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Cutaneous reflex in human locomotion

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Cutaneous, superficial,[1] or skin reflexes, are activated by skin receptors and play a valuable role in
locomotion, providing quick responses to unexpected environmental challenges. They have been
shown to be important in responses to obstacles or stumbling, in preparing for visually challenging
terrain, and for assistance in making adjustments when instability is introduced. In addition to the role
in normal locomotion, cutaneous reflexes are being studied for their potential in enhancing
rehabilitation therapy (physiotherapy) for people with gait abnormalities.

Contents

Background of reflex pathway

General reflex pathways

Cutaneous receptors and reflexes

Functional role
Superficial fibular nerve (SF) Tripping Activates Cutaneous
Reflex
Tibial nerve (TN)

Sural nerve (SN)

Superficial radial nerve (SR)

Additional variables modulating cutaneous reflex response

Complexity or challenge of the task

Potential clinical applications of cutaneous reflex modulation Quick responses to obstacles

External links

References

Background of reflex pathway

Reflexes are a vital part of our everyday activities. We have all experienced how fast and automatic
these responses to environmental interactions can be. They can protect us from potentially dangerous
situations such as touching a hot stove or stepping on a tack. There are also reflex pathways involved
in more dynamic activities such as walking and running, helping to ensure a smooth gait and allowing
us to respond quickly to obstacles or unexpected perturbations or disturbances.

The reflex pathway (reflex arc) is a sequence of neurons connecting the

sensory input (afferent neuron) to the motor output (efferent neuron),
resulting in a behavioral response. The general pathway of a spinal
reflex is one which involves neurons contained within the spinal cord.
However, the brain may also provide additional (supraspinal)
contributions, which can modulate the responsiveness of the reflex to
Pathway of a Monosynaptic Reflex
the sensory input.

General reflex pathways

Reflexes can be very simple, as in the

monosynaptic reflex, which only contains one
synapse, or more complicated, as in the
polysynaptic reflex, which involves more than
one synapse. The knee jerk reflex is a common
example of a monosynaptic reflex when one is
looking at the quadriceps motor response of kicking your leg out. It can also be used as an example of
a polysynaptic reflex when looking at the involvement of inhibitory interneurons to relax the
hamstrings. The complexity of the reflex can be estimated by examining the time delay, or latency,
between the electrical stimulation of the sensory neuron and the corresponding motor response, as
measured by EMG (electromyography). Most reflexes can be categorized in one of three groups
depending on the latency of EMG response. The short-latency reflex (SLR) is the fastest (~40-50 ms)
and involves a mono-synaptic pathway. The medium-latency reflex (MLR) utilizes interneurons within
the spinal cord and is typically ~80-90 ms. The long-latency reflex (LLR) is ~120-140 ms, suggesting
that it is mediated by additional supraspinal input from the brain.[2]

Cutaneous receptors and reflexes

Cutaneous receptors are a type of sensory receptor, which respond to stimuli (touch, pressure, pain,
temperature) that provide information regarding contact with the external environment. A common
reflex involving cutaneous receptors is the crossed extensor reflex. This reflex is recruited when we
experience a painful stimulus on the bottom of our foot, such as stepping on a tack. The response is to
quickly pull the foot that stepped on the tack away, and at the same time, shift our weight to the
opposite (contralateral) leg for balance.

It has been noted that the muscle activation response to cutaneous receptor stimulation can be
modulated by a variety of factors. These include the:

cutaneous nerve stimulated

phase of the gait cycle

intensity of the stimulation

nature of the task being performed

rhythmic arm or leg movements

complexity of the task.

