Cortical Motor Threshold Research Articles

The cutaneous silent period as a measure of upper motor neuron dysfunction in amyotrophic lateral sclerosis

ObjectivesWe investigated the cutaneous silent period (CutSP) as a measure of upper motor neuron (UMN) dysfunction in amyotrophic lateral sclerosis. MethodsThe onset latency, duration, and amount of EMG suppression of the CutSP were compared with clinical UMN signs in 24 patients with amyotrophic lateral sclerosis (ALS). UMN signs were quantified using a clinical index and transcranial magnetic stimulation (TMS). Central motor conduction time (CMCT), cortical motor threshold and motor evoked potential amplitudes were assessed as measures of UMN dysfunction. CutSP was studied in abductor digit minimi (ADM) and tibialis anterior (TA) EMG recordings following stimulation of the 5th finger and sural nerves respectively. Non-parametric tests and binomial logistic regression were applied to evaluate the data. ResultsCutSP onset latency was increased in ALS patients, compared to healthy controls, both for ADM and TA muscles. In limbs with clinical UMN signs or abnormal TMS findings, the CutSP onset latency was particularly increased. There was a significant positive correlation between CutSP onset latency and the UMN score in both upper and lower limbs. In TA muscles there was also a negative correlation between CutSP onset latency and EMG suppression. The logistic regression model based on CutSP parameters correctly classified more than 70% of the cases regarding the presence of clinical signs of UMN lesion, in both upper and lower limbs. The results were not significant for TMS. ConclusionWe conclude that upper limb CutSP changes associates with UMN lesion in ALS. This neurophysiological measurement merits further investigation in ALS.

Evaluation of the effect of low-intensity rhythmic transcranial magnetic stimulation on motor and non-motor manifestations of Parkinson's disease

BACKGROUND: The use of repetitive transcranial magnetic stimulation as a method of non-drug therapy of Parkinson's disease has been actively studied over the past decades. The prevailing number of repetitive transcranial magnetic stimulation protocols in Parkinson's disease use a high intensity of stimulation (80120% of the value of the threshold of the evoked motor threshold from the muscles of the hand), while the choice of the stimulation intensity parameter was carried out empirically.
 AIM: to study the effectiveness of low-intensity unilateral repetitive transcranial magnetic stimulation on motor and non-motor symptoms of Parkinson's disease.
 MATERIAL AND METHODS:An open prospective non-randomized clinical trial included 37 patients with stage IIII Parkinson's disease according to HoehnYahr (1967), akinetic-rigid and mixed (akinetic-rigid-tremor) forms. All patients underwent repetitive transcranial magnetic stimulation according to the protocol: M1 stimulation zone, frequency 5 Hz, intensity 40% of the cortical motor threshold, on 6s, off 8s, total number of pulses per session 3000. The course of treatment is 10 procedures with 2 days (weekend) off.
 RESULTS: All patients completed the study in accordance with the protocol. When analyzing the results of the UPDRS scale (Unified Parkinson's disease rating scale), positive dynamics was noted in all parts of the questionnaire: part I ― from 2 (0; 3) to 0 (0; 1) points, p 0.05; part II ― from 9 (5.5; 12.5) to 4 (2; 6.5) points, p 0.05; part III ― with 11 (7; 14.5) to 6 (2; 7.5) points, p 0.05; part IV (Schwab and England scale) ― from 80% (70; 95) to 90% (85; 100), p 0.05. There was also a selective effect on non-motor symptoms.
 CONCLUSION: Low-intensity exposure (40% of the motor threshold) has a significant clinical effect on motor and non-motor symptoms of Parkinson's disease; stimulation of the primary motor cortex can have an antidepressant effect; repetitive transcranial magnetic stimulation has a selective effect on non-motor symptoms of Parkinson's disease: a predominant effect has been demonstrated with respect to olfactory, emotional, cognitive disorders, sleep disorders and hypersalivation; when assessing the dynamics of motor disorders, a more pronounced effect was noted with respect to rigidity, postural disorders, walking speed, and to a lesser extent, the effect on tremor was noted.

