reflexes can be modulated at dissimilar points in signal intensity, whereas muscles that achieved eccentric actions
range and under various conditions such as the degree of contraction, showed little or no change. T2 relaxation times increased significantly

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 Serag ME (2018) Autogenic inhibition versus reciprocal inhibition techniques on spastic children

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Copyright: ©2018 Serag ME. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
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