In addition to modulation, the cutaneous reflex has been shown to evoke both a MLR (medium latency
response) and LLR (long latency response) EMG response, indicating that it is a polysynaptic reflex,
involving spinal interneurons or supraspinal pathways[3]

Functional role

The cutaneous reflex has been attributed to functional responses

Cutaneous nerves
[4] to disturbances encountered during locomotion and is, therefore,

dependent on which cutaneous nerve is stimulated. Examples of

nerves whose cutaneous branches have been examined are the:

1. Superficial fibular nerve or peroneal nerve (innervating the dorsal

aspect of the foot) 2. Tibial nerve (innervating the plantar surface of
the foot)3. Sural nerve (innervating the lateral portion of the foot)4.
Superficial branch of radial nerve (innervating forearm and hand on General surface location for activation
of three cutaneous receptors
the thumb side)

Stance and swing phase of a gait cycle

Human locomotion is often examined from the perspective of the gait cycle. Cutaneous reflexes
demonstrate variations in the muscles activated and the timing at which they are activated depending
on which portion of the gait cycle the stimulation occurs. This variation suggests a functional role for
the reflex to provide us with a smooth gait alteration when encountering or anticipating obstacles and
challenging terrain. The major muscles impacted involve four (4) motions important to locomotion:

Typical muscle Thigh muscles responding to

Muscle measured cutaneous reflex
Leg Motion
Group
for EMG activity

Knee flexion Hamstrings Biceps femoris

Knee extension Quadriceps Vastus lateralis

Gastrocnemius or
Ankle plantar flexion (pointing Calf
toes) muscles Soleus

Ankle dorsiflexion (raising toes

Shin muscle Tibialis anterior
up)

Superficial fibular nerve (SF)

Cutaneous stimulation of the superficial fibular nerve (SF) would

typically occur when the top of the foot encounters an obstacle.
The reflexive response to this activation is to pull the leg up and Vastus lateralis Biceps femoris (knee
over the obstacle, while also preparing for a possible stumble or (knee extensor) flexor)

fall. Observed EMG muscle responses to SF stimulation help to

Lower leg muscles responding
explain how this reflexive response is accomplished:
to cutaneous reflex
Increased biceps femoris activity flexes the knee, pulling the leg up
and over the obstacle.

Decreased tibialis anterior activity allows the gastrocnemius to more

completely plantar flex, or point the toe. This allows the foot to slide
over the obstacle.

Increased vastus lateralis activity produces a co-contraction of the

hamstrings and quadriceps, which provides increased knee stability
in case of a stumble or fall.[5]

Tibial nerve (TN)

Tibial nerve (TN) stimulation demonstrates a phase dependent

response, in which the muscle activation varies depending on what
part of the gait cycle a person is in when the stimulation occurs.

1. In normal, unimpeded walking, TN activation during the transition

from stance to swing should decrease as the foot begins to leave
the ground. In this case, increased TN stimulation would suggest Tibialis anterior Gastrocnemius
(dorsiflexor) (plantar flexor)
scuffing of the bottom of the foot along the ground. The reflexive
response will bring the foot up, pulling it off the ground. EMG responses to stimulation, again, help to
explain how this is accomplished.

Increased tibialis anterior activity produces dorsiflexion, raising the foot off the ground.

2. TN activation during late swing in normal walking should begin to increase as the foot begins to
contact the ground. TN stimulation during this phase is, therefore, similar to a normal gait pattern
sensory input. In this situation, the foot will plantar flex to allow smooth placement for the transition to
the stance phase. Here, the opposite EMG effect is observed.

Decreased tibialis anterior activity reduces active dorsiflexion, allowing the ankle to achieve greater
plantar flexion.[6]

Sural nerve (SN)

Sural nerve (SN) stimulation results in a reflex that is both phase and intensity dependent. The sural
nerve innervates the lateral (outside) portion of the foot and could be activated during either the swing
or stance phase when encountering uneven terrain. The intensity dependent response is indicative of
the level of activation and, therefore, the potential for harm.

1. During the swing phase, SN stimulation indicates encountering an obstacle on the lateral side of
the foot. The reaction is to move the foot inward and the leg up, out of the way. Observed EMG
responses are:

Increased tibialis anterior activity to cause dorsiflexion and inversion (turning the foot inward) of the foot.