Evaluation and Utility of Submaximal Stimulation Intensity in Transcranial Magnetic Stimulation in the Standing Horse☆

Transcranial magnetic stimulation (TMS) has been successfully used in horses to evaluate function and integrity of descending motor pathways in patients affected by neurological gait abnormalities. In preceding studies, lengthening latency times (LT) of cranially evoked limb muscle potentials have been considered a reliable diagnostic parameter. Standardized settings use device output signal intensities of 100%. The aim of this study was to determine the effect of submaximal stimulation intensities (SI) and to determine the minimum coil output necessary to evoke motor unit potentials. As an additional effect, lower stimulation intensities are supposed to decrease sensory irritation of the equine patient. Altogether, 36 neurologically healthy horses underwent TMS under sedation with a dome coil at stimulation intensities varying from 40% to 100% of device output intensity. Motor potentials were recorded by surface electrodes from all four limbs and LT was calculated in milliseconds. To further refine the stimulation settings, cortical motor thresholds (CMT) were assessed in triplets, using IFCN recommendations. The electromyographic recordings were evaluated in 30 horses. Increasing stimulation intensities resulted in significant (P < .05) LT shortening until application of 80% of maximal output intensity. Further increase to maximal SI of 100%, brought up no significant differences (P > .05). Gating effects were excluded as there was no difference of LT upon ascending and descending SI changes (P > .05). CMT revealed a large inter-individual variability amongst horses independent of their body size. There was a strong linearity in between CMT and LT even within submaximal SI ranges (P < .001). The inverse impact of SI on LT may be explained by deeper penetration of the magnetic field, circumvention of interposed neurons and subsequent activation of fast acting motor pathways. However, in warmblood horses a stimulation intensity of 80% coil output already appeared sufficient for reproducible activation of lower motor neurons in all limbs. Furthermore, due to the strong linear correlation of CMT and LT, the tested CMT algorithms may be used to estimate the normal LT on submaximal stimulation for equine myelopathy patients in future.

Are there differences in cortical excitability between akinetic-rigid and tremor-dominant subtypes of Parkinson's disease?

ObjectiveTo assess by transcranial magnetic stimulation (TMS) the excitability of various cortical circuits in akinetic-rigid and tremor-dominant subtypes of Parkinson's disease (PD). MethodsThe study included 92 patients with PD according to UK Brain Bank criteria, with akinetic-rigid (n = 64) or tremor-dominant (n = 28) subtype. Cortical excitability study, including resting and active motor thresholds (rMT and aMT), input—output curve of motor evoked potentials, contralateral and ipsilateral silent periods (cSP and iSP), short and long-interval intracortical inhibition (SICI and LICI), and intracortical facilitation (ICF) were measured. The results obtained were compared to a control group of 30 age- and sex-matched healthy subjects. ResultsThe patients in the tremor group had significantly lower rMT and aMT compared to controls and akinetic-rigid patients and significantly shorter iSP duration compared to akinetic-rigid patients, while iSP latency tended to be longer in akinetic-rigid patients compared to controls. There were no significant differences between the two PD subgroups regarding other cortical excitability parameters, including paired-pulse TMS parameters. ConclusionsOnly subtle differences of cortical excitability were found between patients with akinetic-rigid vs. tremor-dominant subtype of PD. SignificanceThe clinical heterogeneity of PD patients probably has an impact on cortical excitability measures, far beyond the akinetic-rigid versus tremor-dominant profile.

Characterizing and minimizing the contribution of sensory inputs to TMS-evoked potentials

BackgroundTranscranial magnetic stimulation (TMS) evokes voltage deflections in electroencephalographic (EEG) recordings, known as TMS-evoked potentials (TEPs), which are increasingly used to study brain dynamics. However, the extent to which TEPs reflect activity directly evoked by magnetic rather than sensory stimulation is unclear. ObjectiveTo characterize and minimize the contribution of sensory inputs to TEPs. MethodsTwenty-four healthy participants received TMS over the motor cortex using two different intensities (below and above cortical motor threshold) and waveforms (monophasic, biphasic). TMS was also applied over the shoulder as a multisensory control condition. Common sensory attenuation measures, including coil padding and noise masking, were adopted. We examined spatiotemporal relationships between the EEG responses to the scalp and shoulder stimulations at sensor and source levels. Furthermore, we compared three different filters (independent component analysis, signal-space projection with source informed reconstruction (SSP-SIR) and linear regression) designed to attenuate the impact of sensory inputs on TEPs. ResultsThe responses to the scalp and shoulder stimulations were correlated in both temporal and spatial domains, especially after ∼60 ms, regardless of the intensity and stimuli waveform. Among the three filters, SSP-SIR showed the best trade-off between removing sensoryrelated signals while preserving data not related to the control condition. ConclusionsThe findings demonstrate that TEPs elicited by motor cortex TMS reflect a combination of transcranially and peripherally evoked brain responses despite adopting sensory attenuation methods during experiments, thereby highlighting the importance of adopting sensory control conditions in TMS-EEG studies. Offline filters may help to isolate the transcranial component of the TEP from its peripheral component, but only if these components express different spatiotemporal patterns. More realistic control conditions may help to improve the characterization and attenuation of sensory inputs to TEPs, especially in early responses.

Changes in Spinal and Corticospinal Excitability in Patients with Chronic Ankle Instability: A Systematic Review with Meta-Analysis.

The objective of this systematic review with meta-analysis was to determine alterations in spinal and corticospinal excitability of ankle muscles in patients with chronic ankle instability (CAI) compared to uninjured controls. Independent researchers performed comprehensive literature searches of electronic databases and included studies that compared groups with and without CAI and investigated neural excitability with Hoffmann reflex (H-reflex) and/or transcranial magnetic stimulation (TMS). A fixed-effect meta-analysis was conducted to determine group differences for (1) soleus and fibularis maximal H-reflex (Hmax)/maximal M-wave (Mmax)-ratios, and (2) soleus and fibularis longus cortical motor thresholds (CMTs). Seventeen studies were included in the current meta-analysis. They showed that the Hmax/Mmax-ratios of the soleus and the fibularis longus in the CAI group were significantly lower than those in the uninjured control group (soleus: d = −0.41, p < 0.001; fibularis longus: d = −0.27, p = 0.04). There was no evidence for changes in the CMT. This systematic review is the first to demonstrate evidence that patients with CAI present decreased spinal reflex excitability in the soleus and fibularis longus. However, there is no evidence of changes in supraspinal excitability when considering only the CMT. The latter result needs to be interpreted with caution as all except one study demonstrate some changes at the supraspinal level with CAI.

Cortical motor threshold determination in dogs

In humans, determining the cortical motor threshold (CMT) is a critical step in successfully applying a transcranial magnetic stimulation (TMS) treatment. Stimulus intensity, safety and efficacy of a TMS treatment are dependent of the correct assessment of the CMT. Given that TMS in dogs could serve as a natural animal model, an accurate and reliable technique for the measurement of the CMT should be available for dogs. Using a visual descending staircase paradigm (Rossini paradigm), the CMT repeatability was assessed and compared to the electromyographic (EMG) variant. The influence of a HF-rTMS treatment on the CMT was examined. Subsequently, the CMT was measured under sedation and general anaesthesia. Finally, the coil-cortex distance was associated with the CMT, weight, age and gender. During one year the CMT was measured three times, during which it remained constant, although a higher CMT was measured (40% higher machine output) when using EMG (P-value < .001) and under general anaesthesia (P-value = .005). On average, a 40% and 12% higher machine output were registered. An aHF-rTMS protocol does not influence the CMT. Males have on average a 5.2 mm larger coil cortex distance and an 11.81% higher CMT. The CMT was positively linearly associated (P-value < .05) with the weight and age of the animals. Only within female subjects, a positive linear association was found between the CMT and the coil-cortex distance (P-value = .02). Using the visual Rossini paradigm, the CMT can be reliably used over time and during a TMS treatment. It has to be kept in mind that when using EMG or assessing the CMT under general anaesthesia, a higher CMT is to be expected. As in humans, every parameter that influences the coil-cortex distance may also influence the CMT.

Effect of repetitive transcranial magnetic stimulation on action myoclonus: A pilot study in patients with EPM1

ObjectiveThe objective of this study was to explore the short-term effects of repetitive transcranial magnetic stimulation (rTMS) on action myoclonus. MethodsNine patients with Unverricht–Lundborg (EPM1) progressive myoclonus epilepsy type underwent two series of 500 stimuli at 0.3Hz through round coil twice a day for five consecutive days. Clinical and neurophysiological examinations were performed two hours before starting the first rTMS session and two hours after the end of the last rTMS session. ResultsEight patients completed the protocol; one discontinued because of a transient increase in spontaneous jerks. The unified myoclonus rating scale indicated a 25% reduction in posttreatment myoclonus with action score associated with an increase in the cortical motor threshold and lengthening of the cortical silent period (CSP). The decrease in the myoclonus with action scores correlated with the prolongation of CSP. ConclusionsRepetitive transcranial magnetic stimulation can be safely used in patients with EPM1, improves action myoclonus, and partially restores deficient cortical inhibition.