Increased biceps femoris activity will cause knee flexion to raise the foot higher and away from the
obstacle.

Decreased vastus lateralis activity will increase the ability for the biceps femoris to flex the knee to pull it
up.

2. During the stance phase, a moderate intensity SN stimulation is indicative of uneven terrain and
will result in a response that provides stiffness and stability to the ankle. The mechanism for this
response is accomplished through the simultaneous activation of two antagonistic ankle muscles

Increased gastrocnemius and tibialis anterior activity will provide stiffness to the ankle joint, helping to
prevent the spraining of the ankle.

3. During the stance phase, a high intensity SN stimulation is indicative of an obstacle that could
potentially cause physical damage to the foot. In this case, the goal of the reflex would be to remove
the foot completely away from the stimulus.

Decreased activity of the gastrocnemius will allow for a more complete dorsiflexion and inversion by the
tibialis anterior pulling the foot both up and inward, preventing the foot from staying in contact with the
potentially damaging surface.[7]

Superficial radial nerve (SR)

Cutaneous stimulation of the superficial radial nerve (located on the thumb side of the
forearm) will evoke a cutaneous reflex in arm muscles during rhythmic arm movements in a
manner similar to that observed with leg muscles during locomotion. In addition to its role in
reflex responses to the arm itself, it will modulate leg muscle cutaneous reflexes during
locomotion.[8] This reflexive response may be a vestigial remnant from our quadruped
ancestry, connecting forelimb movement with hindlimb movement.[9] This connection can be seen
with normal walking, when the arm swings in rhythm with the opposite leg. The crossed synchrony
may be partially due to a shared neural pathway between upper and lower limbs. While the function of
this coordinated movement may be involved in maintaining balance while shifting our center of mass, it
is also involved in locomotive reflexes. Stimulation of the radial nerve during walking is unusual and
often indicative of an obstacle that is high enough to make contact with the swinging arm. Concurrent,
or simultaneous stimulation of both the superficial fibular nerve (top of the foot) and the superficial
radial nerve of the opposite (contralateral) arm suggests that the obstacle is large enough to cause a
major stumble or fall. The response is, therefore, one which activates the leg muscles in a way as to
prepare for that possibility. EMG responses to this type of simultaneous stimulation involves significant
changes in the leg opposite or (contralateral) to the side receiving the radial simulation:

Increased activity of the contralateral tibialis anterior and contralateral vastus lateralis to provide
additional stiffness and stability to the leg.

Additional variables modulating cutaneous reflex response

The magnitude of the cutaneous reflex in leg muscles can be altered by multiple variables. The
alterations are movement dependent, gait phase dependent, and can be either excitatory or inhibitory
to the normal cutaneous reflex pattern.

Complexity or challenge of the task

Cutaneous reflexes are modulated in conditions which present instability or challenging locomotive
movements. In unstable conditions, such as disturbances occurring when the arms are crossed, there
is facilitation or amplification in both the ipsilateral and contralateral reflexes which are muscle
specific.[10] With superficial fibular nerve stimulation, the ipsilateral biceps femoris (knee flexor) and
ipsilateral soleus (plantar flexor) reflexes are amplified during swing to allow the leg to clear the
obstacle. In contrast, the contralateral, opposite, leg demonstrates amplification of both the tibialis
anterior (dorsiflexor) and the gastrocnemius (plantar flexor) providing additional leg stiffness for
stability of the stance leg.

Similar amplification results are seen in both visually challenging environments, such as horizontal
ladder stepping,[11] and backward walking.[12] These situations demonstrate facilitation of the
contralateral reflexes during the stance phase to in a manner which would provide stability and
ipsilateral reflex modulation in a way to allow smooth transition past the perceived obstacle.