Anatomical and functional correlates of cortical motor threshold of the dominant hand

BackgroundResting Motor threshold (rMT) provides information about cortical motor excitability. Interestingly, the influences of the structural or functional variability of the motor system on the rMT inter-individual variability have been poorly investigated. Objective/hypothesisTo investigate relationships between rMT and measures of brain structures and function of the motor system. The hypothesis is that cortical excitability not only depends on the primary motor cortex (M1) but also on the integration of information originating from its vicinity such as premotor (PMd and SMA) and post-central (S1) cortices. MethodsWe measured brain structures, including grey and white matter properties (cortical volume and fiber coherence respectively), and functional interaction (resting-state functional connectivity-FC) in areas contributing to the corticospinal tract axons, i. e, M1, S1, SMA and PMd in the dominant hemisphere of 21 healthy subjects. ResultsThe rMT was inversely correlated with the FC between PMd and M1 (r = −0.496, 95%CI: −0.764; −0.081; p = 0.02) and the grey matter volume of the dominant hemisphere (r = −0.463, 95%CI: −0.746; −0.039; p = 0.03). The multiple regression analysis model retained the FC between M1 and PMd (coefficient: −25 ± 9) as well as the grey matter volume of the dominant hemisphere (coefficient: −0.15 ± 0.06) explaining 44% of the variance of the rMT (p: 0.005). When adding age and coil-to-cortex distance, two factors known to influence rMT, the model reached a R2 of 75% (p: 0.0001). ConclusionsThese results underline the major role of the PMd and the cortico-cortical connections toward M1 in the excitation of the corticospinal fibers likely through trans-synaptic pathways.

33. Special characteristics of cortical motor mapping in children

Direct Cortical Stimulation (DCS) for motor mapping and monitoring has special characteristics in children. Several physiological, pathological, and pharmacological factors determine higher cortical motor thresholds (CMT) in this population. It is known that physiological CMT to electrical or magnetic stimulation progressively decrease from the first months of life reaching adult values at about the age of 18 years. Certain pathological conditions such as errors in neuronal migration, dysembryoplastic neuroepithelial tumor, cortical dysplasia, and retro-rolandic low grade glioma may further increase CMT. In addition, some antiepileptic drugs, especially those blocking voltage-dependent Na+ channels also decrease cortical excitability. Despite these difficulties, in our experience DCS was successful in mapping the motor cortex in 34 out of 34 surgeries in 32 children aged 3–17 years old. Under total intravenous anesthesia (propofol plus remifentanil) and employing five-stimulus anodic trains with inter-stimulus intervals of 2–3 ms, DCS intensities needed to evoke limb- or face-muscle responses ranged from 20 to 85 mA. Although these intensities are higher than those reported in adult patients, they remained within safety limits (5.95 uC/ph) and did not exert seizures in any case. Atypical somatotopic representation due to anatomical distortion or cortical reorganization was also found in some patients.

The role of transcranial magnetic stimulation in evaluation of motor cortex excitability in Rett syndrome.

Rett syndrome (RTT) is a frequent neurodevelopmental disorder confirmed by clinical criteria and supported by the methyl-CpG-binding protein 2 gene (MECP2) mutation. A short central motor conduction time (CMCT) was reported in transcranial magnetic stimulation (TMS) studies performed in RTT. This was attributed to hyperexcitability of the motor cortex and/or spinal motor neurons, but was not studied further. We performed TMS in RTT to evaluate motor cortex excitability by determining the cortical motor threshold (CMT) and motor cortex inhibition by the cortical silent period (CSP) besides measuring CMCT. Single-pulse TMS was performed in 17 Rett patients, diagnosed by clinical criteria and MECP2 mutation testing, and the same number of healthy controls. The outcome measures were compared between RTT groups with different antiepileptic drugs (AED) and those with and without the MECP2 mutation. CMCT was shorter, but we found elevated CMT and shorter CSP, which suggests decreased excitatory and inhibitory motor cortical function. The outcome was independent of AED and the presence or absence of the MECP2 mutation. Decreased excitatory and inhibitory motor cortical function could explain the short CMCT, with higher stimulus intensities needed to excite pyramidal neurons.

Cortical beta oscillations and motor thresholds differ across the spectrum of post-stroke motor impairment, a preliminary MEG and TMS study

BackgroundCortical oscillatory activity in the beta frequency band (13–30Hz) is associated with voluntary movement and may be altered in motor disorders such as stroke. MethodsWe used a multimodal case-series approach to investigate movement-related beta oscillations, cortical excitability and upper-limb motor-function in 10 chronic stroke-patients across a broad range of motor-impairment. Assessments included: (i) whole-head magnetoencephalography (MEG) during a voluntary motor task; (ii) resting and active motor-thresholds to transcranial magnetic stimulation (TMS); and (iii) assessments of upper-limb motor-function. ResultsMEG revealed distinct patterns of movement-related beta oscillations according to motor-function. An elongated event-related desynchronisation (ERD) was correlated with poorer motor-function (p=0.004) whereas an elongated event-related resynchronisation (ERS) was correlated with higher motor function and lower TMS motor thresholds on the more-affected side (p=0.014 and p<0.001, respectively). Oscillation amplitude and laterality were also correlated with motor-function, where a stronger ERD/ERS and a greater relative contribution from the ipsilesional hemisphere were correlated with better motor-function (p=0.016, p=0.025). Unlike TMS responses and motor-function, the temporal profile of beta oscillations was largely symmetrical for movements of the more- and less-affected hands. ConclusionsBeta ERD/ERS patterns differ across the post-stroke motor impairment spectrum, and are bilaterally similar after stroke. Both the amplitude and duration of beta oscillations relate to post-stroke motor-function. SignificanceThe contralesional hemisphere is not unaffected post-stroke. Caution is needed when generalising imaging and neurophysiological findings from patients with moderate to high motor ability to the more heterogeneous general stroke population and particularly those with low levels of residual voluntary motor-function.

Motor Cortex Excitability Changes in Mild Alzheimer's Disease Are Reversed by Donepezil

Background: Recent neuroimaging studies in humans support the clinical observations that the motor cortex is affected early in the course of Alzheimer's disease (AD). Methods: We used transcranial magnetic stimulation to measure the active cortical motor threshold (ACMT) in AD patients in the very early stage of the disease, and we explored whether and in which way the pharmacologic manipulation of the cholinergic system could have a direct effect on the excitability of the motor cortex. Results: An increase of the ACMT was observed in AD patients in the early stage in comparison to controls. After 2 months of treatment with donepezil, the threshold did not differ significantly from normal subjects. Conclusions: The results suggest an early functional impairment of cholinergic neurotransmission in AD, which is associated to early changes in the excitability of the motor system.

P 10. Acute state-dependent changes in corticomotor threshold in the absence of overt motor activity

The cortical motor threshold (CMT) is often used to individually adjust the intensity of transcranial magnetic stimulation (TMS). It reflects the integrated excitability of the corticomotor projection, including the excitability at the spinal level. The CMT reflects axonal and synaptic excitability as CMT can be modified by drugs that voltage-gated sodium channel blockers or non-NMDA glutamatergic drugs. The CMT is not a static measure but is subject to state-dependent fluctuations. To test this hypothesis we used an adaptive stair-case procedure to track acute changes in CMT associated with motor imagery (MI) or shifts in visuospatial attention (VA). Eight healthy subjects were asked to imagine a continuous thumb-index movement with the left or right hand (MI-left and MI-right), to shift their visuospatial attention to the left or right FDI (VA-left and VA-right) or to fixate a cross in the central visual field. Using a fast (<15 pulses) threshold-hunting procedure (Borckardt, 2006), we assessed task-dependent CMT changes in the left primary motor hand area (M1) during each task. CMT was defined as the stimulus intensity, at which a single TMS pulse elicited a MEP of 50 μV in the relaxed right first dorsal interosseus muscle (FDI) with a probability of 0.5. The CMT measurements during the VA and MI task were normalized to the control condition. All participants underwent two experimental sessions on separate days, in which the TMS pulse either induced a posterior-to-anterior (PA) or anterior-to-posterior (AP) current in M1. The number of pulses needed to determine rMT did not significantly differ across conditions (average: 13.5). Using the normalized CMT values as dependent variable, we computed a repeated measures ANOVA with the factors Current (AP/PA), Task (MI/VA) and Site (Left/Right). We found a significant Task-by-Site interaction ( p = 0.004). Post hoc testing confirmed that CMT during MI-right was significantly lower than during MI-left or during VA-right. This was the case for AP and PA current direction. The resting CMT is subject to rapid state-dependent changes in the absence of overt motor activity. We show that these acute CMT changes can be captured with a threshold-hunting procedure. The “CMT tracking” approach might be particularly useful to assess the temporal dynamics of corticomotor excitability changes induced by interventional brain stimulation protocols.