Potential clinical applications of cutaneous reflex modulation

The ability to modulate the magnitude of cutaneous reflexes via rhythmic arm movements or
challenging environments has potential implications in rehabilitation for patients with motor weakness.
Some stroke patients with lower limb complications demonstrate reduced or blunted cutaneous
reflexes. These lower limb reflexes can be amplified with superficial radial nerve stimulation by taking
advantage of the interlimb reflex observed during rhythmic arm locomotion between the upper and
lower limbs. The amplification of the contralateral tibialis anterior seen during the swing to stance
transition may be clinically useful in preventing foot drop during the swing phase for stroke
patients.[13] Future research is needed to further explore the efficacy of cutaneous reflex amplification
for as a tool for enhancing motor receptivity with stroke rehabilitation.

External links

Video example of the Stumble Response in NYC

Gait Analysis

Interlimb Coordination of Locomotion

Upper limb reflexes in rehabilitation

Visual Input and Locomotive Coordination

References

1. ^ "Reflexes" . Physiopedia. Retrieved 2022-10-06.
2. ^ Scholz, E., Diener, H. C., Noth, J., Friedemann, H.,
Dichgans, J., & Bacher, M. (1987). Medium and long
latency EMG responses in leg muscles: Parkinson's
disease. Journal of Neurology, Neurosurgery, and
Psychiatry, 50(1), 66-70.
3. ^ Nakajima, T., Barss, T., Klarner, T., Komiyama, T.,
& Zehr, E. P. (2013). Amplification of interlimb
reflexes evoked by stimulating the hand
simultaneously with conditioning from the foot
during locomotion. Bmc Neuroscience, 14.
7. ^ Zehr, E. P., Stein, R. B., & Komiyama, T. (1998).
Function of sural nerve reflexes during human
walking. Journal of Physiology-London, 507(1),
305-314.
8. ^ de Kam, D., Rijken, H., Manintveld, T., Nienhuis,
B., Dietz, V., & Duysens, J. (2013). Arm movements
can increase leg muscle activity during submaximal
recumbent stepping in neurologically intact
individuals. Journal of Applied Physiology, 115(1),
34-42.
9. ^ Nakajima

4. ^ Zehr, E. P., Komiyama, T., & Stein, R. B. (1997).
Cutaneous reflexes during human gait:
Electromyographic and kinematic responses to
electrical stimulation. Journal of Neurophysiology,
77(6), 3311-3325.
5. ^ Zehr, E. P., Komiyama, T., & Stein, R. B. (1997).
Cutaneous reflexes during human gait:
Electromyographic and kinematic responses to
electrical stimulation. Journal of Neurophysiology,
77(6), 3311-3325.
6. ^ Zehr, E. P., Komiyama, T., & Stein, R. B. (1997).
Cutaneous reflexes during human gait:
Electromyographic and kinematic responses to
electrical stimulation. Journal of Neurophysiology,
77(6), 3311-3325.
10. ^ Lamont, E. V., & Zehr, E. P. (2007). Earth-
referenced handrail contact facilitates interlimb
cutaneous reflexes during locomotion. Journal of
Neurophysiology, 98(1), 433-442.
11. ^ Ruff, C. R., Miller, A. B., Delva, M. L., Lajoie, K., &
Marigold, D. S. (2014). Modification of cutaneous
reflexes during visually guided walking. Journal of
Neurophysiology, 111(2), 379-393.
12. ^ Hoogkamer, W., Massaad, F., Jansen, K., Bruijn,
S. M., & Duysens, J. (2012). Selective bilateral
activation of leg muscles after cutaneous nerve
stimulation during backward walking. Journal of
Neurophysiology, 108(7), 1933-1941.
13. ^ Zehr, E. P., & Loadman, P. M. (2012). Persistence
of locomotor-related interlimb reflex networks
during walking after stroke. Clinical
Neurophysiology, 123(4), 796-807.

Last edited on 18 November 2022, at 05:52

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