Can Cortical Silent Period and Motor Threshold Be Practical Parameters in the Comparison of Patients with Generalized Epilepsy and Patients with Psychogenic Non-Epileptic Seizures?

Background/Aim: This study aimed to compare the cortical excitability of patients with generalized tonic-clonic seizures (GTCSs) and that of patients with psychogenic non-epileptic seizures (PNESs). Methods: Patients were classified into groups according to their electroencephalogram (EEG) findings and seizure types: group 1 = GTCS with an abnormal EEG, group 2 = GTCS with a normal EEG and group 3 = PNES with a normal EEG. The control group included healthy volunteers with normal EEGs. Cortical silent period (CSP) and motor threshold (MT) were measured for all groups and the results were compared. Results: CSPs were significantly prolonged in groups 1 and 2 when compared with group 3 and the control group. No differences were found between the MT measurements of all groups. Conclusion: The prolongation of CSP may demonstrate the differences between the pathophysiological mechanisms of GTCS and those of PNES.

Direct-current-dependent shift of theta-burst-induced plasticity in the human motor cortex

Animal studies using polarising currents have shown that induction of synaptic long-term potentiation (LTP) and long-term depression (LTD) by bursts of patterned stimulation is affected by the membrane potential of the postsynaptic neurone. The aim of the present experiments was to test whether it is possible to observe similar phenomena in humans with the aim of improving present protocols of inducing synaptic plasticity for therapeutic purposes. We tested whether the LTP/LTD-like after effects of transcranial theta-burst stimulation (TBS) of human motor cortex, an analogue of patterned electrical stimulation in animals, were affected by simultaneous transcranial direct-current stimulation (tDCS), a non-invasive method of polarising cortical neurones in humans. Nine healthy volunteers were investigated in a single-blind, balanced cross-over study; continuous TBS (cTBS) was used to introduce LTD-like after effects, whereas intermittent TBS (iTBS) produced LTP-like effects. Each pattern was coupled with concurrent application of tDCS (<200 s, anodal, cathodal, sham). Cathodal tDCS increased the response to iTBS and abolished the effects of cTBS. Anodal tDCS changed the effects of cTBS towards facilitation, but had no impact on iTBS. Cortical motor thresholds and intracortical inhibitory/facilitatory networks were not altered by any of the stimulation protocols. We conclude that the after effects of TBS can be modulated by concurrent tDCS. We hypothesise that tDCS changes the membrane potential of the apical dendrites of cortical pyramidal neurones and that this changes the response to patterned synaptic input evoked by TBS. The data show that it may be possible to enhance LTP-like plasticity after TBS in the human cortex.

Corticomotor representation to a human forearm muscle changes following cervical spinal cord injury

Functional imaging studies, using blood oxygen level-dependent signals, have demonstrated cortical reorganization of forearm muscle maps towards the denervated leg area following spinal cord injury (SCI). The extent of cortical reorganization was predicted by spinal atrophy. We therefore expected to see a similar shift in the motor output of corticospinal projections of the forearm towards more denervated lower body parts in volunteers with cervical injury. Therefore, we used magnetic resonance imaging-navigated transcranial magnetic stimulation (TMS) to non-invasively measure changes in cortical map reorganization of a forearm muscle in the primary motor cortex (M1) following human SCI. We recruited volunteers with chronic cervical injuries resulting in bilateral upper and lower motor impairment and severe cervical atrophy and healthy control participants. All participants underwent a T1-weighted anatomical scan prior to the TMS experiment. The motor thresholds of the extensor digitorum communis muscle (EDC) were defined, and its cortical muscle representation was mapped. The centre of gravity (CoG), the cortical silent period (CSP) and active motor thresholds (AMTs) were measured. Regression analysis was used to investigate relationships between trauma-related anatomical changes and TMS parameters. SCI participants had increased AMTs (P = 0.01) and increased CSP duration (P = 0.01). The CoG of the EDC motor-evoked potential map was located more posteriorly towards the anatomical hand representation of M1 in SCI participants than in controls (P = 0.03). Crucially, cord atrophy was negatively associated with AMT and CSP duration (r(2) ≥ 0.26, P < 0.05). In conclusion, greater spinal cord atrophy predicts changes at the cortical level that lead to reduced excitability and increased inhibition. Therefore, cortical forearm motor representations may reorganize towards the intrinsic hand motor representation to maximize output to muscles of the impaired forearm following SCI.

Action of 5 Hz repetitive transcranial magnetic stimulation on sensory, motor and autonomic function in human spinal cord injury

Objective To assess the effectiveness of physiological outcome measures in detecting functional change in the degree of impairment of spinal cord injury (SCI) following repetitive transcranial magnetic stimulation (rTMS) of the sensorimotor cortex. Methods Subjects with complete or incomplete cervical (or T1) SCI received real and sham rTMS in a randomised placebo-controlled single-blinded cross-over trial. rTMS at sub-threshold intensity for upper-limb muscles was applied (5 Hz, 900 stimuli) on 5 consecutive days. Assessments made before and for 2 weeks after treatment comprised the ASIA (American Spinal Injuries Association) impairment scale (AIS), the Action Research Arm Test (ARAT), a peg-board test, electrical perceptual test (EPT), motor evoked potentials, cortical silent period, cardiovascular and sympathetic skin responses. Results There were no significant differences in AIS outcomes between real and sham rTMS. The ARAT was increased at 1 h after real rTMS compared to baseline. Active motor threshold for the most caudally innervated hand muscle was increased at 72 and 120 h compared to baseline. Persistent reductions in EPT to rTMS occurred in two individuals. Conclusions Changes in cortical motor threshold measures may accompany functional gains to rTMS in SCI subjects. Significance Electrophysiological measures may provide a useful adjunct to ASIA impairment scales.

Deficit of sensorimotor integration in normal aging

Sensorimotor performance declines with normal aging. The present study explored age-related changes in sensorimotor integration by conditioning a supra-threshold transcranial magnetic stimulation pulse with a peripheral nerve shock at different interstimulus intervals. Cortical motor threshold of the abductor pollicis brevis muscle, intracortical inhibition and facilitation were measured. We also assessed the influence of median nerve stimulation on motor cortex excitability at intervals which evoked short- and long-latency afferent inhibition (SAI and LAI, respectively) and afferent-induced facilitation (AIF). We observed a marked decrease of the long latency influence of proprioceptive inputs on M1 excitability in the elderly, with the loss of AIF and LAI. The SAI, motor thresholds and intracortical inhibition and facilitation were not age-related. Decreased sensorimotor performance with aging appears to be associated with a decrease in the influence of proprioceptive inputs on motor cortex excitability at longer intervals (probably via higher order cortical areas).

Sensitivity of electrophysiological tests for upper and lower motor neuron dysfunction in ALS: A six‐month longitudinal study

By following a group of amyotrophic lateral sclerosis (ALS) patients longitudinally using lower motor neuron (LMN) and upper motor neuron (UMN) markers of dysfunction it may be possible to better understand the functional relationships between these motor systems in this disease. We used neurophysiological techniques to follow UMN and LMN dysfunction in a group of 28 patients with ALS, in comparison with the ALS functional rating scale (ALS-FRS) score and the forced vital capacity (FVC). We used motor unit number estimation (MUNE), compound muscle action potential (CMAP) amplitude, and the Neurophysiological Index (NI) to quantify the LMN disorder, and transcranial motor stimulation to study cortical motor threshold, motor-evoked response amplitude, central motor conduction time, and cortical silent period (CSP). The patients were studied shortly after diagnosis and then 6 months later, using both abductor digiti minimi muscles (ADM); ADM strength was initially >MRC 3 (Medical Research Council, UK). The NI and MUNE changed more than any other variable. CSP increased by about 30%, a change more marked than the slight increase observed in the cortical motor threshold (9%). The normal increase of CSP after acute muscle fatigue was preserved during disease progression. The CSP increase correlated with the MUNE rate of decay but not to the NI reduction, perhaps because NI includes F-wave frequency in itscalculation. There was no definite correlation between UMN and LMNdysfunction or progression, but there was a link between CSP and LMN changes in ALS. The CSP may be a useful variable in following UMN dysfunction in clinical practice and in clinical trials.